Transcript Preoperative Medical Assessment

Preoperative Medical
Assessment
Eric E. Leonheart DPM
Primary Assessment
History (Detailed)
Physical Exam
Review of Rx Medication
Review of Non-Rx Medication
Evaluation of Organ Systems
Advanced Directives
Other considerations
Functional status
Risk level of the surgery
Expected blood loss
Anesthesia type and duration
History
HPI (NLDOCAT)
PMH
PSH
Medications
Family History
Social History
Review of systems
Cardiac Evaluation
American College of Cardiology &
American Heart Association published
guidelines in 1996
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
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
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
Risk Stratification
High Risk
– Unstable angina, Unstable CHF, Symptomatic
ventricular arrhythmias
– Must have their cardiac problems resolved
prior to elective procedure
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
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
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
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
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
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
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
Endocrine Evaluation
Objective
– Is to rule out diabetes or thyroid disease
– Evaluate control of blood sugar
– Determine whether the patient is experiencing
adrenal suppression
Endocrine Evaluation
Diabetes
Fasting blood sugar < 200mg/dL
If elevated must gain control with oral
hypoglycemics or insulin prior to surgery
Endocrine Evaluation
Thyroid disorders
– Common symptoms, fatigue and constipation
– TSH testing, possibly T3 or T4
– Regulation of TSH is needed prior to surgery
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
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
Gastrointestinal Evaluation
History liver disease
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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
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
Neurologic Evaluation
Conditions of concern
– Myasthenia gravis
– Amyotrophic lateral sclerosis
– Parkinson’s
– CVA
– Seizures
– Dementia
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
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
Psychiatric Issues
High incident of ETOH abuse
Benzodiazepine abuse is common
Smoking history
Must manage withdrawal
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
Conclusion
Varying levels of risk
Imperative for the surgeon to be aware of
at risk issues
Work with PCP or other specialists