Case presentation

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Case presentation
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consult from surgery- 51y female

• 51y female with Traumatic Brain injury _at_ 12yo
• Obese (BMI 40)
• HTN- well-controlled on lisinopril 40mg/d
• OSA
• Chronic cough intermittent hemoptysis
• Extensive pulmonary w/u normal to date
  (PFTbronch)
• Hx of left fem/pop DVT 9mo ago
• Recent Pap normal

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• What issues are pertinent to her surgery?
• What tests need to be done now?
• Should she be cleared for the surgery?

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The Pre-operative evaluation

• August Hein, M.D.
• LtCol USAF, MC, SFS

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Stratification

• Patient factor
• Different classification systems
• Goldman 1977
• Detsky 1986
• Lees revised 1999
• Recognize similar key points
• Surgical factors/risk
• Low
• Intermediate
• High

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Surgery classification

• Invasiveness
• Emergent / Routine

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Surgical Stratification

• Cardiac risk
• High ( 5 risk of cardiac event)
• Emergent major operations, esp. in elderly
• Aortic/ major vascular surgery
• Peripheral vascular surgery
• Anticipated large fluid shifts and/or blood loss
• Cardiac event fatal and non-fatal MI

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• Intermediate risk (
• Carotid endarterectomy
• Head and neck surgery
• Intraperitoneal and intrathoracic surgery
• Orthopedic or Prostate surgery

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• Low risk (
• Endoscopic procedures
• Superficial procedures
• Cataract surgery
• Breast surgery

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Pulmonary risk

• Definite factors
• Upper abdominal surgery
• Thoracic surgery
• AAA repair
• Surgery 3hrs
• Probable factors
• General anesthesia
• Emergency surgery

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Patient Factors

• Exercise Capacity
• Medication use
• Obesity
• Age
• Labs EKG CXR PFT

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Source http//uptodateonline.com/utd/content/imag
e.do?imageKeyprim_pix/preop_pa.gif
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Source AAFP 15 April 2004
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(No Transcript)
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Exercise Capacity

• Good capacity 4 METs
• Two level blocks without symptoms
• One flight of stairs with two bags of groceries
• Poor exercise capacity two flights of stairs
• Expected Complications
• Total 20 vs 10
• Cardiac 10 vs 5
• Pulmonary 9 vs 6 (not statistically signif.)

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Medication use

• Back door route to forgotten medical hx
• HTN
• Hypothyroid
• Asthma/COPD
• May forget OTCs (aspirin, NSAIDS)
• So ask!

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Obesity

• DESPITE
• Reduced lung volume
• V/Q mismatch
• Relative hypoxemia
• NOT a risk factor, but considered in pulmonary
  and upper abdominal surgery
• Studies that show increased RR tend to not use
  multivariate analysis

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Age

• Mortality risk
• 80-89 11.3
• Multiple factors present, not a good sole
  criterion for withholding surgery

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Labs

• CBC
• Asymptomatic anemia
• Surgically significant anemia is even lower
• Mortality for surgery with expected blood loss
• Hct 12 ? 1.3
• Hct
• Remainder of CBC not useful (wbc,plt) in
  asymptomatic individuals

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Labs (contd)

• Lytes
• History/medication use more useful
• BUN/Cr
• Reasonable over 50 recent emphasis on CRI
• Major surgery
• Hypotension expected
• Nephrotoxic meds anticipated

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Labs (contd)

• FBS/FBG/FSG or just serum glucose
• Not recommended for surgical screening
• Recent control hx imperative for diabetics
• LFT only if history/exam suggest disease
• PT/PTT low correlation of abnl to postop comp.
• perfectly unhelpful predictor
• likelihood ratio 0.0
• - likelihood ratio 1.01

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Labs (contd)

• UA
• ? id renal disease or UTI?
• Serum Cr would id renal dz better
• UTIs may contribute to 4-5 post-op
  infections/year
• If UA for all non-prosthetic knee operations
• 1.5 million per infection prevented!
• Post-op infection adds 3000 to surgical costs

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EKG

• Low likelihood of changing management
• Recent MI important to detect
• Cardiac event risk increased by
• Non-sinus rhythm
• PACs
• 5 PVCs
• No risk increase with BBB

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EKG

• Recommendations
• Men 45 Women 55
• Known cardiac dz
• HP suggesting possibility of cardiac dz
• Electrolyte imbalance risk (ie diuretic use)
• DM/HTN
• Candidates for major surgeries

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CXR

• Abnormalities not well associated with
  post-operative risk
• 0.1 affected management
• Routine use not recommended
• 2 exceptions (by consensus)
• 60y
• Suspected cardiac or pulmonary disease

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Pulmonay Function Test

• No improvement over clinical eval
• Where the money is
• Decreased breath sounds
• Prolonged expiratory phase
• Rales, rhonchi, wheezes
• PFTs for unexplained dyspnea after good clinical
  eval

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Minor risk predictors

• Advanced age
• Abnormal electrocardiogram
• Left ventricular hypertrophy
• Left bundle branch block
• ST-T-wave abnormalities
• Rhythm other than sinus rhythm (e.g., atrial
  fibrillation)
• Low functional capacity inability to climb one flight of stairs holding a
  bag of groceries)
• History of stroke
• Uncontrolled systemic hypertension

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Intermediate risk predictors

• Mild angina pectoris
• Previous MI based on the history or the presence
  of pathologic Q waves
• Compensated or previous CHF
• Diabetes mellitus, particularly insulin-dependent
  diabetes
• Renal insufficiency

