Preop Evaluation
- 1. Preoperative Evaluation and Clearance for Surgery Joshua Steinberg MD Wilson Family Medicine Residency Binghamton, New York
- 2. Your pt, 72 y.o. Symptomatic gallstones Going for lap chole
- 3. Special Kind of Visit Family Physician usually serves just one person at a visit At a Preoperative Evaluation visit, we serve three parties
- 5. Goal of Pre-Op Eval At VERY LEAST, what does surgeon want to hear from you? CNY Cardiology 1234 Main St. Wherever, NY 67890 Yours Truly, Fred the Cardiologist Dear Bill the Orthopedist, I had the pleasure of seeing Mrs. Mabel Jones at your kind request. You may proceed to surgery.
- 6. Let’s do better than minimum! What should we do at the preoperative evaluation of a patient? What would the surgeon and anesthesiologist like us to do? How could we help a patient endure the challenges of surgery and recovery? How could we help surgeon & anesthesiologist give good care?
- 7. Organize the Activities Suggest/implement periop interventions 4 Optimize medical issues 2 Consider cardiac status 3 Report medical issues 1
- 8. Full History HPI: “asked by Dr. Aronis to evaluate pt prior to cholecystectomy for gallstones” Past Medical History: everything Past Surgical Hx (note problems bleeding or anesthesia) Allergies & Reactions, Meds FamHx (note problems anesthesia, bleeding) SocHx: EtOH, tobacco, drugs ROS: cardiac, those pertinent to PMHx, functional capacity Report medical issues 1
- 9. Physical Exam Vitals Cardiocirculatory Pulmonary Abdominal anything else you think is pertinent and helpful (neuro exam, mental status exam, skin exam, etc.) Report medical issues 1
- 10. Assessment & Plan Report medical issues 1 10/27/11, 8:15 am Samantha Smith S: Asked by Dr. Aronis to evaluate pt with cholecystitis prior to lap chole. PMHx, PSHx, All, Meds, SocHx, FamHx, ROS etc. O: vitals, lungs, heart, abd, ext, etc. A/P: 1. Preop clearance: clear to proceed to surgery (more later) 2. Asthma: mild, stable, continue Flovent MDI 3. Chronic Renal Insufficiency: creat stable at 1.5 baseline 4. Anemia: chronic, from malabsorption after bariatric surgery, recommend check Hct post-op 5. Please note anaphylactic Cefazolin allergy signed, JP Intern
- 11. Not so rosy after nausea and vomiting of cholecystitis, dehydrated, creat bumped to 2.1 asthma not controlled HTN uncontrolled Diabetes uncontrolled COPD or CHF exacerbated Optimize medical issues 2
- 12. Not so rosy Optimize medical issues 2 10/27/11, 8:15 am Samantha Smith S: Asked by Dr. Aronis to evaluate pt with cholecystitis prior to lap chole. PMHx, PSHx, All, Meds, SocHx, FamHx, ROS O: vitals, lungs, heart, abd, ext, etc. A/P: 1. Preop clearance: pending items 2-4, I anticipate pt will be clear to proceed to surgery 2. Dehydration: giving 2 L NS 3. Chronic Renal Insufficiency: recheck after IVF, aim to get back to baseline creat 1.5 4. HTN: SBP 197/98 unsafe for surgery, will resume Amlodipine and Coreg 5. Severe O2 dept COPD: it’s awful, horrendous, 115.3 pack-year smoking hx, but optimized on meds and at baseline signed, JP Intern
- 13. Check for sub-optimal stuff All kinds of labs & workup you could do preop checking if anything is suboptimal BUT, every guideline recognizes that the yield of useful results that influence care is VANISHINGLY LOW. Over-testing is rampant many preop tests already ordered by surgeon if you choose tests, order only ones indicated avoid cost, risk of false positives, unnecessary delay surgery K+ or BMP: certainly digoxin, diuretics, ACE/ARB, ok for others CBC: anything suggests anemia or blood loss Optimize medical issues 2
- 14. Check for sub-optimal stuff CXR: only for s/sx new or unstable cardiopulm disease, 4 organizations beg you to stop routine CXR Coags: known hx coag d/o, hx suggests new coag d/o, on anticoagulant, needs anticoagulant post-op, otherwise don’t do UA: urologic surgery, prosthetic implants, otherwise don’t do EKG: most patients (ICSI vs ACC) any cardiovasc risk factors, age 65+, any cardiovascular s/sx, surgery of intermediate or high risk anything else you can justify, i.e. renal fxn for known/suspected kidney disease, LFT’s for known/suspected liver disease, HCG, etc. Never do any testing before cataract surgery Optimize medical issues 2
- 15. Cardiac Eval Algorithm American College of Cardiology (ACC) guideline for stepwise consideration of cardiac status revised 1997, 2002, 2007, 2014 always gets easier since evidence shows that pts simply do well! Consider cardiac status 3
- 17. Step 1 Consider cardiac status 3 Emergency surgery? If so, go to the OR – it’s an emergency! Figure things out and clean up any mess post-op!
