Preoperative Risk. Geoffrey C Zarrella DO FACC. Assessment
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1 Preoperative Risk Geoffrey C Zarrella DO FACC Assessment
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4 your late add ons
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6 keep calm use your tools stick to your guns
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8 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
9 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
10 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
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13 ????
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16 establishing risk previous phrasing : low risk patient for moderate risk surgery current diction : low risk // mace < 1% elevated risk // mace >1%
17 risk calculators
18 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
19 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
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21 ready?
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28 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
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30 >10 mets strenuous sports swimming singles tennis basketball football skiing
31 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
32 1 met take care of yourself? eat, dress, toilet? walk indoors in the house? walk a block or two on level ground (2-3mph)
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34 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%
35 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%
36 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%
37 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)
38 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%
39 60yo M knee replacement uncertain functional capacity bmi 38 htn osa afib controlled V response creat 1.6 nsqip 0.26% rcri 0.4%
40 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
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50 preoperative evaluation / Coronary Revascularization
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58 Antiplatelet management in pci and noncardiac surgery
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63 preoperative evaluation / Valve Disease
64 preoperative evaluation / Valve Disease
65 preoperative evaluation / Valve Disease
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70 cied s?#$%? cardiac implantable electronic device put plan in place prior to OR complicated device > dump it on eps
71 preoperative evaluation / Pacemaker - ICD
72 pulmonary htn pt should be evaluated by phtn specialist prior to OR continue meds through procedure PVR>3wu s PASPR > 70mmhg on phtn meds
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74 preoperative evaluation / Pulmonary Vascular Disease
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83 omeone please reschedule this man, (or send him to cardiology as a same day consultation.)
84 preoperative evaluation
85 preoperative evaluation
86 preoperative evaluation
87 preoperative evaluation
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89 preoperative evaluation / timing with previous PCI
90 preoperative evaluation / beta-blocker therapy
91 preoperative evaluation / beta-blocker therapy
92 preoperative evaluation / other meds
93 preoperative evaluation / antiplatelet therapy
94 preoperative evaluation / antiplatelet therapy
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98 KEYS
99 Keys
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101 Geoffrey C Zarrella DO FACC Preoperative Risk Assessment
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