Many patients take over-the-counter herbal remedies. In the perioperative period patients should be advised
A. To continue taking their usual herbal remedies
B. Stop only those remedies that have been approved by their physician
C. Continue taking only those remedies that have been approved by the FDA
D. Stop all over-the-counter herbal remedies
D. Stop all over-the-counter herbal remedies. Although the use of herbal medications has been around for many years, none have been approved by the FDA. Many times the pharmacology of these remedies is unknown and the remedies may not contain the correct amounts of active ingredients stated on the label. It is estimated that up to 12% of patients are using these herbal drugs.
Regarding the timing of the preoperative anesthesia workup for patients scheduled for a surgical procedure
A. The initial assessment can be done the day of surgery for healthy patients undergoing procedures of high surgical invasiveness.
B. The initial assessment should be done at a minimum the day before surgery for patients undergoing procedures of high surgical invasiveness.
C. The preoperative assessment for healthy patients by an anesthesiologist is not required.
D. A note from the patient’s primary care physician stating that the patient is “cleared for anesthesia and surgery” will suffice as the preoperative assessment.
B. The initial assessment should be done at a minimum the day before surgery for patients undergoing procedures of high surgical invasiveness. The timing of the preoperative evaluation by an anesthesiologist depends primarily on the planned degree of the surgery. Even healthy patients undergoing a surgical procedure that involves a high degree of surgical invasiveness that may include the risks of a high volume of blood loss, prolonged surgical time, special positioning requirements, etc, should be seen at least a day before the planned procedure. Patients with significant comorbidities should be seen in a PAC at least the day before surgery no matter the degree of surgical invasiveness as it is necessary to ascertain the degree of control of the comorbidities.
Regarding patients who have had a recent drug-eluting stent placed and scheduled for an elective surgical procedure with a high risk of bleeding
A. Surgery may be performed within 4 weeks of stent placement as long as the patient continues taking aspirin and clopidogrel.
B. Surgery may be performed within 4 weeks of stent placement with the patient stopping the clopidogrel and continuing on low-dose aspirin.
C. Should have the surgical procedure delayed until the procedure can be performed with the patient only taking low-dose aspirin.
D. Surgery should be delayed for up to 1 year.
D. Surgery should be delayed for up to 1 year. The risk of stent thrombosis makes it necessary to place patients who have had a drug-eluting stent placed on antiplatelet agents such as clopidogrel and aspirin. Stopping these drugs prematurely to allow for the performance of an elective surgical procedure requires careful consideration of the risk of bleeding as well as the risk of stent thrombosis if the antiplatelet agents are both stopped. At a minimum aspirin should be continued. Emergent procedures that involve a high risk of bleeding require that the clopidogrel be stopped, but continuing the low-dose aspirin is recommended.
Strategies to prevent intraoperative awareness include
A. Strict monitoring of intraoperative vital signs by the anesthesiologist will always detect intraoperative awareness
B. Informing patients during the preoperative workup of the possibility of awareness
C. Monitoring brain electrical activity with the BIS monitor
D. None of the above. There is no way to be 100% of preventing intraoperative awareness. Anesthesiologists performing strict equipment check before beginning an anesthetic to ensure that vaporizers have sufficient agent levels, that there is an agent concentration monitor as part of the anesthesia monitoring system, and frequent observation that IV lines are patent and intact when intravenous medications are used is one way to eliminate the preventable components. Stable vital signs throughout a case are not always a reliable sign that a patient may not suffer from intraoperative awareness. Finally the processed EEG BIS monitor has been shown to be no more effective in preventing awareness than careful monitoring of end-tidal agent concentration.
The preoperative assessment by an anesthesiologist includes an assessment of a patient’s risk for an intraoperative cardiac event. The RCRI factors include all of the following except
A. A history of ischemic heart disease
C. Obesity. The RCRI factors of (1) ischemic heart disease, (2) heart failure, (3) high-risk surgery, (4) diabetes mellitus, (5) renal insufficiency, and (6) cerebral vascular diseases are a validated set of independent predictors of cardiac risk for patients. There RCRIs were derived from a single-center prospective group of patients undergoing elective major noncardiac surgery. The anesthesiologist in a pre-op clinic will screen for these factors and recommend further studies based on the presence or absence of RCRIs. Patients with no RCRIs had a very low (0.4%) cardiac risk while patients with three or more risk factors have a 5.4% risk of an adverse cardiac event and warrant further testing or optimization of the factor(s).