preop evaluation workshop (2)

Preoperative evaluation

workshop

Ahmad abou leila

PGYIV Ahmad Abou Leila-AUBMC

Patient disease Anesthesia surgery

Satisfied

Readmitted

Minor morbidity

Major morbidity

Death

Ahmad Abou Leila-AUBMC

Anesthesiologist role


Uncover the patient

risk factors

Preoperative treatment

And optimization

consultations

Further testing

Anesthesia plan


Steps for preop evaluation

Asses patient risk Asses surgical risk


Patient risk

• History

• Physical exam

• Lab and radiology testing


Preop evaluation steps

Acute history

Chronic history

Physical exam

Labs and

radiology


Acute history

• History of present illness

• Exercise tolerance

– Surgery is major stress

– Good exercise tolerance

– Hewill tolerate surgical stress.

• Fasting hours

• Presence of concurrent symptoms

– Jaundice,wheezes,GERD,toxic symptoms


Chronic history

• Chronic medical problems

• Medications and allergies

• social history

– smoking (packet per year, cessation,risk factor)

– Alcohol(opiods tolerance,alcoholic cardiomyopathy)

• History of prior operations (difficult airway,malignant hyperthermia,PONV


Physical exam

• Air way

• Cardiac

• Lungs


As a routine in order to

complete our preop

evaluation we send the

patient to lab or radiology


Labs or radiology

Only when indicated


Tutorial on preop evaluation

Ahmad abouleila


Acute History

Assessment of present illness

Physiologic disturbances

What is the surgery?


What is the Surgery

Elective or emergent(LIFE SAVING)

Elective one can wait and optimized

Life saving no anesthesia clearance


The pathologic impact


Acute history

Assess exercise tolerance

Assessment of Cardiac and

pulmonary reserve


Good exercise Tolerance mean

that the heart will not fail upon

the surgical stress

Opposite is true

excellent exercise tolerance in

patients with stable angina means

that myocardium can be stressed

without failing Ahmad Abou Leila-AUBMC

Able to climb the 4th floor

without dyspnea,chest pain

Good exercise tolerance

Take care in patient who suffer

from back pain,poor exercise

tolerance not due to limited

cardiopulmonary reserve


HIGH RISK

Low RISK


Acute history

NPO status

Risk of Aspiration


What is the minimum fasting hours

for

6 hours

6 hours

4 hours

2 hours


Normal medication allowed with

sips of water


Any fluid u can read print thought it

is clear fluid


Acute history

Presence of concurrent symptoms


In preop evaluation of patient with history of

mild intermittent asthma u find chest

wheezes

Would u cancel the case

Yes if the condition not optimized

If patient has severe persistent asthma

With optimal treatment

Still wheezing

Stable and proceed

With good preparation and minimal instrumentation Ahmad Abou Leila-AUBMC

If patient has symptomatic hyperthyroidism

and scheduled for elective surgery

What should u do

Cancel the case and refer to endocrinologist


Thyroid storm


1 year old baby with runny nose, shall we

cancel surgery

no

If discharge clear ,no fever,no wheezes ,normal cxr

Don’t cancel


Chronic history

Past medical history



CVS diseases

CAD,HTN,HF,arrythmias


Cardiovascular events are the leading cause

of morbidity and mortality peri-operatively

MI accounts for up to 40% of

perioperative fatalities.


A 65-year-old postmenopausal female with a medical

history of coronary artery disease (CAD), hypertension,

atrial fibrillation, and dyslipidemia presents to the

emergency department (ED) complaining of an acute onset

of leg pain. Further testing and evaluation reveals that she

has an acute arterial emboli and needs immediate

embolectomy. Her heart rate is 85 bpm. As the medical

consultant, what is the MOST APPROPRIATE next step?

A. Complete a full preoperative evaluation, including a stress test, because she

will need a vascular procedure.

B. Ask the patient about her physical activity so you can calculate her metabolic

equivalents (METs) because she will have an intermediate-risk surgery.

C. Evaluate her postoperatively for signs and symptoms of a myocardial

infarction (MI).

D. Ask for surgery to be delayed for 2 days until a ß blocker lowers her heart

rate to between 55 and 65 bpm slowly.


Patient with uncomplicated MI,his

surgery must be postponed at least

6 weeks


A 54-year-old male gun shot survivor is evaluated prior to surgery for a

herniated lumbar disc. He has had increasing lower back pain for the

past year that is poorly controlled with pain medications. He also had a

non-ST-segment elevation MI and underwent cardiac catheterization

with coronary artery stent placement 2 weeks ago with a subsequent

stress test that did not show any residual ischemia. His ECG shows a

normal sinus rhythm. Which statement is MOST CORRECT?

