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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?. Assess risks of anesthesia Assess the risks of the procedure Manage “complicated” medical problems

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Preoperative Medical Evaluation

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  1. Preoperative Medical Evaluation Colin McMahon, MD. Division of Combined Internal Medicine and Pediatrics University at Buffalo, School of Medicine

  2. 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

  3. General Considerations • Limit number of recommendations • Focus on critical problems • Be specific about drugs, dosage and intervals • Don’t ask the surgeon to think

  4. General Approach • Diagnosis • Develop a problem list • Treatment • Directed toward decreasing surgical risk • Prognosis • Anesthesia complications • Procedural complications

  5. Misconceptions • Advise on type of anesthesia • General, local or spinal • Change ongoing treatment plans • Initiate diagnostic work-ups

  6. Risk Evaluation • Overall perioperative mortality – 0.3% • Anesthesia induction – 10% • Intraoperatively – 35% • Postoperatively (48 hours) – 55%

  7. ASA Classification

  8. Procedure Risk • Low risk • Eye surgery, oral surgery, D&C, hysterectomy, herniorrhaphy • High risk • Craniotomy and cardiovascular

  9. Specific Risks • Pulmonary • Cardiac • Hematologic • Endocrine • Thromboembolism Prophylaxis

  10. Pulmonary Risks • Complications • Hypoventilation • Pneumonia • Atelectasis • Occur in about a third of patients • Accounts for half of perioperative mortality

  11. Who’s at Risk • Smokers • COPD • Obesity • Age > 70 • Thoracic surgery • Upper abdominal surgery • Anesthesia > 2 hours

  12. Risk Assessment • FEV1 > 2L, probably safe • FEV1 between 1 and 2L, increased risk • FEV1 <1L, high risk

  13. Risk Management • Quit smoking • Bronchodilator therapy • CPT • Early treatment of bronchitis • Early mobilization

  14. Cardiac Risks • Complications • Myocardial Infarction • CHF • Hypertension • 50% fatal, 60% silent • Increased mortality post-op day 3

  15. Who’s at Risk • Recent MI • Valvular heart disease • CHF • Unstable angina • Diabetes

  16. Risk Assessment • Goldman Cardiac Risk-Index for Noncardiac Surgery • American College of Cardiology Risk Assessment

  17. 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

  18. Hemetologic Risks • Complications • Thromboembolic • Bleeding

  19. Who’s at Risk • Polycythemia vera • Thrombocytopenia

  20. Risk Assessment • Hematocrit • Platelet count • Bleeding time • PT/PTT

  21. Risk Management • Phlebotomy to decrease hct < 45% • Maintain plts > 50,000

  22. Endocrine Risks • Thyroid storm • Diabetic complications

  23. Risk Management • Good control of thyroid function for at least 3 months prior • Hold oral hypoglycemics • Reduce insulin by half

  24. Thrombembolic Prophylaxis • Specific to surgery • Increased risk • Elderly • Obesity • Prolonged anesthesia • Immobility

  25. Other Considerations • Antibiotic prophylaxis • Herbal medicines • Geriatric patient

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