Preoperative assessment
- 1. Pre-operative AssessmentPre-operative Assessment of the Surgical Patientof the Surgical Patient Augusto Torres, MDAugusto Torres, MD Department of AnesthesiologyDepartment of Anesthesiology MetroHealth Medical CenterMetroHealth Medical Center July 2007
- 2. OutlineOutline Discuss anesthesiaDiscuss anesthesia specific riskspecific risk Discuss patientDiscuss patient specific riskspecific risk Surgery specific riskSurgery specific risk Pre-operativePre-operative laboratory and studieslaboratory and studies Example caseExample case
- 3. Reason for evaluationReason for evaluation Anesthesia and surgery are physiologicallyAnesthesia and surgery are physiologically stressful, invasive interventions which maystressful, invasive interventions which may exacerbate or uncover underlying diseaseexacerbate or uncover underlying disease processesprocesses Some of the most feared complications includeSome of the most feared complications include catastophic events such as myocardialcatastophic events such as myocardial infarction,difficulty oxygenating or ventilating,infarction,difficulty oxygenating or ventilating, and cerebral vascular accident, among othersand cerebral vascular accident, among others A proper pre-operative assessment allows theA proper pre-operative assessment allows the perioperative providers (anesthesiologist andperioperative providers (anesthesiologist and surgeon) the ability to stratify and reduce risk forsurgeon) the ability to stratify and reduce risk for the patientthe patient
- 4. Why is anesthesia risky?Why is anesthesia risky? There can be difficulty obtaining an airway to adequatelyThere can be difficulty obtaining an airway to adequately oxygenate and ventilateoxygenate and ventilate Induction (i.e. “going to sleep”): time of hemodynamicInduction (i.e. “going to sleep”): time of hemodynamic stress – patient may become hypotensive from thestress – patient may become hypotensive from the induction agents or hypertensive with laryngoscopy andinduction agents or hypertensive with laryngoscopy and intubationintubation Maintanence (bulk of case): differing degrees ofMaintanence (bulk of case): differing degrees of stimulation, fluid shifts, blood lossstimulation, fluid shifts, blood loss Emergence (i.e. “waking up”): physiologically stressful,Emergence (i.e. “waking up”): physiologically stressful, secure airway may be lost, hypothermiasecure airway may be lost, hypothermia Anaphylactic reactions to medications, injury duringAnaphylactic reactions to medications, injury during laryngoscopy, neuropathy from positioninglaryngoscopy, neuropathy from positioning Even spinal/epidural carries risk: inadequate, need toEven spinal/epidural carries risk: inadequate, need to convert to general, sympathectomy with vasodilation, etcconvert to general, sympathectomy with vasodilation, etc
- 5. ACC/AHA Guideline Update forACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation forPerioperative Cardiovascular Evaluation for Noncardiac Surgery – Executive SummaryNoncardiac Surgery – Executive Summary Published in 2002 inPublished in 2002 in Circulation 105:1257-Circulation 105:1257- 1267.1267. Eagle KA et alEagle KA et al Guidelines for evaluation of cardiac riskGuidelines for evaluation of cardiac risk
- 6. Clinical Predictors of IncreasedClinical Predictors of Increased Perioperative Cardiovascular RiskPerioperative Cardiovascular Risk MAJORMAJOR – Unstable coronary syndromesUnstable coronary syndromes Acute (<7d) or recent MI (<1mo) with evidence of ischemicAcute (<7d) or recent MI (<1mo) with evidence of ischemic riskrisk Unstable or severe anginaUnstable or severe angina – Decompensated heart failureDecompensated heart failure – Significant arrhythmiasSignificant arrhythmias High-grade AV blockHigh-grade AV block Symptomatic ventricular arrhythmiaSymptomatic ventricular arrhythmia SVT uncontrolled rateSVT uncontrolled rate – Severe valvular diseaseSevere valvular disease
- 7. Clinical Predictors of IncreasedClinical Predictors of Increased Perioperative Cardiovascular RiskPerioperative Cardiovascular Risk INTERMEDIATEINTERMEDIATE – Mild angina pectorisMild angina pectoris – Previous myocardial infarction (>1mo) byPrevious myocardial infarction (>1mo) by history of pathological Q waveshistory of pathological Q waves – Compensated or prior heart failureCompensated or prior heart failure – Diabetes mellitus (particularly insulinDiabetes mellitus (particularly insulin dependent)dependent) – Renal insufficiency (creatinine >2.0)Renal insufficiency (creatinine >2.0)
