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Preoperative Assessment

Preoperative Assessment. Dr. Greg Bryson Head, Pre-Admission Units Department of Anesthesiology. Goals n objectives. Understand the role of patient history in preoperative evaluation Identify risk factors adverse outcomes Recognize limited role of testing in healthy patients

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Preoperative Assessment

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  1. Preoperative Assessment Dr. Greg Bryson Head, Pre-Admission Units Department of Anesthesiology

  2. Goals n objectives • Understand the role of patient history in preoperative evaluation • Identify risk factors adverse outcomes • Recognize limited role of testing in healthy patients • Highlight planning issues for common preoperative problems

  3. Resectable vs Operable • Resectability is surgical decision making • Does this operation suit the patient’s problem? • You folks will be the experts on this subject • Operability is a shared responsibility • Will this patient tolerate the given procedure? • Will this patient leave the hospital? Return to function? • Anesthesia • Critical Care • Internal medicine • Rehabilitation • Family medicine

  4. Anesthesia is bad for you • Unable to protect airway • Altered control of ventilation • Diminished response to  Raw, CO2, and O2 • Altered respiratory mechanics • FRC, restrictive chest wall defect • Decreased contractility • Decreased conduction • Vasodilatation

  5. The Killing Fields • Getting patients out of the OR is easy • Getting patients home is another matter • Postoperative course complicated by: • Increased O2 demand • Myocardial ischemia/infarction • Respiratory depression / VQ mismatching • Hemorrhage • Fluid and electrolyte shifts • Hypercoagulable • Protein catabolism

  6. Functional capacity and outcome • The ability to do predicts risk • Patients who can’t hack the activities of daily living must be carefully evaluated/optimized before surgery

  7. Put your clinic on the 3rd floor Girish M. Chest 2001;120:1147-51

  8. ACC-AHA 2007 Guidelines Fleisher LA. Circulation 2007; 116:e418-99

  9. Pulmonary resection Slinger PD. J Cardiothorac Vasc Anesth 2000;14:202-11

  10. ASA Physical Status Classification

  11. ASA class and mortality

  12. Causes of 3-day postop death NCEPOD 2002 www.ncepod.org. uk

  13. Cardiac risks

  14. Revised Cardiac Risk Index Validation cohort n = 1422 Major cardiac events = 36 (2.5%) Lee TH. Circulation 1999;100:1043-1049

  15. Revised Cardiac Risk Index

  16. Preoperative ECG in the elderly Liu LL. JAGS 2002; 50:1186-91

  17. Pulmonary risks

  18. CXR - systematic review Results reported as median (range) Munro J. Health Technol Assess 1997;1:1-62

  19. What is the risk of postop pneumonia? Arozullah AM. Ann Intern Med 2001;135:847-57.

  20. Spirometry and pulmonary events? Abnormal CXR 1.80 (0.41-7.85) FEV1<1000 6.51 (1.36-30.6) McAlister FA. Am J Resp Crit Care Med 2005;171:514-7

  21. Renal risks

  22. Risk factors for renal failure Kheterpal S. Anesthesiology 2007;107:869-70

  23. Risk factors for renal failure Kheterpal S. Anesthesiology 2007;107:869-70

  24. What tests would you order?

  25. Preop bloodwork in the elderly? Dzankic S. Anesth Analg 2001; 93(2):301-8

  26. NHS - Routine preoperative tests • “…produce a wide range of abnormal results, even in apparently healthy individuals.” • “..the clinical importance of these abnormal results is uncertain.” • “…lead to changes in clinical management in only a very small proportion of patients and for some tests virtually never.” Munro J Health Technol Assess 1997;1:1-62

  27. Big picture… • Information from history provides most predictive value • Preoperative assessment is not about ordering tests • Preoperative assessment is about talking to patients • Consult if unsure or unusual condition

  28. Some Caveats… • Trials reflect elective surgery • Acute illness should influence choice of tests • Trials don’t reflect your staff guy • Some tests ordered as part of a larger workup • Some habits are hard to break • Be reasonable • Get an INR on someone taking coumadin • Get an ECG in a guy with a pacemaker • Refer to testing directive if in doubt • Appendix M in the Periop Navigator

  29. Trouble spots • Some patients cause more trouble in the OR than others. • Anesthesiologist looks pissed off • Surgeon upset case cancelled • $#!t runs down hill • These issues can be worked around if communicated in advance

  30. A is for Airway • Misadventures in airway management are leading cause of anesthesia-related morbidity/mortality • Past history of airway problems • Head and neck trauma • Head and neck masses • Morbid obesity • Short chin (think Joe Clark) • Easily dealt with, but requires planning

  31. Fasting is about the airway • Regurgitation and aspiration of gastric contents under anesthesia can make a bad airway day worse. • Increased morbidity/mortality with solid, acidic gastric contents • Ottawa Hospital Fasting Guidelines • 8 hour fast for solids • 3 hour fast for water • Ranitidine 90 min preop to increase pH in those with reflux

  32. B is for Breathing • Chronic, stable pulmonary disease is something to be worked around • Acute decompensation should be fixed preop • Wheezing asthmatic • Increased SOB in COPD • Productive cough with fever

  33. C is for Circulation/Clopidogrel Artang R. Am J Cardiol 2007;99:1039–43

  34. D is for Device/Defibrillator • Pacemakers • Electrocautery may inhibit pacing • If pacemaker dependent, reprogram to VOO • Use bipolar cautery, if possible • Short bursts if monopolar required • AICDs • Electrocautery may cause defibrillation • Must be turned off in monitored environment • Sign of badness

  35. E is for Electrolytes • Euvolemia is expected • Beware the patient with • GI pathology • Diuretics • Malignancy • These numbers will usually get you cancelled • K+ less than 2.7 or greater than 5.5 • Na+ less than 120 or greater than 150 • Ca + + less than 1.0 or greater than 3.0

  36. F is for Family History • Malignant hyperthermia • Autosomal dominant, variable, 1:50000 • Disordered calcium handling by skeletal muscle • TO, acidosis, rhambdomyolysis,hyperkalemia… • Atypical plasma cholinesterase • Autosomal recessive, 1:3000 • Unable to metabolize succinylcholine • 10 minute drug now lasts hours. • Friend of a friend

  37. G is for G$d D#mn Anticoagulants • Normal coagulation expected preoperatively • Neuraxial hematoma & surgical hemorrhage • Coumadin held for 5 days • INR less than 1.4 • LMWH held for 24 hours • UFH held for 6 hours • Fancy antiplatelet drugs withdrawn (7 days) • Beware drug eluting stents • ASA is OK for most procedures • Don’t drown folks with FFP • Octaplex 40 units for average adult • Vitamin K 1-2 mg (plus time) often enough

  38. H is for Held Medications • NPO does not mean hold medications • In general, keep patients on the medications they take every day, in particular… • Antianginals • Antihypertensive • Antiarrythmics • Puffers • Steroids • Narcotics

  39. Withholding preop medications NCEPOD 2002 www.ncepod.org. uk

  40. Summary • Patients not expected to be perfect • Patients expected to be at “their best” • More talk…less test • Poor functional capacity is trouble • Shared care • Trouble starts when they leave the OR

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