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ÖGARI Task Force „Preoperative Evaluation“ Guideline for preoperative Patient Evaluation 1) Introduction: These guidelines were compiled and published by the members of the ÖGARI Task Force on Preoperative Evaluation. The current version may either by obtained directly through ÖGARI or online at www.oegari.at. The information displayed here serves as preoperative evaluation of adults undergoing elective surgical intervention. A guideline for preoperative evaluation of pediatric patients is displayed separately from this expose. The extent of preoperative examination on the one hand results from the type and invasiveness of the intervention and on the other hand, from the medical history or clinical peculiarities of the patients or from a combination of both. The role of the anesthetist in preoperative patient evaluation is defined by the sole responsibility in the planning and execution of anaesthesiological treatment. Type and invasiveness of the surgical treatment Depending on the effect on physiologic and/or pathophysiologic parameters the following 2 types of surgical treatment are being defined [11]: Duration of procedure Estimated blood-loss Anatomic region Pathophysiologic interactions minor < 2 hours < 500 ml All except visceral cavities, diagnostic endoscopic surgery incl. laparoscopic cholecystectomy, laparoscopic herniotomy and thoracoscopic procedures without resection major ≥ 2 hours ≥ 500 ml Surgery of thorax and abdomen including laparoskopic bowel-surgery (resection und anastomosis) and thoracoskopic lobectomy Major hemodynamic and respiratoric changes caused by the procedure; major fluidshifts 2) Medical history and clinical examination a) Anamnesis: The ascertainment is performed according to the anamnesis questionnaire of the task force ( available on www.oegari.at)[1;7;29;28;31] b) Clinical examination [14;16]: • Weight, size, calculation of BMI • Measurement of blood pressure, pulse (rate and rhythmic) • Pupils: size, reaction to light, in separate mode and bilateral comparison • Respiratory system: ∗ Mallampati Score (sitting, maximum mouth opening, head in neutral position, tongue sticking out unvoiced) ∗ Thyreomental distance (distance between thyroid cartilage and point of the chin at maximum hyperextension of cervix), - should be more then 6 cm [19]. ∗ Mandible protrusion test (mandible incisors are adjustable before/atop/behind maxillar incisors) Seite 1 von 14 ÖGARI Work Group „Preoperative Evaluation“ Gerhard Fritsch (Members: H. Ferstl, R. Germann, H. Gombotz, B. Gschiel, M. Haisjackl, K. Holaubeck, B. Horvath, S. Kozek, W. Lingnau, G. Prause, M. Seyr, F. Spiegl, G. Ulber) • • Compilation of dental chart Inspection of the corresponding anatomic area for preparation of regional anesthesia and vascular access • Auscultation of lungs and heart • In case of suspicion of neurological disease a cursory neurological examination shall be performed. In case of minor surgical intervention and without pathological findings in both the medical history and the clinical examination no further testing is necessary [2; 7; 13; 14; 16; 30]. From pathologic anamnesis and clinical examination the indication for further clarification arises (see 3-7). Stress Anamnesis: The cardio-respiratory capacity constitutes the essential factor for estimation of the perioperative risk [1; 11; 29]. As a rule, a close patient interview should suffice. For objectification machine-aided stress tests are applied. MET 1 CCS/NYHA-Classification IV 2-3 III 3-4 II 4-5 I 5-10 >10 Medical history No exercise possible Resting dyspnea Walking on the plane (100-150 m without stopping), minor activities Shortness of breath under minor activities Mild shortness of breath caused by activities, walks 1 flight of stairs Walking in normal speed, climbs 2 flights of stairs, running short distances no limitations, minor sporting activities (playing golf, skiing, hiking) Competitive sports, endurance sports MET = Metabolic Equivalent Threshold (1 MET = consumption of 3.5ml O2/kg body weight/min for men; consumption of 3.15ml O2/kg body weight/min for women = resting metabolic rate; Definition acc. to [1] CCS = Canadian Cardiovascular