PREOPERATIVEMEDICALEVALUATION I. PreoperativeMedicalEvaluation: primarycarephysicianbeingaskedto: 1.) Establishbaselinehistoryandphysical. 2.) Identifypreviouslyundetecteddisease. 3.) Assessoperativerisk.Shouldthepatientproceedwithelectivesurgery? 4.) Makespecificrecommendationsregardingpreoperativetreatment thatmightlowertheriskofsurgery. 5.) Givesuggestionsregardingintraoperativeandpostoperativecare. II.

History: Age seelabalgorithmforadditionalstudies(page2) CC whattypeofoperation whattypeofanesthesia

HarryColt 8/26/09

PMHx surg problemswithanesthesia,DVT,PE med diabetes,COPD,bleedingdisorders,cardiac,sleepapnea,H/Otraumaor surgerytoback,?needforantibioticprophylaxis OB LMP allergies meds prescription OTC Herbal(seereference#2) SHx tobacco,ETOH,druguse FHx malignanthyperthermia(autosomaldominant),bleedingdisorders, diabetes,ASCVD ROS thorough,esp.LMP,cardiovascular,pulmonary,functionalstatus Advanceddirectives/CodeStatus III. P.E.: Thoroughesp.examinationofairwayandmouth,ROMofneck,cardiovascular pulmonary. IV. Lab: (MedClinNorthAm 77:289307) routineornonselectivelabtestingnotjustifiable screeningshouldbebasedonage,coexistentillness,typeofsurgery severalfactorsimportanttoconsiderwhendecidingwhethertoorderlab testsinasymptomaticindividuals 1.) Istheresignificantlikelihoodtestwillbeabnormal? 2.) Willdiscoveryofabnormaltestresultleadtotreatmentsor investigationsthatreducethepatient'ssurgicalrisk? 3.) Isitimportanttogetabaselinetestforteststhatmayberepeatedafter surgery? LabTestinginAsymptomaticLowRiskPatients: and

Hgb/HCT recommendedinpatientsbeforemajorsurgeryexpectedtohave highbloodloss notrecommendedforminorsurgeryinasymptomaticindividuals WBC notrecommended Platelets notrecommended Lytes notrecommended Renalfunction asymptomaticrenalinsufficiencymorecommonwithage, andisrelatedtoperioperativemorbidity.Management decisionsbasedonrenalfunction.Therefore,recommended inpatientover50*scheduledformajorelectivesurgery. Glucose notrecommended* LFTs notrecommended Coags abnormalitiesrareinpatientswithoutcluesonHxorPx notrecommended UA notrecommended CXR debatable.Somerecommendinpatients>60.Otherssuggest CXRonlyifHx+Pxsuggestsitorintrathoracicsurgeryplanned EKG EKGformalepatient>45*,femalepatient>50* Pregnancytestanyquestionofpregnancy Otherthoughts: Ifdementiaorhistoryinadequate,routinetestingmorejustifiable. Somestudiessuggestpriortestresults(<4monthsold*)adequate,ifpriortest normalandnochangeinstatus. InSummary: Routinepreoperativetestingbeforeelectivesurgerynotjustified,becausethe frequencyofunexpectedabnormalitiesthatchangemanagementissolow. Onepossiblealgorithm: Test/Age H&P CXR EKG:Males Females Cr/BUN HCT PT/PTT 040 X 4045 X 4549 X X* 5059 X 60+ X X* X* X

X* X* X* beforemajorsurgeryexpectedtohavehighbloodloss notindicatedinotherwisehealthypatients

V. PreoperativePulmonaryEvaluation: Pulmonarycomplicationsareimportantcauseofpostoperativemorbidity

andmortality.Includeaspiration,pneumonia,atelectasis,pulmonary edema,PE. Riskfactors: siteofoperation(mostimportant),durationofsurgeryand anesthesia,tobaccouse,chroniclungdisease,pulmonaryhypertension, obstructivesleepapnea. Siteofoperation: pulmonarycomplicationshigherassurgerynearsthediaphragm PPC1033%ofupperabdominalsurgery,010%lowerabdominalsurgery Generalanesthesiacauses10%dropinFRCduetoanestheticandmuscle relaxant Whenupperabdominalorganshandled,diminisheddiaphragmatic contractilitylastsfordays anestheticanddiaphragmaticparesistogethercause2050%decreasein FRCandexpiratoryflows.Maylastuptotwoweeks. Postoperatively:higherRR,lowerTV.Shallowrespirationscause atelectasis 1030%dropinp02believedduetoV/Qmismatches Innormalpatient,thesechangesunimportant.Incompromisedpatient, thesechangescanbecrucial. Whatcanwedotoreducepulmonarycomplications? Reductionofriskfactors(preoperatively) Tobaccoabuse stopsmoking8weekspriortosurgery. COPD smokingcessation,optimizelungfunction(Ipratrupiumortiotropium, betaagonistprn,steroidifindicated),lungexpansion Ifinfectedsputum,antibioticsanddelaysurgery. Inhighriskpatientsincentivespirometry15min.QIDpreoperatively. Reductionofriskfactors(postoperatively) deepbreathingexercisesorincentivespirometry paincontrol earlymobilization

