Preoperative medical assessment
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Preoperative Medical Assessment. Eric E. Leonheart DPM. Primary Assessment. History (Detailed) Physical Exam Review of Rx Medication Review of Non-Rx Medication Evaluation of Organ Systems Advanced Directives. Other considerations. Functional status Risk level of the surgery

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Preoperative Medical Assessment

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Preoperative medical assessment

Preoperative Medical Assessment

Eric E. Leonheart DPM


Primary assessment

Primary Assessment

  • History (Detailed)

  • Physical Exam

  • Review of Rx Medication

  • Review of Non-Rx Medication

  • Evaluation of Organ Systems

  • Advanced Directives


Other considerations

Other considerations

  • Functional status

  • Risk level of the surgery

  • Expected blood loss

  • Anesthesia type and duration


History

History

  • HPI (NLDOCAT)

  • PMH

  • PSH

  • Medications

  • Family History

  • Social History

  • Review of systems


Cardiac evaluation

Cardiac Evaluation

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


Cardiac evaluation1

Cardiac Evaluation

  • Phase 1

    • Emergent or elective

      • If emergent and the patient’s life is in danger proceed with surgery

    • Undergone revascularization within 5 years

    • Received a recent coronary evaluation


Cardiac evaluation2

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


Cardiac evaluation3

Cardiac Evaluation

  • Risk stratification

    • Helps to determine the necessary work up based on the risk inherent to the procedure, patient’s PMH and functional status


Risk stratification

Risk Stratification

  • High Risk

    • Unstable angina, Unstable CHF, Symptomatic ventricular arrhythmias

    • Must have their cardiac problems resolved prior to elective procedure


Risk stratification1

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


Risk stratification2

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


Risk stratification3

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


  • Antibiotic prophylaxis

    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


    Pulmonary evaluation

    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


    Hematology evaluation

    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

      • >100,000 mm³ for major surgery


    Hematology evaluation1

    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


    Endocrine evaluation

    Endocrine Evaluation

    • Objective

      • Is to rule out diabetes or thyroid disease

      • Evaluate control of blood sugar

      • Determine whether the patient is experiencing adrenal suppression


    Endocrine evaluation1

    Endocrine Evaluation

    • Diabetes

    • Fasting blood sugar < 200mg/dL

    • If elevated must gain control with oral hypoglycemics or insulin prior to surgery


    Endocrine evaluation2

    Endocrine Evaluation

    • Thyroid disorders

      • Common symptoms, fatigue and constipation

      • TSH testing, possibly T3 or T4

      • Regulation of TSH is needed prior to surgery


    Endocrine evaluation3

    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


    Endocrine evaluation4

    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


    Gastrointestinal evaluation

    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


    Urologic evaluation

    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


    Neurologic evaluation

    Neurologic Evaluation

    • Conditions of concern

      • Myasthenia gravis

      • Amyotrophic lateral sclerosis

      • Parkinson’s

      • CVA

      • Seizures

      • Dementia


    Neurologic evaluation1

    Neurologic Evaluation

    • MG, ALS neuromuscular disorders

      • Increased complications with general anesthesia

      • Greater difficulty with function post-op

    • CVA

      • > incidents of clot formation, take perioperative precautions

      • SCD, anti-coagulate (LMH), ROM, no tourniquet


    Neurologic evaluation2

    Neurologic Evaluation

    • Seizures

      • Inherent risk to themselves during and after surgery

    • Delirium

      • > incident with; age, MI, hypoxia, hypotension. dementia, CVA, electrolyte abnormalities, ulcer, bleeding, constipation, urinary retention, infection, hypoalbuminemia, medications (opiates), trauma, pain


    Psychiatric issues

    Psychiatric Issues

    • High incident of ETOH abuse

    • Benzodiazepine abuse is common

    • Smoking history

    • Must manage withdrawal


    Functional status

    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


    Conclusion

    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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