Transcript The preoperative consult: An introduction

THE PREOPERATIVE CONSULT:
AN INTRODUCTION
Anthony Worsham, MD
Best Practices
Division of Hospital Medicine
Department of Internal
Medicine
University of New Mexico
Health Sciences Center
PRESENTATION OUTLINE
What is the preoperative consult?
Organ system specific review:
 Cardiac
 Pulmonary
 Endocrine (Diabetes)
 Hematologic (Anemia)
 GI (Liver disease)
Good practices
Questions
CORE COMPETENCIES IN HOSPITAL
MEDICINE: CLINICAL CONDITIONS
Clinical conditions
Clinical conditions (cont.)
 Acute Coronary Syndrome
 Acute Renal Failure
 Alcohol and Drug Withdrawal
 Asthma
 Cardiac Arrhythmia
 Cellulitis
 Chronic Obstructive Pulmonary
Disease
 Community Acquired Pneumonia
 Congestive Heart Failure
 Delirium and Dementia
 Diabetes Mellitus
 Gastrointestinal Bleed
 Hospital-Acquired Pneumonia
 Pain Management
 Perioperative Medicine
 Sepsis Syndrome
 Stroke
 Urinary Tract Infection
 Venous Thromboembolism
Dressler, et. al. The Core Competencies in Hospital Medicine: Development and Methodology. Journal
of Hospital Medicine 2006;1:48-56.
PERIOPERATIVE MEDICINE
KNOWLEDGE
Hospitalists should be able to:
 Explain the effect of anesthesia and surgical intervention on physiology.
 Explain the goals and components of preoperative risk assessment.
 Identify patients who require selective preoperative testing based on patient
specific factors, type of surgery, and urgency of surgical procedure.
 Describe risk factors for perioperative complications.
 Explain risks for perioperative complications in specific patient populations.
 Explain pharmacologic therapies that should be modified or held prior to surgery.
 List widely accepted risk assessment tools and explain their value and limitations in
patients undergoing nonvascular surgery.
 Describe the evidence supporting prophylactic perioperative β-blockade.
Dressler, et. al. The Core Competencies in Hospital Medicine: Development and Methodology. Journal
of Hospital Medicine 2006;1:48-56.
PERIOPERATIVE MEDICINE
SKILLS
Hospitalists should be able to:
 Elicit a thorough history, review the medical record and inquire about functional capacity in
patients undergoing surgery.
 Perform a targeted physical examination, focused on the cardiovascular and pulmonary
systems and other systems based on patient history.
 Perform a directed and cost effective diagnostic evaluation based on patient relevant history
and physical examination findings.
 Employ published algorithms and validated clinical scoring systems, when available, to assess
and risk stratify patients.
 Assess the urgency of the requested evaluation and provide feedback and evaluation in an
appropriate timeframe.
 Recognize medical conditions that increase risk for perioperative complications and make
specific evidence based recommendations to optimize outcomes in the perioperative period.
 Determine the perioperative medical management strategies required to address specific
disease states.
 Reassess patients for postoperative complications and make medical recommendations as
indicated.
Dressler, et. al. The Core Competencies in Hospital Medicine: Development and Methodology. Journal
of Hospital Medicine 2006;1:48-56.
PERIOPERATIVE MEDICINE
ATTITUDES
Hospitalists should be able to:
 Communicate with patients and families to explain the hospitalist's role in their perioperative
medical care, any indicated preoperative testing related to their medical conditions or risk assessment,
and any adjustment of pharmacologic therapies.
 Communicate with patients and families to explain any indicated perioperative prophylactic measures.
 Communicate with patients and families to explain the need for follow-up medical care post-discharge.
 Initiate indicated perioperative preventive strategies.
 Recommend specific prophylactic measures, which may include β-blockade, VTE prophylaxis, or
aspiration precautions, to avoid complications in the perioperative period.
 Serve as an advocate for patients.
 Promote a collaborative relationship with surgical services, which includes effective communication.
 Assess pain in perioperative patients and make recommendations for pain management when
indicated.
 Facilitate discharge planning early in the hospitalization, including communicating with the primary
care provider, and presenting the patient and family with contact information for follow-up care.
 Utilize evidence based recommendations for the evaluation and treatment of patients in the
perioperative period.
Dressler, et. al. The Core Competencies in Hospital Medicine: Development and Methodology. Journal
of Hospital Medicine 2006;1:48-56.