Society; NYHA = New York Heart Association MET = Metabolic Equivalent Threshold (1 MET = consumption of 3.5ml O2/kg body weight/min for men; consumption of von 3.15ml O2/kg body weight/min for women = resting metabolic rate; definition acc. to Ainsworth) In case of MET < 4 the cardiopulmonary evaluation is to be considered (see 3.and 4.). Seite 2 von 14 ÖGARI Work Group „Preoperative Evaluation“ Gerhard Fritsch (Members: H. Ferstl, R. Germann, H. Gombotz, B. Gschiel, M. Haisjackl, K. Holaubeck, B. Horvath, S. Kozek, W. Lingnau, G. Prause, M. Seyr, F. Spiegl, G. Ulber) MET = Metabolic Equivalent Threshold (1 MET = demand of 3,5ml O2/kg bodyweight/min in men; demand of 3,15ml O2/kg bodyweight/min in women = oxygen-consumption at rest; definition according to Ainsworth) MET<4 consider further cardiopulmonar evaluation Seite 3 von 14 ÖGARI Work Group „Preoperative Evaluation“ Gerhard Fritsch (Members: H. Ferstl, R. Germann, H. Gombotz, B. Gschiel, M. Haisjackl, K. Holaubeck, B. Horvath, S. Kozek, W. Lingnau, G. Prause, M. Seyr, F. Spiegl, G. Ulber) 3) Cardio-vascular evaluation This evaluation aims at identifying patients with an increased perioperative cardiovascular risk. This procedure also includes medical history with regard to cardio or cerebrovascular diseases and an assessment of the individual physical load of the patient. The functional capacity of an organism is the more important value than ischemic changes in the repolarization phase in ECG. Not until then the indication for further diagnostics should be performed. The guidelines of the ACC and AHA as well as the Revised Cardiac Risk Index acc. to Lee serve as practical support and the classification of the New York Heart Association (NYHA) resp. the Cardiovascular Society (CCS) (s. section on risk-scores) a) Further diagnostic investigation for preoperative clarification ONLY in case of • stable chest pain, Angina pectoris and high operative risk • instable angina • respiratory distress of unknown cause • history of myocardial infarction in the anamnesis (if MET ≥ 4 only resting ECG) • State after revascularization (if MET ≥ 4 only resting ECG) b) Should further preoperative clarification be necessary, the following tests are recommended: • 12-chanel resting ECG Obligation in case of positive cardiac anamnesis, especially before larger surgical treatment. Cave: A resting ECG without pathological findings does NOT exclude a coronary heart disease. • Chest X-ray: only in combination with positive clinical examination findings, reduced capacity, spirometry and blood gas analysis [18] • Stress ECG, Spiroergometry: with planned high operative risk AND anamnestic reduced capacity < 4 METS (noted athero-sclerotic vascular disease or continuing physical lack of exercise due to orthopedic disease). Exercise tolerance is an existing risk factor independent of the ST-segment depression. ∗ If bicycle ergonomics is not possible (a) Maybe arm turner ergometry (b) Pharmacological exercise, stress-echocardiography (Dipyridamol, Dobutamin, Dobutamin with atropine) (c) Myocardial scintigraphy • Echocardiography: Clinical evidence for acute cardiac insufficiency or valvular defect (Quantification of valvular function pressure gradient) Seite 4 von 14 ÖGARI Work Group „Preoperative Evaluation“ Gerhard Fritsch (Members: H. Ferstl, R. Germann, H. Gombotz, B. Gschiel, M. Haisjackl, K. Holaubeck, B. Horvath, S. Kozek, W. Lingnau, G. Prause, M. Seyr, F. Spiegl, G. Ulber) Cave: Echocardiography in resting does not provide any additional information for a foretelling of preoperative cardiac complications • Coronary angiography, coronary revascularization: An effective myocardial revascularization is the adequate means for lowering the perioperative risk, especially with instable angina, isolated LAD stenosis or 3-vessel disease. By means of stress-echocardiographically proven cardiac wall movement disorders (also of all 5 segments) are NOT an indication. Cave: Complications with CABG or PTCA neutralize advantages! Depending on the type of stent (platelet aggregation inhibitors) it is advisable not to perform any operation up to 1 year! c) Special Risk • Valvular heart disease ∗ Aortic valve stenosis is another