Preoperative medical evaluation consultation of the healthy patient
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Preoperative Medical Evaluation/Consultation of the Healthy Patient. Greg Rosencrance, MD 2006 Nevada Chapter Scientific Meeting Saturday June 14, 2006 Las Vegas, Nevada. Principles of Consultation. Determine the question Establish the urgency Gather data “look for yourself”

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Preoperative medical evaluation consultation of the healthy patient

Preoperative Medical Evaluation/Consultation of the Healthy Patient

Greg Rosencrance, MD

2006 Nevada Chapter

Scientific Meeting

Saturday June 14, 2006

Las Vegas, Nevada


Principles of consultation

Principles of Consultation

  • Determine the question

  • Establish the urgency

  • Gather data “look for yourself”

  • Communicate briefly

  • Make specific recommendations

  • Understanding of the role

  • Communicate directly

  • Provide appropriate follow-up


Compliance with recommendations

Compliance with Recommendations

  • Improves with Brevity

  • Predictors

    • Severity of illness

    • Type and number < 5

  • Best with medications

  • Worst with those requiring action

  • Interaction with requesting physician


Following of patients

Following of Patients

  • Patients should be followed through the postoperative period. Perioperative MI’s peak at the 3rd to 5th days.


Clearance

Clearance

  • You are not “clearing” the patient for surgery

  • Seek factors that may put the patient at higher than average risk and try to reduce these

  • Risks are specific to the individual patient, type of procedure, type of anesthesia

  • Average Risk


Anesthesia effects

Anesthesia Effects

  • JAMA 1988, 100,000 procedures

    • patient and surgical risk factors were more important than anesthesia factors

      • duration

      • experience of operator

      • inhalation techniques

JAMA 1988;260:2859


Asa or dripps

ASA or Dripps

  • Considers mortality based on the general clinical impression

  • Diagnose the severity of systemic illness

  • Reproducible despite broadly defined categories


Asa criteria

ASA Criteria

American Society of Anesthesiologists Classification of

Preoperative Risk*

ASASystemic disturbanceMortality

1Healthy patient with no disease <0.03 percent outside of the surgical process

2Mild to moderate systemic disease 0.2 percent caused by the surgical condition

or by other pathological processes

3Severe disease process which 1.2 percent limits activity but is not incapacitating


Asa criteria1

ASA Criteria

ASASystemic disturbance Mortality

4Severe incapacitating disease process 8 percent

that is constant threat to life

5Moribund patient not expected to survive 34 percent

24 hours with or without an operation

E Suffix to indication emergency surgery Increased

for any class

* Adapted from Cohen, MM, Duncan, PG, Tate, RB, JAMA 1988; 260:2859


Anesthetic risk

Anesthetic Risk

  • Stress Responses

  • Adverse and Idiosyncratic Reactions

    • eg malignant hyperthermia and hepatitis

  • Organ system effects

    • myocardial depressants (preload dependent)

      • dehydration

      • autonomic neuropathies


Anesthetic risk1

Anesthetic Risk

  • Effects of inhalational anesthesia

    • decrease in FRC with atelectasis and V/Q mismatch

    • loss of sighs

    • decreased mucociliary clearance


Type of anesthesia

Type of Anesthesia

  • No difference in cardiac or overall perioperative mortality between general or spinal anesthesia

  • Lower risk with minor regional anesthesia

  • Since the type of anesthesia does not influence mortality, the medical consultant should not recommend a particular anesthetic technique


Clinical evaluation

Clinical Evaluation

Preoperative Patient Questionnaire†

  • Do you feel unwell?

  • Have you ever had any serious illnesses in the past?

  • Do you get any more short of breath with exertion than other people of your age?

  • Do you have any coughing?

  • Do you have any wheezing ?

  • Do you have any ankle swelling?

  • Have you taken any medicine or pills in the last three months (including excess alcohol)?


Clinical evaluation continued

Clinical Evaluation (continued)

Preoperative Patient Questionnaire*

  • Have you any allergies?

  • Have you had an anesthetic in the last two months?

  • Have you or your relatives had any problems with a previous anesthetic?

  • Observation of serious abnormality from “end of bed” which might affect anesthetic ?

  • What is the date of your last menstrual period?

    *Adapted from Wilson, ME, Williams, MB, Baskett, PJ, et al, BR Med J 1980; 1:509


Exercise capacity

Exercise Capacity

  • Ask all patients

  • Two Blocks on level ground or carrying two bags of groceries up one flight of stairs without symptoms = 4 METS

  • Average cardiac risk if they can perform these


Preoperative medical evaluation

Age

  • Increased Risk with Increased Age

  • 50,000 elderly patients (elective)

    • Under 60, 1.3% mortality

    • 80-89, 11.3% mortality

Ann Intern Med 2001;134:637


Preoperative medical evaluation

Age

  • 795 patients over 90

    • 80% ASA 3 or higher

    • Survival at 2 years no different than controls

    • Age alone should not be used as the sole criterion to withhold surgery

Ann Intern Med 2001;134:637


Laboratory evaluation

Laboratory Evaluation

  • 2000 pts undergoing elective surgery

    • 60% would not have been performed if testing had been done for recognizable indications