PERIOPERATIVE MEDICINE
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations,
Hospitalists should:
 Lead, coordinate or participate in multidisciplinary efforts to develop clinical
guidelines, protocols and pathways to improve the timing and quality of
perioperative care from initial preoperative evaluation through all care transitions.
 Lead, coordinate or participate in efforts to improve the efficiency and quality of
care through innovative models, which may include co-management of surgical
patients in the perioperative period.
 Lead, coordinate or participate in multidisciplinary initiatives to promote patient
safety and optimize diagnostic and management strategies for surgical patients
requiring medical evaluation.
 Lead, coordinate or participate in multidisciplinary protocols to promote the rapid
identification, triage, and expeditious evaluation of patients requiring urgent
operations.
Dressler, et. al. The Core Competencies in Hospital Medicine: Development and Methodology. Journal
of Hospital Medicine 2006;1:48-56.
WHAT IS THE PREOPERATIVE CONSULT?
A consult is an opportunity for the medical consultant to provide
helpful management suggestions to the operative team.
A fundamental objective of a consult is to optimize a patient’s
underlying disease before it is compounded by the insult of surgery.
The purpose of a consult is never to “clear” a patient for surgery.
Whether or not to proceed to surgery is a question for the
anesthesiologist, surgeon, and patient to decide after weighing the
risks and benefits once the patient’s comorbidities are optimally
managed.
Lubarsky and Candiotti. Giving anesthesiologists what they want: how to write a useful preoperative
consult. Cleve Clin J Med. 2009 Nov;76 Suppl 4:S32-6.
WHAT SHOULD THE PRE-OP EVAL FOCUS
ON?
Consultative and Perioperative Medicine Essentials for Hospitalists
Perioperative Medication Management
Pulmonary Risk Management in the Perioperative Setting
Perioperative Cardiac Risk Assessment
Preoperative Diagnostic Testing and Utilization of Basic Statistics
Perioperative Management of Anticoagulation
Anesthesia for Internists
Evaluation and Management of Perioperative Cirrhosis and Liver Disease
Neurosurgery for the Hospitalist
The Obese Patient and Bariatric Surgery
Evaluation and Management of Perioperative Anemia
Perioperative Care of the Patient with Cancer
Perioperative Cardiac Risk Management
SHM consults. http://www.shmconsults.com
ARE PREOPERATIVE EVALUATIONS
USEFUL? (1/3)
survey about cardiology consultations sent to random New York
anesthesiologists, surgeons, and cardiologists
 400 surveys sent to each specialty
 192 (48%/44%) were returned from anesthesiologists
 113 (28%/26%) were returned from surgeons
 129 (32%/30%) were returned from cardiologists.
substantial disagreement on the importance and purposes of a
cardiology consult:
 Intraoperative monitoring, “clearing the patient for surgery,” and advising as to the
safest type of anesthesia were regarded as important by most cardiologists and
surgeons but as unimportant by anesthesiologists (all P < 0.05)
 Most surgeons (80.2%) felt obligated to follow cardiology recommendations; few
anesthesiologists (16.6%) felt so obligated (P < 0.05).
Katz et al. A survey on the intended purposes and perceived utility of preoperative cardiology
consultations. Anesth Analg. 1998 Oct;87(4):830-6.
ARE PREOPERATIVE EVALUATIONS
USEFUL? (2/3)
charts of 55 consecutive patients aged >50 yr with preoperative
cardiology consultations were examined
substantial disagreement on the importance and purposes of a
cardiology consult:
 Most commonly stated purpose of the 55 cardiology consultations examined was
“preoperative evaluation.”
 Only 5 of these (9%) were obtained for patients in whom there was a new finding.
 40% contained no recommendations other than “proceed with case,” “cleared for
surgery,” or “continue current medications.”
 Recommendations regarding intraoperative monitoring or cardiac medications were
largely ignored.
Katz et al. A survey on the intended purposes and perceived utility of preoperative cardiology
consultations. Anesth Analg. 1998 Oct;87(4):830-6.
ARE PREOPERATIVE EVALUATIONS
USEFUL? (3/3)
Survey of surgeons in Saskatoon, Saskatchewan, Canada regarding
an internist's potential role in perioperative care.
Pausjenssen et al, An internist's role in perioperative
medicine: a survey of surgeons' opinions. BMC Fam
Pract. 2008 Jan 21;9:4.
PATHWAYS OF CARE
Dhatariya et al. NHS Diabetes guideline for the perioperative management of the
adult patient with diabetes. Diabet Med. 2012 Apr;29(4):420-33.
ACC/AHA CARDIAC EVALUATION ALGORITHM
Fleisher et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2007 Oct 23;116(17):e418-99.
