Transcript Clinical Slide Set. Preoperative Evaluation for Noncardiac Surgery

In the Clinic
PREOPERATIVE
EVALUATION
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
What is the risk for medical complications
from surgery in healthy patients?
 Risk for serious medical complications: <0.1%
 Evaluate preoperatively to predict risk for serious
medical complications
 Use focused history and physical exam
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
How does the procedure influence risk for
complications in healthy patients
undergoing surgery?
 Influences risk for complications independent of other
patient risk factors
 Complexity: third strongest predictor of postoperative
morbidity after low albumin and ASA class (VHA study)
 Influences risk for specific types of complications
 Upper abdominal and thoracic surgery: postoperative
pulmonary complications occur in 10%-40%
 Other types of surgery: postoperative pulmonary
complications rarely reported
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
Perioperative Risk Classifications for Surgical Procedures
 Low (<1%)
 Superficial surgery
 Breast
 Dental
 Cataract
 Intermediate (1%–5%)
 High (>5%)
 Intrathoracic
(nonmajor)
 Intraperitoneal
 Carotid (CEA or CAS)
 Endoscopic
 Endovascular
aneurysm repair
 Thyroid
 Head and neck surgery
 Gynecologic, minor
 Aortic, major vascular
surgery, peripheral
vascular surgery
 Major abdominal
surgery, prolonged
procedures with large
fluid shifts or blood
loss
 Esophagectomy
 Neurologic or
orthopedic, major
 Pneumonectomy
 Urologic, minor
 Urologic or
gynecologic, major
 Reconstructive or
cosmetic
 Lung, liver, or
pancreas
transplantation
 Renal transplantation
 Orthopedics, minor
 Adrenal resection
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
How do underlying chronic conditions
influence the risk for medical
complications of surgery?
 More comorbid conditions = higher risk for perioperative
complications
 Increasing ASA Class = increasing morbidity, mortality
 Grade I: Healthy patient
 Grade II: Mild systemic disease—no functional limitations
 Grade III: Severe systemic disease—definite functional
limitation
 Grade IV: Severe systemic disease that is a constant threat
to life
 Grade V: Moribund patient not expected to survive without
the surgery
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
How do lifestyle factors influence the risk
for perioperative complications?
 Ability to exercise strongly predicts perioperative
medical complications
 Smoking increases risk for perioperative pulmonary
complications
 Preoperative alcohol consumption increases risk for
perioperative morbidity
 Alcohol intake >60 g/d increases mortality risk
 Obesity increases overall surgical risk
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
CLINICAL BOTTOM LINE: Risk Factors...
 Comorbid conditions increase the risk for complications
 Ischemic heart disease, cerebrovascular disease, HF
 Diabetes mellitus, CKD, bleeding disorders, liver disease
 Other patient factors that affect perioperative risk
 Poor nutritional status, obesity
 Smoking, hazardous alcohol use, illicit substance use
 Poor exercise tolerance
 Type of surgery influences the risk of complications
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
Who should undergo preoperative evaluation?
 All patients scheduled for surgery
 Very low-risk procedures
 May need only to confirm lack of significant risk factors
 Minor surgery and patient has no medical history
 Patient screening by phone may suffice
 More complex surgery and patient comorbidities
 Consider evaluation by physician experienced in
preoperative assessment
 Screening triage tool may be useful
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
What are the essential elements of a
preoperative history and physical exam?
 Patient’s age, whether patient pregnant
 Exercise tolerance and ability to perform ADL
 Medication use
 Use of tobacco, alcohol, and illicit substances
 Overall health, including comorbid conditions, reaction
to past surgeries, experience with anesthesia
 Risk factors for cardiac, pulmonary, infectious
complications
 Physical: look for signs of undiagnosed or
decompensated conditions
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
Which laboratory tests should be
performed preoperatively?
