PRE-OP H&P S: WHAT REALLY MATTERS

Transcription

1 1 2 PRE-OP H&P S: WHAT REALLY MATTERS Jenikka Soyring, DNP Why Pre-op Assessments Reduce risk for cardiac, pulmonary and infectious complications Not meant to clear for surgery It is to evaluate and implement measures to prepare higher risk patients for surgery Factors Contributing to Risk Increase demand for surgery in older and sicker patients Functional decline Decreased ability to compensate for impaired function or increased physical demand Multiple comorbidities 3 Basics of what a surgeon needs Quality care Co-management of complex patients Communication (they want to focus on the surgical issue) Timely care 4 Potential Problems Disagreement with multiple opinions Lack of ownership Additional cost 5 What can the RN do? Make sure the H&P is complete Cardiac Renal Endocrine (DM) Pulmonary Home instructions are clear for pre-op 6 Post-discharge plans

2 7 8 What s Important? History What surgery Pt s experience with anesthesia Recent illness Cardiac Risk Assessment Evaluate risk for both pt and surgeon Optimize appropriate testing and intervention Clinical judgment PMH (heart and lungs), meds including OTCs Functional Assessment 9 10 Cardiac Risk Assessment Risk reduction Timing of surgery Anesthesia (MAC vs general) Medications Intervention Cardiac Timing of surgery Postop MI risk after recent MI: <30days ~33% risk days: ~18% days ~9% : ~5% >1 year: <2% Livhits, M. et al. Annals of Surgery, May Cardiac Anesthesia (regional vs general) Pros of regional Less myocardial, respiratory depression Avoid ET tube (autonomic stimulation) Cons of regional Anxiety myocardial oxygen consumption Spinal vasodilation decreased BP

3 13 14 Bottom line for cardiac Low risk: OK for surgery Elevated risk: METS >/=4 then OK for surgery Elevated risk: METS <4 then stress test Renal CKD Typically with multiple comorbidities Increased risk for major complications including cardiac Look for lab evaluation Fluid and electrolyte balance: EKG? Anemia Nutritional status Glucose Cardiac risk eval ESRD Nephrologist involved? Recent Echo Left ventricular dysfunction increases surgical M&M Dialysis Timing Elective: day before Emergency: can be pre-op Endocrine Diabetes Risk for wound infection, pneumonia, UTI, sepsis, ileus and mortality Type 1 or Type 2! Never stop insulin in type 1 Ketoacidosis in hospitalization mean no payment Hgb A1c level controversial <8.5% for elective surgery within my system Pulmonary Postop Pulmonary Complication (PPC) risk 5.8% Risk increases with type of surgery Close to diaphragm can decrease vital capacity by 50-60% Medications used Anesthetics, opioids decrease respiratory drive and cough reflex Neuromuscular blockers relax chest wall and diaphragm Pulmonary Smoking history Smoking cessation 4 weeks preop COPD and asthma Preop optimization inhaler use Meds Take meds day of surgery Pre and postop Lung expansion exercises