- 8. Clinical Predictors of IncreasedClinical Predictors of Increased Perioperative Cardiovascular RiskPerioperative Cardiovascular Risk MINORMINOR – Advanced ageAdvanced age – Abnormal ECG (LVH, LBBB, ST-TAbnormal ECG (LVH, LBBB, ST-T abnormalities)abnormalities) – Rhythm other than sinus (e.g. a fib)Rhythm other than sinus (e.g. a fib) – Low functional capacity (e.g. inability to climbLow functional capacity (e.g. inability to climb one flight of stairs with a bag of groceries)one flight of stairs with a bag of groceries) – History of strokeHistory of stroke – Uncontrolled systemic hypertensionUncontrolled systemic hypertension
- 9. Clinical Predictors of IncreasedClinical Predictors of Increased Perioperative Cardiovascular RiskPerioperative Cardiovascular Risk Functional CapacityFunctional Capacity – Metabolic equivalentsMetabolic equivalents – 1 MET – Can you take care of yourself? Eat,1 MET – Can you take care of yourself? Eat, dress, use the toilet? Walk a block or two ondress, use the toilet? Walk a block or two on level ground 2-3 MPHlevel ground 2-3 MPH – 4 METs – Do light work around the house like4 METs – Do light work around the house like dusting or washing the dishes? Climb a flightdusting or washing the dishes? Climb a flight of stairs?of stairs? – >10 METs – Participate in strenuous sports>10 METs – Participate in strenuous sports like swimming, singles tennis, football?like swimming, singles tennis, football?
- 10. Clinical Predictors of IncreasedClinical Predictors of Increased Perioperative Cardiovascular RiskPerioperative Cardiovascular Risk Functional CapacityFunctional Capacity – Perioperative cardiac and long-term risks arePerioperative cardiac and long-term risks are elevated in patients unable to obtain 4-METelevated in patients unable to obtain 4-MET demanddemand – www.1000takes.comwww.1000takes.com
- 11. Surgery-specific riskSurgery-specific risk Two important factorsTwo important factors – The type of surgery and degree ofThe type of surgery and degree of hemodynamic stresshemodynamic stress
- 12. Surgery Specific RiskSurgery Specific Risk High (Reported riskHigh (Reported risk >5%)>5%) – Emergent majorEmergent major operations, particularlyoperations, particularly in elderlyin elderly – Aortic and other majorAortic and other major vascular surgeryvascular surgery – Surgical proceduresSurgical procedures associated with largeassociated with large fluid shifts and/or bloodfluid shifts and/or blood lossloss – www.services.epnet.comwww.services.epnet.com
- 13. Surgery Specific RiskSurgery Specific Risk IntermediateIntermediate (Reported risk <5%)(Reported risk <5%) – CarotidCarotid endarterectomyendarterectomy – Head and neckHead and neck surgerysurgery – Intraperitoneal andIntraperitoneal and intrathoracicintrathoracic proceduresprocedures – Orthopedic surgeryOrthopedic surgery – Prostate surgeryProstate surgery
- 14. Surgery Specific RiskSurgery Specific Risk Low (Reported riskLow (Reported risk <1%)<1%) – EndoscopicEndoscopic proceduresprocedures – Superficial proceduresSuperficial procedures – Cataract surgeryCataract surgery – Breast surgeryBreast surgery – www.steenhall.comwww.steenhall.com
- 15. The AlgorithmThe Algorithm Step 1: What is the urgency of surgery?Step 1: What is the urgency of surgery? – Emergency: No time for further evaluationEmergency: No time for further evaluation Step 2: Coronary revascularization in theStep 2: Coronary revascularization in the past five years?past five years? – Free ticket for five years if no new symptomsFree ticket for five years if no new symptoms have arisen (chest pain or SOB)have arisen (chest pain or SOB) Step 3: Coronary evaluation in the past 2Step 3: Coronary evaluation in the past 2 years?years? – Free ticket for two years if no new symptomsFree ticket for two years if no new symptoms
- 16. The AlgorithmThe Algorithm Step 4: Unstable coronary syndrome or majorStep 4: Unstable coronary syndrome or major predictor of risk?predictor of risk? – Will lead to cancellation or delay of surgeryWill lead to cancellation or delay of surgery Step 5: Intermediate clinical predictors of risk?Step 5: Intermediate clinical predictors of risk? Step 6:Step 6: – Intermediate clinical predictors and moderate toIntermediate clinical predictors and moderate to excellent functional capacity are good candidates forexcellent functional capacity are good candidates for intermediate risk surgeryintermediate risk surgery – Intermediate clinical predictors and poor functionalIntermediate clinical predictors and poor functional capacity or moderate to excellent functional capacitycapacity or moderate to excellent functional capacity with high risk surgery often need further testingwith high risk surgery often need further testing
