Pre-Op Eval

technical skills, diagnosis and treatment, a genuine sympathy

The management of surgical disorders requires

leading the witness, cooperative patients give the answer you want to here, mutual satisfaction with the wrong answer

Discrepancies in the history are often due to

Pain, Vomiting, Change in bowel habits, hematemesis/hematochezia

What are some common symptoms of surgical conditions that requires special emphasis in the history?

PAIN

What is one of the most important features of a surgical history?

polyposis of the colon, DM, Peutz-jegher’s syndrome, chronic pancreatitis, multiglandular syndromes, other endocrine abnormalities, cancer

What are some important family hx questions?

CBC, CMP, PT/INR, UA (must treat UTIs before surgery), beta hCG, blood type(if the surgery has a high hemorrhage risk), other directed at specific conditions (echo, PFTs, tumor markers, hormones etc)

Basic Pre-Op labs

risk, benefits, alternatives (RBA)

What needs to be discussed in an informed consent?

Surgery team member, patient, and a witness; 2 docs (emergency), MPOA (if patient is unable)

Who can signed an informed consent?

get baseline vitals, remove jewelry, contacts, dentures; mark site and laterally, confirm fasting status and medications in the last 24 hours, local hair removal

Basic Pre-op Precautions

ACEI (24 hours prior - refractory hypotension), diuretics (withheld on the morning of in operations with high risk of fluid losses)

Which medications should be withheld pre-surgery?

within 1 hour before incision for certain clean operation, clean-contaminated, contaminated and dirty wounds

When should abx (Ancef AKA cefazolin) given prophylactically (full dose given parenterally stopped after 24 hours)?

Colorectal operations, implantation of a foreign body, contaminated wounds, immunocompromised patients

Abx are continued longer than 24 hours in which patients

Assign ASA category, prior intubation, previous anesthetic reactions, underlying metabolic disease, current medications/allergies, upper airway assessment (LEMON score), Mallampati classification

What are some risk assessments we need to do prior to surgery?

normal healthy patient

Describe an ASA 1 (PS 1) classification

A patient with mild systemic disease (may not be associated with the surgical issues - ex: COPD, extremes of age)

Describe an ASA 2 (PS 2) classification

A patient with severe systemic disease (limits activity but does not incapacitate - insulin-dependent DM)

Describe an ASA 3 (PS 3) classification

A patient with SEVERE systemic disease that is a constant threat to life (active cardiac ischemia)

Describe an ASA 4 (PS 4) classification

A moribund patient who is not expected to survive without the operation (emergency - major cerebral trauma with increasing ICP)

Describe an ASA 5 (PS 5) classification

A declared brain dead patient whose organs are being removed for donor purposes

Describe an ASA 6 (PS 6) classification

Focused on minimizing cardiac complications, Watch for decreased breath sounds, wheezes, rhonchi, prolonged expiration (its giving underlying disease), consider CXR, ABG, PFTs

Pre-op evaluation for Pulm

Advanced age, elevated ASA class, CHF, functional dependence, known COPD

Risk Factors for post-op pulmonary complications

consult RT and pulmonary medicine, smoking cessation, asthma control, incentive spirometry (prevents pnuemonia)

Ways to mitigate pulmonary complications

early ambulation, mechanical prophylaxis + intermittent pneumatic compression (IPC) devices; LMWH or low dose heparin, IPC + LMWH or heparin

Ways to prevent VTE

Caprini Scores

What can determine if the patient needs VTE prophylaxis?

Hx of ischemic heart disease, CHF (JVD and S3), cerebrovascular disease, pre-op treatment with insulin, high risk operation, pre-op serum creatinine over 2.0

What are the 6 independent predictors of cardiac complications (for patients with non-cardiac surgery) - MACE?

intraperitoneal, intrathoracic, suprainguinal vascular surgery

How is a high risk surgery defined?

Stress test (exercise, dipyridamole/thallium, dobutamine/adenosine echo)

Findings suggestive of ischemic heart disease should be screened with

6+ months

In general, how long should we try to wait before an elective surgery post-MI?

ASA guidelines about pre-op fasting, minimize retained gastric volume and maximize gastric pH (no clear liquids for at least 2 hours, light food for 6, fatty meals for 8), bowel prep (depends on the procedure)

Pre-op eval for GI surgeries

Evaluate for coagulopathy and underlying hepatorenal syndrome, PT/INR, PTT, bilirubin, Calculate a Child-Turcotte-Pugh or Model for End-Stage Liver Disease score, ammonia levels (treat high levels with lactulose)

Pre-op eval for the liver

spider telangiectasia, jaundice, prolonged bleed/anticoags

Signs of liver failure

All patients with liver disease risk hepatic decomp with surgery (class C has a 63%+ mortality)

Who should have a calculated MELD?

BUN/Creatinine, GFR, UA, Elevated creatinine (mild-moderate), Dialysis treatment and eventual transplant (severe), dosage adjustment of anesthetics and other meds with other nephrotoxic effects

Pre-op eval for renal

IV fluids (be mindful of 3rd spacing)

Post-op oliguria is treated with

arrhythmias (hella K), SOB (pulmonary edema), anemia

Renal complications

Document pre-existing deficits, pre-op positioning (ensure pressure points are padded and avoid overstretching joints)

Pre-op eval for Neuro

neuropraxia

A peripheral nerve injruy

Greater chance of SSIs, Blood glucose at 140-180 (sliding scale), IV insulin is best for perioperative care, frequently dehydrated while NPO, patients are not managing their glucose

Pre-op eval for DM homies

Increased Epi, Nor-epi, and cortisol; ADH leads to decreased urinary output (3rd spacing, RAAS, hyponatremia)

Endocrine PAIN stress response

Steroids must be tapered, Ensure patients are euthyroid

Post-op endocrine issues

thorough history, bleeding mucosa, petechiae, deformed joints, DVT, stop warfarin/ASA/NSAIDs 1 week prior, PT/INR elevated if liver is affected, thromboelastogram, PT/BT (petechial rash)

Pre-op Eval for blood dyscrasia

Pre-op feedings via the gut or TPN (watch albumin under 3 means chronic malnutrition, Prealbumin under 16 means acute malnutrition)

Pre-op eval for nutrition

delayed wound healing, anergy, decreased pulmonary reserve

Any fat loss over 12% is linked to

Correct physiologic issues prior to surgery, restore circulatory volume, correct coags, correct acid base, replete electrolytes

Pre-op eval for fluid management and blood volume