preopAssessment - Pre-operative Assessment of the Surgical...

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Unformatted text preview: Pre-operative Assessment of the Surgical Patient of Augusto Torres, MD Department of Anesthesiology MetroHealth Medical Center July 2007 Outline Outline Discuss anesthesia Discuss specific risk specific Discuss patient Discuss specific risk specific Surgery specific risk Pre-operative Pre-operative laboratory and studies laboratory Example case Reason for evaluation Reason Anesthesia and surgery are physiologically Anesthesia stressful, invasive interventions which may exacerbate or uncover underlying disease processes processes Some of the most feared complications include Some catastophic events such as myocardial infarction,difficulty oxygenating or ventilating, and cerebral vascular accident, among others and A proper pre-operative assessment allows the proper perioperative providers (anesthesiologist and surgeon) the ability to stratify and reduce risk for the patient the Why is anesthesia risky? Why There can be difficulty obtaining an airway to adequately There oxygenate and ventilate oxygenate Induction (i.e. “going to sleep”): time of hemodynamic Induction stress – patient may become hypotensive from the induction agents or hypertensive with laryngoscopy and intubation intubation Maintanence (bulk of case): differing degrees of Maintanence stimulation, fluid shifts, blood loss stimulation, Emergence (i.e. “waking up”): physiologically stressful, Emergence secure airway may be lost, hypothermia secure Anaphylactic reactions to medications, injury during Anaphylactic laryngoscopy, neuropathy from positioning laryngoscopy, Even spinal/epidural carries risk: inadequate, need to Even convert to general, sympathectomy with vasodilation, etc convert ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery – Executive Summary Published in 2002 in Circulation 105:1257Circulation 1267. Eagle KA et al Guidelines for evaluation of cardiac risk Clinical Predictors of Increased Perioperative Cardiovascular Risk Perioperative MAJOR – Unstable coronary syndromes Acute (<7d) or recent MI (<1mo) with evidence of ischemic Acute risk risk Unstable or severe angina – Decompensated heart failure – Significant arrhythmias High-grade AV block Symptomatic ventricular arrhythmia SVT uncontrolled rate – Severe valvular disease Clinical Predictors of Increased Perioperative Cardiovascular Risk Perioperative INTERMEDIATE – Mild angina pectoris – Previous myocardial infarction (>1mo) by Previous history of pathological Q waves history – Compensated or prior heart failure – Diabetes mellitus (particularly insulin Diabetes dependent) dependent) – Renal insufficiency (creatinine >2.0) Clinical Predictors of Increased Perioperative Cardiovascular Risk Perioperative MINOR – Advanced age – Abnormal ECG (LVH, LBBB, ST-T Abnormal abnormalities) abnormalities) – Rhythm other than sinus (e.g. a fib) – Low functional capacity (e.g. inability to climb Low one flight of stairs with a bag of groceries) one – History of stroke – Uncontrolled systemic hypertension Uncontrolled Clinical Predictors of Increased Perioperative Cardiovascular Risk Perioperative Functional Capacity – Metabolic equivalents – 1 MET – Can you take care of yourself? Eat, MET dress, use the toilet? Walk a block or two on level ground 2-3 MPH level – 4 METs – Do light work around the house like METs dusting or washing the dishes? Climb a flight of stairs? of – >10 METs – Participate in strenuous sports >10 like swimming, singles tennis, football? like Clinical Predictors of Increased Perioperative Cardiovascular Risk Perioperative Functional Capacity – Perioperative cardiac and long-term risks are Perioperative elevated in patients unable to obtain 4-MET demand demand – www.1000takes.com Surgery-specific risk Surgery-specific Two important factors – The type of surgery and degree of The hemodynamic stress hemodynamic Surgery Specific Risk Surgery High (Reported risk High >5%) >5%) – Emergent major Emergent operations, particularly in elderly in – Aortic and other major Aortic vascular surgery vascular – Surgical procedures Surgical associated with large fluid shifts and/or blood loss loss – www.services.epnet.com Surgery Specific Risk Surgery Intermediate Intermediate (Reported risk <5%) (Reported – Carotid Carotid endarterectomy endarterectomy – Head and neck Head