1

Pre-operative evaluation
Chutintorn Sriphrapradang, MD
29 May 2014
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:+ elective vse emergency
Indication ?
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! ..-.:-.., .?, .-..-.?
! Focused review
" ..-.\-/-, functional status
" ..-, :./-...
! Vital signs, weight, height
! Cardiac and pulmonary exam.
! Anatomical conditions
" Airway examination
o+soeu consult
! os.+aeuus:.o os.+s++o+a .aov.e+.a:e
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! :plan
" Anticipate problems & questions
! ooel
! Talk is cheap and effective.
" Direct verbal communication
! Consult, don't insult !
! Follow recommendation
Perioperative Cardiovascular
Evaluation for
Noncardiac Surgery
ACC/AHA 2007 Guideline on Perioperative CV
Evaluation and Care for Noncardiac Surgery
ACC/AHA 2009 Focused Update on
Perioperative Beta-Blocker Therapy
American College of Cardiology - www.acc.org
American Heart Association -www.americanheart.org
Preoperative Clinical Evaluation
Identification of potentially
serious cardiac disorders
Evaluate severity, stability,
and cardiac disorders
CAD eg prior MI, angina
HF
Significant arrhythmia
Severe valvular disease
Other factor to determine
cardiac risk
Functional capacity
Age
Comorbid conditions
eg DM, PVD, CKD, COPD
Type of surgery
2
Active Cardiac Conditions
Unstable coronary syndromes
Unstable or severe angina
Recent MI (<7days/within 30 days)
Decompensated HF
NYHA fn class IV; worsening or new onset HF
Significant arrhythmias
Severe valvular disease
Severe AS
Severe MS
Further
preoperative
cardiac testing is
not generally
required.
Cardiac Risk Stratification for
Noncardiac Surgical Procedures
Vascular
(cardiac risk >5%)
Aortic and other major vascular surgery
Peripheral vascular surgery
Intermediate
(cardiac risk 1-5%)
Intraperitoneal and intrathoracic surgery
Carotid endarterectomy
Head and neck surgery
Neuro surgery
Orthopedic surgery (hip & spine)
Prostate surgery
Low (cardiac risk <1%)
Endoscopic procedures
Superficial procedure
Cataract surgery
Breast surgery
Ambulatory surgery
GYN surgery
Orthopedic (knee)
Estimated Energy Requirements for Various Activities
MET ( metabolic equivalent)
VO2 of a 70kg, 40-year-old man
in a resting stateis 3.5 ml/ kg/min or 1 MET.
Adapted from the Duke Activity Status Index
!
!
Clinical Risk Factors
History of IHD
History of compensates or prior HF
History of cerebrovascular disease
DM
Renal insufficiency
Step
1
Need for emergency
surgery
OR

Postop. surveillance and postop. risk
stratification and risk factor management
Yes

Step
2
Active cardiac conditions
Evaluate and treat per
ACC/AHA guidelines
Consider
OR
Yes