ACTIVE CARDIAC CONDITIONS FOR WHICH THE PATIENT
SHOULD UNDERGO EVALUATION AND TREATMENT BEFORE
NONCARDIAC SURGERY (1/4)
ACC/AHA
 Unstable coronary syndrome
 Decompensated HF
 Significant arrhythmia
 Severe valvular disease
ESC
 Unstable angina pectoris
 Acute heart failure
 Significant cardiac arrhythmias
 Symptomatic valvular heart disease
 Recent MI and residual myocardial ischemia
Fleisher et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for
noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines. Circulation. 2007 Oct 23;116(17):e418-99.
ACTIVE CARDIAC CONDITIONS FOR WHICH THE PATIENT
SHOULD UNDERGO EVALUATION AND TREATMENT BEFORE
NONCARDIAC SURGERY (2/4)
Unstable coronary syndrome
 Unstable or severe angina* (CCS class III or IV)†
 Recent MI‡
Decompensated HF
 NYHA functional class IV
 Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort.
Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is
undertaken, discomfort increases.
 worsening or new-onset HF
Fleisher et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for
noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines. Circulation. 2007 Oct 23;116(17):e418-99.
ACTIVE CARDIAC CONDITIONS FOR WHICH THE PATIENT
SHOULD UNDERGO EVALUATION AND TREATMENT BEFORE
NONCARDIAC SURGERY (3/4)
Significant arrhythmia
 High-grade atrioventricular block
 Mobitz II atrioventricular block
 Third-degree atrioventricular heart
 block
 Symptomatic ventricular arrhythmias
 Supraventricular arrhythmias (including
 atrial fibrillation) with uncontrolled
 ventricular rate (HR greater than 100
 bpm at rest)
 Symptomatic bradycardia
 Newly recognized ventricular tachycardia
Fleisher et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for
noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines. Circulation. 2007 Oct 23;116(17):e418-99.
ACTIVE CARDIAC CONDITIONS FOR WHICH THE PATIENT
SHOULD UNDERGO EVALUATION AND TREATMENT BEFORE
NONCARDIAC SURGERY (4/4)
Severe valvular disease
 Severe aortic stenosis (mean pressure gradient greater than 40 mm Hg, aortic valve
area less than 1.0 cm2, or symptomatic)
 Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional
presyncope, or HF)
Fleisher et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for
noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines. Circulation. 2007 Oct 23;116(17):e418-99.
ACC/AHA CARDIAC EVALUATION ALGORITHM
Fleisher et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2007 Oct 23;116(17):e418-99.
NEW YORK HEART ASSOCIATION (NYHA)
FUNCTIONAL CLASSIFICATION
I
Patients with cardiac disease but resulting in no limitation of
physical activity. Ordinary physical activity does not cause undue
fatigue, palpitation, dyspnea or anginal pain.
II
Patients with cardiac disease resulting in slight limitation of
physical activity. They are comfortable at rest. Ordinary physical
activity results in fatigue, palpitation, dyspnea or anginal pain.
III
Patients with cardiac disease resulting in marked limitation of
physical activity. They are comfortable at rest. Less than ordinary
activity causes fatigue, palpitation, dyspnea or anginal pain.
IV
Patients with cardiac disease resulting in inability to carry on
any physical activity without discomfort. Symptoms of heart failure or
the anginal syndrome may be present even at rest. If any physical
activity is undertaken, discomfort increases.
CARDIAC RISK STRATIFICATION FOR
NONCARDIAC SURGICAL PROCEDURES
Poldermans et al. Guidelines for pre-operative cardiac risk assessment and perioperative
cardiac management in non-cardiac surgery. Eur Heart J. 2009 Nov;30(22):2769-812.
REVISED CARDIAC RISK INDEX (RCRI)
Six independent predictors
 high-risk type of surgery
 history of ischemic heart disease
 history of congestive heart failure
 history of cerebrovascular disease
 preoperative treatment with insulin
 preoperative serum creatinine >2.0 mg/dL
Rates of major cardiac complication
 0: 0.5%-0.4%
 1: 1.3%-0.9%
 2: 4%-7%
 >=3: 9%-11%
Lee et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major
noncardiac surgery. Circulation. 1999 Sep 7;100(10):1043-9.