AlgorithmforPreoperativePulmonaryEvaluation

4 Possiblepreoperativemeasurestoimprovepulmonaryfunction: 1) smokingcessation(8weeks) 2) bronchodilators 3) incentivespirometry

Postoperativemeasurestoimprovefunction: 1) incentivespirometry 2) earlymobilization 3) paincontrol Whoneedspreoperativepulmonaryfunctiontesting?(seebelow) Veryfew.Onlythosewith: 1) Unexplaineddyspneaorexercisetolerance 2) ThosewithCOPDorasthmaandunclearwhetherattheirbaseline 3) plannedlungresection

VI.

PreoperativeCardiovascularTesting: 1/3to1/2ofperioperativedeathsarecardiac. Manyrecentstudiesdevisedtolookathowwecanbetterpredictwhowill

developthesecardiacevents,sothatwecanintervenemedicallyor surgicallypreoperatively. A. MultifactorialRiskStudies: 1.) Goldman bestknown,mostwidelyused.Lookedat1,001patients whounderwentnoncardiacsurgeryinthelate70's.Cameupwith GoldmanCriteriaandriskcategories: GoldmanCriteria

S3galloporjugularvenousdistentiononpreoperative physicalexamination Transmuralorsubendocardialmyocardialinfarctioninthe previous6months Prematureventricularbeats,morethan5/mindocumented atanytime Rhythmotherthansinusorpresenceofprematureatrial contractionsonlastpreoperativeelectrocardiogram Ageover70years Emergencyoperation Intrathoracic,intraperitonealoraorticsiteofsurgery Evidenceofimportantvalvularaorticstenosis Poorgeneralmedicalcondition (K3,HCO320,BUN>50,Cr>3,pO2<60,pCO2>40 Abnormalliver(GOT),orbedridden) CardiacMorbidity ClassI(0to5points) ClassII(6to12points) ClassIII(12to25points) ClassIV(26ormore) 0.7% 5% 11% 22%

Points 11 10 7 7 5 4 3 3 3

CardiacDeath 0.2% 2% 2% 56%

Predictedcomplicationsofclass4well Lowsensitivityforidentifyinghighriskpatientintheintermediateriskgroups

2.) Detsky addedanginaclasses,remoteMI,andCHF B. FunctionalCapacity: canhelpassesscardiacriskbeforenoncardiacsurgery C. SugerySpecificRisk D. Algorithm(ACC/AHA)seebelow 1.)includesurgencyofsurgery,majoractivecardiacconditions,surgery specificrisk,andfunctionalcapacity

ACC/AHAGuidelines(seep6ofhandout)

5Keyquestions(steps) 1) Isthenoncardiacsurgeryurgent? 2) Isthereamajoractivecardiaccondition?(seetable2,p9) 3) Itthepatientundergoinglowrisksurgery?(seetable3,p10) 4) Doesthepatienthavegoodfunctionalcapacitywithoutsymptoms?(seetable4, p10) 5) ClinicalRiskFactors(seetable5,p10) a) Noneproceedwithsurgery b) 1or2proceedwithsurgerywithBetaBlockers c) 3ormoreconsidercardiactestingifitwillchangemanagement;beta blockers E. ReducingPostoperativeCardiacComplications:BBlockers KEYPOINT Bblockersrecommendedforpatientswithknownorhighriskfor coronaryarterydisease.Canreducecardiaccomplicationsignificantly. aimforHR<55(seesampleMGHprotocol,page11) F.Possiblyreducingpostoperativecardiaccomplications 1.)statinsinstudy,theyreduceabsolutemortality1% startstatinsifindicatedlongterm G.Summary: Useperioperativebetablockersifpatienthighriskforheartdisease Considerpreoperativecardiactestingonlyifitwillchangemanagement VII. SpecificSituations: A. Diabetes littledataonperioperativecare Theoretically:elevatedglucosescancausediminishedleukocyte function,increasedinfectionrate,delayedwoundhealing. Aimforglucoses<200. 1.) DietControlled nodextroseorinsulin.Followglucose. 2.) OralAgents Holdoralhypoglycemicthedayofsurgery(holdmetformin for2days). Ifwellcontrolledandshortsurgery,maynotneedinsulin Ifpoorlycontrolled,variablerateIVinsulininfusion(seetable6,page12) Restartoralhypoglycemicwheneatingnormally. 3.) IDDM VariablerateIVinsulininfusion(seetable6,page12) Aimforglucoseof120180 B. Hypertension mildmoderatediastolicHTN(<110)adjustmedsduringtheseveral weekspriortosurgery.Acutecontrolnotadvisable. poorlycontrolledHTNpostponeelectivesurgeryuntilBP<180/110. Iftimeallows,bringBPto140/90overseveralweeks. Takemedsthemorningofsurgery(exceptdiuretic*). C. Anemia Noabsolutethresholdfortransfusions.Overallclinicalpictureiswhat