considerable risk factor for perioperative complications. There is an independent relative risk (RR) of 5.2 with gradients of 25 to 50 mmHg and 6.8 for gradients > 50 mmHg. ∗ Mitral valve stenosis also increases the perioperative risk. Besides carefully performed auscultation an echocardiography should be performed in case of suspicion. ∗ Other valvular defects and prosthetic mitral valve replacement: the extent of the cardiac insufficiency is predictive. Antimicrobial endocarditis prophylaxis is also necessary after valve replacement. • Heart failure: no evidence-based management. Too strong drainage is to be avoided. Beta blockers are NO acute perioperative option. • Cardiac heart rhythm disturbance: no independent risk. Coronary cardiac disease and heart failure are the main pathologies. • Arterial hypertension is not an independent perioperative risk until a blood pressure value of >180/>110 mmHg is reached. No cancellation of surgery! • Pulmonary hypertension: NO interventions. Perioperative antibiotic prophylaxis. • Hypertrophic cardiomyopathy: perioperative danger of exacerbation of the dynamic efflux obstruction. NO additional clarification. Volume substitute therapy and alpha-adrenergic substances • Antibiotic prophylaxis in order to avoid endocarditis ∗ perioperative necessary for patients with: (a) prosthetic valvular transplants (b) complex congenital cyanotic organic heart defects (c) already suffered endocarditis (d) systemic or pulmonary conduits (Ross, Bentall) ∗ ∗ (e) acquired valvular disease (AVS) (f) Mitral valve collapse with MI (g) Non-cyanotic organic heart defects (exception ASD II) (h) hypertrophic (obstructive) CMP with the following planned operations: (a) dental, oral intervention, ENT area, rigid bronchoscopy (b) septic abortion interruption (c) surgical treatment at the genitourinary tract (cytoscopy, TURP, hysteroscopy, etc.) (d) Esophagus dilatation, sclerosing of esophagus varices Which antibiotics, which procedure: Seite 5 von 14 ÖGARI Work Group „Preoperative Evaluation“ Gerhard Fritsch (Members: H. Ferstl, R. Germann, H. Gombotz, B. Gschiel, M. Haisjackl, K. Holaubeck, B. Horvath, S. Kozek, W. Lingnau, G. Prause, M. Seyr, F. Spiegl, G. Ulber) ∗ (a) Oral: Amoxicillin 2.0 g (children 50 mg/kg body weight) 1 hour prior to planned surgical treatment (b) i.v.: Amoxicillin or Ampicillin 2.0 g (children 50 mg/kg body weight) 30 minutes prior to planned surgical treatment, 6 hrs. after; combination with Gentamicin 1.5 mg/kg urogenital with proven MRSA: Vancomycin 1 g over 60 minutes before. (c) Penicillin allergy: Clindamycin 600 mg (children 20 mg/kg body weight) or Azithromycin or Clarithromycin 0.5 g, 1 hr. before surgical treatment, 6 hrs. after. No prophylaxis for patients with: (a) isolated ASD II (b) 6 months after ASD, VSD, PDB (c) prolapse of mitral valve without mitral regurgitation (d) Accidental cardiac murmur, sclerosis of the aortic valve(vmax < 2 m/s) (e) physiological mitral regurgitation without morphology and cardiac murmur (f) physiological tricuspidal regurgitation or regurgitation of pulmonary valve without morphology and cardiac murmur 4) Pulmonary Evaluation [13;16;18;23] From an intraoperative point of view, respiratory problems only play a minor role, whilst in the postoperative phase they range high on the list of the most frequent complications. Pulmonary examination: a) History of preexisting pulmonary desease: • Obstructive (bronchial asthma, COPD) • Restrictive (pulmonary fibrosis, st. p. lobectomy/pneumectomy) • Neuro muscular (Myasthenia) b) Clinical examination: • Inspection • Percussion • Auscultation c) Evaluation of pulmonary function (with positive anamnesis, large upper abdomen resp. intrathoracic interventions) • Spirometry („small lung function test“; measures vital capacity , the maximum air flow (PEF) and 1-second-volume (Tiffeneau, FEV1) • Static lung volume (additionally measures residual volume, total lung capacity) Other tests ∗ Maximum breathing capacity (maximum minute ventilation): evaluates functional ventilation disorder ∗ Diffusion measuring (DLCO): measures the actual diffusion capacity independent of circulation (cardiac output) ∗ Provocative test (allergic asthma) d) Spiroergometry (see also: cardiovascular evaluation): determines the cardiopulmonary and metabolic capacity. Indication in case of intra-thoracic resp. massive respiratory strenuous interventions and simultaneous impediments MET< 4. Seite 6 von 14 ÖGARI Work Group „Preoperative Evaluation“ Gerhard Fritsch (Members: H. Ferstl, R. Germann, H. Gombotz, B. Gschiel, M. Haisjackl, K. Holaubeck, B. Horvath, S. Kozek, W. Lingnau, G. Prause, M. Seyr, F. Spiegl, G. Ulber) 5) Preoperative Coagulation Diagnostics The basis of preoperative clarification of coagulation is an exact survey of the coagulation anamnesis [7; 28] according to the recommendation of the task force on Perioperative Coagulation by ÖGARI under www.oegari.at. Co-morbidity and co-medication are included in the wider evaluation algorithm (see fig.). Basically, all patients with uncertain pathological laboratory-confirmed coagulation monitoring should have to be seen by coagulationexperienced physicians, able to arrange for continuative analysis according to findings (e.g. single factor analyses, detailed platelet function analytics). * surgery on spinal chord, cerebrum and retina Neuraxial blockade in connection with cathether except obstretics, central venous lines infra-, supraclavicular # known impaired coagulation e.g. hemophelia ¶ www.oegari.at, Task Force on AGPG aPTT=activated partial Thromboplastintime; Fibr=Fibrinogen; POCT=Point-of-care testing (e.g. ROTEM); PHC=primary hemostatic capacity i.e. vWF:Ag, vWF:RCo, PFA-100 (aggregometry); PT=Prothrombintime; ThC=platelet count Exemplary Constellation of Findings: Patients with healthy organs without specific risk consideration in the bleedings anamnesis: No laboratory analysis (LoE Grade A) [7; 9; 21; 28]. Also prior to tonsillectomy and adenotomy the risk of bleeding is unforeseeable and not avoidable through laboratory tests alone [21]. Thus, in case of insuspicient bleeding anamnesis no laboratory test is necessary. But: should, due to language barrier, impairment of consciousness or lack of compliance, patients be not able to adequately answer the questionnaire on bleeding, the laboratory coagulation test shall be performed as with patients with noticeable bleeding anamnesis (with clinical bleeding symptoms). Patients with noticeable bleeding anamnesis with clinical bleeding symptoms: In case of unknown coagulation disorder the determination of PTZ, aPTT, fibrinogen and platelet-count, as well as the clarification of the primary hemostasis capacity (PHK; e.g. by Willebrand Syndrome, platelet malfunction) is to be carried out (LoE Grade A)[7;21;28]. PHK may be collected with determination of the von Willebrand Factor Antigens (vWF: Ag), the Ristocetin cofactor (vWF: RCo) and platelet function analytics as e.g. Platelet Function Analyzer (PFA-100) or aggregometry (e.g. Multiplate). In case of known coagulation disorder (e.g. hemophilia, von Willebrand Syndrome) further diagnostic clarification and coagulation therapy (haemostasiology, Internal Medicine, pediatrics, medical laboratory) is to be performed. Seite 7 von 14 ÖGARI Work Group „Preoperative Evaluation“ Gerhard Fritsch (Members: H. Ferstl, R. Germann, H. Gombotz, B. Gschiel, M. Haisjackl, K. Holaubeck, B. Horvath, S. Kozek, W. Lingnau, G. Prause, M. Seyr, F. Spiegl, G. Ulber) Patients with noticeable bleeding anamnesis caused by intake of anticoagulants: On the basis of an individual risk-benefit consideration (individual medicine) the perioperative continuation or discontinuing of anticoagulants shall be determined interdisciplinary [7; 20; 28]. In case of clear cardiac indication or recent cerebral ischaemia the surgical intervention shall be performed by continuously administering Aspirin. For recommendations with locoregional anesthesia when using anticoagulant therapy: see www.oegari.at. Medication management in case of dual anti-platelet therapy (LoE Grade A): Due to the high risk of stent thrombosis Clopidogrel is not to be discontinued with cardiac drug-eluting stents for 12 months, with cardiac bare-metal stent for at least one month (elective interventions should be delayed accordingly). Interventions shall be performed under continued administering of aspirin. Warning: Attention is