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Antonio Alan S. Mangubat Preoperative Testing Guidelines.

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Presentation on theme: "Antonio Alan S. Mangubat Preoperative Testing Guidelines."— Presentation transcript:

1 Antonio Alan S. Mangubat Preoperative Testing Guidelines

2 Clinical Pathway


4 MEDICAL CONDITIONS Cardiovascular System Hypertension Cardiac Murmur Angina Pectoris, Arryhthmias, Cardiac failure Pacemaker Triple vessel disease

5 CV conditions Hypertension Newly diagnosed: Refer to IM Poorly controlled: Refer to IM Postpone operation if BP > 180/110 with less than two weeks to optimized Inform surgeon, allow 2 weeks for BP control

6 Hypertension Stage 1 or 2 hypertension is not an independent risk factor for perioperative cardiac complications Mild/moderate hypertension with no associated CV/metabolic abnormalities  not beneficial to delay surgery

7 Hypertension Continue all anti-hypertensive medications except ACE inhibitors and ARBs (controversial) Continue beta-blockers and clonidine up to the day of operation because of the risk of rebound hypertension May use IV beta-blockers or transdermal clonidine in patients unable to take oral medications

8 Hypertension For SBP > 180 and DBP > 110 without any other associated s/s  risk benefit of postponing the surgery should be weighed Evidence is inconclusive IV anti-hypertensives can bring down the BP to manageable levels in a few hours IV beta-blockers seem to be the most effective agents

9 CV conditions Cardiac murmur Refer to cardio for 2D-echo if murmur is unlikely to be functional (functional murmurs are soft and change/disappear with changes in posture) Severe AS needs cardio assessment

10 CV conditions Angina Pectoris, Arryhthmias, Cardiac failure Follow guidelines for referral to cardiology

11 CV conditions Pacemaker Refer to cardio to check function of pacemaker if on poor follow-up or asymptomatic Refer if pacemaker spikes are absent on ECG

12 CV conditions Triple vessel disease (refuses CABG) Refer to cardiology Inform of risk if proceeding with surgery

13 Guidelines for referral to cardiology Patients with Major clinical predictors Require intensive management, and will result in delay or cancellation of surgery unless emergent Recent MI < 30 days Unstable/severe angina Decompensated congestive heart failure Signigicant arrhythmia High-grade AV block Severe valvular disease

14 Clinical Predictors (Risks of MI, heart failure, death) Major: Unstable coronary syndromes AMI < 7 days, recent MI < 30 days Unstable/severe angina Decompensated CHF Significant arrhythmias High-grade AV block Symptomatic ventricular arrhythmias with underlying heart diseass Supraventricular arrhythmia with uncontrolled ventricular rate Severe valvular disease

15 Clinical Predictors Intermediate (Increase periop cardiac risk and require careful assessment of current status) Mild angina pectoris Prior MI > 1 month by history of pathologic Q waves Compensated or previous CHF DM Renal insufficiency

16 Clinical Predictors Minor Elderly Abnormal ECG (LVH, LBBB, ST-T changes) Rhythm other than sinus Stroke Uncontrolled hypertension

17 Effort tolerance Poor (1-4 Mets) Eating Dressing Walking around the house Washing dishes Moderate to Good (4-10 Mets) Climbing one flight of stairs Walking on level ground at 6.4 kms/hour Running a short distance Scrubbing the floor Playing a game of golf

18 Surgical Risks High (reported death > 5%) Aortic/other major vascular surgery Peripheral vascular surgery Prolonged procedures with massive fluid shifts and blood loss Emergent major operation, especially in the elderly

19 Surgical Risks Intermediate (cardiac risk < 5%) Carotid endarterectomy Head and neck surgery Intraperitoneal/ intrathoracic surgery Orthopedic surgery Prostate surgery Low (Cardiac risk < 1%) Endoscopic/superficial procedures Cataract surgery Breast surgery

20 Respiratory Conditions ConditionAction Asthma COPD Interstitial lung diseases Refer to pulmo for assessment and optimization if control is poor PneumoniaRefer to pulmo urgently Postpone operation CXR abnormalities lung nodules Consolidation/Active TB pulmonary congestion suggestive of CHF refer to pulmo. May not need to postpone refer to pulmo. Postpone. refer to guidelines for cardiology referral

21 Endocrine System ConditionAction Hypothyroidism/HyperthyroidismRefer to endocrine for treatment/optimization if not well controlled. In general, euthyroid patients with normal free T4 levels can proceed with surgery. Poorly controlled DMKnown DM, CBG > 18 mmol/L, or undiagnosed DM CBG > 11 mmol/L Refer to endocrine for optimization. In general, patient can proceed with surgery if compliant with medication, no s/s of diabetic crisis and random DBG < 18 mmol/L. Emphasize compliance with medication and dietary control.

22 Diabetes Mellitus Mild hyperglycemia is preferable to hypoglycemia. Patients should not take oral hypoglycemics on the day of the procedure. Patient should not take short-acting insulin bolus the morning of procedure. Long-acting or intermediate insulin may be used to cover basal insulin needs; 50%-100% of usual dose is often reasonable. Insulin pumps should be continued but only to provide basal insulin coverage. The details of the insulin recommendations are influenced by the insulin sensitivity of the patient, the timing of the procedure, the length of the procedure, and how long the patient will need to be NPO following the procedure.

23 Hematologic System ConditionAction RBC: severe anemia polycythemia (Hb greater than 17) may need transfusion pre-operatively if estimated intraop blood loss if moderate to high. May proceed with surgery of no s/s and anemia work-up is not urgent. refer to hematology if with no obvious secondary causes Platelets thrombocytopenia thrombocytosis (> 500,000) refer to hematology. May need to prepare platelet for transfusion pre-/intraoperatively refer to hematology

24 Renal Diseases ConditionAction Newly diagnosed renal failure with hyperkalemia Refer to nephrology for assessment and optimization. Postpone operation Known ESRD on dialysisAll patients should be dialyzed a day before the operation.