A. This patient is at low risk for cardiac complications because his

stress test was negative.

B. Because the patient had a negative stress test, he no longer has

any red flag/active cardiac conditions.

C. Depending on the type of stent placed, elective surgery may be

contraindicated for up to 1 year.

D. If a bare-metal stent (BMS) was placed, the patient can safely

proceed to surgery in 1 week.


Balloon angioplasty…………2-4weeks


Mayo Clinic Data: Bare Metal

Stents

• major adverse cardiac events (MACE)

after non-cardiac surgery (NCS)

decreased with increased time post-

BMS placement • 10.5% (< 30d)

• 3.8% (31-90d)

• 2.8% (> 90d)

• and that bleeding complications were not associated with

antiplatelet therapy within a week of surgery

[Nuttal et. al. Anesthesiology 109: 588, 2008]


Mayo Clinic Data: Drug Eluting

Stents

• MACE after NCS was independent of time

post-placement

• 6.4% (0-90d)

• 5.7% (91-180d)

• 5.9% (181-365d)

• 3.3% (>356d) Rabbitts et. al. Anesthesiology 109: 596, 2008].


You are evaluating a patient who is scheduled for cataract surgery. She is 78-years-old and has a complicated medical history, including diabetes mellitus, hypertension, chronic kidney disease, dyslipidemia, CAD with a 3-vessel coronary artery bypass graft (CABG) 2 years ago, and a 110 pack/year smoking habit that ended after her CABG. After you take her history and examine her, you determine she does not have any red flag issues. Which of the statements concerning the rest of the preoperative evaluation is MOST ACCURATE?

Because this patient has a strong history of CAD, she will need noninvasive cardiac

stress testing before her surgery.

Because this patient had a CABG in the last 2 years, an evaluation of her MET capacity

is unnecessary.

Because the planned surgery is a high-risk procedure, the patient needs noninvasive

cardiac stress testing before surgery.

Because the planned surgery is a low-risk surgery, no further evaluation is needed.


Which one of the following surgical procedures is associated with the highest risk for perioperative myocardial ischemia

Femoropopliteal bypass

Pulmonary lobectomy

Hip arthroplasty

Transurethral resection of the prostate

Mastectomy


• Low risk Surgery

• cardiac risk < 1%

– Endoscopic procedures

– Superficial procedures

– Cataract surgery

– Breast surgery


• Intermediate Risk

• cardiac risk < 5%

– Carotid endarterectomy

– Head and neck surgery

– Intraperitoneal and

Intrathoracic

– Orthopedic surgery

– Prostate surgery Ahmad Abou Leila-AUBMC

• High risk

• reported risk of adverse cardiac event >5%

– Emergency surgery

– Aortic procedures

– Peripheral vascular surgery

– Prolonged surgical procedures associated with large volume shifts or high EBL


Patients with DBP between 110 and 130 mmHg were randomly

allocated to admission for BP control, followed by surgery,

versus 10 mg intranasal nifedipine and immediate surgery

no statistically significant differences in postoperative complications

(no neurologic or cardiovascular complications in either group).

However, the average hospitalization time was significantly longer (12

vs. 6 days, p = 0.003)

Weksler et. al. Randomized, Prospective Study (n = 989)

Howell: Metaanalysis and Retrospective/Cohort Studies

No significant relationship between admission blood

pressure and outcome


Resting ECG

• Class I (definite indication) – Recent ischemic symptoms

– Major / intermediate clinical predictors and high or intermediate risk procedure

• Class II (probably warranted) – Asymptomatic diabetics

– History of cardiac revascularization

– Asymptomatic man > 45 yo or woman > 55 yo

– Prior hospitalization for cardiac causes

• Class III (not indicated) – Asymptomatic patient; low risk procedure


Relative Risk of Cardiovascular Death

(EKG Findings):

Atrial fibrillation 4.0

Left or right bundle branch block 2.0

Left ventricular hypertrophy 1.8

Premature ventricular complexes 2.3

Pacemaker rhythm 4.4

Q-wave 2.4

STD 2.1

Any abnormal EKG 4.5

Multivariate logistic regression was applied to evaluate the relation between ECG abnormalities and cardiovascular death

Patients with abnormal ECG findings had a greater incidence of cardiovascular death than those with normal ECG results (1.8% vs 0.3%; adjusted OR 4.5, CI 3.3 to 6.0).



