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Preoperative Medical Evaluation. Colin McMahon, MD. Division of Combined Internal Medicine and Pediatrics University at Buffalo, School of Medicine. What are You Really Being Asked to Do?. Assess risks of anesthesia Assess the risks of the procedure Manage “complicated” medical problems

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preoperative medical evaluation

Preoperative Medical Evaluation

Colin McMahon, MD.

Division of Combined Internal Medicine and Pediatrics

University at Buffalo, School of Medicine

what are you really being asked to do
What are You Really Being Asked to Do?
  • Assess risks of anesthesia
  • Assess the risks of the procedure
  • Manage “complicated” medical problems
  • Predict the future
general considerations
General Considerations
  • Limit number of recommendations
  • Focus on critical problems
  • Be specific about drugs, dosage and intervals
  • Don’t ask the surgeon to think
general approach
General Approach
  • Diagnosis
    • Develop a problem list
  • Treatment
    • Directed toward decreasing surgical risk
  • Prognosis
    • Anesthesia complications
    • Procedural complications
misconceptions
Misconceptions
  • Advise on type of anesthesia
    • General, local or spinal
  • Change ongoing treatment plans
  • Initiate diagnostic work-ups
risk evaluation
Risk Evaluation
  • Overall perioperative mortality – 0.3%
  • Anesthesia induction – 10%
  • Intraoperatively – 35%
  • Postoperatively (48 hours) – 55%
procedure risk
Procedure Risk
  • Low risk
    • Eye surgery, oral surgery, D&C, hysterectomy, herniorrhaphy
  • High risk
    • Craniotomy and cardiovascular
specific risks
Specific Risks
  • Pulmonary
  • Cardiac
  • Hematologic
  • Endocrine
  • Thromboembolism Prophylaxis
pulmonary risks
Pulmonary Risks
  • Complications
    • Hypoventilation
    • Pneumonia
    • Atelectasis
  • Occur in about a third of patients
  • Accounts for half of perioperative mortality
who s at risk
Who’s at Risk
  • Smokers
  • COPD
  • Obesity
  • Age > 70
  • Thoracic surgery
  • Upper abdominal surgery
  • Anesthesia > 2 hours
risk assessment
Risk Assessment
  • FEV1 > 2L, probably safe
  • FEV1 between 1 and 2L, increased risk
  • FEV1 <1L, high risk
risk management
Risk Management
  • Quit smoking
  • Bronchodilator therapy
  • CPT
  • Early treatment of bronchitis
  • Early mobilization
cardiac risks
Cardiac Risks
  • Complications
    • Myocardial Infarction
    • CHF
    • Hypertension
  • 50% fatal, 60% silent
  • Increased mortality post-op day 3
who s at risk15
Who’s at Risk
  • Recent MI
  • Valvular heart disease
  • CHF
  • Unstable angina
  • Diabetes
risk assessment16
Risk Assessment
  • Goldman Cardiac Risk-Index for Noncardiac Surgery
  • American College of Cardiology Risk Assessment
risk management17
Risk Management
  • Monitor for perioperative ischemia
  • Repair severe aortic stenosis first
  • Treat CHF aggresively preoperative
  • Postpone non-emergent procedures for at least 6 months after an MI
hemetologic risks
Hemetologic Risks
  • Complications
    • Thromboembolic
    • Bleeding
who s at risk19
Who’s at Risk
  • Polycythemia vera
  • Thrombocytopenia
risk assessment20
Risk Assessment
  • Hematocrit
  • Platelet count
  • Bleeding time
  • PT/PTT
risk management21
Risk Management
  • Phlebotomy to decrease hct < 45%
  • Maintain plts > 50,000
endocrine risks
Endocrine Risks
  • Thyroid storm
  • Diabetic complications
risk management23
Risk Management
  • Good control of thyroid function for at least 3 months prior
  • Hold oral hypoglycemics
  • Reduce insulin by half
thrombembolic prophylaxis
Thrombembolic Prophylaxis
  • Specific to surgery
  • Increased risk
    • Elderly
    • Obesity
    • Prolonged anesthesia
    • Immobility
other considerations
Other Considerations
  • Antibiotic prophylaxis
  • Herbal medicines
  • Geriatric patient