25 Obesity/OSA Clinical diagnosis of OSA Daytime somnolence (easily falls asleep during quiet times or Epworth score of > 14) Snoring with arousal BMI 30 or more Neck circumference 42 cms. or more Small receding mandible Hypertension (> 140/90)

26 Obesity/OSA Determination of Severity of OSA based on Clinical s/s No. of S/SSeverityScore 2Mild1 4Moderate2 6Severe3 Determination of Severity of OSA based on Sleep Study AHISeverityScore 5-15Mild1 15-30Moderate2 > 30Severe3

27 Obesity/OSA Scoring of Invasiveness of Anesthesia or Surgery SurgeryAnesthesiaScore Superficial or peripheralNo sedation0 Superficial or peripheralSedation or RA1 Superficial or peripheralGA2 MajorGA3 Scoring of Opioid Requirement Opioid RequirementScore None0 Low dose oral1 High dose oral2 Parenteral/Neuraxial3

28 Obesity/OSA Determination of Peri-Operative Risk of OSA OSA severity + Invasiveness OR post-op opioids (1-3)(0-3)(0-3) 4 or less: OPD acceptable but inpatient preferable 5 or more: significantly increased perioperative risk

29 Obesity/OSA Perioperative risk 4 or less Monitoring in PACU for 3 hours longer than non-OSA patients in an unstimulated environment Sp02 should be at baseline and with no airway obstruction Perioperative risk 5 or more Continuous postoperative Sp02 monitoring in ICU or high- dependency unit

30 Epworth Sleepiness Scale Scoring of Chances of Dozing Situations0 No chance 1 Slight chance 2 Moderate chance 3 High chance Sitting and reading Watching TV Sitting inactive in a public place As a passenger in a car for an hour Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic TOTAL

31 Rheumatology ConditionAction Rheumatoid ArthritisOrder cervical spine x-rays: 3 views (open mouth, flexion and extension) to assess for atlanto-axial dislocation

32 Coagulation System ConditionAction Anti-Platelet AgentsStop all anti-platelet agents 7-14 days before operation clopidogrel – 7 days dipyridamole – 10 days ticlopidine – 14 days GP IIb/IIIa – 4 weeks aspirin – alone, not associated with increased risk NSAIDS/COX-2 inhibitorsAlone, not associated with significantly increased risk Herbal Medications garlic – 7 days ginkgo – 36 hours ginsent – 24 hours LMWH 10-12 hours after last dose Warfarin stop warfarin for 3 days. Check PT/INR. If INR is less than 2 start LMWH q12. Omit on day of surgery 10-12 hours after last dose

33 Allergies ConditionAction Drug Allergies Adverse Reactions Name of medications and type or reactions experienced

34 Preoperative Laboratory Examinations ASA I AGERISK OF BLOOD LOSS CBCBUN/Crea Electrolytes Glucose ECGCXRPT/PTT < 50Eye/Low--- ModerateY--- HighYYYYY 50-64Eye--- Low--- Y 65-70Eye---YY LowYYY--- 50-70ModerateYYYYY HighYYYYY

35 Preoperative Laboratory Examinations ASA II and III ASARISK OF BLOOD LOSS CBCBUN/Crea Electrolytes Glucose ECGCXRPT/PTT ASA IIEye---YY LowYYY--- ModerateYYYYY HighYYYYY ASA III or more Eye---YY LowYYYY--- ModerateYYYYY HighYYYYY

36 Guidelines for Preop Investigations ECG Age > 50 years ASA II or more High risk surgery Cardio-respiratory symptoms or signs

37 Guidelines for Preop Investigations CXR ASA II with cardiorespiratory symptoms or signs ASA III or more High risk surgery s/s of active respiratory disease History of pneumonia within the last 6 months History of pneumothorax History of childhood tracheostomy Large multinodular goiters Thorascopic procedure or thoracotomy Cervical lymph node biopsy under GA Extremes of age, smoking, stable pulmo/cardio disease, resolved recent URTI are not considered unequivocal indications

38 Guidelines for Preop Investigations Biochemistry ASA I and age > 65 ASA II or more Moderate risk surgery and age >50 High risk surgery Drug history of: Diuretics Theophylline Digitalis Systemic steroids

39 Guidelines for Preop Investigations CBC Age > 65 ASA II or more Moderate and high-risk surgery NSAID use within past 6 months History of anemia within the past year Pallor on PE Polycythemia CAD Malignancy Recent radiation or chemotherapy Severe coexisting disease or unstable condition – renal failure, liver disease, poorly controlled HPN, malnutrition Female with menorrhagia

40 Guidelines for Preop Investigations Coagulation profile High risk surgery Moderate risk surgery (except for ASA I and age <50) Patients with: History or symptoms of bleeding diathesis Severe active liver disease or renal disease Anticoagulation therapy Sepsis severe malnutrition or malnutrition syndrome Vascular procedure

41 Guidelines for Preop Investigations Liver function tests Known or suspected cirrhosis Potential active hepatitis Therapy with hepatotoxic drugs

42 Guidelines for Preop Investigations Other investigations Pregnancy test for females who are unable to exclude pregnancy Thyroid function test: only free T4 required, TSH no needed if patient is clinically euthyroid

43 Validity of Tests In the absence of new clinical changes: blood tests are valid for a period of 3 months ECG for 6 months CXR for 1 year

44 Thank you!

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