The following medications need to be managed in what way before surgery? A. Acetominophen B. Aspirin C. NSAIDS D. Clopidogrel
A. Acetominophen: continue use
B. Aspirin: Hold 7-10d prior.. due to irreversible inhibition of platelet cyclooxygenase.
C. NSAIDS: hold 3d, due to reversible inhibition of cyclooxygenase
D. Clopidogrel: Hold 7-10d prior.. due to irreversible inhibition of antiplatelet effect
Can a patient use:
- digoxin
- clonidine
- B blockers
- Ca blocker
the day of surgery?
YES
When should you hold diuretics, ACEi, Ang2RB, drugs?
Cholesterol lowering drugs?
- Hold on the morning of surgey.. esp if indication is CHF, which can cause increased risk of hypotension
- Cholesterol meds can be held 1 day prior to surgery. Due to risk of Rhabdo and myositis
Prior to surgery what is the protocol for:
- long lasting insulin?
- Metformin?
- Sulfonylureas, thiazlidediones, alpha glucoseidase inhibitors?
- long lasting insulin: give HALF the normal dose, HOLD short acting morning of surgery.
- Metformin: Hold 2d prior, risk of lactic acidosis if patient has renal issues.
- Sulfonylureas, thiazlidediones, alpha glucoseidase inhibitors: hold the morning of.
When should I get an ECG preoperatively?
Chest XR?
Patient is >40 yo if woman, or >50 if man and in those with known CV dx.
- rarely changes anything. Only do it if hosp/anesthesiology requires it.
XR: in pt with Pulm dx.
Pre-op Anesthesia Assessment: American Society of Anesthesiology Classification 1-6
- normal/healthy
- mild systemic dx ( controlled HTN/DM)
- severe systemic dx (controlled CHF, old MI, mordibly obese, CRF)
- severe systemic dx and constant threat to life (unstable angina)
- critical medical condition, little chance for survical without procedure.
- declared brain dead
E. EMERGENCY procedure. (2E) etc.
To prevent lung complications post operatively, what should the patient always do?
Use incetive spirometry! and deep breathing exercises.
- esp if they are obese or have lung dx
Before surgery would you rather have a patient mildly HYPER or Hypoglycemic?
HYPER!
Extra sugar can be used by the body under stress.
However, too much sugar puts pt as risk for:
- impaired infection fighting
- proinflammatory effects
- increase in mortality
For a patient reliant on IM insulin, what must be ordered for them during a surgical procedure?
IV insulin with dextrose.
A patient with end stage renal disease, will require what pre op treatment? ( think metabolic)
Treatment to prevent hyperkalemia, hypocalcemia, hyperphosphatemia.
- discuss with anesthesia.
- dialysis needs to be done 1d prior to surgery
What is one of the most specific and reliable sx associated with PAD?
Claudication.
- due to skeletal muscle ischemia produced with exertion.
What is Buerger dx? Main sx?
AKA Thromboangitis obliterans (TAO): affects distal vessels of arms and legs in people under the age of 40 who SMOKE. men> women. TRIAD 1. claudication 2. raynauds 3. superficial thrombophlebitis
What is Takayasu Arteritis? Main Sx?
occurs in ages 20-40, muscle pain and diminished pulse.
Claudication of upper extremity, patietns have constitutional sx ( fever, arthralgias, fatigue, and weight loss).
Can you use epinephrine in a Raynaud’s patient due secondary cause?
Secondary cause: CT disorder, arterial occlusive dx, blood dyscrasis, trauma, or drugs.
Giving patient epi will constrict vessels even more. So avoid this medication post opertively.
Heighted cortisol levels due to surgery return to normal, when?
48-72 hours.
- In response to stress of surgery, body secreted 75-150mg/day.
- 100mg of methyprednisone administered pre-op to select patients.
- post op: 25-50 mg every 8 hours can be continued.
How long should methotrexate be held prior to surgery?
2 weeks! This can increase susceptibility to post-op infections. Re-continue after wound healing is ensured.
*** other meds for RA can also increase this risk too!
What concerns should I have pre-op with an RA patient?
They will have poor bone stalk… therefore more fixation will be required or longer periods of NWB.
CONCERN for ATLANTOAXIAL SUBLUXATION due to RA and also concern in ankylosing spondylitis.
*** patients with arthritis need to have neck and jaw assessed so proper intubation can occur.
What should I warn patients that have had episodes of gout in the past?
That surgery can precipitate a gouty attack!
** to helpl remedy this, you can prescribe indomethocin 1w after surgery to reduce the possibility of a gout attack.
When should surgery be delayed due to HTN?
> 200mgHg, must be <180/110
If a patient is on warfarin prior to surgery, when should it be discontinued ?
Warfarin should be stopped 3-5 days prior to surgery to allow INR to return to normal and then restarting therapy shortly after surgery.
