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In the Clinic PREOPERATIVE EVALUATION © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. What is the risk for medical complications from surgery in healthy patients? Risk for serious medical complications: <0.1% Evaluate preoperatively to predict risk for serious medical complications Use focused history and physical exam © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. How does the procedure influence risk for complications in healthy patients undergoing surgery? Influences risk for complications independent of other patient risk factors Complexity: third strongest predictor of postoperative morbidity after low albumin and ASA class (VHA study) Influences risk for specific types of complications Upper abdominal and thoracic surgery: postoperative pulmonary complications occur in 10%-40% Other types of surgery: postoperative pulmonary complications rarely reported © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. Perioperative Risk Classifications for Surgical Procedures Low (<1%) Superficial surgery Breast Dental Cataract Intermediate (1%–5%) High (>5%) Intrathoracic (nonmajor) Intraperitoneal Carotid (CEA or CAS) Endoscopic Endovascular aneurysm repair Thyroid Head and neck surgery Gynecologic, minor Aortic, major vascular surgery, peripheral vascular surgery Major abdominal surgery, prolonged procedures with large fluid shifts or blood loss Esophagectomy Neurologic or orthopedic, major Pneumonectomy Urologic, minor Urologic or gynecologic, major Reconstructive or cosmetic Lung, liver, or pancreas transplantation Renal transplantation Orthopedics, minor Adrenal resection © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. How do underlying chronic conditions influence the risk for medical complications of surgery? More comorbid conditions = higher risk for perioperative complications Increasing ASA Class = increasing morbidity, mortality Grade I: Healthy patient Grade II: Mild systemic disease—no functional limitations Grade III: Severe systemic disease—definite functional limitation Grade IV: Severe systemic disease that is a constant threat to life Grade V: Moribund patient not expected to survive without the surgery © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. How do lifestyle factors influence the risk for perioperative complications? Ability to exercise strongly predicts perioperative medical complications Smoking increases risk for perioperative pulmonary complications Preoperative alcohol consumption increases risk for perioperative morbidity Alcohol intake >60 g/d increases mortality risk Obesity increases overall surgical risk © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. CLINICAL BOTTOM LINE: Risk Factors... Comorbid conditions increase the risk for complications Ischemic heart disease, cerebrovascular disease, HF Diabetes mellitus, CKD, bleeding disorders, liver disease Other patient factors that affect perioperative risk Poor nutritional status, obesity Smoking, hazardous alcohol use, illicit substance use Poor exercise tolerance Type of surgery influences the risk of complications © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. Who should undergo preoperative evaluation? All patients scheduled for surgery Very low-risk procedures May need only to confirm lack of significant risk factors Minor surgery and patient has no medical history Patient screening by phone may suffice More complex surgery and patient comorbidities Consider evaluation by physician experienced in preoperative assessment Screening triage tool may be useful © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. What are the essential elements of a preoperative history and physical exam? Patient’s age, whether patient pregnant Exercise tolerance and ability to perform ADL Medication use Use of tobacco, alcohol, and illicit substances Overall health, including comorbid conditions, reaction to past surgeries, experience with anesthesia Risk factors for cardiac, pulmonary, infectious complications Physical: look for signs of undiagnosed or decompensated conditions © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. Which laboratory tests should be performed preoperatively? Base laboratory testing on history, physical exam, and planned surgical procedure For minor procedures, routine testing not indicated if history and physical exam are normal Consider comorbid conditions and medications Age alone is not a reason to order tests No need to repeat testing if tests were done within 4 months of surgery, results were normal, and clinical status is unchanged © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. Lab Tests Before Elective Noncardiac Surgery Hemoglobin: Symptoms of anemia or anticipated major blood loss Electrocardiography: Known coronary artery disease, diabetes, uncontrolled hypertension, chronic kidney disease Chest radiography: Symptoms or examination findings suggesting active pulmonary disease Platelet count: Myelotoxic