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Preoperative Evaluation and Management with Cardiac Evaluation Lauren Hojdila, MSA, AA-C Nova Southeastern University The Preoperative Evaluation A Standard of Care • The Joint Commission for the Accreditation of Healthcare Organizations (TJC) requires that all patients receive a preoperative anesthetic evaluation • The American Society of Anesthesiologists (ASA) has approved Basic Standards for PreAnesthetic Care, which outlines the minimum requirements for a preoperative evaluation Goals of the Preoperative Evaluation • Primary Goals – Reduce patient risk – Reduction of perioperative morbidity and mortality • Secondary Goals – Promote efficiency – Reduce costs *Conducting a preoperative evaluation is based on the premise that it will modify patient care and improve outcome. Does the Preoperative Evaluation alter Patient Care ? • Gibby et al found that anesthetic plans were altered in 20% of all patients due to conditions identified at the preoperative evaluation • The most common conditions resulting in modification of the anesthetic plan were gastric reflux, IDDM, asthma, and suspected difficult airway • These findings indicate the need to do the initial preoperative evaluation before the day of surgery Components of the Preoperative Evaluation • Personal Interview • Review of systems • Prior anesthetic experience (Difficult intubation, delayed emergence, MH, delayed NMB, PONV) • Drug allergies • Physical Examination • Airway exam • Body habitus • Review of Medical Records • • • • Medications Substance use (alcohol, tobacco, illicit) Surgical history Surgical Diagnosis (Organ systems involved, Planned procedure) ASA Classification Class 1: Healthy patient, No medical problems Class 2: Mild systemic disease Class 3: Severe systemic disease, but not incapacitating Class 4: Severe systemic disease that is a constant threat to life Class 5: Moribund, not expected to live 24 hours irrespective of operation Class 6: Organ donor E may be added to the status number to designate an emergency operation Thyromental Distance Airway Examination • Distance from the thyroid cartilage to the inside of the mentum • Measured with the neck in the sniff position • What is normal thyromental distance? A higher Mallampati class combined with a mental distance <2 finger-breadths may better predict increased difficulty with intubation. Mallampati Classification Airway Examination • Class I: Soft palate, fauces, uvula, tonsillar pillars • Class II: Soft palate, fauces, uvula • Class III: Soft palate, base of uvula • Class IV: Hard palate only What other feature increase the likelihood of difficult intubation? • • • • • • Short, thick neck (Neck circumference) Diminished neck extension Decreased tissue compliance Large tongue Teeth (Overbite, Large teeth) Decreased TMJ mobility NPO Guidelines • Healthy Adults (No risk factors) • No solid foods for a minimum of 6 hours • Clear liquids up to 2 hours prior to elective case • Oral medications up to 1-2 hours with sip of water • Pediatric patients • Clear liquids up to 2 hours preOp • Breast milk up to 4 hours preOp • Solid foods, nonhuman milk, formula up to 6 hours preOp Aspiration Who has a higher risk ? Gastrointestinal Obstruction GERD Diabetes mellitus Recent solid-food intake Abdominal distention Pregnancy Depressed consciousness Recent opioid administration Upper GI or naso-oropharyngeal bleeding, with or without trauma • Emergency surgery • • • • • • • • • The Healthy Patient Systems Approach • Airway • Examination as previously described • Pulmonary • History – Tobacco use, asthma, SOB/DOE, sleep apnea, wheezing, cough, etc. • Physical exam – Lung sounds, chest excursion, use of accessory muscles, cyanosis, clubbing, etc. • Cardiovascular • HTN, CAD, MI, angina, CHF, dysrhythmias, valvular dx, heart sounds, carotid bruits, peripheral pulses • Neurologic • Mental status, h/o seizures, neuromuscular disease, nerve injury • Endocrine • Diabetes mellitus, thyroid disease, adrenal cortical suppression, etc. The Patient with Known Cardiac Disease • Define risk – Goldman risk index (Independent predictors) • High-risk surgery, h/o ischemic heart dx, h/o CHF, h/o cerebrovascular dx, preOp insulin therapy, and preOp serum creatinine > 2 mg/dL • Need for further testing • Recent MI or ECG changes • Poor exercise tolerance • Need for cardiac surgery • Prior to current elective surgery The Patient with Pulmonary Disease • Site and Type of