Overview of pre-anesthesia exam (PAME )

1. Overview of pre-anesthesia exam (PAME) Becky Ness MPAS, PA-C MCHS Mankato Internal Medicine/Nephrology

2. Objectives • 1) Identify key diagnostic exams for pre-anesthesia patients • 2) Identify components of Metabolic Equivalents Exam Testing (METS) and when further evaluation is needed. • 3) Identify high risk medications and necessary adjustments in the perioperative period.

3. Purpose of the PAME • Identify risks that could complicate a surgery or result in a poor outcome. • Provide insight to the surgeon and anesthesia staff (MD or CRNA) that will require close monitoring during surgery (i.e. Hx of anesthesia complications, HTN, apnea etc.) • Identify potential postsurgical complications that will need to be monitored (blood clot risk, hx of lung disorders, cardiac issues, blood sugars, infection risks)

4. Key Elements of the PAME • Surgery details – facility, surgeon, surgery to be performed, type of anesthesia expected to be used • HPI – must include pertinent details as they would relate to the planned procedure (what symptoms are present, duration, other treatments options tried) • Hx – surgical, medical, family, and social • ROS – must include pertinent positives such as: chest pain/SOB with activity, palpitations, recent fevers/febrile illness, unexplained weight loss/gain. • Physical • Appropriate labs / tests • Recommendations –Risk assessment and management

5. Surgery Details • Intended procedure • Surgeon’s full name • Location of surgery • Date of surgery • Prior surgical infections • Prior anesthetic complications – anaphylaxis, malignant hyperthermia, significant intolerance (projectile vomiting, prolonged arousal time)

6. History of Present Illness (HPI) • Symptoms – onset, duration, severity, disability, aggravating/relieving factors, acute vs. chronic • Prior treatments – medical, PT/OT, etc.. • Expected benefit from planned surgical procedure – pain/symptom relief, increased mobility, improved quality of life

7. Assess Level of Risk of the Planned Surgery • Major risk – • Aortic and other major vascular surgeries, emergent trauma • Intermediate (reported cardiac risk generally 1 to 5 percent) • Intraperitoneal and intrathoracic surgeries, carotid endarterectomy, Head and neck surgery, Orthopedic surgery, Prostate surgery • Low (reported cardiac risk generally less than 1 percent) • Endoscopic, superficial, or cataract procedures, breast or ambulatory surgery Adapted from Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA guidelines on perioperative cardiovascular evaluation and care for non-cardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2007;116(17):e429

8. Histories • Surgical – previous procedures and indications for procedure, especially those that might impact the intended surgery. Include procedures that might have required sedations. i.e. wisdom teeth, ear tubes, colonoscopy/gastroscopy. • Medical – any significant medical conditions that might impact surgery or postop recovery – such as asthma/COPD, prolonged periods of lack of activity, cardiac history, diabetes, autoimmune disease, OSA, immunosuppression (chronic steroid use) • Social –smoking, ETOH, levels of stairs in home, family support (if relevant to the surgery), caffeine use, recreational/IV drug use, physical activity • Family – History of anesthesia difficulty, premature cardiac disease, death during surgery

9. Review of Systems • Needed to identify any specific concerns that might complicate the surgery or require further testing before proceeding • Chest pain with or without dyspnea – clarify aggravating/relieving factors, duration of episodes, acute vs. chronic complaint • Dyspnea – clarify aggravating/relieving factors, duration, presence of orthopnea, acute vs. chronic • Address pertinent positives within HPI or Plan depending on if further assessment is warranted

10. Physical Exam Main components • HEENT – dentition, Mallampati scoring, pupils/scleral appearance • Cardiac –cardiac sounds (+/- murmur), pedal edema, +/- carotid bruit, stability and assess need for further testing • Pulmonary – auscultations (+/- abnormal sounds or airflow), chest movement, assess need for further testing or potential complications • Abdominal- assess for organ enlargement, ascites, pain • Skin- rashes(infectious or simply identified to avoid confusion postoperatively), scarring and etiology • Neuro – define what is functional/ baseline as a reference for any postop changes Other systems as warranted

11. Mallampati Scoring

12. Metabolic Equivalent TestingA Predictor of Cardiac Function METs Activity 1 Sitting quietly at rest. 2 Walking slowly on level ground, eat, dress, toilet, make bed 3-4 Doing light work around the house. 4 Walking on level ground at 4 mph, light housework (dust/dishes), golf, bowling 4-5 Climbing a flight of stairs, walking up a hill, sex, scrubbing floors, moving furniture 6 Moderate recreational activity e.g. dancing, doubles tennis, moderate cycling, >10 Strenuous sports e.g. singles tennis, basketball, skiing. 

