Download Preoperative assessment

Pre-operative Assessment for
Elderly Patient in ENT
Presenter: Dr Isaac Tan
Supervisor:Ms Aneeza Khairiyah Wan Hamizan
Case 1
• An 81-year-old woman presented to the
preoperative assessment clinic (PAC)
prior to an elective endoscopic sinus
surgery for chronic rhinosinusitis with
bilateral grade 4 nasal polyposis.
• She had a medical history of rheumatic
heart disease, with a previous mitral
valve replacement with a tissue valve,
atrial fibrillation with chronic
anticoagulation and pacemaker
placement, and coronary artery disease.
• She denied any cardiac symptoms except for
mild shortness of breath on exertion.
• The patient was taking metoprolol, valsartan,
aspirin, simvastatin, and warfarin.
• Her blood pressure was 150/81 mmHg,
• heart rate was 78 beats/min,
• oxygen saturation was 98% on room air.
• Her heart beat was irregularly irregular without
murmurs. Her lung sounds were clear.
• There was no pitting edema.
• Per the Revised Cardiac Risk Index (RCRI) for
preoperative risk, the patient had one risk factor
(coronary artery disease) with an expected risk of
having a major postsurgical adverse cardiac
event of 0.9%–1.1%
Elderly Population in
Malaysia
• Despite the national census data
classifying elders as those aged 65
and above,
• Malaysia classifies elders as persons
aged 60 years and above for its policy
development related to older persons,
following the United Nations World
Assembly on Ageing held in Vienna in
1982.
Source: 2018 National Health and Morbidity (NHMS) survey
Pre-operative Assessment
• to identify co-morbidities
• To foresee and prevent patient
complications during the anaesthetic,
surgical, or post-operative period.
• scheduled for elective procedures will
generally attend a pre-operative
assessment 2-4 weeks before the date of
their surgery.
• RAP PRIOP - Reassurance, Advice,
Prescription, Referral, Investigations,
Observations, Patient understanding and
follow-up:
Preoperative Management For
Geriatric Patients
• increased age is associated with multiple
systemic comorbidities.
• Preoperative consent and postoperative
delirium and cognitive dysfunction
• Normal age-related physiologic changes such as
• impaired left ventricular compliance,
• stiffening of the systemic vasculature,
• decreased lung mechanics,
• reduced renal function
• limit the physiologic reserve of older patients
and make them more vulnerable to
postoperative stress and illness.
Domains for Elderly Adults Undergoing
Elective Surgery
Domain
Description
Goal
Overall health goals
Patient understanding of surgery and complication and outcome/QoL
Function
Baseline function – Eating, Dressing, Mobility, Social Support
Nutrition
Proper Nutritional Assessment
Cognition
Dementia risk/Consent
Medical Illness
Cardiac
Pulmonary
Endocrine
Renal
Medication management
Marwell, J. G., Heflin, M. T., & McDonald, S. R. (2018). Preoperative Screening. Clinics in Geriatric
Medicine, 34(1), 95–105. doi:10.1016/j.cger.2017.08.004
American Society of Anaesthesiologists Grade
Grade
Definition
I
II
III
IV
V
E
Normal healthy patient
Mild systemic disease
Severe systemic disease
Severe systemic illness that is a
constant threat to life
Moribund, who is not expected
to survive without the operation
Suffix added if an emergency
operation
Absolute Mortality (%)
0.1
0.2
1.8
7.8
9.4
–
Modified Frailty Index (11)
1.
2.
3.
4.
History of diabetes mellitus
History of congestive heart failure
History of hypertension requiring medication
History of either transient ischemic attack or
cerebrovascular accident
5. Functional status 2 (not independent)
6. History of myocardial infarction
7. History of either peripheral vascular disease or
rest pain
8. History of cerebrovascular accident with
neurological deficit
9. History of either COPD or pneumonia
10. History of either prior PCI, PCS, or angina
11. History of impaired sensorium
Increasing mFI scores was
associated with an increase in
• wound infection,
• wound occurrence,
• any infection,
• any occurrence of
complications,
• mortality.
Farhat JS, Velanovich V, Falvo AJ, et al. Are the frail destined to fail? Frailty index as predictor of
surgical morbidity and mortality in the elderly. J Trauma Acute Care Surg. 2012;72(6):1526–
1530. discussion 1530–1531.