Surgery • Thoracic and upper abdominal procedures are associated with increased pulmonary complications • Type and Severity of Disease • Does the disease have a reversible component ? • When were they last hospitalized ? • Interview • Exercise tolerance, chronic cough, smoking history • What are their current treatment modalities? • Physical Exam • Lungs sounds – wheezing, rhonchi, decreased breath sounds Other Diseases of Concern • Diabetic Mellitus • Increased risk of CAD, perioperative MI, hypertension, and CHF • Consider beta-blockade in diabetics with CAD to help limit myocardial ischemia • Renal Disease • Altered drug metabolism • Fluid management • Liver Disease • Coagulation abnormalities • Altered protein binding and volume of distribution Perioperative Lab Testing • No evidence supports the use of routine laboratory testing • There is support for the use of selected lab analysis based on the patient’s preOp history, physical exam, and proposed surgical procedure • A positive result is frequently a false-positive • High incidence of false-positives when performing tests in normal patients (a population with a very low prevalence of disease) • Risk/Cost vs. Benefit • Medical testing is associated with significant cost • The risk of intervention may outweigh the benefit • Is it going to change what you do ??? Recommended Lab Tests • CBC / Hemoglobin • Hgb of 7 g/dL is acceptable in patients without systemic disease (depending upon proposed surgical procedure) • In patients with systemic disease, signs of inadequate systemic oxygen delivery are an indication for transfusion • Electrolytes • Creatinine and glucose in older asymptomatic adults • BUN and creatinine in patients with systemic disease or on medications that affect the kidneys • Coagulation Studies • Recommended in patients with bleeding disorders, liver dysfunction, or on anticoagulant therapy Recommended Lab Tests Continued • Pregnancy Testing • Current practice: – testing all females of child-bearing age • Chest X-rays • Routine testing in the population without risk factors can lead to more harm than good • Is indicated in patients with a history or clinical evidence of active pulmonary disease, and may be indicated routinely in patients of advanced age Preoperative Medications • What is the goal of premedication ? • Anxiolysis, Sedation, Amnesia, Analgesia, etc. • What drug, when, and how much ? • Several classes of drugs may be available to facilitate the desired goal • Timing of drug delivery is as important as drug selection • There is no BEST drug or combination of drugs for preoperative medication • The specific drugs selected are based on the goals of premedication balanced with the potential side effects these drugs may produce Preoperative Medications • Benzodiazepines • Act on GABA receptors to produce selective anxiolysis at doses that do not produce excessive sedation, depression of ventilation, or adverse cardiac effects • Note: May lead to any of the above when given with opioids • Opioids • Should be used when there is a need to provide analgesia Preoperative Medications Continued • Antiemetics • Administered in the preOp or intraOp period as prophylaxis against PONV • Droperidol (Black-Boxed), Reglan (? Antiemetic), 5HT3 inhibitors, Decadron, Scopolamine patch (apply several hours before induction of anesthesia) • Drugs used to alter gastric volume/pH • Clinically significant pulmonary aspiration of gastric fluid is rare in healthy patients undergoing elective surgery, maintenance of a patent airway is more important than routine pharmacologic prophylaxis • Use in patients with specific indications What has changed about your plan? • Airway • Medications • Trends of Vital Signs Pre-Operative Cardiac Evaluation Cardiovascular Disease • During a lifetime, a heart contracts more than 4 billion times – To support the active cardiac state, the heart supplies more than 4 million liters of blood to the myocardium and more than 200 million liters to the systemic circulation • Cardiac output can vary from 3 L/min to 30 L/min depending on activity level – Regional blood flow can vary up to 200% Cardiovascular Disease Major Disease Categories • Coronary heart disease (CHD/CAD) • Hypertension (HTN) • Rheumatic heart disease (RHD) • Bacterial endocarditis • Congenital heart disease Coronary Heart Disease • Leading cause of death in the United States • Around 1 million deaths per year from cardiovascular pathology • About ½ of these related to