CARDIAC RISK CALCULATOR: YET
ANOTHER RISK STRATIFICATION TOOL
RCRI has relatively low discriminative ability
5 predictors of perioperative myocardial infarction or cardiac arrest:
 type of surgery,
 dependent functional status,
 abnormal creatinine,
 American Society of Anesthesiologists’ class, and
 increasing age
Developed on 2007 ACS NSQIP database, validated with 2008 set
Predictive performance improved over RCRI
Gupta et al. Development and validation of a risk calculator for prediction of cardiac risk after
surgery. Circulation. 2011 Jul 26;124(4):381-7.
ACC/AHA CARDIAC EVALUATION ALGORITHM
Fleisher et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2007 Oct 23;116(17):e418-99.
MET (METABOLIC EQUIVALENT)
ratio of the work metabolic rate to the resting metabolic rate. One
MET is defined as 1 kcal/kg/hour and is roughly equivalent to the
energy cost of sitting quietly. A MET also is defined as oxygen uptake
in ml/kg/min with one MET equal to the oxygen cost of sitting quietly,
equivalent to 3.5 ml/kg/min.
METS for common activities
 1.0: lying quietly and watching television
 2.3: getting ready for bed, general, standing
 3.5: walking for pleasure
 3.8: cleaning, sweeping, slow, moderate effort
 4.0: stair climbing, slow pace
 4.0: bicycling, <10 mph, leisure, to work or for pleasure
 4.0: raking lawn
Ainsworth et al. 2011 Compendium of Physical Activities: a second update of codes and MET values.
Med Sci Sports Exerc. 2011 Aug;43(8):1575-81.
METS AND FUNCTIONAL CAPACITY
Poldermans et al. Guidelines for pre-operative cardiac risk assessment and perioperative
cardiac management in non-cardiac surgery. Eur Heart J. 2009 Nov;30(22):2769-812.
ACC/AHA CARDIAC EVALUATION ALGORITHM
Fleisher et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2007 Oct 23;116(17):e418-99.
ACC/AHA ALGORITHM (2/2)
ESC ALGORITHM (1/3)
Poldermans et al. Guidelines for pre-operative cardiac risk assessment and perioperative
cardiac management in non-cardiac surgery. Eur Heart J. 2009 Nov;30(22):2769-812.
ESC ALGORITHM (2/3)
Poldermans et al. Guidelines for pre-operative cardiac risk assessment and perioperative
cardiac management in non-cardiac surgery. Eur Heart J. 2009 Nov;30(22):2769-812.
ESC ALGORITHM (3/3)
Poldermans et al. Guidelines for pre-operative cardiac risk assessment and perioperative
cardiac management in non-cardiac surgery. Eur Heart J. 2009 Nov;30(22):2769-812.
BETA-BLOCKER TRIALS
Poldermans et al. Guidelines for pre-operative cardiac risk assessment and perioperative
cardiac management in non-cardiac surgery. Eur Heart J. 2009 Nov;30(22):2769-812.
BETA-BLOCKER TRIALS
Poldermans et al. Guidelines for pre-operative cardiac risk assessment and perioperative
cardiac management in non-cardiac surgery. Eur Heart J. 2009 Nov;30(22):2769-812.
BETA-BLOCKER RECOMMENDATIONS
Siddiqui and Feldman. Perioperative Cardiac Risk Assessment. SHM Consults.
MEDICATION RECOMMENDATIONS
Statins
 Continue statins for any patient already on them chronically.
 Start a statin at least 2 weeks ahead of time for any patient who:
 should be treated with one based on the NCEP guidelines,
 those undergoing vascular surgery,
 and those with 1 or more clinical risk factors who are undergoing intermediate surgery.
Aspirin
 Continue aspirin unless difficult hemostasis expected.
PREOPERATIVE INTERVENTIONS
PCI [percutaneous coronary intervention] before noncardiac surgery
is of no value in preventing perioperative cardiac events, except in
those patients in whom PCI is independently indicated for an acute
coronary syndrome.
A history of coronary bypass surgery reduces the cardiac event rate
to 0.6% for noncardiac surgeries in the subsequent 6 years
RECOMMENDATIONS FOR TIMING OF
NON-CARDIAC SURGERY AFTER PCI
ECGS FOR POSTOPERATIVE MONITORING
In patients with high or intermediate clinical risk who have known or
suspected CAD and who are undergoing high- or intermediate-risk
surgical procedures, the procurement of ECGs at baseline,
immediately after the surgical procedure and daily on the first 2
days after surgery appears to be the most cost-effective strategy.
