medical evaluation of the surgical patient
- 1. Medical Evaluation of the Surgical Patient Dr Amit Kumar Shrestha MDGP Resident First Year (NAMS) Bharatpur Hospital
- 2. Surgery: Gradation of Risk of Common Noncardiac Surgical Procedures Higher -Emergent major operations, especially elderly -Aortic and other non carotid major vascular surgery -Prolonged surgery associated with large fluid shift and/or blood loss Intermediate -Major thoracic surgery -Major abdominal surgery -Carotid end arterectomy surgery -Head/neck surgery -Orthopedic surgery -Prostate surgery Lower -Eye, skin, and superficial surgery -Endoscopic procedures
- 3. Standardized Preoperative Questionnaires 1. Age, weight, height 2. Are you: Female and 55 years of age or older or male and 45 years of age of older? If yes, are you also 70 years of age or older? 3. Do you take anticoagulant ("blood thinners") medications? 4. Do you have or have you had any of the following heart-related conditions? -Heart disease -Heart attack within the last six months -Angina (chest pain) -Irregular heartbeat -Heart failure
- 4. 5. Do you have or have you ever had any of the following? -Rheumatoid arthritis -Kidney disease -Liver disease -Diabetes 6. Do you get short of breath when you lie flat? 7. Are you currently on oxygen treatment? 8. Do you have a chronic cough that produces any discharge or fluid? 9. Do you have lung problems or diseases? 10. Have you or any blood member of your family ever had a problem with any anesthesia other than nausea? If yes, describe: 11. If female, is it possible that you could be pregnant? Pregnancy test: Please list date of last menstrual period:
- 5. Preoperative Cardiac Risk Assessment Functional Status
- 6. Revised Cardiac Risk Index Clinical Markers High-risk surgical procedures -Vascular surgery -Major intra peritoneal or intra thoracic procedures Ischemic heart disease -History of myocardial infarction -Current angina considered to be ischemic -Requiring sublingual nitroglycerin -Positive exercise test -Pathological Q-waves on ECG -History of PTCA and/or CABG with current angina considered to be ischemic
- 7. Congestive heart failure -Left ventricular failure by physical examination -History of paroxysmal nocturnal dyspnea -History of pulmonary edema -S3 gallop on cardiac auscultation -Bilateral rales on pulmonary auscultation -Pulmonary edema on chest x-ray Cerebrovascular disease -History of transient ischemic attack -History of cerebrovascular accident Diabetes mellitus -Treatment with insulin Chronic renal insufficiency -Serum creatinine >2 mg/dL
- 8. - The risk of major cardiac events—defined as myocardial infarction, pulmonary edema, ventricular fibrillation or primary cardiac arrest, and complete heart block—can then be predicted -Based on the presence of none, one, two, three, or more of these clinical predictors, the rate of development of one of these major cardiac events is estimated to be 0.5, 1, 5, and 10%, respectively
- 10. Risk Modification Using Preventive Strategies to Reduce Cardiac Risk Perioperative Coronary Revascularization Perioperative Medical Preventive Therapies B- Adrenergic Antagonists (1) continued in high-risk patients who previously received these drugs and undergo vascular surgery, and they should be administered to high-risk patients identified by myocardial ischemia on preoperative assessment who are scheduled to undergo vascular surgery. (2) recommended for high-risk patients defined by multiple clinical predictors who undergo intermediate- or high-risk procedures. (3) They may be considered for intermediate-risk patients who undergo intermediate- or high-risk procedures and for low-risk patients who undergo vascular surgery.
- 11. HMG-CoA Reductase Inhibitors (Statins) -considered in intermediate- or high-risk patients with atherosclerotic cardiovascular disease who are undergoing major noncardiac surgery. Angiotensin-Converting Enzyme (ACE) Inhibitors -discontinuation of ACE inhibitors and angiotensin receptor blockers for 24 hours prior to noncardiac surgery due to adverse circulatory effects after induction of anesthesia. Oral Antiplatelet Agents -If clinicians elect to withhold antiplatelet agents prior to surgery, they should be restarted as soon as possible postoperatively Calcium Channel Blockers -Evidence is lacking to support the use of calcium channel blockers as a prophylactic strategy to decrease perioperative risk in major noncardiac surgery.
