Surgical Procedures and Anesthetic Implications - The Ultimate Resource for Anesthesia Practice, 2nd Ed.

*Dosing and re-dosing guidelines – follow your institutions guidelines.

Normal CrCl: women: 88-128 mL/min; men: 97-137 mL/min.

Initial dose: 1-2 g IV

If Creatinine clearance (CrCl) normal, redose in: 2 hours

CrCl < 50 mL/min: 12 hours

CrCl < 10 mL/min: no re-dose

Ampicillin/Sulbactam (Unasyn)

Initial dose: 3 g IV

If Creatinine clearance (CrCl) normal, redose in: 2 hours

CrCl < 50 mL/min: 12 hours

CrCl < 10 mL/min: no re-dose

Cefazolin (Ancef, Kefzol)

Initial dose: 2 g IV; 3 g IV if patient> 120 kg

If Creatinine clearance (CrCl) normal, redose in: 4 hours

CrCl < 50 mL/min: 12 hours

CrCl < 10 mL/min: no re-dose

Cefuroxime (Ceftin, Zinacef)

Initial dose: 1.5 g IV

If Creatinine clearance (CrCl) normal, redose in: 4 hours

CrCl < 50 mL/min: 12 hours

CrCl < 10 mL/min: no re-dose

Clindamycin (Cleocin)

Initial dose: 900 mg IV

If Creatinine clearance (CrCl) normal, redose in: 6 hours

CrCl < 50 mL/min: 8 hours

CrCl < 10 mL/min: 8 hours

Ertapenem (Invanz)

Initial dose: 1 g IV; no re-dose

Gentamicin (Garamycin)

Initial dose: 5 mg/kg IV adjusted body weight

If Creatinine clearance (CrCl) normal, redose in: 8 hours

CrCl < 50 mL/min: 12 hours

CrCl < 30 mL/min: 24 hours

Initial dose: 1.5 mg/kg adjusted body weight

If Creatinine clearance (CrCl) normal, redose in: 8 hours

CrCl < 50 mL/min: 12 hours

CrCl < 30 mL/min: 24 hours

Levofloxacin (Levaquin)

Initial dose: 500 mg IV; no re-dose

Metronidazole (Flagyl)

Initial dose: 500 mg IV; no re-dose

Vancomycin (Vancocin)

Initial dose: 15 mg/kg IV, max 2 g

If Creatinine clearance (CrCl) normal, redose in: 12 hours

CrCl < 50 mL/min: no re-dose

CrCl < 10 mL/min: no re-dose

Screening tests are not commonly performed preoperatively without, at least, some criteria based on the age, gender, medical/surgical history, likelihood of pregnancy, the reliability of the patient, type of surgery, and planned anesthetic.

•For example: older or less reliable patients may be more likely to have an unsuspected abnormality picked up by a “screening” test and may need more extensive testing than would otherwise be indicated.

•The surgical procedure. Major procedures are associated with significant physiologic stress. Existing medical conditions which may be of little concern during a brief and minor procedure may cause problems during (and after) a long and complex surgery. Testing should reflect this need for an increased level of preparedness and monitoring.

•The type of anesthesia. For some procedures done without general anesthesia, fewer tests may be needed. However, it should be considered that conversion to a general anesthetic may occur due to unforeseen circumstances.

To be useful, the preoperative test result should give information to the caregiver that affects how the anesthesia is given or an idea of the perioperative risk if the result is abnormal.

**Some labs, usually a hematocrit, are needed before any surgery but more may be needed. Use institutional guidelines and good judgment. Specifically, listed laboratory or preoperative testing with the surgeries in this book are suggestions; more or fewer tests may be needed for a particular patient.

An HCG pregnancy test should be done preoperatively, either on blood or urine, on a woman of child-bearing age. It may not be done if the patient states that “it is not possible to be pregnant” and surgeon does not want test done, chart all conversations.

•CXR within 1 year; if it was normal or showed a stable condition and if there has been no intervening clinical event.

•EKG within 6 months; if it was normal or showed a stable condition and if there has been no intervening clinical event.

•Blood tests within 30 days; if it was normal or showed a stable condition and if there has been no intervening clinical event.

•Echocardiogram within one year if they have cardiac valve disease.

Most medications are held before sugery though there are some the patient should take the morning of surgery with small sips of water (unless otherwise instructed):

•Antihypertensive medications

•Statins

•Medications for asthma or emphysema

•Antiseizure medications

•Cardiac medications

•Anti-reflux (GERD) medications

Medications patient should NOT take the morning of surgery (unless otherwise instructed):

•Oral hypoglycemic agents

Medications patient should take HALF of the normal dose the morning of surgery: (unless otherwise instructed):

•Subcutaneous injected insulin

The ACC/AHA guidelines recommend a step-wise approach to the preanesthetic evaluation in patients with a cardiac history that present for non-cardiac surgery. The risk index outlines the risk of developing major adverse cardiac events during non-cardiac surgery. An increasing number of these risk factors correlates with an increased risk of major cardiac complications. These risk factors include not only medical conditions; they also include the type of surgical risk. Medical conditions: having 2 or more risk factors places patient at high risk for adverse perioperative cardiac events: ischemic heart disease, congestive heart failure (CHF), cerebral vascular disease, or chronic renal failure with creatinine > 2.0 mg/dL/176.8 micromoles/liter.

Surgical risk in non-cardiac surgery are now divided into two categories: low and high-risk procedures. Having one or more risk factors places the patient at high risk for adverse perioperative cardiac events with high-risk surgery.

High-risk surgeries are surgeries that take place in:

•Intraperitoneal

•Intrathoracic

•Supra-inguinal vascular

Low-risk surgeries include all procedures not included in high-risk procedures such as ophthalmologic surgery.

Risk for cardiac death, nonfatal myocardial infarction, and nonfatal cardiac arrest: 0 predictors – 0.4%, 1 predictor = 0.9%, 2 predictors = 6.6%, > 3 predictors = > 11%.

MET Score - indicates metabolic equivalent and exercise tolerance – a MET is the ratio of the rate of energy expended during an activity to the rate of energy expended at rest. 1 MET is the ratio of energy expenditure while at rest. 4 METS is an activity that expends 4 times the energy used by the body at rest. Metabolic equivalent helps to assess the level of functional capacity and is a predictor of perioperative cardiac adverse events. A person who can walk up a flight of stairs without getting short of breath can reasonably proceed for surgery.

•At least 2 months should elapse following MI before noncardiac surgery.

•At least 14 days should elapse following balloon angioplasty.

•At least 4 weeks should elapse following a percutaneous coronary intervention.

•At least 1 month should elapse following placement of a bare metal stent.

•At least 3 months should elapse following placement of a newer generation drug eluding stent, though optimally the wait should be six months.

•Severe aortic or mitral stenosis is considered an acceptable contraindication to...