Chapter 13 (PREOPERATIVE EVALUATION AND MEDICATION)
Terms in this set (14)
Explain the ASA classes.
*E added to the above classes adds the condition of emergency surgery.
Explain Mallampatti scores.
Explain cardiac algorithm in preop assessment.
5 steps: emergency - risk reduction
2) if active cardiac conditions - risk reduction first.
3) if low risk proceed to surgery
4)if good functional capacity proceed to surgery
5) consider clinical predictors then if vascular surgery or not. if > 3 w/ vascular surgery consider testing if will change management.
DES BMS anti-platelet therapy considerations in the pre-operative evaluation?
DES require 1 year of dual AP therapy
BMS require 1 mo of AP therapy.
CHF in pre-surgical mortality/morbidity?
Heart failure is a significant risk factor for perioperative adverse events. Patients with compensated heart failure have a 5% to 7% risk of perioperative cardiac complications, and those with decompensation have an even higher rate—a 20% to 30% incidence.
What is an acceptable preoperative BP without changing mortality?
Compare contrast the preoperative risk of Asthma versus COPD - how to prevent risk as well?
Well controlled asthma poses little or no risk to surgery, while active asthma/wheezing does. COPD increases risk of surgery despite being well controlled, and the severity further increases the risk.
Prednisone 0.5 to 1 mg/kg orally for 1 to 4 days before surgery for patients who are likely to require endotracheal intubation and who have persistent
airway obstruction despite use of inhaled medications is recommended.
What is the STOP-Bang questionaire, and what are the implications of this questionair w/ preoperative risk?
The STOP-Bang questionnaire was developed and validated in an anesthesia preoperative clinic to screen for OSA (Fig. 13-5).23 Patients with OSA have increased rates of diabetes, hypertension, atrial fibrillation, bradyarrhythmias, ventricular ectopy, stroke, heart failure, pulmonary hypertension, dilated cardiomyopathy, and CAD.24 Ventilation
via a mask, direct laryngoscopy, endotracheal intubation, and fiberoptic visualization of the airway are more difficult in patients with OSA.
General xfusion goal in anesthesia?
Is preoperative testing needed in ambulatory surgery (in general)?
In a pilot study of over 1000 patients undergoing ambulatory surgery, there was no increase in adverse perioperative events in patients who had no preoperative tests
A prospective observational study in patients aged 50 years or older having major noncardiac surgery found abnormalities in 45% of the preoperative ECGs. Bundle branch blocks, associated with postoperative MI and death, had no added predictive value over clinical risk factors
Chest radiographs do not predict postoperative pulmonary
Cardiac risk factor pretesting indications
What is the feeling about stopping ASA prior to surgery? Indications where it's definitely beneficial?
Stopping ASA has recently become controversial. A meta-analysis of almost 50,000 patients undergoing a variety of noncardiac surgeries (30% taking aspirin perioperatively) found that aspirin increased bleeding complications by a factor of 1.5, but not the severity, except in patients undergoing intracranial surgery and possibly transurethral resection of the prostate
Acute coronary syndromes occurred 8.5 3.6 days and acute cerebral
events 14.3 11.3 days after aspirin cessation, the typical duration of interruption for surgery, and events were twice as common in patients who had stopped taking aspirin in the previous 3 weeks when compared to those who continued aspirin.8 Stopping aspirin for 3 to 4 days is usually
sufficient, if aspirin is stopped at all, and dosing should be resumed as soon as possible.
Describe when steroids are needed pre-operatively?
Stress-associated adrenal insufficiency in some patients may require additional steroids perioperatively. A normal daily adrenal output of cortisol (30 mg) is equivalent to 5 to 7.5 mg of prednisone. The hypothalamic-pituitary axis (HPA) is not suppressed with less than 5 mg/day of prednisone or its equivalent. In patients taking 5 to 20 mg/day of prednisone or its equivalent for more than 3 weeks, the HPA may be suppressed. The HPA is suppressed with more than 20 mg/day of prednisone or its equivalent when taken for more than 3 weeks. The risk of adrenal insufficiency remains for up to 1 year after the cessation of high-dose steroids.
High, intermediate, low risk surgeries in cardiac pts?
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