4 19 20 Perioperative Medications Limited data via clinical trials Wide variation Overall most meds are tolerated well with anesthesia General Med Rules Accurate complete list Are they taking their meds Individualize plan Co-morbidities, procedure, pharmacokinetics, withdrawal, interactions Communication Clearly written which meds to hold and for how long Antihypertensives Hold diuretics Volume depletion Electrolytes Individualize ACE/ARB General consensus Hold Continue beta blockers Decreased ischemia and prevents arrhythmias Increase risk of ischemia with withdrawal Generally continue all others 2014 ACC/AHA Guideline on perioperative cardiovascular eval Anticoagulants/Antiplatelet ASA Individualize. Bleeding risk vs thrombotic risk Increases risk of major bleeding 4.8% vs 3.8% without Hold 5-7 days before surgery Anticoagulants: look at half-life 5 to completely clear (Common practice. Always individualize) Coumadin: Stop 5 days before Clopidogrel (Plavix): stop 7 days in advance Prasugrel (Effient): stop 7-10 days in advance Apixaban (Eliquis): stop 2 days before surgery Rivaroxaban (Xarelto): Stop 2 days before surgery Anticoagulants--bridging Bridging (Lovenox or heparin) Individualize Unclear benefit, may harm Risk of thrombosis 0.4% vs 0.3% with bridging Risk of major bleeding 1.3% vs 3.2% with bridging Risk of minor bleeding 12% vs 20.9% with bridging ACCP 2012: CHADS 5-6, TIA/CVA within 3 months, Rheumatic valve disease ACC/AHA 2014: Mechanical heart valve, prior stroke, CHADS2-Vasc >=2 Other factors to consider: active cancer, VTE in last 12 weeks, severe thrombophilia (Factor V, etc) 23 Oral Diabetes Medications Hold all oral agents Risk for: Lactic acidosis Kidney injury Hypoglycemia Fluid retention Slowed gastric motility 24

5 25 26 Insulin NO short acting insulin while NPO Half NPH at usual time DMARDs Hold Hold 1-2 half lives preoperatively (Imuran, methotrexate, rituxan, plaquenil, humira, enbrel, etc) Long acting insulin: Half dose Case 1 89 yo F Toe amputation d/t osteo PMH: 34 on list cerebral infarction, CHF, CKD stage 3, HTN, DM 2, pulmonary htn, MI x2, uses CPAP Meds: 19 Imdur, Metoprolol, cozaar, Lasix, ASA 81 Case 1 What is your plan? Is she OK for surgery? METs 4 METs YES! Meds: Only take beta blocker Pulm: IS OSA: Monitor Labs: K 4.9, hgb 13, crt 1.06 EKG: Sinus, evidence old MI, No acute findings VS: 110/62, , 93%RA PE: WNL Case 2 79 yo M Sacral Nerve stimulator MAC PMH: TIA, HTN, Pacer, Afib, BPH, CPAP Meds: 26 Metoprolol, Lasix, Apixaban, ASA, finasteride Labs: hgb 14.2, K 4.6, Crt 0.74 VS 128/82, , 97% PE: Normal, Pacer L chest Meds: Eliquis stop 2 days before surgery, Stop ASA 1 week before, take all others why? Case 3 79 yo F Glossectomy d/t tongue cancer PMH: MI this year about 5 months ago with cardiac arrest-defibrillator, anemia, CHF EF 35% Meds: Metoprolol, synthroid, Iron, asa, sertraline, donepezil Dilaudid 4mgQ4H, tramadol 100mgBID, Lorazepam 1mgTID, Ambien 5mg, amitriptyline 50mg dulcolax, miralax, senokot, kids gummy vitamin VS: 112/64, , 96%RA

6 31 32 Case 3 PE: Cachectic, in a wheel chair, faint murmur Labs: WBC 1.7 hgb 8.9 (1mo ago 10.2) plt 85 K 3.7 crt 0.42 Albumin 3 Case 3 What do you do? Or what did I do? Nothing! Send to Cardiology! Given OK by Cards: Hold ASA about 5 days EKG: 100% V-paced (previously about 50% paced) Case 4 71 yo M Ischemic finger, amputation PMH: ESRD, DM 1, htn, PVD Meds: Lasix, Coreg, Plavix, Humalog pump, ASA 325 VS: 135/85, , 99% RA Surg Hx: Multiple toe amputations, AV Fistula placed 1 week ago Case 4 Labs K 4.8 Crt 6.39 Hgb A1C 8.7 Hgb 10 EKG: R BBB, unchanged from previous PE: R 5 th finger black distal phalanx, multiple scabs along dorsal aspect of finger Case 4 What did I do? Insulin cut basal dose by 25%. Why? Recent lower glucose Plavix Continue. Why? Embolic cause of ischemia and surgery just 1 week ago Lasix hold Questions? Thanks! Jenikkalee@gmail.com