Perioperative assessment - Revision history

Aidan at 18:21, 27 February 2022

2022-02-27T18:21:23Z

← Older revision		Revision as of 18:21, 27 February 2022
Line 17:		Line 17:
	** Continue β-blockers		** Continue β-blockers
	** Hold non-essential		** Hold non-essential
			**See [[perioperative medication management]] for details
	* '''Stress dose steroids'''		* '''Stress dose steroids'''
	** <5 mg/d: continue home dose		** <5 mg/d: continue home dose

Aidan at 18:20, 27 February 2022

2022-02-27T18:20:43Z

← Older revision		Revision as of 18:20, 27 February 2022
Line 27:		Line 27:
	** For [[T1DM]], or for [[T2DM]] with OR >3 hours, consider IV insulin		** For [[T1DM]], or for [[T2DM]] with OR >3 hours, consider IV insulin
	** For [[CABG]], do IV insulin		** For [[CABG]], do IV insulin
			** Insulin dose:
	** ~~Insulin dose: take~~ 1/2 home dose of long-acting the night before, and monitor blood sugars regularly with prn rapid-acting		***Take 1/2 home dose of long-acting the night before, and monitor blood sugars regularly with prn rapid-acting
			***See [[perioperative insulin management]] for details
	* '''Delirium'''		* '''Delirium'''
	** Prevention (non-pharm and pharm)		** Prevention (non-pharm and pharm)

Aidan at 19:45, 15 October 2021

2021-10-15T19:45:40Z

← Older revision		Revision as of 19:45, 15 October 2021
Line 1:		Line 1:
	== ~~Mnemonic: RAMS IDLE C~~ ==		== Background ==

			* The complexity of surgical patients is increasing
			* Risks of surgery include bleeding, sepsis, and myocardial injury, all three of which have a risk of death
			** Risks increase with age, and are highest with thoracic surgery, followed by vascular surgery, neurosurgery, and general surgery
			* Purpose is to assess and communicate perioperative risk and to attempt to decrease that risk as much as possible

			== Mnemonic: RAMS IDLE C ==
	* '''Risk assessment'''		* '''Risk assessment'''
	** RCRI: 4C's HD: CAD, CHF, CVD, ~~creat~~>176, high-risk OR, diabetes on insulin		** [[RCRI]] (4C's HD): CAD, CHF, CVD, creatinine>176, high-risk OR, diabetes on insulin
	** Surgical risk: high (>5%) for aortic and peripheral vascular OR, intermediate (1-5%) for ortho, HEENT, prostate, low risk (<1%) for endoscopy, breast, dental		** Surgical risk: high (>5%) for aortic and peripheral vascular OR, intermediate (1-5%) for ortho, HEENT, prostate, low risk (<1%) for endoscopy, breast, dental
	* '''Anticoagulation'''		* '''Anticoagulation'''
	** ~~ASA~~: indication?; stop 7 days preop, restart 1-2 days postop		** Aspirin: assess indication; stop 7 days preop, restart 1-2 days postop
	*** Unless recent stenting		*** Unless recent stenting
			**Assess need for bridging anticoagulation
	** Bridge?
	* '''Medication management'''		* '''Medication management'''
	** Continue ~~beta~~-blockers		** Continue β-blockers
	** Hold non-essential		** Hold non-essential
	* '''Stress dose steroids'''		* '''Stress dose steroids'''
Line 19:		Line 25:
	** > 20 mg/d: same as above		** > 20 mg/d: same as above
	* '''Insulin'''		* '''Insulin'''
	** For T1DM, or for T2DM with OR >3 hours, consider IV insulin		** For [[T1DM]], or for [[T2DM]] with OR >3 hours, consider IV insulin
	** For CABG, do IV insulin		** For [[CABG]], do IV insulin
	** Insulin dose: take 1/2 home dose of long-acting the night before, and monitor blood sugars regularly with prn rapid-acting		** Insulin dose: take 1/2 home dose of long-acting the night before, and monitor blood sugars regularly with prn rapid-acting
	* '''Delirium'''		* '''Delirium'''
Line 26:		Line 32:
	** Counselling		** Counselling
	* '''Lungs''' (Pulmonary)		* '''Lungs''' (Pulmonary)
	** OSA: STOP-BANG		** [[OSA]]: STOP-BANG
	** Surgical site: closer to the diaphragm is riskier		** Surgical site: closer to the diaphragm is riskier
	** Smoking cessation, ideally 4 weeks before		** Smoking cessation, ideally 4 weeks before
Line 32:		Line 38:
	** Consider need for preop CXR or PFTs		** Consider need for preop CXR or PFTs
	* '''Endocarditis prophylaxis'''		* '''Endocarditis prophylaxis'''
	** High risk patient (prior IE, transplant with ~~valve~~ dz, CHD, prosthetic material), AND		** High risk patient (prior [[endocarditis]], transplant with valvular disease, CHD, prosthetic material), AND
	** High risk procedure (dental manipulation, incision of respiratory tissue)		** High risk procedure (dental manipulation, incision of respiratory tissue)
	* '''Consults'''		* '''Consults'''
	** Rheumatology: for RA or APLA		** Rheumatology: for [[rheumatoid arthritis]] or [[APLA]]
	** Cardiology: if ischemic chest pain		** Cardiology: if ischemic chest pain
	** Anesthesia: if AS murmur or other high risk		** Anesthesia: if AS murmur or other high risk
	** Endocrinology: T1DM needing IV insulin		** Endocrinology: [[T1DM]] needing IV insulin

