#preop eval

[mcatmemoranda]

Patient is a [ ] yo male/female presenting to the clinic for a preoperative evaluation.

Procedure [ ]

Scheduled date of procedure [ ]

Surgeon performing procedure requesting consultation for preop is [ ] and can be contacted at [ ]

This patient is/is not medically optimized for the planned surgery, see below for details.

EKG collected in office, interpreted personally and under the direct supervision of attending physician as follows- sinus rate and rhythm, no evidence of ischemia or ST abnormalities, no blocks, normal QTc interval.

The following labs are to be completed prior to surgery, and will be evaluated upon completion. Procedure is to be performed as scheduled barring any extraordinary laboratory derangements of concern.

Current medication list has been thoroughly reviewed and should not interfere with surgery as written.

Patient has no prior history of adverse reactions to anesthesia, problems with airway management, difficult IV access, prolonged emergence, or postoperative nausea/vomiting.

Airway Mallampati score: This patient is a Grade based on the criteria listed below

-Grade I Tonsillar pillars, soft palate, entire uvula

-Grade II Tonsillar pillars, soft palate, part of uvula

-Grade III Soft palate, base of uvula

-Grade IV Hard palate only, no uvula visualized

Patient is a low/medium/high risk for this low/medium/high risk surgical procedure.

Will send documentation of this preoperative visit to surgeon [ ].

**** ADDITIONAL INFORMATION****

Patient Risk for Elective Surgical Procedure as Determined with the Criteria Below:

1- Very Low Risk

No known medical problems

2- Low Risk

Hypertension

Hyperlipidemia

Asthma

Other chronic, stable medical condition without significant functional impairment

3- Intermediate Risk

Age 70 or older

Non-insulin dependent diabetes

History of treated, stable CAD

Morbid obesity (BMI > 30)

Anemia (hemoglobin < 10)

Mild renal insufficiency

4- High Risk

-Chronic CHF

-Insulin-dependent diabetes mellitus

-Renal insufficiency: creatinine > 2

-Moderate COPD: FEV1 50% to 70%

-Obstructive sleep apnea

-History of stroke or TIA

-Known diagnosis of dementia

-Chronic pain syndrome

5- Very High Risk

-Unstable or severe cardiac disease

-Severe COPD: FEV1 < 50% predicted

-Use of home oxygen

-Pulmonary hypertension

-Severe liver disease

-Severe frailty; physical incapacitation

Surgical Risk Score Determined as Below:

1- Very Low Risk

Procedures that usually require only minimal or moderate sedation and have few physiologic effects

-Eye surgery

-GI endoscopy (without stents)

-Dental procedures

2- Low Risk

Procedures associated with minimal physiologic effect

-Hernia repair

-ENT procedures without planned flap or neck dissection

-Diagnostic cardiac catheterization

-Interventional radiology

-GI endoscopy with stent placement

-Cystoscopy

3- Intermediate Risk

Procedures associated with moderate changes in hemodynamics, risk of blood loss

-Intracranial and spine surgery

-Gynecologic and urologic surgery

-Intra-abdominal surgery without bowel resection

-Intra-thoracic surgery without lung resection

-Cardiac catheterization procedures including electrophysiology studies, ablations, AICD, pacemaker

4- High Risk

Procedures with possible significant effect on hemodynamics, blood loss

-Colorectal surgery with bowel resection

-Kidney transplant

-Major joint replacement (shoulder, knee, and hip)

-Open radical prostatectomy, cystectomy

-Major oncologic general surgery or gynecologic surgery

-Major oncologic head and neck surgery

5- Very High Risk

Procedures with major impact on hemodynamics, fluid shifts, possible major blood loss:

-Aortic surgery

-Cardiac surgery

-Intra-thoracic procedures with lung resection

-Major transplant surgery (heart, lung, liver)

High risk surgery: yes/no

Hx of ischemic heart disease: y/n

Hx of CHF: y/n

Hx of CVA/TIA: y/n

Pre-op tx with insulin: y/n

DM/how are blood sugars?

Pre-op Cr >2mg: y/n

OTHER EVALUATIONS BASED OFF PATIENT HISTORY SEE BELOW:

1. CARDIAC EVALUATION

A. Ischemic Cardiac Risk- Describe any history of cardiovascular disease and list the cardiologist/electrophysiologist. For CAD, report the results of the most recent stress test or cardiac cath, type of procedures or type of stents, date of MI, and recommendations for perioperative management. Include antiplatelet management. Continue baby aspirin for patients with cardiac stents - unless having neurosurgery, then coordinate with surgeon.

B. Ventricular function - include most recent echocardiogram evaluation ideally performed within the past 2 years

C. Valvular heart disease- include most recent echocardiogram, type of prosthetic valve

D. Arrhythmias - include any implanted devices and recent interrogation report, contact electrophysiology about device management during the surgery and include recommendations provided. For A-Fib, include CHA2DS2-VASc score

E. Beta blockade - All patients on chronic beta blockers should have these medications continue throughout the perioperative period unless there is a specifically documented contraindication.

