1. Preoperative Assessment
Ambulatory Skills
Preoperative Assessment
Rex Wilford, DO
Summa Department of Medicine

2. Preoperative Assessment: Learning Objectives
Review the major goals of a preoperative assessment
Learn to efficiently utilize Carepath to document preoperative assessment
Encourage review of preop guidelines via completion of the self study preoperative case

3. Major Goals of the Preoperative Assessment
Assess medical problems and optimize treatment
Determine risk of complications (by assessing surgery specific risks and patient specific risks)
Provide recommendations for optimized perioperative management

4. Low Risk < 1% Elevated Risk >/=1%

5. Estimated Energy Requirements
Can You:
Take care of yourself?
Eat, dress, or use the toilet?
Walk indoors around the house?
Walk a block or two on level ground at 2-3 mph? ( kph)?
Can You:
Climb a flight of stairs or walk up a hill?
Walk on level ground at 4 mph (6.4 kph)?
Run a short distance?
Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture?
Participate in moderate recereational activities like golf, bowling, dancing, doubles tennis or throwing a baseball or football?
Participate in strenuous sports like swimming, singles tennis, football, basketball or skiing?
1 MET
4 MET
>10 METS
Modified from Hlatky et al, copyright 1989 with permission from Elsevier, adapted from Fletcher et al.

7. Mechanical Heart Valve
Suggested Patient Risk Stratification for Perioerative Arterial or Venous Thromboembolism
Risk Stratify
Mechanical Heart Valve
Atrial Fibrillation
VTE
High
Any mitral valve prosthesis
Older caged ball or tilting disc; aortic valve prosthesis
Recent (within 6 months) stroke or TIA
CHADS score 5-6
Recent (within 3 mos) stroke or TIA
Rheumatic valvular heart disease
Recent (within 3 mos) VTE
Severe thrombophilia (eg deficiency of protein C, S or antithrombin, antiphospholipid Ab or multiple abnormalities
Moderate
Bileaflet aortic valve prosthesis and one of the following: atrial fibrillation, prior stroke or TIA, HTN, DM, CHF, age > 75
CHADS score 3-4
VTE within the past 3-12 months
Nonsevere thrmbophilic condition: heterogenous Factor V Leiden mutation, heterogenous Factor II mutation
Recurrent VTE
Active cancer: treated within 6 months or palliative
Low
Bileaflet aortic valve prosthesis without atrial fibrillation and no other risk factors for stroke
CHADS score 0-2 and no prior stroke or TIA
Single VTE occurred > 12 months ago and no other risk factors

8. PPC’s General Complications Atelectasis Infection Bronchitis Pneumonia
Bronchospasm
Pulmonary Embolism
Exacerbation of underlying chronic lung disease
Respiratory failure and prolonged invasive or noninvasive ventilation
OSA
ARDS
Specific cardiothoracic surgical complications
Phrenic nerve injury
Pleural effusion
Bronchopleural fistula
Sternal wound infection and empyema
Gastroesophageal anastomotic leak
Postoperative arrhythmias
Adapted and modified from Swenson.

9. Risk Factors for PPC’s Preoperative risk factors COPD Age>75
Inhaled tobacco use
NYHA class II pulmonary hypertension
OSA
Nutrition status
Intraoperative risk factors
Site of Surgery
General anesthesia
Pancuronium use
Duration of surgery
Emergency surgery

10. Proven Risk Reduction Strategies
Preoperative
Smoking cessation 6-8 weeks before undergoing surgery
Inspiratory muscle training
Intraoperative
Use of neuromuscular agents other than pancuronium
Postoperative IS
CPAP

12. Withhold noninsulin agents the morning of surgery
Pre-Op Recommendations for Patients Admitted Day of Surgery: Patients on Noninsulin Agents
Withhold noninsulin agents the morning of surgery
Insulin is necessary to control glucose in patients with BG >180 mg/dL during surgery
Noninsulin agents can be resumed postoperatively when:
Patient is reliably taking PO
Risk of liver, kidney, and heart failure are lower

13. Pre-op Recommendations for Patients Admitted Day of Surgery: Patients on Insulin
Patients on basal or basal-bolus insulin
Give ~50% of usual NPH dose that morning or ~80% of usual dose of NPH, glargine, or detemir the night before
Goal: Avoid hypoglycemia during NPO periods but also prevent presurgical BG >180 mg/dL if possible
Patients on premix insulin (70/30 or 75/25)
Give 1/3 of total dose as NPH only prior to procedure
Patients undergoing prolonged procedures (eg, CABG)
Hold SC insulin and start IV insulin infusion (which will also be needed post-op)

14. Pre-op Recommendations: Patients Using Insulin Pump
Discontinue insulin pump and change to IV insulin according to patient’s current basal rate
If basal rate <1 unit/h, start IV insulin at 0.5 units/h
If basal rate 1-2 units/h, start IV insulin at 1 units/h
Brief/minor procedures in which pump catheter insertion site is not in surgical field
May continue insulin pump with 20% reduction in basal rate (eg, 1 u/h changes to 0.8 u/h)
Hypoglycemia and hyperglycemia treated in manner similar to that of patients receiving SC insulin pre-op

15. CarePath Use the smartphrase: .IMCPREOP
Under LOS and FOLLOW UP; send chart upon closing section – select surgeon note needs forwarded to

16. Helpful Up To Date Topics
Perioperative medication management
Perioperative management of diabetes mellitus
The Surgical Patient Taking Glucocorticoids

17. Preoperative Assessment
Ambulatory Skills
Preoperative Assessment
Rex Wilford, DO
Summa Department of Medicine