isimportant.Inhigherriskpatient,keepHgbabove9*, D. AdrenalInsufficiency If3weeksofsuppressivedoses(Prednisone>7.5QD)inpast6months, needstresssteroiddoses. E. Anticoagulation IfonCoumadin(INR23):stopCoumadinapproximately4daysbefore surgery Considerpreoperativeanticoagulation(LMWHorHeparin)forthoseat highestriskofthromboembolism(seeTable8,pg12).Postoperativelycan heparinize.DiscusstimingofstartingHeparinwithsurgeon. D/Cnonsteroidalsatleastoneweekbeforesurgery. D?CASAatleastoneweekpriortosurgery*(unlesscoronarystent). ifpriorPCI,seetable9,page14 F. DVT/PEProphylaxis Prophylaxis:Warfarin,LMWH,SQHeparin,externalpneumatic compression,earlyactivity. G. EndocarditisProphylaxis Efficacyofprophylaxisunproven. AHA2007Guidelines:antibioticsforhighriskcardiac abnormalities(prostheticheartvalves,priorendocanditis,certain congenitalheartdisease)undergoinghighriskprocedure(seeTable7, p.12). VIII. Summary: Preoperativemedicalevaluationismorethana"routine"H&P.Doboth thoroughandfocusedH&P,orderappropriatelabtests,decidewhether furthercardiovascularorpulmonarytestingindicated,makespecific recommendationsregardingpreoperativeandperioperativecare.

IX.

Cases: 1.) L.T.isa68yearoldmanwithdiabetes,COPD,osteoarthritis,whois scheduledforhipreplacementintwoweeks.Hehasa56packyear smokinghistory.Medsinclude:glyburide,albuterol,ibuprofen.On exam,hehasoccasionalwheezes,barrelshapedchest. 2.) D.R.isa71yearoldwomanwithahistoryofhypertensionscheduledfor carotidendarterectomy.Medsincludebenazepril.ExamnotableforBPof 160/100,rightcarotidbruit.EKGshowsQwavesinferiorly.LastEKG8 yearsagounremarkable.

Whatelsedoyouwanttoknow? Anyfurthertesting? Whatareyourrecommendations?

9 ForAdditionalInfo: 1.) ACC/AHAGuidelinesonPerioperativeCardiovascularEvaluation:ExecutiveSummary. Anesthesia&Analgesia106(3):685712,2008. 2.) AngLeeMKetall.HerbalMedicinesandPerioperativeCare.JAMA286(2):208216,2001. 3.) BepojeSRetal.PerioperativeEvaluationofthePatientwithPulmonaryDisease.Chest 132(5):16371645,2007. 4.) FloodC,FleisherLA.PreparationoftheCardiacPatientforNoncardiacSurgery.AmerFam Phys75(5):656665,2007. 5.) MarksJB.PerioperativeManagementofDiabetes.AmFamPhys67(1):93100,2003. 6.) MacphersonDS.PreoperativeLaboratoryTesting:ShouldanyTestbe"Routine"Before Surgery?MedClinNorthAm77(2):289207,1993.

Table3. Cardiac Risk Stratification for Noncardiac Surgical Procedures**

10

Highrisk(reportedcardiacriskoften>5percent) Emergentmajoroperations,particularlyintheelderly Aorticandothermajorvascularsurgery Peripheralvascularsurgery Anticipatedprolongedsurgicalproceduresassociatedwithlargefluidshiftsand/orbloodloss Intermediaterisk(reportedcardiacriskgenerally<5percent) Carotidendarterectomy Headandnecksurgery Intraperitonealandinthrathoracicsurgery Orthopedicsurgery Prostatesurgery Low risk (reported cardiac risk generally < 1 percent) = Endoscopicprocedures Superficialprocedures Cataractsurgery Breastsurgery **Combinedincidenceofcardiacdeathandnonfatalmyocardialinfarction. =Donotgenerallyrequirefurtherpreoperativecardiactesting.

Table4. FunctionalCapacityAssessmentfromClinicalHistory Excellent(Activitiesrequiring>7METs) Carry24lbup8steps Carryobjectsthatweigh80lb Outdoorwork(shovelsnow,spadesoil) Recreation(ski,basketball,squash,handball,jog/walk5mph) Moderate(Activityrequiring>4METsbut<7METs) Havesexualintercoursewithoutstopping Walkat4mphonlevelground Outdoorwork(garden,rake,week) Recreation(rollerskate,dance,foxtrot) Poor(Activityrequiring<4METs) Shower/dresswithoutstopping,stripandmakebed,dusting,dishwashing Walkat2.5mphonlevelground Outdoorwork(cleanwindows) Recreation(playgolf,bowl)

Table5 ClinicalRiskFactors*CardiacRiskIndex HLoischemicheartdisease HLocompensatedorpriorheartfailure HLocerebrovasculardisease diabetesmellitus renalinsufficiency

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