The patient has xxx pulmonary risk factors (COPD, OSA, tobacco)
Elevated risk elective surgery may be reasonable if there is severe but asymptomatic Aortic stenosis (valve area less than 1.0cm**2) or severe mitral stenosis (if cannot balloon commissurotomy) or asymptomatic severe mitral or aortic regurg. 2014 ACC/AHA Pre-op guidelines
If bare-metal stent, may need to postpone elective surgery for 1 month while on Clopidogrel
If drug-eluting-metal stent, may need to postpone elective surgery for 12 months while on Clopidogrel
If balloon angioplasty, may need to postpone elective surgery for 14 days
Smoking cessation 6-8 weeks before elective surgery
If coronary stents, consider continuing Asa and Clopidogrel if BMS or DES placement within 6 weeks of urgent surgery (weigh risks of bleed vs stent thrombosis). Otherwise, try to continue Aspirin alone, and then retsart Clopidogrel soon after surgery
If on Coumadin, hold for surgery and resume with bridge if mechanical mitral valves
Continue statins day of surgery
Continue Pulm-HTN meds day of surgery (PDE inhibitors, endothelin antagonists, prostanoids, ets)
Post-operatively monitor for A-Flutter (peak incidence 1-3 days post-op, with incidence 1 to 30 percent)
If A-Flutter, rate control with betablockers or Calcium channel Blockers (such as Diltiazem, but avoid if reduced EF). Cardioversion is usually not required
If SVT, break with Adenosine and then rate control with beta blockers or Calcium channel Blockers (such as Diltiazem, but avoid if reduced EF or AF)
Pre-operative colonization with Staphylococcus aureus increases SSI risk. Screening and decolonization with intra-nasal mupirocin and pre-operative chlorhexidine bathing remains the most common and effective strategy, especially for orthopedic and cardiovascular surgery. Intra-nasal povidone-iodine immediately before surgery appears effective in preliminary studies, is less expensive, and may be easier to implement in the clinical setting.