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Pre-operative, I ntra-operative
and post-operative Evaluation
related Systemic Diseases;
I nitial Assesment
T. Realsyah Renardi
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y
The preoperative evaluation consists of gathering
information about the patient and formulating ananesthetic plan. The overall objective is reduction ofperioperative morbidity and mortality.
Inadequate preoperative planning and errors inpatient preparation are the most common causes ofanesthetic complications.
Anesthesia and elective surgery should not proceeduntil the patient is in optimal medical condition.
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If any procedure is performed without
the patient's consent, the physicianmay be liable for assault and battery.
The intra-operative anesthesia recordsserves many purposes. It functions as
a useful intraoperative monitor, a
reference for future anesthetics for thatpatient, and as a tool for quality
assurance.
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Routine Pre-operative Anesthetic
Evaluation
I- His to ry :-
1- Current problem2- Other known problems
3- Medication history
4- Previous anesthetics ; surgery &obstetric deliveries.
5- Family history.
6- Last oral intake.
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7- Review of organ systems:-
General ( including activity level ).
Respiratory.
Cardiovascular.
Renal.GIT.
Hematological.
Neurological.Psychiatric.
Endocrinal.
..
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Preoperative management
Areas to investigate inpreop history.
Previous adverse
responses related toanesthesia
Allergic Reactions
Sleep apnea
Prolonged skeletal muscleparalysis
Delayed awakeningNausea and vomiting
Adverse responses inrelatives
Central NervousSystemCerebrovascular insufficiency
Seizures
Cardiovascular SystemExercise Tolerance
Angina
Prior MI
HTN
Claudication
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LungsExercise Tolerance
Dyspnea and Orthopnea
Cough and Sputum Production
Cigarette consumption
PneumoniaRecent upper resp. tract
infection
LiverAlcohol Consumption
Hepatitis
Kidneys
Nocturia
Pyuria
Skeletal and Muscular
Systems
Arthritis
Osteoporosis
Weakness
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Endocrine SystemDiabetes mellitus
Thyroid gland dysfunction
Adrenal gland dysfunction
CoagulationBleeding tendency
Easy bruising
Hereditary coagulopathies
Reproductive System
Menstrual History
STDs
DentitionDentures
Caps
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II- Phys ical Examination
Vital signs.
Airway.Heart.
Lungs.
Extremities.Neurological Examination.
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Physical Exam:
CNS
Level of ConsciousnessEvidence of peripheral,
sensory or skeletal muscle
dysfxn
CVAuscultation of heart
Systemic blood pressure
Peripheral pulses
VeinsPeripheral edema
Lungs
Auscultation of LungsPattern of breathing
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Upper Airway
Cervical spine mobility
Temporomandibular mobility
Tracheal mobilityProminent central incisors
Diseased or artificial teeth
Ability to visualize uvula
Thyromental distance
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III- Laboratory Evaluation
Hematocrite or Hemoglobinconcentration :
- All menstruating women.
- All patients over 60 years.- All patients who are likely to
experience significant blood loss & may
require transfusion.Serum glucose & Creatinine.
ECG & Chest X-ray.
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Lab TestCXR
ECG
Clinical indicationsPneumonia, pulmonary
edema,
Atelectasis,mediastinal or
pulmonary masses,pulm.HTN,cardiomegaly, Advanced
COPD with blebs, PE
Hx of CAD,Age > 50, HTN,
chest pain, CHF, diabetes,
PVD, SOB, DOE,palpitations,
murmurs
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Lab test
LFT
Renal fxn testing
ClinicalIndicationsHx of Hepatitis, Cirrhosis,portal HTN, GB or biliary
tract disease, Jaundice
HTN, increased fluidoverload, diabetes,
urinary problems, dialysispts
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Lab Test
CBC
Coagulation testing
Pregnancy testing
Clinical IndicationsHematologic disorder,bleeding, malignancy,
Chemo/radiation tx, renal ds.,
highly invasive or trauma sx.
Bleeding disorder hx.,Anticoagulant meds, Hepaticds.
Sexually active, time of lastmenstrual period.
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IV- ASA Classif icat ionThe American Society of Anesthesiologists(ASA) physical
status classification serves as a guide, to allow communication
among anesthesiologists about clinical conditions of patients.A way to predict their anesthetic/surgical risks -the higher ASA
class, the higher the risks.
Class Definition
1 A normal healthy patient.
2 A patient with mild systemic disease & no
functional limitation.
3 Moderate to severe systemic disease that
result in some functional limitation.
4 severe systemic disease that is a constant
threat to life and functionally incapacitating.
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IV- ASA Classif icat ion ( continued )
Class Definition
5 A patient who is not expected to survive 24
hours with or without surgery.