 Base laboratory testing on history, physical exam, and
planned surgical procedure
 For minor procedures, routine testing not indicated if
history and physical exam are normal
 Consider comorbid conditions and medications
 Age alone is not a reason to order tests
 No need to repeat testing if tests were done within 4
months of surgery, results were normal, and clinical status
is unchanged
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
Lab Tests Before Elective Noncardiac Surgery
 Hemoglobin: Symptoms of anemia or anticipated major blood
loss
 Electrocardiography: Known coronary artery disease, diabetes,
uncontrolled hypertension, chronic kidney disease
 Chest radiography: Symptoms or examination findings
suggesting active pulmonary disease
 Platelet count: Myelotoxic medications or a history of bleeding
diathesis, myeloproliferative disorder, or liver disease
 Prothrombin time: Recent or long-term antibiotic use, warfarin
use, or a history of bleeding diathesis, liver disease, or
malnutrition
 Partial thromboplastin time: Heparin use or a history of
bleeding diathesis
continued…
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
Lab Tests Before Elective Noncardiac Surgery
 Electrolytes: Medications that affect electrolytes, renal
insufficiency, or congestive heart failure,
 Creatinine and blood urea nitrogen: CKD, hypertension,
diabetes, cardiac disease, major surgery, medications that may
affect renal function
 Glucose: Known diabetes, obesity
 Liver function tests: Cirrhosis
 Leukocyte count: Myelotoxic medications or symptoms
suggesting infection or myeloproliferative disorder
 Urinalysis: Symptoms suggestive of UTI, instrumentation of the
genital-urinary tract (not indicated before total joint replacement)
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
When should clinicians consider
preoperative cardiac stress testing?
 When patients have worrisome symptoms
 Evaluate for cardiac ischemia
 Decide about further testing based on urgency of surgery,
presence of recent ACS, combined clinical/surgical
procedure risk, and functional capacity
 Tools to determine cardiac complication risk
 Revised Cardiac Risk Index
 American College of Surgeons National Surgical Quality
Improvement Program risk calculator
 Myocardial infarction (MI) or cardiac arrest (MICA) tool
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
CLINICAL BOTTOM LINE: Evaluation...
 Essential elements of preoperative history and physical:
 Establishing overall health and underlying conditions
 Pregnancy, exercise tolerance
 Reaction to previous anesthesia and surgery
 Use of medications, tobacco, alcohol, illicit drugs
 Laboratory testing: history and physical should guide
 Noninvasive cardiac testing: only in patients with elevated
cardiac risk and poor functional status if the results are
likely to change management
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
How should clinicians manage medications
in the perioperative period?
 Continue essential medications
 Discontinue or adjust dose of other medications
 Only stop medications with significant potential for AEs
 Beware potential for withdrawal or rebound syndromes
 Aspirin/NSAIDs: stop before surgery if bleeding risk
outweighs thrombosis risk
 Oral hypoglycemics: withhold on morning of surgery
(maintain glucose control perioperatively with insulin)
 Diuretics and ACE inhibitors: often withheld unnecessarily
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
What should clinicians recommend to
reduce the risk for postoperative
thromboembolic complications?
 Stratify risk preoperatively in all surgical patients
 Caprini score or Rogers score
 Prescribe measures to reduce risk
 VTE prophylaxis based on risk class, surgical procedure
 Early ambulation
 Pharmacologic and mechanical methods
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
What should clinicians recommend to
reduce the risk for postoperative surgical
site infections?
 Preoperative antibiotic prophylaxis based on the
surgical procedure
 First-generation cephalosporin is a frequent choice
 Give within 1 h before skin incision
 Discontinue by 24 h after surgery
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
When are supplemental (stress-dose)
steroids indicated?
 When patients have taken >5 mg/d prednisone (or
equivalent) for ≥3 weeks within 6-12 months before
surgery, and they will have a procedure of at least
moderate stress
 Either, test the patient’s response to cosyntropin
preoperatively; if the test result is positive, administer
larger-than-physiologic doses of hydrocortisone
 Or, skip testing and simply administer larger-thanphysiologic doses of hydrocortisone
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
Perioperative Stress-Dose Corticosteroid Therapy
 Major surgeries
 Start hydrocortisone, 75–100 mg IV before surgery
 50 mg IV every 8 h for 24–48 h
 Reassess level of stress and either continue 50 mg dose
or taper to 25 mg every 8 h and then resume usual
outpatient dose in uncomplicated cases
 Moderate surgeries
 Start hydrocortisone, 50 mg IV before surgery
 25 mg every 8 h for 3 doses
 Resume usual outpatient dose in uncomplicated cases
 Minor procedures
 Usual dose on the day of surgery (some advocate giving
25 mg IV hydrocortisone preoperatively or doubling usual
oral dose)
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
What are the indications for perioperative
β-blockade?
 Theoretically protects heart from excessive workload
and prevents plaque rupture and subsequent
thrombosis, cardiac ischemia, and infarction
 However study results have been mixed
 Most studies suggest perioperative β-blockers are
associated with reduced MI and nonfatal MI and
increased bradycardia, hypotension, and stroke
 Effect on total mortality is unclear but may be increased
 Optimal type and dose of β-blocker unknown
 If using a β-blocker, start it >24 h before surgery
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
What are special preoperative considerations
for patients with cardiovascular disease?
