Preoperative assessment

1. Pre-operative Assessment Pre-operative Assessment
of the Surgical Patientof the Surgical Patient
Augusto Torres, MDAugusto Torres, MD
Department of AnesthesiologyDepartment of Anesthesiology
MetroHealth Medical CenterMetroHealth Medical Center
July 2007

2. OutlineOutline
Discuss anesthesia Discuss anesthesia
specific riskspecific risk
Discuss patient Discuss patient
specific riskspecific risk
Surgery specific riskSurgery specific risk
Pre-operative Pre-operative
laboratory and studieslaboratory and studies
Example caseExample case

3. Reason for evaluationReason for evaluation
Anesthesia and surgery are physiologically Anesthesia and surgery are physiologically
stressful, invasive interventions which may stressful, invasive interventions which may
exacerbate or uncover underlying disease exacerbate or uncover underlying disease
processesprocesses
Some of the most feared complications include Some of the most feared complications include
catastophic events such as myocardial catastophic events such as myocardial
infarction,difficulty oxygenating or ventilating, infarction,difficulty oxygenating or ventilating,
and cerebral vascular accident, among othersand cerebral vascular accident, among others
A proper pre-operative assessment allows the A proper pre-operative assessment allows the
perioperative providers (anesthesiologist and perioperative providers (anesthesiologist and
surgeon) the ability to stratify and reduce risk for surgeon) the ability to stratify and reduce risk for
the patientthe patient

4. Why is anesthesia risky?Why is anesthesia risky?
There can be difficulty obtaining an airway to adequately There can be difficulty obtaining an airway to adequately
oxygenate and ventilateoxygenate and ventilate
Induction (i.e. “going to sleep”): time of hemodynamic Induction (i.e. “going to sleep”): time of hemodynamic
stress – patient may become hypotensive from the stress – patient may become hypotensive from the
induction agents or hypertensive with laryngoscopy and induction agents or hypertensive with laryngoscopy and
intubationintubation
Maintanence (bulk of case): differing degrees of Maintanence (bulk of case): differing degrees of
stimulation, fluid shifts, blood lossstimulation, fluid shifts, blood loss
Emergence (i.e. “waking up”): physiologically stressful, Emergence (i.e. “waking up”): physiologically stressful,
secure airway may be lost, hypothermiasecure airway may be lost, hypothermia
Anaphylactic reactions to medications, injury during Anaphylactic reactions to medications, injury during
laryngoscopy, neuropathy from positioninglaryngoscopy, neuropathy from positioning
Even spinal/epidural carries risk: inadequate, need to Even spinal/epidural carries risk: inadequate, need to
convert to general, sympathectomy with vasodilation, etcconvert to general, sympathectomy with vasodilation, etc

5. ACC/AHA Guideline Update for ACC/AHA Guideline Update for
Perioperative Cardiovascular Evaluation for Perioperative Cardiovascular Evaluation for
Noncardiac Surgery – Executive Summary Noncardiac Surgery – Executive Summary
Published in 2002 in Published in 2002 in Circulation 105:1257-Circulation 105:1257-
1267.1267.
Eagle KA et alEagle KA et al
Guidelines for evaluation of cardiac riskGuidelines for evaluation of cardiac risk

6. Clinical Predictors of Increased Clinical Predictors of Increased
Perioperative Cardiovascular RiskPerioperative Cardiovascular Risk
MAJORMAJOR
–Unstable coronary syndromesUnstable coronary syndromes
Acute (<7d) or recent MI (<1mo) with evidence of ischemic Acute (<7d) or recent MI (<1mo) with evidence of ischemic
riskrisk
Unstable or severe anginaUnstable or severe angina
–Decompensated heart failureDecompensated heart failure
–Significant arrhythmiasSignificant arrhythmias
High-grade AV blockHigh-grade AV block
Symptomatic ventricular arrhythmiaSymptomatic ventricular arrhythmia
SVT uncontrolled rateSVT uncontrolled rate
–Severe valvular diseaseSevere valvular disease

7. Clinical Predictors of Increased Clinical Predictors of Increased
Perioperative Cardiovascular RiskPerioperative Cardiovascular Risk
INTERMEDIATEINTERMEDIATE
–Mild angina pectorisMild angina pectoris
–Previous myocardial infarction (>1mo) by Previous myocardial infarction (>1mo) by
history of pathological Q waveshistory of pathological Q waves
–Compensated or prior heart failureCompensated or prior heart failure
–Diabetes mellitus (particularly insulin Diabetes mellitus (particularly insulin
dependent)dependent)
–Renal insufficiency (creatinine >2.0)Renal insufficiency (creatinine >2.0)

