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preoperative evaluation & management

Notes: - in general, proceed to urgent or emergency surgery without additional testing or medications - in general, obtain a personal & family medical history before elective surgery - frailty assessment in the elderly predicts postoperative complications [39] === preoperative medication management === - see perioperative management - also see preoperative medication management guidelines from the Mayo Clinic [34] === preoperative laboratory testing === - see preoperative laboratory testing === Cardiovascular risk for non cardiac surgery (also see cardiac stress testing) === 1) preoperative electrocardiogram - not indicated for asymptomatic patients ungoing low-risk surgery [11] - indicated for asymptomatic patients with known arrhythmia or cardiovascular disease & good performance status (> 4 METS) [11] - within 3 months adequate [37] 2) cardiac stress testing NOT needed for a) low-risk surgery [11] 1] endoscopic surgery 2] cataract removal 3] superficial surgery under local anesthetic 4] breast surgery 5] ambulatory surgery 6] except if a] unstable angina or myocardial infarction within 30 days b] decompensated heart failure c] unstable cardiac arrhythmia d] severe valvular heart disease [11] b) age < 55 years, no cardiac murmur, no preexisting illness c) recent (6 month-1 year) normal coronary imaging & no new symptoms d) stable angina e) emergent surgical intervention indicated f) wait at least 9 months after ischemic stroke or TIA prior to elective non-cardiac surgery [18] 3) preoperative cardiac stress testing reserved for patients with intermediate-risk or high-risk surgery when testing would influence management a) these are patients with low exercise tolerance & multiple major risk factors - minimum functional capacity that obviates the need for preoperative cardiac stress testing is 4 METS (walking up a flight of stairs or a hill) b) CT angiography is an alternative to stress testing but may overestimate risk [45] c) adequate exercise tolerance is defined as >= 4 METS without symptoms [11] 4) carotid ultrasound for asymptomatic carotid stenosis is not indicated - asymptomatic carotid bruit is not predictive or perioperative stroke [11] - carotid artery stenosis not associated with postoperative myocardial injury [20] - combining carotid endarterectomy with cardiac surgery in patients with > 70% but asymptomatic carotid stenosis is associated with more perioperative strokes than cardiac surgery alone [21] 5) major risk factors: a) congestive heart failure b) unstable angina c) myocardial infarction within 6 months d) critical aortic stenosis e) dysrhythmias, ventricular or supraventricular g) stroke within 2 weeks h) pulmonary hypertension [11] 6) other risk factor requring preoperative testing - coronary artery disease - cerebrovascular disease - chronic kidney disease - diabetes mellitus - heart failure. 7) signs/symptoms as risk factos: a) shortness of breath at rest or exertion b) chest pain or anginal equivalent c) prolonged palpitations, presyncope or syncope: d) pulmonary crackles e) increased jugular venous pressure f) gallop rhythm, irregular rhythm g) systolic murmur of aortic stenosis 8) risk associated with surgical site (descending risk) - vascular thoracic - orthopedic - abdominal - otolaryngolic - urologic, ophthalmic 9) Laboratory: - see preoperative laboratory testing - preoperative serum NT pro-BNP predicts postoperative cardiovascular events [31,45] 10) Management: a) surgery without further testing for low-risk patients - may include patients for orthopedic surgery - if no risk factors [11] - small area of reversible ischemia on nuclear stress testing [37] - exertional angina after 30 minutes of walking briskly resolving with rest [37] b) all usual cardiac & antihypertensive medications should be taken on the morning of surgery with a sip of water; continue statins in patients taking them [9] c) treat congestive heart failure until well compensated prior to surgery - exception: proceed with emergency surgery without delay - administration of loop diuretic while preparing for emergency surgery d) cardiac stress testing should be done only if the results of testing will affect management [11] e) estimated functional capacity as metabolic equivalents (METS) does not predict risk for MI or death at 30 days [29] f) non-invasive testing for intermediate risk patients - echocardiogram for suspected aortic stenosis - pharmacologic stress test prior to vascular surgery - pharmacologic stress test prior to orthopedic surgery with risk of major adverse cardiac event > 1% (exercise stress test not an option) [11] - exercise stress test before non-vascular surgery - poor choice for a patient with knee osteoarthritis [11] - preoperative electrocardiogram for asymptomatic patients with known cardiovascular disease & good performance status (> 4 METS) [11] g) MI within the last 6 months - postpone surgery if