Pre-op Evaluation

Reem Issa
Preoperative Evaluation
1. Detect unrecognized disease
2. Evaluate factors that increase risk of surgery
3. Propose strategies to reduce this risk
• Adverse outcomes of surgery:
• Death
• Myocardial infarction
• Respiratory failure •
• Heart failure
• Arrythmias (atrial fibrillation)
• Bleeding
Preoperative evaluation
• History and physical exam
• Blood tests: CBC, chemistries
• EKG
• Cardiac stress test
• Chest x-ray
• Pulmonary function tests
Preoperative Evaluation
• Cardiovascular Assessment
• The #1 limiting factor prior to surgery is a history of cardiovascular
disease.
1. History and physical exam
• Acute coronary syndrome or acute heart failure
• Treat or stabilize ACS or HF prior to surgery
2. EKG
• Usually done prior to surgery
• Not absolutely necessary in completely healthy patients
3. If no evidence of ACS or HF → proceed to surgery
• No stress testing or other cardiac testing indicated
• One exception: elective vascular surgery
Preoperative Evaluation : Cardiac
• A patient who has a history of cardiac disease, regardless of age,
must have:
i. EKG.
ii. Stress testing to evaluate for ischemic coronary lesions.
iii. Echocardiogram for structural disease and to assess ejection
fraction.
Ejection fraction:
Ejection fraction <35% (normal 55%) poses prohibitive cardiac risk for
elective non-cardiac operations.
Incidence of peri-operative myocardial infarction (MI) could be as high as
75-85%, and mortality for such an event as high as 50-90%.

Jugular venous distention:

Jugular venous distention, which indicates the presence of CHF, is the
worst single finding predicting high cardiac risk.
If at all possible, treatment with ACE inhibitors, beta-blockers, digitalis,
and diuretics should precede surgery.

Recent Ml is the next worse predictor of cardiac complications:

Operative mortality within 3 months of the infarct is 40% but drops to 6%
after 6 months.
Therefore, delaying surgery longer than 6 months from MI is the best
course of action.
• Goldman's index of cardiac risk assigns the following.
1. 11 points to jugular venous distention (evidence of CHF).
2. 10 points to recent MI (within 6 months).
3. 7 points each to either premature ventricular contractions (> 5
per min) or a rhythm other than sinus rhythm.
4. 5 points to age >70.
5. 4 points to emergency nature of surgery.
6. 3 points each to either aortic valve stenosis, poor medical
condition, or surgery within the chest or abdomen.
• The risk of life-threatening cardiac complications is :
1. Only 1% with total score 0-5.
2. The risk becomes 5% if the points 6-12.
3. Increases to 11% with 13-25.
4. Reaches 22% when the points >25.
 Pulmonary risk:
Smoking : the most common cause of increased pulmonary risk
compromised ventilation (high PCO2, low forced expiratory volume
in 1 second [FEV1]), rather than compromised oxygenation.
- The smoking history, or the presence of chronic obstructive
pulmonary disease (COPD), should lead to evaluation.
- Start with pulmonary function tests, and, if abnormal, obtain an
arterial blood gas.
- Cessation of smoking for 8 weeks and intensive respiratory
therapy should precede surgery.
Liver Disease
• Surgery usually acceptable for patients with cirrhosis
Child Pugh class : predictors of mortality.
• Points for encephalopathy, ascites, bilirubin, albumin, PT
• Class assigned based on points
• Classes A and B=lower risk
• Highest risk= class C
MELD score
• Point system using bilirubin, creatinine, INR
• Estimates 3-month mortality
• MELD Score >15 = higher risk
Hematology
• High risk of bleeding with low platelets or coagulopathy
• Goal platelets: > 50,000
• Normal platelet count: 150,000 to 450,000/μL
• Bleeding risk usually not increased unless<50,000
• Goal INR < 1.5
• Normal INR=1.0
• Bleeding risk increased INR>1.5
• Goal Hgb>7g/dL (hct>21)
• Adverse outcomes below this level
• Emergency surgery
• Risk off or going surgery extremely high
• Very little role for preoperative evaluation
• Classic example: trauma
Renal Risk
• Patients with known renal disease must be kept adequately
hydrated;
• otherwise, hypoperfusion of the kidneys can lead to increased
mortality.
• If a preexisting renal disease is present, volume loss during
surgery will adversely and acutely affect renal function.
• Subsequent renin-angiotensin system activation will lead to
further constriction of renal vasculature and make the creatinine
clearance even lower.
Anticoagulants and anti platelets
1. Warfarin
• Hold 4-5 days before surgery
• Goal INR < 1.5
2. Heparin drip
• Half life 60 to 90 minutes
• Discontinue hours before surgery
3. LMWH
• Last dose 24 hours before surgery
• Last dose 50% normal dose
4. Aspirin, clopidogrel, ticagrelor, prasugrel
• Discontinue 5 to 7 days before surgery
• Oral hypoglycemic agents
 Sulfonylureas
 Hold morning of surgery
 Metformin
 Associated with lactic acidosis with renal hypoperfusion
 Hold morning of surgery
 Insulin
 Continue, but decrease dose morning of surgery(NPO