8. Clinical Predictors of Increased Clinical Predictors of Increased
Perioperative Cardiovascular RiskPerioperative Cardiovascular Risk
MINORMINOR
–Advanced ageAdvanced age
–Abnormal ECG (LVH, LBBB, ST-T Abnormal ECG (LVH, LBBB, ST-T
abnormalities)abnormalities)
–Rhythm other than sinus (e.g. a fib)Rhythm other than sinus (e.g. a fib)
–Low functional capacity (e.g. inability to climb Low functional capacity (e.g. inability to climb
one flight of stairs with a bag of groceries)one flight of stairs with a bag of groceries)
–History of strokeHistory of stroke
–Uncontrolled systemic hypertension Uncontrolled systemic hypertension

9. Clinical Predictors of Increased Clinical Predictors of Increased
Perioperative Cardiovascular RiskPerioperative Cardiovascular Risk
Functional CapacityFunctional Capacity
–Metabolic equivalentsMetabolic equivalents
–1 MET – Can you take care of yourself? Eat, 1 MET – Can you take care of yourself? Eat,
dress, use the toilet? Walk a block or two on dress, use the toilet? Walk a block or two on
level ground 2-3 MPHlevel ground 2-3 MPH
–4 METs – Do light work around the house like 4 METs – Do light work around the house like
dusting or washing the dishes? Climb a flight dusting or washing the dishes? Climb a flight
of stairs?of stairs?
–>10 METs – Participate in strenuous sports >10 METs – Participate in strenuous sports
like swimming, singles tennis, football?like swimming, singles tennis, football?

10. Clinical Predictors of Increased Clinical Predictors of Increased
Perioperative Cardiovascular RiskPerioperative Cardiovascular Risk
Functional CapacityFunctional Capacity
–Perioperative cardiac and long-term risks are Perioperative cardiac and long-term risks are
elevated in patients unable to obtain 4-MET elevated in patients unable to obtain 4-MET
demanddemand
–www.1000takes.comwww.1000takes.com

11. Surgery-specific riskSurgery-specific risk
Two important factorsTwo important factors
–The type of surgery and degree of The type of surgery and degree of
hemodynamic stresshemodynamic stress

12. Surgery Specific RiskSurgery Specific Risk
High (Reported risk High (Reported risk
>5%)>5%)
–Emergent major Emergent major
operations, particularly operations, particularly
in elderlyin elderly
–Aortic and other major Aortic and other major
vascular surgeryvascular surgery
–Surgical procedures Surgical procedures
associated with large associated with large
fluid shifts and/or blood fluid shifts and/or blood
lossloss
– www.services.epnet.comwww.services.epnet.com

13. Surgery Specific RiskSurgery Specific Risk
Intermediate Intermediate
(Reported risk <5%)(Reported risk <5%)
–Carotid Carotid
endarterectomyendarterectomy
–Head and neck Head and neck
surgerysurgery
–Intraperitoneal and Intraperitoneal and
intrathoracic intrathoracic
proceduresprocedures
–Orthopedic surgeryOrthopedic surgery
–Prostate surgeryProstate surgery

14. Surgery Specific RiskSurgery Specific Risk
Low (Reported risk Low (Reported risk
<1%)<1%)
–Endoscopic Endoscopic
proceduresprocedures
–Superficial proceduresSuperficial procedures
–Cataract surgeryCataract surgery
–Breast surgeryBreast surgery
– www.steenhall.comwww.steenhall.com

15. The AlgorithmThe Algorithm
Step 1: What is the urgency of surgery?Step 1: What is the urgency of surgery?
–Emergency: No time for further evaluationEmergency: No time for further evaluation
Step 2: Coronary revascularization in the Step 2: Coronary revascularization in the
past five years?past five years?
–Free ticket for five years if no new symptoms Free ticket for five years if no new symptoms
have arisen (chest pain or SOB)have arisen (chest pain or SOB)
Step 3: Coronary evaluation in the past 2 Step 3: Coronary evaluation in the past 2
years?years?
–Free ticket for two years if no new symptomsFree ticket for two years if no new symptoms

16. The AlgorithmThe Algorithm
Step 4: Unstable coronary syndrome or major Step 4: Unstable coronary syndrome or major
predictor of risk?predictor of risk?
–Will lead to cancellation or delay of surgeryWill lead to cancellation or delay of surgery
Step 5: Intermediate clinical predictors of risk?Step 5: Intermediate clinical predictors of risk?
Step 6: Step 6:
–Intermediate clinical predictors and moderate to Intermediate clinical predictors and moderate to
excellent functional capacity are good candidates for excellent functional capacity are good candidates for
intermediate risk surgeryintermediate risk surgery
–Intermediate clinical predictors and poor functional Intermediate clinical predictors and poor functional
capacity or moderate to excellent functional capacity capacity or moderate to excellent functional capacity
with high risk surgery often need further testingwith high risk surgery often need further testing