- 17. The AlgorithmThe Algorithm Step 7:Step 7: – Minor or no clinical predictors with moderateMinor or no clinical predictors with moderate or excellent functional capacity usually needor excellent functional capacity usually need no further testingno further testing – Minor or no clinical predictors with poorMinor or no clinical predictors with poor functional capacity and high risk surgery mayfunctional capacity and high risk surgery may need further testingneed further testing Step 8: Results of non-invasive testingStep 8: Results of non-invasive testing determines need for invasive testing ordetermines need for invasive testing or interventionintervention
- 18. Pre-operative TestsPre-operative Tests 12-Lead ECG12-Lead ECG – Class I: Recent episode of chest pain orClass I: Recent episode of chest pain or ischemic equivalent etcischemic equivalent etc – Class IIB:Class IIB: Prior coronary revascularizationPrior coronary revascularization Asymptomatic male >45yrs old or female >55 yrsAsymptomatic male >45yrs old or female >55 yrs old with 2 or more risk factorsold with 2 or more risk factors Prior hospital admission for cardiac causesPrior hospital admission for cardiac causes – Class III: Routine in asymptomatic individualsClass III: Routine in asymptomatic individuals
- 19. Pre-operative TestsPre-operative Tests EchoEcho – Class I: Patients with current or poorlyClass I: Patients with current or poorly controlled heart failurecontrolled heart failure – Class IIa: Prior heart failure and dyspnea ofClass IIa: Prior heart failure and dyspnea of unknown originunknown origin – Class III: As a routine testClass III: As a routine test
- 20. Pre-operative TestsPre-operative Tests Exercise or Pharmacological StressExercise or Pharmacological Stress TestingTesting – Class I:Class I: Patients with intermediate pretest probabilityPatients with intermediate pretest probability Change in clinical status of patient with suspectedChange in clinical status of patient with suspected or proven CADor proven CAD Proof of ischemia prior to revascularizationProof of ischemia prior to revascularization Evaluation of adequacy of medical therapyEvaluation of adequacy of medical therapy – Class IIa: Evaluation of exercise capacityClass IIa: Evaluation of exercise capacity when subjective assessment unreliablewhen subjective assessment unreliable
- 21. Pre-operative TestsPre-operative Tests Class IIbClass IIb – Diagnosis of CAD in patients with high or lowDiagnosis of CAD in patients with high or low pretest probability: resting ST depressionpretest probability: resting ST depression <1mm, taking digitalis, or LVH<1mm, taking digitalis, or LVH – Detection of restenosis in high-riskDetection of restenosis in high-risk asymptomatic patientsasymptomatic patients Class IIIClass III – Routine screening of asymptomatic patientsRoutine screening of asymptomatic patients
- 22. Pre-operative TestsPre-operative Tests Coronary AngiographyCoronary Angiography – Class IClass I Evidence of adverse outcome from non-invasiveEvidence of adverse outcome from non-invasive testtest Angina unresponsive to therapyAngina unresponsive to therapy Unstable angina, especially with intermediate orUnstable angina, especially with intermediate or high risk surgeryhigh risk surgery Equivocal noninvasive test in high clinical riskEquivocal noninvasive test in high clinical risk patient undergoing high risk surgerypatient undergoing high risk surgery
- 23. Pre-operative TestsPre-operative Tests Class IIaClass IIa – Multiple markers of intermediate clinical riskMultiple markers of intermediate clinical risk and planned vascular surgeryand planned vascular surgery – Moderate to large ischemia on non-invasiveModerate to large ischemia on non-invasive testing but without high-risk features andtesting but without high-risk features and lower left ventricular functionlower left ventricular function – Nondiagnostic noninvasive test results inNondiagnostic noninvasive test results in patients at intermediate clinical riskpatients at intermediate clinical risk – Urgent noncardiac surgery while recoveringUrgent noncardiac surgery while recovering from acute MIfrom acute MI