Studies analyzing signs and symptoms of perioperative MI have
shown that chest pain can occur in as little as 10% to 20% of the
patients who rule in by enzymes, ECG, or scintigraphy
POSTOPERATIVE
PULMONARY COMPLICATIONS (PPCS)
General complications
 Atelectasis
 Infection
 Bronchitis
 Pneumonia
 Bronchospasm
 Pulmonary embolism
 Exacerbation of underlying chronic
lung disease
 Respiratory failure and prolonged
invasive or noninvasive ventilation
 OSA
 ARDS
Specific cardiothoracic surgical
complications
 Phrenic nerve injury
 Pleural effusion
 Bronchopleural fistula
 Sternal wound infection and
empyema
 Gastroesophageal anastomotic leak
 Postoperative arrhythmias
Bapoje et al. Preoperative evaluation of the patient with pulmonary disease. Chest. 2007
Nov;132(5):1637-45.
RISK FACTORS FOR PPCS
Preoperative risk factors
 COPD
 Age
 Inhaled tobacco use
 NYHA class II pulmonary hypertension
 OSA
 Nutrition status
Intraoperative risk factors
 Site of surgery
 General anesthesia
 Pancuronium use
 Duration of surgery
 Emergency surgery
Bapoje et al. Preoperative evaluation of the patient with pulmonary disease. Chest. 2007
Nov;132(5):1637-45.
Bapoje et al. Preoperative evaluation of the patient with pulmonary disease. Chest. 2007
Nov;132(5):1637-45.
STEPWISE APPROACH TO PREOPERATIVE
PULMONARY ASSESSMENT (1/2)
Bapoje et al. Preoperative evaluation of the patient with pulmonary disease. Chest. 2007
Nov;132(5):1637-45.
STEPWISE APPROACH TO PREOPERATIVE
PULMONARY ASSESSMENT (2/2)
Bapoje et al. Preoperative evaluation of the patient with pulmonary disease. Chest. 2007
Nov;132(5):1637-45.
ACP GUIDELINES
Recommendation 1: All patients undergoing noncardiothoracic
surgery should be evaluated for the presence of the following
significant risk factors for postoperative pulmonary complications in
order to receive pre- and postoperative interventions to reduce
pulmonary risk:
 chronic obstructive pulmonary disease,
 age older than 60 years,
 American Society of Anesthesiologists (ASA) class of II or greater,
 functionally dependent, and
 congestive heart failure.
The following are not significant risk factors for postoperative
pulmonary complications:
 obesity and
 moderate asthma.
Qaseem et al. Risk assessment for and strategies to reduce perioperative
pulmonary complications for patients undergoing noncardiothoracic surgery: a
guideline from the American College of Physicians. Ann Intern Med. 2006 Apr
18;144(8):575-80.
ACP GUIDELINES
Recommendation 2: Patients undergoing the following procedures are
at higher risk for postoperative pulmonary complications and should
be evaluated for other concomitant risk factors and receive pre- and
postoperative interventions to reduce pulmonary complications:
 prolonged surgery (3 hours),
 abdominal surgery,
 thoracic surgery,
 neurosurgery,
 head and neck surgery,
 vascular surgery,
 aortic aneurysm repair,
 emergency surgery, and
 general anesthesia.
Qaseem et al. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients
undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med. 2006 Apr
18;144(8):575-80.
ACP GUIDELINES
Recommendation 3: A low serum albumin level (35 g/L) is a powerful
marker of increased risk for postoperative pulmonary complications
and should be measured in all patients who are clinically suspected
of having hypoalbuminemia; measurement should be considered in
patients with 1 or more risk factors for perioperative pulmonary
complications.
Recommendation 4: All patients who after preoperative evaluation
are found to be at higher risk for postoperative pulmonary
complications should receive the following postoperative procedures
in order to reduce postoperative pulmonary complications:
 1) deep breathing exercises or incentive spirometry and
 2) selective use of a nasogastric tube (as needed for postoperative nausea or
vomiting, inability to tolerate oral intake, or symptomatic abdominal distention).
Qaseem et al. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients
undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med. 2006 Apr
18;144(8):575-80.
ACP GUIDELINES
Recommendation 5: Preoperative spirometry and chest radiography
should not be used routinely for predicting risk for postoperative
pulmonary complications.
Preoperative pulmonary function testing or chest radiography may
be appropriate in patients with a previous diagnosis of chronic
obstructive pulmonary disease or asthma.
Recommendation 6: The following procedures should not be used
solely for reducing postoperative pulmonary complication risk:
 1) right-heart catheterization and
 2) total parenteral nutrition
Qaseem et al. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients
undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med. 2006 Apr
18;144(8):575-80.
