A preoperative evaluation allows us to: learn about the patient. risk stratify them based on their comorbities

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2 A preoperative evaluation allows us to: learn about the patient risk stratify them based on their comorbities assists in anesthesia preop, intraop and postoperative planning

3 COMPONENTS OF A PREOP Thorough patient history Anesthetic hx, PMHx, SurgHx, SHx Don t make diagnostic assumptions only note a diagnosis if patient tells you its been officially made, or you see it documented by a primary care physician E.g. if a patient snores, do not assume they have OSA Current Medications Recent labs/workup Physical exam Assessment and plan

4 HISTORY BREAKDOWN BY ORGAN SYSTEM Anesthesia history Past anesthetics h/o complications, reactions, difficult intubations/airway issues PFMHx of problems looking for h/o MH anesthesia fever

5 CARDIAC CAD?stents, antiplatelet therapy CHF orthopnea, doe, pedal edema Arrythmias rate controlled? Symptomatic? New? Check EKG Murmurs symptomatic? New? METs-define exactly what their exercise tolerance is and what limits them Want > 4mets aka 2 flights of stairs w/o symptoms

6 PULM OSA--?CPAP, daytime fatigue/sleepiness COPD--?home 02, meds? Recent exacerbations, steroid use Asthma--?meds, h/o hospitalization/intubation Recent URI

7 NEURO h/o TIA/CVA residual symptoms Seizures when was last seizure and what meds Depression what medications are they on May interfere with anesthesia orders Neuromuscular disorders Myasthenia medications, symptoms, steroids

8 GI GERD Medication, symptoms, can they lie flat? Cirrhosis status of ascites, encephalopathy

9 ENDO Diabetes 1 or 2, meds, home f/s levels, check Hba1c within 60 days of surgery Thyroid: hyper vs hypo,?symptoms, TSH level

10 HEME/ONC H/o cancer?chemoradiation last treatment? Coagulopathies Recent labs? h/o transfusion, bleeding

11 RENAL ESRD HD (when) Recent labs Do they make urine

12 INFECTIOUS DISEASE Chronic infections HIV, Hep B/C Want to know for our own safety

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14 JUST AS A REMINDER ASA Classification ASA 1 Normal/healthy No organic, physiologic, or psychiatric disturbance; excludes the very young and very old; ASA 2 Patients with mild systemic disease No functional limitations; well-controlled disease of one body system; (e.g., HTN, DM, smoke but no COPD, preganant, mild obesity). ASA 3 ASA 4 ASA 5 ASA 6 Patients with severe systemic disease Patients with severe systemic disease that is a constant threat to life Moribund patients who are not expected to survive without the operation Not alive Some functional limitation; controlled disease of more than one body system or one major system; no immediate danger of death; (e.g., controlled CHF, stable angina, old MI, morbid obesity, CRF) Has at least one severe disease that is poorly controlled or at end stage; possible risk of death; unstable angina, symptomatic COPD, symptomatic CHF, hepatorenal failure Not expected to survive > 24 hours without surgery; imminent risk of death; multiorgan failure, sepsis syndrome with hemodynamic instability, hypothermia, poorly controlled coagulopathy

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16 THE 12-LEAD EKG:

17 2014 ACC/AHA guidelines Re: CAD assessment and testing

18 REVISED CARDIAC RISK INDEX Creatinine >/= 2 Heart failure, Ischemic heart disease IDDM h/o CVA/TIA Intrathoracic, intra-abdominal, or supra-inguinal vascular surgery >/= 2 factors elevated MACE risk Cardiac arrest, Vfib, MI, CHB, pulmonary edema,

19 EXERCISE STRESS TESTING FOR MYOCARDIAL ISCHEMIA & FUNCTIONAL CAPACITY: 1. Elevated risk + excellent (>10 METs) or moderate (4-10 METS) functional capacity = to forgo further exercise testing with cardiac imaging proceed to surgery. 2. Elevated risk + poor (<4METS) or unknown functional capacity = reasonable to perform exercise testing to assess for functional capacity if it will change management A. alternate: pharmacologic stress testing 3. Routine screening with noninvasive stress testing is not useful for patients at low risk for noncardiac surgery

20 ECHO Moderate or greater degrees of valve stenosis or regurgitation preoperative Echo If no prior echo within 1 year, or a significant change clinically since last evaluation Those who need intervention 2/2 severity of symptoms or stenosis/regurgitation, should have repair before elective non cardiac surgery New arrythmias, new or worsening DOE

21 PCI Limit this to those with left main or LAD disease, or those with unstable CAD (Aka STEMI, NSTEMI, unstable anginas) Stents and anticoagulation Angioplasty- 14 days BMS- 30 days DES If placed during an ACS 1 year (or 180 days for urgent surgery) If not (aka SIHD) can stop plavix after 6 months

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23 LABS BMP h/o HTN, HF, CKD, DM, liver disease Meds: e.g., diuretics, ACE-Inhibitors, ARB, NSAIDS, Digoxin CBC h/o CKD, cancer, h/o chemo Procedures with high anticipated EBL LFTs Only if patient has liver disease, undergoing liver surgery

24 MORE LABS Coagulation studies h/o coagulopathy liver disease, reports of easy bruising/bleeding etc On anticoagulants T&S High EBL surgery Especially in coagulopathic or anemic patients Misc Pregnancy test order for any female who has not yet hit menopause Exception: patients s/p TAH or BTL

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26 PHYSICAL EXAM CHECK VITALS do NOT ignore aberrant values recheck them, tell someone, check EPIC trends Refresh the preop note to ensure the numbers populate Cardiopulmonary exam murmurs, irregularities Wheezing, decreased breath sounds

27 AIRWAY EXAM

28 AIRWAY EXAM Dentition Mouth opening Thyromental distance With head tilted back, measure body tip of chin to thyroid notch >3 fingerbreadths good <3 suspicious/difficult-patient may be anterior with laryngoscopy Neck circumference: Short, thick necks difficult intubation conditions and difficult mask ventilation Anyone w/a beard, regardless of neck size can be considered a difficult mask ventilation

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30 PLAN Explain what you believe the anesthesia plan will be Includes: General anesthesia, sedation, extra IV s, arterial lines, central lines, need for possible post op intubation etc. If patient is likely to receive a block, either PRE or POST op, then explain Thoracic epidurals-give handout Handouts for spinal and TAP blocks to come This and any other discussion had with patient should be documented in the Notes section of the Preop

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32 BETA BLOCKERS Patients on B-blockers chronically continue Tests for myocardial ischemia are positive preop start b-blockers Risk factors: DM, HF, CAD, CRI, CVA start b-blockers Should start at least more than one day prior to surgery ensure tolerability of medication Do not start beta blockers on the day of surgery (DOS)

33 ACE INHIBITORS/ARBS Due to intraoperative hypotension, have patients hold their AM dose on DOS.

34 STATINS Continue them on DOS if already on them

35 ANTICOAGULATION Coumadin stop 3-5 days prior, bridge to Lovenox Pradaxa stop 3 days prior Eliquis stop 2 days prior Anyone on Lovenox, last dose should be day before surgery

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37 FOR ELECTIVE CASES Active CP, worsening DOE with no work up Uncontrolled thyroid Active wheezing from infection COPD/Asthma exacerbation Urine toxicology positive