To do or not to do
A healthy, asymptomatic patient is scheduled for a low-risk procedure. The surgeon asks for a routine preoperative ECG “just to be safe.” To do or not to do?
What is DON’T DO IT?
A patient with a severe allergy to this food needs an iodinated-contrast study. Many people think premedication is indicated due to cross-reactivity but this is a myth.
What is shellfish allergy?
Shellfish allergy is caused by tropomyosin, not iodine, and does not predict an iodinated-contrast reaction.
During a multilevel spine case, major blood loss is expected. According to AABB guidance, reaching this percentage of the patient’s estimated blood volume is an indication to consider cell salvage.
What is ≥20% of estimated blood volume?
Your robotic pelvic case is in steep Trendelenburg with pneumoperitoneum. Peak airway pressures are rising and compliance is worsening. According to the presentation, switching to this ventilation mode can lower peak airway pressures, improve compliance, and improve CO₂ clearance.
What is pressure-controlled ventilation?
This medical condition is considered an independent risk factor for difficult intubation, difficult mask ventilation, or both. Adequate difficult airway management precautions should be taken.
What is OSA?
Before a planned spinal, your patient reports recurrent unexplained bruising and prolonged bleeding after a dental extraction. This structured preoperative questionnaire helps determine whether the bleeding history warrants further investigation.
What is HEMSTOP?
HEMSTOP screens for features such as unusual/prolonged bleeding, spontaneous large bruises, excessive bleeding after dental extraction or surgery, family history of coagulation disease, heavy menstrual bleeding, and excessive postpartum bleeding. A score <2 indicates low risk, while ≥2 indicates increased risk of a bleeding disorder.
A patient requires time-sensitive noncardiac surgery 6 weeks after PCI. Because surgery cannot be delayed, the team plans to interrupt DAPT. This type of coronary stent keeps the patient within the period where continuation of DAPT is still recommended when feasible.
What is DES?
30-day threshold applies to BMS, whereas the relevant period after DES is 3 months.
During massive hemorrhage, cell-saver blood is being rapidly reinfused. Unlike allogeneic packed RBCs, the salvaged product contains essentially RBCs suspended in saline, so large-volume replacement can leave the patient deficient in these hemostatic components.
What are platelets and coagulation factors?
Steep Trendelenburg combined with CO₂ pneumoperitoneum increases this pressure, which can be indirectly assessed by measuring optic nerve sheath diameter.
What is intracranial pressure (ICP)?
During controlled ventilation of a COPD patient, expiratory flow does not return to baseline before the next breath and airway pressures progressively rise. This complication of inadequate expiratory time is developing.
What is auto-PEEP?
A patient undergoing elevated-risk noncardiac surgery has poor functional capacity and elevated predicted perioperative cardiovascular risk. You consider this test for inducible myocardial ischemia before surgery.
What is stress testing?
Stress testing may be considered when poor/unknown functional capacity and elevated perioperative risk coexist.
Despite the common tendency to adjust every DOAC interruption according to creatinine clearance, this factor Xa inhibitor’s general surgical interruption schedule in the presented pathway is based primarily on procedural bleeding risk rather than CrCl.
What is apixaban?
Apixaban and rivaroxaban have a fixed interruption based mainly on procedural bleeding risk: 1 full day for low/moderate bleeding-risk surgery and 2 full days for high-risk surgery.
Dabigatran perioperative interruption is strongly influenced by renal function, requires a longer interruption when CrCl <50 mL/min because of its greater dependence on renal elimination.
A patient with a previous immediate allergic-like reaction to iodinated contrast is scheduled for an elective contrast-dependent procedure tomorrow. Contrast cannot be avoided. This premedication regimen should be given before re-exposure.
What are prednisone + diphenhydramine?
Prednisone 50 mg PO at 13 hours, 7 hours, and 1 hour before contrast administration + diphenhydramine 50 mg PO 1 hour before contrast.
