Dr.

Vithal Dhulkhed
Professor and Head ,Dept of Anesthesiology Krishna Institute of Medical Sciences (Deemed University) Karad, Maharashtra

PURPOSE OF THE PREOPERATIVE EVALUATION BY CONSULTING PHYSICIAN

The purpose is not to give medical clearance but rather

informed clinical judgment to the anesthesiologist and the surgical team The patients current medical status Recommendations regarding the management and risk of cardiac(other) problems during the periop Period The patients clinical risk profile, to assist with treatment decisions that may affect short- or longterm cardiac (other)outcomes.
LEE A. FLEISHER, MD Robert D. Dripps Professor and Chair, Department of Anesthesiology and Critical Care, and Professor of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA

THE OBJECTIVES OF PRE-OPERATIVE ASSESSMENT

The aim in assessing patients before anaesthesia and surgery is to improve outcome. This is achieved by: Identifying existing medical conditions Identifying potential anaesthetic difficulties Improving safety by assessing and quantifying risk Allowing planning of peri-operative care Providing the opportunity for explanation and discussion Allaying fear and anxiety for the patient and relatives This will only be achieved when all health professionals work as a team [2].

THE OBJECTIVES OF PRE-OPERATIVE ASSESSMENT

Good pre-operative assessment will help to: Reduce costs Increase efficiency of operating theatre time Such action should: Reduce the number of patients who fail to attend on the day of surgery Reduce cancellation of surgery for clinical reasons Provide an opportunity to discuss with patients any selfhelp matters to improve outcome (e.g. stopping smoking or losing weight). Patients should have access to easily understood information.

Preoperative Assessment
Objectives

To deliver good quality care To establish doctor-patient rapport To establish a clinical picture of the patient To identify risk factors To draw up a management plan To optimise any concurrent medical conditions To minimise the occurrence of critical incidents in the perioperative period, drug interactions

% of pts

Approx75% who suffer periop death have CVS disease

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Perioperative Stress
With increasing surgical risk there is need to increase VO2

for several days post op not Misch

Postop mortality -

function of preop cardiopulm failure,

Surgical risk for cardiac events are related to the urgency, magnitude, type, and duration of the procedure, as well as the change in body core temperature, blood loss, and fluid shifts

OER- Oxygen Extraction Ratio

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Perioperative Stress.
Inability to increase CO is periop cardiac failure (PCF); focus on detection of forward CF.
.

It, is frequently occult in elderly;manifests as reduced exercise tolerance; Normally elderly patients adjust their level of activity when O2 demand>supply. The postop patient does not have this option

Surgery Related Risk*

High Risk (Risk > 5%): Emergent major operations Aortic and other major vascular Peripheral vascular Intermediate Risk (Risk < 5%): Carotid endarterectomy Endovascular AAA repair Head and neck Intraperitoneal and intrathoracic Ortho,uro,neuro major Low Risk Surgery (Risk < 1%):

Anticipated prolonged or associated with large fluid shifts and/or blood loss

Endoscopic procedures Superficial procedure Cataract surgery Breast surgery Gynaecology

Reconstruct ive Minor ortho,uro

*Risk of MI and cardiac death within 30 ddays of surgery

Perioperative Stress
low risk surgery -postopVO2 need <120 ml/min/m2
intermediate risk -VO2 120-150. high risk surgery >150 ml/M2. 40% over basal

Need to increase VO2 by 50%. for several days Post op

In normal exercise OER can increase to 75%, but

after an operation OER is only 30%. Requiring 2.5-fold increase in postop CO Post op mortality is a function of preop cardiopulm failure and not MIsch
OER- Oxygen Extraction Ratio
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Patient Factors

Age Existing Co-morbidity Exercise Tolerance

Medication

Patient Factors.
The low risk group < 60 yrs with no history of

cardiopulmonary disease or non-specific ECG changes, may proceed to surgery with little evaluation.
The high-risk group includes acute coronary

syndromes, decompensated cardiac failure, recent MI and supraventricular arrhythmias. -need further assessment and management.

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Patient Factors.
Intermediate group >60 yrs ;stable angina, previous

MI, compensated or prior CCF and DM, determine functional capacity

The ideal screening test should provide an accurate

assessment of myocardial function, detect M ischaemia, and be non-invasive,easily performed in elderly patients, reproducible and cost effective

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What is important in screening?

History-taking and the physical examination are still

the best means of preop screening, and

Lab tests other than those indicated by history and

physical examination are not cost effective, do not provide medicolegal protection, and in fact may harm the patient" (Roizen, 1987 ).

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History Taking
Chart review
Present illness Family History: porphyria, malignant hyperpyraxia,

haemophilia, cholinesterase abnormalities and dystrophy myotonica . Disease of CVS & RS, exertional dyspnoea, paroxysmal nocturnal dyspnoea, orthopnoea, angina of effort, MI and COPD.