especially directed towards a possible (sustainable) bleeding inducing effect. Additionally, a drug monitoring is recommended (LoE Grade C) with • interventions without preoperative therapy-free period. • reduced elimination (e.g. severe renal insufficiency with Hirudin or low molecular weight heparin: aPTT) • drugs with clinically relevant increase bleeding quantity (e.g. Hirudin: aPTT or ecarin tests; Danaparoid: anti-Xa-activity; Clopidogrel plus Aspirin: aggregation with specific agonist-activation; oral anticoagulation: International Normalized Ratio INR) Drug interaction of von anticoagulants and other substances (e.g. analgesics, herbal medicines, antidepressants and anticonvulsants) are to be taken into account (LoE Grade C). Patients with noticeable thrombosis anamnesis: A diligent perioperative thrombosis prophylaxis is recommended (LoE Grade A), as well – depending on the individual - a pre- or postoperative visit to a coagulation-experienced physicians for further clarification of the thrombophilia. *)Intervention specific bleeding risk: The intervention per se does not constitute an indication for preoperative coagulation analysis [21; 26]. In fact, a blood-saving surgical technique is required (e.g. CUSA, microscopy) and intra-operatively in case of imminent or manifest high haemorrhage a coagulation testing as rational basis for the coagulation therapy should be collected. For this purpose, intra-operatively PTZ, aPTT, fibrinogen (Degree A) and platelet count are to be determined. In addition or alternatively, a point-of-care functional coagulation monitoring is recommended as diagnostically valuable (rotational thrombelastometry ROTEM, maybe in addition a blood platelets function test, e.g. with Multiplate) (LoE Grade B). Exceptions from these intervention-specific recommendations arise in case of interventions with hazardous localization of a potential source of bleeding (e.g. ZNS, retina) (LoE Grade C). Invasive anesthesiologic interventions should be performed as a-traumatically as possible. Although a (spinal) bleeding with unobtrusive bleeding anamnesis is rather very unlikely and cannot be predicted or avoided by means of coagulation testing, it may nevertheless be performed in addition to the assessment of the bleeding anamnesis for the planning of the anesthesiologic management (e.g. selection of block techniques and –inlet) Seite 8 von 14 ÖGARI Work Group „Preoperative Evaluation“ Gerhard Fritsch (Members: H. Ferstl, R. Germann, H. Gombotz, B. Gschiel, M. Haisjackl, K. Holaubeck, B. Horvath, S. Kozek, W. Lingnau, G. Prause, M. Seyr, F. Spiegl, G. Ulber) 6) Preoperative Laboratory Diagnostic The laboratory diagnostic shall be adjusted to the individual patient anamnesis and to the individual situation of the intervention and the „routine laboratory findings” subject to age group shall be abandoned in favor of an individualized laboratory requirement. [2;8;13;14;16;23;25;27;30]. a) A blood count analysis is recommended in case of: • Interventions with possibly considerable bleedings (>500ml), from which the necessity of transfusions arises. • Older patients (>75 years), having to undergo larger inventions [33] • Anemia in the anamnesis • Increased cardiac risk [11] • Chronic renal dysfunction (Hb + number of blood platelets) • Bleedings in the anamnesis • Liver dysfunction (Hb + number of blood platelets) b) An examination of the serum electrolyte is recommended in case of: • severe interventions • clinic or anamnesis based indication of renal dysfunction or diabetes mellitus. • c) d) e) f) Long-term medication with: ∗ ACE-inhibitor, angiotensin II-antagonists ∗ Diuretics (high-ceiling diuretics, spironolactone) ∗ Corticoids ∗ Digitalis - only determination of potassium in serum ∗ Antidepressants • Liver dysfunction An examination of the serum creatinine and GFR (computed)[32] is indicated in case of: • clinic or anamnesis based indication of a renal dysfunction • clinic or anamnesis based indication of diabetes mellitus • severe intervention [8] • systemic corticoid therapy • increased cardiac risk [8;11] • intended intra-operative administration of contrast agent • Cirrhosis of the liver Liver function parameters (GPT, bilirubin, PTZ or INR) • indications of liver dysfunctions Measurement of blood sugar is indicated in case of: • Noted diabetes mellitus ∗ additional HBA 1C in case of planned severe intervention ∗ current fasting blood glucose on day of operation • every severe intervention • systemic corticoid therapy Examination of blood group and antibody diagnostic test is recommended in case of expected transfusion indigent loss of blood. In consideration of geographic and logistic peculiarities this indication is to be posed generously. Seite 9 von 14 ÖGARI Work Group „Preoperative Evaluation“ Gerhard Fritsch (Members: H. Ferstl, R. Germann, H. Gombotz, B. Gschiel, M. Haisjackl, K. Holaubeck, B. Horvath, S. Kozek, W. Lingnau, G. Prause, M. Seyr, F. Spiegl, G. Ulber) The perioperative risk is difficult to display by means of laboratory values [8; 30]. Best appropriate are the results of the kidney function test and sodium [8]. With minor surgical interventions and geriatric patients no correlation exists between laboratory tests and perioperative complications [30]. red cell count Leucocyte count platelet count sodium potassium Crea; GFR PTZ; INR ALT Bilirubin Glucose HbA1C TSH FT3; FT4 The following table represents a summary of the recommended preoperative laboratory tests: Cardiovascular, MET < 4 Respiratory System Lee-Index ≥ 3; CCS ≥ 3 Liver + + + + + + + positive history for liver disease Kidneys Cirrhosis + positive history for kidney diseases + + + + + + + + + + + + + Endocrine Disorders DM + (+) + + clinically relevant disorder of the thyroid gland Hematology and known hematological desease + + + Onkology malignancy + + + ongoing chemotherapy + + + Medication Type of Surgery* + ACE-inhibitors; AT II-Antagonists, Digitalis, Diuretics + + + antidepressant therapy + + corticosteroids + + + + + + + + minor surgery major surgery + * see 1) Rare diseases (esp. rare endocrinical diseases) as well as the clarification of blood coagulation are not included in this algorithm and are dealt with in the corresponding chapters. In case of difficult ascertainment of anamnesis (e.g. language barriers) or geriatric patients a broad preoperative laboratory diagnostics is recommended. Seite 10 von 14 ÖGARI Work Group „Preoperative Evaluation“ Gerhard Fritsch (Members: H. Ferstl, R. Germann, H. Gombotz, B. Gschiel, M. Haisjackl, K. Holaubeck, B. Horvath, S. Kozek, W. Lingnau, G. Prause, M. Seyr, F. Spiegl, G. Ulber) 7) Recommended assessment of patients with endocrinologic desease 8) Perioperative medication management [3;5;6] Seite 11 von 14 ÖGARI Work Group „Preoperative Evaluation“ Gerhard Fritsch (Members: H. Ferstl, R. Germann, H. Gombotz, B. Gschiel, M. Haisjackl, K. Holaubeck, B. Horvath, S. Kozek, W. Lingnau, G. Prause, M. Seyr, F. Spiegl, G. Ulber) ÖGARI Task Force „Preoperative Evaluation“ Administration: Dr. Gerhard Fritsch Universitätsklinik für Anästhesie, perioperative Medizin und allgemeine Intensivmedizin PMU Salzburg Müllner Hauptstrasse 48 5020 Salzburg e-mail: [email protected] Members: Dr. Harald Ferstl AKH Linz; Scores Dr. Gerhard Fritsch Universitätsklinikum LKH Salzburg; Labor Prim. Univ. Doz. Dr. Reinhard Germann KH Feldkirch; Anamnese und klinische Untersuchung Prim. Univ. Prof. Dr. Hans Gombotz; AKH Linz Drin. Bernadette Gschiel LKH Klagenfurt; präoperatives Medikamentenmanagement Univ. Prof. Dr. Markus Haisjackl; Jemen Prim. Dr. Karl Holaubeck; KH Zwettl; endokrinologische Vorerkrankungen Drin..Brigitte Horvath; KH Wiener Neustadt Univ. Profin. Drin. Sibylle Kozek; Medizinische Universität Wien; präoperative Gerinnungsdiagnostik Univ. Prof. Dr. Werner Lingnau; Medizinische Universität Innsbruck; kardiovaskuläre Evaluierung Univ. Prof. Dr. Gerhard Prause; Medizinische Universität Graz; pulmonale Evaluierung Prima. Drin. Michaela Seyr; KH Krems; Kinderleitlinie Prim. Dr. Franz Spiegl; KH Güssing; präoperative Eigenblutspende Dr. Gerald Ulber; KH der BHB Eisenstadt Seite 12 von 14 ÖGARI Work Group „Preoperative Evaluation“ Gerhard Fritsch (Members: H. Ferstl, R. Germann, H. Gombotz, B. Gschiel, M. Haisjackl, K. Holaubeck, B. Horvath, S. Kozek, W. Lingnau, G. Prause, M. Seyr, F. Spiegl, G. Ulber) Refrences: 1. Ainsworth BE, Huskell WL, Witt MC (2000) Compendium of