Preoperative We Need to Know About

8/17/2019 Preoperative We Need to Know About

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Mayo School of Continuous Professional Development

©2011 MFMER | 12!""1#1

Pre#operative $estin%& 'hat is Really (ee)e)*

Ro+ert ,- .ohr/ MD FCP

South Daota CP Meetin%Septem+er 12/ 201

Dea)oo)/ SD


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Disclosures

3 (o financial )isclosures3 (o )iscussion of 4off la+el5 use of )ru%s


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6+7ectives

3 $o un)erstan) the rationale for evi)ence +ase)

preoperative testin%3 $o un)erstan) hen preoperative testin% is not

in)icate)8Most of the time9


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$o)ay:s 6utline

3 ;ac%roun)

3 Cases3 Discussion


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>s Preoperative $estin% a Pro+lem

3 ?es/ an) a +i% one3 >t astes valua+le resources3 >t e@poses patients to nee)less +loo) or an)

proce)ures

3 >t can creat an@iety for patients3 >t is costly8A0 +illiont is still a pro+lem#

sur%eonsanesthesiolo%istspreoperative )irectors

3 GatH/ nesth nal% 20113 RoiHen/ nesthesiol Clin (orth m 1!


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'hy Shoul) e $est*

3 $o i)entify or verify a con)ition hich coul) affect

anesthetic care3 $o help formulate or mo)ify anesthetic care of the

patient

3 Can the i)entifie) ris +e miti%ate)*3 Car)iac3 Pulmonary3 Dru%s3 ;lee)in%/ clottin%/ an) +ri)%in%

3 DM3 6ther Bliver/ i)neys/ en)ocrine

nesthesiolo%y 2012 BS Practice )visory for PreanesthesiaEvaluation


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,o Do ?ou Deci)e*

3 My last case Bthat ent south8

3 'hat my chief resi)ent tol) me to )o

3 E;M

3 Iui)elines8hich ones*

3 ,ospital policies8ho )evelops*


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Case 1

3 ?ou are ase) to see a J year ol) male for apreoperative me)ical evaluation- ,e issche)ule) for an in%uinal hernia repair ne@tee

3 ,is past me)ical history is nota+le only foro+esity B;M> 2 an) an uncomplicate) 6R>F ofa ti+#fi+ fracture at a%e 1J

3 ,e has never use) to+acco an) has 1#2 oH ofEt6,


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Case 1

3 ,e )oes construction or an) can easilye@cee) J ME$S of activity

3 ,e taes only a men:s multivitamin )aily

3 ,is e@am is noteorthy for his ei%ht an) aneasily re)uci+le R in%uinal hernia-


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Case 1

3 For preoperative testin% you or)er&3 n ECI an) C;C3 ; n ECI an) creatinine

3 C C;C an) creatinine3 D C;C an) >(R3 E (o tests


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Case 2

3 ?ou are ase) to see a ! year ol) female for apreoperative me)ical evaluation- She issche)ule) for an elective R $G tomorro

3 ,er past me)ical history is noteorthy forhypertension/ hyperlipi)emia/ o+esity/ DKD/ an)coronary artery )isease for hich she receive)2 )ru% elutin% stents J years a%o-


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Case 2

3 She has ha) a hysterectomy an) carpel tunnelrepair in the past ithout complication

3 ,er me)ications inclu)e lisinopril


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Case 2

3 ,er e@am reveals a ;P of 1J of!/ an) a mo)erate effusion on the R nee-Car)iovascular an) pulmonary e@ams arenormal

3 ?ou have an ECI availa+le B(SR/ non#specificlateral S$ chan%es from months a%o

3 ?ou have no other la+oratory )ata availa+le


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Case 2

3 Preoperatively you or)er&3 n ECI/ electrolytes/ creatinine3 ; Electrolytes/ creatinine

3 C n ECI/ electrolytes/ creatinine/ an) >(R3 D Electrolytes/ creatinine/ ECI/ an) a

)o+utamine stress Echo

3 E (o testin%


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Case

3 ?ou are ase) to see a " year ol) male for apreoperative me)ical evaluation- ,e issche)ule) for a R $S ne@t ee

3 ,is past me)ical history is si%nificant forhepatitis C +ut no history of cirrhosis- ,e ha)an in%uinal hernia repaire) as a chil) ithoutcomplication- ,e has ha) no recent follo up

re%ar)in% his liver-3 Me)ications inclu)e a multivitamin


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Case

3 ,is functional capacity is e@cellent/ e@cee)in% JME$S

3 ,is e@am is normal e@cept for a )ecrease)

ran%e of motion of his R shoul)er


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Case

3 Preoperatively you or)er&3 n ECI/ electrolytes/ creatinine3 ; Electrolytes/ .F$/ creatinine

3 C .F$/ >(R/ creatinine3 D >(R an) aP$$3 E (o stu)ies


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Case J

3 ?ou are ase) to )o a pre#operative evaluationfor a 2 year ol) female colle%e +aset+allpoint %uar) for repair of a torn . C.

