PreOp Evaluation

1
Pre-Op Evaluation

• By Jagroop Basraon D.O
• April 1, 2007

2
Pre-Op Objective

• Assess current medical status
• Address cardiac risks posed by planned operation
• Recommend strategies to decrease risk
• Usually consists of basic observation by
  internists
• Good history and physical exam is necessary

3
Clinical Evaluation

• Identify any current cardiac conditions which
  place the patient at high risk
• Recent MI, decompensate Heart Failure, Unstable
  Angina, Significant Arrhythmias, and valvular
  heart disease
• Address other current co-morbid conditions such
  as Diabetes mellitus, Vascular disease, Hx of
  stroke, renal disease, and pulmonary disease
• Address functional capacity based on patients
  ability to perform daily tasks. (METS 1-4 normal,
  4-10 active, and gt10 strenuous exercise)

4
Physical Exam

• BP in both arms
• Carotid pulse and bruits
• Heart sounds and extremity pulses
• Lung field auscultation
• Abdomen exam, focus on any Aneurysm
• Concerning findings, Aortic stenosis murmur, JVD,
  S3, pulmonary edema

5
Type of Surgery

• High Risk Procedures (gt5 risk) Emergent
  procedures in elderly, Aortic or peripheral
  vascular surgery, Extensive operation w/volume
  shifts
• Intermediate Risk (lt5 Risk) orthopedic,
  urological, intraperitoneal and intrathoraic,
  head and neck surgery, carotid endarterectomy
• Low Risk(lt1 Risk) Breast surgery, Cataract,
  Endoscopic procedure, superficial procedure

6
Lab Evaluation

• Routine Test CBC, Chem 10, LFTS to evaluate
  liver and renal function if needed
• Coagulation tests for patients with coagulopathy,
  familial or acquired
• Pulmonary disease patients may require
  pre-operative ABG
• ECG (usually Mandatory) look for blocks,
  pauses, arrhythmias, prior MI

7
Criteria

• Compile History, Physical exam, lab values to
  provide overall index/risk for the patient
• Main ones include Goldmans, Eagle, ACC/AHA. Easy
  referenced on the web.
• http//www.acc.org/qualityandscience/clinical/guid
  elines/perio/update/periupdate_index.htm
• High risk patients need further testing, usually
  in form of cardiovascular stress test before
  proceeding unless in emergent situation. These
  include patients with unstable coronary
  syndromes, dysrythmias, decompensated CHF

8
Special Cases

• Valvular Heart Disease
• Critical Aortic stenosis must be recognized and
  corrected before any non-cardiac surgery
• Mitral Stenosis mild and asymptomatic managed
  medically. Severe or symptomatic needs to be
  addressed first.
• Aortic/Mitral Regurg- optimize with diuretics and
  afterload before surgery
• Appropriate prophlaxsis for endocarditis for
  prosthetic valves
• Prosthetic Valves switch to IV
  anti-coagulation,d/c oral (i.e coumadin)

9
Special Cases - cont

• Arrhythmias and conduction disease
• Supraventricular Tachycardias- need to be rate
  controlled and underlying cause managed
  w/hemodynamically significant cause requiring
  cardioversion
• Ventricular Arrhythmias may require
  preoperative supperessive therapy (i.e
  Lidocane/Amiodaraone depending on local
  preference)
• Bradyarrthmia are managed with temporary pacing
  as needed.
• Permanent Pacemaker are checked pre and
  post-operatively

10
Special Cases - cont

• Hypertension severe, diastolic gt110 needs to be
  controlled. Rapid active b-blockers are
  preferred, because of anti-ischemic properties
• Cardiomyopathy LV dysfunction may require swan
  guide hemodynamic optimization. Hypertrophic
  Cardiomyopathy usually required close volume
  control.

11
Special Cases- cont

• Coronary Artery Disease pre-operative CABG and
  prophylactic PCI have had different outcomes in
  different populations, no consensus.
• B-Blockers have been show to reduce mortality.
• Give B-blocker to any patient who has risk
  factors for CAD, known CAD, peripheral vascular
  disease, and symptomatic arrhythmias.
• NTG if need for symptomatic ischemia in patient
  who have daily use.
• CONSULT CARDIOLOGY IF IN DOUBT
• Ca channel blockers do not have sufficient data

12
Special Cases

• Carotid Disease Tx remains controversial
• Individualized strategy.
• Carotid Endarteretomy with or without CABG have
  had similar outcomes.
• CONSULT CARDIOLOGY

13
Conclusion

• Good history and physical exam required
• ECG required
• Look for symptomatic cardiovascular disease (MI,
  CHF, carotid disease)
• Peri-operative B-blocker therapy in CAD and
  equivalents
• Address any other active acute medical issues.
• CONSULT and delay surgery if in doubt.

14
Reference

• References
• Goldman L, Caldera, Multifactorial index of
  cardiac risk in noncardiac surgical procedures. N
  Eng J of Medicine 1977.
• Landmark Articles
• Eagle KA, Rihal CS, Mickel MC. Cardiac risk of
  noncardiac surgery 199796188201887 Circulation
• AHA/ACC Periopertive Guideline. On AHA website