6 A brain-dead patient whose organs are being
harvested.
E If the procedure is an emergency, thephysical status is followed by E.
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ASA Classification &
preoperative mortality rates
Class Mortality Rate
1 0.060.08 %
2 0.270.4 %
3 1.84.3 %
4 7.823 %
5 9.451 %
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The Anesthetic Plan
1 - Pre-medication.
2 - Types of Anesthesia :-
* General
* Local or Regional anesthesia
* Monitored Anesthesia Care3 - Intra-operative management.
4 - Post-operative management.
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Types of Anesthesia
General :
Airway management.
Induction
MaintenanceMuscle Relaxation
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Local or Regional :
Technique.
Agents.
Mon itored Anesthesia Care :
Supplemental Oxygen.
Sedation.
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Intra-operative management
Monitoring.
Positioning.
Fluid Management.
Special Techniques.
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Post-operative management
Pain control.
Intensive Care :
- Post-operative Ventilation.
- Hemodynamic Monitoring.
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Postoperative Complications
Pulmonary
- Pneumonia, atelectasis ,fever,
leukocytosis,
- Respiratory failure/mechanical
ventilation
- Pulmonary embolism
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Postoperative Complications
Cardiovascular
- Anemia- Arrhythmias
- Ischemia
- Air embolism- Hypotension/hypertension
- DVT (both lower and upper limb
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Postoperative Complications
Neurological- Stroke
- Psychosis
Cerebrospinal fluid CSF leak
Bone flap infection Infection, sepsis
Neuropraxia, pressure areas (eg fromcompression while on operating table)
Neurological deterioration eg weakness
arachnoiditis
Wound, lines, others
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Postoperative Complications
Gastrointestinal
Constipation
- Constipation is an inability to move the bowels
(defecate) for many days.
- Associated with bowel paralysis with stasis of intestinal
contents, interfering with normal digestion and nutrient
absorption.
Vomiting
is a dangerous in patients with depressed consciousnesswho are at risk for inhaling (aspirating) their stomachcontents and developing a chemical pneumonitis that all
too frequently progresses to pneumonia
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Postoperative Complications
Others
Fever
Many patients have fevers (are "febrile")
in the first 24 to 48 hours following
- Neurosurgery (brain, spine, or nerve)
- Decubitus ulcers
- Musculoskeletal issues eg shoulder
pain, contractures
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Is anesthesia safe?
Like airplane?
Anesthesia related deaths:
1940 1/10001970 1/10 000
1995 1/250 000
2005 ?
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Safety of anesthesia
1950 - 25 000deaths during 108 hours ofanesthesia
2000 - 500deaths during 108
hours ofanesthesia
Airplane risk (very low) -5deaths during
108
hours of flightRisk of anaesthesia: 100 x higher
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6/6/05 Copyright Quarnstrom Donaldson
Mortality from Anesthesia 1970-1979 U. K.Mortality from Anesthesia 1970-1979 U. K.
Dentists 1:260,000
Physicians 1:248,000
Single Operator / Anesthetist 1:143,000
One Operator One Anesthetist 1:598,000
Conscious sedation 1:1,000,000
(patient died on a motorcycle later the same day)
Dentists 1:260,000
Physicians 1:248,000
Single Operator / Anesthetist 1:143,000
One Operator One Anesthetist 1:598,000
Conscious sedation 1:1,000,000
(patient died on a motorcycle later the same day)
Dionne, Pharmacologic Considerations in Training of Dentists inAnesthesia and Sedation, Anes Prog 36:113-116 1989
note - this study was pre pulse oximeter useagenote - this study was pre pulse oximeter useage
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6/6/05 Copyright Quarnstrom Donaldson
The Spectrum of Anesthesia
Normal
Anxiolysis
ConsciousSedation
Deep
Sedation GeneralAnesthesia
1. Protective reflexes intact
Patient can independently
and continuously maintain
an airway
Patient can respond
appropriately to verbal
commands
2. Partial loss of
protective reflexes
Inability to
independently maintain
an airway
May not respond to
verbal commands
3. Loss of protective
reflexes
Inability to independently
maintain an airway
No pain sensation or reflex
withdrawal from stimuli
Total unconsciousness
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Risks of Anesthesia
low
high
N20
Anxiolysis
Local
Anesthesia
ModerateSedation
Deep
Sedation
General
Anesthesia
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AGE VS ANESTHETIC-INDUCED,
CARDIAC ARREST / DEATH
AGE VS ANESTHETIC-INDUCED,
CARDIAC ARREST / DEATH
> 60> 60
incidence
rate
incidence
rate
1-101-10 11-2011-20 21-3021-30 31-4031-40 41-6041-60< 1< 1
0.010.01
0.020.02
0.030.03
0.040.04
0.050.05
Marx, Anes ., 39:54-58, 1973Marx, Anes ., 39:54-58, 1973
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age range = 21 mo. - 59 yr.age range = 21 mo. - 59 yr.