(EKG Findings):






Q-wave 2.4

STD 2.1



(EKG Findings):






Q-wave 2.4

STD 2.1



Preoperative

ECHOCARDIOGRAM • Resting Left Ventricular Function: has not

been shown to be a consistent predictor of

perioperative ischemic events

[ACC/AHA Guidelines}

Patients with poor functional status should

undergo noninvasive testing unless low-risk

surgery is planned


NO cardiac evaluation

EMEREGENCY

CABG < 5 years(no new syptoms)

Favorable Cardiac workup

< 2years (no new syptoms)


Chest conditions


5-10% of all surgical patients (and 940% of

those undergoing abdominal surgery) will

experience post-operative pulmonary

complications

Obese patients do have a higher incidence of pulmonary

thrombotic complications [Gutt Am J Surg 189: 14, 2005]


POST OPERATIVE Respiratory Failure


Predictor Points

Surgery

AAA 27

Thoracic Surgery 21

NSGY, upper abdominal, or peripheral

vascular 14

Neck 11

Emergency 11

Albumin < 30 g/dL 9

BUN > 30 mg/dL 8

Partially or fully dependent 7

COPD 6

Age >= 70 6

Age 60-69 6Risk

<=10 0.5%

11-9 2.2%

20-27 5.0%

28-40 11.6%

>40 30.5%


Preventive measures

• Lung expansion maneuvers (deep-

breathing exercises and incentive

spirometry

• Pain control(epidural analgesia)

• Preoperative education

• intermittent positive pressure breathing

and CPAP, while effective, are not

recommended due to their high cost


Which of the following would be the most appropriate test

for preoperative evaluation?


PFTS and CXR ordered only

in

1.Patient symptomatic

2.Unexplained dyspnea

3.Intrathoracic procedure such as lung

volume reduction


Past medical history Diabetes mellitus

CVS risk factor

Intraop hypoglycemia

Gastroparesis

Wound infection

Difficult airway


Prayer sign in DM

Difficult airway



Renal failure

Drug metabolism disturbance

Electrolyte imbalance

Anemia

Uraemic gastroparesis


Chronic history

Medication and allergies


A 70-year-old man with a history of coronary artery disease,

hyperlipidemia, and hypertension is admitted with community-

acquired pneumonia. On his second hospital day he has a

seizure. A computed tomography scan reveals a 5-cm mass with

evidence of midline shift. He is taking clopidogrel and aspirin

after having a recent coronary artery stent placed 4 weeks ago.

The neurosurgeon says your patient will need to go to the

operating room in the next 7 days. What would be the optimal

management of this patient’s antiplatelet medications?

A. Discontinue both aspirin and clopidogrel immediatelyso that the

antiplatelet effects will be minimal when your patient goes to

surgery.

B. Discontinue aspirin and clopidogrel and start your patient on

UFH.

C. Continue aspirin and clopidogrel until the day before surgery.

D. Discontinue aspirin and clopidogrel and start your patient on a

glycoprotein IIb/IIIa inhibitor until surgery.


A 66-year-old man with coronary artery disease had a

bare-metal stent placed in his left anterior descending

coronary artery 3 weeks ago. He has gallstones and wants

his gallbladder removed. Which of the following is the most

appropriate management plan?

A. Postpone the surgery until he has had at least 6 weeks of dual

antiplatelet therapy with aspirin and clopidogrel. Then proceed with

surgery while the patient is taking aspirin.

B. Discontinue his aspirin and clopidogrel and proceed with the

surgical procedure using LMWH as a bridging antithrombotic agent.

C. Discontinue his aspirin and clopidogrel and proceed with the

surgical procedure using eptifibatide as a bridging antithrombotic

agent.

D. Discontinue his aspirin and clopidogrel and proceed with the

surgical procedure using bivalirudin for bridging anticoagulation.


A 70-year-old man with hypertension had a stroke 3

months ago for which he takes 81 mg aspirin daily and 5

mg amlodipine daily. He is scheduled for a dental

extraction. What is the best preoperative recommendation

to manage his aspirin therapy?

A. Do not stop aspirin before surgery.

B. Stop aspirin 1 to 3 days before surgery.

C. Stop aspirin 5 to 7 days before surgery.

D. Stop aspirin 10 to 14 days before surgery.


A patient scheduled for cataract surgery develops urinary

retention 3 days before his scheduled surgery and is

hospitalized. A Foley catheter is inserted and the urologist

recommends starting tamsulosin. The ophthalmologist

decides to proceed with scheduled surgery because the

patient is already in the hospital. The patient’s blood

pressure is 120/80 mm Hg. Which of the following is most

correct about management of tamsulosin in the

perioperative period?

