PERIOPERATIVE RISK Assessment and Improvement

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PERIOPERATIVE RISKAssessment and Improvement

• Anwer Ghani
• FIBMS
• Iraq

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The goals

• The goals of preoperative assessment
• (1) Reduce the morbidity associated with surgery.
• (2) Increase the quality of perioperative care.
• (3) Decrease the cost.

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Systematic Assessment

• The Role of History (Hx)
• The Role of Physical Examination (Ex)
• History and examination are very important in
  perioperative risk assessment.
• The Role of Investigations (Ix)
• The Role of Diagnosis (Dx)
• The surgery, the cardiac disease, the frailty and
  the comorbidity are very important factors in
  perioperative risk.
• Conclusions

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Hx

• General Hx
• Specific Hx
• Hx of bleeding disorder
• Hx of a problem with wound healing
• Hx of anticoagulants, anti-angina drugs
• Hx of Allergies
• Hx of Active cardiac disease

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Hx

• Hx Hx of specific risk factors
• ?Arrhyth
• ?HRT
• ?CAD
• ?Heart D
• ?COPD
• ?Asthma
• ?thromb.

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Hx

• Hx of bleeding disorder
• -a clotting disorder?
• -nosebleed for no apparent reason?
• -bruises under the skin for no apparent reason?
• -bleeding into the joints?
• -prolonged bleeding after a cut?
• -unusually intense bleeding during an operation?
• - unusually intense menstruation?

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Ex

• Upper respiratory pathway
• Heart
• Lungs
• Cardiopulmonary reserve
• Potential signs of heart failure

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Ex

• .

MET
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Hx Ex

• If the initial evaluation (Hx Ex) yields no
  evidence of any conditions significantly
  affecting the perioperative risk, then, as a
  rule, no further testing is needed.

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Ix

• ? Routine
• ?Hb ?WBCC ?
  Plat
• ?RBS ?BU ?
  Scr
• ?ECG
• The value of a routine preoperative ECG is not
  yet fully clear.

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Ix

• ? On indication
• ?CXR
  ?PFT
• ?Echo.
  ?U/S
• ? Another test

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Ix

• -There is no reason to perform laboratory testing
  routinely in all cases.
• -There is no correlation between the number of
  abnormal laboratory findings and the outcome of
  surgical treatment.
• -Laboratory tests of coagulation should be
  performed only if indicated by a specific drug
  history or a positive bleeding history.

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Dx

• The operation .
• ? high risk ? low risk
• The cardiac disease .
• ? Uncontrolled ? Controlled

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Dx

• Perioperative risk factors
• ?DM
• ?HRT
• ? Coagulopathies
• ?Anemia
• ?Obesity
• ?allergies
• ?Old age (frailty)
• ?Other Co-morbidity

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Dx

• Low risk surgery
• -superficial procedures
• -endoscopic procedures
• -breast surgery
• -cataract surgery

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Dx

• Cardiac risk factors
• CAD
• PAD
• CHF
• CVA
• DM
• CRF

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Dx

• CFS

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Dx

• The strongest predictors of perioperative
  complications are the patients pre-existing
  illnesses.

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The Risk

• Predictors of periop. complications
• -Age (Frailty)
• - Invasiveness of the procedure,
• -History of renal disease
• - Anemia
• -Abnormal ECG.

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The Risk

• Perioperative risk
• - Active (uncontrolled) Heart disease risk
• - Cardiac risk factor
• - Surgery risk
• - Frailty risk
• - Co-morbidity risk
• Expert Opinion
• 0 low risk
• 1 but not active HD intermediate.
• 2 or more, or active HD high risk.

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The Risk

• Outcome
• -LOS
• -Complications
• -Mortality
• -Readmission

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The Risk

• The Recommendations
• -Risk assessment and outcome discussion
• - Improve the outcome
• - Modifying the risk
• - Precautions and recommendations
• - Pre, intra and post-operative management.
• -Interventions and consultations.