When can a patient eat prior to a major surgery?
NPO after midnight or at least 8 hours
What risks should be discussed with all patients and
... [Show More] documented on the consent form for a surgical procedure?
Risk: Bleeding, infection, anesthesia, scars
If a patient is on anti-HTN meds should the patient take them on the day of the procedure?
Yes
Should a patient who smokes cigarettes stop before an operation?
Yes - improvement is seen in just 2-4 weeks of smoking cessation
What lab test must all women of childbearing age have before entering the OR?
B-Hcg and CBC
What is a preop colon surgery "bowel prep"?
Bowel prep with a colon cathartic (GoLYTELY), oral abx (neomycin, erythromycin), IV antibiotic before incidsion
What must you always order preoperatively for you patient undergoing a major surgery?
1. NPO/IVF
2. Preop abx
3. Type and cross blood (PRBCs)
What electrolyte must you check preoperatively if a patient is on hemodialysis?
Potassium
Who gets a preop EKG?
Patients over 40 or undergoing cardiac procedure
What is the most important preoperative eval performed by the surgical team?
H&P - no documentation exists linking a reduction in mortality and morbidity to routine lab testing in otherwise healthy patients undergoing elective procedures
Detailed H&P prior to surgery including special attention to...
Hx of CVA, heart dz, pulm dz, renal dz, liver dz, GI d/o, DM, prior surgeries, bleeding problems, clotting problems, difficulty w/ anesthesia, nutrition, etoh, illicit drugs
What is an ASA score?
American Society of Anesthesiologists (ASA) classification system which stratifies the degree of perioperative risk for patients
Describe the ASA classification system
ASA 1: Normal healthy patient
ASA 2: Patient with mild systemic disease
ASA 3: Patient with severe systemic disease
ASA 4: Patient with severe systemic disease with a constant threat to life
ASA 5: Moribound patient who are not expected to survive without an operation
ASA 6: Brain dead patient
Mouth PE important to note
Teeth - if loose worry about intubation
Tongue - think sleep apnea if large
Jaw - TMJ could be difficult intubation
Mallampati score
Airway concerns with surgery
Tracheal deviation - can be issue for maintaining airway during surgery
Neck concerns with surgery
If >17in there is concern for sleep apnea, masses, deformities, ROM
Mallampati score
Classifies how open the airway is
1 - Can see the uvula, no prob w/ intubation
IV- No uvula, hard intubation
Routine preop labs/tests for patients with cardiac disease/vascular disease?
CBC
EKG
What are major cardiac risk factors for surgery?
Unstable coronary syndromes
Recent MI
Severe valvular disease
Ventricular arrhythmias
What are minor cardiac risk factors for surgery?
Hx of CVA
Uncontrolled HTN
What is the Goldman Criteria for Cardiac Risk?
Assesses risk of perioperative fatal and nonfatal cardiac events. Another used is Detsky's
What are moderate cardiac risk factors for surgery?
Asymptomatic MI
DM
Compensated CHF
What is Lee's revised cardiac risk index?
Validated way to predict risk in patients who undergo elective noncardiac procedures. There are 6 predictors (each get one point):
History of ischemic heart disease
CHF
Hx of CVA
High-risk operation
Preoperative treatment with insulin
Preoperative SCr >2.0 mg/dL
Goldman criteria points
0-5 = Class I
6-12 = Class 2
13-25 = Class 3
>25 = Class 4
Preop lab assessment for cardiac disease?
Resting LV function
Ambulatory EKG monitoring
Exercise stress test or nuclear stress test
Stress echo
Patients with an EF <___% are at greatest risk for complications during surgery
<35%
What are indications for preop coronary angiography?
Patients with suspected left main disease, triple vessel coronary occlusive disease, or unstable coronary syndromes (high risk patients)
What is appropriate medical therapy for CAD prior to surgery?
BB, CCBs, nitrates to ensure myocardial oxygen demand does not exceed supply
What do patients with a history of rheumatic heart disease require prior to surgery?
Prophylactic antibiotics to prevent endocarditis
What should you do if you find your patient to have carotid artery disease?
Endorterectomy prior to surgery - wait 6 months before operation if possible
What are the 2 big things to worry about in surgery w/ a cardiac patient
1. Catecholamine surge which causes an increase in myocardial o2 demand
2. Suppression in the fibrinolytic system which leads to thrombosis
What kind of murmurs are usually benign?
Short, soft, systolic murmurs that are asymptomatic often don't require further investigation
What are risk factors for postop pulmonary complications (PPC)?
Advanced age
Elevated ASA class
CHF
Functional dependence
COPD
Sleep apnea
Smoking status
Low arterial O2 sat
Anemia
Upper abdominal/thoracic operations
Duration of operations over 2 hours
Emergency surgery
Routine preop labs/tests for pulmonary disease?
CBC
EKG
CXR
CXR screening guidelines
All >60
Patients with cardiac/lung disease
Patients undergoing thoracic procedure
Patient education to reduce risk of PPC?
Use of incentive spirometry
Deep inspiration
Coughing
Smoking cessation
Early mobilization
Oral hygiene
Use of CPAP/BiPAP
Clinical features of thrombophlebitis/DVT?
Dull pain
Erythema
Tenderness
Induration of involved vein
Swelling of involved area with heat and redness
Homan's sign (unreliable)
What is Virchow's triad?
Used to identify patients at risk for VTE
Risk factors for DVT?
Prolonged bed rest/immobility
Ortho surgery (total hip replacement)
Long air travel
Malignancy
Nephrotic syndrome
Use of OCPs/HRT
Hypercoagulable state (Pregnancy, Factor V Leiden)
Where does a DVT most commonly occur?
Lower extremities (Long saphenous vein)
Pelvis
Diagnostic test for DVT?
Duplex ultrasound <---preferred study
Venography <--- most accurate study, rarely done
D-dimer (neg is <500)
Spiral CT if PE is suspected (or VQ scan if there is renal impairment)
Treatment for thrombophlebitis/DVT?
Superficial thrombophlebitis is treated with bed rest, local heat, elevation of extremity, NSAIDs
Antibiotics
Surgical intervention if serious
When should DVT prophylaxis be started?
Preoperatively because it is thought that thrombosis starts as early as at the induction of anesthesia
What is the Caprini score?
Elaborate risk factor index for DVT [Show Less]