- 24. Pre-operative TestsPre-operative Tests Class IIbClass IIb – Perioperative MIPerioperative MI – Medically stabilized angina and low-risk surgeryMedically stabilized angina and low-risk surgery Class IIIClass III – Low risk surgery with known CADLow risk surgery with known CAD – Asymptomatic after coronary revascularization withAsymptomatic after coronary revascularization with excellent exercise capacityexcellent exercise capacity – Noncandidate for coronary revascularization owing toNoncandidate for coronary revascularization owing to concomitant medical illness, severe left ventricularconcomitant medical illness, severe left ventricular dysfunction (EF <20%)dysfunction (EF <20%)
- 25. Perioperative TherapyPerioperative Therapy CABGCABG – Indications for CABG same as for those notIndications for CABG same as for those not undergoing surgeryundergoing surgery – Consider in those who long-term outcomeConsider in those who long-term outcome improved by CABGimproved by CABG Percutaneous Coronary InterventionPercutaneous Coronary Intervention – Delay of 4-6 weeks for antiplatelet therapy forDelay of 4-6 weeks for antiplatelet therapy for re-endothelializationre-endothelialization
- 26. Day of SurgeryDay of Surgery History of present illnessHistory of present illness NPO statusNPO status PMHPMH PSHPSH – Problems with anethesiaProblems with anethesia Malignant hyperthermiaMalignant hyperthermia Post-operative nausea and vomitingPost-operative nausea and vomiting Difficulty with intubation – letter fromDifficulty with intubation – letter from anesthesiologistanesthesiologist
- 27. Day of SurgeryDay of Surgery AllergiesAllergies – Antibiotics, latexAntibiotics, latex Vital signs (are vital)Vital signs (are vital) – Baseline blood pressure for cerebral autoregulationBaseline blood pressure for cerebral autoregulation Physical examination (directed)Physical examination (directed) – Airway examinationAirway examination – CorCor – LungsLungs – Neurologic (especially if regional technique planned)Neurologic (especially if regional technique planned)
- 28. Day of SurgeryDay of Surgery LaboratoryLaboratory – Eg. Renal function, starting HCT, PlateletsEg. Renal function, starting HCT, Platelets – Beta HCG women of childbearing ageBeta HCG women of childbearing age ImagingImaging – CXR: Trauma, CHF, COPDCXR: Trauma, CHF, COPD – CT scan in thyroidectomyCT scan in thyroidectomy
- 29. Day of SurgeryDay of Surgery Assessment of patientAssessment of patient – Risk of anesthesia and surgeryRisk of anesthesia and surgery – MonitoringMonitoring – Technique of anesthesia and agents to beTechnique of anesthesia and agents to be usedused – Post-operative carePost-operative care
- 30. Example of PatientExample of Patient 59 year old female presents for an Aorto-bifemoral bypass59 year old female presents for an Aorto-bifemoral bypass PMH:PMH: – HTNHTN – DM IIDM II – HypercholesterolemiaHypercholesterolemia PSH:PSH: – Hysterectomy at age 49Hysterectomy at age 49 Social HX: Tob 35 pack yrSocial HX: Tob 35 pack yr NKDANKDA Meds: atenolol, glucophage, lipitorMeds: atenolol, glucophage, lipitor VS 145/73, P: 71, R:18, Sat 96%VS 145/73, P: 71, R:18, Sat 96% NAD, A&O x3NAD, A&O x3 MP 2, Neck FROMMP 2, Neck FROM Cor: RRRCor: RRR Lungs: BS distant, no wheezingLungs: BS distant, no wheezing Abd: soft, no palpable massAbd: soft, no palpable mass Ext: lower ext cool, difficult to palpate pulsesExt: lower ext cool, difficult to palpate pulses
- 31. Example of PatientExample of Patient 59 year old female presents for an59 year old female presents for an Aorto-bifemoral bypassAorto-bifemoral bypass PMH:PMH: – HTNHTN – DM IIDM II – HypercholesterolemiaHypercholesterolemia PSH:PSH: – Hysterectomy at age 49Hysterectomy at age 49 Social HX: Tob 35 pack yrSocial HX: Tob 35 pack yr NKDANKDA Meds: atenolol, glucophage, lipitorMeds: atenolol, glucophage, lipitor VS 145/73, P: 71, R:18, Sat 96%VS 145/73, P: 71, R:18, Sat 96% NAD, A&O x3NAD, A&O x3 MP 2, Neck FROMMP 2, Neck FROM Cor: RRRCor: RRR Lungs: BS distant, no wheezingLungs: BS distant, no wheezing Abd: soft, no palpable massAbd: soft, no palpable mass Ext: lower ext cool, difficult toExt: lower ext cool, difficult to palpate pulsespalpate pulses What if any further preoprativeWhat if any further preoprative laboratory or investigative studieslaboratory or investigative studies are necessary?are necessary?
