surgery: pre-op evaluation lori meyers, md assistant professor of anesthesiology...

Surgery: Pre-Op Evaluation

Lori Meyers, MDAssistant Professor of Anesthesiology

[email protected]

LSI Part 2Understanding Patients with Reproductive and Surgical Needs

Learning Objectives Evaluate and treat patients with common surgical

problems in all phases of their care. Evaluate the impact of patient and surgical factors on

preoperative planning, healing and recovery for the following conditions:

Obesity

Chronic medical conditions

Diabetes

Anticoagulation

Stress

Infection

Surgical complications

Transfusion

Socioeconomic factors

Surgical trauma (including MIS)

Surgical technique and resources and anesthesia

Learning Objectives Evaluate and treat patients with common surgical

problems in all phases of their care.

Prevent and manage postoperative complications:

Exacerbation of comorbid conditions

Infection

DVT & DVT Prophylaxis

Bleeding

Learning Objectives Decide between medical and surgical intervention

for patients with common signs and symptoms.

Evaluate and discuss the management of various bleeding disorders: Hemophilia, Von Willebrand’s disease Qualitative and quantitative platelet deficiencies Disseminated intravascular coagulation Hypofibrinogenemia Immune thrombocytopenic purpura Hemolytic uremic syndrome

Learning Objectives

Differentiate hematologic disorders associated with the spleen and the role/indications for splenectomy and perioperative considerations (i.e. immunizations, Overwhelming Post-Splenectomy Sepsis OPSS)

Integrate causes of immunosuppression and the relationship of immune status to management of the perioperative patient.

Learning Objectives

Develop understanding of the pathophysiology of skin and wound healing.

Discriminate factors that positively or negatively impact wound healing.

Outline diseases (i.e. connective tissue disorders, etc.) that impact wound healing.

Relate how glucose control affects risk of perioperative infection and wound healing.

Relate the impact and assessment of nutritional status on perioperative patients and wound healing.

Learning Objectives

Develop understanding of the surgical and/or obstetric management of patients in order to critically evaluate and improve upon the care administered

Learning Resources

Jarrell, Bruce E & Carabasi, R Anthony (2008). NMS Surgery (5th ed). Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia: London

Hines, Roberta L. & Marschall, Katherine (2012). Stoelting's Anesthesia and Co-Existing Disease (6th ed.) Saunders, an imprint of Elsevier Inc: Philadelphia

Foundational Science

Even though this module deals with many clinical issues some of the basic science topics covered will include:

Pathophysiology of organ systems

Physiology and progression of possible complications that occur with surgery and anesthesia

Pharmacology for select medications

Pre-op Evaluation: Planning for Surgery

Patient conditions to consider Obesity Malnutrition Diabetes CAD COPD Liver Disease Renal Disease Infection Coagulopathies and hypercoagulable states Socioeconomic issues

Medical and surgical conditions associated with obesity

Organ System

Respiratory system

Cardiovascular system

Comorbid ConditionsObstructive sleep apneaObesity hypoventilation syndromeRestrictive lung disease

Systemic hypertensionCoronary artery diseaseCongestive heart failureStrokePeripheral vascular diseasePulmonary hypertensionHypercoagulable syndromesHypercholesterolemiaHypertriglyceridemiaSudden death

Obstructive Sleep Apnea: Risk Factors

S – Snoring History

T – daytime Tiredness

O – Observed Obstruction

P – high blood Pressure

B – BMI > 35 kg/m2

A – Age > 50

N – Neck circumference > 40 cm

G – male Gender


Organ System Endocrine system

Gastrointestinal system

Musculoskeletal system

Comorbid ConditionsMetabolic syndromeDiabetes mellitusCushing’s syndromeHypothyroidism

Nonalcoholic steatohepatitisHiatal herniaGallstonesFatty liver infiltrationGERD, delayed gastric emptying

Osteoarthritis of weight-bearing jointsBack painInguinal herniaJoint pain


Organ System

Malignancy

Other

Comorbid ConditionsPancreatic

Kidney

Breast

Prostate

Cervical, uterine, endometrial

Colorectal

Kidney failure

Depression

Overall shorter life expectancy

Modified from Adams JP, Murphy PG. Obesity in anaesthesia and intensive care. Br J Anaesth. 2000;85:91-108.


