Preoperative evaluation

1. PRE OPERATIVE EVALUATION
Moderators - Dr. MV Kalasuramath sir
- Dr. Raina D’souza mam
Presentor – Dr. Mohammed Ameen

2. Cardiovascular and pulmonary complications continue to account for
major morbidity and mortality in patients undergoing noncardiac
surgery. Emerging evidence-based practices dictate that the internist
should perform an individualized evaluation of the surgical patient to
provide an accurate preoperative risk assessment and stratification that
will guide optimal perioperative risk-reduction strategies.

3. • Individualized evaluation of the surgical patient to provide an accurate
preoperative risk assessment and stratification.
1. Cardiovascular risk assessment
2. Pulmonary risk assessment
3. Nutritional status
The purpose of a preoperative evaluation is not to “clear” patients for
elective surgery, but rather to evaluate and, if necessary, implement
measures to prepare higher risk patients for surgery.

4. • Risk assessment of a patient planned for a surgery depends on
- Type of surgery
- History and clinical examination of the patient with focus on risk
factors for cardiovascular and pulmonary complications.

5. • STANDARDIZED PREOPERATIVE QUESTIONNAIRE:
1. Age, Sex, Height, Weight and BMI.
2. H/o smoking tobacco, alcohol consumtion.
3. Any medications? ( anticoagulant and antiplatelets)
4. H/o Heart disease, CKD, CLD, DM, RA
5. H/o chronic cough with expectoration, SOB.
6. H/o orthopnea and PND.
7. Family history of IHD.
8. If female, Pregnant? LMP?
9. ECG/ 2d ECHO finding. Routine investigation.
10. General physical examination and vitals signs
11. systemic examination
12. Opinion by physician.

6. Standardized Preoperative Questionnaire

8. Risks of various surgical procedures for MACEs
(Major adverse cardiovascular events)

9. • Risks associated with various surgical procedures can be calculated
using
- College of Surgeons’ National Surgical Quality Improvement Program
(NSQIP) risk calculator (http://www.riskcalculator.facs.org)
- Revised Cardiac Risk Index (RCRI).

10. NSQIP
• Five predictors of perioperative myocardial infarction (MI) and cardiac
arrest based on
- Increasing age
- American Society of Anesthesiologists (ASA) class
- Type of surgery
- Dependent functional status
- Abnormal serum creatinine level.

11. *For emergency case, the mortality rate doubles.

12. • Revised Cardiac Risk Index (RCRI)

14. Patient related predictors for cardiovascular risks
Major clinical predictors
Myocardial infarction ≤6 weeks previously
Unstable angina
Decompensated congestive heart failure
Significant arrhythmias (e.g., causing hemodynamic instability)
Severe valvular disease (e.g., aortic or mitral stenosis with valve area < 1.0 cm2)
Intermediate clinical predictors
Mild angina pectoris
Myocardial infarction > 6 weeks previously
Compensated congestive heart failure
Diabetes mellitus

15. Minor clinical predictors
Advanced age
Abnormal electrocardiogram
Cardiac rhythm other than sinus
Low functional capacity, history of stroke, uncontrolled hypertension

18. • In case of Drug eluting stent placement, antiplatelets have to be given for
atleast 6months and elective non cardiac surgery delayed by 6 months.
• In case of Bare metal stent placement, antiplatelets have to be given for
atleast 1 month and elective non cardiac surgery delayed by 1 month.
• In case of Angioplasty without stent placement, 14 days of antiplatelet
therapy have to be given.
• Proceed to surgery with aspirin or, if indicated, with dual antiplatelet
therapy. If discontinued, give a single Aspirin 325mg immedediately pre
operatively.
• Peri operative beta blockers indicated in patients with myocardial ischemia
on stress test and RCRI is >3.
PREVENTIVE STRATEGIES TO REDUCE CARDIAC RISK

19. Pulmonary risk assessment
• Pulmonary complications include
- respiratory failure
- pneumonia, atelectasis, bronchospasm, or
- an exacerbation of COPD.
• Many postoperative pulmonary complications are due to exaggerations of
the usual postoperative changes in pulmonary function:
- decreased lung volumes
- diaphragmatic dysfunction
- V/Q mismatch, hypoventilation, hypoxia and impaired defense
mechanisms.

20. Risk factors for pulmonary complications

21. Elevated risk for pulmonary complications
- emergency or prolonged (3–4 h) surgery
- aortic aneurysm repair
- vascular surgery
- major abdominal, thoracic, neurologic, head, or neck surgery and
- general anesthesia should be considered to be at elevated risk for
postoperative pulmonary complications.

22. Risk modifications