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Preoperative Medical Assessment. Eric E. Leonheart DPM. Primary Assessment. History (Detailed) Physical Exam Review of Rx Medication Review of Non-Rx Medication Evaluation of Organ Systems Advanced Directives. Other considerations. Functional status Risk level of the surgery

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preoperative medical assessment

Preoperative Medical Assessment

Eric E. Leonheart DPM

primary assessment
Primary Assessment
  • History (Detailed)
  • Physical Exam
  • Review of Rx Medication
  • Review of Non-Rx Medication
  • Evaluation of Organ Systems
  • Advanced Directives
other considerations
Other considerations
  • Functional status
  • Risk level of the surgery
  • Expected blood loss
  • Anesthesia type and duration
history
History
  • HPI (NLDOCAT)
  • PMH
  • PSH
  • Medications
  • Family History
  • Social History
  • Review of systems
cardiac evaluation
Cardiac Evaluation
  • American College of Cardiology & American Heart Association published guidelines in 1996
cardiac evaluation1
Cardiac Evaluation
  • Phase 1
    • Emergent or elective
      • If emergent and the patient’s life is in danger proceed with surgery
    • Undergone revascularization within 5 years
    • Received a recent coronary evaluation
cardiac evaluation2
Cardiac Evaluation
  • Elective workup
    • PMH, functional status, ECG
      • Abnormal findings non-invasive testing (exercise stress test, thallium stress, dobutamine stress )
      • If abnormal results are found on stress test may proceed to invasive testing (angiogram, catheterization
      • If abnormal results are found may require coronary artery bypass graft (CABG) prior to elective procedure
cardiac evaluation3
Cardiac Evaluation
  • Risk stratification
    • Helps to determine the necessary work up based on the risk inherent to the procedure, patient’s PMH and functional status
risk stratification
Risk Stratification
  • High Risk
    • Unstable angina, Unstable CHF, Symptomatic ventricular arrhythmias
    • Must have their cardiac problems resolved prior to elective procedure
risk stratification1
Risk Stratification
  • Intermediate Risk
    • Mild angina pectoris, stable or prior CHF
    • May proceed to surgery if functional status is good
    • If functional status is poor (bed-bound or difficulty walking) additional workup needed
risk stratification2
Risk Stratification
  • Low Risk
    • Can proceed to surgery without additional workup unless:
      • Scheduled for high risk surgery (major vascular procedure)
      • AND have poor functional capacity (walk two or three blocks, climb stairs, light activity around the house) additional workup
risk stratification3
Risk Stratification
  • Based on procedure
  • High Risk
      • Emergencies, Aortic, Major vascular, peripheral vascular, prolonged procedures w/ fluid shifts and/or blood clots
  • Intermediate Risk
      • Carotid, Head & Neck, Intraperitoneal, Intrathoracic, Orthopedic, Prostate
  • Low Risk
      • Endoscopic, Dermatologic, Cataract, Breast
antibiotic prophylaxis
Antibiotic Prophylaxis
  • Bacterial endocarditis
  • Recommendations change frequently
  • MVP without leaflet thickening and no regurgitation no abx. necessary
  • MVP with thickened leaflets and some regurgitation abx. appropriate
pulmonary evaluation
Pulmonary Evaluation
  • Can obtain pulmonary status from history
  • Exercise tolerance, walk up steps with or without shortness of breath, chest pain with activity
  • History of asthma, COPD
    • Pulmonary function tests can help in patient management prior to surgery
    • Arterial blood gas may be drawn on pt. with COPD to determine if retaining CO2 or hypoxemic at rest
hematology evaluation
Hematology Evaluation
  • History of bleeding disorder, scheduled for high risk neurologic procedures
    • Order PT (prothrombin time), PTT (partial thromboplastin time), INR (international normalized ratio)
  • Platelets
    • >100,000 mm³ for major surgery
hematology evaluation1
Hematology Evaluation
  • Medications
    • Anticoagulant held 48-72 hours prior to surgery
    • Antiplatelet (aspirin) held 5-7 days prior to surgery
    • If patient requires continuous anticoagulation IV heparin
endocrine evaluation
Endocrine Evaluation
  • Objective
    • Is to rule out diabetes or thyroid disease
    • Evaluate control of blood sugar
    • Determine whether the patient is experiencing adrenal suppression
endocrine evaluation1
Endocrine Evaluation
  • Diabetes
  • Fasting blood sugar < 200mg/dL
  • If elevated must gain control with oral hypoglycemics or insulin prior to surgery
endocrine evaluation2
Endocrine Evaluation
  • Thyroid disorders
    • Common symptoms, fatigue and constipation
    • TSH testing, possibly T3 or T4
    • Regulation of TSH is needed prior to surgery
endocrine evaluation3
Endocrine Evaluation
  • Adrenal insufficiency
    • Common in older patients
    • Even 5mg q.d. for a year can cause adrenal suppression
    • Require perioperative supplementation of corticosteroids
    • RA patients need C spine x-rays, subluxation of atlantoaxial joint, hyperextension of the neck severed spinal cord
endocrine evaluation4
Endocrine Evaluation
  • Normal supplement of hydrocortisone is 20-30mg/day
  • Perioperatively increase to 200-300 mg/day usually IV and can taper down if patient is afebrile and improving on day 4 or 5 postoperative
gastrointestinal evaluation
Gastrointestinal Evaluation
  • History liver disease
    • PT, INR evaluate coagulation
    • Albumin testing
    • May change anesthesia due to metabolism of agent
    • History of ulcers or GI bleeds, may change post-op oral meds
    • Opiates can decrease peristalsis and lead to post-op constipation
    • Constipation can actually lead to delirium in patients with mild dementia
urologic evaluation
Urologic Evaluation
  • Appropriate for;
    • Frequency, urgency, incontinence, hesitancy
    • May be signs of UTI
    • Patients with recent UTI should have U/A repeated if undergoing orthopedic procedures
    • BPH may lead to urinary retention post-op leading to UTI, pain, and the necessity for catheterization
neurologic evaluation
Neurologic Evaluation
  • Conditions of concern
    • Myasthenia gravis
    • Amyotrophic lateral sclerosis
    • Parkinson’s
    • CVA
    • Seizures
    • Dementia
neurologic evaluation1
Neurologic Evaluation
  • MG, ALS neuromuscular disorders
    • Increased complications with general anesthesia
    • Greater difficulty with function post-op
  • CVA
    • > incidents of clot formation, take perioperative precautions
    • SCD, anti-coagulate (LMH), ROM, no tourniquet
neurologic evaluation2
Neurologic Evaluation
  • Seizures
    • Inherent risk to themselves during and after surgery
  • Delirium
    • > incident with; age, MI, hypoxia, hypotension. dementia, CVA, electrolyte abnormalities, ulcer, bleeding, constipation, urinary retention, infection, hypoalbuminemia, medications (opiates), trauma, pain
psychiatric issues
Psychiatric Issues
  • High incident of ETOH abuse
  • Benzodiazepine abuse is common
  • Smoking history
  • Must manage withdrawal
functional status
Functional Status
  • Home environment
  • Help at home
  • Ability to engage in the duties of daily living
  • Discharge planning
  • Need for nursing care, SNF placement
  • Ability to be NWB or PWB
conclusion
Conclusion
  • Varying levels of risk
  • Imperative for the surgeon to be aware of at risk issues
  • Work with PCP or other specialists
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