When comparing robotic with conventional laparoscopic abdominal surgery, this factor—not the robotic approach itself—emerged as the major determinant of postoperative pulmonary complications.
What is prolonged surgical/operative time?
A 55-year-old man has hypertension, BMI 37 kg/m² and a neck circumference of 42 cm, but denies snoring, daytime tiredness or witnessed apnea. Based on his STOP-BANG score, he falls into this OSA risk category.
What is intermediate risk?
A parturient with thrombocytopenia is being considered for spinal anesthesia. In the absence of other bleeding risk factors, SOAP considers the risk of spinal/epidural hematoma likely very low at or above this platelet count.
What is 70,000/µL?
A patient taking rivaroxaban needs urgent surgery. PT, INR, and aPTT are all normal. Despite these reassuring results, you cannot exclude a clinically relevant anticoagulant effect. This is the preferred assay when available.
What is drug-calibrated anti-Xa?
Routine PT/aPTT can remain normal despite clinically relevant apixaban or rivaroxaban levels, so they cannot reliably clear the patient for surgery.
During CO₂ insufflation in robotic surgery, your patient suddenly develops a sharp fall in EtCO₂, hypoxemia, and hemodynamic collapse. Identify the complication and give all four immediate management steps, in order.
What is venous CO₂ gas embolism?
A high-BMI patient is scheduled for a robotic procedure expected to last >4 hours. Besides worsening ventilatory mechanics, this combination specifically increases the risk of this position-related extremity complication.
What is well-leg compartment syndrome?
Explanation: The presentation identifies high BMI, large calf circumference, and case duration >4 hours as risk factors for well-leg compartment syndrome. Preventive measures include minimizing lithotomy time, improved leg supports, and intraoperative lower-limb pressure monitoring.
After intubating a patient with severe COPD, you want to minimize dynamic hyperinflation and auto-PEEP. Your ventilator strategy should prioritize this I:E ratio to provide adequate expiratory time.
What is 1:3–1:4?
Three patients are awaiting elective noncardiac surgery: one has ACS, one has chronic coronary disease with ≥50% left-main stenosis, and one has non-left-main CAD. Which two warrant coronary revascularization before surgery, with deferral of the elective operation?
What are ACS and ≥50% left-main stenosis?
Two patients taking dabigatran are scheduled for the same high-bleeding-risk surgery. Both took their last dose at the same time, but one has a CrCl of 35 mL/min. This patient's interruption must be extended to approximately this duration.
What are 4 days?
Dabigatran perioperative interruption is strongly influenced by renal function, requires a longer interruption when CrCl <50 mL/min because of its greater dependence on renal elimination.
Apixaban and rivaroxaban have a fixed interruption based mainly on procedural bleeding risk: 1 full day for low/moderate bleeding-risk surgery and 2 full days for high-risk surgery. =
A patient with a previous immediate allergic reaction to iodinated contrast needs an urgent contrast-dependent procedure in 5 hours. Oral premedication cannot be completed. This IV prophylactic regimen should be given (including doses and timing)
What are hydrocortisone + diphenhydramine?
Give hydrocortisone 200 mg IV at 5 hours and 1 hour before contrast, plus diphenhydramine 50 mg IV 1 hour before contrast.
An alternative is methylprednisolone 40 mg IV at 5 hours and 1 hour before contrast
Despite being minimally invasive, robotic surgery should not lead you to underestimate this postoperative requirement. It may be greater than expected.
What is postoperative analgesia?
Minimally invasive access DOES NOT MEAN minimal analgesic requirement
A mechanically ventilated COPD patient suddenly becomes profoundly hypotensive. Breath stacking and dynamic hyperinflation are suspected. This immediate maneuver can both diagnose the problem and rapidly improve venous return.
What is ventilator disconnection?
Hypotension on the ventilator? Disconnect and reassess. This allows trapped gas to escape when dynamic hyperinflation is producing hemodynamic compromise.