DIP Episode 613 - Peri-operative Medicine (Social Sciences)

All right, welcome. This is episode 613 of the Divine Intervention Podcasts. Into this podcast, we're going to be talking about a topic I've titled a Perioperative Medicine. This podcast is pretty high yield for the USML Es and it's one of these things that falls under the purview of social sciences. Okay, again, remember the social sciences these days constitute about, you know, you know, between that and bio statistics, probably about 10 to 15% of the USML Es. And if those are subjects you struggle with, you may be interested in the classes I offer. So not this coming week, but next week, the week after that, I do have a four hour bio statistics class and a five hour social sciences and ethics class. Tons of people have taken those classes and found them to be extremely helpful. All right. So this podcast, I guess maybe the first question I should answer is, why is this material hard? The thing is, a lot of this material is hard because many times it's not something you can reason through. It's something that you have to actually like, you know, know about, like either it's it's one of those you either know it or you don't kind of propositions, right? So you're going to see me discuss a lot of scenarios, scenarios, scenarios with this. If you pay attention, you know, make good notes, go through them. I think you're going to be in some really good, in some really good shape. Okay. I think you're going to be in some really, really good, good shape. All right.

So let's, let's go ahead and begin, right? So what if they give you a question about a diabetic and you're told that this diabetic, you know, is on a bunch of different, you know, diabetes medications, you know, they can give you like metformin or the person is on a sulfonyl urea or whatever. What are you supposed to do? You know, the person is coming in for surgery or whatever. I would really hope that you're telling the person to hold his or her oral hypo glycemic agents. Okay. Please, if a person is getting surgery, it is very, very important that those people's oral hypo glycemic agents be held. You should not be taking oral diabetes medications and getting surgery. No, you can get in some very serious troubles, right? Like the classic one that they love to test is, for example, with a person that has that seeking metformin, remember, metformin can cause lactic acid doses, it can cause kidney problems, it can cause liver problems, right? So you want to hold it because they can give you, even give you a question about a person coming in for surgery and the morning of surgery, the person's bicarb is extremely low and is a diabetic. That person either has DKA or HHS or the person has metformin toxicity. So that's something you just really want to be careful about, right? People that are preoperative patients, if you want to control their glucose in the hospital, the thing you should be doing is to use insulin, okay?

You want to use insulin for those people and generally you want to keep their blood glucose is under 180 milligrams per deciliter, under 180 milligrams per deciliter. That's a number you definitely want to make sure you know for your exams, right? Another preoperative thing, so what if they give you a question about a patient? And this patient has rheumatoid arthritis, right? And the person is having some kind of procedure that requires intubation. What kind of preoperative screening has to be done? Well, I would really hope you're picking the answer that talks about a cervical x-ray, right? Because remember, people that have rheumatoid arthritis, they have a high risk of something known as Atlantoaxial instability, Atlantoaxial instability. So because they have a high risk of Atlantoaxial instability, which sometimes is called C1 C2 sub-location, those people are gonna need some kind of preoperative cervical x-ray, just to screen them for those things, right? Because again, you're literally gonna be manipulating these people's necks in the process of intubation or just in your surgery or whatever. So just make sure they don't have that before taking them to the OR. This same vignette could be created easily for a person that has Down syndrome, Down syndrome is also associated with Atlantoaxial instability. This could also be created for a person that has ankylosein spondylitis. Ankylosein spondylitis also has a stronger association with Atlantoaxial instability. All right.

Now, 13-ary, what if they give you a question about a person and you're told that this person has valvular, like some kind of valvular disease or they've had like some kind of prosthetic heart valve placed. And then the person is on warframe, you know, is always on warframe as a, as a, you know, thrombone and polyg disease profile axis, right? Because remember, if you have valvular disease and let's say you've had a valve placed, especially those mechanical valves, right? You got to be on warframe. So for those people, what do you need to do preoperatively? Well, I would really hope that you're thinking that, oh, wait, this person's warframe has to be helped, right? If a person is on those oral anticoagulants, they cannot take them with surgery. They just can't. If not, they're going to have an increased risk of bleeding complications. They're going to have an increased risk of bleeding complications. For those people, you need to bridge them with warframe, those, I mean with heprin, sorry, those people need to be on heprin. Even these anti-platelet drugs like clopidograal and aspirin, those things you need to hold them for a few days before surgery. I know some people may be wondering, excuse me. So some people may be wondering, define how many days, don't worry about the number of days. All you should care about is these drugs should be held. These drugs should be held. Okay. These drugs should be held.