surgery surgery – Intraperitoneal and Intraperitoneal intrathoracic procedures procedures – Orthopedic surgery – Prostate surgery Surgery Specific Risk Surgery Low (Reported risk Low <1%) <1%) – Endoscopic Endoscopic procedures procedures – Superficial procedures – Cataract surgery – Breast surgery – www.steenhall.com The Algorithm The Step 1: What is the urgency of surgery? – Emergency: No time for further evaluation Step 2: Coronary revascularization in the Step past five years? past – Free ticket for five years if no new symptoms Free have arisen (chest pain or SOB) have Step 3: Coronary evaluation in the past 2 Step years? years? – Free ticket for two years if no new symptoms The Algorithm The Step 4: Unstable coronary syndrome or major Step predictor of risk? predictor – Will lead to cancellation or delay of surgery Step 5: Intermediate clinical predictors of risk? Step 6: Step – Intermediate clinical predictors and moderate to Intermediate excellent functional capacity are good candidates for intermediate risk surgery intermediate – Intermediate clinical predictors and poor functional Intermediate capacity or moderate to excellent functional capacity with high risk surgery often need further testing with The Algorithm The Step 7: Step – Minor or no clinical predictors with moderate Minor or excellent functional capacity usually need no further testing no – Minor or no clinical predictors with poor Minor functional capacity and high risk surgery may need further testing need Step 8: Results of non-invasive testing Step determines need for invasive testing or intervention intervention Pre-operative Tests Pre-operative 12-Lead ECG – Class I: Recent episode of chest pain or Class ischemic equivalent etc ischemic – Class IIB: Class Prior coronary revascularization Prior Asymptomatic male >45yrs old or female >55 yrs Asymptomatic old with 2 or more risk factors old Prior hospital admission for cardiac causes – Class III: Routine in asymptomatic individuals Pre-operative Tests Pre-operative Echo – Class I: Patients with current or poorly Class controlled heart failure controlled – Class IIa: Prior heart failure and dyspnea of Class unknown origin unknown – Class III: As a routine test Pre-operative Tests Pre-operative Exercise or Pharmacological Stress Exercise Testing Testing – Class I: Class Patients with intermediate pretest probability Patients Change in clinical status of patient with suspected Change or proven CAD or Proof of ischemia prior to revascularization Evaluation of adequacy of medical therapy – Class IIa: Evaluation of exercise capacity Class when subjective assessment unreliable when Pre-operative Tests Pre-operative Class IIb – Diagnosis of CAD in patients with high or low Diagnosis pretest probability: resting ST depression <1mm, taking digitalis, or LVH <1mm, – Detection of restenosis in high-risk Detection asymptomatic patients asymptomatic Class III – Routine screening of asymptomatic patients Pre-operative Tests Pre-operative Coronary Angiography – Class I Evidence of adverse outcome from non-invasive Evidence test test Angina unresponsive to therapy Unstable angina, especially with intermediate or Unstable high risk surgery high Equivocal noninvasive test in high clinical risk Equivocal patient undergoing high risk surgery patient Pre-operative Tests Pre-operative Class IIa – Multiple markers of intermediate clinical risk Multiple and planned vascular surgery and – Moderate to large ischemia on non-invasive Moderate testing but without high-risk features and lower left ventricular function lower – Nondiagnostic noninvasive test results in Nondiagnostic patients at intermediate clinical risk patients – Urgent noncardiac surgery while recovering Urgent from acute MI from Pre-operative Tests Pre-operative Class IIb – Perioperative MI – Medically stabilized angina and low-risk surgery Class III – Low risk surgery with known CAD – Asymptomatic after coronary revascularization with Asymptomatic excellent exercise capacity excellent – Noncandidate for coronary revascularization owing to Noncandidate concomitant medical illness, severe left ventricular dysfunction (EF <20%) dysfunction Perioperative Therapy Perioperative CABG – Indications for CABG same as for those not Indications undergoing surgery undergoing – Consider in those who long-term outcome Consider improved by CABG improved Percutaneous Coronary Intervention – Delay of 4-6 weeks for antiplatelet therapy for Delay re-endothelialization re-endothelialization Day of Surgery Day History of present illness NPO status PMH PSH PSH – Problems with anethesia Malignant hyperthermia Post-operative nausea and vomiting Difficulty with intubation – letter from Difficulty anesthesiologist anesthesiologist Day of Surgery Day Allergies – Antibiotics, latex Vital signs (are vital) – Baseline blood pressure for cerebral autoregulation Physical examination (directed) – – – – Airway examination Cor Lungs Neurologic (especially if regional technique planned) Day of Surgery Day Laboratory – Eg. Renal function, starting HCT, Platelets – Beta HCG women of childbearing age Imaging – CXR: Trauma, CHF, COPD – CT scan in thyroidectomy Day of Surgery Day Assessment of patient – Risk of anesthesia and surgery – Monitoring – Technique of anesthesia and agents to be Technique used used – Post-operative care Example of Patient Example 59 year old female presents for an Aorto-bifemoral bypass PMH: – – – HTN DM II Hypercholesterolemia PSH: – Hysterectomy at age 49 Social HX: Tob 35 pack yr NKDA Meds: atenolol, glucophage, lipitor VS 145/73, P: 71, R:18, Sat 96% NAD, A&O x3 MP 2, Neck FROM Cor: RRR Lungs: BS distant, no wheezing Abd: soft, no palpable mass Ext: lower ext cool, difficult to palpate pulses Example of Patient Example 59 year old female presents for an 59 Aorto-bifemoral bypass Aorto-bifemoral PMH: – HTN – DM II – Hypercholesterolemia PSH: – Hysterectomy at age 49 Social HX: Tob 35 pack yr NKDA Meds: atenolol, glucophage, lipitor VS 145/73, P: 71, R:18, Sat 96% NAD, A&O x3 MP 2, Neck FROM Cor: RRR Lungs: BS distant, no wheezing Abd: soft, no palpable mass Ext: lower ext cool, difficult to Ext: palpate pulses palpate What if any further preoprative What laboratory or investigative studies are necessary? are Laboratory Laboratory Basic metabolic profile? CBC? CBC? Coagulation profile? Coagulation Laboratory Laboratory Basic metabolic profile – Assessment of baseline renal function CBC – HCT and Platelets Coagulation profile – History of bleeding and/or bruising ECG? ECG? ECG? ECG? 12-Lead ECG – Class IIB: Class Asymptomatic male >45yrs old or female >55 yrs old with 2 or more risk factors old ECG ECG NSR with non-specific ST and T wave NSR changes changes www.library.med.utah.edu Chest X-ray? Chest Chest X-ray Chest Clinical Clinical characteristics to consider: consider: – Smoking, COPD, Smoking, recent respiratory infection, cardiac disease disease – If the above are stable, If no unequivocal indication indication Further cardiac evaluation? Further Further cardiac evaluation Further Clinical predictors? – Intermediate i.e. diabetes mellitus Intermediate diabetes Functional capacity? Functional Capacity Functional “I can’t walk one flight of can’t steps because my legs hurt!” hurt!” <4 mets Non-invasive testing Exercise or Exercise Pharmacological Stress Testing Testing – Class IIa: Evaluation of Class exercise capacity when subjective assessment unreliable unreliable – www.users.interport.net Non-invasive testing Non-invasive Dobutamine stress echo – EF 50%, mildly reduced EF ventricular function ventricular – Area of scar inferior Area segment segment – With injection of With dobutamine, area of hypokinesis lateral segment of the left ventricle segment – www.folk.ntnu.no Coronary angiography? Coronary angiography? Coronary Class I Evidence of adverse Evidence outcome from nonoutcome invasive test Coronary angiogram – – – Left main: normal vessel LAD: area of 40% proximal Circumflex: 80% proximal Circumflex: lesion lesion – RCA: severe diffuse RCA: disease with collateral filling from PCA filling – Procedure: one stent Procedure: successfully placed in proximal cirumflex artery proximal Coronary Angiography Coronary Patient placed on plavix and surgery Patient postponed for six weeks postponed Patient, surgeon, and anesthesiologist Patient, aware of tenuous blood supply to RCA territory but no stress-induced ischemia territory www.health.yahoo.com Conclusion Conclusion Preoperative evaluation is necessary to Preoperative stratify risk to the patient stratify The evaluation delineates patient clinical The factors as well as extent of surgery factors The patient, surgeon, anesthesiologist are The aware of the perioperative risk and may plan therapy accordingly plan ...
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