Preoperative Medical Assessment

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Preoperative Medical Assessment

• Eric E. Leonheart DPM

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Primary Assessment

• History (Detailed)
• Physical Exam
• Review of Rx Medication
• Review of Non-Rx Medication
• Evaluation of Organ Systems
• Advanced Directives

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Other considerations

• Functional status
• Risk level of the surgery
• Expected blood loss
• Anesthesia type and duration

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History

• HPI (NLDOCAT)
• PMH
• PSH
• Medications
• Family History
• Social History
• Review of systems

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Cardiac Evaluation

• American College of Cardiology American Heart
  Association published guidelines in 1996

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Cardiac Evaluation

• Phase 1
• Emergent or elective
• If emergent and the patients life is in danger
  proceed with surgery
• Undergone revascularization within 5 years
• Received a recent coronary evaluation

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Cardiac Evaluation

• Elective workup
• PMH, functional status, ECG
• Abnormal findings? non-invasive testing (exercise
  stress test, thallium stress, dobutamine stress )
• If abnormal results are found on stress test may
  proceed to invasive testing (angiogram,
  catheterization
• If abnormal results are found may require
  coronary artery bypass graft (CABG) prior to
  elective procedure

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Cardiac Evaluation

• Risk stratification
• Helps to determine the necessary work up based on
  the risk inherent to the procedure, patients PMH
  and functional status

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Risk Stratification

• High Risk
• Unstable angina, Unstable CHF, Symptomatic
  ventricular arrhythmias
• Must have their cardiac problems resolved prior
  to elective procedure

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Risk Stratification

• Intermediate Risk
• Mild angina pectoris, stable or prior CHF
• May proceed to surgery if functional status is
  good
• If functional status is poor (bed-bound or
  difficulty walking) additional workup needed

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Risk Stratification

• Low Risk
• Can proceed to surgery without additional workup
  unless
• Scheduled for high risk surgery (major vascular
  procedure)
• AND have poor functional capacity (walk two or
  three blocks, climb stairs, light activity around
  the house)? additional workup

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Risk Stratification

• Based on procedure
• High Risk
• Emergencies, Aortic, Major vascular, peripheral
  vascular, prolonged procedures w/ fluid shifts
  and/or blood clots
• Intermediate Risk
• Carotid, Head Neck, Intraperitoneal,
  Intrathoracic, Orthopedic, Prostate
• Low Risk
• Endoscopic, Dermatologic, Cataract, Breast

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Antibiotic Prophylaxis

• Bacterial endocarditis
• Recommendations change frequently
• MVP without leaflet thickening and no
  regurgitation no abx. necessary
• MVP with thickened leaflets and some
  regurgitation abx. appropriate

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Pulmonary Evaluation

• Can obtain pulmonary status from history
• Exercise tolerance, walk up steps with or without
  shortness of breath, chest pain with activity
• History of asthma, COPD
• Pulmonary function tests can help in patient
  management prior to surgery
• Arterial blood gas may be drawn on pt. with COPD
  to determine if retaining CO2 or hypoxemic at
  rest

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Hematology Evaluation

• History of bleeding disorder, scheduled for high
  risk neurologic procedures
• Order PT (prothrombin time), PTT (partial
  thromboplastin time), INR (international
  normalized ratio)
• Platelets
• gt100,000 mm³ for major surgery

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Hematology Evaluation

• Medications
• Anticoagulant held 48-72 hours prior to surgery
• Antiplatelet (aspirin) held 5-7 days prior to
  surgery
• If patient requires continuous anticoagulation IV
  heparin

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Endocrine Evaluation

• Objective
• Is to rule out diabetes or thyroid disease
• Evaluate control of blood sugar
• Determine whether the patient is experiencing
  adrenal suppression

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Endocrine Evaluation

• Diabetes
• Fasting blood sugar lt 200mg/dL
• If elevated must gain control with oral
  hypoglycemics or insulin prior to surgery

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Endocrine Evaluation

• Thyroid disorders
• Common symptoms, fatigue and constipation
• TSH testing, possibly T3 or T4
• Regulation of TSH is needed prior to surgery

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Endocrine Evaluation

• Adrenal insufficiency
• Common in older patients
• Even 5mg q.d. for a year can cause adrenal
  suppression
• Require perioperative supplementation of
  corticosteroids
• RA patients need C spine x-rays, subluxation of
  atlantoaxial joint, hyperextension of the neck?
  severed spinal cord

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Endocrine Evaluation

• Normal supplement of hydrocortisone is
  20-30mg/day
• Perioperatively increase to
  200-300 mg/day usually IV and can taper down if
  patient is afebrile and improving on day 4 or 5
  postoperative

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Gastrointestinal Evaluation

• History liver disease
• PT, INR evaluate coagulation
• Albumin testing
• May change anesthesia due to metabolism of agent
• History of ulcers or GI bleeds, may change
  post-op oral meds
• Opiates can decrease peristalsis and lead to
  post-op constipation
• Constipation can actually lead to delirium in
  patients with mild dementia

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Urologic Evaluation

• Appropriate for
• Frequency, urgency, incontinence, hesitancy
• May be signs of UTI
• Patients with recent UTI should have U/A repeated
  if undergoing orthopedic procedures
• BPH may lead to urinary retention post-op leading
  to UTI, pain, and the necessity for
  catheterization

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Neurologic Evaluation

• Conditions of concern
• Myasthenia gravis
• Amyotrophic lateral sclerosis
• Parkinsons
• CVA
• Seizures
• Dementia

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Neurologic Evaluation

• MG, ALS neuromuscular disorders
• Increased complications with general anesthesia
• Greater difficulty with function post-op
• CVA
• gt incidents of clot formation, take perioperative
  precautions
• SCD, anti-coagulate (LMH), ROM, no tourniquet

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Neurologic Evaluation

• Seizures
• Inherent risk to themselves during and after
  surgery
• Delirium
• gt incident with age, MI, hypoxia, hypotension.
  dementia, CVA, electrolyte abnormalities, ulcer,
  bleeding, constipation, urinary retention,
  infection, hypoalbuminemia, medications
  (opiates), trauma, pain

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Psychiatric Issues

• High incident of ETOH abuse
• Benzodiazepine abuse is common
• Smoking history
• Must manage withdrawal

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Functional Status

• Home environment
• Help at home
• Ability to engage in the duties of daily living
• Discharge planning
• Need for nursing care, SNF placement
• Ability to be NWB or PWB

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Conclusion

• Varying levels of risk
• Imperative for the surgeon to be aware of at risk
  issues
• Work with PCP or other specialists

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