Preoperative Medical Assessment

1. Preoperative Medical Assessment Eric E. Leonheart DPM

2. Primary Assessment • History (Detailed) • Physical Exam • Review of Rx Medication • Review of Non-Rx Medication • Evaluation of Organ Systems • Advanced Directives

3. Other considerations • Functional status • Risk level of the surgery • Expected blood loss • Anesthesia type and duration

4. History • HPI (NLDOCAT) • PMH • PSH • Medications • Family History • Social History • Review of systems

5. Cardiac Evaluation • American College of Cardiology & American Heart Association published guidelines in 1996

6. Cardiac Evaluation • Phase 1 • Emergent or elective • If emergent and the patient’s life is in danger proceed with surgery • Undergone revascularization within 5 years • Received a recent coronary evaluation

7. Cardiac Evaluation • Elective workup • PMH, functional status, ECG • Abnormal findings non-invasive testing (exercise stress test, thallium stress, dobutamine stress ) • If abnormal results are found on stress test may proceed to invasive testing (angiogram, catheterization • If abnormal results are found may require coronary artery bypass graft (CABG) prior to elective procedure

8. Cardiac Evaluation • Risk stratification • Helps to determine the necessary work up based on the risk inherent to the procedure, patient’s PMH and functional status

9. Risk Stratification • High Risk • Unstable angina, Unstable CHF, Symptomatic ventricular arrhythmias • Must have their cardiac problems resolved prior to elective procedure

10. Risk Stratification • Intermediate Risk • Mild angina pectoris, stable or prior CHF • May proceed to surgery if functional status is good • If functional status is poor (bed-bound or difficulty walking) additional workup needed

11. Risk Stratification • Low Risk • Can proceed to surgery without additional workup unless: • Scheduled for high risk surgery (major vascular procedure) • AND have poor functional capacity (walk two or three blocks, climb stairs, light activity around the house) additional workup

12. Risk Stratification • Based on procedure • High Risk • Emergencies, Aortic, Major vascular, peripheral vascular, prolonged procedures w/ fluid shifts and/or blood clots • Intermediate Risk • Carotid, Head & Neck, Intraperitoneal, Intrathoracic, Orthopedic, Prostate • Low Risk • Endoscopic, Dermatologic, Cataract, Breast

13. Antibiotic Prophylaxis • Bacterial endocarditis • Recommendations change frequently • MVP without leaflet thickening and no regurgitation no abx. necessary • MVP with thickened leaflets and some regurgitation abx. appropriate

14. Pulmonary Evaluation • Can obtain pulmonary status from history • Exercise tolerance, walk up steps with or without shortness of breath, chest pain with activity • History of asthma, COPD • Pulmonary function tests can help in patient management prior to surgery • Arterial blood gas may be drawn on pt. with COPD to determine if retaining CO2 or hypoxemic at rest

15. Hematology Evaluation • History of bleeding disorder, scheduled for high risk neurologic procedures • Order PT (prothrombin time), PTT (partial thromboplastin time), INR (international normalized ratio) • Platelets • >100,000 mm³ for major surgery

16. Hematology Evaluation • Medications • Anticoagulant held 48-72 hours prior to surgery • Antiplatelet (aspirin) held 5-7 days prior to surgery • If patient requires continuous anticoagulation IV heparin

17. Endocrine Evaluation • Objective • Is to rule out diabetes or thyroid disease • Evaluate control of blood sugar • Determine whether the patient is experiencing adrenal suppression

18. Endocrine Evaluation • Diabetes • Fasting blood sugar < 200mg/dL • If elevated must gain control with oral hypoglycemics or insulin prior to surgery

19. Endocrine Evaluation • Thyroid disorders • Common symptoms, fatigue and constipation • TSH testing, possibly T3 or T4 • Regulation of TSH is needed prior to surgery

20. Endocrine Evaluation • Adrenal insufficiency • Common in older patients • Even 5mg q.d. for a year can cause adrenal suppression • Require perioperative supplementation of corticosteroids • RA patients need C spine x-rays, subluxation of atlantoaxial joint, hyperextension of the neck severed spinal cord

21. Endocrine Evaluation • Normal supplement of hydrocortisone is 20-30mg/day • Perioperatively increase to 200-300 mg/day usually IV and can taper down if patient is afebrile and improving on day 4 or 5 postoperative

22. Gastrointestinal Evaluation • History liver disease • PT, INR evaluate coagulation • Albumin testing • May change anesthesia due to metabolism of agent • History of ulcers or GI bleeds, may change post-op oral meds • Opiates can decrease peristalsis and lead to post-op constipation • Constipation can actually lead to delirium in patients with mild dementia

23. Urologic Evaluation • Appropriate for; • Frequency, urgency, incontinence, hesitancy • May be signs of UTI • Patients with recent UTI should have U/A repeated if undergoing orthopedic procedures • BPH may lead to urinary retention post-op leading to UTI, pain, and the necessity for catheterization

24. Neurologic Evaluation • Conditions of concern • Myasthenia gravis • Amyotrophic lateral sclerosis • Parkinson’s • CVA • Seizures • Dementia

25. Neurologic Evaluation • MG, ALS neuromuscular disorders • Increased complications with general anesthesia • Greater difficulty with function post-op • CVA • > incidents of clot formation, take perioperative precautions • SCD, anti-coagulate (LMH), ROM, no tourniquet

26. Neurologic Evaluation • Seizures • Inherent risk to themselves during and after surgery • Delirium • > incident with; age, MI, hypoxia, hypotension. dementia, CVA, electrolyte abnormalities, ulcer, bleeding, constipation, urinary retention, infection, hypoalbuminemia, medications (opiates), trauma, pain

27. Psychiatric Issues • High incident of ETOH abuse • Benzodiazepine abuse is common • Smoking history • Must manage withdrawal

28. Functional Status • Home environment • Help at home • Ability to engage in the duties of daily living • Discharge planning • Need for nursing care, SNF placement • Ability to be NWB or PWB

29. Conclusion • Varying levels of risk • Imperative for the surgeon to be aware of at risk issues • Work with PCP or other specialists