Pre Operative Clearance for Non Cardiac Surgery:

ALL CLEAR

Dominique Renee Abell, RN, MSN, CCRN, ACNP-BC(ACLS, PALS, TNCC)

rbeckum@crossroadsdevelopers.com

OBJECTIVES

1. Outline evidence based practice guidelines related to pre operative

evaluation for surgery

2. Describe conditions that require pre operative diagnostic evaluations

3. Review the findings that would postpone or cancel surgery

“The purpose of preoperative evaluation is not simply to give medical clearance but rather to perform an evaluation of the patient's current medical status, make recommendations concerning the evaluation, management and risk of cardiac problems over the entire perioperative period; and provide a clinical risk profile that the patient, primary physician, anesthesiologist and surgeon can use in making treatment decisions that may influence short term and long term cardiac outcomes”.

Goals of Preoperative Evaluation

Documentation for which surgery is needed Assessment of patient overall condition/health status Uncovering issues that could cause problems during

and after surgery Perioperative risk determination Optimize medical condition to reduce morbidity and

mortality Develop perioperative plan of care

Goals of Preoperative Evaluation

Education of patient and family

Surgery Anesthesia Intraoperative care Post operative pain control Reduce anxiety Facilitate recovery

Goals of Preoperative Evaluation

Reduce cost Decrease length of stay Reduce cancellations day of surgery Increase patient/family satisfaction

Nurse Practitioner Responsibilities

Perform complete History and Physical Review/Order labs and ancillary studies Assess risk related to patient's co-morbidities Assess need for preoperative specialty consults Communicate with anesthesia provider and surgeon Assist with optimal timing of surgery

Medically optimize patient condition preoperatively

Situation for Surgery

Emergent: life threatening situation, risk of or death of patient if not preformed

Urgent: life threatening or debilitating, needs to be done sooner than later

Elective: patient may “need” procedure but can be scheduled at any time

Cardiac Risk

Definition:

Combined incidence of cardiac death and nonfatal myocardial infarction

Focus on cardiac and pulmonary risk factors that can contribute to complications

Determine patient's functional capacity, Metabolic equivalent (MET)

Cardiac Risk

ACC/AHA guidelines

ASA guidelines

Lee's Revised Cardiac Risk Index

http://www.statcoder.com/cardiac.htm

Cardiac Risk Indices

Factors associated with life threatening cardiac complications/perioperative cardiac death

MI within 6 months S3 gallop or jugular venous distention Age >70 ECG other than Sinus Rhythm, >5 PVC's/min Aortic Stenosis Poor general health/medical status Emergency surgery Intraperitoneal, intrathoracic, aortic surgery

Different Levels of Risk

High:Unstable Coronary Symptoms- acute or recent MI with

evidence of ischemia

Unstable or Severe Angina

Decompensated Heart Failure

Symptomatic/Significant Arrhythmias

High Grade Atrioventricular Block

Severe Valve Disease

Intermediate:

Mild Angina

Previous MI

Compensated or History of Heart Failure

Diabetes Mellitus

Renal Insufficiency

Minor:

Advanced Age

Abnormal ECG

Any other Rhythm besides Sinus

Low functional Capacity

History of Stroke

Uncontrolled Hypertension

surgeon

Primary car provider

anesthesiologistpatient

History and Physical

Medical history-past and current

Review of Systems- cardiac risk factors, cardiac conditions, associated diseases, changes in symptoms

Medication Alcohol, Tobacco, Non-

Prescribed drugs

Vital signs

Central and Peripheral pulses

Lungs/Cardiac Auscultation/Palpation

Abdominal palpation

Examine Lower Extremities

Functional Capacity

History and Physical

Surgical History Allergies Family History of

adverse reaction to anesthesia

Studies- CBC, INR, aPTT, BMP/CMP,ECG, CXR, Stress Test, PFT, ECHO, Cardiac Cath,

Children include birth history- premature,perinatal complications, congenital, chromosomal, anatomic malformations

Functional Capacity

1 Metabolic Equivalent (MET)

Can you take care of yourself?

ADL's- eat, dress,toilet,

Walk indoors around the house

Walk a block or two on level ground 2-3 mph

Do light housework-dusting, wash dishes

Functional Capacity

4 MET Can you climb a flight of stairs or walk up hill

Walk on level ground at 4mph

Run a short distance

Heavy housework-scrub floors, lift or move heavy furniture

Moderate recreational activities-golf,throwing a football

Functional Capacity

>10 MET Swimming, singles tennis, football, basketball, skiing

Management of Cardiac Risk

Continue current medications

Cardio-protective Beta Blockade

Coronary angiography/revascularization

Pulmonary Complication

Definition: revised to clinically significant Pneumonia Respiratory failure with prolonged mechanical

ventilation Bronchospasm Atelectasis Exacerbation of underlying lung disease

Pulmonary Complications

Decreased functional residual capacity/vital capacity Cough Aspiration pneumonia Atelectasis Pneumonia Smoking- even in absence of lung disease

Pulmonary complications

Procedure specific risk factors Surgical site- most important risk factor Duration Anesthesia Neuromuscular blockade

Pulmonary Complications

COPD/Asthma Goal is “Personal Best” Poor PFT's do no exclude from surgery or correlate

with risk of post operative complications Poor exercise capacity is probably best predictor Along with type and duration of surgery Age and obesity are not independent risk factors Metabolic markers- BUN>30, albumin <3

Pulmonary Complications

Reducing Risk Preoperative

smoking cessation 8 weeks prior Treat airflow obstruction in patients with

COPD/Asthma Administer antibiotics and delay surgery Begin patient education regarding post op

lung expansion maneuvers

Pulmonary Complications

Intraoperative Surgery less than 3 hours Spinal or epidural Regional or local blocks Avoid pancuronium Minimally invasive as possible

laparoscopic

Pulmonary Complications

Post Operative

Turn, Cough, and Deep Breath Early mobilization Adequate analgesia Incentive Spirometer/Acapella valve Continuous Positive Airway Pressure (CPAP) Epidural analgesia Intercostal nerve blocks

Hematologic Risk

Hematocrit < 24% Thrombocytopenia <50,000 History of bleeding diathesis Cirrhosis Hematologic malignancy Antiplatelet medication Anti-coagulation therapy DVT/VTE prophylaxis

Chronic Medications

Consider every medication/supplement Diabetes- adjust insulin or oral

hypoglycemics Chronic steroids- stress dose Hypertensive medications- PO or IV Anti-ischemic medications- transdermal

or IV Alcohol use and withdrawal

Chronic Medications

Monoamine oxidase inhibitors- taper and withdraw 2-3 weeks before surgery

Oral contraceptives- stopped 6 weeks before elective surgery secondary to increased VTE risk

Herbal supplements discontinued 2 weeks before surgery

Aspirin discontinued 7-10 days before Thienopyridines (clopidogrel) 2 weeks before Non-steroidal Anti-inflammatories 7-10 days before

Chronic Medications

Oral anticoagulants stopped 4-5 days INR 1.2-1.5 before surgery Evaluate for “bridge therapy” Cox 2 inhibitors may be continued up to surgery

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