risk assessment in noncardiac surgery
TRANSCRIPT
Risk assessment in noncardiac surgery
Lee’s Revised cardiac risk index
High risk surgery h/o IHD h/o CHF h/o CVA Preop insulin tmt Creat >2
Some include age also.
Zero- low
One or two –intermediate
Three or more- high
Risk of surgery
Aortic, major vascular, peri. vascular- high
Intraperitoneal,intrathoracic, carotid endarterectomy, head&neck, orthopedic, prostate- intermediate
Endoscopy, superficial, cataract, breast, ambulatory- low.
Step 1
Emergency Sx
Op.room Periop surveillance, postop risk stratification & mmt.
Step 2
Elective
yes
Active cardiac conditions
Evaluate & treat, consider OR
Active cardiac conditions Acute MI / Recent MI Unstable angina,
recent MI Decompensated HF Significant
arrhythmias
Severe valve d/s- severe AS, severe MS
High grade AV blockSymtomatic ventricular ASVT HR > 100Symptomatic brady
Step 3
No ACC
Low risksurgery Proceed with sx
Step 4
Intermediate or high risk
Functional capacity > 4 mets without symptoms
yes
proceed
Functional capacity
1 met: taking care of self, eat, dress, use toilet, indoor walking.
4 met: light work, climb a flight of stairs, golf, dancing.
>10 met: strenuous sports.
Step 5
No or unsure of functional capacity
No clinical risk factors
proceed
Step 5
No clinical risk factors Proceed with planned surgery
1 or 2 RF(vascular / intermediate risk sx)
Proceed with HR control or consider noninvasive testing If it will change mmt.
Step 5
3 or more RF intermediate
Proceed with HR control or noninvasive testing If it will change mmt.
High
Testing if it change mmt
Management changes
Cancellation of sx for prohibitive risk
Delay of sx for further medical mmt.
Coronary interventions before sx.
Use of ICU.
Changes in monitoring.
Noninvasive testing
Exercise ECG
Phamacologic stress imaging
Stress echocardiography
Role of MRI, multislice CT, coronary calcium scores, PET is rapidly evolving.
IHD
ACS & decompensated HF of ischaemic origin high risk of periprocedural further worsening.
Highest risk cohort: within 30 days of
MI.
SHTN
Htve crisis postop: DBP>120 and end organ damage- papilloedema, myocardial ischaemia, ARF.
Withdrawal of antiHTve tmt may ppt.
SHTN
SX need not be postponed in uncomplicated mild to moderate HTN.
Severe HTN DBP >110, benefits of delaying sx Vs risk of delaying sx. IV drugs may be used.
HF
Assessment help to adjust periop fluid & vasopressor mmt.
HOCM: thought to be high risk, but major sx under GA– low risk. Relative C.I for SA
Valvular HD
Aortic systolic murmurs require full eva’n. MV d/s less risk. Prosthetic heart valve: I.E. pxis. Stop Oral AntiCoagulants 5 days prior, INR < 1.5, restart pop day 1. Conversion to heparin periop period. LMWH cost effective, residual anticoagulant effect in two
thirds.
Prosthetic valve- AHA/ACC guidelines
Heparin in only•Mechanical MV/TV.•Mechanical AV with AF Prev. thromboembolism Hypercoagulable state Older gen. valve EF < 30% > 1 mech. valve
Cong. HD in adults
Presence of PHT & Eisenmenger
Avoid regional anasthesia, sympathetic blockade , worsening R to L shunt.
Preop coronary revasc
Class 1 1. Stable angina with LMCA d/s. 2. SA with TVD esp. if EF < 50 3. SA, DVD with prox. LAD d/s &
either EF < 50% or demonstrable
ischaemia 4. High risk UA or NSTEMI 5. Acute STEMI
Sx in prior revasc
CABG in last 5 yrs- sent for sx without delay
Bare Metal Stent- minimum of 6 wks, optimum of 3 mths.
Drug Eluting Stent- one yr.
Balloon Angioplasty- 2 wks
Previous PCI
Balloon Angioplasty < 14 days- delay for elective sx.
> 14 days- proceed with asp.
Previous PCI
BMS
>30-45 days : proceed with asp. < 30-45 days : delay sx
Previous PCI
DES
< 1 yr : delay sx
> 1 yr : proceed with asp.
Beta blockers
Continuation of BB : class 1
Use of BB titrated to HR & BP : class 11-A in Vascular sx with CAD Ishaemia on preop testing.
Routine high dose BB without dose titration maybe harmful.