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Preoperative Assessment

Preoperative Assessment. Risk assessment and management. Objectives. Perioperative morbidity and mortality You can’t avoid what you can’t anticipate Preoperative testing Less than you’d expect NPO guidelines Problems. Preoperative assessment. Just like the rest of medicine… History

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Preoperative Assessment

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  1. Preoperative Assessment Risk assessment and management

  2. Objectives • Perioperative morbidity and mortality • You can’t avoid what you can’t anticipate • Preoperative testing • Less than you’d expect • NPO guidelines • Problems

  3. Preoperative assessment • Just like the rest of medicine… • History • Physical • Laboratory

  4. An approach to preoperative evaluation • What’s wrong with the patient? • Is the patient is good as they can get? • If not, does it have to be better pre-op? • Getting to the OR is less than half the job. • Anticipate postoperative problems, then plan.

  5. Anesthesia is bad for you • Unable to protect airway • Aspiration • Obstruction • Altered control of ventilation • Diminished response to CO2 and O2 • Altered respiratory mechanics • FRC, restrictive chest wall defect • Myocardial depression • Decreased conductivity • Vasodilatation • Immune suppression

  6. 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

  7. Causes of 3-day postop mortality NCEPOD 2002 www.ncepod.org. uk

  8. Functional capacity predicts outcome • Postoperative cardiac deaths confined to those with VO2Max < 3 METS Older P. Chest 1999;116:355-62 • Inability to climb 2 flights of stairs 82% PPV (97% specific) for postoperative CV/RS complications Girish M. Chest 2001;120:1147-51 • Self-reported exercise tolerance < 2 flights of stairs doubled risk of complications following non-cardiac surgery (20% v 10%) Reilly DF. Arch Intern Med 1999;159(18):2185-92

  9. ASA Physical Status Classification

  10. ASA class and mortality

  11. Revised Cardiac Risk Index Lee TH. Circulation 1999;100:1043-1049

  12. Revised Cardiac Risk Index and Cardiac Events Lee TH. Circulation 1999;100:1043-1049

  13. Risk factors for postoperative pneumonia Arozullah AM. Ann Intern Med 2001;135:847-57.

  14. Preoperative testing • Routine preoperative testing isn’t helpful Munro J. Health Technology Assessment 1997;1(12) • Testing should “follow” history and physical • Like most testing, it’s most helpful when you don’t know what the answer is. • OMA-GAC statement • http://gacguidelines.ca/pdfs/tools/Ontario%20Preoperative%20Testing%20Grid.pdf • Elective versus emergency patient

  15. OMA-GAC recommendations http://gacguidelines.ca/pdfs/tools/Ontario%20Preoperative%20Testing%20Grid.pdf

  16. TOH fasting guidelines • For elective surgery: • NPO solids at 2400 • Unlimited water until 3 hours preop • For urgent surgery: • NPO solids a minimum of 6 hours • NPO clear fluids 3 hours • Modified by urgency of surgery • All usual medications given, except • Anticoagulants, oral hypoglycemics, MAOIs • Insulin and glucose require physician order

  17. Withholding preoperative medication NCEPOD 2002 www.ncepod.org. uk

  18. Valvular or congenital heart disease • Stenotic lesions intolerant of changes in preload/afterload • RL shunts aggravated by hypoxia & SVR • Important to understand the plumbing • Preoperative echocardiogram helpful • Anticoagulation issues • SBE prophylaxis • www.americanheart.org/Scientific/statements/1997/079701.html

  19. Subacute bacterial endocarditits • Oral / dental surgery • Ampicillin 2000 mg (50 mg/kg) IV 60 min pre-op • Cefazolin 1000 mg (25 mg/kg) IV 60 min pre-op • Clindamycin 600 mg (20 mg/kg) IV 60 min pre-op • Gastrointestinal, genitourinary • As above, plus • Gentamicin 1.5 mg/kg IV 60 minutes pre-op • Vancomycin 1000 mg (20 mg/kg) IV 60 minutes pre-op, if penicillin-sensitive • Repeat Ampicillin 6 hours post-op if high-risk pathology http://circ.ahajournals.org/cgi/content/full/96/1/358

  20. Pacemakers and AICDs • Pacemakers • Should be evaluated preoperatively • If pacemaker dependent, reprogram to VOO • Rate adaptive functions may need to be disabled • Use bipolar cautery, if possible • Short bursts if monopolar required • AICDs • Must be turned off preoperatively • in monitored environment

  21. Anticoagulation • 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) • ASA is OK for most procedures • Vitamin K needs a day • Don’t drown folks with FFP