			== Risk Assessment ==

			* Calculators
			** See http://perioperativerisk.com/
			** For geriatrics, consider the [https://qxmd.com/calculate/calculator_448/geriatric-sensitive-perioperative-cardiac-risk-index-gscri GSCRI]

			=== Cardiovascular Risk Assessment ===

			* [https://www.mdcalc.com/revised-cardiac-risk-index-pre-operative-risk RCRI]: ischemic heart disease, CHF, stroke/TIA, insulin, creat>177, high risk surgery

			{\| class="wikitable"
			!RCRI
			!Risk of major cardiovasular event
			\|-
			\|0
			\|4%
			\|-
			\|1
			\|6%
			\|-
			\|2
			\|10%
			\|-
			\|≥3
			\|15%
			\|}

			* BNP
			** Routine screening should be done for patients with RCRI ≥1, age ≥65 years, age 45-64 years with significant cardiovascular disease
			** Considered elevated if preoperative NT-proBNP ≥300 ng/L or BNP ≥92 mg/L
			** For these high-risk patients, follow [[troponin]] and [[ECG]] daily after surgery, with for 48 to 72 hours or until peak

			=== Delirium Risk Assessment ===

			* Age ≥70, alcohol abuse, TICS score <30, SAS class IV, markedly abnormal preoperative sodium, potassium, or glucose, aortic aneurysm surgery (2 points), and noncardiac thoracic surgery
			* See the Best Practices Guideline from the ACS NSQIP and American Geriatrics Society 2012

	[[Category:Perioperative medicine]]		[[Category:Perioperative medicine]]

Maintenance script: Imported from text file

2020-07-04T01:17:49Z

Imported from text file

New page

== Mnemonic: RAMS IDLE C ==

* '''Risk assessment'''
** RCRI: 4C's HD: CAD, CHF, CVD, creat>176, high-risk OR, diabetes on insulin
** Surgical risk: high (>5%) for aortic and peripheral vascular OR, intermediate (1-5%) for ortho, HEENT, prostate, low risk (<1%) for endoscopy, breast, dental
* '''Anticoagulation'''
** ASA: indication?; stop 7 days preop, restart 1-2 days postop
*** Unless recent stenting
** Bridge?
* '''Medication management'''
** Continue beta-blockers
** Hold non-essential
* '''Stress dose steroids'''
** <5 mg/d: continue home dose
** 5-20 mg/d
*** Minor: double home dose for morning of OR
*** Moderate: 50 mg IV on call to OR, then 25 mg IV TID for 1-2 days
*** Major: 100 mg IV on call or OR, then 50 mg IV TID for 1 day, then 25 mg IV TID for 1 day
** > 20 mg/d: same as above
* '''Insulin'''
** For T1DM, or for T2DM with OR >3 hours, consider IV insulin
** For CABG, do IV insulin
** Insulin dose: take 1/2 home dose of long-acting the night before, and monitor blood sugars regularly with prn rapid-acting
* '''Delirium'''
** Prevention (non-pharm and pharm)
** Counselling
* '''Lungs''' (Pulmonary)
** OSA: STOP-BANG
** Surgical site: closer to the diaphragm is riskier
** Smoking cessation, ideally 4 weeks before
** Incentive spirometry postop
** Consider need for preop CXR or PFTs
* '''Endocarditis prophylaxis'''
** High risk patient (prior IE, transplant with valve dz, CHD, prosthetic material), AND
** High risk procedure (dental manipulation, incision of respiratory tissue)
* '''Consults'''
** Rheumatology: for RA or APLA
** Cardiology: if ischemic chest pain
** Anesthesia: if AS murmur or other high risk
** Endocrinology: T1DM needing IV insulin

[[Category:Perioperative medicine]]