17. The AlgorithmThe Algorithm
Step 7: Step 7:
–Minor or no clinical predictors with moderate Minor or no clinical predictors with moderate
or excellent functional capacity usually need or excellent functional capacity usually need
no further testingno further testing
–Minor or no clinical predictors with poor Minor or no clinical predictors with poor
functional capacity and high risk surgery may functional capacity and high risk surgery may
need further testingneed further testing
Step 8: Results of non-invasive testing Step 8: Results of non-invasive testing
determines need for invasive testing or determines need for invasive testing or
interventionintervention

18. Pre-operative TestsPre-operative Tests
12-Lead ECG12-Lead ECG
–Class I: Recent episode of chest pain or Class I: Recent episode of chest pain or
ischemic equivalent etcischemic equivalent etc
–Class IIB: Class IIB:
Prior coronary revascularizationPrior coronary revascularization
Asymptomatic male >45yrs old or female >55 yrs Asymptomatic male >45yrs old or female >55 yrs
old with 2 or more risk factorsold with 2 or more risk factors
Prior hospital admission for cardiac causesPrior hospital admission for cardiac causes
–Class III: Routine in asymptomatic individualsClass III: Routine in asymptomatic individuals

19. Pre-operative TestsPre-operative Tests
EchoEcho
–Class I: Patients with current or poorly Class I: Patients with current or poorly
controlled heart failurecontrolled heart failure
–Class IIa: Prior heart failure and dyspnea of Class IIa: Prior heart failure and dyspnea of
unknown originunknown origin
–Class III: As a routine testClass III: As a routine test

20. Pre-operative TestsPre-operative Tests
Exercise or Pharmacological Stress Exercise or Pharmacological Stress
TestingTesting
–Class I: Class I:
Patients with intermediate pretest probabilityPatients with intermediate pretest probability
Change in clinical status of patient with suspected Change in clinical status of patient with suspected
or proven CADor proven CAD
Proof of ischemia prior to revascularizationProof of ischemia prior to revascularization
Evaluation of adequacy of medical therapyEvaluation of adequacy of medical therapy
–Class IIa: Evaluation of exercise capacity Class IIa: Evaluation of exercise capacity
when subjective assessment unreliablewhen subjective assessment unreliable

21. Pre-operative TestsPre-operative Tests
Class IIbClass IIb
–Diagnosis of CAD in patients with high or low Diagnosis of CAD in patients with high or low
pretest probability: resting ST depression pretest probability: resting ST depression
<1mm, taking digitalis, or LVH<1mm, taking digitalis, or LVH
–Detection of restenosis in high-risk Detection of restenosis in high-risk
asymptomatic patientsasymptomatic patients
Class IIIClass III
–Routine screening of asymptomatic patientsRoutine screening of asymptomatic patients

22. Pre-operative TestsPre-operative Tests
Coronary AngiographyCoronary Angiography
–Class IClass I
Evidence of adverse outcome from non-invasive Evidence of adverse outcome from non-invasive
testtest
Angina unresponsive to therapyAngina unresponsive to therapy
Unstable angina, especially with intermediate or Unstable angina, especially with intermediate or
high risk surgeryhigh risk surgery
Equivocal noninvasive test in high clinical risk Equivocal noninvasive test in high clinical risk
patient undergoing high risk surgerypatient undergoing high risk surgery

23. Pre-operative TestsPre-operative Tests
Class IIaClass IIa
–Multiple markers of intermediate clinical risk Multiple markers of intermediate clinical risk
and planned vascular surgeryand planned vascular surgery
–Moderate to large ischemia on non-invasive Moderate to large ischemia on non-invasive
testing but without high-risk features and testing but without high-risk features and
lower left ventricular functionlower left ventricular function
–Nondiagnostic noninvasive test results in Nondiagnostic noninvasive test results in
patients at intermediate clinical riskpatients at intermediate clinical risk
–Urgent noncardiac surgery while recovering Urgent noncardiac surgery while recovering
from acute MIfrom acute MI