possible - cardiac catheterization with angioplasty may reduce cardiac risk to an acceptable level h) stroke: postpone elective surgery for at least 9 months after ischemic stroke [11,18] i) unstable angina - postpone surgery if possible - optimize medical management - cardiac catheterization, PCI < 90 days prior to surgery may increase cardiac risk [11] j) moderate to severe aortic stenosis - echocardiogram within 1 year or change in status [11] - critical aortic stenosis - consider valve replacement or valvuloplasty prior to elective procedure k) dysrhythmias - consider cardioversion for atrial fibrillation - target ventricular response for patients with chronic atrial fibrillation to undergo elective surgery is < 110/min [37] - see direct oral anticoagulant vs warfarin or perioperative anticoagulation if patient anticoagulated - sustained or complex dysrhythmias - rule out electrolyte & blood gas abnormalities - rule out MI, CHF exacerbation, PE l) rule out cardiac disease in patients with: - peripheral vascular disease - carotid stenosis m) perioperative beta-blocker reduces cardiac morbidity in patients with cardiovascular disease (see perioperative management) n) perioperative clonidine reduces mortality o) routine coronary angiography &/or coronary artery revascularization in patients with stable coronary artery disease NOT helpful before elective vascular surgery [5,6,9,11] p) delay elective surgery after PCI [9] - 1-4 weeks for recipients of PCI without stents - 4-6 weeks for recipients of PCI with bare metal stents - >= 3-6 months recipients of PCI with drug-eluting stents [36] - hold clopidogrel 5-7 days prior to surgery, continue low dose aspirin [36] - hold prasugrel 7 days & ticagrelor 3-5 days prior to surgery - witholding low-dose aspirin & clopidogrel may be reasonable if bleeding risk is extreme or consequences catastrophic, as with neurosurgery q) delay or cancel elective surgery for patients with pulmonary hypertension [11] - refer patient for evaluation of pulmonary hypertension === Bleeding disorders === 1) risk factors a) inherited coagulation disorders - hemophilia A & hemophilia B - von Willebrand's disease (vWD) b) acquired coagulation disorders - vitamin K deficiency - disseminated intravascular coagulation (DIC) - liver disease - drugs - warfarin - cefamandole c) quantitative platelet disorders - thrombocytopenia d) qualitative platelet disorders - aspirin & other non-steroidal anti-inflammatory drugs - clopidogrel (Plavix) - renal insufficiency, uremia 2) clinical manifestations: a) bleeding into soft tissues or retroperitoneum with hematoma suggests coagulation disorder b) mucosal bleeding, petechiae or purpura suggests platelet disorder c) arterial or venous thrombosis in a bleeding patient suggests DIC 3) Laboratory: a) PT, aPTT b) CBC 4) Management: a) obtain a personal & family medical history & bleeding history before elective surgery [37] b) desmopressin (DDAVP) 0.3 ug/kg over 15-30 minutes - hemophilia A, hemophilia B, vWD, uremia - effects lasts 6 hours c) cryoprecipitate 0.1-0.5 bags/kg preceding surgery, then 0.1-0.3 bags/kg every 12-24 hours - hemophilia A, hemophilia B, vWD d) factor VIII concentrate - 30 units/kg followed by 10-20 units/kg every 12 hours - alternative to cryoprecipitate in patients with hemophilia A e) fresh frozen plasma - hemophilia B - 40 mg/kg followed by 10-15 mL/kg every 12 hours - liver disease - 10-20 mg/kg followed by 10 mL/kg every 6-12 hours f) correct vitamin K deficiency: 10 mg vit K SC QD g) treat underlying etiology of DIC h) platelet transfusions - platelets < 50,000-75,000/mm3 - 6-8 unit increments given - follow platelet counts === Pulmonary disease === 1) complications: a) asthma - bronchospasm - inspissated secretions - moderate asthma not risk factor for noncardiothoracic surgery [8] b) COPD - atelectasis - post-operative purulent bronchitis c) obesity: NOT a risk factor for pulmonary complications [8] d) postoperative pneumonia 2) clinical manifestations: a) dyspnea, wheezing b) productive cough - best clinical predictor of post-operative complications c) barrel chest, hyperresonance, intercostal retractions, cyanosis, clubbing, active wheezing, rhonchi d) smoking 3) Laboratory: a) pulmonary function tests - indications - lung resection - controversial indications: age > 60. history of asthma or COPD, history of smoking, anesthesia requirement > 2 hours, upper abdominal or thoracic surgery - not routinely indicated in patients with chronic lung disease [11] (see indications for preoperative laboratory testing) - minimum pulmonary reserve necessary for general anesthesia - FEV1 > 500 mL - FVC > 1 liter - no absolute value of FEV1 or FEV1/FVC precludes surgery [40] - values do not help predict perioperative pulmonary complications b) arterial blood gas - as indicated 4) Radiology - chest X-ray - as indicated - not routine in patients with chronic lung disease [8,11] 5) Management: a) smoking cessation 1-2 months prior to surgery reduces