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  • Questions and Answers

  • The questions and answers below are meant to be general guidelines. Medicine is an art and specific patients may fall outside of the realm of generalities.


    What are the NPO guidelines?

    Aspiration is a serious complication that can occur on induction of anesthesia. Even when regional or "MAC" anesthesia is planned, there is always the possibility that general anesthesia will be required. When a surgical procedure is emergent and cannot be delayed to allow gastric emptying, this must be documented in the chart. In these cases the risk of aspiration is outweighed by the risk of delaying surgery.

    For all other cases the guidelines are as follows:

    • Solid foods > 8 hours
    • Clear liquids > 2 hours

    Diabetics may use apple juice or ginger ale to treat hypoglycemia.

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    What medications must patients take on the morning of surgery?

    Patients should take the following on the morning of surgery:

    • Anit-anginals
    • Anti-hypertensives
    • H2 blockers or PPIs
    • Bronchodilators
    • Long acting insulins (Lantus, Ultralente)
    • ½ of intermediate acting insulins (NPH)

    Patients should not take the following on the morning of surgery:

    • Oral glucose agents (sulfonureas or metformin)
    • Short acting insulins (regular or humalog)

    Case by case decisions include:

    • Antiplatelet drugs (plavix, ticlid, aspirin, NSAIDs)
    • Anticoagulants (Heparin, LMWH, Coumadin, fundaparinux)

    * Patients on Plavix are not eligible for neuraxial anesthesia (epidural or spinal) for ten days after the last dose. Patients on LMWHs are not eligible for 24 hours after their last dose. Patients on ASA or NSAIDs are generally eligible for a neuraxial anesthetic without holding the medication.

    For more information on anticoagulants and neuraxial anesthesia visit www.asra.com/consensus-statements/2.htm and refer to the society consensus statement.

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    What should you know about preoperative laboratory and ECG guidelines?

    Multiple studies have suggested that healthy patients do not need to have routine laboratory studies prior to surgery unless a history or physical exam findings of co-morbidity indicate a need for such studies. Unneeded studies may actually be detrimental for the following reasons.

    • False positives may lead to unnecessary workup with associated expense and potential morbidity
    • Unchecked abnormal labs may increase liability yet have little impact on surgical outcome

    The department of anesthesia at Rhode Island Hospital has adopted the following guidelines for routine preoperative evaluation of the healthy adult surgical patient. These are on the basis of the type of surgery that is planned and assume no co-morbidity in the patient or medications which might affect laboratory values. Patients with significant co-morbidities will often require a more extensive laboratory workup. In addition, patients on medications that may result in anemia, thrombocytopenia or electrolyte imbalance may also require laboratory workup in addition to what is listed below.

    No Labs Required

    • Surgical category: Minimally invasive with little or no blood loss
      Procedures: Breast bx, removal of minor skin lesions, ear tubes, cystoscopy, vasectomy, circumcision and bronchoscopy
      Excludes: Open exposures of internal organs, repair of vascular or neurologic structures, entry into abdomen, thorax, neck, cranium, or extremities and placement of prosthetic device
    • Surgical category: Minimal to moderately invasive, blood loss less than 500cc
      Procedures: Diagnostic laparoscopy, D&C, LTL, arthroscopy, inguinal hernia, laparoscopic lysis of adhesions, T&A, umbilical hernia repair, septo/rhinoplasty, percutaneous lung biopsy and laparoscopic cholecystectomy
      Excludes: open exposures of internal organs, repair of vascular or neurologic structures, entry into abdomen, thorax, neck, cranium, or extremities and placement of prosthetic devices.