PreOperative History HOPI
• Brief history of why the patient first
attended
• What procedure they have subsequently
been scheduled for
• Indication for surgery
• NYHA/MMRC
• Sepsis Symptoms
• Airway Compromise and Compression
Symptoms
• Fall Risk – Otology surgery
Pre-Operative History – Past Medical History
Cardiovascular Disease
• American Heart Association
(ACC/AHA) perioperative guidelines,
head and neck surgery is rated
intermediate risk with a reported
cardiac risk generally of 1%–5% [36].
• History of Congenital
anomalies/cardiac surgery
• Recent IHD
• Palpitation, Chest pain, Presyncope
attacks
NYHA
Classification
Class I - No symptoms and no limitation in ordinary physical activity, e.g. shortness
of breath when walking, climbing stairs etc.
Class II - Mild symptoms (mild shortness of breath and/or angina) and slight
limitation during ordinary activity.
Class III - Marked limitation in activity due to symptoms, even during less-thanordinary activity, e.g. walking short distances (20–
100 m).Comfortable only at rest.
Class IV - Severe limitations. Experiences symptoms even while at rest. Mostly
bedbound patients.
Cardiovascular Risk Assessment –
Revised Cardiac Risk Index for Pre-Operative Risk
(RCRI – 2019) for non cardiac surgery
Risk factor
High-risk surgery
History of ischemic
heart disease
History of congestive
heart failure
History of
cerebrovascular
disease
Pre-operative
treatment with insulin
Description
Intraperitoneal; intrathoracic; suprainguinal vascular
History of myocardial infarction (MI); history of positive exercise test;
current chest pain considered due to myocardial ischemia; use of
nitrate therapy or ECG with pathological Q waves
Pulmonary edema, bilateral rales or S3 gallop; paroxysmal nocturnal
dyspnea; chest x-ray (CXR) showing pulmonary vascular redistribution
Points
+1
Prior transient ischemic attack (TIA) or stroke
+1
--
+1
+1
+1
Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O'Malley TA, Goroll AH, Caplan CH, Nolan J, Carabello B,
Slater EE. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977 Oct 20;297(16):845-50.
Revised Cardiac Risk Index for Pre-Operative
Risk (RCRI – 2019) for non cardiac surgery
RCRI Score
Risk of major cardiac event (95%
CI)*
Management
0
3.9% (2.8-5.4%)
No Preop cardiac assessment needed
1
6.0% (4.9-7.4%)
the patient’s age is ≥65, or they are ≥40, with
significant cardiac disease*
2
10.1% (8.1-12.6%)
≥3
15% (11.1-20.0%)
monitored with an ECG in the PACU and
troponin measurements daily for 48-72 hours
Defined as death, myocardial infarction, or cardiac arrest at 30 days
after noncardiac surgery
PERIOPERATIVE APPROACHES FOR
HYPERTENSION PATIENT
• Exaggerated intraoperative blood pressure fluctuation is associated
ECG evidence of myocardial ischaemia and stroke
• Haemostasis intraoperatively
• Renal Function
Myocardium
Infarction / PCI
• < 12 months
• Elective – Postpone surgery
until 12 post stenting
• Urgent – Consider Bridging
therapy
• >12 months
• High risk - Consider Bridging
therapy
• Low Risk – Consider single ASA
Pacemaker / Cardioverter Defibrillator
• Implantable Pacemakers and implantable ICDs in patients
face problems resulting from Electrical interference from
the use of surgical diathermy / electro-cautery
• If Cautery is deemed essential – BIPOLAR with limit to short
bursts
• History
• INDICATION for DEVICE
• device manufacturer, model number, serial number
• implanting hospital, follow-up hospital
• date of implant
• extent of any heart failure
• degree of pacemaker dependency
• Facial Nerve Stimulation - could be considered with
caution in patients with pacemakers and ICDs with lowest
amplitude possible. Ground electrode should be place
away from thorax (*Limited studies for facial nerve, more
on lower limb stimulation)
Badger J, Taylor P, Swain I. The safety of electrical stimulation in patients with pacemakers and implantable cardioverter defibrillators: A systematic review. J Rehabil
Assist Technol Eng. 2017;4:2055668317745498. Published 2017 Dec 5. doi:10.1177/2055668317745498
PERIOPERATIVE MANAGEMENT OF PATIENTS
ON ANTI-THROMBOTIC THERAPY
• Aspirin
• In patients at moderate to high risk - continuing ASA around the time of surgery
• In patients at low risk for cardiovascular events - stopping ASA 7 to 10 days before
surgery
• Dual Anti-platelet - continuing ASA around the time of surgery and
stopping
• clopidogrel/prasugrel 5 days before