physical activities: an update of activity codes and MET intensities Med Sci Sports Exerc. (9 Suppl) 32:498504 2. American Society of Anesthesiologists Task Force on Preanesthesia Evaluation (2002) Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 96(2):485-96 3. Beattie WS, Wijeysundera DN, Karkouti K (2008) Does tight heart rate control improve beta-blocker efficacy? An updated analysis of the noncardiac surgical randomized trials. Anest Analg 106(4)1039-48 4. Behnia R, Molteni A, Igic R (2003) Angiotensin-converting enzyme inhibitors: mechanism of action and implications in anesthesia practice. Curr Pharm Des 9(9):763-76 5. Biccard BM, Sear JW, Foex P (2006) Acute perioperative Beta-Blockade in intermediate –risk Patients Anaesthesia 61:924-31 6. Buhre K, de Rossi L, Buhre W (2005) Preoperative long-term therapy. Anästhesist 54(9):902-13 7. Dempfle CE (2005) Perioperative coagulation diagnostics. Anästhesist 54(2):167-75 8. Dzankic S, Pastor D, Gonzales C (2001) The prevalence and predictive value of abnormal preoperative laboratory tests in elderly surgical patients. Anest Analg 93(2):301-8 9. Dzik WH (2004) Predicting hemorrhage using preoperative coagulation screening assays. Curr Hematol Rep 3(5):324-30. Review. 10. Ferrari LR (2004) Preoperative evaluation of pediatric surgical patients with multisystem considerations. Anest Analg 99:1058-69 11. Fleisher LA, Beckman JA, Brown KA (2007) ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 116(17):e418-99 12. Fleisher LA, Beckman JA, Brown KA (2006) ACC/AHA 2006 Guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy-a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Anesth Analg.104(1):15-26 13. Garcia-Miguel FJ, Serrano Aguilar PG, Lopez-Bastida J (2004) Preoperative assessment. Lancet.362(9397):1749-57 14. Halaszynski TM, Juda R, Silverman DG (2004) Optimizing postoperative outcomes with efficient preoperative assessment and management. Crit Care Med 32 (4 Suppl):76-86 Seite 13 von 14 ÖGARI Work Group „Preoperative Evaluation“ Gerhard Fritsch (Members: H. Ferstl, R. Germann, H. Gombotz, B. Gschiel, M. Haisjackl, K. Holaubeck, B. Horvath, S. Kozek, W. Lingnau, G. Prause, M. Seyr, F. Spiegl, G. Ulber) 15. Homer JR, Elwood T, Peterson D (2007) Risk factors for adverse events in children with colds emerging from anesthesia: a logistic regression. Pediatr Anesthesia 17:15461 16. Jaffer AK, Michota FA(2006) Proceedings of the Perioperative Medicine Summit Using Evidence to Improve Quality, Safety, and Patient Outcomes. Cleveland Medical Journal of Medicine Vol. 73 Supplement 1 17. Jimenez N, Posner K, Cheney F (2007) An Update on pediatric liability: a closed claims analysis. Anest Analg 104:147-53 18. Joo HS, Wong J, Naik VN (2005) The value of screening preoperative chest x-rays: a systematic review. Can J Anaesth 52(6):568-74 19. Krobbuaban B, Diregpoke S, Kumkeaw S (2005) The predictive value of the height ratio and thyromental distance: four predictive tests for difficult laryngoscopy. Anesth Analg 101(5):1542-5. 20. Kozek-Langenegger SA, Fries D, Gütl M (2005) Locoregional anesthesia and coagulation inhibitors. 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World J Surg 26:515-20 27. Olson RP, Stone A, Lubarsky D (2005) The prevalence and significance of low preoperative hemoglobin in ASA 1 or 2 outpatient surgery candidates. Anest Analg 101 (5): 1337-40 28. Pfanner G, Koscielny J, Pernerstorfer T (2007) Die präoperative Blutungsanamnese. Empfehlungen der Arbeitsgruppe perioperative Gerinnung (AGPG) der Österreichischen Gesellschaft für Anästhesiologie, Reanimation und Intensivmedizin (ÖGARI) Anästhesist 56(6):604-11 29. Reilly DF, Mc Neely MJ, Doerner D (1999) Self-reported Exercise Tolerance and the Risk of Serious perioperative Complications. Arch Intern Med 159:2185-92 30. Schein OD, Katz J, Bass EB (2000) The value of routine preoperative medical testing before cataract surgery. Study of Medical Testing for Cataract Surgery. New Engl J Med 342(3): 168-75 31. Vacanti C, Houten R van, Hill R (1970) A statistical analysis on the relationship of physical status to postoperative mortality in 68,388 cases. Anesth Analg 49:564-566 32. 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