6.23.16 - Pre-OP Evaluation

The correct answer is ASA Class II. ASA (American Society of Anesthesiologists) classification is used to assess the overall health status of a patient before surgery. ASA Class II is assigned to patients with mild systemic disease, in this case, exercise-induced asthma. These patients have well-controlled disease and are able to perform daily activities without limitations. They have a low risk of complications during surgery.

Dyspnea on exertion can represent an angina equivalent. This means that experiencing shortness of breath during physical activity can be a symptom of myocardial ischemia, even if the person does not experience chest pain. Angina equivalent refers to symptoms other than chest pain that can indicate a heart condition. In this case, the positive exercise test for myocardial ischemia suggests that the attorney may have a heart condition, despite not having any symptoms.

The patient in this scenario is a 68-year-old man with severe arthritis of both knees who is scheduled to undergo a major hepatic resection. He has no cardiac symptoms and his EKG is normal. Based on this information, it is reasonable to proceed with the hepatectomy without further cardiac evaluation. The absence of cardiac symptoms and normal EKG suggest a low risk for significant cardiac disease. Additional cardiac evaluations such as cardiac catheterization, stress echocardiography, or cardiac imaging with dobutamine or dipyridamole-thallium would not be necessary in this case.

The RCRI (Revised Cardiac Risk Index) is a risk assessment tool used to predict the risk of cardiac complications following non-cardiac surgery. It includes various risk factors such as history of CHF, history of diabetes, and serum creatinine > 2.0 mg/dL. However, a history of COPD on home O2 is not considered a risk factor in the RCRI. This may be because COPD itself is already a risk factor for cardiac complications, and the use of home oxygen therapy may indicate more severe disease but does not add additional risk beyond the presence of COPD.

The patient in this scenario has a growing painful groin bulge, which is likely a hernia. The fact that he had elevated troponins and underwent stent placement in the past suggests that he has coronary artery disease. The medications he is currently taking, including the beta blocker and statin, are important for managing his cardiovascular health. However, the ACE-inhibitor, Plavix, and Aspirin may increase the risk of bleeding during surgery. Therefore, it is recommended to continue the beta blocker and statin for cardiovascular protection, hold the ACE-inhibitor to minimize the risk of hypotension during surgery, continue Aspirin for its antiplatelet effects, and hold Plavix for 5 days pre-operatively to reduce the risk of bleeding.

The 45-year-old man with obesity, type II diabetes, and biopsy-proven non-alcoholic fatty liver disease should receive pre-op PT/INR and PTT before an elective umbilical hernia repair. Non-alcoholic fatty liver disease is associated with impaired liver function and coagulopathy, which can increase the risk of bleeding during surgery. Therefore, it is important to assess the patient's clotting profile before the procedure to ensure safe surgical outcomes.

Patients with severe pulmonary disease often have compromised lung function, making it important to choose an anesthetic technique that minimizes respiratory depression. An anesthetic that produces bronchodilation can help improve airway function and reduce the risk of complications. Epidural analgesia is preferred for post-operative pain control as it avoids the use of systemic opioids, which can depress respiration. Intubating the patient at a deep level of anesthesia ensures a smooth intubation process and reduces the risk of bronchospasm or coughing. Therefore, all of the above choices are appropriate anesthetic techniques for patients with severe pulmonary disease.

Patients with atypical symptoms and borderline positive results on stress tests may still require coronary angiography. This is because these patients have a higher likelihood of having significant coronary artery disease, and angiography can provide more accurate information about the extent of the disease. The presence of risk factors also increases the likelihood of significant disease in these patients. Therefore, arteriography is necessary to confirm the diagnosis and guide further management in these individuals.

Withdrawal of medical therapy with beta blockers can adversely affect the risk of perioperative cardiac complications and re-infarction for this patient. Beta blockers are commonly used in patients with CAD to reduce the risk of cardiac events. Abrupt withdrawal of beta blockers can lead to rebound hypertension, increased heart rate, and increased myocardial oxygen demand, which can increase the risk of perioperative cardiac complications and re-infarction. Therefore, it is important to continue beta blocker therapy perioperatively in patients with CAD.

The correct answer is ASA Class V. ASA classifies the physical status of patients before surgery, with Class V indicating a moribund patient who is not expected to survive without the surgery. In this case, the patient has alcoholic cirrhosis, a history of esophageal variceal bleed, and encephalopathy, indicating severe liver disease and complications. This patient's condition is critical, and without the portal-mesenteric shunt, their survival is unlikely.