How long does a patient need to wait after revascularization to undergo elective non cardiac surgery? Should antiplatelet therapy be discontinued?
If the elective procedure involves risk of bleeding, it should be deferred until an appropriate course of thienopyridine therapy has been completed – 12 mo. After placement of drug eluting stent and 1 mo. After placement of a bare metal stent. Antiplatelet therapy should not be discontinued without consultation with a cardiologist. continue ASA if possible & restart clopidogrel ASAP
When should surgery be delayed due to elevated blood pressure? What is severe hypertension? What is the preoperative goal for hypertensive patients?
Surgery should be delayed for patients with pressures above 200/115 until BP is below 180/110. If significant end-organ damage is present or intraoperative hypotensive techniques are planned, blood pressure should be restored to as close to normal as possible before surgery. Note that mild hypertension with BP > 180/110 is not associated with increased perioperative cardiac risk.
What impact does OSA have for anesthesia? What are the American Society of Anesthesiologists’ (ASA) published recommendations for perioperative care of patients with OSA?
Ventilation of patients with OSA is more difficult. They are more likely to have perioperative airway obstruction, hypoxemia, atelectasis, ischemia, pneumonia and prolonged hospitalizations. ASA recommendations for perioperative care of OSA patients include preoperative diagnosis and treatment and appropriateness of ambulatory surgery.
How does the patient’s do not resuscitate (DNR) status transfer from the hospital ward to the operating room?
DNR status for anesthesia and operations should be discussed with the patient
regardless of their DNR status on the wards.
Should beta-blockers and ace inhibitors be continued perioperatively? How long should anticoagulants be held prior to surgery? What are the recommendations for the management of diabetic medications perioperatively?
Generally speaking, beta blockers and ACE inhibitors should be continued
preoperatively. Vasopressin should be available however for hypotension
Ace inhibitors: Generally continue (may consider discontinuing if surgery necessitates significant blood loss/if BP is well controlled/if pt is on multiple HTN medications)
Anticoagulants: Dependent on risk (of bleeding during surgery)
Aspirin: 6 days (for high risk of bleeding surgery)
Low Molecular Weight Heparin: 12-24 hours
Warfarin: 5 days
Other NSAIDS: 1-4 days
Diabetes: Both type 1 and 2 pts should discontinue short-acting insulin
Type 1: Take 1/2-1/3 of usual intermittent/long acting insulin the morning of surgery
Type 2: Take none-1/2 of usual intermittent/long acting insulin the morning of surgery
Metformin should be held on the day of surgery; but even if it’s taken, it won’t cause hypoglycemia