Preoperative Risk Geoffrey C Zarrella DO FACC Assessment
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
omeone 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