13. Scoring MET • Patients unable to meet a MET score of 4 are at increased risk for surgical complications. • If patient can not meet a MET of 4 additional cardiovascular risk assessment is warranted – choice of study dependent of patient’s physical ability and other co-morbid conditions • Therefore, asking if the patient can walk a flight of stairs or 2 city block at a brisk pace without chest pain or severe SOB is a good indicator of cardiac stability • Nengl J Med 1995; 333;1750

14. Risk Assessments • Major Cardiac Risks • Hx of ischemic disease • CVA • CHF • DM • Renal insufficiency • Major Pulmonary Risks • Age > 50, 60, 70, 80 • Chronic Lung Disease • Asthma • Smoking • Heart Failure • Low Albumin • High BUN

15. Cardiac Risk Assessment • Cardiac Risk Assessment Multiple tools exist, the most straight forward is Lee’s Simple Cardiac Risk Index High risk surgery 1 point CAD 1 point CHF 1 point Hx of CVD 1 point Insulin therapy for DM 1 point Pre-op Serum Cr > 2.0 1 point Score 0-1 =low risk >=3 high risk 2 = moderate risk

16. Pulmonary Risk Assessment Class • Healthy • Mild Systemic Disease • Severe Systemic Disease- limits activity, but not incapacitating • Incapacitating systemic disease, which is a constant threat to life • Moribund, not expected to survive 24 hrs with or without surgery • Score • Low Risk – Class 1 or 2 that is controlled • Medium Risk Class 2 that is not optimally controlled • High Risk > = 3

17. Selecting Perioperative Testing • Appropriateness is determined by planned surgical procedure and co-morbid conditions • Timing of all laboratory studies need to be within 30 days of planned procedure per Medicare Rule • Testing needs to be correlated with a condition for billing purposes • Not every patient NEEDS perioperative testing beyond the PAME

18. Common Perioperative Tests • CBC + Appropriate if patient has a history of anemia, recent infection or there is a potential significant blood loss. • BMP (K+ and Cr) + Appropriate for diabetics, HTN, Renal disease, diuretic use, CHF or digoxin use • INR/PTT + If history of coagulopathy or suspicion for one, currently on anticoagulation or history of liver disease.

19. Common testing cont... • EKG + History of DM, Cardiovascular disease, Pulmonary disease, > than 20pk-yr smoking history, unable to achieve MET>4, morbid obesity or use of ACE-I, diuretics or digoxin. • Chest X-ray + History of pulmonary disease, malignancy, radiation therapy or smoking history > 20 pk-yr.

20. Medication adjustments • Meds to continue • Statins • Beta-Blockers (if previously on) • Ca++ channel blockers • Antiarrhythmics • Chronic scheduled pain medications • High dose antidepressants • Anti-epileptics (regardless of indication) • Inhalers • Steroids (may need to consider stress dosing based on indication for chronic use) • Long acting insulin (dosing adjustments will be needed based on blood sugars and diabetes control)

21. Medication adjustment cont.. • Meds to hold • Oral diabetic medications • Rapid acting insulin's • ACE-Inhibitors • Angiotensin receptor blockers • Diuretics • Vitamins (multivitamins within 7 days of surgery) • Mineral supplements • Herbal medications • OTC NSAID’s (stop within 7 days of surgery)

22. Medication Adjustments Cont... • Anticoagulants • Held per provider and surgeon’s discretion based on indication for use, planned surgical procedure and patient’s thromboembolic risk • HIGH risk = bridge prior to procedure, resumption based on bleeding risk of procedure • Mitral valve replacement, A-fib with CHA2DS2-VASC>1 or CVA/TIA within 1 month, VTE within 3 weeks or with other thromboembolic state (active cancer, APLA, chronic CVD or PulmDz) • Moderate Risk = bridge prior to procedure, resumption based on bleeding risk of procedure • VTE within 6 months, VTE with prior DC of anticoagulation • Low risk = Very little support for stopping anticoagulation

23. Pulling it all together 1)This patient is at low/moderate/high risk for cardiac and or pulmonary complications for this low/moderate/high risk scheduled procedure 2) Labs done today include: List those done; results and further testing/repeat testing needed prior to surgery. 3)Cardiac: EKG was/was not indicated and results if done, additional testing if indicated such as stress testing or echocardiography with results. 4) Statement of optimization for planned procedure. Patients are NEVER cleared. 5) Medication recommendations: The patient was counseled about which meds to hold/adjust prior to surgery these include… 6) Final Recommendations The patient was instructed to contact the surgeon if any illness or new symptoms arise between this assessment and the intended surgery. This includes URI symptoms, fever, or other illness.

24. Questions??? ness.becky@mayo.edu