493.2 📚 國考版（醫師國考 / PGY OSCE）

493.2.0.1 📌 Cram Sheet

493.2.0.1.1 🔥 高 yield 20
  1. RCRI 6 因子：high-risk surgery、IHD、CHF、CVD、insulin DM、Cr > 2
  2. RCRI ≥ 3 → 11%+ event rate
  3. NSQIP MICA：integrated risk calculator
  4. METs ≥ 4 = adequate（爬 1-2 層樓）
  5. ACS pre-op → 先治 ACS（goal-directed medical therapy）
  6. Elective surgery 延後 post-PCI：BMS 1 mo、DES stable 6 mo、ACS 12 mo
  7. β-blocker：continue chronic；不 day-of 新開（POISE）
  8. Statin continue + 新開 vascular surgery
  9. ACEi / ARB：morning hold（hypotension 風險）
  10. SGLT2i hold 3-4 d（euglycemic DKA）
  11. GLP-1 RA hold ≥ 1 wk（aspiration risk，ASA 2023）
  12. Metformin：day-of hold（傳統）/ continue if renal OK + no contrast (新)
  13. Chronic prednisone > 5 mg/d ≥ 3 wk → stress dose hydrocortisone
  14. Stress dose：minor 25 mg、moderate 50-75 mg/d、major 100-150 mg/d × 2-3 d
  15. Pheochromocytoma：α-block 14 d → β-block；avoid β-block alone
  16. VTE prophylaxis：Caprini score、LMWH or DOAC
  17. Pre-op NPO：clear 2 h、light 6 h、heavy 8 h
  18. IE prophylaxis：prosthetic valve / prior IE / cyanotic CHD + dental gingival
  19. Smoking cessation ≥ 8 wk preferable
  20. Severe AS symptomatic → AVR before non-urgent surgery；asymptomatic + preserved EF + low/mod surgery → 多 OK
493.2.0.1.2 🔢 必背數字
項目 數值
RCRI factors 6
RCRI low risk event 0.4-0.5% (0 factor)
RCRI moderate 6-7% (2 factors)
RCRI high 11%+ (≥ 3)
Low-risk surgery MACE < 1%
MET threshold ≥ 4
Cr threshold (RCRI) > 2 mg/dL
BMS DAPT before surgery 1 mo
DES stable CAD DAPT 6 mo
DES ACS DAPT 12 mo
Balloon angioplasty 14 d
SGLT2i hold 3-4 d
GLP-1 RA weekly hold ≥ 1 wk (some 2 wk)
Glycemic peri-op target 100-180 mg/dL
Chronic prednisone HPA suppression > 5 mg/d × ≥ 3 wk
Stress dose minor 25 mg × 1
Stress dose moderate 50-75 mg/d × 1-2 d
Stress dose major 100-150 mg/d × 2-3 d
α-block pre pheo surgery ≥ 14 d
Saline pre pheo 1-2 L/d × 24-48 h
NPO clear liquid 2 h
NPO light meal 6 h
NPO heavy meal 8 h
Smoking cessation ≥ 8 wk
Warfarin hold 5 d
DOAC hold (low BR, CrCl > 50) 24 h
DOAC hold (high BR) 48 h
LMWH pre-needle (prophylactic) 12 h
LMWH pre-needle (therapeutic) 24 h
HbA1c elective delay > 8-9%

493.2.0.2 ⭐ 高 yield 表

493.2.0.2.1 RCRI（Revised Cardiac Risk Index）
因子 (1 分/項)
High-risk surgery（vascular, major intra-peritoneal/thoracic）
Ischemic heart disease
Congestive heart failure
Cerebrovascular disease (TIA/CVA)
Insulin-treated DM
Cr > 2.0 mg/dL
Score Cardiac event rate
0 0.4-0.5%
1 0.9-1.3%
2 6-7%
≥ 3 11%+
493.2.0.2.2 圍術期藥物 Hold / Continue
藥 處置
β-blocker chronic Continue
β-blocker 新開 不 day-of
Statin Continue + 鼓勵 (vascular)
ACEi / ARB Morning hold
ASA mono 多 continue (CHD/stent)
DAPT post-stent Delay surgery; emergent 多 keep ASA
Clonidine 新開 不（POISE-2）
CCB 不 prophylactic 新開
SGLT2i Hold 3-4 d（DKA）
GLP-1 RA Hold ≥ 1 wk（aspiration ASA 2023）
Metformin Hold day of (傳統)
Sulfonylurea Hold day of
Long-acting insulin 50-100% continue
Short-acting insulin Hold NPO
493.2.0.2.3 Stress Dose Hydrocortisone
Surgery Hydrocortisone
Minor (dental, cataract, hernia, endoscopy) 25 mg IV × 1 (or usual maintenance)
Moderate (cholecystectomy, TKA) 50-75 mg/d divided × 1-2 d → taper
Major (CABG, Whipple, colectomy) 100-150 mg/d divided × 2-3 d → taper
Septic ICU + fludrocortisone if primary AI
493.2.0.2.4 Pheochromocytoma Peri-op
Step 處置
1 α-block ≥ 14 d (phenoxybenzamine or doxazosin)
2 β-block AFTER α-block
3 Saline 1-2 L/d × 24-48 h pre-op
4 Avoid β-block alone, ephedrine, ketamine, cocaine, morphine
493.2.0.2.5 Anticoagulation Bridge Decision