F. Hypertension - Other than for cataract surgery, ACEI inhibitors and ARBs should be held for 24hours prior to surgery and diuretics should be held the morning of surgery

G. Vascular disease - include antiplatelet management and dates of strokes

2. PULMONARY EVALUATION

A. COPD/Asthma - include any recent exacerbations, intubations, chronic O2 use, amount of rescue inhaler use

B. OSA risk - STOPBANG score - address severity of sleep apnea and CPAP use

3. HEMATOLOGIC EVALUATION

A. Bleeding Risk - assess the bleeding risk and history for every patient

B. VTE Prophylaxis/Thrombotic risk - estimate risk and provide recommendations

C. Anticoagulation management - include pre-op and post-op medication instructions

D. Anemia - pre-op treatment plan

D. Oncology - history and treatments

4. ENDOCRINE EVALUATION

A. Diabetes mellitus - include type, medication use, recent A1c, pre-op and post-op management instructions

B. Adrenal insufficiency risk - assess for prolonged steroid use in the last year

5. RENAL EVALUATION

A. CKD - include stage, baseline labs

B. ESRD - include dialysis schedule, type, access, dry weight, location of dialysis. Generally, surgery should not be scheduled on a dialysis day.

C. Electrolyte abnormalities

6. GI EVALUATION

A. Liver disease - including MELD score and Child-Pugh classification

7. OTHER relevant comorbidities or anesthesia considerations

[substance abuse, chronic pain, delirium risk, PONV (post-operative nausea and vomiting) risk, psych disorders, neurologic disorders, infectious disease, etc.]

[mcatmemoranda]

Cardiac clearance

Identify the type of surgery

Urgency of surgery

Emergency surgery: benefit of surgery outweighs risk of MACE (major adverse cardiovascular event). STOP HERE AND PROCEED WITH SURGERY.

Not an emergency surgery, proceed below:

History/Physical/Findings

Perform ROS for chest pain, dyspnea on exertion, decreased exercise tolerance, dizziness on exertion, syncope, etc.

Perform physical exam for lung crackles, leg edema, JVD, murmurs/gallops, etc.

Review patient's prior cardiology data: EKGs, CXRs, stress testing, cardiac catheterization, echo, cardiac medication history.

Obtain EKG*, in all patients with symptoms/signs of cardiovascular disease.

Obtain CXR, in all patients with new or unstable cardiopulmonary symptoms/signs.

Consider obtaining proBNP** if RCRI > 1 (RCRI explained below), age > 65, or age 45-64 with active cardiac conditions.

Consider checking troponin I if proBNP elevated

Obtain echo*** to assess LV function in patients with dyspnea from an unknown cause, history of CHF with worsening dyspnea/clinical status, and/or acutely decompensated CHF as below.

Active Cardiac Conditions: If patient has symptoms/signs of active cardiac conditions, STOP HERE AND EVALUATE/TREAT. Cardiology consultation recommended at this point.

Acute coronary syndrome

Recent MI (within 30 days)

Decompensated CHF

Obtain echo (if not done in the past year)

Severe valvulopathy or new murmur

Obtain echo (if not done in the past year)

Significant arrhythmia on EKG or cardiac monitor

bradycardia, pauses, rapid atrial fibrillation, SVT, VT, etc.

If no evidence of acute coronary syndrome, acute decompensated congestive heart failure, or significant arrhythmia, proceed with risk calculation as below.

Estimate surgical and clinical risk of MACE

Surgical Risk of cardiac death or nonfatal MI

High Risk(> 5% risk)

e.g., aortic and major vascular surgery, peripheral vascular surgery

Intermediate Risk (1-5% risk)

e.g., intraperitoneal or intrathoracic surgery, carotid endarterectomy, head and neck surgery, orthopedic surgery, prostate surgery

Low Risk (< 1% risk)

e.g., ambulatory surgery, breast surgery, endoscopic procedures, superficial procedures, cataract surgery

If low risk surgery, risk of MACE is low (even with multiple clinical risk factors): STOP HERE AND PROCEED WITH SURGERY.

If intermediate/high risk surgery, risk of MACE is elevated (even with few clinical risk factors):

Obtain EKG if high risk surgery even with 0 clinical risk factors, or intermediate risk surgery with 1+ clinical risk factor.

Proceed with clinical risk calculation as below.

Clinical Risk

The RCRI (Revised Cardiac Risk Index) score (https://www.mdcalc.com/revised-cardiac-risk-index-pre-operative-risk) is an estimate of 30-day risk of death, MI, or cardiac arrest.

FYI, an intermediate or high risk surgery automatically gives 1 point on the RCRI.

