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Goals
1. describe purpose of preoperative evaluation
2. delineate features of H&P which are most important 3. outline sensible cost effective approach to lab testing
I.
elective surgery?
4.) Make specific recommendations regarding preoperative treatment that might lower the risk of surgery. 5.) Give suggestions regarding intraoperative and postoperative care.
II. History
Age see lab algorithm (page 2)for additional studies CC what type of operation what type of anesthesia PMHx surg problems with anesthesia, DVT, PE med diabetes, COPD, bleeding disorders, cardiac, sleep apnea, H/O trauma or surgery to back, ? Need for antibiotic prophylaxis OB LMP allergies meds prescription OTC Herbal (see reference #2) SHx tobacco, ETOH, drug use FHx malignant hyperthermia (autosomal dominant), bleeding disorders, diabetes, ASCVD ROS thorough, esp. LMP, cardiovascular, pulmonary, functional status Advanced directives/Code Status
III. P.E.
Thorough esp. examination of airway and mouth, ROM of neck, cardiovascular and pulmonary.
of surgery -several factors important to consider when deciding whether to order lab tests in asymptomatic individuals 1.) Is there significant likelihood test will be abnormal? 2.) Will discovery of abnormal test result lead to treatments or investigations that reduce the patients surgical risk? 3.) Is it important to get a baseline test for tests that may be repeated after surgery?
UA CXR
- not recommended - debatable. Some recommend in patients >60. Others suggest CXR only if Hx + Px suggests it or intrathoracic surgery planned EKG - EKG for male patients >45*, female patient >50* Pregnancy test - any question of pregnancy
Other thoughts:
- If dementia or history inadequate, routing testing more justifiable. - Some studies suggest prior test results (<4 months old*) adequate, if prior test normal and no change in status. - Routine preoperative testing before elective surgery not justified, because the frequency of unexpected abnormalities that change management is so low. - One possible algorithm:
Test/Age 0-40 40-45 45-49 50-59 60+
H&P
CXR EKG: Males Females Cr/BUN HCT PT/PTT
X*
X* X* X*
X* X* X
before major surgery expected to have high blood loss not indicated in otherwise healthy patients
Site of operation:
-pulmonary complications higher as surgery nears the diaphragm -PPC 10-33% of upper abdominal surgery, 0-10% lower abdominal surgery -General anesthesia causes 10% drop in FRC due to anesthetic and muscle relaxant -When upper abdominal organs handled, diminished diaphragmatic contractility lasts for days -10-30% drop in p02 believed due to V/Q mismatches -In normal patient, these changes unimportant. In compromised patient, these changes can be crucial
What can we do to reduce pulmonary complications? Reduction of risk factors (preoperatively) Tobacco abuse - stop smoking 8 weeks prior to surgery COPD - smoking cessation, optimize lung function, (ipratropium or tiotropium, beta agonist prn, steroids if indicated, lung expansion) -if infected sputum, antibiotics and delay surgery In high-risk patients - incentive spirometry 15 min. QID preoperatively.
Reduction of risk factors (post-operatively)
Algorithm for Preoperative Pulmonary Possible preoperative measures to improve pulmonary function: 1.) smoking cessation (8 weeks) 2.) bronchodilators 3. ) incentive spirometry Postoperative measures to improve function: 1.) incentive spirometry 2.) early mobilization 3.) pain control
A. Multifactorial Risk Studies: 1.) Goldman- best known, most widely used. Looked at 1,001 patients who under went noncardiac surgery in the late 70s. Came up with Goldman Criteria and risk categories:
Goldman Criteria
Points
S3 gallop or jugular venous distention on preoperative physical examination Transmural or subendocardial myocardial infraction in the previous 6 months Premature ventricular beats, more than 5/min documented at any time Rhythm other than sinus or presence of premature atrial contractions on last preoperative electrocardiogram Age over 70 years Emergency operation Intrathoracic, intraperitoneal or aortic site of surgery Evidence of important valvular aortic stenosis Poor general medical condition (K 3, HCO3 20, BUN > 50, Cr > 3, pO2 < 60, pCO2> 40 Abnormal liver (GOT), or bedridden) 11
10 7 7 5 4 3 3 3
Cardiac Morbidity
Class I (0 to 5 points) Class II (6 to 12 points) 0.7% 5%
Cardiac Death
0.2% 2%
11%
22%
2%
56%
-Predicted complication of class 4 well -Low sensitivity for identifying high-risk patient in the intermediate risk groups 2.) Detsky added angina classes, remote MI, and CHF
B. Functional Capacity:
-can help assess cardiac risk before noncardiac surgery
KEY POINT - B-blockers recommended for patients with known or high-risk for coronary artery disease.
Aim for HR <55 (see MGH protocol, p.11) -STATINS in 1 study, they reduce absolute mortality 1%
Summary: -Use perioperative beta blockers if patient high risk for heart disease -Consider pre-operative cardiac testing only if it will change management
VII. Specific Situations A. Diabetes -Little data on perioperative care -Theoretically: elevated glucoses can cause diminished leukocyte function, increased infection rate, delayed wound healing. -Aim for glucoses <200.
B. Hypertension
- mild-moderate diastolic HTN (<110) - adjust meds during the several weeks prior to surgery. Acute control not advisable.
- No absolute threshold for transfusions. Overall clinical picture is what is important. In higher risk patient, keep Hgb above 9*.
D. Adrenal Insufficiency -If three weeks of suppressive doses (Prednisone >7.5 QD) in past six months, stress steroid doses E. Anticoagulation -If on Coumadin (INR 2-3): stop Coumadin approximately 4 days before surgery, Consider preoperative anticoagulation (LMWH or Heparin) for those at highest risk of thromboembolism (see table 8, pg 13). Postoperatively can heparinize. Discuss timing of starting Heparin with surgeon. -D/C ASA at least one week prior to surgery* (unless stent) -D/C nonsteroidals at least one week prior to surgery -if prior PCI, see table 9, page 14 F. DVT/PE Prophylaxis -Prophylaxis: Warfarin, LMWH, SQ Heparin, external pneumatic compression, early activity.
G. Endocarditis Prophylaxis -Efficacy of prophylaxis unproven -AHA 2007 Guidelines: antibiotics for high-risk cardiac abnormality (prosthetic heart valves, prior endocarditis, certain congenital heart disease) undergoing high-risk procedure (see Table 7; p. 12)
VIII. Summary
Preoperative medical evaluation is more than a routine H & P. Do both thorough and focused H & P, order appropriate
IX. Cases
1.) L.T. is a 68 year old man with diabetes, COPD, osteoarthritis, who is scheduled for hip replacement in two weeks. He has a 56-pack year smoking history. Meds include glyburide, albuterol, ibuprofen. On exam, he has occasional wheezes, barrel shaped chest.
2.) D.R. is a 71 year old woman with a history of hypertension scheduled for carotid endarterectomy. Meds include benazepril. Exam notable for BP of 160/100, right carotid bruit. EKG shows Q waves inferiorly. Last EKG 8 years ago unremarkable. What else do you want to know? Any further testing? What are your recommendations?