• Ticlopidine 10 -14 days before
• Vitamin K Antagonist / Warfarin –
• Low risk – 5 days before
• High risk In patients with a mechanical heart valve, atrial fibrillation, or VTE at high
risk for thrombo-embolism, bridging anticoagulation (UFH,LMWH) 1 -2 days before
surgery
• IV Unfractionated Heparin - stopping 4 to 6 h before surgery
• LMWH (Clexane) – stopping 24 hours before surgery, if high risk bleeding –
48 – 72 hours before
PERIOPERATIVE MANAGEMENT OF PATIENTS
ON NEW ANTI-THROMBOTIC THERAPY
• Dabigatran – Stop 1 to 2 days (CrCl ≥ 50 mL/min) or 3 to 5 days (CrCl
< 50 mL/min). Consider longer times for patients undergoing major
surgery
• Rivaroxaban - Stop rivaroxaban at least 24 hours before procedure. If
reduced Renal function, consider longer times and bridge with UWFH
if the risk of thrombo-embolism is high
• Apixaban - Discontinue at least 48 hours before elective surgery and
bridge with UWFH if the risk of thrombo-embolism is high
• Edoxaban – Discontinue 2–3 days prior and bridge with UWFH if the
risk of thrombo-embolism is high
Anti-thrombotic Therapy And Its Antidotes
Drug
Antidote
Antiplatelets – ASA, Clopidogrel
None – Consider Platelet infusion
Warfarin
Vitamin K
UFW Heparin
protamine sulfate – dosage depending of time since last heparin dose
LMW Heparin (Clexane)
None - Limited role of protamine sulfate
Dabigatran
Idarucizumab
Rivaroxaban
Andexanet alfa
Apixaban
Charcoal (if last intake within 2–3 hours)
IV Prothrombin complex concentrate
Edoxaban
Charcoal (if last intake within 2–3 hours)
IV Prothrombin complex concentrate
Case 1
• Perioperatively, she was also
bridged with low molecular
weight heparin and
unfractionated heparin.
• Her postoperative course was
uneventful, and she was
discharged on postoperative
day (POD) 2 to home.
Respiratory disease
• adequate oxygenation and ventilation is essential in reducing the risk
of acute ischaemic events in the peri-operative period
• Important to assess risk of postoperative pulmonary complications
• MMRC
• Asthma / COPD – pre op nebulisation (On and OT call)
• Smoking cessation – 4 – 8 weeks prior to surgery
• Respiratory muscle training (incentive spirometry) to maximize
respiratory support in preparation for upcoming surgery that may be
particularly beneficial for high-risk surgeries, as it reduces the risk of
postoperative atelectasis and pneumonia
mMRC (Modified Medical Research Council)
Dyspnea Scale
Grade
Symptom severity
0
Dyspnea only with strenuous exercise
1
Dyspnea when hurrying or walking up a slight hill
2
Walks slower than people of the same age because of dyspnea or has to stop for breath when
walking at own pace
3
Stops for breath after walking 100 yards (91 m) or after a few minutes
4
Too dyspneic to leave house or breathless when dressing
Renal disease
• many features of renal disease (such as anaemia, coagulopathy,
biochemical disturbances) can increase the incidence of surgical
complications
• Fluid restriction
• Type of renal replacement therapy
• Dry weight
• Urine output at home
• Dialysis Frequency, Centre, Complications
Endocrine disease
• specifically diabetes mellitus and thyroid disease
• Many medications often require specific changes to be made in the
peri-operative period
Preoperative Assessment For Patients With
Diabetes Mellitus
• Should focus on the long-term complications of diabetes
(microvascular, macrovascular, and neuropathic), which may
potentiate risk.
• Pharmacological regimen - Medication type, Dosage. Timing
• Control – HbA1c
• End Organ Damage – Renal Function, Cardiac Function
Principles Of Management for Patients With
Diabetes Mellitus
1. Stabilise bood sugar 2-3 days before elective operation.
2. OHA - Omit Morning dose of OHA
3. Insulin - Omit morning dose of insulin if BG <7mmol/L or Half the normal
dose if >7 mmol/L
4. Major surgery - Convert to insulin (sliding scale) for major surgery or one
with poor control on oral hypoglycaemic drugs.
5. Short acting drugs are preferred to long acting ones.
6. If possible the patient should be scheduled early in the OT list to limit the
durationof preoperative fasting
7. Bedside blood glucose concentration monitoring using reagent strip and
refractometer is usually adequate
Sliding Scale Regime
• Variable rate infusion of insulin 50U in 50mls 0.9% saline
(concentration of insulin 1U/ml), adjusted according to blood glucose
concentration.