A. Continue tamsulosin preoperatively to minimize ongoing prostatic

obstruction.

B. Continue tamsulosin preoperatively to avoid rebound hypertension (if

it is stopped).

C. Discontinue tamsulosin preoperatively to avoid floppy iris syndrome.

D. Discontinue tamsulosin preoperatively to avoid intraoperative

hypotension.


A 60-year-old woman with hypertension and a myocardial

infarction 1 year ago is hospitalized for cholecystitis and is

scheduled for a laparoscopic cholecystectomy in 1 week.

Her medications include an aspirin, metoprolol 25 mg twice

a day, and a statin. Her blood pressure is 110/70 mm Hg

and her pulse is 64 BPM. What is the best perioperative

recommendation for her ß-blocker therapy?

A. Stop the metoprolol 2 to 3 days before surgery.

B. Stop the metoprolol on the morning of surgery.

C. Continue the metoprolol preoperatively.

D. Increase the dose of the metoprolol to 50 mg twice a day to slow

her heart rate to less than 60 BPM.


POISE trial: B-blockers

increase mortality

• metoprolol 100 mg 2-4 hr preop.

• Total mortality increased from 2.3 to

3.1% at 30 days.

• An important exclusion criteria in POISE

was "receiving a β-blocker or their

physician planned to start one

perioperatively“

• [Devereaux et al. Lancet 31: 371, 2008]


Preop evaluation -medication

Oral hypoglycemic

warfarin

ACEI

Plavix

ticlopidine

Skip morning dose

7 days before

14 days before

3-4 days

1 day prior surgery


Patient A.B receiving therapeutic dose of LMWH

What is the optimal timing to stop LMWH preop?

A-12hrs

B-18hrs

Therapeutic LMWH doses should be stopped 24hrs

Prophylactic LMWH doses should be stopped 12 hrs Ahmad Abou Leila-AUBMC

Preop evaluation -allergies

Latex allergy Shall we use this tube for intubation

Yes because they are made of PVC not latex

Avoid red rubber tube

And adhesives


http://images.google.com/imgres?imgurl=http://ecom.coastal.com/Image/ProductImage/LTX000-VHS-ENG.jpg&imgrefurl=http://ecom.coastal.com/LTX000-VHS-ENG/HT/ProductDetails/Latex-training.aspx&h=300&w=400&sz=12&hl=en&start=24&tbnid=G_l6uv-LK7-0dM:&tbnh=93&tbnw=124&prev=/images?q=latex+allergy&start=20&gbv=2&ndsp=20&hl=en&sa=N

Penicillin most common medication

causing allergy

Patient allergic to penicillin are 3 x

more liable to develop allergy to

other medication


Allergic to pencillin ,and 2g of kefzol are sent

to the OR to be giver prior to surgeries


What is the cross allergencity between

Cephalsporins and pencillin

Shall I give or not


Penicillin

Cephalosporin

B-lactam ring is unstable in Cephalosporin

Skin tests have not confirmed cross reactivity

There is risk of cross allergenicity between 1st generation Cephalosporin and

penicillin Ahmad Abou Leila-AUBMC

Allergy to penicillin

Don’t give imipenem Ahmad Abou Leila-AUBMC

Patients who have experienced pronounced

allergic reactions with penicillins

such as anaphylaxis, angioedema, or

bronchospasm

should not

receive therapy containing a cephalosporin or

imipenem.

Aztreonam may be safely administered to patients

with a history of penicillin allergy



Allergic to sulfa drugs

Sulfonamides-bactrim

sulfonylureas

Which diuretic is sulfa

drug and comonly

used in the OR


Egg allergy

One of the components of

propofol is egg

Is it safe to use propofol in these

patients


Yes it is safe

Propofol made of the yellow ,whereas

allergy to egg is to white


Chronic history

Social History ,Smoking,and alcohol


Dec oxygen carrying capacity

Stimulates sympathetic system

Coronary narrowing

Irritable airway

Postoperative infection

Smoking


Preop evaluation

Patient A has stopped

smoking for few days

prior or

Patient B has stopped

smoking for 8 weeks prior

OR

How cessation of smoking

Affect the outcome of anethesia In these

2 patients

Increase in air way reactivity

Decrease in the pulmonary complication

Improve cilliary function

Decrease carboxy HB

Increase tissue oxygenation


Alcohol

>50 unit per week associated with

Liver enzyme induction and

anesthetic agent tolerance


Chronic history

Check the old anesthesia chart


Anesthesia Chart checking

History of difficult airway

Allergies

Complications(PONV,MH)