Please, that's very, very important to keep at the back of your mind, for exams, right? So many of these anti-coagulants, many of these anti-platelet drugs, they got to be held with surgery. They got to be held a few days before surgery, right? If you need anti-coagulation in the period of preoperative period, heprin is what you're going to be able to, what is what you're going to use? You know why? Because you can turn off heprin pretty quickly and the effects wear off fairly quickly, all right? So that's something I want to make sure you know for your exams. All right. Now, what if they give you a question about a person, you know, that is getting some kind of dental procedure, right? And you're told that this person has a prior histrovent effective endocraditis. Now, what do you need to do? Okay. You're going to give them endocraditis for relaxes, right? Remember, if you have a history of a prior histroventendocraditis or you have an unrepaired, sanitary congenital heart defect, or you have a, let's see. So prior histroventendocraditis, unrepaired sanitary congenital heart defect, right? Or you have a prosthetic valve. If you're getting any kind of dental thing, any kind of dental procedure, guess what? You're going to need endocraditis for relaxes, okay? You need to do this about 30 to 60 minutes before your procedure begins. You need to be given a cell wall inhibitor, like a moxacillin, one piscillin or something along those lines, right?

So that's something that's pretty high yield to know for you exams. And honestly, like just even on the same strength as that, if you're getting pretty much any kind of surgery, you deserve antibiotic prophylaxis. About 30 to 60 minutes before you get surgery, you should get antibiotic prophylaxis of some sort, okay? You should get antibiotic prophylaxis of some sort, right? Typically it's going to be sephazolin, right? You're going to get it about 30 to 60 minutes before the incision is made, okay? 30 to 60 minutes before the incision is made. All right. Now, what if they give you a question about a patient? And you're told that this patient is a 55-year-old female that has a history of temporal arthritis that she has had it for the past like, you know, and she has been on pharmacotherapy for it for the past like six months. And the person is getting any kind of surgery. What kind of perioperative considerations should you have for this patient? Well, I would really hope that you're saying that, oh, divine, this person needs to get like a stress dose of steroids, right? They have to get a prophylactic dose of corticosteroids, you know why? Because when people have giant cell arthritis, they typically have to be on corticosteroids for months, sometimes even up to a year, right? So those people's HPA axes have been suppressed heavily.

So because their HPA axes have been suppressed, when they undergo some kind of metabolic stressor, like for example, they're getting surgery or they have a medical illness, right? The body is stressed. The body wants to ramp up cortisol production to deal with that stress. But you know what? You won't be able to do that if your HPA axis has been suppressed. So for people of that sort, for people that have those kinds of issues, it is actually very high-yield to know that those people need a stress dose of steroids. If not, they're going to run into an adrenal crisis of some sort with surgery, okay? They're going to run into an adrenal crisis of some sort with surgery. That's very, very high-yield to know for your exams. All right. Now, what if they give you a question about a patient? And you're told that this patient has a history of MEN2, right? And the person is having some kind of procedure done. What kind of preoperative or perioperative consideration do you have to think about? Well, I would really hope you're saying that, hey, this person is going to need some pharmacological tune-ups, some pharmacological tune-ups, right? Like either, you know, they get the alpha blockade first and then they get better blockade. Because again, the process of surgery, if you have like a few chromosidoma already, I mean, I would hope that you fix it.