PATIENT FACTORS WITH PPCS
Smetana et al. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic
review for the American College of Physicians. Ann Intern Med. 2006 Apr 18;144(8):581-95.
PROCEDURE FACTORS WITH PPCS
Smetana et al. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic
review for the American College of Physicians. Ann Intern Med. 2006 Apr 18;144(8):581-95.
SUGGESTED RISK-REDUCTION STRATEGIES
Preoperative
 Smoking cessation 6–8 wk before undergoing surgery
 Inspiratory muscle training
Intraoperative
 Use of neuromuscular agents other than pancuronium
Postoperative
 IS
 But note recent Cochrane reviews found no evidence regarding the effectiveness of
the use of incentive spirometry for prevention of postoperative pulmonary
complications in upper abdominal surgery (Guimarães et al 2009) and following
CABG (Freitas et al 2007, Freitas et al 2012).
 CPAP
Bapoje et al. Preoperative evaluation of the patient with pulmonary disease. Chest. 2007
Nov;132(5):1637-45.
INTERVENTIONS TO REDUCE RISK OF
POSTOPERATIVE PULMONARY
COMPLICATIONS
Lawrence et al. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic
review for the American College of Physicians. Ann Intern Med. 2006 Apr 18;144(8):596-608.
POSTOPERATIVE COMPLICATIONS
ASSOCIATED WITH PREOPERATIVE ANEMIA
mortality
delirium
perioperative infections
 massive transfusion related risks
 hypothermia
pulmonary microembolization
increased length of stay
Kumar, A. Evaluation and Management of Perioperative Anemia. SHM Consults.
RISK FACTORS FOR PREOPERATIVE
ANEMIA
Symptoms of anemia
 chest pain
 dyspnea
 fatigue
Physical examination findings
 tachycardia
 Skin pallor
Comorbid illnesses
 hematologic diseases
 chronic kidney disease
 liver disease
 alcohol abuse
Kumar, A. Evaluation and Management of Perioperative Anemia. SHM Consults.
EXPECTED BLOOD LOSS FOR SEVERAL
COMMON SURGERIES
Total hip arthoplasty: 2100 mL
Total knee arthroplasty: 2000 mL
Spine fusion: 1000 mL
Hip fracture repair: 750 mL
Open prostatectomy: 750 mL
Transurethral resection of prostate: 500 mL
Coronary bypass grafting: 500 mL
Kumar, A. Evaluation and Management of Perioperative Anemia. SHM Consults.
EVALUATE ANEMIA WHEN:
Hemoglobin <10 g/dL
Hemoglobin ≥10 g/dL but expected blood loss from surgery
expected to lower hemoglobin to <8 g/dL
Occult gastrointestinal blood loss suspected as cause and
postoperative care will include pharmacologic VTE prophylaxis
Major hematologic disorder or malignancy are suspected as cause of
anemia
Kumar, A. Evaluation and Management of Perioperative Anemia. SHM Consults.
DIFFICULTIES WITH IN-HOSPITAL PRE-OP
EVALS
Hgb recovers within 1 mo of starting nutritional (B12 or folate)
supplementation
ESAs + iron takes 1-2 weeks to be effective; goal Hgb 11-12 g/dL
(NKF).
Kumar, A. Evaluation and Management of Perioperative Anemia. SHM Consults.
RECOMMENDED CRITERIA FOR
PERIOPERATIVE TRANSFUSION
hemoglobin < 7 g/dL
hemoglobin <10 g/dL and..
 Signs or symptoms strongly suggestive of significant anemia with a
 chest pain
 dyspnea
 hypotension
 tachycardia
 Anticipated large blood loss
Kumar, A. Evaluation and Management of Perioperative Anemia. SHM Consults.
DIABETES MANAGEMENT
Surgery and anesthesia can induce hormonal and inflammatory
stressors that increase the risk of complications in patients with
diabetes.
Elevated blood glucose levels are associated with worse outcomes in
surgical patients, even among those not diagnosed with diabetes.
The perioperative glycemic target in critically ill patients is 140 to
180 mg/dL. Evidence for a target in patients who are not critically ill
is less robust, though fasting levels less than 140 mg/dL and random
levels less than 180 mg/dL are appropriate.
Postoperative nutrition-related insulin needs vary by nutrition type
(parenteral or enteral), but ideally all regimens should incorporate a
basal/bolus approach to insulin replacement.
Meneghini LF. Perioperative management of diabetes: translating evidence into
practice. Cleve Clin J Med. 2009 Nov;76 Suppl 4:S53-9.