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History Taking ........

Hematological Disease : Anemia , Clotting

abnormalities , Thromboprophylaxis . Musculoskeletal Disease : Rheumatoid Arthritis . Renal Disease : Renal Failure , Patients on Dialysis . CNS Disease: Seizures , TIA , Stroke, Raise ICP. GI: Liver Disease , GERD , vomiting , diarrhea Endocrine Disease: Diabetes Mellitus

GERD-Gastroesophageal reflux dis

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History Taking ...........

Allergy to drugs, food, antibiotics, anesthetic agent,

latex allergy and atopic patient HBV,HCV,HIV carriers have additional risk on staff. Special Precaution in infected patient:

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A history of previous anaesthesia .

Sore throat and headache Post-operative nausea or vomiting.

Expose to Halothane within 3 mths prior

DVT problem. Difficulties with tracheal intubation.

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Pregnancy
If its elective surgery then postpone it till delivery.
Many anaesthetic are teratogenic especially in early

stage.
They may induct spontaneous abortion.

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Smoking; Alcohol
Smoking indicate: CVS problems , chronic bronchitis

or Lung CA. Causes tachycardia, increase peripheral resistance, decrease the availability of O2 by 25%, and increase RS complications by 6 folds. Stop 1 month prior ; or at least 6 hours before. Alcohol causes induction of liver enzyme, hepatic & cardiac damage, post-op delirium tremors due to withdrawal

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Drug History
CVS medication: ACE Inhibitors, Diuretics,

B-

Blockers, Calcium channel blockers Antibiotics: Aminoglycosides,Sulphonamides. Anticoagulant: Warfarin, Aspirin, oral contraceptive, hormone replacement therapy Lithium and Insulin . Some drugs must be stopped before (contraceptive tablets .warfarin and MAOI )

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Physical Examination
Full examination must be done even if its a minor surgery.
General: color, activity, weight, dehydrated, & type

of breathing. CVS: pulse volume, rate, and pressure, heart sounds, & BP. RS: Breathing sound, chest expansion, airway and trachea. Assessment of the ease of tracheal intubation.
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Physical Examination
Teeth should be inspected for caries, caps and loose

teeth. Mouth opening Flexion of cervical spine & extension of Atlanto-occipital joint. CNS : cranial nerve examination , Eye Examination , Peripheral sensory & Motor Dysfunction

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Anaesthetic history/assessment
Family history
Previous anaesthetics
PONV

allergy
malignant hyperpyrexia difficult airway

difficult IV access

Airway assessment
Best done by an anaesthetist Certain features of concern
small mouth poor dentition limited neck mobility scars/surgery/anatomical abnormalities obesity

Mallampati scoring system

Preoperative investigation
The request for pre-operative investigations should be

based on:
Factors apparent from the clinical assessment The likelihood of asymptomatic abnormalities The severity of the surgery contemplated Unnecessary lab testing is still common. A substantial

excess cost is incurred due to this

Barnard N A, Williams R W, Spencer E M. Preoperative patient assessment: a review of the literature and recommendations. Ann R Coll Surg Eng 1994; 76: 293-297
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Electrocardiogram Age >50 CVS disease DM Renal disease

Chest X-ray Age >60 Significant RS disease CVS disease , If not done on last year, Rheu arthritis, thyroid goitre, diphtheria, malignancy

Full Blood Count Age >60 ,Clinical anaemia (?include for Hb age.<6mths,>40y or female:If Hb not obtained in 2mths,smoking >40 PY ) Haematological disease Renal disease ,Chemotherapy Procedures with bl loss > 15% Random Blood Sugar Age > 60 Symptoms of DM, DM, Liver dysfn, CNS dis, surgery involving interruption of bl supply to brain, Steroids, BMI>33 and no test in 2 mths
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PFT COPD,Dyspnoea, Orthpnoea To test reversibility of bronchospasm, anticipated postop intubation, lung rsection

Coagulation Profile Haematological disease Liver disease ,SLE, Malnutrition Anticoagulation Intra-thoracic/Intra-cranial procedures Acute major trauma Preeclampsia, Vascular dis Renal disease

Renal Profile Age >60 , Morbid obesity Renal disease ,Liver disease DM, CVS, renal disease Procedures with bl loss > 15% Stable and unstable symptom swith no test for 2 mths Steroids, diuretics, drugs excreted by kidney

Liver Function Tests Hepatobiliary disease Alcohol abuse

(These tests are recommended for administration of anaesthesia and are not intended to limit those required for issues specific to their surgical management)

Note: For healthy patients undergoing short, minimally invasive procedures, investigations may not be necessary.

