Preoperative Risk Assessment - Lourdes Health System · PURPOSE OF THE PREOP EVAL ASSESS PERIOP...
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Transcript of Preoperative Risk Assessment - Lourdes Health System · PURPOSE OF THE PREOP EVAL ASSESS PERIOP...
Preoperative Risk Assessment
Geoffrey C Zarrella DO FACC
your late add ons
keep calm
use your tools
stick to your guns
PURPOSE OF THE PREOP EVAL
❖ ASSESS PERIOP RISK
❖ CAN INFORM DECISION TO PROCEED OR CHOICE OF SX
(INCLUDES PT PERSPECTIVE)
❖ DETERMINE NEED FOR CHANGES IN MANAGEMENT
❖ medicines/perform cv interventions/postop monitoring
❖ optimal location and timing of surgery
❖ alternative strategies
❖ IDENTIFY CV CONDITIONS AND/OR RISK FACTORS
REQUIRING LONGER-TERM MANAGEMENT
urgency
❖ emergency
❖ >> life or limb threatened if not in operating room
❖ >> NO or very limited time for clinical evaluation
❖ < 6 hours
❖ urgent
❖ time for limited clinical eval.
❖ life or limb threatened if not in OR soon
❖ 6-24 hours
urgency
❖ time sensitive
❖ a delay of 1-6 weeks to allow for evaluation and
significant changes in management will negatively
affect outcome
❖ elective
❖ procedure can be delayed for up to 1 year
?? ??
establishing risk
❖ previous phrasing : low risk patient for moderate risk
surgery
❖ current diction :
❖ low risk // mace < 1%
❖ elevated risk // mace >1%
risk calculators
risk estimators / tools
❖ RCRI (revised cardiac risk index)
❖ developed from stable pts / 50+ / elective major sx
❖ high risk surgery
❖ intrathoracic / intraperitoneal / suprainguinal vascular surgery
❖ cad
❖ chf
❖ cerebrovascular disease
❖ diabetes on insulin
❖ serum creatinine >2mg/dl
❖ if Y to 2 or more >> you are “high risk”
risk estimators / tools
❖ Surgeon’s NSQIP / Gupta score
❖ >400,000 pts - intended to supplement judgment - predictive ability C statistic 0.88
❖ age
❖ creatinine
❖ ASA classification
❖ preoperative functional status
❖ procedure site
❖ advantage to nsquip // higher degree of accuracy / more
detailed /granular tool
ready?
defining functional capacity
❖ excellent >10mets
❖ good 7-10 mets
❖ fair 4-6 mets
❖ poor <4 mets
❖ ?can you walk up a flight of stairs or a hill?
❖ can you walk 4mph on a treadmill for > 5 minutes
>10 mets
❖ strenuous sports
❖ swimming
❖ singles tennis
❖ basketball
❖ football
❖ skiing
4 mets
❖ light work around the house?
❖ climb a flight of stairs or walk up a hill?
❖ walk on level ground 4mph?
❖ run a short distance?
❖ heavy housework; scrub floor / lift - move furniture
❖ golf, bowling, dancing, doubles tennis, throw baseball /
football
1 met
❖ take care of yourself?
❖ eat, dress, toilet?
❖ walk indoors in the house?
❖ walk a block or two on level ground (2-3mph)
51
Shoulder surgery
hypertension hyperlipidemia
family hx ascvd
dyspnea with climbing stairs
lisinopril/hctz simvastatin toprol xl
normal ecg
4-6 mets
NSQIP/Gupta 0.12% mace….
RCRI 0.4%
55
❖ hernia surgery
❖ htn bmi34
❖ ecg >> sr lvh possible
inferior mi
❖ asx / can climb 2 flights /
mets >6
❖ NSQIP/Gupta 0.06%
❖ rcri / 0.4%
70yo M
prostate cancer / needs radical
prostatectomy
cad / htn / crcl 40 cr1.7 /
albuminuria
singles tennis / prefers scotch
stable angina w/ des lad 7yrs ago
NSQIP 0.11%
RCRI 0.9%
62yo M w/ adisopathy
htn + dm + met syndrome
sedentary>>can walk 1-2 flights of steps
bowel ischemia due to strangulated hernia >>
EMERGENT SURGERY
ecg: afib 120 / lvh / inferior q waves
Cr1.5
NSQIP 0.38%
RCRI 0.9% (counting emergent sx a high
risk)
64yo M
double whammy
cp x 24hrs >> late presenting
NSTEMI
acute cholecystitis
active angina / killip2 heart failure
creat 1.3
nsqip 1.28%
rcri >11%
60yo M
knee replacement
uncertain functional capacity
bmi 38
htn
osa
afib controlled V response
creat 1.6
nsqip 0.26%
rcri 0.4%
80yo M’s
subject A
afib on apixaban
htn
needs clearance for cataract
subject B
afib on warfarin / hx hfref / cva related to
afib
needs dental extraction and “periapical
scaling”
preoperative evaluation / Coronary Revascularization
Antiplatelet management in pci and noncardiac surgery
preoperative evaluation / Valve Disease
preoperative evaluation / Valve Disease
preoperative evaluation / Valve Disease
cied’s ?#$%?
❖ cardiac implantable electronic device
❖ put plan in place prior to OR
❖ complicated device > dump it on eps
preoperative evaluation / Pacemaker - ICD
pulmonary htn
❖ pt should be evaluated by phtn specialist prior to OR
❖ continue meds through procedure
❖ PVR>3wu’s
❖ PASPR > 70mmhg
❖ on phtn meds
preoperative evaluation / Pulmonary Vascular Disease
someone please reschedule this man,
(or send him to cardiology
as a same day consultation.)
preoperative evaluation
preoperative evaluation
preoperative evaluation
preoperative evaluation
preoperative evaluation / timing with previous PCI
preoperative evaluation / beta-blocker therapy
preoperative evaluation / beta-blocker therapy
preoperative evaluation / other meds
preoperative evaluation / antiplatelet therapy
preoperative evaluation / antiplatelet therapy
KEYS
Keys
Geoffrey C Zarrella DO FACC
Preoperative Risk Assessment