No

Step
3
Low risk surgery
Proceed with
planned surgery
Yes

No

Step
4
Fn capacity ! 4 METs
without symptoms
Proceed with
planned surgery
Yes

No

Step
5
No or unknown
!3 clinical risk
factors
1-2 clinical risk
factors
No clinical risk
factors
Vascular
surgery
Intermediate risk
surgery
Consider testing if it
will change
management
Proceed with planned surgery with HR
control or consider noninvasive testing if it
will change management
Proceed with
planned
surgery
Vascular
surgery
Intermediate risk
surgery
Hypertension
Keep at least BP < 180/110 mmHg
Anti-HT medications should be continued
during periop. period.
Avoid withdrawal of beta blockers and
clonidine
3
Preoperative administration of beta blockers
Decrease the incidence of postop AF
Reduce mortality and the incidence of CV complications
in pts who have or are at risk for CAD
Should be started 1 wks-30 days before elective surgery
Dose titrated to achieve a resting HR 60-70 /min with SBP >100
Recommend in pts with IHD
Not recommend in pts scheduled for low-risk surgery
without risk factors
Preoperative administration of statin
Recommend in high risk surgery pts
Should be started 1 wks-30 days before elective
surgery
Implanted pacemakers and ICDs
Notify cardio
!"#$#%&'()*+, device, settings & battery status,
indication (pacemaker dependent for
antibradycardia pacing?)
Pacemakers
Asynchronous mode during surgery
Magnet
ICDs
Turned off tachyarrhythmia Rx algorithms
Intraop continuous EKG monitoring
Previous PCI
Balloon
angioplasty
Bare-metal
stent
Drug-eluting
stent
Time since
PCI
< 14
days
> 14
days
> 30-45
days
< 30-45
days
< 365
days
> 365
days
Delay for elective or
nonurgent surgery
Proceed to the OR
with aspirin
Delay for elective or
nonurgent surgery
Proceed to the OR
with aspirin
Management of patients with previous PCI
requiring noncardiac surgery
Acute MI, high-risk ACS, or high-risk cardiac anatomy
Bleeding risk of surgery
Treatment for patients requiring PCI
who need subsequent surgery
Stent and continued dual
antiplatelet therapy
Low
Not low
14-29 days 30-365 days > 365 days
Balloon
angioplasty
Bare-metal
stent
Drug-eluting
stent
Timing of
surgery
Aspirin
Risk of periop. hemorrhage vs vascular complications
Continue
- stent ./+01234 CABG ./+ peripheral arterial surgery
5%6) cataract
Stop
7 days
7+8235%6)9-:+;%< perioperative hemorrhage =>8 CNS
o Bleeding time is not recommended as a predictor of
perioperative hemorrhage.
o Postop ?@A+B%C?8 24 'D.E%2F-GH.% bleeding
4
Rationale of IE prophylaxis
IE is more likely result from frequent exposure to random
bacteremias associated with daily activities than from
bacteremia caused by a dental, GI, or GU procedure
Maintenance of optimal oral health and hygiene may
reduce the incidence of bacteremia from daily activities
and is more important than prophylactic antibiotics
ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis
Endocarditis Prophylaxis
Patients at highest risk from IE who undergo dental
procedures that involve manipulation of either gingival
tissue or the periapical region of teeth or perforation of the
oral mucosa
Patients with prosthetic cardiac valves or prosthetic material used for
cardiac valve repair
Patients with previous IE
Cardiac transplant recipients with valve regurgitation due to a structurally
abnormal valve
Specific patients with congenital heart disease (CHD)
Unrepaired cyanotic CHD, including palliative shunts and conduits
Completely repaired congenital heart defect repaired with prosthetic material or device,
whether placed by surgery or by catheter intervention, during the first 6 months after the
procedure
Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch
or prosthetic device (both of which inhibit endothelialization)
Prophylaxis against infective endocarditis is
not recommended for
Nondental procedures
Transesophageal echocardiogram,
esophagogastroduodenoscopy, or colonoscopy in the
absence of active infection.
Dental procedures
I)C%'%&J="K noninfected tissue
x-ray L8
?M/N+)/3O& prosthodontic ./+ orthodontic appliances
3%;PQ;
Endocarditis Prophylaxis
IE regimens for a dental procedure
Back to REAL LIFE
If emergency
" Go on surgery, do not wait for investigation
" Notify anesth.
If urgent
" Follow guideline
" Call for help in the hard decision
Tel.! fellow "
DM
Pre-op.
Pregnancy
Endocrine
disorders
Thyroid
Adrenal insufficiency
5
Diabetes Mellitus
a+noe+s:.+
Asymptomatic cardiac
ischemia
Cardiac autonomic
neuropathy
Proteinuria or abnormal
creatinine clearance
! Risk of
developing periop.
complications
Infectious
Metabolic
Electrolyte
Renal
Cardiac
Hyperglycemia and DM in Hospitalized Setting
e+l::us:.o DM a.sos.+ plasma glucose .:eoev admission
Iv monitor CBG ea++veaIvs.+ 24-48 s:.
1. Fasting PG > 140 mg/dL
Random PG > 140 mg/dL
os.+ HbA1c .a
2. Glucocorticoid therapy
3. Octreotide therapy
4. Enteral/parenteral nutrition
Endocrine Society Clinical Practice Guideline 2012
New Onset
Hyperglycemia