ischemic disease • No. 1 cause of death among women in the U.S. • Lifetime risk of death from CHD: 31% • Lifetime risk of death from breast CA: 2.8% Coronary Heart Disease Risk Factors • Past medical history • Chronic disorder – – – – Hypertension Hyperlipidemia Diabetes mellitus Thyroid dysfunction • Cardiac surgery • Rhythm disorder • Acute rheumatic fever Coronary Heart Disease Risk Factors: Family History • • • • Diabetes mellitus Heart disease Hypertension Congenital heart defects – Particularly VSD • Sudden death • Early age cardiovascular disease Coronary Heart Disease Risk Factors: Social History • • • • • • • Stressful or physical work Tobacco use Poor nutritional status “High strung” personality Lack of relaxing activities Use of alcohol Use of illegal drugs Preoperative Clinical Evaluation Identification of serious cardiac disorder CAD, CHF, Arrhythmias Initial history, Physical examination, ECG Define disease severity, stability, and prior treatment Functional capacity Age Comorbidities DM, peripheral vascular disease, renal dysfunction, chronic pulmonary disease Type of surgery Consider higher risk Vascular procedures Prolonged complicated thoracic, abdominal and head and neck procedures Hypertension Management of Preoperative Cardiovascular Conditions • Severe Htn(DBP >110mmHg) should be controlled before surgery when possible • Continuation of preoperative antihypertensive treatment is critical to avoid severe postoperative hypertension. • Consider the urgency of surgery and the potential benefit of more intensive medical therapy. Valvular Heart Disease Management of Preoperative Cardiovascular Conditions • Symptomatic stenotic lesions (MS or AS): associated with risk of perioperative severe CHF or shock and often require percutaneous valvotomy or replacement to lower cardiac risk. • Symptomatic regurgitant lesions (AR or MR): usually better tolerated perioperatively and may be stabilized before surgery with intensive medical therapy and monitoring Myocardial Heart Disease Management of Preoperative Cardiovascular Conditions • Dilated and hypertrophic cardiomyopathy are associated with an increased incidence of perioperative CHF. • Maximizing preoperative hemodynamic status and providing intensive postoperative medical therapy and surveillance. Arrhythmias and Conduction Abnormalities Management of Preoperative Cardiovascular Conditions • Careful evaluation for underlying cardiopulmonary disease, drug toxicity, or metabolic abnormality. • Therapy: reverse any underlying cause and treat the arrhythmia Medical Therapy for Coronary Artery Disease • If patients require β-blockers, calcium channel blockers, or nitrates before surgery, continue them into the operative and post-op period. • The same is true for therapies used to control CHF • β-blockers reduce postoperative ischemia – Protection against ischemia may also reduce risk of MI Cardiac Evaluation • Clinical predictors • Functional capacity • Surgical risk • Non-invasive testing • Invasive testing Method of Assessing Cardiac Risk • Resting Left Ventricular Function • Exercise Stress Testing • Pharmacological Stress Testing • Ambulatory EKG monitoring • Coronary Angiography Clinical Predictors of Increased Perioperative Cardiovascular Risk (Myocardial Infarction, Congestive Heart Failure, Death) • Minor Advanced age Abnormal EKG(LVH, LBBB, ST-T abnormalities) Rhythm other than sinus (eg, atrial fibrillation) Low functional capacity (eg, unstable to climb one flight of stairs with a bag of groceries) History of stroke Uncontrolled systemic hypertension • Intermediate Mild angina pectoris(Canadian Cardiovascular Society Class I or II) Prior myocardial infarction by history or pathological waves Compensated or prior CHF Diabetes mellitus Clinical Predictors of Increased Perioperative Cardiovascular Risk (Myocardial Infarction, Congestive Heart Failure, Death) • Major Unstable coronary syndromes – Recent myocardial infarction with evidence of important ischemic risk by clinical symptoms or noninvasive study – Unstable or severe angina – Decompensated CHF Significant arrhythmias – High grade atrioventricular block – Symptomatic ventricular arrhythmias in the presence of underlying heart disease – Supraventricular arrhythmias with uncontrolled ventricular rate Severe valvular disease Functional Capacity 1 MET Can you take care of yourself? Can you eat, dress, or use the toilet? Can you walk indoors around the house? Can you walk a block or two on level ground at 2-3 mph? Can you do light housework, such as dusting or washing dishes? 