Pre-Operative Management

Preoperative Testing Guidelines

ASA Physcial Status Classification

Cardiac Disease

• Pre-op tests: BUN/Cr, CXR(PA/Lat), EKG
• Increased risk of peri-operative mortality and morbidity.
• EKG abnormalities should be evaluated by internist or cardiologist. Even minor abnomalities are independent associated with increased risk of cardiac event/mortality especially in post-menopausal women.
• Left-Ventricular ejection faction <35% = increased cardiac complications
• See Washington Manualfor full pre-op cardiac recommendations.
• Pre-op Cardiac Cath recommended for: unstable CAD, uncompensated CHF, symptomatic arryhthias, high-grade AV-block, significant valvular disease.
• Intermittent Risk factors without functional limitations (stable angina, prior MI, compensated CHF, diabetes, chronic renal failure): little cardiac risk for surgery.
• Intermittent Risk factorw with funtional limitations: Cardiology clearance before surgery.

Hemophilia

• knee is most common location for spontaneous bleeding in children
• Generally treated with factor VIII administration until patient reaches 40-50% of normal.
• Plasma level rises 2% for every unit (per kg body weight) of factor VIII administered
• Pre-op levels should be 100% of normal

Smoking

• Increased risk of pulmonary complications with surgery.
• Smoking should stop at least 8 weeks prior to elective surgery.

Renal Disease

• Pre-op tests: CBC, PT, PTT , lytes, BUN/Cr, EKG
• Increased risk of peri-operative mortality and morbidity.
• Risks of electrolyte abnormalties, anemia, coagulopathy, increased medication excretion times, Uremia-induced platelet dysfunction (bleeding time should be <10 minutes prior to surgery).
• Potossium should by <5.5mmol/L prior to surgery.
• Hematocrit >20% prior to surgery.
• Patients on dialysis should undergo dialysis the day prior to surgery.

Hepatic Disease

• Pre-op tests: CBC, PT, PTT, EKG, SGOT, ALK Phos
• Increased risk of peri-operative mortality and morbidity.
• May need vit K and FFP replacement for Vit-K deficient coagulopathy.
• Child-Turcotte-Pugh Scale

Perioperative Antibiotics

• Cefazolin 1-2g IVPB or Cefuroxime 1.5g IVPB.
• For MRSA colinization / high MRSA rate institutions or PCN allergic patients: Vancomycin 1g IVPB. Consider intranasal mupirocin ointment.
• IV antibiotics started withing 1 hour of surgical incision and completed before tourniquet is inflated.
• For obese patients antibiotic dose should be increased appropriately (Ancef 2g IVPN OCTOR). (Forse A, Surgery 1989;106:750).
• Prophylactic antibiotics shouldbe discontinued within 24 hours of the end of surgery.
• Open fracture Prophylactic antibiotic recommendations.
• AAOS Advisory Statement. 
• AAFP Guidelines.

Perioperative Medications

• NSAIDs, aspirin(325mg) and clopidogrel should be stopped one week before surgery. (Aspirin 7 days, ibuprofen 2days, indomethacin 2 days, naproxen 7 days, piroxicam 7 days). Low dose aspirin (81mg) may be taken as usual including day of surgery.
• Herbal medicines (echinacea, ephedra, garlic, ginkgo, ginseng, kava, St. Johns Wort, valerian) should be stopped one week before surgery. (Ang-Lee MK, JAMA 2001;286:208). ASAHQ Patient information.
• Cardiac, HTN, pulmonary, psychiatric medications: in general should be continued until surgery and taken with a small sip of water on the day of surgery.
• Corticosteroids: patients taking long term (prednisone 5mg QD) or short term high dose (prednison 20mg QD) should be given Hydrocortisone 25 to 100mg at the time of minor surgery and resume previous dose postoperatively. For major surgery Hydrocortisone 100mg Q8hours x 24 hours, resume previous dose postoperatively.
• Glucosamine/Chondroitin should be discontinued 2 weeks prior to surgery.
• Methotrexate: may be continued in perioperative period. (Grennan D, Ann Rheum Dis 2001;60:214). Discontinue for 1 week before and after surgery for patients with poor renal function, poor oral intake, alcholosim, pulmonary disease, diabetes, hepatic disease.
• TNF inhibitors: should be stopped 5 half-lives before surgery and restarted 2 weeks after surgery provided incision is well healed and there have been no surgical complications.
  -Embrel: stop 2 weeks before surgery
  -Humira: stop 4 weeks before surgery
  -Remicade: stop 8 weeks before surgery
• Diuretics (HCTZ, lasix, butmetanide, chlorthalidone, metolazone, spironolactone): stop day of surgery
• Insulin: skip the last dose of insulin prior to surgery including the night before if that is the last dose. Bring insulin to hospital. Finger stick ordered DOS.
• Hypoglycemics (glipizide, glyburide, metformin, actos, amaryl, diabeta): stop all hypoglycemics DOS. Order finger stick DOS.
• Pavix (clopidogrel): stop 7 days prior to surgery.
• Ticlid (ticlopidine): stop 10-14 days prior to sugery.
• Corticosteriods (prednisone): continue
• Lipid-lowering drugs (gemfibrozil, atorvastatin, lovastatin, lipitor, Mevacor, niacin, cholestyramine): controversial. Discontinuation may increase risk of cardiac events. Continueing may be associated with postoperative rhabdomyolysis.
• Antiepileptics: continue
• Antiparkinsons (Sinement): continue
• Antidepressants: continue tricyclics and serotonin reuptake inhibitors. Discontinue monoamine oxidase inhibitors (Nardil, Parnate, phenelzine, tranylcypromine) 14 days prior to surgery.
• Antipsychotics: continue
• Benzodiazepines: continue
• Lithium: continue, consider monitoring levels.
• Myasthenia gravis (pyridostigmine, neostigmine): continue
• Theophylline (Theodur, Uniphyl): continue
• Inhalers (albuteral, atrovent, inhaled steroids): continue

Pre-operative Screening

• Preoperative screening for Staphyloccus aureus carriage
• Methicillin-sensitive or methicillin-resistant carriers prescribed intranasal mupirocin for 5-7 days prior to surgery.
• If MRSA carrier, vancomycin used as perioperative prophylactic antibiotic
• Urine cultures performied prior to surgery: treat with antibiotics if positive (generally bactrim DS, 1 tab PO BID
• Advise to bathe or shower with chlorhexidine-based soap (hibiclens) the day prior to surgery

Factor V Leiden

• Abnormality in Factor V due to a single amino acid substitution of glutamine for arginine in the protein D clevage region leading to decreased inactivation of factor V
• Increased risk of DVT/PE
• >50% of patients with Factor V Leiden will develop DVT with the addition of a single risk factor (long bone fracture, joint replacement).