Provocation:
infection or stress ?
Hyperglycemia and DM in Hospitalized Setting
e+:us:.o DM :+oev
Current medication
Insulin vsea+suus:n+v
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Ivos.+ HbA1c e+a+l:.aaos.+n+aIv 3 .ev
Hyperglycemia and DM in Hospitalized Setting
Initial Approach
Always consider and rule out DKA
In general, most patients with type 2 DM
will require insulin therapy
DISCONTINUE oral hypoglycemic agent
Glycemic Goal
Fasting PG < 140 mg/dL
After meal PG 140 - 180 mg/dL
ICU 140 -180 mg/dL
Terminal illness PG < 200 mg/dL

If PG < 100 reassess regimen
PG < 70 modify regimen
Basal
Prandial
Is the patient eating?
6
BASAL INSULIN
NPO
Basal insulin
Glargine (Lantus)
0.3 unit/kg q 24 hr
NPH (HN, insulatard)
0.2 unit/kg AM
0.1 unit/kg PM
GFR <45
Reduce 50%
=!C2R insulin D%7+8
Glargine
continue same dose
NPH
Reduce 50%
(if eating reduce 25%)
Premixed 70/30 or 75/25
50% total dose "NPH

PRANDIAL INSULIN
=!C2R prandial
insulin
Reduce 25%
=!C2R 70/30 or
75/25
Reduce 20%
Eating
Basal + Prandial insulin
Aspart (Novorapid),
Lispro (Humalog)
?@ST+D+%.%#./+
.U,+%.%# 20 8%V2R
RI (HR, actrapid)
0.1 unit/kg
AM Noon PM (Glargine)
AM PM (NPH)
GFR <45
Reduce 50%
Special consideration
ICU patient
RI IV drip if BG > 180
Target BG 140-180
CBG q 1-2 hr
D/C IV RI 1 hr after
SQ insulin
Transition IV to SQ insulin
NPO or minimal oral intake
Glargine
20x last stable IV rate
example, 2 unit/hr
20x2
NPH
10x last stable IV rate
bid

Special consideration
Hyperalimentation/
Tube feeds
Continuous tube feeds
NPH q 12 hr
<%C.W)
P*"8 10DW
prevent hypoglycemia
Bolus feeds
Aspart I).U, feed 2R
TPN
RI add 0.1 unit/g dextrose
plus SQ insulin as needed

