Download Pre-operative evaluation for non-cardiac surgery - Dr. Ben

Ryan Hampton
January 2015
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Risks and benefits of surgery
Timing of surgery
Type of Surgery
Goal is to uncover undiagnosed problems or
treat prior conditions previously sub-optimally
treated.
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Myocardial Infarction
Heart Failure
Ventricular Fibrillation
Cardiac Arrest
Complete Heart Block
Cardiac Death
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Revised Cardiac Risk Index (RCRI)
American College of Surgeons’ National
Surgical Quality Improvement Program (ACSNSQIP) risk calculator
Gupta MI or cardiac arrest (MICA) calculator
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These calculators generate risk as a percent
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Subjective
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PMH: DM2, CKD, HTN, CVA, PAD
ROS: angina, dyspnea, syncope, palpitations
Cardiac Functional Status
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Expressed in metabolic equivalents (METs)
1 MET = 3.5 mL O2 uptake/kg/min
Can use equivalent functions to determine METs
Eg: if patient can take care of self = 1 MET
Eg: can participate in strenuous sports = >10 METs
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Functional Status Threshold
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Important Indicator: does patient’s cardiac function
allow him/her to climb two flights of stairs or walk four
blocks
Objective
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Blood pressure
Auscultation of heart and lungs
Abdominal exam
Extremity exam for edema and vascular integrity
EKG for known CV disease
 Limited utility in asymptomatic patient
 Not part of RCRI or NSQIP criteria due to lack of prognostic
specificity
 However, routinely obtained pre-op for baseline comparison
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History of ischemic
heart disease
History of heart
failure
History of CVA
Insulin dependent
DM
Pre-op serum Cr >2.0
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American Society of
Anesthesiologist’ class
Pre-operative
functional status
Increasing age
Atrial Fibrillation*
Obesity*
*Not used in prediction models
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POISE Trial (Perioperative Ischemic
Evaluation)
8351 patients at high risk for or with atherosclerosis
undergoing non-cardiac surgery
 35 (0.4%) required coronary revascularization postoperatively
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So, value of risk prediction models may be waning
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Information from assessment combined with
risk associated with the surgery is used to
estimate perioperative risk of adverse cardiac
events.
Risk Determines:
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If surgery can proceed without further CV testing
If stress testing, echo, 24-hour ambulatory
monitoring, changing plan of surgery to decrease
risk, or canceling surgery so coronary
revascularization can be performed is necessary
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Used to determine
risk factors associated
with intraoperative/
postoperative MI or
cardiac arrest (MICA)
Among 200,000
patients undergoing
surgery in 2007, 0.65%
developed
perioperative MICA
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5 Factors Contributing
to MICA
Type of Surgery
2. Dependent
Functional Status
3. Abnormal
Creatinine
4. ASA Class
5. Increased Age
1.
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Low Risk Patients
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Estimated risk of death is less than 1 percent
No additional CV testing is required
Higher Risk Patients
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Risk of death is 1% or higher
May require additional CV evaluation
Often, known CAD or valvular heart disease
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Stress testing
Not indicated in perioperative patient solely because of
the surgery if there is no other indication
 Patients with moderate to good function (>4 – 10 METs),
reasonable to forego further testing
 May be considered for patients undergoing elevated risk
procedure in whom functional capacity is unknown if
management will be affected (Level of Evidence: B)
 Indicated with elevated risk and <4 METs or unknown
functional capacity
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Resting Echocardiography
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Not indicated in the perioperative patient unless there is
another indication (eg: murmur, valve function, LVEF,
etc.)
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Routine preoperative coronary angiography
NOT recommended – insufficient data to
support coronary angiography in all patients