Pre Operative Clearance for Non Cardiac Surgery:
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Pre Operative Clearance for Non Cardiac Surgery: ALL CLEAR Dominique Renee Abell, RN, MSN, CCRN, ACNP-BC (ACLS, PALS, TNCC) [email protected]

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Pre Operative Clearance for Non Cardiac Surgery: ALL CLEAR

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Pre operative clearance for non cardiac surgery all clear

Pre Operative Clearance for Non Cardiac Surgery:

ALL CLEAR

Dominique Renee Abell, RN, MSN, CCRN, ACNP-BC

(ACLS, PALS, TNCC)

[email protected]


Pre operative clearance for non cardiac surgery all clear

OBJECTIVES1. Outline evidence based practice guidelines related to pre operative evaluation for surgery2. Describe conditions that require pre operative diagnostic evaluations3. Review the findings that would postpone or cancel surgery


Pre operative clearance for non cardiac surgery all clear

“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

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 evaluation1

Goals of Preoperative Evaluation

  • Education of patient and family

    • Surgery

    • Anesthesia

    • Intraoperative care

    • Post operative pain control

    • Reduce anxiety

    • Facilitate recovery


Goals of preoperative evaluation2

Goals of Preoperative Evaluation

  • Reduce cost

  • Decrease length of stay

  • Reduce cancellations day of surgery

  • Increase patient/family satisfaction


Nurse practitioner responsibilities

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


Pre operative clearance for non cardiac surgery all clear

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


Pre operative clearance for non cardiac surgery all clear

ACC/AHA guidelines

ASA guidelines

Lee's Revised Cardiac Risk Index

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

Cardiac Risk


Cardiac risk indices

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


Pre operative clearance for non cardiac surgery all clear

Different Levels of RiskHigh:Unstable Coronary Symptoms- acute or recent MI with evidence of ischemiaUnstable or Severe AnginaDecompensated Heart FailureSymptomatic/Significant ArrhythmiasHigh Grade Atrioventricular BlockSevere Valve Disease


Pre operative clearance for non cardiac surgery all clear

Mild Angina

Previous MI

Compensated or History of Heart Failure

Diabetes Mellitus

Renal Insufficiency

Intermediate:


Pre operative clearance for non cardiac surgery all clear

Advanced Age

Abnormal ECG

Any other Rhythm besides Sinus

Low functional Capacity

History of Stroke

Uncontrolled Hypertension

Minor:


Pre operative clearance for non cardiac surgery all clear

Primary car provider

patient

surgeon

anesthesiologist


History and physical

Vital signs

Central and Peripheral pulses

Lungs/Cardiac Auscultation/Palpation

Abdominal palpation

Examine Lower Extremities

Functional Capacity

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


History and physical1

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

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,


Functional capacity

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

  • 1 Metabolic Equivalent (MET)


Functional capacity1

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

  • 4 MET


Functional capacity2

Swimming, singles tennis, football, basketball, skiing

Functional Capacity

  • >10 MET


Continue current medications cardio protective beta blockade coronary angiography revascularization

Continue current medications

Cardio-protective Beta Blockade

Coronary angiography/revascularization

Management of Cardiac Risk


Pulmonary complication

Pulmonary Complication

  • Definition: revised to clinically significant

    • Pneumonia

    • Respiratory failure with prolonged mechanical ventilation

    • Bronchospasm

    • Atelectasis

    • Exacerbation of underlying lung disease


Pulmonary complications

Pulmonary Complications

  • Decreased functional residual capacity/vital capacity

    • Cough

    • Aspiration pneumonia

    • Atelectasis

    • Pneumonia

    • Smoking- even in absence of lung disease


Pulmonary complications1

Pulmonary complications

  • Procedure specific risk factors

    • Surgical site- most important risk factor

    • Duration

    • Anesthesia

    • Neuromuscular blockade


Pulmonary complications2

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 complications3

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 complications4

Pulmonary Complications

  • Intraoperative

    • Surgery less than 3 hours

    • Spinal or epidural

    • Regional or local blocks

    • Avoid pancuronium

    • Minimally invasive as possible

      • laparoscopic


Pulmonary complications5

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

Hematologic Risk

  • Hematocrit < 24%

  • Thrombocytopenia <50,000

  • History of bleeding diathesis

  • Cirrhosis

  • Hematologic malignancy

  • Antiplatelet medication

  • Anti-coagulation therapy

  • DVT/VTE prophylaxis


Chronic medications

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 medications1

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 medications2

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


Pre operative clearance for non cardiac surgery all clear

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Pre operative clearance for non cardiac surgery all clear

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Lee, MD, P., Rabkin, MD, M. Medical assessment of the perioperative patient: Preoperative assessment. Retrieved from http://www.medicineclinic.org

Olson, E. (2013, April 30). Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea. Retrieved from www.uptodate.com

Shammash, MD, J., Kimmel, MD, MS, S., Morgan, MD, PhD, Morgan, J. (2013, November 20). Estimation of cardiac risk prior to noncardiac surgery. Retrieved from www.uptodate.com


Pre operative clearance for non cardiac surgery all clear

Shammash, MD, J., Kimmel, MD, MS, S., Morgan, MD, PhD, Morgan, J., Devereaux, MD, PhD, P. (2014, February 4). Management of cardiac risk for noncardiac surgery. Retrieved from www.uptodate.com

Schumann, MD, R. (2013, November 26). Perianesthesia medical evaluation of the obese patient. Retrieved from www.uptodate.com

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Pre operative clearance for non cardiac surgery all clear

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