PERIOPERATIVE RISK Assessment and Improvement

1. Anwer Ghani FIBMS Iraq PERIOPERATIVE RISKAssessment and Improvement

2. The goals • The goals of preoperative assessment • (1) Reduce the morbidity associated with surgery. • (2) Increase the quality of perioperative care. • (3) Decrease the cost.

3. Systematic Assessment • The Role of History (Hx) • The Role of Physical Examination (Ex) • History and examination are very important in perioperative risk assessment. • The Role of Investigations (Ix) • The Role of Diagnosis (Dx) • The surgery, the cardiac disease, the frailty and the comorbidity are very important factors in perioperative risk. • Conclusions

4. Hx • General Hx: • Specific Hx: • Hx of bleeding disorder: • Hx of a problem with wound healing: • Hx of anticoagulants, anti-angina drugs: • Hx of Allergies: • Hx of Active cardiac disease:

5. Hx Hx Hx of specific risk factors □Arrhyth □HRT □CAD □Heart D □COPD □Asthma □thromb.

6. Hx • Hx of bleeding disorder • -a clotting disorder? • -nosebleed for no apparent reason? • -bruises under the skin for no apparent reason? • -bleeding into the joints? • -prolonged bleeding after a cut? • -unusually intense bleeding during an operation? • - unusually intense menstruation?

7. Ex • Upper respiratory pathway: • Heart: • Lungs: • Cardiopulmonary reserve: • Potential signs of heart failure:

8. Ex . MET

9. Hx & Ex • If the initial evaluation (Hx & Ex) yields no evidence of any conditions significantly affecting the perioperative risk, then, as a rule, no further testing is needed.

10. Ix • ►: Routine • ►Hb: ►WBCC: ► Plat: • ►RBS: ►BU: ► Scr: • ►ECG • The value of a routine preoperative ECG is not yet fully clear.

11. Ix • □: On indication • □CXR: □PFT: • □Echo.: □U/S: • □ Another test:

12. Ix • -There is no reason to perform laboratory testing routinely in all cases. • -There is no correlation between the number of abnormal laboratory findings and the outcome of surgical treatment. • -Laboratory tests of coagulation should be performed only if indicated by a specific drug history or a positive bleeding history.

13. Dx • The operation: ……. • □ high risk □ low risk • The cardiac disease: ……. • □ Uncontrolled □ Controlled

14. Dx Perioperative risk factors: • □DM • □HRT • □ Coagulopathies • □Anemia • □Obesity • □allergies • □Old age (frailty) • □Other Co-morbidity:

15. Dx • Low risk surgery: • -superficial procedures • -endoscopic procedures • -breast surgery • -cataract surgery

16. Dx • Cardiac risk factors • CAD • PAD • CHF • CVA • DM • CRF

17. Dx • CFS

18. Dx • The strongest predictors of perioperative complications are the patient’s pre-existing illnesses.

19. The Risk • Predictors of periop. complications: • -Age (Frailty) • - Invasiveness of the procedure, • -History of renal disease • - Anemia • -Abnormal ECG.

20. The Risk • Perioperative risk: • - Active (uncontrolled) Heart disease risk: • - Cardiac risk factor: • - Surgery risk: • - Frailty risk: • - Co-morbidity risk: • Expert Opinion: • 0 = low risk • 1 but not active HD = intermediate. • 2 or more, or active HD = high risk.

21. The Risk • Outcome: • -LOS • -Complications • -Mortality • -Readmission

22. The Risk • The Recommendations: • -Risk assessment and outcome discussion • - Improve the outcome • - Modifying the risk • - Precautions and recommendations • - Pre, intra and post-operative management. • -Interventions and consultations.