- 32. LaboratoryLaboratory Basic metabolic profile?Basic metabolic profile? CBC?CBC? Coagulation profile?Coagulation profile?
- 33. LaboratoryLaboratory Basic metabolic profileBasic metabolic profile – Assessment of baseline renal functionAssessment of baseline renal function CBCCBC – HCT and PlateletsHCT and Platelets Coagulation profileCoagulation profile – History of bleeding and/or bruisingHistory of bleeding and/or bruising
- 34. ECG?ECG?
- 35. ECG?ECG? 12-Lead ECG12-Lead ECG – Class IIB:Class IIB: Asymptomatic male >45yrs old or female >55 yrsAsymptomatic male >45yrs old or female >55 yrs old with 2 or more risk factorsold with 2 or more risk factors
- 36. ECGECG NSR with non-specific ST and T waveNSR with non-specific ST and T wave changeschanges www.library.med.utah.eduwww.library.med.utah.edu
- 38. Chest X-rayChest X-ray ClinicalClinical characteristics tocharacteristics to consider:consider: – Smoking, COPD,Smoking, COPD, recent respiratoryrecent respiratory infection, cardiacinfection, cardiac diseasedisease – If the above are stable,If the above are stable, no unequivocalno unequivocal indicationindication
- 39. Further cardiac evaluation?Further cardiac evaluation?
- 40. Further cardiac evaluationFurther cardiac evaluation Clinical predictors?Clinical predictors? – Intermediate i.e.Intermediate i.e. diabetes mellitusdiabetes mellitus Functional capacity?Functional capacity?
- 41. Functional CapacityFunctional Capacity ““I can’t walk one flight ofI can’t walk one flight of steps because my legssteps because my legs hurt!”hurt!” <4 mets<4 mets Non-invasive testingNon-invasive testing Exercise orExercise or Pharmacological StressPharmacological Stress TestingTesting – Class IIa: Evaluation ofClass IIa: Evaluation of exercise capacity whenexercise capacity when subjective assessmentsubjective assessment unreliableunreliable – www.users.interport.netwww.users.interport.net
- 42. Non-invasive testingNon-invasive testing Dobutamine stress echoDobutamine stress echo – EF 50%, mildly reducedEF 50%, mildly reduced ventricular functionventricular function – Area of scar inferiorArea of scar inferior segmentsegment – With injection ofWith injection of dobutamine, area ofdobutamine, area of hypokinesis lateralhypokinesis lateral segment of the left ventriclesegment of the left ventricle – www.folk.ntnu.nowww.folk.ntnu.no Coronary angiography?Coronary angiography?
- 43. Coronary angiography?Coronary angiography? Class IClass I Evidence of adverseEvidence of adverse outcome from non-outcome from non- invasive testinvasive test Coronary angiogramCoronary angiogram – Left main: normal vesselLeft main: normal vessel – LAD: area of 40% proximalLAD: area of 40% proximal – Circumflex: 80% proximalCircumflex: 80% proximal lesionlesion – RCA: severe diffuseRCA: severe diffuse disease with collateraldisease with collateral filling from PCAfilling from PCA – Procedure: one stentProcedure: one stent successfully placed insuccessfully placed in proximal cirumflex arteryproximal cirumflex artery
- 44. Coronary AngiographyCoronary Angiography Patient placed on plavix and surgeryPatient placed on plavix and surgery postponed for six weekspostponed for six weeks Patient, surgeon, and anesthesiologistPatient, surgeon, and anesthesiologist aware of tenuous blood supply to RCAaware of tenuous blood supply to RCA territory but no stress-induced ischemiaterritory but no stress-induced ischemia www.health.yahoo.comwww.health.yahoo.com
- 45. ConclusionConclusion Preoperative evaluation is necessary toPreoperative evaluation is necessary to stratify risk to the patientstratify risk to the patient The evaluation delineates patient clinicalThe evaluation delineates patient clinical factors as well as extent of surgeryfactors as well as extent of surgery The patient, surgeon, anesthesiologist areThe patient, surgeon, anesthesiologist are aware of the perioperative risk and mayaware of the perioperative risk and may plan therapy accordinglyplan therapy accordingly