Patient conditions to consider Obesity Diabetes Malnutrition CAD HTN COPD Liver Disease Renal Disease Coagulopathies and hypercoagulable states Socioeconomic issues


Outside factors to consider Urgent or emergent surgery Anticoagulation Surgical complications, including surgical trauma Transfusion The hospital’s/center’s resources


Outside factors to consider Urgent or emergent surgery Anticoagulation Surgical complications, including surgical trauma Transfusion

Febrile/allergic reactions ABO incompatibility Delayed hemolytic reaction Disease transmission Electrolyte disturbances and coagulopathy TRALI / TACO Increase in recurrence of cancer

The hospital’s/center’s resources


Outside factors to consider Urgent or emergent surgery Anticoagulation Surgical complications, including surgical trauma Transfusion The hospital’s/center’s resources

Pre-op Evaluation: Recovery Considerations

Common Post-op Complications Exacerbation of comorbid conditions Infection Bleeding

From surgery From patient co-morbidity From DVT prophylaxis or other patient medications Transfusion reaction DIC

DVT / PE

Pre-op Evaluation: Factors That Influence Healing

Diabetes Nutritional status

Malnutrition Obesity

Jaundice Renal dysfunction

Uremia

Pre-op Evaluation: Factors That Influence Healing

Immunosuppression Steroids Chemotherapy / radiation

Smoking, COPD Connective tissue disorders

Ehler-Danlos

Excessive bleeding/clotting

Pre-op Evaluation: Special Considerations

Patients with bleeding disorders Medical treatment vs. surgical treatment

Disorders of the spleen Splenectomy indications Splenectomy consequences

Immunosuppressed patients


Splenectomy indications Massive splenic trauma or rupture Splenic abscess Primary splenic tumor Splenic cyst Disorders of splenic flow (esophageal varices) Hereditary spherocytosis Relative indications include but are not limited

to TTP, ITP, sickle cell anemia, and primary hypersplenism


Splenectomy consequences Atelectasis of left lower lung Injury to stomach or pancreas during surgery Post operative hemorrhage Sub phrenic abscess Thrombocytosis Overwhelming post splenectomy sepsis


Patients with bleeding disorders Medical treatment vs. surgical treatment

Disorders of the spleen Splenectomy indications Splenectomy consequences

Immunosuppressed patients Previous transplant Steroids Chemotherapy and radiation Diseases such as HIV and EBV

Summary

There are many comorbidities patients have that can affect their perioperative care and postoperative course.

Being aware of the risk these comorbid conditions cause and taking steps to mitigate them can improve patient outcomes.

Thank you for completing this module

Questions? Contact me at:

[email protected]

?

Formative Quiz

Question 1 A 53 year old male has recently been diagnosed with an aggressive renal cancer. He had a DES stent placed in his right coronary artery 6 months ago and is currently on clopidogrel and aspirin. What is the correct preoperative management for this patient?

Correct Answer Schedule surgery urgently. Stop Plavix for 7 days preoperatively and continue aspirin as scheduled.

This is the current recommendation to minimize risk of perioperative bleeding and perioperative stent thrombosis.

Distractor 1 Schedule surgery in 6 months.

An aggressive cancer can become non-resectable in 6 months.

Distractor 2 Stop Plavix and Aspirin and proceed to surgery in 7-10 days.

This will greatly increase the risk of perioperative stent thrombosis.

Distractor 3 Proceed to surgery immediately and give FFP and platelets for bleeding problems perioperatively.

This will greatly increase the risk of perioperative bleeding.

Formative Quiz

Question 2 All of the following are risk factors for obstructive sleep apnea (OSA) EXCEPT:

Correct Answer Female gender Males are at greatest risk

Distractor 1 BMI > 35kg/m2 This is a risk factor

Distractor 2 Hypertension This is a risk factor

Distractor 3 Age > 50 This is a risk factor

Formative Quiz

Question 3 A 15 year old male presents for urgent appendectomy. He had a splenectomy 12 months ago s/p an ATV rollover accident. All of the following are true EXCEPT:

Correct Answer The patient should have been revaccinated for Hepatitis B post splenectomy.

These patients need protection from encapsulated bacteria, not viruses.

Distractor 1 The patient is at increased risk for sepsis.

True for many reasons: post splenectomy and appendicitis being 2 big reasons.

Distractor 2 The patient should receive preoperative prophylactic penicillin.

This is a specific post splenectomy recommendation.

Distractor 3 The patient should have received a polyvalent pneumococcal vaccine post splenectomy.

This is a specific post splenectomy recommendation.

Formative QuizQuestion 4 A patient in the preop holding area has a history of

Type 2 Diabetes. He is scheduled for a partial colectomy and his glucose level in preop is 240. How should you proceed?

Correct Answer Start an regular insulin drip and check glucose levels every hour during the surgery.

Of all the options, this one is the best for maintaining tight glucose control.

Distractor 1 Cancel the surgery. The patient’s glucose is not controlled.

The glucose level is high, but not high enough to cancel surgery.

Distractor 2 Proceed with surgery without intervention. The patient hasn’t eaten so the level will decrease on its own.

Glucose levels may actually climb from the stress of having surgery.

Distractor 3 Give a sliding scale dose of lispro insulin and check glucose level in recovery.

This option does not provide enough vigilance and glucose control.

surgery: pre-op evaluation lori meyers, md assistant professor of anesthesiology...

Documents

understanding patients

learning objectivesevaluate

preoperative module

patients general health

learning objectivesdecide

surgical factors

learning objectivesdevelop

common surgical problems