 Coronary artery disease
 Prevent cardiac events by optimizing preoperative
medications and selective revascularization
 Recognize the risk for perioperative stent thrombosis when
there are recently placed coronary stents
 Heart failure
 Delay elective surgery with decompensated HF
 Optimize preoperative medications
 Investigate unexplained dyspnea, HF with change in
condition, and suspected valvular heart disease
continued…
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
 Rhythm and conduction disorders
 Common after open cardiac and thoracic procedures
 Increased with a history of AF, advanced age, and HF
 If at high risk for AF: consider β-blocker or amiodarone
preoperatively
 Warfarin can be stopped 5 days before surgery if the
patient has chronic nonvalvular AF
 Stop novel oral anticoagulants 1 to 3 d before surgery
based on half-lives, renal function, and bleeding risk
 Interrogate defibrillators and pacemakers before surgery
continued…
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
 Suspected valve disease
 Order transthoracic ECHO
 Patients with symptomatic aortic stenosis require aortic
valve replacement before other surgery
 Hypertension
 Is the reason many surgical procedures are cancelled
 Obtain preoperative ECG, check for renal insufficiency and
electrolyte disturbances, and continue β-blockade and
calcium-channel blockers
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
What are special preoperative considerations
for patients with pulmonary disease?
 To minimize postoperative pulmonary complication risk
 Cease smoking at least 4 to 8 weeks before surgery
 Conduct lung expansion maneuvers or CPAP
 Reduce airflow obstruction and treat respiratory infection
 Preoperative chest PT and inspiratory muscle training
 Screen patients for OSA (STOP-BANG questionnaire)
 Spirometry: only for those having lung resection, active
wheezing, unexplained impaired exercise tolerance
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
What are the special preoperative
considerations for patients with diabetes?
 Check basic chemistry panel
 Advise patients on adjusting medications and
monitoring glucose levels
 Elevated glucose, HbA1C increases complication risk
 Early-morning surgery limits disruption of glycemic
control
 Use an insulin pump or insulin glargine for bowel prep,
history of hypoglycemic episodes, or late-day surgery
 Morning of surgery: reduce NPH dose to 1/2 or 2/3 and
withhold short-acting insulin and oral hypoglycemics
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
What are special preoperative considerations
for patients with chronic kidney disease?
 Preoperative evaluation
 CBC, serum chemistries and creatinine concentration,
estimated GFR
 ECG in patients with existing or possible cardiac disease
 Assess and optimize fluid status
 Dialyze patients on hemodialysis the day before surgery
 Perioperative measures
 Avoid potentially nephrotoxic medications
 Adjust dose for drugs metabolized by the kidney
 Continue immunosuppressants for renal transplants
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
What are special preoperative considerations
for patients with liver disease?
 Evaluate based on Child-Pugh criteria or MELD score
 Child-Pugh: albumin, bilirubin, INR, ascites, hepatic
encephalopathy
 MELD: INR, bilirubin, creatinine, sodium
 Cancel elective surgery for patients at very high risk
 Acute hepatitis
 Child’s C criteria
 MELD scores > 15
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
What are the special preoperative
considerations for patients with
rheumatologic disease?
 Precautions to avoid perioperative neurologic problems
 Cervical collar
 Fiberoptic intubation
 Preoperative cervical spine films to assess C1–2 stability
 Careful neck positioning
 Rheumatologic treatments may increase infection risk
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
What are the special considerations for
pregnant women undergoing surgery?
 Conduct a pregnancy test in all women of child-bearing
potential
 Postpone nonemergency surgery in pregnant women
because surgery increases the perioperative risk for
 Miscarriage
 Preterm labor and delivery
 Intrauterine growth restriction
 Stillbirth
 Anesthesia risk to fetus, particularly in first trimester
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.
CLINICAL BOTTOM LINE: Risk
Reduction...
 Preoperative evaluation in unstable heart or lung disease
 Determine which medications to stop or continue
 Prevent VTE with early postoperative ambulation and
pharmacologic or mechanical prophylaxis
 Preoperative prophylactic antibiotics
 Minimize length of the preoperative hospital stay
 Limit use of immunosuppressive drugs
 Follow recommended guidelines for catheters
 Control glucose in patients with diabetes
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (6): ITC6-1.