DIP Ep 613: Peri-operative Medicine (Social Sciences)

Uh this podcast is pretty high yield for the USMLEs and it's one of these things that falls under the purview of uh social sciences. Okay. Um again remember the social sciences these days constitute about You know, you know, between that and biostatistics, probably about ten to fifteen percent of the US ML.

And um if those are subjects you struggle with, you may be interested in the classes I offer. Um so not this coming week, but next week. The the week after that I do have a four-hour biostatistics class. and a five hour social sciences and ethics class. Tons of people have taken those classes and found them to be extremely helpful.

So this podcast, um uh I guess maybe the 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 you either it's it's one of those you either know it or you don't kind of propositions, right? So um you're gonna 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 gonna be in some really good, in some really good shape. Okay. I think you're gonna be in some really, really, really good, good shape. All right. So let's uh 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 sulfur urea or whatever. What are you supposed to do? um you know the person is coming in for surgery or whatever. I would really hope that you're telling the person to hold uh his or her oral hypoglycemic agents. Okay. Please, if a person is getting surgery, it is very, very important

That those people's oral hypoglycemic 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 uh Uh that's TK and metformin. Remember metformin can cause lactic acidosis.

It can cause kidney problems. It can cause liver problems, right? So you want to hold it because they 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.

Uh that person either has DKA or HHNS or the person has metformin toxicity. So that's something you just really want to be careful about, right? People that are pre-operative 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 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 pre-operative 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 uh intubation. What kind of pre-operative pr uh 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 atlantoxial instability. Atlantoaxial instability. So, because they have a high risk of Atlanto axial instability, which sometimes is called C1 C2 subluxation, 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 um Down syndrome. Down syndrome is also associated with Atlanto axial instability. This could also be created for a person that has a

Um, ankylosin spondylitis. Ankylosin spondylitis also has a strong association with Atlanto axial instability. All right. Now. Third scenario, what if they give you a question about a person and you're told that this person has like some kind of valvul disease or they've had like some kind of prosthetic heart valve play? And then the person is on warfarin, you know, is w is on warfareing as a as a you know.

Thromboembolic disease prophylaxis, right? Because remember, if you have valvular disease and let's say you've had a valve placed, especially those mechanical valves, right? You you gotta be unworked. So for those people, uh, what do you need to do preoperatively? Well I would really hope that you're thinking that, oh, wait.

This person's warfareing 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 gonna have an increased risk of bleeding complications. They're gonna have an increased risk of bleeding complications. For those people, you need to bridge them with warfarin. Those I mean with heparin, sorry. Those people need to be on heparin. Even these anti-platelet drugs like Clopidogrel and aspirin.

Those things you need to hold them for a few days before surgery. I know some people may be wondering, excuse me. Excuse me. So some people may be wondering, Divine, 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 uh to keep at the back of your mind for exams, right? So many of these

Uh anticoagulants, many of these antiplatelet drugs, they gotta be held with surgery. They gotta be held be a few days before surgery, right? If you need anticoagulation in the perioperative period. Heparin is what you're gonna be able to what is what you're gonna use. You know why? Because you can turn off heparin pretty quickly and the effects wear off uh fairly quickly. All right. So that's something I wanna 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 uh dental procedure, right? And you're told that this person has a prior history of infective endocarditis, then what do you need to do? You're gonna give them endocarditis prophylaxis, right? Remember, if you have a history of a prior history of endocarditis, or you have an unrepaired cyanotic congenital heart defect, or you have um

Let's see. Um, so prior history of endocritis, unrepaired psynotic 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 gonna need endocrititis prophylaxis.

Okay, you need to do this about 30 to 60 minutes before you your procedure begins. You need to be given a cell wall inhibitor like amoxicillin or ampicillin or something along those lines, right? So that's something that's pretty high yield to know for you, exam. 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 of some sort, right? Typically, it's going to be cephazolin, 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, um, that she has had it for the past life. You know, and she's been on pharmacotherapy for it for the past like six months. And the person is getting any kind of surgery. Um What kind of perioperative considerations should you have for this baby?

Well I would really hope that you're saying that, oh divine, um this person needs to uh 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? Um, 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 access 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 gonna run into an adrenal crisis of some sort with surgery. Okay, they're gonna 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 pre-operative or perioperative consideration has to do you have to think about? Well, I would really hope you're saying that hey, this person is gonna need some pharmacological tuna. some pharmacological tune ups, right? Like um either um you

They get the alpha blockade first and then they get better blockade. Because again, the process of surgery, if you have like a phyochromocytoma already, I mean I would hope that you you you fix it. But honestly, even if you you don't you don't e even if You're getting surgery for your phytochromocytoma. You still need to do this thing about to say, but you need to do alpha blockade first.