High dose glucocorticoids
NPH bid
Prandial insulin-aspart
Half-life prednisolone is
shorter than
dexamethasone
" risk AM hypoglycemia
Pre-op. but pregnancy
Similar as hospitalized patient
After delivery; immediately off insulin (except type 1!)
Post op.GDM usually not or less need insulin
F/U q 6 hr or premeal &hs in postop day1
D/C: F/U OPD endocrine 6wk + 75gm OGTT
Keep CBG 100-200 mg%
NO! Pregancy must keep CBG < 120 mg%
Adrenal insuffiency
Steroid abuse
Prednisolone (or equivalent)
> 7.5 mg/day (more than physiologic dose)
> 3weeks
Systemic, inhaled, topical
Cushingoid appearance
1 ug ACTH stimulation test
Hydrocortisone 100 mg IV then 200 mg/day
( q 8hr or drip continuously)
7
Degree of
surgical
stress
Definition Glucocorticoid dose
Minor
Procedure
under local anesthesia
and < 1h in duration
(e.g. inguinal hernia repair)
Hydrocortisone
25 mg or equivalent
Moderate
Procedure such as
vascular surgery of a lower
extremity or
a total joint replacement
Hydrocortisone
50 75 mg or equivalent
This could be continuation of usual
daily steroid dose (eg, pred 10 mg
a day and HC 50 mg IV during
surg)
Major
Procedure such as
esophagogastrectomy or
CABG
Usual glucocorticoid (eg, pred 40
mg or parenteral equivalent within
2 h before surg) and
hydrocortisone 50 mg IV q 8h after
the initial dose for first 48 72 hr of
postoperative period
Hyper- hypothyroidism
Overt hyperthyroidism
Delay surgery if possible
If emergency surgery! treat as thyroid storm
(in tough situation # fellow/staff)
Overt hypothyroidism
Lab showed hypothyroidism
" delay surgery in elective case
" but in urgent case and pt looks euthyroid, the pt may
proceed to surgery
Notify Anesth.
Difficult extubation
Decreased clearance of sedative drugs
Surgical Hypoparathyroidism
Treatment
0.5 1.5 mg elemental Ca/kg/hr
Mix 10 vials (10 ml) of
10% Ca gluconate in 1L of D5W
= 1 mg elemental Ca/ml
Rate 30 100 ml /hr
Keep Ca 7.2 7.6 mg/dL
dont want to blunt PTH effect & PTH recovery
long term: prevent hypercalciuria from
hypoparathyroidism
10 amps
Iv 1 aos
Preop Hip Fracture
Patients with hip fracture should be
evaluated for secondary cause of
osteoporosis.
Plan for
prevention of fall
and treatment of
osteoporosis
Liver disease
CKD
Pulmonary disease
Rheumatoid arthritis
Liver disease
Avoid surgery if possible
because periop. mortality is very high
Child A 10%, B 30% and C 80% !!!
Avoid hepatotoxic drug
Observe liver failure
Hepatic encephalopathy,
Bilirubin, coagulopathy
Acidosis
Hypoglycemia
Liver size
8
CKD
If elective case and on chronic HD
Adequate HD (BUN>50 ! risk of bleeding)
May use ddAVP 0.3 ug/kg (4 ug/mL = 1amp)
= 4amp in 50mL NSS IV in 15-20min oevluOR 30v+n
!"#platelet $%&'&()*+ uremic bleeding
Fluid & electrolyte imbalance
a++ Nephro standby oe+ueooev admit
Avoid nephrotoxic drug
Contrast induced nephropathy
Onset 24- 48 hrs
peak 3-5 days
Serum Cr ! 0.5mg/dl in 48hrs
Recovery in 1-2wks
Risk factors
Elderly
CHF, LV failure
Pre-existing renal insufficiency
Diabetic nephropathy
Hypovolemia, shock
Abd. aortic angiography
Multiple exposure in 72hrs
Impaired liver function
Contrast Osm ~ 1,000-2,000
MM (light chain deposit)
Prevention
Use lower dose, nonionic contrast
Repeated doses should be avoid within
72 hrs
Adequate hydration: NSS (1mL/kg/hr) 24
hrs, give 2-12hrs before contrast
NAC 600mg PO bid before and after
Alkalinized urine in MM, uric acid
nephropathy
Avoid nephrotoxic drug eg. NSAIDs
Metformin, ACEI/ARB va 48 hrs aa:restart
va+ S. creatinine uoo 48-72 hrs
Nephrogenic systemic fibrosis
High risk: CKD stage 4-5, on dialysis, AKI
Prevention
Macrocyclic chelated agent (Gadoteridol/ Gadovist)
Lowest dose
Avoid repeated exposure
HD within 24 hr x 2 times if needed (after exposure)
PD cant remove Gd.
Risk must inform patient with
GFR 30-60 ml/min even low risk.
120
90
60
15
30
1
2 3
4
5
Pulmonary Evaluation
Definite risk factors
Age >50 years
COPD
CHF
Poor general health (ASA class >2)
Functional dependence
OSA
Pulmonary hypertension
Low oxygen saturation
Serum albumin <35 g/L
Upper abdominal, thoracic, aortic, head
and neck, neurosurgery, and abdominal
aortic aneurysm surgery
Surgery >3 hours
Emergency surgery
Use of pancuronium as a neuromuscular
blocker

