What is the most impt thing about the preop hx and physical?
- assessing cardiac risk
- CV events are leading cause of perioperative death
Joint commission for accreditation of hospitals requrires what for all surgical pts?
- reqrs all surgical pts to have a H and P documented in the medical record w/in 30 days b/f surgery
- the goal is to reduce complications and health care costs
- a standard preop eval hasn’t been defined
- routine lab, cv and pulm tests are often performed w/o justification
Serious morbidity during surgical procedures usually is a result of what? What is the role of the medical consultant b/f surgery?
- 3-10% of pts undergoing surgical procedures experience serious morbidity, most of which results from cardiac, pulmonary or infectious complications
Role of medical consultant b/f surgery is:
- clearly defining the pt’s medical conditions
- eval severity and stability of these conditions, -optimizing all medical conditions
- providing a surgical risk assessment
- recommending perioperative measures to reduce the risk
Physiologic changes during aneshesia and surgery?
- physiologic effects of anesthesia: peripheral vasodilation leading to hypotension, most of the anesthetic agents also lead to reduced myocardial contractility
- the decrease in tidal volume caused by general and spinal epidural anesthesia can cause atelectasis
- epi and NE levels are elevated during surgery and the 1st and 2nd postop days
- the serum cortisol is generally elevated for 1-3 days (increases sugar, suppresses immune system)
- serum ADH may be elevated for up to 1 wk postop
What is the most impt aspect of the preop eval?
a thorough hx including:
- thorough ROS
- extensive med hx, OTC
- allergies
- surgical and anesthetic hx
- fxnl status
What should you pay attention to in the ROS?
- undx or inadequately controlled chronic disease
- cardiac and pulm (recent chest pain or exertional SOB esp impt)
- bleeding disorders (hemophilia, von willebrands)
- hx of DVT
What do you need to ask about in medication hx?
- not just Rx meds that are impt
- recent use of anticoagulants, aspirin, and nonselective NSAIDs
- don’t forget supplements, herbs
Potential effects of preop use of common herbal therapies?
- echinacea: hepatotoxicity
- ginseng: PLT inhibitor, hypoglycemia
- garlic: PLT inhibitor, preload reduction
- gingko: PLT inhibitor, alters vasoregulation
- St. John’s wort: upregulates P450, drug-drug rxns
- kava: potentiates sedation, drug-drug rxns
What are impt allergies to ask about?
- allergies to rubber product? Latex?
- allergies to any foods assoc w/ latex rxns such as bananas, avocados, kiwis, apricots, melons, and chestnuts?
Impt surgical and anesthetic hx ?s to ask about?
- hx of bleeding complications during surgery
- personal or family hx of major rxns to anesthetics
Impt fxnl status eval of pt?
- what is pt’s self reported exercise tolerance?
- what is pt’s activity level?
- a great tool to use for assessing fxnl status is the duke activity status index (ability to perform greater than 4 metabolic equivalents has been assoc w/ a lower CV risk)
Preop eval of cardiac risk?
- cardiac complications of noncardiac surgey are perhaps major cause of perioperative morbidity and demise
- approx 1 mill pts undergoing surgery each year suffer a cardiac complication, 50,000 pts have MI
- pts w/o a hx of CAD are at extremely low risk (less than 0.5%) for perioperative ischemic complications
What are the RFs for major cardiac complications (lee index)?
1 pt for each of the following:
- high risk surgery
- hx of ischemic heart disease
- hx of CHF
- hx of stroke or TIA
- insulin-dependent DM
- serum Cr over 2 mg/dL
pts and complication rate:
- 0 pts, 0.4% complication rate
- 1 pt, 1% complication rate
- 2 pts, 7% complication rate
- greater or equal to 3 pts, 11% complication rate
- complications include MI, pulmonary edema, Vfib or primary cardiac arrest, complete heart block
Is there a routine noninvasive cardiac test done preop?
- no, there is no convincing evidence that routine noninvasive cardiac stress testing improves periop care
When is noninvasive cardiac testing preop indicated?
if 2 of the following factors are present:
1) intermediate clinical predictor
- class 1 or 2 angina
- prior MI based on hx or pathologic Q waves
- compensated or prior herat failure
- diabetes
2) poor fxnl capacity (less than 4 metabolic equivalents)
3) procedure w/ high surgical risk (emergency surgery, aortic repair or peripheral vascular surgery, prolonged procedure w/ large fluid shifts or blood loss)
Management of low risk pt w/ CAD perioperatively?
- these pts have 4-5% risk of major cardiac complication
- they should be considered for prophylactic revascularization only if indications for revascularizaiton exist independent of noncardiac surgery
- preop anti-anginal meds should be continued preop and in post op period
- prophylactic IV nitro may reduce ischemia but hasn’t been shown to reduce the rate of postop complications
Management of high risk pts w/ CAD for surgery?
- in these pts surgery should be delayed until CAD is tx, if possible
- for pts w/ recent MI, delaying the surgery for 3-6 months may be useful
Preop eval for CHF pts?
- decompensated CHF as indicated by elevated JVP, an audible 3rd heart sound or evidence of pulmonary edema on exam or CxR significantly increases risk of perioperative pulmonary edema (15%) and death (2-10%)
- preop control of CHF w/ diuretics and afterload reducing agents decreases the risk but diuretics can increase risk of intraop hypotension
- electrolytes and digoxin level should be checked
- the anesthesiologist and surgeon should be made aware of presence and severity of CHF
What would you do if you heard a murmur in a pt who has come in for a routine preop history and physical?
- get an echo
Preop eval for pt w/ valvular heart disease?