00
11
22
33
44
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age range = 21 mo. - 59 yr.age range = 21 mo. - 59 yr.
00
11
22
33
44
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Standards for Conscious Sedation
Level 1 minimal sedation - Anxiolysis
Level 2 Moderate Sedation/Analgesia -
Conscious Sedation
Level 3 Deep Sedation/Analgesia
Level 4 Anesthesia
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Standards for Conscious Sedation
Level 1 minimal sedation - AnxiolysisA drug-induced state during which patients respondnormally to verbal commands. Although cognitive functionand coordination may be impaired, ventilatory andcardiovascular functions are unaffected.
Level 2 Moderate Sedation/Analgesia -Conscious Sedation
Level 3 Deep Sedation/AnalgesiaLevel 4 Anesthesia
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Standards for Conscious Sedation
Level 1 minimal sedation - AnxiolysisLevel 2 Moderate Sedation/Analgesia -Conscious Sedation
A drug-induced depression of consciousness during which
patients respond purposefully to verbal commands, eitheralone or accompanied bylight tactile stimulation. Nointerventions are required to maintain a patient airway andspontaneous ventilation isadequate. Cardiovascular
function is usually maintained.Level 3 Deep Sedation/AnalgesiaLevel 4 Anesthesia
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Standards for Conscious Sedation
Level 1 minimal sedation - AnxiolysisLevel 2 Moderate Sedation/Analgesia -Conscious Sedation
Level 3 Deep Sedation/AnalgesiaA drug-induced depression of consciousness during whichpatients cannot be easily aroused but respond purposefullyfollowing repeated or painful stimulation. The ability toindependently maintain ventilatory function may be
impaired. Patients may require assistance in maintaining apatent airway, and spontaneous ventilation may beinadequate. Cardiovascular function is usually maintained.
Level 4 Anesthesia
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Standards for Conscious Sedation
Joint Commission on Accreditation of HealthcareOrganizations (JCAHO)
Level 1 - None
Level 2 - conscious sedation - pulse oximeter andBlood Pressure, ability to resuscitate.Monitoring YES
Patient assessment - ASA status YES - 1 OR 2
Staff - someone is always with the patient YESEquipment YES
Informed consentYESCompetent at least one level greater than where
you normally practice if patients slip into next levelResek, Jayne, MS RN, Anesthesia Today vol.11 No. 2 Fall 2000 p. 2
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Pain
Unpleasant sensory and emotionalexperience associated with actual orpotential tissue damage
Injection of local anesthetic agents,corticosteroids, opiates, and
neurolytic agents around nerves canrelieve pain.
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Advantages
Reduced postoperative analgesiarequirements
Reduced duration at the hospital
Greater patient satisfaction
Examples Use of continuous femoral nerve block expedites
rehabilitation efforts Early ambulation and discharge with decreased side effects
of N/V, drowsiness .
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Advantages
Suitable for older and multimorbid patients
Few side effects
Easier monitoring
Continuous nerve block
Suitable for nonoperative cases
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Advantages
Fewer complications related to pain:
Tachycardia, hypertension, increasedperipheral vascular resistance
increased myocardial oxygenconsumption
Decreased intestinal motility
postoperative ileus
Decreased vital capacity and FRC withthoracic and abdominal procedures
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Limitations
Additional time is requiredforinduction and onset of block
Contraindications
Coagulopathy, neuropathies, anatomicaldeviations, systemic disease or infection
Need experience & cooperative andinformed patient
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Complications Hematoma , infection
Injury or anesthetic blockade of adjacent structures:
injection of anesthetic into epidural or subarachnoid spaceduring brachial plexus block = total spinal
Pneumothorax
Nerve damage Needle trauma or injection into nerve
Systemic local anesthetic toxicity, allergy Tachycardia and hypertension (epinephrine), tinnitus, metallic
taste in mouth, perioral numbness, seizures, cardiovascular &CNS depression
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Symptoms of lidocaine toxicity
5
10
15
20
25
ConvulsionsUnconsciousnessMusclar twitchingVisual disturbanceLightheadedness
Numbness of tongue
coma
Repiratory arrest
CVS depression
30
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W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Early history of regional anesthesia
Koller and Gartner
report local anesthesia(1884)
Carl Koller1857 -1944
E l hi f i l h i
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W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Early history of regional anesthesia
Koller and Gartner
