Pre-Operative Medical Assessment : in Healthy Patients Mazen Badawi Medical Resident 1/2010.
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Transcript of Pre-Operative Medical Assessment : in Healthy Patients Mazen Badawi Medical Resident 1/2010.
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Pre-Operative Medical Assessment :in Healthy Patients
Mazen BadawiMedical Resident1/2010
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Introduction
Goal : decrease risk of surgery : Identify unrecognized co-morbid disease
and risk factors for medical complications of surgery
Optimize preoperative medical condition Understand, recognize, and treat potential
complications Work as a team with surgeon and
anesthesiologist
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Questions to answer in each case
Why was the consult requested?What is the benefit to the patient of the
proposed procedure?May one substitute a lower risk
procedure?What are the known risks?What is the balance of risk-benefit?What are the patient's goals?
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Things to remember
Keep no. of recommendations to a minimumClarify the specific reason for the consult
requestAdherence to recommendations is greater for
consults requested earlyFollow patients through the postoperative
period Don’t say “cleared” , say “Average risk”
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Anesthesia factor
Patient and surgical factors are more important risk predictors than anesthetic considerations (JAMA 1988;260:2859)
ASA (Dripps) Classification is a powerful predictor of overall perioperative mortality. It also predicts cardiac and pulmonary morbidity
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ASA classification
ClassSys. Disturb.Mortality
1Healthy patient with no disease outside of the surgical process <0.03%
2Mild-to-mod. systemic disease caused by the surgical condition or by other pathologic processes
0.2%
3Severe disease process which limits activity but is not incapacitating 1.2%
4Severe incapacitating disease process that is a constant threat to life 8%
5Dying patient not expected to survive 24 hours with or without an operation
34%
ESuffix to indicate an emergency surgery for any class Increased
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Anesthesia risk
Drugs : Stress response, interaction, SE
Mechanical and operational errors
Cardiac : • Inhalational agents are mycardial depressant
Accentuated hypotensive response…
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Anesthesia risk
Pulm. :• Vital capacity decreased by 50%• Decreased Fun.Resd.C below closing volumes
atelectasis and V/Q mismatch• Decreased mucociliary clearance• Depression of response to hypoxia and
hypercarbia• Diaphragmatic dysfunction
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Anesthesia risk
Spinal vs. epidural : No difference in cardiac mortality. Probable decrease in the risk of pulm.
complications
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Assessment of healthy indiv.
High false +ve , ?QuestionnaireIf all answered “NO” no need for
complete Hx, Ex
Wilson, ME, Williams, MB, Baskett, PJ, et al. Assessment of fitness for surgical procedures and the variability of anaesthetists' judgments. Br Med J 1980; 1:509
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Questionnaire for healthy people
13 questionsGeneral : past serious illnessesResp, CVS: exertional SOB, anginal chest
pain, cough, wheeze, ankle swellingRx: pills in the last 3 months (incl. excess
alcohol)AllergiesAnesthetic in last 2 months, problem with
anesthesia (pt. or relative)
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Q. To determine need for anesth. App.
17 Q Resp, CVS : SOB, chest pain when climbing 2 flight
of stairs, hx of heart attack, angina, HF, asthma, bronchitis
Renal disease Neuro: stroke, epilepsy Anesthesia : previous problems in family Thyroid disease Liver disease Joint pain, stiffness esp. neck and jaw DM and insulin use
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Clinical assessment
1- Exercise capacity :
poor if symptomatic with walking 4 blocks or climbing 2 flights of stairs doubles the risk for post op. complications, CVS complications but not pulm.
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Clinical assessment
2- Medication use :
Including OTC, complementary, alternative
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Clinical assessment
3- Obesity : surprisingly, it is not a risk factor for most major adverse postoperative outcomes there was no difference in postop.
complication rates between patients whose BMI was > or < 30 incl. pulm.
But it still a major risk for postop. DVT & PE
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Clinical Assessment
3- Age: <60 yr 1.3% mortality
80-89 yr 11.3%Age 70 as turning point
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Labs
Routine lab inv. Aren’t usually recommended in healthy indiv.