- pts w/ heart murmurs should have echos to define the nature and severity of valvular lesions. Pts w/ sig lesions may need abx prophylaxis and appropriate fluid management and consideration of invasive intraop monitoring
- pts w/ severe sx aoritc stenosisare at especially high risk for complications
Preop eval of arrhythmias?
- finding of a rhythm disturbance during preop eval should prompt consideration of further cardiac eval, especially if the finding of structural heart disease would alter perioperative management. Pts found to have a rhythm disturbance w/o structural heart disease are at very low risk for perioperative complications
- in pts w/ a fib, rate should be controlled and they should be covered w/ lovenox window
- sx supraventricular and ventricular tachycardia should be controlled b/f surgery
- pts who have indications for permanent pacemaker should have these placed b/f surgery
Preop eval of HTN?
- severe HTN (greater tahn 180/110) has been assoc w/ higher risk of cardiac complications
- therefore BP should be controlled b/f surgery if possible
Preop eval for pulm complications?
- risk of developing pulm complications is highest in pts undergoing cardiac, thoracic, and upper abdominal surgery
- the 3 pt specific factors assoc w/ increased risk of postop pulmonary complications are: chronic lung disease, morbid obesity and tobacco use
- pts w/ chronic lung disease, esp those w/ FEV1 less than 500ml or an arterial pCO2 greater tahn 45mmHg are at highest risk
- CXR for pts older than 60 good preop eval
- pts w/ asthma at optimal pulm fxn at time of surgery don’t appear to be at increased risk
- smoking cessation for at least 8 wks has been show to reduce risk of pulm complications in pts undergoing CABG
- the use of incentive spirometry and deep breathing exercises begun preop and continued for 3-5 days in postop period reduces the incidence of postop atelectasis
Periop management of pts w/ lung disease?
- DVT prophylaxis is impt, esp in pt undergoing or hip surgery
- abx may be useful in pts coughing purulent sputum
- pts who take theophylline should be maintained on IV theophylline when necessary (narrow therapeutic window)
Preop heme eval- what if blood work shows that the pt has some anemia?
- does this pt need preop eval for anemia: certain types of pts (with immune hemolytic anemia and sickle cell disease need to be eval b/f surgery) are at high risk
- does this pt need transfusions: usually pts w/ hemoglobin of 8-9 g/dL do well though in some situations like pts w/ CAD, CHF and PVD we like to see a higher hemoglobin
Bleeding risk assessment preop?
- hx is most impt part of eval
- when the hx is unavailable a formal eval should be done and should consist of PT, PTT, platelet count and bleeding time
What ?s should you ask to eval risk of bleeding?
- have you ever bled a long time or developed a swollen tongue or mouth after cutting or biting your tongue, cheek or lip?
- do you develop bruses larger than a silver dollar w/o being able to remember how you injured yourself?
- has bleeding ever started again the day after a tooth extraction?
- was bleeding after surgery ever hard to stop? Have you had unusual bruising around an area of surgery or injury?
- has any 1st degree blood relative had a problem w/ unusual bleeding or bleedin after surgery?
Neuro eval - preop?
- 2 MC serious SEs of surgery in the area are acute delirium and stroke
- it is impt to avoid meds that can cause delirium. Meperidine, anticholinergics, and benzos have all been assoc w/ delirium
- postop stroke is a relatively infrequent complication. Older age, sx carotid stenosis and the occurence of postop afib and RFs for development of stroke
Preop eval for DM?
- pts w/ diabetes are at increased risk for postop infections and MIs
- regulation of blood sugar can also be difficult in these pts: generally, the goal should be to keep the sugar b/t 100-250 mg/dL
- all pts w/ diabetes should have their renal fxn, and electrolytes measured and corrected b/f surgery.
When should glucocorticoid replacement be considered?
- in any pt who has been on 7.5 mg of prednisone for 3 wks or 20 mg prednisone for a wk
- if there is evidence of adrenocortical insufficiency, these pts should receive 100mg of hydrocortisone every 8 hrs beginning on morning of surgery and continuing for 48-72 hrs. Tapering the dose is not necessary
Preop eval of hypothyroidism?
- severe sx hypothyroidism should be corrected b/f surgery
- pts w/ mild or asx hypothyroidism generally tolerated surgery well
Preop eval for renal disease?
- these pts are at high risk for periop comlications such as postop hyperkalemia, pneumonia and fluid overload
- dialysis dependent pts should be dialyzed 24 hrs b/f surgery. Their electrolytes should be carefully monitored in periop period
- pts w/ renal insufficiency, defined as elevated serum Cr or BUN should have their volume status monitored as hypovolemia can increase the risk of postop deterioration in renal fxn
Physical exam preop?
- ensure thorough CV and pulm exam
- unexpected abnormal findings on physical exam should be fully characterized and investigated b/f elective surgery
What are the med recommendations perioperatively?
- most Rx meds should be continued on morning of surgery w/ small sips of water ,unless CI
- ACEI and diuretics usually withheld day of surgery (increases risk for renal failure and hypotension)
- pts w/ diabetes: no metformin or oral hypoglycemics day of surgery, whether or not and how much insulin a diabetic takes largely dependent on pt
- d/c herbal supplements 2 wks prior to surgery
- pts whose risk of bleeding from preop use of ASA for 7-10 days, nonselective NSAIDs for 3-5 days, and thienopyridine (such as plavix) for 2 wks
- although much more complicated, as a general rule, a pt taking warfarin may have surgery as long as INR is less than 1.5
- all pts w/ CV RFs should receive bbs perioperatively unless strongly CI
Best tool to use when performing preop eval?
- hx