But honestly, even if you're getting surgery for your few chromosidoma, you still need to do this thing about to say, but you need to do alpha blockade first. And then after that, you're going to do beta blockade, right? Because again, you don't want to trigger a hypertensive crisis from whatever few chromosidoma or everything that they have. Please, this is actually very important to know. I know some of these vignettes I'm talking about, me seem crazy to some of you as you're listening to it. But I promise you, you'll be putting yourself in some very grave danger if you don't know the stuff for your exams. And the thing is things like these are not things that people can ordinarily prepare for very well, right? Again, very, very high up to know these things for your exams, right? Very, very high up to know these things for your exams. Why did I use MEN2 as my backdrop? I used MEN2 as my backdrop because because because because, right? MEN2 and 2 B are both associated with fiochromosidomas, okay? They are both associated with fiochromosidomas. All right. Now, another thing to, and you know, I've kind of talked about like the warframe and the aspirin and the clopidogre. Why do you think we stopped those things a few days before surgery? Well, the thing is those things increase your risk of major bleeding with surgery. They literally increase your risk of major bleeding with surgery, okay? This does increase your risk of major bleeding with surgery.

Now, one weird scenario you may see on your exams where it's like, uh, don't stop the aspirin that they're taking before surgery. Is it for example, a person has a coronary stent that has been placed, right? So they have like a bare metal stent or drug-alute instant, right? Those people, if they really need surgery, you should probably continue, you should, you should probably continue their aspirin, right? Because you don't want them to have wrist and noses during the period of perioperative period. During the period of perioperative period. All right. Now, one other thing that is super high to know, remember I've made a podcast recently about herbal supplements and the USML Es. That's a podcast you should go back and listen to. There's a lot of stuff they love to test with those. But the thing is herbal supplement. If a patient is on herbal supplements, what kind of recommendation should you give them preoperatively on the USMLE exams? I would really, really hope that you should, uh, you should remember to tell them to stay off of these things for at least a week before surgery, at least what a week before surgery, right? And this applies to practically every herbal supplement, right? Things like a fedra, right? Uh, ginkgo, you know, ginkgo biloba, ginseng, uh, you know, kava kava, you know, st. John's word, right? Echinesea, all those things, these people need to hold them what? One week before surgery, okay? One week before surgery. All right.

Now, what if a person has uncontrolled hypertension? Add some considerations you should keep at the back of your mind for the perioperative period? Yes, there are, right? Yes, there are. You want to make sure that these people's blood pressures are under 180 over 110. I'm going to say that again, you want to make sure that their blood pressures are under 180 over 110 because those people, right? If a person has uncontrolled hypertension, right? And they have really high blood pressures that can be really bad for them in the process of surgery, right? That can be really bad for them in the process of surgery. So I will encourage you if a person's blood pressure is really high, again, if it's over 180 systolic, over 110, that's stolic, right? Make sure that their blood pressure is controlled. Bring it down first. Bring it down first, okay? Before you take them to surgery, okay? Before you take them to surgery, before you take them to surgery. That's very important to know for you exams. And one other thing I'm thinking about here that I think I want to throw in as a tidbit is that if a person has, if a person has, I want to make this an integration here, but yes, if your systolic blood pressure is over 180, that's a TPA contraindication. That's another thing they love to test on the exams, right? If a person's systolic blood pressure is over 180, you should not give them TPA for like an ischemic stroke or for an MI, right?

Because again, they can have very dangerous hemorrhage with that. Something just, again, I want to keep at the back of your mind for exams. All right. Now, what if they give you a question about a patient? And you're told that this patient has a history of an MI and the patient was on the went coronary angiography with 10 placement and the person requires surgery. How long, how long after an MI, how long should you wait after an MI before you do surgery on a person? Elective surgery, elective surgery. I would really hope that you're seeing the vine at least 60 days, at least 60 days, right? If you try to have any kind of elective surgery less than 60 days after a person has an MI, that's not good, right? They have a very, very high risk of things like refarction, high risk of things like death, right? Again, obviously many of these rules I'm discussing apply to elective surgeries. If a surgery is emergent, you're going to go ahead and do the surgery. If not the patient is going to die, right? So it's just very important. After a person has had an MI, if had a coronary intervention, you need to wait for at least 60 days before you do any kind of elective procedure, okay? Before you do any kind of elective procedure, that is very, very high yield to know for your exams. All right. Now, what if they give you a question about a patient that is on beta blockers? What if they give you a question about a patient that is on beta blockers? What are you supposed to do with surgery?