GOALS OF DIABETIC MANAGEMENT
Maintenance of fluid and electrolyte balance
Prevention of ketoacidosis
Avoidance of marked hyperglycemia
Avoidance of hypoglycemia
Khan et al. Perioperative management of diabetes mellitus.
UpToDate 2012.
INITIAL EVALUATION
History and physical to include:
 Determination of the type of diabetes, since type 1 diabetes patients are at much
higher risk of diabetic ketoacidosis
 Long-term complications of diabetes mellitus, including retinopathy, nephropathy,
neuropathy, autonomic neuropathy, coronary heart disease, peripheral vascular
disease, hypertension
 Assessment of baseline glycemic control, including frequency of monitoring, average
blood glucose levels, range of blood glucose levels, hemoglobin A1C levels
 Assessment of hypoglycemia, including frequency, timing, awareness, and severity
 Detailed history of diabetes therapy, including insulin type, dose, and timing
 Other pharmacologic therapy, including type of medication, dosing, and specific
timing
 Characteristics of surgery, including when the patient must stop eating prior to
surgery, type of surgery (major or minor), timing of the operative procedure, and
duration of the procedure
 Type of anesthetic, including epidural versus general anesthesia (epidural anesthesia
has minimal effects on glucose metabolism and insulin resistance)
DIABETES MEDICATION MANAGEMENT
(1/2)
Discontinue oral agents.
Omit any short-acting insulin on the morning of surgery.
For patients who take insulin only in the morning, give between onehalf to two-thirds of their usual total morning insulin dose (both
intermediate and short-acting insulin) as intermediate or long-acting
insulin to provide basal insulin during the procedure and prevent
ketosis.
For patients who take insulin two or more times per day, give
between one-third to one-half of the total morning dose (both
intermediate and short-acting insulin) as intermediate acting insulin
only.
Khan et al. Perioperative management of diabetes mellitus.
UpToDate 2012.
DIABETES MEDICATION MANAGEMENT
Patients on continuous insulin infusion may continue with their usual
basal infusion rate.
Start dextrose containing intravenous solution (either dextrose with
water or one-half isotonic saline) at a rate of 75 to 125 cc/hour to
provide 3.75 to 6.25 g glucose/hour to avoid the metabolic changes
of starvation.
Khan et al. Perioperative management of diabetes mellitus.
UpToDate 2012.
MANAGEMENT OF LIVER DISEASE
Goals
Evaluate whether liver disease severity influences
perioperative morbidity and mortality.
Outline the risk associated with different types of
surgery in patients with cirrhosis.
Identify the elements of the preoperative evaluation for
a patient with cirrhosis including how to manage
medications on the day of surgery.
Formulate a perioperative care plan for the patient with
cirrhosis based on the underlying severity of disease
including how to manage medications.
Qamar, A. Evaluation and Management of Perioperative
Cirrhosis and Liver Disease. SHM Consults.
MANAGEMENT OF LIVER DISEASE
Acute hepatitis, especially alcoholic hepatitis, and decompensated
cirrhosis are contraindications to elective surgery.
Qamar, A. Evaluation and Management of Perioperative
Cirrhosis and Liver Disease. SHM Consults.
RISK ASSESSMENT IN CIRRHOSIS
CHILD-PUGH SCORE
Qamar, A. Evaluation and Management of Perioperative
Cirrhosis and Liver Disease. SHM Consults.
RISK ASSESSMENT IN CIRRHOSIS
MELD SCORE
Qamar, A. Evaluation and Management of Perioperative
Cirrhosis and Liver Disease. SHM Consults.
OPERATIVE FACTORS ASSOCIATED WITH INCREASED
RISK WITH SURGERY IN PATIENTS WITH CIRRHOSIS
type of surgery
 emergency surgery
 upper abdominal and cardiovascular surgery (75% perioperative mortality rate in
Child-Pugh class C)
 intraoperative hypotension
 perioperative hemorrhage
 use of vasopressor support
 use of prolonged cardiac bypass
type of anesthetic
SUGGESTED PREOPERATIVE ALGORITHM
FOR PATIENTS WITH CIRRHOSIS
Etiology of liver disease
Presence or absence of cirrhosis
Evidence of synthetic dysfunction or portal hypertension
Use of medications
Calculate MELD and Child-Pugh score
Imaging for new symptoms or no recent studies
Qamar, A. Evaluation and Management of Perioperative
Cirrhosis and Liver Disease. SHM Consults.
DRUG MANAGEMENT
Hepatitis B: continue nucleoside and nucleotide analogues.
