Preoperative Care II
more of the same, just a little more detail...again.
Terms in this set (27)
Main considerations preop?
Risk of planned procedure
-Low, intermediate, high
Planned anesthetic technique
Postoperative disposition of the patient
Low risk procedures:
Dermatologic procedures (skin and subcutaneous tissue)
Breast biopsy or other Breast surgery
Ophthalmologic Procedures (e.g. Cataract resection)
Ambulatory surgery (contrasted with hospital procedures)
Intermediate risk procedures:
Uncomplicated abdominal or thoracic surgery
Uncomplicated head and neck surgery
High risk procedures:
Emergency surgery (especially over age 75 years)
Major Thoracic Procedures
Aortic or other major vascular procedures
Peripheral arterial vascular procedures
Prolonged surgery anticipated (>4 hours)
- Anticipated large fluid shift or blood loss
- Examples: Whipple Procedure, Major spinal surgery
What is the ASA classicfication?
I. Normal Healthy Patient
II. Patient with mild systemic disease
III. Patient with severe systemic disease that limits activity, but is not incapacitating
IV. Patient who has incapacitating disease that is a constant threat to life
V. Moribund patient not expected to survive 24 hours with or without an operation
Cardiovascular health is very influential on surgery outcomes, for planning purposes, what do we review?
-History - Careful history is critical to discover cardiac and/or co-morbid diseases
-Identify serious cardiac conditions
-Determine the patient's functional capacity
-Give patient a cardiac score based on the 'Revised Cardiac Risk Index (1999)'
CVD Risk algorithm:
Steps of the Focused Cardio exam:
-Vitals, including BP in both arms
-Carotid pulse contour, bruits
-JVP and pulsations
-Auscultation of the lungs
-Precordial palpation and auscultation
-Examination of the extremities for edema, vascular integrity
When is a pulmonary assessment required?
Before and After every surgery. Specific function tests may be required for thoracic and gen surgery procedures, which are of higher risk.
Which thoracic and upper abdominal procedures require pulmonary function tests?
-All lung resection cases
-Thoracic procedures requiring single-lung ventilation
-Major abdominal and thoracic cases in patients
-Who are older than 60 years
-Significant underlying medical disease
-Overt pulmonary symptomology
What are the specific tests for Pulmonary Function?
Forced expiratory volume in 1 second (FEV1): the volume of air that can forcibly be blown out in one second, after full inspiration
Forced vital capacity: the volume of air that can forcibly be blown out after full inspiration
Diffusing capacity of carbon monoxide (DLCO): to determine the overall ability of the lung to transport gas into and out of the blood
What pulmonary interventions should be performed preoperatively?
--Smoking cessation (within 2 months)
-Antibiotic treatment for preexisting infection
-Pretreatment of asthmatic patients with steroid
-Exercise: walk 3 miles in less than one hour 3 times weekly
What are some interventions that can be done perioperatively to improve pulmonary function?
Vigorous pulmonary toilet and rehabilitation
Continued bronchodilator therapy
Prep and Plan with a Renal system focus includes:
Thorough H&P, with particular questioning about previous MI consistent with ischemic heart disease
-Serum Chemistry panel
Lab abnormalities typically seen in advanced renal disease
**Pt.s with end stage renal failure will undergo dialysis prior to surgery, focus is on controlling potassium levels and preventing hyperkalemia.
Prep and Plan with a Endocrine(DM1&2) focus includes:
-H&P focus should be on the adequacy of glycemic control and identifies the presence of diabetic complications
-Document evidence of diabetic complications
-Fasting glucose, Hgb A1C
-Serum electrolytes, BUN, Creatinine
-EKG in long standing diabetics
Prep and Plan with a Hematological focus includes:
-Inherited or acquired coagulopathy
-The need for perioperative prophylaxis for venous thromboembolism must be carefully reviewed in every surgical patient.
Hematological system lab tests for anemia:
What is coagulopathy and why is it a concern
Coagulopathy - easy bleeding
-Platelet or factor disorders
-Organ dysfunction or medications
-History should specifically include inquiry of medical or family history of abnormal bleeding
~Easy bruising, abnormal bleeding with minor procedures
~History of liver dysfunction, or common bile duct obstruction
~Medication review for NSAIDs, salicylates
Physical exam findings of coagulopathies:
What ranges are we watching for when we test platelets?
CBC to measure platelets:
Normal range 150,000 - 400,000 platelets per microliter (mcL).
Consideration to transfuse <100k
General cutoff <50k
Patients with documented disorders of coagulation may require perioperative management of factor deficiencies, often in consultation with a hematologist
How do we manage Warfarin pre and peri-operatively?
-Hold dosing 5 days preop
-Desire is to get INR < 1.5 for surgery
-Can be started day of, or day after surgery
~Likely needs 5 days to become therapeutic
-High Risk patients should have full bridging with LMWH, or perioperative IV Heparin
~Stop LMWH 24 hours before surgery, re-start in 12-24 hours
~Stop IV Heparin 6 hours before surgery, restart in 12-24 hours
Assess all pt for VTE:
All surgical patients need to be assessed for their risk for venous thromboembolism (VTE) and receive adequate prophylaxis according to current guidelines
Medical and Family history important to explore
protein C, protein S, antithrombin III, and antiphospholipid antibody
Risk factors for VTE/PE?
age, type of surgical procedure, previous thromboembolism, cancer, obesity, varicose veins, cardiac dysfunction, indwelling central venous catheters, inflammatory bowel disease, nephrotic syndrome, pregnancy, and estrogen or tamoxifen use...
Monitor Nutritional status and use "significant weight loss" as a clinical term:
Significant weight loss
>10% body weight over period of 6 months
> 5% body weight over the past month
Nutritional exam findings to watch for:
Tests for nutrional status?
Albumin (half-life, 14 to 18 days)
Transferrin (half-life, 7 days),
Prealbumin (half-life, 3 to 5 days)
Best used serially in the hospital setting
4 final tid-bits on nutrition:
1-Patients with most severe weight loss seem to benefit the most from preoperative nutrition
2- Nutritional support (Enteral) usually starts within 5-10 days post op
3- Burn patients start parenteral support ASAP
4- Enteral route of feeding is preferred
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