    • 0.22% revealed abnormalities that might influence perioperative management

    • May increase medicolegal risk

JAMA 1985;253:3576


Laboratory evaluation1

Laboratory Evaluation

Probability of an Abnormal Screening Test Result


Laboratory evaluation2

Laboratory Evaluation

Predictive Value of Positive Test Results


Laboratory evaluation3

Laboratory Evaluation

  • Probably safe to use labs that were performed and normal within the past 4 months unless a change in the clinical status

  • 7549 preop tests in 1109 patients

    • 47% duplicates within the prior year

    • 461 abnormal 78 (17%) of repeat values were outside accepted norms

Ann Intern Med 1990;113:969


Laboratory evaluation4

Laboratory Evaluation

  • CBC

    • Anemia in 1% of asymptomatic patients

    • Use as a baseline in patients expected to have significant blood loss

    • No evidence to support baseline testing of WBC or Platelets

JAMA 1985;253:3576


Laboratory

Laboratory

  • Electrolytes

    • 0.6% frequency of abnormality

    • relationship between operative morbidity is unclear

    • Routine determinations are not recommended

JAMA 1985;253:3576


Laboratory1

Laboratory

  • Renal Function

    • 0.2% prevalence of elevated creatinine if asymptomatic and no renal history

    • prevalence increases with age

    • 46-60 9.8% prevalence

    • Renal Insufficiency is associated with increased surgical morbidity

    • reasonable to obtain Cr if > 50


Laboratory2

Laboratory

  • Glucose

    • Abnormalities increase with age

    • 25% of patients > 60 have an increase

    • operative risk and diabetes

      • vascular or CABG

    • Routine not rec prior to elective surgery

    • Exceptions obese,steroids,FH


Laboratory3

Laboratory

  • LFT’s

    • 0.3% of asymptomatic patients

    • severe abnormalities increase morbidity

    • not clear if mild abnormalities are similar

    • Routine testing not recommended


Laboratory4

Laboratory

  • Hemostasis

    • Routine testing is not indicated

    • Restrict to those with a known bleeding diathesis


Laboratory5

Laboratory

  • Urinalysis

    • Relationship between asymptomatic urinary tract infections and surgical infection is unclear

    • 4.58 wound infections in nonprosthetic knee operations may be prevented by the use of routine urinalysis.

    • $1.5 million per wound infection prevented


Laboratory6

Laboratory

  • EKG

    • Abnormalities increase with age

    • Unsuspected arrhythmias

      • other than sinus, >5 PVC’s, PAC’s increases risk of perioperative cardiac events

    • BBB does not increase the risk of cardiac complications following non cardiac sugery


Laboratory7

Laboratory

  • Electrocardiogram

    • Unrecognized myocardial infarctions are relatively common

    • Framingham study

      • 5127 participants, 708 MI’s, 25% were identified only via routine EKG

      • Proportion of unrecognized infarcts higher in women and older men


Ekg guidelines

EKG Guidelines

  • Men > 40

  • Women > 50

  • Known cardiac disease

  • Clinical Evaluation suggesting the possibility of cardiac disease

  • Patients at risk for electrolyte abnormalities


Ekg guidelines1

EKG Guidelines

  • DM, HTN

  • Major Surgical Procedures


Chest x ray

Chest X-Ray

  • Add little

  • 905 surgical admissions

    • screened for risk factors for abnormal preop CXR,

      • age>60, clinical findings c/w cardiac or pulmonary disease

      • no risk factors in 368, 1 (0.3%) had an abnormal cxr which did not affect surgery


Chest x ray1

Chest X-Ray

  • 504 had identifiable risk factors

    • 114 (22%) had significant abnormalities

  • Meta analysis 21 studies

    • 14,390 routine cxr

    • 1444 abnormal, 140 unexpected, 14 ( 0.1%) influenced management

  • CXR not routinely performed unless > 60, or suspected cardiac or pulmonary disease


Pulmonary function tests

Pulmonary Function Tests

  • Not routinely recommended for healthy patients

  • ACP recs:

    • lung resection surgery, CABG, upper abdominal surgery w/tobacco history, head and neck or orthopedic surgery w/ uncharacterized pulmonary disease


Summary

Summary

  • Screening questionnaire for all patients

  • History of exercise tolerance for all

  • BP and pulse for all

  • H&P if one of the above is abnormal, > 60, or major surgery

  • Pregnancy test for women who may be pregnant

  • Hg if suspected major blood loss


Summary1

Summary

  • Creatinine if hypotension is suspected, nephrotoxic drugs, > 50

  • EKG unless within 1 month criteria as stated

  • CXR if > 60, suspected disease unless within 6 months

  • PFT’s per ACP position statement

  • All other tests only if clinical evaluation suggests a likelihood of disease


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