Bridge with LMWH 必要： - Mechanical mitral valve - Mechanical aortic valve + risk factor (Afib, prior CVA, EF < 30%) - Recent VTE < 3 mo - AF + CHADS2 ≥ 5 - Recent CVA (< 3 mo)

不 bridge： - AF + CHADS2 ≤ 4 - Remote VTE - DOAC (短 half-life)

493.2.0.2.6 Pre-op Fasting
食物 NPO
Clear liquid 2 h
Breast milk 4 h
Light meal 6 h
Heavy meal 8 h
GLP-1 on 延長 / 24 h NPO
493.2.0.2.7 IE Prophylaxis（ACC/AHA 2021）

對象： - Prosthetic valve（含 TAVR） - Prosthetic material in valve repair - Prior IE - Cardiac transplant + valve regurgitation - Cyanotic CHD unrepaired / repaired with residual

操作：dental gingival / periapical / mucosa perforation

藥：Amoxicillin 2 g PO 30-60 min pre

493.2.0.2.8 VTE Prophylaxis
Caprini 處置
≤ 1 Ambulation
2 Pneumatic compression
≥ 3 + LMWH 40 mg qd 或 UFH 5000 BID-TID
Hip/knee replacement + Rivaroxaban 10 mg qd / Apixaban 2.5 BID 10-35 d
493.2.0.2.9 Pulmonary Risk

ARISCAT 因子 (7): age、SpO2、recent resp infection、上腹/胸腔 surgery、surgery > 2 h、Hb < 10、emergency

Modifiable: smoking、bronchodilator、incentive spirometry、CPAP

493.2.0.3 🎯 自我檢測

  1. RCRI 6 因子？→ high-risk surgery、IHD、CHF、CVD、insulin DM、Cr > 2
  2. RCRI ≥ 3 event rate？→ 11%+
  3. MET threshold for “adequate”? → ≥ 4
  4. Post-PCI surgery delay：BMS / DES stable / DES ACS？→ 1 mo / 6 mo / 12 mo
  5. β-blocker day-of 新開？→ 不（POISE）
  6. ACEi morning of surgery？→ Hold
  7. SGLT2i hold？→ 3-4 d（DKA）
  8. GLP-1 RA hold？→ ≥ 1 wk（aspiration ASA 2023）
  9. Metformin？→ day of hold (傳統)
  10. Chronic prednisone HPA suppression criteria？→ > 5 mg/d × ≥ 3 wk
  11. Minor surgery stress dose？→ 25 mg × 1
  12. Major surgery stress dose？→ 100-150 mg/d × 2-3 d
  13. Pheochromocytoma pre-op order？→ α-block 14 d → β-block
  14. Pre-op fasting clear liquid？→ 2 h
  15. IE prophylaxis 對象？→ Prosthetic valve、prior IE、cyanotic CHD、transplant + valvulopathy
  16. IE prophylaxis 不再給？→ MV prolapse、bicuspid AV
  17. Anticoag bridge with LMWH 必要？→ Mechanical valve、recent VTE < 3 mo、AF CHADS2 ≥ 5
  18. Warfarin hold？→ 5 d
  19. DOAC hold (CrCl > 50)？→ 24-48 h
  20. Smoking cessation 最佳 timing？→ ≥ 8 wk
  21. Severe symptomatic AS → ？→ AVR first if 可
  22. Glycemic peri-op target？→ 100-180 mg/dL
  23. HbA1c delay elective？→ > 8-9%
  24. CABG continue ASA？→ 是
  25. LMWH pre-needle (prophylactic / therapeutic)？→ 12 h / 24 h

493.2.0.4 🆘 OSCE 重點

493.2.0.4.1 場景 1：70 歲女 RCRI 2 + 中-高 risk surgery + 不明 METs
  • 詳問 functional status
  • ECG 12-lead resting
  • 視 stress test 結果是否改 mgmt
  • ASA、statin continue
  • 不 day-of 新 β-blocker
493.2.0.4.2 場景 2：60 歲男 chronic prednisone 20 mg × 10 yr + 預定 hip
  • 確認 HPA suppression
  • Stress dose hydrocortisone：100 mg IV pre-op → 50-75 mg/d × 2 d → taper
  • 監測 BP（hypotension if 不夠）+ glucose（hyperglycemia if 太多）
493.2.0.4.3 場景 3：55 歲女 DM2 on dulaglutide weekly + 預定 elective lap chole
  • Hold dulaglutide ≥ 1 wk pre-op
  • Metformin hold day of
  • 監測 BG q4-6 h
  • Glycemic target 100-180
493.2.0.4.4 場景 4：65 歲男 PCI with DES 4 mo ago on DAPT、預定 elective hernia
  • DAPT 期內 → delay surgery to ≥ 6 mo
  • 若不能 delay → 多專科：keep ASA、cangrelor bridge 考慮
493.2.0.4.5 場景 5：50 歲女 incidental adrenal mass 預定 surgery → 必先排 pheo
  • 24-h urine metanephrines + plasma metanephrines
  • 若 +：α-block 14 d → β-block → saline → Q2 surgery
  • 自然 vaginal delivery / vaginal exam 不要做（catecholamine surge）

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