risk of postoperative complications [30] b) lung expansion maneuvers, incentive spirometry [30] - preoperative inspiratory muscle training reduces risk of postoperative pneumonia & length of stay [30] - training consists of 5-7 sessions/week for 2-3 weeks before surgery - perioperative prophylactic respiratory physiotherapy reudces postoperative pulmonary complications (see perioperative management) [11] - post-operative incentive spirometry of no benefit in preventing postoperative pulmonary complications [44] c) training in postoperative breathing exercises before upper abdominal surgery reduces postoperative pulmonary complications [28] d) COPD: aggressive postural drainage, chest physiotherapy & incentive spirometry 1] continue beta-2 agonist bronchodilators pre- & post operatively 2] stress doses of parenteral glucocorticoids for patients who had received parenteral steroids with the last year - may not be required for patients receiving low-dose & short course glucocorticoids [11] 3] reduce levels of theophylline in perioperative period - toxicity of theophylline is enhanced by general anesthesia 4] short course of broad-spectrum antibiotics in patients with productive cough to decrease volume of pulmonary secretions e) asthma: 1] liberal pre-operative hydration for asthmatic patients 2] patients taking inhaled steroids may need parenteral steroid coverage to avoid exacerbation of pulmonary disease in the perioperative period f) screening for obstructive sleep apnea (STOP-BANG) [11] g) use of nasogastric tubes is not recommended for prevention of postoperative pulmonary complications [44] h) delay or cancel elective surgery for patients with pulmonary hypertension [11] - refer patient for evaluation of pulmonary hypertension === liver disease === 1) liver function testing if examination suggests liver disease 2) delay elective surgery until evaluation of liver disease complete [11] 3) in general, elective surgery is safe if MELD score < 8-10 & is not recommended if MELD score is > 14 [11] 4) a MELD score > 20 precludes elective surgery [42] === endocrine === 1) discontinue oral contraceptives 4 weeks prior to surgery [3] - 2-4 fold increase risk of post-operative thrombosis 2) delay surgery for severe hypothyroidism - mild hypothyroidism is not a risk factor for postoperative complication [11] 3) perioperative adrenal insufficiency a) patient-related risk factors - primary adrenal insufficiency - daily adrenal suppressive dose of glucocorticoid for >= 3 weeks in previous year (prednisone 10 mg QD) b) management - if high risk surgery - hydrocortisone 50-100 mg IV before surgery, then 25-50 mg IV every 8 hours for 24-48 hours - if low risk surgery: - usual dose of glucocorticoid on day of surgery 4) patients with untreated, asymptomatic mild hypothyroidism do not need preoperative testing or treatment [11] === renal disease === - electrolytes & serum creatinine - BUN/creatinine ratio > 20 indicates azotemia, but does not increase risk for postoperative delirium [33] - end-stage renal disease - patients on renal replacement therapy should have dialysis the day prior to surgery [11] === Other considerations === === 1) American Society of Anesthesiologists (ASA) score predicts postoperative complications - frailty score better than ASA score in the elderly 2) discontinue antiplatelet agents (aspirin & clopidogrel) unless low-risk surgery 7-10 days prior to elective surgery [7,11] 3) discontinue Gingko biloba 6 days prior to elective surgery 4) special considerations for warfarin (see warfarin & surgery) 5) cervical spine radiography with flexion & extension views for patients with chronic or aggressive rheumatoid arthritis [11,13] 6) delay of surgery for traumatic hip fracture is associated with increased mortality [11] 7) screen for alcohol abuse (AUDIT-C) - alchohol abuse before surgery increases risk of postoperative complications - abstinence prior to surgery diminishes risk [12] 8) depression (Geriatric Depression Scale score > 4) increase risk for postoperative delirium [33] 9) screen for obstructive sleep apnea [11] STOP-BANG 10) risk for arterial thrombosis or venous thrombosis is increased by sepsis (RR=3.3), septic shock (RR-5.7) & systemic inflammatory response syndrome (RR=2.5) [19] 11) preoperative high-intensity interval training may improve cardiorespiratory fitness & reduce postoperative complications [38] 12) pregnant patients should undergo same preoperative evaluation as non-pregnant patients [11] 13) evaluate for Staphylococcus aurues nasal carriage & decolonize with mupirocin for 5 days with or without chlorhexidine body wash if positive [11]

Related

cardiac stress testing perioperative management perioperative risk assessment post-operative management

Specific

preoperative chest X-ray preoperative laboratory testing simple fitness questions that predict risk of post-operative morbidity

General

risk assessment management

References

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