- 18. Step 2 Consider cardiac status 3 Acute Coronary Syndrome current or recent? clinical syndromes of acute coronary ischemia including unstable angina, STEMI, NSTEMI If so, evaluate, treat, recover, optimize, and then reconsider OR
- 19. Step 3 (and 4) Consider cardiac status 3 Risk of major adverse cardiac event (MACE) < 1%? ACC offers 3 validated schemes to estimate risk RCRI, ACS NSQIP Surgical Risk Calculator (online), ACS NSQIP MICA calculator (.xls!) Risk 0-1: low 2+: high Certain surgeries very low risk no matter what e.g. ophthalmic, plastic, etc. If low risk, go to OR
- 20. Step 5 Consider cardiac status 3 Good functional capacity? If so, go to OR
- 21. Steps 6 & 7 Consider cardiac status 3 Urgent or elective surgery No acute coronary syndr. Elevated risk surgery Poor or unknown functional capacity Consider whether further testing would impact decision making or perioperative care
- 22. Steps 6 & 7 Consider cardiac status 3 Would further testing would impact decision making? would pt facing surgery agree to cath-stent-CABG and post- procedure delay if stress testing found ischemia? would pt facing surgery and possible coronary revascularization opt for non- surgical tx instead (e.g. chemo, xrt for cancer)
- 23. Cardiac Eval Algorithm Consider cardiac status 3 10/27/11, 8:15 am Samantha Smith S: Asked by Dr. Aronis to evaluate pt with cholecystitis prior to lap chole. PMHx, PSHx, All, Meds, SocHx, FamHx ROS: no cardiac sx, good functional capacity O: vitals, lungs, heart, abd, ext, etc. A/P: 1. Preop clearance: according to 2014 ACC guideline, pt is clear to proceed to surgery 2. Asthma: mild, stable, continue Flovent MDI 3. Chronic Renal Insufficiency: creat stable at 1.5 baseline 4. Anemia: chronic, from malabsorption after bariatric surgery, recommend check Hct post-op 5. Please note anaphylactic Cefazolin allergy signed, JP Intern
- 24. Periop interventions Lots of useful things you could do before and after surgery smoking cessation alcohol cessation/detox get the Foley catheter out early mainly medication management beta blockers insulin warfarin & bridging heparins aspirin & plavix Suggest/implement periop interventions 4
- 25. Beta-blockers if on one, stay on it add beta-blocker periop? numerous trials show reduced MI’s for pts with significant MI risk then one showing MI benefit, CVA harm Metoprolol high dose and no titration ACC has softened recommendation but still says offer beta-blockade for higher risk cardiovascular pts with higher risk surgeries and take time to titrate Suggest/implement periop interventions 4
- 26. Diabetes & Insulin Mild hyperglycemia is preferable to hypoglycemia Don’t take oral hypoglycemics on day of procedure Don’t take short-acting insulin morning of procedure Long-acting or intermediate insulin may be used to cover basal insulin needs; 50%-100% of usual dose is often reasonable Insulin pumps should be continued but only to provide basal insulin coverage Details of insulin recommendations influenced by insulin sensitivity of patient, timing of procedure, length of procedure, and how long patient will need to be NPO following the procedure. Suggest/implement periop interventions 4
- 27. Warfarin & bridging Heparins ACCP guideline recommends you handle this based upon risk of thromboembolism during non-anticoagulated time Basically stop Warfarin 5 days before surgery, resume when surgical wounds hemostatic and clinical situation favorable Depending on level of risk of thromboembolic event, cover pt with a Heparin product up until time of surgery and as soon after surgery as pt deemed safe for anticoagulation Suggest/implement periop interventions 4 day preop 5 4 3 2 1 surgery 1 2 day postop WARFARIN ---> // ??? bridging Heparin ??? ---> // WARFARIN +/- Heparin --->
- 28. Aspirin ACC points out that evidence does not clearly support benefit of Aspirin to prevent peri/post-operative MI’s (in non post-stent pts). Aspirin causes more bleeding during surgery. Thus much weaker recommendation on continuing Aspirin during surgery for high ischemia-risk pts and much more permission to stop aspirin in anyone Should be discussed and negotiated with the surgeon Strong recommendation to continue Aspirin if pt was on Aspirin-Clopidogrel combination (“dual antiplatelet therapy” or DAPT) and both cannot be continued during surgery when highly necessary… Suggest/implement periop interventions 4