• Increase rate of infusion by 2mls/hr if blood glucose concentration
remains high, check halfhourly and adjust infusion rate accordingly.
• Approximate guide : Insulin infusion rate= Blood glucose
concentration divide by 5
Blood Glucose Concentration
Infusion rate (ml/hr)
<5
Omit
5 – 10
1
10 – 15
3
15 – 20
4
>20*
5*
PREOPERATIVE ASSESSMENT OF PATIENTS
WITH THYROID DISORDER
• For all symptomatic patients, REFER Endocrine Medical Clinic for early
appointment
• If clinically asymptomatic , but only have laboratory thyroid
abnormalities
• If biochemically hyper or hypothyroid : REFER
• If subclinical hypothyroidism or subclinical hyperthyroidism to send for Free
T3 Level. If normal free T3, can proceed for surgery.
• If TSH ↑ : Repeat TFT in 4 weeks time
Preoperative Assessment For Patients With
Obesity/OSA
• Sedative premedication: Avoid sedative premedication
• Possible difficult airway
• Positive Airway Pressure Devices should be continued till the night
before op and resumed as soon as possible after operation. Patient to
bring own device to hospital
• Gastro-oesophageal reflux disease - Proton pump inhibitors or
antacids for premedication
• PACU/ICU back up depends on ASA Perioperative risk estimation in
patients with obstructive sleep apnea
Nutritional History
• Identify Pre-operative malnutrition
• Provide nutritional support improves surgical outcome
Nasogastric tube
Gastrostomy
Jejunostomy
• If unable to take
sufficient calories
orally or
dysfunctional swallow
• If oesophagus
blocked/dysfunctional
• If stomach
inaccessible or
outflow obstruction
Parenteral
Nutrition (TPN)
• If jejunum
inaccessible or
intestinal failure (IF)
Nutritional status
• prevalence of malnutrition among the elderly was 22.8%
• Morbidity, particularly severe infection, was significantly higher
among malnourished patients, with the odds ratio for morbidity
ranging from 2.30 to 3.47 in the well-nourished vs malnourished
patients
• Traditional scoring systems are based on mathematical equations
using objective measures of nutritional status (eg, Nutritional Risk
Index [NRI]
• Subjective global assessment (SGA) of nutritional status tool
Subjective Global Assessment
Objective Assessment
• NRI = [1.489× serum albumin,
(g/L)] + [41.7× present
weight/usual weight]
• >100: not malnourished
• 97.5–100: mild malnourishment
• 83.5–97.5: moderate
malnourishment
• <83.5: severe malnourishment
• Maastricht Index =20.68 − [0.24×
albumin (g/L)] − [19.21×
prealbumin (g/L)] − [1.86×
lymphocytes, (106/L)] − [0.04×
ideal body weight]
Psychological evaluation and preparation
• Dementia is a known risk factor for morbidity and mortality in the
geriatric population
• Adult patients undergoing laryngectomy may experience very intrusive,
lifechanging impact from loss of speech.
• A preoperative preparation program and counselling have been shown to
alleviate anxiety in not only elderly patients, but also family members
• mild dementia does not preclude capacity for medical decision-making.
• In general, decision-making capacity requires three basic elements:
1. the capacity to understand and communicate;
2. the capacity to reason and deliberate;
3. possession of a set of values and goals
Pre-Operative History – Past Surgical and Anaesthetic History
Past Drug History
• One in 3 older adults
takes 5 or more
prescription medications
and, as a result, has a
high risk of adverse drug
events in the
perioperative period
Physical Assessment
• Vital Signs
• Cardiovascular/Pulmonary
• Mobility assessment - Neck
• Airway assessment
• Otology
• Rhinology
• Laryngology
Pre-Operative Investigations
Routine Investigation
Indication
Full blood count
Age 60 and above
Major surgery
Renal profile
Major surgery
Electrocardiogram (ECG)
Male – Age 40 and above
Female – Age 50 and above
Chest X-ray
Age 60 and above
Major surgery
Liver Function
Major Surgery in patients more than 50 and above
Blood Sugar Monitoring
Age above 60
• Major surgery is empirically defined as one in which the cranium, thorax or abdomen is opened
or when the anticipated blood loss is significant and exceeds 15% of total blood volume.
• Normal investigation results are valid for varying periods of time, ranging
• from 1 week (FBC, urea, renal profile, blood glucose concentration),
• 1 month (ECG) to 6 months (CXR).