Probable risk factors
General anesthesia (when
compared with spinal or epidural
anesthesia)
PaCO2 >45 mmHg
Abnormal chest radiograph
Cigarette use within the previous
eight weeks
Current upper respiratory tract
infection
Pulmonary Evaluation
Pulmonary function tests
Uncharacterized dyspnea or
exercise intolerance
COPD or asthma where clinical
evaluation cannot determine if
airflow obstruction has been
optimally reduced.
History
Exercise intolerance, cough,
and unexplained dyspnea
Chest x-ray
Age > 50 years
Cardiac or pulmonary disease
( unless one has been obtained in
the past 6 months).
Indication for pre-op PFT
! X;!89 plan for lung resection/ intrathoracic surgery
! YZ"C9-+%;%#2+ ./+ unexplained dyspnea
! YZ"C9 history of chronic lung disease
! YZ"C9- history of smoking D%;;[% 20 pack-year
! 2D\!"#4=]8 routine ?8 abdominal surgery, obesity
or old age
normal PFT l:laua.++:l:.o respiratory complication
9
Patient-related factors
Age>60 yrs
Chronic lung disease
CHF
Functional dependence
ASA class >II
Cigarette use
Obesity
Asthma
OSA
Impaired sensorium
Abnormal findings on chest
examination
Alcohol use
Weight loss
Exercise capacity
DM
HIV infection
Procedure-related factors
Surgical site
Thoracic, upper abdominal Sx
Aortic aneurysm repair,
vascular surgery
Neurosurgery
Head and neck surgery
Duration of surgery (3 hrs)
General anesthesia
Emergency surgery
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RISK-REDUCTION STRATEGIES
Preoperative
Cessation of cigarette smoking for at least 8 wks
Treat airflow obstruction--COPD or asthma
Administer antibiotics and delay surgery --respiratory infection
Education--lung-expansion maneuvers
Intraoperative
Limit duration of surgery < 3 hrs
Use spinal or epidural anesthesia
Avoid use of pancuronium
Use laparoscopic procedures when possible
Postoperative
Use deep-breathing exercises or incentive spirometry
Use CPAP
Use epidural analgesia
Use intercostal nerve blocks
Nutritional Support
Selective use of nasogastric tubes
N Engl J Med 1999; 340:937-944
Pulmonary
On call; COPD, asthma
Evaluate severity
If severe or infection; delay surgery
If look stable;
Bronchodilator
Avoid drug-induced bronchospasm
Stop smoking
Breathing exercise
ABG, CXR, PFT (as needed)
Rheumatologic disorders
Disease-specific issues
Sjgren's syndrome
Avoid pilocarpine, aware ocular and oral dryness
Rheumatoid arthritis
Anemia, neutropenia
Psoriatic arthritis
Koebner's phenomenon, infection
SLE
Wound infection, renal insufficiency, pulmonary embolism
Scleroderma
Pulmonary HT, arterial vasospasm, risk aspiration
Extra articular complications
Lung fibrosis
Increased CV risks: RA, COX2 inhibitor
scaly
psoriatic
lesions along
the line of a
ventral
hernia repair
Rheumatologic disorders
Glucocorticoids
NSAIDs
Antiplatelet
Stop 3 half-lives before Sx eg. Ibuprofen stop 1 day, naproxen 4
days, ASA 1 wk
COX-2 inhibitor
No antiplt effect but can interfere wound healing
DMARDs
MTX: can continue
Cyclophosphamide, azathioprine, sulfasalazine: stop 3 days leukopenia
Leflunamide: stop 2 weeks
HCQ: very long T1/2
Biologic agents
TNF-!, IL-1, IL-6
Stop 1-2 treatment cycles
Rheumatoid arthritis
Atlantoaxial subluxation
Cricoarytenoid joint
Down syndrome
Atlantoaxial subluxation
Film x-ray C-spine flexion/
extension
Notify anesth.