Preoperative Evaluation

Ian Magonigal, M.D.

Objectives
Understand the need for accurate preoperative assessment. Identify what factors contribute to surgical and anesthetic risk. Identify what pieces of the history and physical exam are most pertinent in the preoperative evaluation. Understand when diagnostic studies or treatments should be undertaken preoperatively for both cost effectiveness and patient safety. Understand the preoperative care of patients with cardiac disease undergoing non-cardiac surgery.

Goals of pre-op evaluation

Risk stratification and minimization. Inform patient of risks and obtain consent. Educate patients and manage perioperative expectations. Give perioperative instructions, ie. NPO after midnight, which meds to take, etc. Appropriate surgical and anesthetic planning. Improving patient safety. Assess need for optimizing health prior to surgery. In other words, troubleshooting.

Questions that must be answered

Is the patient in optimal health? Can or should the patients physical or psychological health be improved prior to surgery? Are there any medical problems or medications that may unexpectedly influence perioperative events? If so, what further tests or interventions are needed?

History
Detailed history is essential. 56% of correct diagnosis in medical clinics made with history alone, improves to 73% with addition of physical exam. These numbers are even greater in patients with cardiovascular disease.

History
Demographic data
Age sex weight in kg

Type of surgery
Site side

History of present illness, brief targeted

History
Allergies
Drugs FoodsPeanuts, eggs Latex Description of symptoms is key!!

History
Medication list with dose and frequency. Be aware that certain drugs can have adverse interactions and effects perioperatively. Ask about OTC meds and herbal supplements as these can also have significant interactions.

History
Social HistoryParticularly the vicesDrugs, Alcohol, Smoking. Other social history as the situation dictatesie. Peds, ambulatory surgery (pt needs a ride home), incarceration, etc.

History
Medical History Surgical/Anesthetic History
Inquire about perioperative complications. History of Difficult Intubation History of Malignant Hyperthermia, even in relatives.

History--Pulmonary
Exercise Tolerance Dyspnea and Orthopnea AsthmaSeverity, rescue inhaler frequency, Hx of hospitalization or intubation COPDHome O2 requirement, recent PFTs Pneumonia or recent respiratory infection SmokingPack years, Encourage quitting Peripheral vascular disease Obstructive Sleep Apnea Snoring Daytime sleepiness Obesity HTN

History--Cardiac
Exercise Tolerance Hyperlipidemia Hypertension CAD-angina,MI,CABG, angioplasty, stents, recent Stress test, Echo, or Cardiac Cath data Valve Disease-Particularly Aortic and Mitral Valve disease Arrhythmias-Atrial vs. Ventricular, Pacer or AICD Congenital Heart Disease History of Congestive Heart Failure

History--Neuro
TIA or stroke Seizure d/o, when was the last one, what is the character of seizures. Serum drug levels of anticonvulsants rarely needed unless poorly controlled. Neuromuscular disease-ie. Duschennes, Myotonic Dystrophy, or Myasthenia Gravis; all are high risk of post op respiratory complication. Numbness or Weakness-crucial to accurately document prior to surgery.

History--Renal
Renal function-consequences anemia, metabolic disturbances. Classify CKD and verify baseline serum creatinine ESRD-Dialysis Schedule (should be dialyzed within 24 hrs of elective surgery, note location and type of dialysis catheter; oliguric or anuric; right or left arm precautions, Transplant patients
Immunosupression Steroids Avoid nephrotoxic drugs

History--Hepatic
Hepatitisinflammation of hepatocytes, caused by drugs, alcohol, viruses (A-E), or autoimmune disease. CirrhosisConsequences include portal HTN, esophageal varices, ascites, pleural effusions, protein and clotting factor deficiencies, spontaneous bacterial peritonitis. Many drugs used perioperatively are have hepatic pathways involved in their metabolism

History--Hematologic
Bleeding disorders-Consider situations where bleeding occurs easily or if clotting occurs too easily. vWD, Hemophilia, thrombocytopeniaetc. Consider active use of warfarin, heparins, platelet inhibitors, etc. and how they may need to be stopped before surgery and regional or neuraxial anesthesia. AnemiaWhat is the etiology? Is the patient likely to have significant intraop blood loss

HistoryEndocrine
DiabetesInsulin management perioperatively; sequelae neuropathy, nephropathy, gastropathy, cardiovascular disease. Thyroidgoiters can cause airway compression Adrenal insufficiency

History--Psychiatric
Is the patient competent to consent? Will the patient be able to cooperate? Drug interactions

HistoryOdds and Ends

Chance of pregnancy, LMP GERDIs it well controlled with medications. History of motion sickness Cancer-Radiation (especially to the neck) or recent chemotherapy (immunosuppression or anemia)

History in an Emergency
AMPLE History
Allergies Medications Past Medical/Surgical/Anesthesia history Last meal Events leading to the need of emergent surgery

Physical Exam
Should be thorough but focused. Of greatest concern are airway, heart, lungs, and neurologic status. Unless your working for a urologist. Start with the VitalsBP, HR, RR, Temp, Height, and Weight. Document baseline data.

Physical Exam--Airway
Mouth opening Mallampati Classification, Large tongue, thick neck Presence of facial hair ROM of cervical spine Teeth-Document missing or loose teeth, dental hardware, or presence of dentures. Tracheal deviation, cervical masses

Mallampati Classification

Physical Exam--Cardiac
Auscultation for murmurs, rubs, gallops, or rhythm disturbances. Evaluate for JVD or other signs of volume overload such as edema.