medications or a history of bleeding diathesis, myeloproliferative disorder, or liver disease Prothrombin time: Recent or long-term antibiotic use, warfarin use, or a history of bleeding diathesis, liver disease, or malnutrition Partial thromboplastin time: Heparin use or a history of bleeding diathesis continued… © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. Lab Tests Before Elective Noncardiac Surgery Electrolytes: Medications that affect electrolytes, renal insufficiency, or congestive heart failure, Creatinine and blood urea nitrogen: CKD, hypertension, diabetes, cardiac disease, major surgery, medications that may affect renal function Glucose: Known diabetes, obesity Liver function tests: Cirrhosis Leukocyte count: Myelotoxic medications or symptoms suggesting infection or myeloproliferative disorder Urinalysis: Symptoms suggestive of UTI, instrumentation of the genital-urinary tract (not indicated before total joint replacement) © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. When should clinicians consider preoperative cardiac stress testing? When patients have worrisome symptoms Evaluate for cardiac ischemia Decide about further testing based on urgency of surgery, presence of recent ACS, combined clinical/surgical procedure risk, and functional capacity Tools to determine cardiac complication risk Revised Cardiac Risk Index American College of Surgeons National Surgical Quality Improvement Program risk calculator Myocardial infarction (MI) or cardiac arrest (MICA) tool © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. CLINICAL BOTTOM LINE: Evaluation... Essential elements of preoperative history and physical: Establishing overall health and underlying conditions Pregnancy, exercise tolerance Reaction to previous anesthesia and surgery Use of medications, tobacco, alcohol, illicit drugs Laboratory testing: history and physical should guide Noninvasive cardiac testing: only in patients with elevated cardiac risk and poor functional status if the results are likely to change management © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. How should clinicians manage medications in the perioperative period? Continue essential medications Discontinue or adjust dose of other medications Only stop medications with significant potential for AEs Beware potential for withdrawal or rebound syndromes Aspirin/NSAIDs: stop before surgery if bleeding risk outweighs thrombosis risk Oral hypoglycemics: withhold on morning of surgery (maintain glucose control perioperatively with insulin) Diuretics and ACE inhibitors: often withheld unnecessarily © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. What should clinicians recommend to reduce the risk for postoperative thromboembolic complications? Stratify risk preoperatively in all surgical patients Caprini score or Rogers score Prescribe measures to reduce risk VTE prophylaxis based on risk class, surgical procedure Early ambulation Pharmacologic and mechanical methods © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. What should clinicians recommend to reduce the risk for postoperative surgical site infections? Preoperative antibiotic prophylaxis based on the surgical procedure First-generation cephalosporin is a frequent choice Give within 1 h before skin incision Discontinue by 24 h after surgery © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. When are supplemental (stress-dose) steroids indicated? When patients have taken >5 mg/d prednisone (or equivalent) for ≥3 weeks within 6-12 months before surgery, and they will have a procedure of at least moderate stress Either, test the patient’s response to cosyntropin preoperatively; if the test result is positive, administer larger-than-physiologic doses of hydrocortisone Or, skip testing and simply administer larger-thanphysiologic doses of hydrocortisone © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. Perioperative Stress-Dose Corticosteroid Therapy Major surgeries Start hydrocortisone, 75–100 mg IV before surgery 50 mg IV every 8 h for 24–48 h Reassess level of stress and either continue 50 mg dose or taper to 25 mg every 8 h and then resume usual outpatient dose in uncomplicated cases Moderate surgeries Start hydrocortisone, 50 mg IV before surgery 25 mg every 8 h for 3 doses Resume usual outpatient dose in uncomplicated cases Minor procedures Usual dose on the day of surgery (some advocate giving 25 mg IV hydrocortisone preoperatively or doubling usual oral dose) © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. What are the indications for perioperative β-blockade? Theoretically protects heart from excessive workload and prevents plaque rupture and subsequent thrombosis, cardiac ischemia, and infarction However study results have been mixed Most studies suggest perioperative β-blockers are associated with reduced MI and nonfatal MI and increased bradycardia, hypotension, and stroke Effect on total mortality is unclear but may be increased Optimal type and dose of β-blocker