And then after that, you're gonna do beta blockade, right? Because again, you don't wanna trigger a hypertensive crisis from whatever fuel chromocytoma or whatever thing that he has. Please, this is actually very important to know. I know some of these vignettes I'm talking about may 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 this stuff for your exam.

And the thing is things like these are not things that people can ordinarily prepare for very well, right? Again, very, very high yield to know these things for your exams, right? Very, very high you'll 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? M E N2A and 2B are both associated with pheochromocytomas. Okay. They are both associated with pheochromocytomas. All right. Now, another thing to uh

And you know, I I've kind of talked about like the Wolfrain and the aspirin and the clopidogram. Why do you think we stop 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 if for example a person has a cornery stent that has been placed, right? So they have like a bare metal stand.

or drug eluding stent, right? Those people, if if they really need surgery, um you should probably continue their you you should you should probably continue their aspirin, right? Because you don't want them to have uh rhiztenosis uh during the perioperative uh period during the perioperative period. All right.

Now, one other thing that is super high yield to know, remember I've made a podcast recently about herbal supplements and the USMLEs. That's uh that's a podcast you should go back and listen to. Uh there's a lot of stuff they love to test with, though. But the thing is herbal supplements, if a patient is on herbal supplements, what kind of recommendation should you give them preoperatively on the US ML 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 ephedra, right? uh Ginkgo you know, Ginkgo Biloba, Ginseng, uh you know, Kavakava, you know, St. John's War. Right? Echinesia. 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? Are there 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 diastolic.

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 your exams. And one other thing I'm thinking about here that I think I want to throw in as a tidbit. Um is that if a person has uh If a person has uh 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 like very dangerous hemorrhage with that. Something just again I want to keep at the back of your mind for a

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 uh, you know, underwent coronary andrography with stem placement and the person requires surgery, how long? How long after an MR? How long should you wait after an MI before you do uh surgery on a person? Elective surgery. Elective surgery. I would really hope that you're saying divine at least 60 days.

At least 60 days, right? If you try to have any kind of elective surgery, uh Less than 60 days after a person has an MI. Ooh, that's not good, right? They have a very, very high risk of things like reinfarction, high risk of things like death, right? Um again. Obviously, many of these rules I'm discussing apply to elective surgeries. If a surgery is emerging, you're gonna go ahead and do the surgery. If not, the patient is gonna die, right?

So it's just very important. After a person has had an MI, they've 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 blocker?

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 perioperative period. It can be continued during the perioperative period. Uh 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. Uh because actually b beta blockers have actually been shown to be kinda helpful, you know, you know, they actually decrease cardiac events, they decrease mortality.

the the um you know, especially during during the perioperative period. Um so it's just something you wanna keep at the back of your mind for examps, right? Especially people that have like coronary artery disease. Again, if they're not having if if they're not having uh uh side effects from the beta blocker is 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 gonna be having uh an elective cholesteromy or whatever, you know, or some kind of surgery down the line. Um, what kind of Perioperative concentration 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 impairs wound 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?

Uh smoking kind of closes up your airway, right? Kind of closes up your airway. 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.

And then also, I guess since I kind of talked about beta blockers, you know, because sometimes in the process of surgery, you know, especially with like, you know, blood pressure management and stuff, uh, some people can actually get beta blockers during surgery and whatnot.

Well, remember, you want to be careful about beta blockers, especially non-selective beta blockers in people that have a history of what? Of asthma. In people that have a history of asthma. Because remember, people that have a history of asthma, if you give them a non-selective beta blocker, you can have bronchospasm.

Okay, you can have bronchospasm. You can have bronchospasm. So that's something you want to keep at the back of your mind for exams. And even with people that have asthma, besides avoiding non-selective beta blockers. It is actually pretty high yield to know that these people, um, 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 pre-op steroids, getting some pre op in you know, inhaled beta to agonists like albuterol, right? Just to open up their airways, right? Because again, the thing is intubation. Can cause bronchospasm, right? You're literally introducing a hostile, rigid body into a person's earway, right? So some pre-operative corticosteroids, pre-operative, uh, you know, inhaled like beta toagonis.

It's 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 COPD 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. Uh that's not something you wanna do on your exams. That's not something you wanna do on your Okay. Now, what if they give you a question about a person that has COPD, 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 ABGs, 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 exact

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 uh uh the development of aspiration, right? The development of aspiration, the 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 gonna 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 gonna lock up your GI track.

