Master the board step 3

Master the Boards: USMLE Step 3
The table below summarizes important principles in preoperative assessment.
Organ System Risk Factor Modifications/Interventions
Cardiac risk Ejection fraction < 35% Prohibits noncardiac surgery.
Pulmonary risk
Jugular venous distention (sign of CHF)
Recent myocardial infarction
Severe progressive angina
Hepatic risk Bilirubin > 2.0
Nutritional risk
Smoking (compromised ventilation:
high pCO 2 , FEV 1 < 1.5
Prothrombin time > 16
Serum albumin < 3.0
Encephalopathy
Loss of 20% of body weight over several
months
Serum albumin < 3.0
Anergy to skin antigens
Serum transferrin < 200 mg/dL
Diabetic coma
Optimize medications with ACE inhibitors,
beta blockers, digitalis, and diuretics prior
to surgery.
Defer surgery for 6 months after MI.
Perform cardiac catheterization to evaluate
for possible coronary revascularization.
Order PFTs to evaluate FEV 1 .
If FEV 1 is abnormal, obtain blood gas.
Cessation of smoking for 8 weeks prior to
surgery.
~ 40% mortality with any single risk factor.
~ 80–85% mortality is predictable if 3 or
more risk factors are present.
Provide 5–10 days of nutritional supplements
(preferably via gut) before surgery.
Absolute contraindication to surgery.
First stabilize diabetes. Rehydrate and
normalize acidosis prior to surgery.
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