- 12. Preoperative Pulmonary Assessment The guidelines from the American College of Physicians recommend the following: • All patients undergoing non cardiac surgery should be assessed for risk of pulmonary complications • Patients undergoing emergency or prolonged (>3 h) surgery; aortic aneurysm repair; vascular surgery; major abdominal, thoracic, neuro, head, or neck surgery; and general anesthesia should be considered to be at higher risk for postoperative pulmonary complications. • Patients at higher risk of pulmonary complications should receive deep breathing exercises and/or incentive spirometry as well as selective use of a nasogastric tube for postoperative nausea, vomiting, or symptomatic abdominal distention to reduce postoperative risk • Routine preoperative spirometry and chest radiography are less helpful for predicting risk of postoperative pulmonary complications, but may be appropriate for patients with chronic obstructive pulmonary disease (COPD) or asthma. • Pulmonary artery catheterization, total parenteral nutrition, and total enteral nutrition are not encouraged for postoperative pulmonary risk reduction
- 13. Predisposing Risk Factors for Pulmonary Complications 1. Upper respiratory tract infection: cough, dyspnea 2. Age >60 years 3. COPD 4. American Society of Anesthesiologists Class 2 5. Functionally dependent 6. Congestive heart failure 7. Serum albumin <3.5 g/dL 8. FEV1<2 L 9. MVV <50% of predicted 10. PEF <100 L or 50% predicted value 11. PCO2>45 mmHg 12. PO2 <50 mmHg
- 14. Risk Modification to Reduce Perioperative Pulmonary Complications Preoperatively -Cessation of smoking -Training in proper breathing (incentive spirometry) -Inhalation bronchodilator therapy -Control of infection and secretion, when indicated -Weight reduction, when appropriate Intraoperatively -Limited duration of anesthesia -Select shorter acting neuromuscular blocking drugs when indicated -Prevention of aspiration -Maintenance of optimal broncho dilation
- 15. Postoperatively Continuation of preoperative measures, with particular attention to -inspiratory capacity maneuvers -mobilization of secretions -early ambulation -encouragement of coughing -selective use of a nasogastric tube -adequate pain control without excessive narcotics
- 16. Diabetes Mellitus • Many patients with diabetes mellitus have significant symptomatic or asymptomatic CAD and may have silent myocardial ischemia due to autonomic dysfunction. • Evidence supports intensive perioperative glycemic control to achieve near-normal glucose levels (90–110 mg/dL) versus moderate glycemic control (120–200 mg/dL), using insulin infusion. • This practice must be balanced against the risk of hypoglycemic complications. • Oral hypoglycemic agonists should be held on the morning of operation. • Perioperative hyperglycemia should be treated with intravenous infusion of short-acting insulin or subcutaneous sliding-scale insulin. • Patients who are diet-controlled may proceed to surgery with close postoperative monitoring.
- 17. Prophylaxis for Infective Endocarditis prophylactic antibiotics should be administered to patients with congenital or valvular heart disease, prosthetic valves, mitral valve prolapse, or other cardiac abnormalities in accordance with ACC/AHA practice guidelines
- 18. Prophylaxis of Venous Thromboembolism • Aspirin is not supported as a single agent for thromboprophylaxis. • Low-dose unfractionated heparin <5000 units subcutaneous bid), low-molecular weight heparin (e.g., enoxaparin 30 mg bid or 40 mg qd) or a pentasaccharide (fondaparinux 2.5 mg qd) for patients at moderate risk, • unfractionated heparin (5000 units subcutaneous tid) for patients at high risk. • Graduated compression stockings and pneumatic compression devices are useful supplements to anticoagulant therapy.
- 19. THANK YOU