Surgery risk classes
Correct answer- Class 1: benefits outweigh risk, should
be done Class 2a: reasonable to perform
Class 2b: should be
considered Class 3: rarely
appropriate
General rules for surgery: testing
Correct answer- ECG before surgery only if coronary disease, except when
low risk surgery
Stress test not indicated before surgery
Do not do prophylactic coronary revascularization
Meds before surgery
Correct answer- - Diabetic agents: Use insulin therapy to maintain glycemic
goals(iii) Discontinue biguanides, alpha glucosidase inhibitors,
thiazolidinediones, sulfonylureas, and GLP-1 agonists
- Do not start aspirin before surgery
- Stop Warfarin 5 days before surgery. May be bridged with Lovenox.
- Do not stop statin before surgery
- Do not start beta-blocker on day of surgery, but may continue
Assessment of surgical risk
Correct answer- - Unstable cardiac condition (recent MI, active angina, active
HF, uncontrolled HTN, severe valvular disease), concern with CAD, CHF.
arrhythmia, CVD
- patient stable or unstable?
- urgency of the procedure (oncology will be time sensitive)
- risk of procedure
- nutritional status
- immune competence
- determine functional capacity (need to be more than 4 METS, more
than 10 METs makes low risk)
Low risk surgeries
Correct answer-
catarcts breast
biopsy cystoscopy,
vasectomy
laporascopic
procedures Plastic
surgery
intermediate risk surgeries
Correct answer- Head/ neck surgery
,thyroidectomy
Intraperitoneal
Prostate
Laminectomy
Hip/ knee
Hysterectomy
cholecystecto
my
nephrectomy
non majot intrathoracic
High risk surgeries
Correct answer- aortic/
cabg transplants
spinal reconstruction
peripheral vascular
surgery
Lee's revised cardiac risk
index Correct answer- 6
points:
High risk surgery
= 1 CAD = 1
CHF = 1
Cerebrovascular disease
= 1 DM 1 on insulin = 1
Creat greater than 2 = 1
1 = low risk
2 = moderate risk
3 = high risk
SCIP pre-operative infection measures
Correct answer- - Prophylactic antibiotics should be received within 1 h prior
to surgical incision
- be selected for activity against the most probable antimicrobial
contaminants
- be discontinued within 24 h after the surgery end-time
Postoperative infection reduction
methods Correct answer- - pre-op hair
removal (clippers)
- wash hands
- normothermia
- maintain euglycemia
- urinary catheters are to be removed within the first two postoperative days
Osteoarthritis: what, incidence
Correct answer- Slow destruction of bones/ joint followed by production of
replacement collagen which causes inflammatory changes
,- older than 60
- more female after 55
- more black than white women
- men and women equal risk between 45 - 55
- abnormal height or weight (obesity)
- repetitive movement
- prior trauma (sprains/ dislocations)
- diabetic neuropathy
- genetic
Osteoarthritis findings and diagnostics
Correct answer- - Pain in weight bearing
joints
- stiffness after sitting, gets better when arising
- feeling of instability on stairs
- fine motor skills deficit
- larger affected joints
- Heberden nodules (bony bumps on the finger joint closest to the fingernail)
- Bouchard's nodules (bony bumps on the middle joint of the finger)
- limited ROM with crepitus
- xr shows narrowing of joint space (need anteroposterior and lateral
knee films bilaterally)
- synovial fluid is clear and without WBC
Osteoarthritis treatment
Correct answer- Goal is to relieve symptoms, maintain/ improve function,
and avoid drug toxicity
Hand OA:
- rest/ joint protection, with splinting
- heat/ cold therapy
- topical capsaicin
- topical NSAID (trolamine salicylate) (especially for older than 75)
- Oral NSAIDS, incl COX2 inhibitors such as celecoxib (Celebrex) (may
cause cardiac problems)
- tramadol
- no opioids
, Rheumatoid arthritis: what, who
Correct answer- chronic, systemic autoimmune disease that causes
connective tissue,
inflammation of first that of jionts them other soft tissues (renal,
cardiovascular, pulm).
TNF-alpha plays a big role
- more women than men
- unknown cause
- Epstein Barr virus
Rheumatoid arthritis: Findings and diagnostics
Correct answer- - symmetric joint/ muscle pain, worse in the morning then
gets better
- weakness, fatigue
- anorexia, weight loss
- generalized malaise
- swollen joints/ boggy feeling of joints with deformity of joints
- warm, red skin on affected
joints later:
- pleural effusions and pulmonary nodules
- inflammation of sclerea (scleritis)
- pericarditis, myocarditis
- splenomegaly (Felty's syndrome)
- anemia (hypochromic, microcytic) with low ferritin
- possibly: positive rheumatoid factor
- XR: joint swelling, later cortical and space thinning
- synovial fluid: yellow, thick with elevated WBC up to 100.000
Rheumatoid arthritis treatment
Correct answer- - early treatment better than stepwise
- early referral rheumatologist
- disease-modifying anti-rheumatic drugs (DMARDs):
- methotrexate ( no alcohol, monitor renal and liver, give with folic acid)
- cyclosporine
- Gold preparations (can cause thrombocytopenia)
- Hydroxychloroquine: antimalarial drug (may cause visual changes, monitor)
- sulfasalazine, moderate RA
- Leflunomide, moderate to severe RA
- Etanercept
- monitor liver function with DMARDs
- screen for TB (skin test) and Hep B
- surgery: joint debridement, joint replacement
Gout: what, who
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