    CBC, T&S Required

    • Surgical category: Moderately invasive, with estimated blood loss between 500-1500cc
      Procedures: Resection/reconstructive GI, total hip/knee, nephrectomy, laminectomy, open cholecystectomy, cystectomy, hysterectomy, thyroidectomy, myomectomy, major laparoscopic and vascular (carotid, peripheral)
      Excludes:Open thoracic or intracranial, major vascular and planned postoperative ICU admissio

    CBC, T&C, Lytes, Bun, Cr Required

    • Surgical category: Highly invasive, with estimated bloos loss greater than 1500cc and possible postoperative ICU planned
      Procedures: major orthopedic/spine reconstruction without rodding, major GU reconstruction, major GI reconstruction, major vascular (except aortic cross-clamping) and intracranial (non-vascular, non-sitting)

    CBC, T&C, Lytes, Bun, Cr, PT/PTT Required

    • Surgical category: Highly invasive, with estimated blood loss greater than 1500cc and postoperative ICU planned
    • Procedures: All cardiac, intrathoracic, intracranial(vascular or sitting), major head/neck dissection, vascular(aortic cross-clamp) and orthopedic(multiple trauma or multi-level spine instrumentation)

    (It is important to remember that the above are surgical categories; they do not reflect American Society of Anesthesiologist categories, which are related to co-morbidity.)

    ECG is required on all male patients older than 50 years and all female patients older than 60 years.

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    What do you need to know about preoperative cardiac workups?

    Generally speaking, the most important clinical predictor of cardiac risk is the patient's functional status. Most often, a patient's functional status is characterized in "mets" or metabolic equivalents. Generally, if a patient can accomplish more than four or five mets (i.e. able to walk up a flight of stairs) without symptoms (i.e. having to stop, angina or dyspnea) it is unlikely that they need further cardiac or pulmonary workup. Exceptions to this occur immediately after a cardiac intervention.

    Most patients require non-invasive cardiac testing within a year of their cardiac stent due to the risk of in-stent thrombosis. A good resource that can help determine the need for preoperative testing is the American College of Cardiology.

    If a patient has had a recent stress test or echocardiogram, it is best to include this information in the patient's chart. Even if a patient is 'cleared for surgery' by their physicians, information in these studies will often change the way a patient is anesthetized. They may require more intensive monitoring or medical therapy perioperatively.


    How do I get an anesthesia consult?

    All patients undergoing surgery at Rhode Island Hospital will be seen by an anesthesiologist before being anesthetized. For many patients it is appropriate for them to be seen on the day of surgery. If patients have multiple co-morbidities or are having extensive surgery it may be more appropriate for them to be seen further in advance of their procedure to be sure that preoperative risk-stratification or medication changes are not required and to be informed of special procedures that may be required on the day of surgery (epidural, central line, or awake intubation).

    In these circumstances patients can come to our pre-operative testing center. To schedule patient appointments please call 401-444-5030. If the patient is already admitted to the hospital, arrangements can be made for them to be seen by speaking with the anesthesia floor coordinator. He or she can be reached via the opertaing room desk at 401-444-5657.

    On occasion, information regarding a patient's risk from surgery and anesthesia is required to help determine whether or not a patient is an acceptable surgical candidate (as opposed to offering only medical treatment). A consult with an anesthesiologist can be arranged by contacting the pre-operative testing center at 401-444-5030.

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    Epidurals

    My patient has an epidural. How long do I need to hold heparin prior to its removal?

    Epidural hematoma is a rare but catastrophic complication of neuraxial anesthesia/analgesia. It has been described in patients WITHOUT hemostatic abnormality. However, risk is significantly higher in patients that have an intrinsic or pharmacologically induced hemostatic disorder. Removal of an epidural catheter should only be done by an anesthesia provider. Below are general guidelines to safely timing epidural placement and removal around different types of anticoagulants. Sometimes certain patients may require more conservative management especially when multiple hemostatic pathways are blocked.

    • Anticoagulation and Epidurals (Excel File)

    How do I contact the anesthesia department?

    • Main office: 444-5142
    • Davol operating room/Floor coordinator: 444-5671 or 444-5657
    • Hasbro floor coodinator: 444-6030
    • ASC holding unit/ Floor coordinator: 444-5549
    • Pain clinic : 444-6321
    • Davol PACU: 444-8164
    • Hasbro Children's PACU: 444-6887
    • ASC PACU: 444-8232
    • Pre-admission testing: 444-5030

    Fax Numbers

    • Main office: 444-5083
    • Davol OR desk ( adult patients): 444-5951
    • Hasbro Children's anesthesia (pediatric patients): 444-6078

    Other important Rhode Island Hospital numbers

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