Well, the thing I want to keep at the back of your mind for your exams is that if the person is not having any symptoms or side effects from those, then those patients can continue the beta blockers during the period period. It can be continued during the period period period. That's pretty high yield to know for your exams, okay? That is pretty high yield to know for your exams, pretty high yield to know for your exams. All right. Because actually beta blockers have actually been shown to be kind of helpful. They actually decrease cardiac events, they decrease mortality, especially during the period period. So it's just something you want to keep at the back of your mind for exams, right? Especially people that have coronary artery disease. Again, if they're not having, if they're not having side effects from the beta blocker, it's totally fine for them to remain on those drugs. All right. Now, what if they give you a question about a patient that is a smoker, right? And you're told that the person is going to be having an elective colisis stectomy or whatever, you know, or some kind of surgery down the line. What kind of period operative consideration should you have for this person? Well, I would really, really hope that you're encouraging them to stop smoking, right? The thing is smoking in pairs won't healing, right? So tell these people that, hey, four to eight weeks before the surgery that you have, you need to stop smoking. You literally need to do what?

Stop smoking. You need to stop smoking. Because the thing is, if you're a person that smokes, it can cause you a lot of problems, right? Like, for example, it can make it hard for you to clear mucus during surgery. So you have a higher risk of aspiration, right? Smoking kind of closes up your earway, right? Kind of closes up your earway. So you have an increased risk of like respiratory complications, right? So smoking is just not good, right? So four to eight weeks before surgery, you want to make sure that you stop smoking. You want to make sure that you stop smoking. All right. And also just encourage your patients to stop smoking altogether, right? And then also, I guess since I cannot talk about beta blockers, you know, because sometimes in the process of surgery, you know, especially with like, you know, blood pressure management and stuff, some people can actually get beta blockers during surgery and whatnot. Well, remember, you want to be careful about beta blockers, especially nonselective beta blockers in people that have a history of what of asthma, input, I have a history of asthma. Because remember, people that have a history of asthma, if you give them a nonselective beta blocker, you can have bronchospasim, okay? You can have bronchospasim. You can have bronchospasim. So that's something I want to keep at the back of your mind, for example.

And even with people that have asthma, besides avoiding nonselective beta blockers, it is actually pretty high yield to know that these people before their surgery, even like in the days leading up to their surgery, there is nothing wrong with them getting some preoperative steroids, right? Getting some preoperative steroids, getting some preoperative, you know, in heel beta to agonist like I'm better all, right? Just to open up their earways, right? Because again, the thing is intubation can cause bronchospasim, right? You're literally introducing a hostile, rigid body into a person's earway, right? So some preoperative, corticosteroids, preoperative, you know, in heel beta to agonist is not a bad idea in these people, okay? It's not a bad idea in these people. And one thing I want to say, if they give you a question about a person that has asthma and it's not well controlled, you know, they're having like daily symptoms, they're having very severe symptoms. Then those people's elective surgery has to be delayed, right? A person cannot be having like an acute CLPD exacerbation or having like poor control of their asthma and then you still take them for surgery and intubate them for elective surgery, for elective surgery. That's not something you want to do on your exams. That's not something you want to do on your exams, okay? Now, what if they give you a question about a person that has CLPD, right?

And you're asked for what kind of preoperative screening has to be done before the person gets surgery? I mean, it's actually pretty high yield to know that those people should get preoperative AD Gs, right? They should get preoperative arterial blood gases, right? They should get preoperative arterial blood gases, okay? That's very, very high yield to know for your exams. And then, what if they give you a question about a person that is a chronic alcoholic and the person is getting surgery? And then they ask you which of the following complications may this person develop with surgery? I really want you to consider the development of aspiration, right? The development of aspiration, development of aspiration. The thing is, the things that increase your risk of aspiration with surgery are very, very high yield for you to know for your exams. I'm going to say that again, the things that increase your risk of aspiration with surgery are very, very high yield for you to know for your exams. What are those things, right? If you're an alcoholic, right? Basically, things that kind of alter your mental state. So if you're like an alcoholic, right? Or you're a person that has had a stroke, right? Or you're a person that has like a brain tumor or whatever, all these things can raise your risk of aspiration, right? Or say, for example, you're a person that chronically uses opioids. Those things are going to lock up your GI tract, right? That can cause you to aspirate.