3 She reports herself to +e in e@cellent health/ noprior sur%ery/ havin% irre%ular menstrualperio)s felt secon)ary to her level of physicalactivity

3 She is tain% no me)icines an) her physicale@am is normal e@cept for her . nee


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Case J& ?ou or)er pre#operatively

3 C;C

3 EGI

3 P$


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Shoul) e test*


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Preoperative testin%& Shoul) e )oanythin%*

3 (arr et al-3 Ran)omiHe) 10JJ patients ho ha) (6

preoperative testin%/ a%e 0#"/ me)ian 21

3 Deaths& 0-0N3 1! intraoperative la+ testsO a+normal3 (o testin% )one intraoperatively or

postoperatively chan%e) mana%ement3 (arr- Mayo Clin Proc 1!O!2&"0"#"0


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Shoul) e $est*

3 Preoperative testin% shoul) +e )ictate) +y thepatient:s clinical con)ition an) a+normalfin)in%s on history or e@am

3 Preoperative testin% is (6$ >(D>C$ED unlessthere is a specific reason to perform the testan) the result ill chan%e mana%ement/ ormiti%ate perioperative ris


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$he Preoperative ECI

3 (o prospective/ ran)omiHe) clinical controlle)trials

3 (o %oo)/ prospective outcome )ata for or a%ainst

3 .ots of retrospective revies/ case series/ cohortstu)ies

3 .ots of complicate)/ conflictin% consensusstatements re%ar)in% pre#operative ECI

3 Main car)iovascular ris assessment %ui)elinesuse ECI to ris stratify


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Pre#op ECI

3 $he prevalence of an a+normal ECI increasesith a%e ith up to !"N of people ol)er than !"havin% an a+normal ECI

3 $here is evi)ence su%%estin% poorer outcomes inpatients ith a+normal ECIs3 RR J-" B-#-0 of )eath3 ,oever/ a+solute ris re)uction only 0-"N

ith lo an) interme)iate ris sur%ery(oor)Hi7- m K Car)iol !B!& 110#110


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ECIs*

3 Conflictin% recommen)ations amon%stconsensus or%aniHations

3 CCCS>3 ESC


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ECIs*

ECG YES

3 C symptoms Q 1

3 CD euivalent


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ECIs*

ECG NO

3 .o ris sur%ery an) lo ris patient

3 Cataract sur%eryECG MAYBE

3 .o ris patient an) interme)iate ris sur%ery

3 Ris factors an) lo ris sur%ery


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Coa%ulation Stu)ies*3 Coa%ulation stu)ies only as in)icate) +y ,P

3 'hat a+out hi%h ris sur%ery e-%- neurosur%ery&4Patient history as as pre)ictive as la+ testin% forall outcomes Ban) ha) hi%her sensitivity5

Seicean/ K (eurosur% 20123 Gnon h


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C;C*

3 ,P fin)in%s su%%estive of a+normality3 Gnon cytopenia3 Recent chemo

3 h


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Electrolytes/ Creatinine*

3 .ytes/ creatinine

3 Patients on )iuretics3 Patients ith non renal failure3 * Patients on )i%o@in


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CTR*

3 Freuent a+normalities ### 10#2-1N

3 Rarely influence mana%ement ### U 0-1#N

3 Pre)icta+le from ,P

3 'ho follos up on the a+normality* ### sourcefor misse) opportunity/ 4fallin% throu%h thecracs5

3 =aseen et al- Ann Intern Med - 200O 1JJ& "!"#"0


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l+umin*

3 Poerful pre)ictor of perioperativecomplications

3 Pulmonary complications increase)

3 >nfectious complications increase)3 'oun) healin% issues3 >n some settin%s the stron%est pre)ictor of

mor+i)ity an) mortalityIi++s K et al- Arch Surg - 1O1J&#J2


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l+umin*

3 Consi)er serum al+umin

3 >f mo)ifia+le ris factor present3 (D it oul) chan%e your perioperativemana%ement