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Pregnancy Test
Patient is of child-bearing age and is sexually active and history suggests possible pregnancy, e.g., delayed menstruation, or patient is concerned about possible pregnancy or if possibility of pregnancy is uncertain

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Common causes for postponing surgery

Acute upper respiratory tract infection.
Untreated medical diseases. Inadequate resuscitation in emergency( 1/3 of fluid

lost ) in dehydrated pt & low BP in shock pt. Recent ingestion of food. Failure to obtain informed consent. MI : wait 6 months

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Dripps/ASA Classification
Class 1 2 Systemic Disturbance Healthy patient with no disease outside of the surgical process Mild-to-moderate systemic disease caused by the surgical condition or by other pathologic processes Mortality* <0.03% 0.2%

3
4 5 E

Severe disease process which limits activity but is not incapacitating

Severe incapacitating disease process that is a constant threat to life Moribund patient not expected to survive 24 hours with or without an operation Suffix to indicate an emergency surgery for any class

1.2%
8% 34% Increased

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The Assessment of Dyspnea

Grade 0 No dyspnea while walking at a normal pace

Grade I I am able to walk as far as I like provided I

take my time. Grade II Specific street block limitations I have to stop for a while after one or two blocks. Grade III Dyspnea on mild exertion I have to stop and rest while going from kitchen to bathroom. Grade IV Dyspnea at rest,
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 Static Testing
o o o o

Electrocardiography Transthoracic Echocardiography Transoesophageal Echocardiography Cardiac catheterisation

Dynamic Testing o Exercise ECG testing o Dobutamine stress echo o Dipyridimole stress echo o Dipyridimole thallium scintigraphy
o Cardiopulmonary exercise testing

Useful adjunct in evaluating CAD, not recommended for PAE functional assessment
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Stepwise Approach to Preoperative Cardiac Assessment

Need for emergency noncardiac surgery

Yes

Operating room

Vigilant perioperative and postoperative management

No
*Active cardiac conditions

Yes

Evaluate and treat per ACC/AHA Guidelines

Consider Operating Room

No
Low Risk Surgery

Yes

Proceed with planned surgery

No
Asymptomatic and good functional capacity >4MET

Yes
No or unknown

Proceed with planned surgery*

Manage based on clinical risk factors

*Noninvasive testing may be considered before surgery in specifi c patients with risk factors if it will change management.

Acute or recent MI (7-30 d) Unstable coronary syndrome Decompensated CHF Significant Arrhythmias Severe Valvular Disease

Manage based on clinical risk factors

3 or more clinical risk factors*

1 or 2 clinical risk factors*

No clinical risk factors*

Vascular Surgery

Intermediate risk surgery

Vascular Surgery

Intermediate risk surgery

Consider Testing

Proceed with planned surgery with HR control or consider non-invasive testing

Proceed with planned surgery

*Clinical risk factors = known ischemic heart disease, compensated or prior HF, diabetes, renal insufficiency, cerebrovascular disease

 Examines the ability of the CVS to deliver oxygen

to tissues under stress

Exercise at known work rate on ergometer while

a number of variables are measured:

o o o o o o

(1) (2) (3) (4) (5) (6)

ECG Blood pressure; Expired air flow; O2 uptake from the air; CO2 output from the body; Arterial blood gases.

VO2 - volume of oxygen consumed ml/min (absolute) ml/kg/min (relative) METS - metabolic equivalents 1 MET = 3.5 ml/kg/min VCO2 - volume of carbon dioxide produced ml/min
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 During exercise, when rise in VCO2 becomes

disproportionate to rise in VO2 Indicates the level of exercise where body has reached maximal aerobic capacity
Termed the Anaerobic Threshold

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Classification of Cardiac Failure(CF) by Exercise Testing

Functional Class

Definition

VO2 max
(ml/min/kg)

AT
(ml/min/kg)

A B C D

No CF Mild CF Moderate CF Severe CF

>20 16-19.9 10-15.9 <10

>14 11-13.9 8-10.9 <8

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Parameters Measured

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Preoperative cardiopulmonary exercise testing

Differentiates cause of dyspnoea due to CAD,HF

restrictive and obstructive lung disease. Evaluates functional status before major surgery. AT >11 ml/ kg/min -no CV mortality,less hospital stay <11 ml/ kg/min postop CCU Low AT and peak VO2 --with poor outcome Major abdominal or thoracic surgery with significant ischaemia or pulm dysfunction are admitted to HDU postop for ECG and RS monitoring, even if mild CF
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Perioperative Management
Revascularization
Beta blockers Statins

Alpha-2 agonists
Calcium channel blockers Aggressive pain control Avoidance of severe anemia Normothermia Vigilant monitoring
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Acute MI High Risk ACS High risk anatomy

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Class I recommendations for revascularization - 2004

ACC/AHA guidelines:

1 = stable angina and significant left main disease;