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Major risk predictors

• Unstable coronary syndromes
• Acute (important ischemic risk by clinical symptoms or
  noninvasive study
• Unstable or severe angina
• Decompensated CHF
• Significant arrhythmias
• High-grade atrioventricular block
• Symptomatic ventricular arrhythmia in the
  presence of underlying heart disease
• Supraventricular arrhythmias with uncontrolled
  ventricular rate
• Severe valvular disease

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Indications for Ambulatory ECG for ischemia
monitoring

• Class I None
• Class IIa
• Patients with suspected variant angina
•  
• Class IIb
• Evaluation of patients with chest pain who cannot
  exercise
• Preoperative evaluation for vascular surgery of
  patients who cannot exercise
• Patients with known CAD and atypical chest pain
  syndrome
• Class III
• Initial evaluation of chest pain patients who are
  able to exercise
• Routine screening of asymptomatic subjects
• source http//www.americanheart.org/presenter.j
  html?identifier1925

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Pre-op eval take home

• Screening questionnaire
• Exercise tolerance
• Blood pressure and pulse
• Expand H P if above abnl, pt 60y or major
  surgery
• HCG for young women
• HCT for bloody surgery
• Serum Cr for major surg/ possible hypotension/
  nephrotoxic meds/ pt 50
• Beta-blocker for known Ischemic dz -- vascular
  surgery
• Stress-testing if exercise capacity in question

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• ECG Men 45 Women 55
• Known cardiac dz
• Eval suggesting possibility of cardiac dz
• Electrolyte imbalance risk (ie diuretic use)
• DM/HTN
• Candidates for major surgeries

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2007 Dental update

• Antimicrobial prophylaxis FOUR cardiac
  conditions w/ highest risk of adverse outcome
  from endocarditis
• 1. Prosthetic cardiac valves
• 2. Cardiac transplantation with subsequent
  valvulopathy
• 3. Previous history of
  infective endocarditis
• 4. Congenital Heart Disease (CHD), including
  only
• Unrepaired cyanotic CHD, including palliative
  shunts and conduits
• Completely repaired congenital heart defects with
  prosthetic material or device, whether placed by
  surgery or by catheter intervention, during the
  first six months after the procedure
• Repaired CHD with residual defects at the site or
  adjacent to the site of a prosthetic patch or
  prosthetic device (which inhibit
  endothelialization)
• B. Dental Procedures for Which Endocarditis
  Prophylaxis is Recommended All dental
  procedures that involve manipulation of gingival
  tissue or the periapical region of teeth or
  perforation of the oral mucosa.
• No prophylaxis needed routine anesthetic
  injections through non-infected tissue, taking
  dental radiographs, placement of removable
  prosthodontic or orthodontic appliances,
  adjustment of orthodontic appliances, placement
  of orthodontic brackets, shedding of deciduous
  teeth, and bleeding from trauma to the lip or
  oral mucosa.
• C. What Antibiotic Regimens for a Dental
  Procedure? The same single dose antibiotic
  regimens from the 1997 Guidelines can be given 30
  to 60 minutes before the procedure.

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Case 2

• 76y male with debilitating Rt hip OA
• Scheduled for Rt Total Hip
• s/p inferior MI 1yr ago TPA, resolution
• No tobacco use
• No CVD, no DM, EF wnl, Bun/Cr wnl
• Walked 1-2 mi/day until 2mo ago pain
• Simvastatin, HCTZ,
• Rxd Atenolol, stopped after bronchitis 2 wks ago
• BP 157/92 Exam wnl ECG inf Q waves

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Lee's Revised Cardiac Risk Index

• Clinical variable Points
• High-risk surgery (i.e., intraperitoneal,
  intrathoracic, or suprainguinal vascular
  surgery) 1
• Coronary artery disease 1
• Congestive heart failure 1
• History of CVD 1
• Insulin for diabetes mellitus 1
• Preoperative SCr 2.0 mg/dL 1
  Total__1__

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Interpretation of Risk Score

• Risk class Points Complication risk I. Very
  low 0 0.4 II. Low 1 0.9 III.
  Moderate 2 6.6 IV. High 3
  11.0
• - MI, PE, VF, cardiac arrest, or complete heart
  block.

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Review

• Exercise tolerance
• Blood pressure and pulse
• Expand H P if above abnl, pt 60y or major
  surgery
• HCG for young women
• HCT for bloody surgery
• Serum Cr for major surg/ possible hypotension/
  nephrotoxic meds/ pt 50
• Beta-blocker for known Ischemic dz -- vascular
  surgery or history of taking them
• Stress-testing

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Summary

• Pre-op eval is not clearance
• Determine risks, then minimize
• Let surgeon, anesthesia do the clearing
• Screening Labs/Tests rarely useful alone
• Should be driven by suspicions from eval/hx

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Links

• Articles
• http//www.acc.org/clinical/guidelines/perio/updat
  e/periupdate_index.htm
• http//www.aafp.org/afp/20040415/poc.html
• http//www.americanheart.org/presenter.jhtml?ident
  ifier1960
• Smetana, Gerald W. in http//uptodateonline.com/u
  td/content
• http//www.aafp.org/afp/20070301/656.html
• http//circ.ahajournals.org/cgi/reprint/CIRCULATIO
  NAHA.106.183095v1
• forms
• http//www.aafp.org/afp/20040415/pocform.html
• http//uptodateonline.com/utd/content/image.do?ima
  geKeyprim_pix/preop_pa.gif