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Ilucose*

3 (o %oo) evi)ence for or a%ainst

3 'ill it chan%e my mana%ement*3 'oul) > )elay sur%ery if it as hi%h*3 'oul) my perioperative mana%ement chan%e*


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.F$s*

3 Play it a%ain Sam8only if there is suspicion ofliver )isease on the +asis of history/ e@am/ orprevious liver function a+normality3 -nature-com(R/ +iliru+in/ creatinine in or)er to calculateME.D score hich pre)icts post operative

mortality )ue to liver )isease3 Iastroenterolo%y 200!O12&121#12


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Pre%nancy $estin%

3 20" omen of chil) +earin% a%e teste) +efore

elective am+ulatory sur%ery3 ! ha) V pre%nancy testin% B0-N3 Cost of pre%nancy )iscovere)& A2!

3 ll cancelle) their sur%ery3 2"" omen of chil) +earin% a%e teste) +efore

elective orthopae)ic sur%ery

3 " ha) V pre%nancy testin% B0-2N3 Cost of )iscovere) pre%nancy& A2!

nesthesiolo%y 1"

nesth nal% 200


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Pre%nancy $estin%

3 48the literature is ina)euate to inform patientsor physicians on hether anesthesia causesharmful effects on early pre%nancy- Pre%nancytestin% may +e offere) to female patients of

chil)+earin% a%e an) for hom the result oul)alter the patient:s mana%ement-5

nesthesia 2012 BS Practice )visory for PreanesthesiaEvaluation


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Case 1

3 ?ou are ase) to see a J year ol) male for apreoperative me)ical evaluation- ,e issche)ule) for an in%uinal hernia repair ne@tee

3 ,is past me)ical history is nota+le only foro+esity B;M> 2 an) an uncomplicate) 6R>F ofa ti+#fi+ fracture at a%e 1J

3 ,e has never use) to+acco an) has 1#2 oH ofEt6,


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Case 1

3 ,e )oes construction or an) can easilye@cee) J ME$S of activity

3 ,e taes only a mens multivitamin )aily

3 ,is e@am is note orthy for his ei%ht an) aneasily re)uci+le R in%uinal hernia-


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Case 1

3 For preoperative testin% you or)er&3 n ECI an) C;C3 ; n ECI an) creatinine

3 C C;C an) creatinine3 D C;C an) >(R3 E (o tests


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Case 2

3 ?ou are ase) to see a ! year ol) female for apreoperative me)ical evaluation- She issche)ule) for an elective R $G tomorro

3 ,er past me)ical history is note orthy forhypertension/ hyperlipi)emia/ o+esity/ DKD/ an)coronary artery )isease for hich she receive)2 )ru% elutin% stents J years a%o-


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Case 2

3 She has ha) a hysterectomy an) carpel tunnelrepair in the past ithout complication

3 ,er me)ications inclu)e lisinopril


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Case 2

3 ,er e@am reveals a ;P of 1J


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Case 2

3 Preoperatively you or)er&3 n ECI/ electrolytes/ creatinine3 ; Electrolytes/ creatinine

3 C n ECI/ electrolytes/ creatinine/ an) >(R3 D Electrolytes/ creatine/ an) a )o+utamine

stress Echo

3E (o testin%


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Case

3 ?ou are ase) to see a " year ol) male for apreoperative me)ical evaluation- ,e issche)ule) for a R $S ne@t ee

3 ,is past me)ical history is si%nificant forhepatitis C +ut no history of cirrhosis- ,e ha)an in%uinal hernia repaire) as a chil) ithoutcomplication- ,e has ha) no recent follo up

re%ar)in% his liver-3 Me)ications inclu)e a multivitamin


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Case

3 ,is functional capacity is e@cellent/ e@cee)in% JME$S

3 ,is e@am is normal e@cept for a )ecrease)

ran%e of motion of his R shoul)er


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Case

3 Preoperatively you or)er&3 n ECI/ electrolytes/ creatinine3 ; Electrolytes/ .F$/ creatinine

3 C .F$/ >(R/ creatinine3 D >(R an) aP$$3 E (o stu)ies


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Case J& ?ou or)er pre#operatively

3 C;C

3 EGI

3 P$


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$ae ,ome Points

3 ALL PRE6PER$>E $ES$>(I S,6W.D ;ED>C$$ED ;? ?6WR ,>S$6R? (D ETM


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$han ?ou

3 =WES$>6(S

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Preoperative We Need to Know About