24. Pre-operative TestsPre-operative Tests
Class IIbClass IIb
–Perioperative MIPerioperative MI
–Medically stabilized angina and low-risk surgeryMedically stabilized angina and low-risk surgery
Class IIIClass III
–Low risk surgery with known CADLow risk surgery with known CAD
–Asymptomatic after coronary revascularization with Asymptomatic after coronary revascularization with
excellent exercise capacityexcellent exercise capacity
–Noncandidate for coronary revascularization owing to Noncandidate for coronary revascularization owing to
concomitant medical illness, severe left ventricular concomitant medical illness, severe left ventricular
dysfunction (EF <20%)dysfunction (EF <20%)

25. Perioperative TherapyPerioperative Therapy
CABGCABG
–Indications for CABG same as for those not Indications for CABG same as for those not
undergoing surgeryundergoing surgery
–Consider in those who long-term outcome Consider in those who long-term outcome
improved by CABGimproved by CABG
Percutaneous Coronary InterventionPercutaneous Coronary Intervention
–Delay of 4-6 weeks for antiplatelet therapy for Delay of 4-6 weeks for antiplatelet therapy for
re-endothelializationre-endothelialization

26. Day of SurgeryDay of Surgery
History of present illnessHistory of present illness
NPO statusNPO status
PMHPMH
PSH PSH
–Problems with anethesiaProblems with anethesia
Malignant hyperthermiaMalignant hyperthermia
Post-operative nausea and vomitingPost-operative nausea and vomiting
Difficulty with intubation – letter from Difficulty with intubation – letter from
anesthesiologistanesthesiologist

27. Day of SurgeryDay of Surgery
AllergiesAllergies
–Antibiotics, latexAntibiotics, latex
Vital signs (are vital)Vital signs (are vital)
–Baseline blood pressure for cerebral autoregulationBaseline blood pressure for cerebral autoregulation
Physical examination (directed)Physical examination (directed)
–Airway examinationAirway examination
–CorCor
–LungsLungs
–Neurologic (especially if regional technique planned)Neurologic (especially if regional technique planned)

28. Day of SurgeryDay of Surgery
LaboratoryLaboratory
–Eg. Renal function, starting HCT, PlateletsEg. Renal function, starting HCT, Platelets
–Beta HCG women of childbearing ageBeta HCG women of childbearing age
ImagingImaging
–CXR: Trauma, CHF, COPDCXR: Trauma, CHF, COPD
–CT scan in thyroidectomyCT scan in thyroidectomy

29. Day of SurgeryDay of Surgery
Assessment of patientAssessment of patient
–Risk of anesthesia and surgeryRisk of anesthesia and surgery
–MonitoringMonitoring
–Technique of anesthesia and agents to be Technique of anesthesia and agents to be
usedused
–Post-operative carePost-operative care

30. Example of PatientExample of Patient
59 year old female presents for an Aorto-bifemoral bypass59 year old female presents for an Aorto-bifemoral bypass
PMH:PMH:
–HTNHTN
–DM IIDM II
–HypercholesterolemiaHypercholesterolemia
PSH:PSH:
–Hysterectomy at age 49Hysterectomy at age 49
Social HX: Tob 35 pack yrSocial HX: Tob 35 pack yr
NKDANKDA
Meds: atenolol, glucophage, lipitorMeds: atenolol, glucophage, lipitor
VS 145/73, P: 71, R:18, Sat 96%VS 145/73, P: 71, R:18, Sat 96%
NAD, A&O x3NAD, A&O x3
MP 2, Neck FROMMP 2, Neck FROM
Cor: RRRCor: RRR
Lungs: BS distant, no wheezingLungs: BS distant, no wheezing
Abd: soft, no palpable massAbd: soft, no palpable mass
Ext: lower ext cool, difficult to palpate pulsesExt: lower ext cool, difficult to palpate pulses

31. Example of PatientExample of Patient
59 year old female presents for an 59 year old female presents for an
Aorto-bifemoral bypassAorto-bifemoral bypass
PMH:PMH:
–HTNHTN
–DM IIDM II
–HypercholesterolemiaHypercholesterolemia
PSH:PSH:
–Hysterectomy at age 49Hysterectomy at age 49
Social HX: Tob 35 pack yrSocial HX: Tob 35 pack yr
NKDANKDA
Meds: atenolol, glucophage, lipitorMeds: atenolol, glucophage, lipitor
VS 145/73, P: 71, R:18, Sat 96%VS 145/73, P: 71, R:18, Sat 96%
NAD, A&O x3NAD, A&O x3
MP 2, Neck FROMMP 2, Neck FROM
Cor: RRRCor: RRR
Lungs: BS distant, no wheezingLungs: BS distant, no wheezing
Abd: soft, no palpable massAbd: soft, no palpable mass
Ext: lower ext cool, difficult to Ext: lower ext cool, difficult to
palpate pulsespalpate pulses
What if any further preoprative What if any further preoprative
laboratory or investigative studies laboratory or investigative studies
are necessary?are necessary?