- 29. Aspirin & Clopidogrel Most patients on Clopidogrel are on it with Aspirin (DAPT) in the 12 months after stent Stent thrombosis rates super-high 1st 4-6 wks, somewhat high therafter, especially for DES Try not to do surgery 4-6 wks after stent at all and not for 365 days after DES If must operate, try to go to OR on DAPT, and if DAPT too dangerous, try to go to OR on Aspirin alone, restarting Clopidogrel ASAP after This stuff should be discussed and negotiated with the surgeon Suggest/implement periop interventions 4 or the other P2Y12 inhibitors
- 30. Periop Med Mgmt Suggest/implement periop interventions 4 10/27/11, 8:15 am Samantha Smith S: Asked by Dr. Aronis to evaluate pt with cholecystitis prior to lap chole. PMHx, PSHx, All, Meds, SocHx, FamHx ROS: no cardiac sx, good functional capacity O: vitals, lungs, heart, abd, ext, preop labs, EKG A/P: 1. Preop clearance: according to 2014 ACC guideline, pt is clear to proceed to surgery 2. A-fib/Anticoag: as pt is low risk, will stop Coumadin 5 days before surgery and recommend resume when hemostasis achieved 3. DM II: stop Humalog & Metformin, give half dose Lantus night before surgery, resume each when taking PO post-op 4. Please note anaphylactic Cefazolin allergy signed, JP Intern
- 31. Agenda for Preop Eval Suggest/implement periop interventions 4 Optimize medical issues 2 Consider cardiac status 3 Report medical issues 1
- 32. Preoperative Evaluation So you’ve got it all memorized now? Big Important Med School 1234 Main St. Wherever, NY 67890 Yours Truly, Bob the Med Student Dear Dr. Steinberg, That’s a crazy amount o’ stuff to keep straight!
- 33. There’s an App for That…
Editor's Notes
- #4: usually serve just one person at a visit: who? [patient] at preop eval we serve three: who? [pt, surgeon, anesthesiologist]
- #7: read these bullet points and then querry the crowd for ideas, then say… I’m going to organize our activites into four general items
- #9: In theory as a family doctor, you know this patient well and you know medical conditions well. The surgeon knows gallstones and cholecystectomy, but we know asthma and alcoholism and chronic kidney dz and hypertension. And we are really good at doing thorough histories, especially residents, so this is where we shine. Take a thorough history covering eveyrthing that you, a surgeon, and an anesthesiologist might need to know about a patient so that you can report all of it to the team. You might think that these things are already in the EMR your surgeon and anesthesiologist share. But our EMR’s are filled with garbage. Badly worded vague dx’es, old dx’es that aren’t accurate anymore, missing new dx’es, med lists that need to be updated, allergies which need to be clarified, and more. Update the chart so it is pristine.
- #11: Let’s say your patient has a few issues but they are all under decent mgmt, all you have to do is report them could look like this… But what if pt’s status is not so rosy? Let’s move to the 2nd thing you can do at Preop eval
- #15: next item is to evaluate for the number one non-surgical complication of surgery…
- #16: What is that #1 non-surgical complication of surgery in the perioperative period? [ask crowd] Having a heart attack. Fortunately there are steps you can take to consider the risk of periop MI
- #17: This looks like a scary complicated algorithm, but actually it’s pretty straightforward if you break it down into pieces. (and for those of you following along over time, it is quite similar to the 2007 algorithm, except even simpler!)
- #19: Remember I mentioned taking PMHx and cardiac ROS and cardiac exam? It’s first and foremost to discover and/or evaluate this stuff, active cardiac conditions! ACC recommends … 60 days wait p MI 14 days p angioplasty 30-45 days p stent bare metal 365 days p drug-eluting stent (!)
- #28: Can’t go to surgery on Warfarin anticoagulation. You’re definitely going to stop 5-7 days before surgery. You’re definitely going to resume postop when surgery hemostatic. Question is what to do about this middle time, should you provide temporary and effective anticoagulation with a Heparin product like Lovenox? Depends on the risk of thromboembolic event.