4 METs Can you climb a flight of stairs or walk up a hill? Can you walk on level ground at 4 mph? Can you run a short distance? Can you do heavy housework, such as scrubbing floors or lifting or moving heavy furniture? Do you participate in moderate recreational activities, such as golf, bowling, dancing, doubles tennis, or throwing a baseball or football? >10 METs Do you participate in strenuous sports, such as swimming, singles tennis, football, basketball, or skiing? Surgical Risk Low Risk Procedures • Low surgical risk: – Endoscopy – Bronchoscopy – Cystoscopy – Dermatologic procedures – Breast biopsy – Opthalmologic procedures Surgical Risk • Intermediate surgical risk: – Orthopedic surgery – Urologic surgery – Uncomplicated abdominal surgery – Uncomplicated head and neck Surgical Risk • High surgical risk: – Emergency surgery – Cardiac procedures – Aortic or vascular surgery – Anticipated prolonged surgery • Large fluid shifts or blood loss • Ex: Whipple, spinal surgery Electrocardiogram Significant ECG Findings • • • • Past myocardial infarction Left bundle branch block Bifasicular block Atrioventricular block – Mobitz-Type II or 3°AVB • Prolonged QT interval • Right ventricular hypertrophy Echocardiography • Displays 2-dimensional ultrasound images of the heart • Can be used to produce accurate assessment of the velocity of blood and cardiac tissue – Utilizes pulse wave Doppler ultrasound • Diagnostic uses: – – – – Wall motion abnormalities Valvular dysfunction (valve area and function) Septal defects Calculation of cardiac output and ejection fraction Echocardiography Types of Echocardiography • Transthoracic (TTE) • Exercise stress echo • Dobutamine stress echo • Transesophageal (TEE) Stress Testing • Used to evaluate myocardial perfusion during stress as compared to at rest • Diagnostic usefulness debatable! • Types of evaluation: – Exercise (a.k.a. treadmill) – Dobutamine or adenosine – Radiotracer • Tc99m Sestamibi (Cardiolite®) • Thallium Cardiac Catheterization • Invasive angiography of myocardial perfusion • Diagnostic usefulness: – Arterial occlusion – Thrombotic lesions – Aneurysmal enlargement • Concurrent procedures: – Percutaneous transluminal coronary angioplasty (PTCA) – Coronary artery stent placement – Dissection and stroke Stepwise Approach to Preoperative Cardiac Assessment Need for noncardiac surgery emergency Recent coronary evaluation no yes O.R. no Urgent or elective Coronary revascularization within 5 yrs no Postoperative risk stratification and risk factor management yes Recurrent symptoms or signs yes Recent coronary angiogram or stress test? Favorable result and no change in symptoms Unfavorable result and change in symptoms Clinical predictors Major Intermediate Minor or No O.R. Stepwise Approach to Preoperative Cardiac Assessment Minor or no clinical predictors Poor(<4METs) Moderate or excellent(>4METs) High surgical risk procedure Intermediate surgical risk procedure Noninvasive testing High risk low risk Consider coronary angiography Subsequent care by findings and treatment results O.R. Postoperative management Minor clinical predictors: •Advanced age •Abnormal ECG •Rhythm other than sinus •Low functional capacity •History of stroke •Uncontrolled systemic hypertension Stepwise Approach to Preoperative Cardiac Assessment Intermediate clinical predictors Poor (<4METs) Moderate or excellent (>4METs) High surgical risk procedure Noninvasive Low risk testing Intermediate or low surgical procedure O.R. Low surgical risk procedure Postoperative risk stratification and risk factor reduction High risk Consider coronary angiography Subsequent care dictated by findings and treatment results Intermediate clinical predictors: •Mild angina pectoris •Prior MI •Compensated or prior CHF •DM Stepwise Approach to Preoperative Cardiac Assessment Major clinical predictors Major clinical predictors: •Unstable coronary syndromes •Decompensated CHF •Significant arrhythmias •Severe valvular disease Delay or cancel noncardiac surgery Coronary angiography Medical management and risk factor modification Subsequent care dictated by findings and treatment results Summary • How has the information gained in the pre-op evaluation changed your plan? • Is there anything further that you need to deliver a safe anesthetic? • Should you proceed with the case? • Don’t forget to monitor closely. • Have a back-up plan ready to implement.