What is the absolute

contraindication for use of volatile

agents

Malignant hyperthermia


Preop-physical exam


Physical examination

• heart

• Lungs

• Airway


Heart

congested neck veins,murmurs ,PVD


Lungs

Wheezes,abnormal sounds,cynosis


Airway assessment

Lemon Score


Lemon score

• L:Look externally (abnormal faces,facial

trauma,large beard,large tongue)

• E:Evaluate the 3-3 rule(TM distance >3fingers,interincisor distance>3fingers)

• M:Mallampati score

• O:Obstruction(OSA,Head and neck tumor)

• N:Neck mobility


Labs and radiology


Hb ,Hct

• Anemia


Recommended indication for preop

hct

• Any suspicion of anemia

• Patient with renal failure or malignancy

• Neonates

• Patient older than 75

• Any procedure with major blood loss


Blood chemistry

• No blood chemistry are warranted for healthy patient less 65y

• If type B or C surgery to be done glucose ,BUN,albumin are indicated

Renal failure patient BUN,Creatinine,electrlytes

Post dialysis


In the end

Class Physical Status 48 hr mortality

I NHP < 80 years old 0.07%

II Mild systemic disease 0.24%

III Severe, not incapacitating systemic

disease

1.4%

IV Incapacitating disease that is a

constant threat to life

7.5%

V Moribund pt. not expected to survive 24

hrs regardless of surgery

8.1%

E Suffix added to class Doubles risk


It is not the challenge to put

the patient asleep,

but

the challenge to keep the

patient safe and satisfied

AHMAD ABOU LEILA


Thank you all for listening

See u in next seminar


From preopevaluation to

anesthesia planning


Red rubber tube


PONV risk factors

• Female gender

• Non smoker

• Prior history of PONV

• Inhalation agent

• Opiods

• Neostigmine

• Gynecological ,ophthaologhy surgeries


My plan to Prevent PONV

• Use propofol as induction agent

• Avoid opiods

• Avoid sudden movement or change in posture during recovery

• Avoid excessive use use of muscle relaxants

• Anti emetics – Metochlopramide 10mg 10-15 min before the end of

surgery

– Zofran 4 mg at the end of surgery

– Decadron at induction


Patient with Parkinson

Avoid

Metochlopramide


Patient with Parkinson

Drug of choice

diphenhyramine


Intestinal obstruction

Avoid metochlopramide


Risk of aspiration or GERD

Metochlopramide


Thank u


18 year old male patient known to be

previously healthy ,admitted to hospital for

knee arthroscopy

Which ASA class

What type of surgery

What lab test should be obtained

ASA 1

Type A surgery

NONE


Narr and co-workers at the Mayo

Clinic found no harm from

omitting all laboratory testing for

ASA I patients


65 year old male patient admitted for lap

chole,2months ago he was admitted for

cataract surgery ,he underwent extensive

lab testing including CBCD,Chem9,EKG

Would u repeat these tests?

ASA task forces states that results from medical record within 6

months of surgery are accepted if ther is no dramatic change

in the patient medical history


Preop evaluation

• Patient A has mitral

stenosis

•Patient B has mitral

regurge

My plan

Avoid tachycardia My plan

Avoid bradycardia


patient has symptomatic hyperthyroidism

and admitted for emergent sugery

Thyroid storm

My plan

1. Invasive monitoring

2. Big gauge IV

3. Measures to control fever

4. Prepare Beta blockers

5. Firs dose of PTU administered by NGT Ahmad Abou Leila-AUBMC


Patient A has sickle cell

anemia Patient B has PVD

What regional anesthesia must be avoided

IV regional anesthesia Ahmad Abou Leila-AUBMC

Preop evaluation

• Patient A has mitral

stenosis

• Patient B has mitral

regurge

My plan

Avoid tachycardia My plan

Avoid bradycardia


Ventilator setting in COPD

• TV :LOW

• RR:LOW

• FiO2:40%

• I:E =1/3


preop evaluation workshop (2)

Health & Medicine

mayo clinic

coronary artery

ahmad abou

continue tamsulosin

discontinue

preop evaluation

stress test

preop evaluation