Of a person has diabetic gastroporesis. So a person is on a GOP1 agonist. Those things de-gligastric MTN. Those things are going to increase your risk of aspiration. And also, do you know, because many of you kind of think that the surgeons are kind of mean and evil and they say, hey, you know, you got to fast. You can't eat anything before, after a midnight when you're coming for surgery. The reason you're doing that is because they don't want you to have food contents in your belly that you can aspirate during the surgery, right? They'll be like really bad. They'll be really bad, right? And then don't forget some other things as well. If a person has like a high-doubt hernia, right? For a person who has a high-doubt hernia, right? Those things can always a person's risk of aspiration, right? So that's something you want to keep at the back of your mind for your exams. Again, the USMLE is the love, love, love, these risk factors. They love, love, love, these prognostic factors. In fact, in many of my classes these days, my social science class, my bio-stats class, my 20-hour class, my last-minute review, you see me? I talk about a lot of prognostic factors, risk factors, right? Like unusual, novel risk factors that they love to test for the exams, right? So I know this podcast may seem kind of weird. It may seem kind of odd to many of you.

When I promise you, you'll be making a very, very huge mistake if you don't learn the material that is being discussed here in this podcast, right? So make sure you know the stuff and make sure you know it well for your exams. All right. And then just a few more quick things before we wrap up, before we wrap this up. But I will encourage you that, what if they give you a question about a person? And this person has like a history of a, you know, grieves disease or whatever. And the person's grieves disease, you know, has not been definitively treated. And the person requires surgery of some sort. What kind of preoperative intervention would you see this person needs? I would really hope that you're seeing that this person needs preoperative beta blockers, right? Because the thing is sometimes if a person has a risk factor for hyperthyroidism and they get surgery, one thing that can unfortunately happen is thyroid storm. Thyroid storm can literally happen. Thyroid storm can literally happen. So it's very, very important that if a person has a history of hyperthyroidism, they can have thyroid storm, right? So you need to give them a beta blocker preoperatively so that a thyroid storm is not triggered. Because you may wonder why do beta blockers help in thyroid storm? They help because they inhibit an enzyme known as a 5 prime diodeinease, a 5 prime diodeinease. That 5 prime diodeinease inhibits the peripheral conversion of T4 to T3, okay? Peripheral conversion of T4 to T3.

Now one other thing I think I want to throw in here that I think is pretty high yield because I said this earlier that hey, if a person is chronically using steroids, you know, like I give it with the giant cell at the right example, this person deserves a stress dose of steroids preoperatively or even intraoperatively. I will encourage you as well if a person has a history of other things disease, a person has a history of other things disease, primary adrenaline sufficiency, those people should also, okay? Those people should also, those people should also get intraoperative preoperative, a clinical steroid therapy, right? A stress dose of clinical steroids, right? And then what if they give you a question about a person that is getting a thyroid resection for some kind of thyroid cancer, you know, let's say like a follicular thyroid cancer or a papillary thyroid cancer. And then they ask you what kind of intraoperative intervention should be considered? I would really encourage you to make sure that the person's a PT-related labs are checked, right? Make sure that you check their PT-H, make sure you check their calcium, right? Because this is pretty high yield to know for exams, right? But the thing is you can inadvertently destroy the parathyroid gland when you're doing thyroid surgery. So you got to make sure that you've not destroyed it and the way you can make sure is by just checking the acerem calcium and all these things, right?

