Terry Clifford, MSN, RN, CPAN, CAPA Nurse Manager Perioperative Services Portland, Maine, USA
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1 Terry Clifford, MSN, RN, CPAN, CAPA Nurse Manager Perioperative Services Portland, Maine, USA
2 Identify and optimize conditions that increase periop morbidity and mortality OR Detect abnormalities that change management and improve outcomes SDS (Same Day Surgery) 60-70% total annual surgical volume in US done in ambulatory settings SDS generally takes 1-2 hours SDS generally had lower blood loss & complication rates SDS usually performed on pt with NO medical problems or with stable chronic conditions
3 1 Clinical Nurse lead 1 Mid-level provider 3 admins 5-7 RNs 9,000+ surgeries/year 40% ortho 30% general 30% other 100% patients get preop calls by nurses 16 page algorithym/joint Practice Protocols
4 No visit Majority 30 minute RN visit Includes nasal swab for total joint arthroplasties 30 minute Anesthesia visit High risk for anesthesia complications 60 minute mid-level or hospitalist visit High risk for medical complications from anesthesia/surgery
5 Routine??? Not encouraged!! Selective The way to go! Preop tests based on clinical findings and/or the type of planned procedure are helpful (type of surgery is important in risk stratification) Requirements vary among institutions, anesthesia departments
6 Tradition Lack of communication between providers Legal worries Concerns about surgical delay or cancellation Institutional P&P that are outdated Lack of awareness of EBP and Best Practice Guidelines
7 Tests ordered should be based on targeted history, physical exam, risk factors Age Preexisting diseases Surgical procedure American Society of Anesthesiologists (ASA) position statement on routine preoperative testing 1 Diagnostic screening, laboratory tests should be based on the patient s specific clinical risk factors Observe legal requirements Document indications for testing
8 Difficult intubation MH AAA surgery Myasthenia Gravis OSA Oral steroid use Severe morbid obesity Recent MI (<6 months) Angina recent or worsening
9 CV disease w/2 or more known risk factors (age>75; Hx ischemic heart disease; Hx CHF; Hx CVA/TIA; Hx Insulin Treatment; Creatinine>2) Pulmonary w/severe debility Metabolic w/chronic infection and /or protein malnutrition Hepatic or Renal Insufficiency Malignancy w/ ongoing chemotherapy Anticoagulant use
10 Adenoids Anal fissure/hemorrhoid Arthroscopy Eye surgery Biopsy breast/skin Cysto D&C/hysteroscopy Facial plastics Endoscopies Hernia Microdiscetomy Rotator cuff Tubal ligation TURBT Veins UPPP Podiatry Hand Surgery Laminotomy *NO TESTING PCP clearance advised
11 Breast reconstruction Carotid Cholecystectomy Colon resection TURP Lap Nissen Mastectomy ORIF Hip/femur TAH-BSO Thyroidectomy Total Hip Total Knee Fusion single level Laminectomy
12 Medically Managed Stable Pt Hemogram ECG over 65 yrs of age and atenolol initiation advised Major Co- Morbidities Hemogram ECG INR CMP Early anes eval T&S PCP eval and atenolol initiation
13 AAA Fem-pop Fusion multiple levels Radical Neck Radical Prostate Whipple
14 Healthy Asymptomatic Pts Hemogram ECG over 50 yrs CMP Early Anes Eval Type & Hold Medically- Managed/Stable and Major Co-Morbidities Hemogram ECG INR CMP Early anesth eval Type & Hold PCP eval and atenolol initiation
15 General Guidelines Lab work is accepted within 30 days of surgery if patient condition has not changed H&P is valid for 30 days The surgeon is responsible for updating the H&P prior to OR The BIG Question is: Will the results of the test change perioperative management?
16 Studies suggest that abnormal results during routine testing did not change the course of treatment therefore suggest questionable significance FINDINGS (73,596 elective hernias) Less than 1% complication rate Testing didn t change outcomes Abnormal results didn t change outcomes
17 #1: Procedures with expected significant blood loss, or recent blood loss #2: History of anemia or suspected anemia Some guidelines suggest: Extremes of age (<1, >65) Suspected sickle cell disease Known blood dyscrasia or malignancy Signs of coagulopathy Existence of chronic disease
18 BMP/CMP Known liver disease (e.g., hepatitis, alcohol or drug abuse) Known renal disease Hypertension, DM, heart disease or disease states with potential for fluid-electrolyte abnormalities Patients taking chemotherapy, diuretics, digoxin, steroids or ACE-inhibitors
19 Includes Prothrombin (PT), Partial thromboplastin (PTT), Platelet count and International normalized ratio (INR) History of abn bleeding/bruising Anticoagulant drug therapy Renal or liver dysfunction Malabsorption/poor nutritional status
20 No indications in preanesthetic evaluations unless reports of UTI symptoms
21 Per specific facility policy Patient must give verbal consent Document discussion, consent or refusal Ask for last menstrual period ASA suggests offering pregnancy testing to all females of childbearing years
22 Some guidelines recommend all diabetic patients have serum BS checked (unless BMP has been ordered) Some guidelines DO NOT recommend any testing in a pt with well-controlled diabetes Some guidelines recommend testing only if the results will alter periop course In this case, the A1C is more helpful than a random glucose
23 Patients who have donated own blood or may receive blood Patients with potential for extreme blood loss
24 Age alone is not an indicator Cardiac Risk Adjustment tools History or symptoms of chronic disease (cardiac, hypertension, diabetes, morbid obesity, pulmonary, dysrhythmias, vascular disease and/or history of stoke/tia) Smoking history greater than 20 pack-year Cocaine abuse
25 Intermediate Risk Surgery* Hx cardiac, vascular, diabetes, stroke/tia, renal insufficiency, OVER 65 years old High Risk Surgery all pts require ECG* All thoracic surgery All vascular surgery *Within 6 months is acceptable if there has been no change in patient s cardiovascular symptoms
26 There are NO indications for a preop CXR unless: Pt suspected to have pneumonia or an acute infiltrate, to be in pulm edema, or if postop mechanical vent is expected consult with anesthesia regarding CXR S&S of pulmonary or cardiac disease, malignancy S&S of airway obstruction Morbidly obese patients at risk for heart failure
27 Education of providers/practice modification Review and adopt practice guidelines Develop clinical pathways (protocols/standardization) Better information sharing to avoid redundant testing Economic analysis will these tests save money? Outcomes evaluation
28 Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2002; 96: [PubMed: ] Benarroch-Gampel J, et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg. 2012;256(3): Korpman TZ. Routine Preoperative Laboratory and Diagnostic Screening. CSA Bulletin. 2012; Sharma GK, etc. Preoperative Testing. Medscape. 2013;1-6.
29 QUESTIONS???
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