Hepatitis C: complete therapy prior to elective surgery; hold therapy
until complete recovery from emergent surgery.
Alcoholic hepatitis: complete therapy first due to high baseline
postoperative risk
Autoimmune hepatitis: continue steroids or azathioprine + possible stressdose steriods
PBC/PSC: continue ursodeoxycholic acid
Wilson’s disease: half penicillamine dose due to impaired wound healing
Cirrhosis: hold b-blocker on day of surgery; continue lactulose/rifaximin;
?hold diuretics to optimize fluid status; ?albumin prophylaxis esp. with
ascites loss during surgery; ?transfuse to Hgb 25% to prevent
overtransfusion in pts with varices, PLT 50-100K, INR >1.5;
Qamar, A. Evaluation and Management of Perioperative
Cirrhosis and Liver Disease. SHM Consults.
LIVER DISEASE MANAGEMENT
Qamar, A. Evaluation and Management of Perioperative
Cirrhosis and Liver Disease. SHM Consults.
USEFUL INFORMATION TO INCLUDE IN
PREOPERATIVE CONSULTS (1/3)
How to preoperatively optimize function of an unhealthy organ
system
Guidance on managing oral drug regimens
 First-line and second-line agents
 Initial dosage and titration; recommended combinations
 How to manage side effects
Expected time until patient is optimized for the procedure if above
management is followed
Tests that might be indicated preoperatively to direct therapy to
optimize function
Lubarsky and Candiotti. Giving anesthesiologists what they want: how to write a useful preoperative
consult. Cleve Clin J Med. 2009 Nov;76 Suppl 4:S32-6.
USEFUL INFORMATION TO INCLUDE IN
PREOPERATIVE CONSULTS (2/3)
Additional interventions indicated by the patient’s disease, and
appropriate timing (pre-, intra-, postoperatively)
 Include assurance that consultant will follow up with specified nonurgent
postoperative care without prompting
Current pertinent anticoagulation recommendations
Details on coronary stents—when placed, where placed, and type
(drug-eluting or bare metal)
Focused information on cardiac defibrillators and other implanted
devices, specifically:
 Whether patient is pacer-dependent
 Effect of magnet placement
 Has battery recently been checked?
Lubarsky and Candiotti. Giving anesthesiologists what they want: how to write a useful preoperative
consult. Cleve Clin J Med. 2009 Nov;76 Suppl 4:S32-6.
USEFUL INFORMATION TO INCLUDE IN
PREOPERATIVE CONSULTS (3/3)
Recommendations on intra-/perioperative management of:
 Rare diseases
 Blood disorders, especially coagulation abnormalities
 Brittle diabetes (loading doses, optimal make-up of infusions, treatment targets)
 Endocrine disorders (eg, perioperative dosing of thyroid drugs)
Newer recommendations/data (< 5 years old) on acute medical
management, especially in patients with complex comorbidities
Explanations/references when recommendations deviate from
accepted guidelines
Legible contact information, including an emergency phone number to
ensure access prior to early-morning procedures
In all cases, be as specific as possible and favor quantitative over
qualitative information when possible.
A FINAL END USER: THE PLAINTIFF’S
ATTORNEY
A poorly written consult may benefit plaintiffs’ lawyers.
Consults should never give absolute instructions; it is better to use such
phrases as “Strongly consider…” or “The current literature strongly
suggests…”
Otherwise, the surgical team is placed in an awkward position if it
does not follow your recommendations, even if for good reason.
If a certain recommendation absolutely must be followed, then direct
oral communication from the consultant to the attending
anesthesiologist (or surgeon) is best.
Lubarsky and Candiotti. Giving anesthesiologists what they want: how to write a useful preoperative
consult. Cleve Clin J Med. 2009 Nov;76 Suppl 4:S32-6.
QUESTIONS FOR THE GROUP
Should we continue to follow patients after an initial preoperative
consult?
When do you defer a consult to a more specific specialty?
Would a separate consult service be helpful?
Are the consult questions specific enough to form a useful consult?
Do surgery and anesthesia find our consults to be useful?
Are our recommendations acted upon?
Would co-management be useful?
What is your threshold for delaying surgery?
Do you perform a preoperative evaluation on your own patients?
POSSIBLE ACTION ITEMS
Survey surgeons, anesthesiologists, hospitalists, and residents
regarding expectations and attitudes about preoperative evaluation
Develop preoperative consult worksheet and/or template
Fund enough FTE and secure sufficient residents for a dedicated
consult service
Develop a hospital medicine consult curriculum
Mandate completion of the SHM consult series