report local anesthesia(1884)
1884 Halsted injectscocaine directly into
mandibular nerve andbrachial plexus
William S. Halsted
E l hi t f i l th i
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W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Early history of regional anesthesia
Koller and Gartner
report local anesthesia(1884)
1884 Halsted injectscocaine directly into
mandibular nerve andbrachial plexus
1904 Einhorndiscovers procaine
(Novocaine) Procaine
E l hi t f i l th i
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W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Early history of regional anesthesia
Koller and Gartner
report local anesthesia(1884)
1884 Halsted injectscocaine directly into
mandibular nerve andbrachial plexus
1904 Einhorndiscovers procaine
(Novocaine) 1943 Lofgren
discovers lidocaine(Xylocaine)
Lidocaine
Ch l f l l th ti
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W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Chronology of local anesthetics
Cocaine Niemann 1860 Ester
Benzocaine Salkowski 1895 Ester
Procaine Einhorn 1904 Ester
Tetracaine Eisler 1928 Ester
Lidocaine Lofgren 1943 Amide
Chloroprocaine Marks, Rubin 1949 Ester
Mepivacaine Ekenstam 1956 Amide
Bupivacaine Ekenstam 1957 AmideRopivacaine Sandberg 1989 Amide
After: Cartwright & Fyhr. Reg Anesth 1988;13:1-12
ff f &
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W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Effects of medical conditions &
drugs on LA dosing & kinetics
Renal failure: accumulation of metabolic
products
Hepatic failure:amide clearance
Cardiac failure; and H2 blockers: hepaticblood flow and amide clearance
Cholinesterase deficiency or inhibition: ester
clearance Pregnancy: hepatic blood flow; amide
clearance; protein binding
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W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Is there one common mechanismfor LA-induced cardiac death?
Arrhythmias (bupivacaine)? Left-ventricular depression (lidocaine)?
Resuscitation drug failure (bupivacaine)?
Mechanism probably depends on specificdrug!
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W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Treatment of LA CV toxicity
Follow ACLS guidelines Substitute amiodarone for
lidocaine
Substitute vasopressin forepinephrine
Consider cardiopulmonary
bypass or lipid infusion ifstandard drugs fail
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W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Postoperative management
PACU Guidelines
STANDARD I
ALL PATIENTS WHO HAVE RECEIVED GENERALANESTHESIA, REGIONAL ANESTHESIA OR
MONITORED ANESTHESIA CARE SHALL RECEIVE
APPROPRIATE POSTANESTHESIA MANAGEMENT.
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W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
STANDARD IIA PATIENT TRANSPORTED TO THE PACU SHALL BE
ACCOMPANIED BY A MEMBER OF THE ANESTHESIA CARETEAM WHO IS KNOWLEDGEABLE ABOUT THE PATIENT'SCONDITION. THE PATIENT SHALL BE CONTINUALLYEVALUATED AND TREATED DURING TRANSPORT WITHMONITORING AND SUPPORT APPROPRIATE TO THE
PATIENT'S CONDITION.
STANDARD IIIUPON ARRIVAL IN THE PACU, THE PATIENT SHALL BE RE-EVALUATED AND A VERBAL REPORT PROVIDED TO THERESPONSIBLE PACU NURSE BY THE MEMBER OF THE
ANESTHESIA CARE TEAM WHO ACCOMPANIES THEPATIENT
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W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
STANDARD IVTHE PATIENT'S CONDITION SHALL BE EVALUATEDCONTINUALLY IN THE PACU.
STANDARD VA PHYSICIAN IS RESPONSIBLE FOR THE DISCHARGE OFTHE PATIENT FROM THE POSTANESTHESIA CARE UNIT.
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W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Discharge Criteria
Post anesthetic discharge scoring (PADS)system is a simple cumulative index thatmeasures the patient's home readiness.
Five major criteria: (1) vital signs, includingblood pressure, heart rate, respiratory rate, and
temperature; (2) ambulation and mentalstatus; (3) pain and PONV; (4) surgicalbleeding; and(5)fluid intake/output.
Patients who achieve a score of 9 or greater
and have an adult escort are considered fit fordischarge (or home ready).
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W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Vital Signs: 2 = Within 20% of the preoperativevalue, 1 = 20%40% of the preoperative value, 0 =40% of the preoperative value
Ambulation: 2 = Steady gait/no dizziness 1 = Withassistance 0 = No ambulation/dizziness
Nausea and Vomiting:2 = Minimal 1 = Moderate0 = Severe
Pain: 2 = Minimal 1 = Moderate 0 = Severe
Surgical Bleeding:2 = Minimal 1 = Moderate 0 =Severe
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W A K E F O R E S T U N I V E R S I T Y S C H O O L O F M E D I C I N E
Perioperative medications
Take all usual medications Antihypertensives
Beta blockers
Statins
Think about discontinuing/replacing Aspirin
Anticoagulants
Diabetic medications MAOIs
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Questions