  22. I think that’s a blood thinner • Clopidogrel (Plavix) • Abciximab (RheoPro) • Eptifibatide (Integrilin) • Low molecular weight heparins • Dalteparin(Fragmin) • Enoxaparin(Lovenox) • Nadroparin(Fraxiparin) • Tinzaparin(Innohep) • Fondaparinux (Arixtra) • Ximelagatran (Exanta)

  23. Summary • Preoperative assessment must identify and anticipate perioperative problems • Getting to the OR is the easy part • Communication is essential • Fasting should not exclude hydration or medication • Laboratory testing should be individualized

  24. Questions?? The surgeon is a carnivorous beast. It’s happy only when there is fresh meat on the table. Ross Kerridge MD, FRCA Newcastle, Australia At WCA Montreal 2000

  25. Case 1 • 64 yr old male scheduled for hemicolectomy for colon ca. Past history includes: • Diabetes x 15 years (on insulin) • CVA 3 years ago • Stable CCS 3 angina • He takes diltiazem, hctz, and plavix • What is his risk of cardiovascular event? • What preoperative tests would you order? • What preop instructions would you give?

  26. Revised Cardiac Risk Index Lee TH. Circulation 1999;100:1043-1049

  27. Risk of cardiac morbidity? Lee TH. Circulation 1999;100:1043-9

  28. AHA ACC guidelines for cardiac evaluation prior to noncardiac surgery

  29. What about ß-blockers? Mangano DT. NEJM 1996;335(23):1713-20 Wallace A. Anesthesiology 1998;88(1):7-17 Poldermans D. NEJM 1999;341(24):1789-94 Poldermans D. Eur Heart J 2001;22(15):1353-8.

  30. An aspirin an day… Neilipovitz DA. A&A 2001;93:573-80

  31. ASA and perioperative hemorrhage Antiplatelet Trialists’ Collaboration. III. BMJ 1994;308:235-48 Pulmonary Embolism Prevention Trial. Lancet 2000;355:1295-302

  32. Case 2 • A 45 yr old male is scheduled for TURP. • He has hypertension, atrial fibrillation, and had a mechanical aortic valve placed 4 years ago. • He takes metoprolol and coumadin. • What investigations? • What instructions?

  33. Coumadin and thrombosis

  34. Who needs special care with coumadin? • DVT < 3 months ago • History of recurrent DVT • Arterial thromboembolism < 3 months ago • Mechanical prosthetic heart valves • Tissue prosthetic heart valves + embolism • Thrombophilia (lupus ac, Factor V - L, C&S) • Atrial fibrillation + embolism

  35. Coumadin withdrawal plan • Day -5. Stop coumadin. • Day -3. Dalteparin 200 u·kg-1 sc. • Day -2. Dalteparin 200 u·kg-1 sc. • Day -1. Dalteparin 100 u·kg-1 sc. • Day 0. Check INR pre-op • Day +1. Is surgical blood loss controlled? Restart coumadin Dalteparin 200 u·kg-1 until INR >2.0

  36. Subacute bacterial endocarditits • Oral / dental surgery • Ampicillin 2000 mg (50 mg/kg) IV 60 min pre-op • Cefazolin 1000 mg (25 mg/kg) IV 60 min pre-op • Clindamycin 600 mg (20 mg/kg) IV 60 min pre-op • Gastrointestinal, genitourinary • As above, plus • Gentamicin 1.5 mg/kg IV 60 minutes pre-op • Vancomycin 1000 mg (20 mg/kg) IV 60 minutes pre-op, if penicillin-sensitive • Repeat Ampicillin 6 hours post-op if high-risk pathology http://circ.ahajournals.org/cgi/content/full/96/1/358

  37. Case 3 • 45 yr old female for lumbar spinal fusion • Uses “some percocets” for pain control • Smokes 1.5 packs per day

  38. Smoking is bad for you • 6x increase in pulmonary complications • Need to stop > 4 weeks preop Bluman LG. Chest 1998 Apr;113(4):883-9 • 3x increase in wound complications following breast surgery Sorensen LT Eur J Surg Oncol 2002 Dec;28(8):815-20 • 2x increase risk of bony non-union Andersen T. Spine 2001 Dec 1;26(23):2623-8

  39. Smoking cessation works Moller AM. Lancet 2002;359:114-7

  40. Narcotic tolerance • Important to document just how much narcotic patients are taking preoperatively • Previous intake must be accommodated in perioperative care • If patient takes 2 percocets 6 x day • 60 mg oxycodone = 90 mg morphine • 90 mg morphine po = 22.5 mg morphine IV • Adjust PCA settings accordingly

  41. Regional anesthesia and outcome Rodgers A. BMJ 2000; 321:1–12

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