32. LaboratoryLaboratory
Basic metabolic profile?Basic metabolic profile?
CBC? CBC?
Coagulation profile?Coagulation profile?

33. LaboratoryLaboratory
Basic metabolic profileBasic metabolic profile
–Assessment of baseline renal functionAssessment of baseline renal function
CBCCBC
–HCT and PlateletsHCT and Platelets
Coagulation profileCoagulation profile
–History of bleeding and/or bruisingHistory of bleeding and/or bruising

34. ECG?ECG?

35. ECG?ECG?
12-Lead ECG12-Lead ECG
–Class IIB: Class IIB:
Asymptomatic male >45yrs old or female >55 yrs Asymptomatic male >45yrs old or female >55 yrs
old with 2 or more risk factorsold with 2 or more risk factors

36. ECGECG
NSR with non-specific ST and T wave NSR with non-specific ST and T wave
changeschanges
www.library.med.utah.eduwww.library.med.utah.edu

37. Chest X-ray?Chest X-ray?

38. Chest X-rayChest X-ray
Clinical Clinical
characteristics to characteristics to
consider:consider:
–Smoking, COPD, Smoking, COPD,
recent respiratory recent respiratory
infection, cardiac infection, cardiac
diseasedisease
–If the above are stable, If the above are stable,
no unequivocal no unequivocal
indicationindication

39. Further cardiac evaluation?Further cardiac evaluation?

40. Further cardiac evaluationFurther cardiac evaluation
Clinical predictors?Clinical predictors?
–Intermediate i.e. Intermediate i.e. diabetes mellitusdiabetes mellitus
Functional capacity?Functional capacity?

41. Functional CapacityFunctional Capacity
““I can’t walk one flight of I can’t walk one flight of
steps because my legs steps because my legs
hurt!”hurt!”
<4 mets<4 mets
Non-invasive testingNon-invasive testing
Exercise or Exercise or
Pharmacological Stress Pharmacological Stress
TestingTesting
–Class IIa: Evaluation of Class IIa: Evaluation of
exercise capacity when exercise capacity when
subjective assessment subjective assessment
unreliableunreliable
–www.users.interport.netwww.users.interport.net

42. Non-invasive testingNon-invasive testing
Dobutamine stress echoDobutamine stress echo
–EF 50%, mildly reduced EF 50%, mildly reduced
ventricular functionventricular function
–Area of scar inferior Area of scar inferior
segmentsegment
–With injection of With injection of
dobutamine, area of dobutamine, area of
hypokinesis lateral hypokinesis lateral
segment of the left ventriclesegment of the left ventricle
–www.folk.ntnu.nowww.folk.ntnu.no
Coronary angiography?Coronary angiography?

43. Coronary angiography?Coronary angiography?
Class IClass I
Evidence of adverse Evidence of adverse
outcome from non-outcome from non-
invasive testinvasive test
Coronary angiogramCoronary angiogram
–Left main: normal vesselLeft main: normal vessel
–LAD: area of 40% proximalLAD: area of 40% proximal
–Circumflex: 80% proximal Circumflex: 80% proximal
lesionlesion
–RCA: severe diffuse RCA: severe diffuse
disease with collateral disease with collateral
filling from PCAfilling from PCA
–Procedure: one stent Procedure: one stent
successfully placed in successfully placed in
proximal cirumflex arteryproximal cirumflex artery

44. Coronary AngiographyCoronary Angiography
Patient placed on plavix and surgery Patient placed on plavix and surgery
postponed for six weekspostponed for six weeks
Patient, surgeon, and anesthesiologist Patient, surgeon, and anesthesiologist
aware of tenuous blood supply to RCA aware of tenuous blood supply to RCA
territory but no stress-induced ischemiaterritory but no stress-induced ischemia
www.health.yahoo.comwww.health.yahoo.com

45. ConclusionConclusion
Preoperative evaluation is necessary to Preoperative evaluation is necessary to
stratify risk to the patientstratify risk to the patient
The evaluation delineates patient clinical The evaluation delineates patient clinical
factors as well as extent of surgeryfactors as well as extent of surgery
The patient, surgeon, anesthesiologist are The patient, surgeon, anesthesiologist are
aware of the perioperative risk and may aware of the perioperative risk and may
plan therapy accordinglyplan therapy accordingly