Pre Operative Clearance for Non Cardiac Surgery: ALL CLEAR

1. Pre Operative Clearance for Non Cardiac Surgery: ALL CLEAR Dominique Renee Abell, RN, MSN, CCRN, ACNP-BC (ACLS, PALS, TNCC) rbeckum@crossroadsdevelopers.com

3. OBJECTIVES1. Outline evidence based practice guidelines related to pre operative evaluation for surgery2. Describe conditions that require pre operative diagnostic evaluations3. Review the findings that would postpone or cancel surgery

4. “The purpose of preoperative evaluation is not simply to give medical clearance but rather to perform an evaluation of the patient's current medical status, make recommendations concerning the evaluation, management and risk of cardiac problems over the entire perioperative period; and provide a clinical risk profile that the patient, primary physician, anesthesiologist and surgeon can use in making treatment decisions that may influence short term and long term cardiac outcomes” .

5. Goals of Preoperative Evaluation • Documentation for which surgery is needed • Assessment of patient overall condition/health status • Uncovering issues that could cause problems during and after surgery • Perioperative risk determination • Optimize medical condition to reduce morbidity and mortality • Develop perioperative plan of care

6. Goals of Preoperative Evaluation • Education of patient and family • Surgery • Anesthesia • Intraoperative care • Post operative pain control • Reduce anxiety • Facilitate recovery

7. Goals of Preoperative Evaluation • Reduce cost • Decrease length of stay • Reduce cancellations day of surgery • Increase patient/family satisfaction

8. Nurse Practitioner Responsibilities • Perform complete History and Physical • Review/Order labs and ancillary studies • Assess risk related to patient's co-morbidities • Assess need for preoperative specialty consults • Communicate with anesthesia provider and surgeon • Assist with optimal timing of surgery • Medically optimize patient condition preoperatively

10. Situation for Surgery Emergent: life threatening situation, risk of or death of patient if not preformed Urgent: life threatening or debilitating, needs to be done sooner than later Elective: patient may “need” procedure but can be scheduled at any time

11. Definition: Combined incidence of cardiac death and nonfatal myocardial infarction Focus on cardiac and pulmonary risk factors that can contribute to complications Determine patient's functional capacity, Metabolic equivalent (MET) Cardiac Risk

12. ACC/AHA guidelines ASA guidelines Lee's Revised Cardiac Risk Index http://www.statcoder.com/cardiac.htm Cardiac Risk

13. Cardiac Risk Indices Factors associated with life threatening cardiac complications/perioperative cardiac death • MI within 6 months • S3 gallop or jugular venous distention • Age >70 • ECG other than Sinus Rhythm, >5 PVC's/min • Aortic Stenosis • Poor general health/medical status • Emergency surgery • Intraperitoneal, intrathoracic, aortic surgery

16. Different Levels of RiskHigh:Unstable Coronary Symptoms- acute or recent MI with evidence of ischemiaUnstable or Severe AnginaDecompensated Heart FailureSymptomatic/Significant ArrhythmiasHigh Grade Atrioventricular BlockSevere Valve Disease

17. Mild Angina Previous MI Compensated or History of Heart Failure Diabetes Mellitus Renal Insufficiency Intermediate:

18. Advanced Age Abnormal ECG Any other Rhythm besides Sinus Low functional Capacity History of Stroke Uncontrolled Hypertension Minor:

19. Primary car provider patient surgeon anesthesiologist

20. Vital signs Central and Peripheral pulses Lungs/Cardiac Auscultation/Palpation Abdominal palpation Examine Lower Extremities Functional Capacity History and Physical • Medical history-past and current • Review of Systems- cardiac risk factors, cardiac conditions, associated diseases, changes in symptoms • Medication • Alcohol, Tobacco, Non-Prescribed drugs

21. Children include birth history- premature,perinatal complications, congenital, chromosomal, anatomic malformations History and Physical • Surgical History • Allergies • Family History of adverse reaction to anesthesia • Studies- CBC, INR, aPTT, BMP/CMP,ECG, CXR, Stress Test, PFT, ECHO, Cardiac Cath,

23. Can you take care of yourself? ADL's- eat, dress,toilet, Walk indoors around the house Walk a block or two on level ground 2-3 mph Do light housework-dusting, wash dishes Functional Capacity • 1 Metabolic Equivalent (MET)

24. Can you climb a flight of stairs or walk up hill Walk on level ground at 4mph Run a short distance Heavy housework-scrub floors, lift or move heavy furniture Moderate recreational activities-golf,throwing a football Functional Capacity • 4 MET

25. Swimming, singles tennis, football, basketball, skiing Functional Capacity • >10 MET

26. Continue current medications Cardio-protective Beta Blockade Coronary angiography/revascularization Management of Cardiac Risk

27. Pulmonary Complication • Definition: revised to clinically significant • Pneumonia • Respiratory failure with prolonged mechanical ventilation • Bronchospasm • Atelectasis • Exacerbation of underlying lung disease

28. Pulmonary Complications • Decreased functional residual capacity/vital capacity • Cough • Aspiration pneumonia • Atelectasis • Pneumonia • Smoking- even in absence of lung disease

29. Pulmonary complications • Procedure specific risk factors • Surgical site- most important risk factor • Duration • Anesthesia • Neuromuscular blockade

30. Pulmonary Complications • COPD/Asthma • Goal is “Personal Best” • Poor PFT's do no exclude from surgery or correlate with risk of post operative complications • Poor exercise capacity is probably best predictor • Along with type and duration of surgery • Age and obesity are not independent risk factors • Metabolic markers- BUN>30, albumin <3

31. Pulmonary Complications • Reducing Risk • Preoperative • smoking cessation 8 weeks prior • Treat airflow obstruction in patients with COPD/Asthma • Administer antibiotics and delay surgery • Begin patient education regarding post op lung expansion maneuvers

32. Pulmonary Complications • Intraoperative • Surgery less than 3 hours • Spinal or epidural • Regional or local blocks • Avoid pancuronium • Minimally invasive as possible • laparoscopic

33. Pulmonary Complications • Post Operative • Turn, Cough, and Deep Breath • Early mobilization • Adequate analgesia • Incentive Spirometer/Acapella valve • Continuous Positive Airway Pressure (CPAP) • Epidural analgesia • Intercostal nerve blocks

34. Hematologic Risk • Hematocrit < 24% • Thrombocytopenia <50,000 • History of bleeding diathesis • Cirrhosis • Hematologic malignancy • Antiplatelet medication • Anti-coagulation therapy • DVT/VTE prophylaxis

35. Chronic Medications • Consider every medication/supplement • Diabetes- adjust insulin or oral hypoglycemics • Chronic steroids- stress dose • Hypertensive medications- PO or IV • Anti-ischemic medications- transdermal or IV • Alcohol use and withdrawal

36. Chronic Medications • Monoamine oxidase inhibitors- taper and withdraw 2-3 weeks before surgery • Oral contraceptives- stopped 6 weeks before elective surgery secondary to increased VTE risk • Herbal supplements discontinued 2 weeks before surgery • Aspirin discontinued 7-10 days before • Thienopyridines (clopidogrel) 2 weeks before • Non-steroidal Anti-inflammatories 7-10 days before

37. Chronic Medications • Oral anticoagulants stopped 4-5 days • INR 1.2-1.5 before surgery • Evaluate for “bridge therapy” • Cox 2 inhibitors may be continued up to surgery

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