unknown If using a β-blocker, start it >24 h before surgery © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. What are special preoperative considerations for patients with cardiovascular disease? Coronary artery disease Prevent cardiac events by optimizing preoperative medications and selective revascularization Recognize the risk for perioperative stent thrombosis when there are recently placed coronary stents Heart failure Delay elective surgery with decompensated HF Optimize preoperative medications Investigate unexplained dyspnea, HF with change in condition, and suspected valvular heart disease continued… © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. Rhythm and conduction disorders Common after open cardiac and thoracic procedures Increased with a history of AF, advanced age, and HF If at high risk for AF: consider β-blocker or amiodarone preoperatively Warfarin can be stopped 5 days before surgery if the patient has chronic nonvalvular AF Stop novel oral anticoagulants 1 to 3 d before surgery based on half-lives, renal function, and bleeding risk Interrogate defibrillators and pacemakers before surgery continued… © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. Suspected valve disease Order transthoracic ECHO Patients with symptomatic aortic stenosis require aortic valve replacement before other surgery Hypertension Is the reason many surgical procedures are cancelled Obtain preoperative ECG, check for renal insufficiency and electrolyte disturbances, and continue β-blockade and calcium-channel blockers © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. What are special preoperative considerations for patients with pulmonary disease? To minimize postoperative pulmonary complication risk Cease smoking at least 4 to 8 weeks before surgery Conduct lung expansion maneuvers or CPAP Reduce airflow obstruction and treat respiratory infection Preoperative chest PT and inspiratory muscle training Screen patients for OSA (STOP-BANG questionnaire) Spirometry: only for those having lung resection, active wheezing, unexplained impaired exercise tolerance © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. What are the special preoperative considerations for patients with diabetes? Check basic chemistry panel Advise patients on adjusting medications and monitoring glucose levels Elevated glucose, HbA1C increases complication risk Early-morning surgery limits disruption of glycemic control Use an insulin pump or insulin glargine for bowel prep, history of hypoglycemic episodes, or late-day surgery Morning of surgery: reduce NPH dose to 1/2 or 2/3 and withhold short-acting insulin and oral hypoglycemics © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. What are special preoperative considerations for patients with chronic kidney disease? Preoperative evaluation CBC, serum chemistries and creatinine concentration, estimated GFR ECG in patients with existing or possible cardiac disease Assess and optimize fluid status Dialyze patients on hemodialysis the day before surgery Perioperative measures Avoid potentially nephrotoxic medications Adjust dose for drugs metabolized by the kidney Continue immunosuppressants for renal transplants © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. What are special preoperative considerations for patients with liver disease? Evaluate based on Child-Pugh criteria or MELD score Child-Pugh: albumin, bilirubin, INR, ascites, hepatic encephalopathy MELD: INR, bilirubin, creatinine, sodium Cancel elective surgery for patients at very high risk Acute hepatitis Child’s C criteria MELD scores > 15 © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. What are the special preoperative considerations for patients with rheumatologic disease? Precautions to avoid perioperative neurologic problems Cervical collar Fiberoptic intubation Preoperative cervical spine films to assess C1–2 stability Careful neck positioning Rheumatologic treatments may increase infection risk © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. What are the special considerations for pregnant women undergoing surgery? Conduct a pregnancy test in all women of child-bearing potential Postpone nonemergency surgery in pregnant women because surgery increases the perioperative risk for Miscarriage Preterm labor and delivery Intrauterine growth restriction Stillbirth Anesthesia risk to fetus, particularly in first trimester © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1. CLINICAL BOTTOM LINE: Risk Reduction... Preoperative evaluation in unstable heart or lung disease Determine which medications to stop or continue Prevent VTE with early postoperative ambulation and pharmacologic or mechanical prophylaxis Preoperative prophylactic antibiotics Minimize length of the preoperative hospital stay Limit use of immunosuppressive drugs Follow recommended guidelines for catheters Control glucose in patients with diabetes © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 165 (6): ITC6-1.