Right, that can cause you to aspirate. Or if a person has diabetic gastroparosis or a person is on a GLP1 agonist, those things degree gastric emptying, those things are gonna 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 gotta fast. You can't eat anything before after midnight when you're coming for surgery.

The reason they'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? That'll that'll be like really bad. That'll be really bad, right? And then don't forget some other things as well. If a person has like a hydrohernia, right? If a person has a hydrauhernia, right?

Um, those things can all raise 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 USMLEs they 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 biostats 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 kinda odd to many of you. But 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 this stuff and make sure you know it well for your for your exams. All right. And then um

Just a few more quick things before we be before we wrap up. But I I I I will encourage you that what if they give you a question about a person and this person has like a history of uh Graves disease or whatever, and the person's Graves disease um, you know, has not been definitively treated, and the person requires surgery of some sort. What kind of preoperative intervention would you say this person needs?

I would really hope that you're seeing that this person needs pre-operative 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.

Um they can have thyroid storm, right? So you need to give them a beta blocker pre-operatively 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' diiodines, a five prime diiodinese. That 5' diodinese 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 gave it with the giant cell arthritis example. This person deserves uh a stress dose of steroids pre-operatively or even intra-operatively. I will encourage you as well if a person has a history of Addison's disease, if a person has a history of Addison's disease.

Primary adrenaline sufficiency. Those people should also, okay, those people should also, those people should also get. um intraoperative, pre-operative, uh corticosteroid therapy, right? A stress dose of corticosteroids, right? And then what if they give you a question about a person that is getting a thyroid resection?

For some kind of um thyroid cancer. You know, let's say like uh follicular thyroid cancer or papillary thyroid cancer. And then they ask you what kind of intraoperative intervention should be considered. Um I would really encourage you uh to make sure that the person's uh Um uh PTH-related labs are checked, right? Make sure that you check their PTH, make sure you check their calcium, right? Because this is pr pr pretty high yell to know for exams, right? But the thing is.

You can inadvertently destroy the parathyroid gland when you're doing thyroid surgery. So you gotta make sure that you've not destroyed it and the way you can make sure is by just checking the acerum 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 hypocalcemic crisis, ooh, 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 finish wrap up those surgeries, uh we gotta check those calcium labs, right? Just to make sure everything is teed up with the 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? You should get screening for OSA.

You gotta get screened 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 OSA, right? As a primary care screen for OS OSA, right? The stop bang uh questionnaire. The stop bang uh questionnaire. Okay. Very great way to screen for obstructive sleep.

Right. Very good with screen for obstructive obstructive sleep apnea. Right. And again, you know, don't forget your malignant hyperthermia that you can get with inhaled anaesthetics, right? Or even soxinolcholine, right? You know, do you see a person during surgery? They have like very high body temperatures, they have muscle rigidity, they have rhabdomyolysis, their creatine kinase is elevated, their white count is elevated, right?

Those people, um, you need to give them a dantrolin, right? That's a rhinodine receptor antagonist. Because remember, malignant hyperthermia arises because you have um a mutation in the rhinodine receptor. So you have an increased release of release of calcium from the psychoplasmic reticulum. All right.

And it remember that's an autosomal dominant disorder. Okay, so I'm gonna 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. If you're interested, I do offer one-on-one tutoring for all the USML exams. Step one, step two, step three, level one, level two, level three. Um, and then I also have a bunch of review classes. They all start.

Um I've actually made a podcast where I talk about those, but I have a bunch of review classes that are starting. Um within the next about I will say about eight, nine days from now, they're over Zoom. Um I have like the MBME test taking strategies class, I have the four-hour biostatistics 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 this stuff in way more detail, right? 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. very helpful material for for many people for the exam. And then I also have a

uh last minute review for step two and step three and then I have a twenty hour step two, step three review. You know, again, USMLE scores 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 these podcasts on Apple, Google, and Spotify. So check those out. I have a YouTube channel where I have the videos that I have made. And then in addition to that, um I also uh

Have another website titled uh divine intervention lifelessons.com. Divine intervention lifelessons.com. Um, pretty much every week, um, you know, I post like, you know, one or two podcasts right from a biblical perspective, I address a life lesson. There's actually an Apple podcast associated with that called the Divine Intervention Life Lessons Podcast.

Um, I think today I made 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 six hundred and fourteen. Have a wonderful week ahead. God bless you and buy you. Thank you.