So make sure that those labs are checked before you even close up the patient just to make sure, right? Because again, if a person goes into a hypocalemic crisis, that can make things really, really bad for those people. I remember as a medical student, you know, at Hopkins back in the day, I was on an endocrine surgery service and we did a lot of thyroid cases. And before we, before we finished, wrap up those surgeries, we got to check those calcium labs, right? Just to make sure everything is teed up with the patient, right? Just to make sure everything is teed up with the, with the patient, right? And again, what if they give you a question about a person that is very obese? They give you a question about a person that is very obese, a person that is very obese? What kind of preoperative screening should they get? If you get screening for USA, they got to get screen for obstructive sleep apnea, right? There is this, I believe, the stop bang questionnaire that can be used as just like a primary care screen for USA, right? As a primary care screen for OS, USA, right? The stop bang questionnaire, the stop bang questionnaire, okay? Very great way to screen for obstructive sleep apnea, right? Very great way to screen for obstructive sleep apnea, right? And again, you know, don't forget you are my ligand and hypothermia that you can get with inhaled anesthetics, right? Or even succino cooling, right?

You know, you see a person during surgery, they have like very high body temperatures, they have muscle rigidity, they have ruptomyoluses, they're creatine kinase is elevated, they're white count is elevated, right? Those people, you need to give them a dang shulian, right? That's a rannodyne receptor antagonist, because remember, my ligand and hypothermia are rises because you have a mutation in the rannodyne receptor. So you have an increased release of calcium from the sacroplasmic reticulum, all right? And remember, that's an autosomodominant disorder, okay? So I'm going to go ahead and stop here, I think I've said enough, but again, this stuff super, super high yield to know for your exams, okay? And again, just so if you're interested, I do offer one or one tutoring for all the USML exams, step one, step two, step three, level one, level two, level three. And then I also have a bunch of review classes, they all start, I've actually made a podcast where I talk about those, but I have a bunch of review classes that are starting within the next about, I will say about eight, nine days from now, they're over Zoom. I have like the MBME testicking strategies class, I have the four hour bio statistics class, I have the five hour social sciences, quality improvement, hospital medicine and ethics class. So like the kind of stuff I discussed in this podcast, you want to learn way more about the stuff in way more detail, right?

There's only so much you can cover in 30 minutes versus something you can, you know, a five hour class, you know, we cover like what, like almost 300 scenarios in that class, very helpful material for many people for the exams. And then I also have a last minute review for step two and step three, and then I have a 20 hour step two step three review, you know, again, USML discourse really matter these days, right? So if you're interested in these classes, just shoot me an email and I can give you some more information. And then I have this podcast on Apple Google and Spotify, so check those out, have a You Tube channel where I have the videos that I have made. And then in addition to that, I also have another website titled, divineinterventionlifelessons.com, divineinterventionlifelessons.com. Pretty much every week, you know, I post like, you know, one or two podcasts from a biblical perspective, I address a life lesson. There's actually an Apple podcast associated with that called the divineinterventionlifelessons podcast. I think today I made a episode 349, right? So many people have listened to those podcasts and found those to be pretty helpful. So thank you for listening to me today. I will see you God willing in episode 614. Have a wonderful week ahead. God bless you and bye for now. Thank you.

A cervical X-ray, due to high risk of atlantoaxial instability (C1-C2 subluxation).

Antibiotic prophylaxis (e.g., penicillin/moxacillin) 30–60 minutes before the procedure.

Administer a stress dose of steroids to prevent adrenal crisis upon metabolic stress.

Systolic < 180 mm Hg and Diastolic < 110 mm Hg.

Wait at least 60 days before performing any elective procedure.

Nonselective beta blockers, as they can cause bronchospasm.

Checking PTH and Calcium levels (due to risk of inadvertent parathyroid gland destruction).

Rheumatoid Arthritis, Down syndrome, and Ankylosing Spondylitis.

At least one week before surgery.

Increased risk of aspiration.

They inhibit 5'-diiodinase, preventing peripheral conversion of T4 to T3.

No; the antiplatelet agent should generally continue to prevent thrombosis during the perioperative period.

Checking PTH and Calcium levels (due to risk of inadvertent parathyroid gland destruction).

Rheumatoid Arthritis, Down syndrome, and Ankylosing Spondylitis.

At least one week before surgery.

Increased risk of aspiration.

They inhibit 5'-diiodinase, preventing peripheral conversion of T4 to T3.

No; the antiplatelet agent should generally continue to prevent thrombosis during the perioperative period.