Master the board step 3

Surgery
Preoperative and Postoperative Care
Preoperative Assessment
The most important aspect of preoperative assessment is being able to identify
comorbidities that preclude surgery. Other aspects of preoperative assessment
include understanding the modifications that may need to be instituted
to prepare patients for surgery.
A 42-year-old man with hepatitis C cirrhosis presents with a large umbilical hernia
with intermittent pain. On examination he has large amounts of ascites. Surgical
intervention is being considered. His bilirubin is 3.0, his prothrombin time is 32
seconds, INR 2.2, and his serum albumin is 1.9. Which of the following is the best
next step in management?
a. Proceed to emergency surgery.
b. Proceed with surgery after first giving vitamin K.
c. Proceed with surgery after total parenteral nutrition (TPN).
d. Proceed with surgery after albumin infusion.
e. Do not perform surgery.
Answer: E. Do not do surgery in any patients with multiple derangements in hepatic
risk factors. Any 1 of the hepatic risks alone—bilirubin above 2, albumin below 3, prothrombin
above 16, and encephalopathy (as suggested by altered mental status)—predicts
a mortality of over 40 percent. If 3 of them are present, the risk is 85 percent; all
4 risks constitute almost 100 percent risk of mortality.
A 59-year-old man is scheduled for prostatectomy. He has a history of HTN, COPD,
and diabetes mellitus. He takes atenolol for blood pressure, tiotropium and albuterol
for COPD, and glipizide for diabetes. BP is 145/89 mm Hg, and HgbA1c is
7.1. Recent pulmonary tests document FEV 1 1.3. Blood CO 2 is 47. Which of the following
is this patient most at risk of developing?
a. Intraoperative myocardial infarction
b. Pneumothorax
c. Postoperative pneumonia
d. Hypercapnic failure
Answer: C. Severe COPD (FEV 1 < 1.5 L) increases surgical risk, mainly because patients
have an ineffective cough and cannot clear secretions. They are subsequently at risk for
postoperative pneumonia.
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