In a study of 2000 patients undergoing elective surgery, 60 %of routinely ordered tests would not have been performed if testing had only been done for recognizable indications; only 0.22 % of these revealed abnormalities that might influence perioperative management
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Chest X-Ray
ECG
CBC
Type/Screen
INR/PT
LytesUrea
Creat.Blood
glucose
AST/ALP/BILI
Sickle Cell
ScreenMF
Surgical Procedure on Type & Screen List No of Units
Age: <45
45-70
>70
Cvs, HTN
Pulmonary disease
Malignancy
Hepatic disease/ETOH
Renal disease
Blood disorders
Diabetes
Smoking >20 pack years
Use of Digoxin, Diuretics, ACE inhib.
Use of Steroids
Use of Anticoagulants
CNS disease
Sickle Risk*
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CBC
Anemia is present in 1% of asymptomatic ppl
In a study of 2000 pt, 30 days mortality= Pre op. Hb >= 12 1.3% mort. Pre op. Hb < 6 33.3% mort.
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CBC
Conclusion: CBC is recommended in:
All pt. >65 yr before major surgery All pt. <65 yr before major surgery with
expected significant blood loss All pt with symptoms of anemia before
minor surgery
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Electrolytes
Frequency of unexpected electrolyte abnormalities is low, 0.6%
No solid relation of abnormalities with periop. complications
Hints easily collectable from hx routine electrolyte determinations are
NOT recommended
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Renal funct.
Mild to moderate renal impairment is usually asymptomatic
High Cr among asymptomatic patients with no history of renal disease is only 0.2% ,rises in > 46 yrs to reach 9.8%
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Renal funct.
Ass. Of Cr >177 with cardiac, pulm., and post op mortality
Cr level is recommended esp. in >50 yr Hypotension expected Nephrotoxic Rx
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B.S
25% of >60 yr have abnormal b.s level.incidence of asymptomatic hyperglycemia is
unknown. No relationship between op. risk and DM
except in vascular & CABG (but not asymp. hyperglycemia)
routine measurement of b.s is not recommended in healthy ppl before surgery
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LFT
Only 0.3% of healthy ppl. Have abnormal LFTs
routine LFT pre op. in healthy ppl isn’t recommended
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Hemostasis
routine preoperative tests of hemostasis are NOT recommended.
should be restricted to patients with a known bleeding diathesis or an illness associated with bleeding tendency
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Urinalysis
Done to: identify unsuspected renal disease UTI
It is not necessary for the detection of asymptomatic renal disease if a serum creatinine measurement is Normal
relationship between asymptomatic UTI and surgical infection is unclear
not recommended as routine
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ECG
Guidelines : Men > 45 years Women > 55 years Known cardiac disease Clinical evaluation suggesting the possibility of
cardiac disease Patients at risk for electrolyte abnormalities, such
as diuretic use Systemic disease associated with possible
unrecognized heart disease, such as DM, HTN Patients undergoing major surgical procedures
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CXR
Recommended in: >50 yr undergoing major surg. Suspected cardiac or pulm. disease
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PFT
not indicated for healthy patients prior to surgery
reserved for patients who have SOB that remains unexplained after careful clinical evaluation
Clinical findings are more predictive of the risk of postop. Pulm. complication than are spirometric results : decreased breath sounds, prolonged expiratory phase, added sounds.
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Summary : for healthy pt.
screening questionnaire for all patients Hx of exercise tolerance for all patients Blood pressure and pulse for all patients Hx + Ex if one of the above is abnormal, in patients
over 60 years, or in those undergoing major surgery Pregnancy test for women who may be pregnant HCT for all patients undergoing surgery with
expected major blood loss and for patients 65 years or older undergoing major surgery irrespective of potential for perioperative blood loss
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Summary
Serum Cr if major surgery, hypotension is expected, nephrotoxic drugs will be used, or the patient is above age 50
ECG recommendations as above, unless obtained within the previous month
Chest x-ray for patients over 50 years undergoing major surgery, or those with suspected cardiac or pulmonary disease, unless one has been performed within the past six months
All other tests only if the clinical evaluation suggests a likelihood of disease
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Thank you..