College of Anaesthesiologist Academy of Medicine of Malaysia Recommendations on Pre-Anaesthetic Assessment and
Management 2014
Pre-Operative Investigations
Routine Investigation
Indication – Comorbids
Full blood count
1. Anaemia and Other haematological disease
2. Renal disease
3. Patient on chemotherapy
Renal profile
1.
2.
3.
4.
5.
6.
7.
Electrocardiogram (ECG)
1. Heart disease, hypertension or chronic pulmonary disease
2. Diabetes mellitus
3. Renal disease
Chest X-ray
1. Significant respiratory disease
2. Cardiovascular disease
3. Malignancy
Blood sugar
Diabetes mellitus
Liver Disease
Renal disease
Liver diseases
Cardiovascular disease
Metabolic disease, e.g., diabetes mellitus and Abnormal nutritional states
History of diarrhoea, vomiting
Preoperative bowel preparation
Drugs that may alter electrolyte balance or nephrotoxic e.g., diuretics,
corticosteroids
Group Save and Hold (GSH) VS Group Cross-Match (GXM)
Group Save and Hold (GSH)
• Determines patient’s blood group
(ABO and RhD)
• screens the blood for any atypical
antibodies;
Group Cross-Match (GXM)
physically mixing the patient’s blood
with the donor’s blood, in order to see if
any immune reaction takes places
Takes around 40 minutes
Valid for 48 hours
no blood is issued
recommended if blood loss is not
anticipated, but blood may be required
should there be greater blood loss than
expected
40 mins for GSH + 40 mins GXM
Valid for 24 hours
donor blood is issued and reserved
should be done if blood loss is
anticipated
RhD negative patients, blood bank must be informed at least a week prior to the
procedure so as to ensure blood is available before surgery
MAXIMUM SURGICAL BLOOD ORDERING SCHEDULE (MSBOS)
Surgery
Recommendation
Otology
Mastoidectomy-radical
2 units
Rhinology
Skull Base Tumors
4 Units
Laryngology
Larnyngectomy -total/partial +/- pharyngectomy
2 – 4 units
Head and Neck
Adenoidectomy/Adenotonsillectomy/Tonsillectomy
GSH*
Angiofibroma excision
4 – 6 units
Free Flap Reconstructions
2 – 4 units
Parotidectomy-complete/partial
2 units*
Radical neck dissection
2 units*
Glossectomy with / without neck dissection
2 – 4 units
College of Anaesthesiologist Academy of Medicine of Malaysia Recommendations on Pre-Anaesthetic Assessment and Management 2014
Pre-Operative Investigations
Routine Investigation
Indication – Comorbids
Liver Function
1. Hepatobiliary disease
2. History of alcohol abuse
3. Tumour with possible metastases to the liver
Arterial blood gases
(ABG)
1.
2.
3.
4.
Debilitated or septic patients
Moderate to severe pulmonary disease
Patients in respiratory difficulty
Patients scheduled for thoracic surgery
Coagulation screen
1.
2.
3.
4.
5.
Haematological disease
Severe liver disease
Coagulopathy due to any cause
Patients on anticoagulant therapy
Intra-thoracic/Intra-cranial procedures
Thyroid function test
1. Thyroid surgery
2. History of thyroid disease
3. Suspected endocrine abnormalities, e.g., pituitary tumour
Lung function test
1. Patients scheduled for thoracic surgery
2. Moderate to severe pulmonary disease
Cardiac Function Test –
ECHO/Stress Test/Holter
1. Significant cardiovascular disease
2. Patients with atypical cardiac symptoms – palpitations, presyncopal
3. Patients with significant haemodynamic disturbances
Covid Era – New
Normal
• In our inpatient pathway, all patients were
tested prior to procedures.
• Although patients undergoing emergent and
urgent cases received the same day test,
procedures were not delayed for test results,
and they proceeded with appropriate PPE
and precautions
• Types of testing
• Low risk/weekends - Rapid Antigen test
• High risk - rtPCR
Thank You
References
• Abdelmalak, B., & Doyle, J. (Eds.). (2012). Anesthesia for
Otolaryngologic Surgery. doi:10.1017/cbo9781139088312
• Kim S, Brooks AK, Groban L. Preoperative assessment of the older
surgical patient: honing in on geriatric syndromes. Clin Interv Aging.
2014;10:13-27. Published 2014 Dec 16. doi:10.2147/CIA.S75285
• Kumar C, Salzman B, Colburn JL. Preoperative Assessment in Older
Adults: A Comprehensive Approach. Am Fam Physician.
2018;98(4):214-220.