Physical Exam--Pulmonary
Ausculatation for wheezing, rhonchi, and rales. If youre really gung-ho percuss and check for fremitus. Note the work of breathing and use of accessory muscles.

Physical Exam--Neuro
Mental Status Cranial nerve function Cognition Peripheral sensorimotor function

Physical Exam--Abdomen
Distension Masses Ascites May dispose patient to reflux, vomiting, or may compromise ventilation. Obesity also affects ventilation

The most important thing

Document Document Document

ASA Physical Status

ASA 1-Healthy patient ASA 2-Mild systemic disease, no limitation of daily activities ASA 3-Severe systemic disease, limits activity though not incapacitating ASA 4-Severe disease that is a constant threat to life. ASA 5-Moribund patient not expected to survive 24 hours with or without operation. ASA 6-Brain dead organ donor

Dripps-American Surgical Association Classification

Class IHealthy patient, limited procedure Class IIMild to moderate systemic disturbance Class IIISevere systemic disturbance Class IVLife threatening disturbance Class VNot expected to survive, with or without surgery

Laboratory Studies
Routine labs rarely helpful. Let the patients history, risk profile, and the type of procedure guide your decision making. You will rarely be criticized for making a judgement call and being cautious and ordering additional teststhough if this is routine and unwarranted it is a waste of time and moneywhich is very easy to criticize.

Labs continued
Start by reviewing available datathe test you want may have already been done. Ask yourself, Will this test change my perioperative management? The answer to whether or not to order the test will be the same.

Labs continued
H/HNo universally accepted minimum. May need higher number to prevent ischemia in pts with CAD. If anemia with no apparent cause may need work up prior to surgery Not needed in healthy patients undergoing minimally invasive or low risk procedures.

Labs continued
Platelet countIf history positive for easy bruising, excessive bleeding from gums, or family history of bleeding d/o Low counts may postpone surgery, less than 100K may negate neuraxial anesthesia or analgesia.

Labs Continued
Coagulation studiesPT/INR for pts taking warfarin, with hepatic dysfunction, or severe systemic illness. Also needed if pts will need post op anticoagulation. PTT in patients on heparin

Labs continued
Serum chemistriesNot routinely needed except in certain cases, ie. Chronic renal, cardiovascular, hepatic or intracranial disease, diabetes, morbid obesity, or patients on diuretics, digoxin, or steroids. HypokalemiaCommon with diuretics. Above 2.8 usually finein patients taking Digoxin correction is advisable HyperkalemiaCommon in ESRD. Affects choices of fluids and meds. If greater than 6 may need to delay surgery and treat.

ECG
Recommendations for Preoperative Resting 12-Lead Electrocardiogram Class I A preoperative resting 12-lead ECG is recommended for patients with at least one clinical risk factor* who are undergoing vascular surgical procedures A preoperative resting 12-lead ECG is recommended for patients with known congestive heart failure, peripheral arterial disease, or cerebrovascular disease who are undergoing intermediate-risk surgical procedures Class IIa A preoperative resting 12-lead ECG is reasonable in persons with no clinical risk factors who are undergoing vascular surgical procedures

ECG
Class IIb A preoperative resting 12-lead ECG may be reasonable in patients with at least one clinical risk factor who are undergoing intermediate-risk operative procedures Class III Preoperative and postoperative resting 12-lead ECGs are not indicated for asymptomaticpersons undergoing low-risk surgical procedures
Class I recommendations: the procedure should be performed; class IIa: it is reasonable to perform the procedure; class IIb: the procedure may be considered; class III: the procedure should not be performed because it is not helpful.

CXR
Rarely necessary Rarely helpful Only when clinically indicated

PFTs
Primarily used in patients with known pulmonary disease or those undergoing thoracic surgery. Not typically a good assessment of perioperative risk except in patients undergoing lung resection.

Cardiac Risk Assessment

The goals of preoperative evaluation are to Identify the risk for heart disease based on risk factors Identify the presence and severity of heart disease from symptoms, physical findings, or diagnostic tests Determine the need for preoperative interventions Modify the risk for perioperative adverse events

Cardiac Risk Stratification

Cardiac Risk* Stratification for Noncardiac Surgical Procedures

Risk Stratification

Procedure Examples

Vascular (reported cardiac risk often more than 5%) Intermediate (reported cardiac risk generally 1% to 5%)

Aortic and other major vascular surgery, Peripheral vascular surgery Intraperitoneal and intrathoracic surgery, Carotid endarterectomy, Head and neck surgery, Orthopedic surgery, Prostate surgery Endoscopic procedures, Superficial procedure, Cataract surgery, Breast surgery, Ambulatory surgery

Low (reported cardiac risk generally less than 1%)

*Combined incidence of cardiac death and nonfatal myocardial infarction. These procedures do not generally require further preoperative cardiac testing.

METS

ECHO

Pulmonary Risk Factors

Second most common cause of serious surgical/anesthetic morbidity behind adverse cardiovascular events. Pulmonary complications occur in 5-10 percent of patients undergoing nonthoracic surgery. As high as 22% in high risk patients

Pulmonary Risk Factors

Summary