RCRI score 0-1 = 0.4-0.9% risk of MACE = low risk --> no further preoperative testing advised, STOP HERE AND PROCEED WITH SURGERY.

RCRI score 2+ = 6.6%+ risk of MACE =  elevated risk --> evaluate functional capacity as below.

Functional Capacity

Functional capacity can also be expressed as "METs" and can be used as a reliable predictor of future cardiac events. One MET is defined as the amount of oxygen consumed while sitting at rest, and is equal to 3.5 ml oxygen / kilogram body weight / minute. In other words, a means of expressing energy cost of physical activity as a multiple of the resting rate. Generally, >7 METs of activity tolerance is considered excellent while <4 is considered poor for surgical candidates.

1 MET

self care

eating, dressing, using the toilet

walking indoors and around the house

walking 1-2 blocks on level ground at 2-3mph

light housework (dusting, washing dishes)

4 METs

climbing 1 flight of stairs or walking up a hill

walking on level ground at 4mph (i.e. a 15:00 mile)

running a short distance

heavy housework (e.g., scrubbing floors, moving heavy furniture)

moderate recreational activities (e.g., golf, dancing, doubles tennis, throwing a baseball or football)

> 10 METs

strenuous sports (e.g., swimming, singles tennis, football, basketball, skiing)

If  4+ METS, no further testing advised, STOP HERE AND PROCEED WITH SURGERY.

Noninvasive stress testing can be considered in patients undergoing high risk surgery with an RCRI score 2+, even in patients who have good functional capacity (4+ METs).

Stress Testing

If functional capacity poor or unknown: consider stress testing, only if will impact decision-making. That is the decision, to proceed with the original surgery, and/or the stress patient's willingness to undergo PCI/CABG followed by delay of proposed surgery, if the stress test is abnormal.

Original proposed surgery needs to be postponed by cardiac stenting and or CABG:

30-45 days after bare metal stent

6-12 months after drug-eluting stent

“Surgery should be performed, whenever possible, with at least 1 antiplatelet agent ongoing (preferably aspirin) and antiplatelet therapy should be entirely discontinued only if surgical hemostasis is predicted to be difficult or consequences of even minor bleeding (e.g., intracranial or endocular) are potentially very serious”1

*Pre-op EKG should be considered for patients with known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other structural heart disease, except for those undergoing low-risk surgery. Routine preoperative EKG is not indicated for asymptomatic patients undergoing low-risk surgery.

**Biomarkers

BNP/proBNP

BNP < 92pg/ml or proBNP < 300pg/ml = 4.9% 30-day death/MI

BNP > 92pg/ml or proBNP > 300pg/ml = 21.8% 30-day death/MI

***Echocardiography may be used to evaluate ventricular function in patients with history of heart failure or dyspnea of unknown origin. It is also useful to assess valvular pathology in patients with a history of valvular disease or a newly identified heart murmur.

Source

[mcatmemoranda]

The lecture we had today was about perioperative care.

Geriatric Preop:

Cognition - dementia, delirium, depression

Capacity - Aid to Capacity Evaluation

Function - ADLs (bathing, dressing), IADLs (money management, shopping)

Mobility & fall risk screening

Frailty - Fried criteria (if at least 3/5 are positive, they’re frail; should do PT before surgery)

Nutrition - Mini Nutritional Assessment

EtOH & tobacco use - CAGE questionnaire (pts who have EtOH use disorder are at risk for withdrawal; look for tongue fasciculations). Pts who smoke should have patch and gum while in the hospital.

Cardiac evaluation 9- 2014 ACC/AHA algorithm for noncardiac surgery

Med room review - STOPP/START criteria, Beers criteria

Confusion Assessment Method (CAM) screens for delirium.

More than 4 METS = climbing 2 flights of stairs; walking up a hill, walking at 4 MPH on level ground

Duke Activity Status Index

Surgery is ok if HR is controlled (HR 50-100 or 110)

Predicting post op pulmonary complications- Gupta postoperative respiratory failure risk

D/c warfarin 5 days prior w/o bridging for AFib

If mechanical valve, d/c warfarin with heparin bridge once INR falls outside therapeutic range

Stop LMWH 24 hours before surgery; hold unfractionated heparin 4-5 hours before surgery

Hold ASA 7 days prior for primary prevention. Those on it for secondary prevention, continue it unless surgery has high bleeding risk.

Post op VTE ppx - 2019 American Society of Hematology Guidelines. For hip/knee surgeries start 8-12 hours after surgery. Duration is 14 days or until pt is fully weight bearing. Duration is up to 6 weeks for total hip arthroplasty.

LMWH (doesn’t alter PTT), low dose DOACs (work as well as or better than LMWH). ASA can be used, but it’s not as good as LMWH or DOACs. ASA alone is inferior to LMWH or DOACS alone. Can do ASA after 5 days of DOACS.