Evaluasi Pasien

Rencana Operasi Nonkardiak

PRADITA DIAH PERMATASARI

PENDAHULUAN

Non-kardiak surgery berhubungan dengan angka komplikasi 7-11% dan angka

mortalitas 0.8-1.5% 42 % di antaranya karena komplikasi kardiak

Di Negara uni-eropa 167.000 kasus komplikasi kardiak, 19.000 di antaranya

mengancam jiwa.

Evaluasi Pre-operative
1.

Surgical risk for Cardiac Events

- Cardiac compilcation after non-cardiac surgery depends on patient related
risk factor, type of surgery and the circumstences under where it takes
place
- Surgical factors that influence cardiac risk urgency, invasiveness, type
and duration, change in body core temperature, blood loss, fluid shifts.

2. Type of surgery

3. Functional capacity

4. Risk indices
- type of surgery
- history of IHD
-history of heart failure
- history of cerebrovascular disease
-pre-operative treatment with insulin
-pre-operative creatinine > 2 mg/dl

5. Biomarker

6. Non-invasive testing
Non-Invasive

testing on cardiac disease

a. ECG
b. Assessment of LV function

Non-Invasive testing on ischemic heart disease

treadmill or bicycle ergometer

7. Invasive coronary angiografi

RISK REDUCTION STRATEGIES

1. Pharmacological
Beta-blocker

2. Statins

3. Nitrates
use of nitroglycerin decrease preload and may lead to tachycardia and
hypotension
4. ACE-I dan ARB

5. CCB
heart rate reducing CCB may be considered in patients who do not tolerate
beta-blocker
6. Alpha2 receptor antagonist
increased the risk of clinically important hypotension
7. Diuretics
volume status in patients with heart failure should be monitored carefully

PERIOPERATIVE MANAGEMENT IN
PATIENTS ON ANTI-PLATELET AGENTS
1.

Aspirin
The use of low-dose aspirin should be based on individual decision
2. Dual antiplatelet therapy
In patients needing surgery within a few days, ESC recommend withholding clopidogrel
and ticagrelol for five days and prasugrel for seven days prior to surgery unless there
isi a high risk of thrombosis
3. Reversal of antiplatelet therapy
Patients receiving anti platelet therapy, who have excessive or life threatening
perioperative bleeding, transfusion of platelet is recommended

PERIOPERATIVE MANAGEMENT IN
PATIENTS ON ANTI-COAGULATIONS
1.

Vitamin K Antagonist

2. Non-VKA oral anticoagulant (NOACs)

3. Reversal of anticoagulant therapy

- Vitamin K antagonist
Patient receiving VKA reversal low dose (2.5-5.0 mg) intravenous or
oral vitamin K
- Non-vitamin K oral anticoagulant
reversal prothrombin complex concentrate

REVASCULARIZATION

SPECIFIC DISEASES
1.

Chronic heart failure

2. Arterial Hypertension

3. Valvular Heart Disease

4. Arrythmias

5. Renal diseases

6. Cerebrovascular diseases

7. Peripheral artery diseases

8. Pulmonary diseases

9. Congenital Heart Diseases

SUMMARY OF PRE-OPERATIVE CARDIAC RISK

EVALUATION AND PERIOPERATIVE MANAGEMENT

History
Age > 70 years (5 points)
Myocardial infarction within
6 months (10 points)

0-5 Points: Class I 1% Complications

6-12 Points: Class II 7% Complications

Cardiac Exam
Signs of CHF: ventricular
gallop or JVD (11 points)
Significant aortic stenosis (3
points)
Electrocardiogram
Arrhythmia other than sinus
or premature atrial
contractions (7 points)
5 or more PVC's per minute
(7 points)
General Medical Conditions
PO2 < 60; PCO2 > 50; K < 3;
HCO3 < 20; BUN > 50; Creat
> 3; elevated SGOT; chronic
liver disease; bedridden (3
points)
Operation
Emergency (4 points)
Intraperitoneal,
intrathoracic or aortic (3
points)

13-25 Points: Class III 14% Complications

26-53 Points: Class IV 78% Complications

THANK YOU