2 =stable angina and 3 vessel disease, especially when

LV EF <50%; 3 = stable angina and 2-vessel disease with significant proximal LAD stenosis and either LV EF<50% or demonstrable ischaemia on non-invasive testing; 4 =high-risk unstable angina or non-STEMI; 5 =acute STEMI

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Perioperative Beta Blockers

AHA/ACC Recommendations: 2006 Update

Beta blockers required in recent past to control symptoms of angina or patients with symptomatic arrhythmias or hypertension
Patients at high cardiac risk owing to the finding of ischemia on preoperative testing who are undergoing vascular surgery Patients undergoing vascular surgery and with identified CAD Vascular surgery and multiple cardiac risk factors Moderate or high risk surgery and multiple cardiac risk factors
Key Point: if known or suspected CAD and undergoing moderate or high risk surgery, use a beta blocker!

Perioperative Statins
ACC/AHA 2007 Recommendations: Statins Class I: Patients currently taking statins Class IIa: Patients undergoing vascular surgery Class IIb: Patients with at least 1 clinical risk factor undergoing intermediate risk surgery

Hindler, et al. Anesthesiology 2006;105:1260-72

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Can anticoagulation be stopped in the patient with a mechanical heart valve?

Low risk patients (bileaflet Aortic valve, no risk factors*)
Stop warfarin 48-72 pre-op Resume 24 hrs post-op

High risk patients (mitral valve, aortic valve + any risk factor*)
Bridge with UFH, starting when INR < 2
*Risk factors: AF, previous thromboembolism, LV dysfunction, hypercoagulable state, older generation valve, mechanical tricuspid valve, more than one mechanical valve

Risk assessment of pulmonary diseases

Pulmonary issues
PPC play important role in risk for patients
Contribute similar to cardiac complications in

morbidity mortality and length of stay

PPC
Atelectasis Infection Bronchitis Pneumonia Bronchospasm Pulmonary embolism
Exacerbation of underlying chronic lung disease Respiratory failure and prolonged invasive or noninvasive ventilation ARDS

PPC- Postoperative pulmonary complications

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Preoperative risk factors for PPCs

Age,

BMI Dyspnea, COPD, OSA Inhaled tobacco use NYHA class >II, IHD, arrhythmia, pulmonary hypertension Nutrition status, lower serum albumin concentrations, DM, alk PO4 level of 125 U/L, increased complexity scores, and decreased functional status.

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Factor or Intervention Age 60-69;70-79 vs <60yrs Smoking Preoperative chest roentgenograms

Incidence PPC %

OR 2.09;3.04 1.26

12.8% vs 16%),

Serum Albumin 3.5 g/dL

COPD;CCF Functional dependence,total; partial In ILD Composite physiologic index (CPI) of > 40 GA; Emergency surgery Noncardiothoracic surgery: duration of surgery cardiothoracic surgery Esophagectomy transhiatal approach VS transthoracic
Ann Intern Med 2006:144:574-580 ILD-Intersitial Lung disease

22 to 44%
1.79 ;2.93 2.51;1.65 50% 1.83;2.21 from 2 to 19 ; 8 to 39 (27% vs 57%, respectively; 2.14

CPI = 91.0 - (0.65 * % predicted DLCO) - (0.53* % predicted FVC) - (0.34 * % predicted FEV1).
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Preoperative pulmonary assessment

Spirometry ,forced-vital capacity (FVC), maximal

inspiratory and expiratory (MEP) pressures, and peak cough flow (PCF). For patients with FVC < 30%, preop use of noninvasive IPPV to be considered. Ineffective cough, defined as PCF < 270 L/min or MEP < 60 cm H2O, preop manual- and mechanically assisted cough considered.

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Pulmonary function tests: Indications

Lung resection -should have (PFT). CABG , upper abdominal surgery with H/O smoking

or dyspnea. Head and neck, orthopedic, or lower abdominal surgery with unexplained dyspnea or pulmonary symptoms. Preop PFT need not lead to cancellation. Even severe COPD, can undergo surgery with an acceptable risk of pulm complications. Results should be interpreted in context of clinical situation
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The Snider Match Test

A patient who can extinguish at 15 cm with his

mouth wide open has a FEV 0.75 sec of at least 1,000 cc and a PFR of at least 130 liters per min.

Breath-holding test:
Rest five minutes. Take a full breath. Hold it

with mouth and nostrils closed. Note time in seconds. Breath-holding test of 10 to 15 seconds would indicate a vital capacity of 1500 cc. or less
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6 minute walk test

Inexpensive, easy. How far can walk along a flat corridor,

turning around at each end, at normal pace, in 6 min. Median normal - 500600 m. Other measurements include SpO2 , HR ,dyspnoea scale and leg fatigue. >563 m - not routinely CPET; <427 m -further evaluation. uncertainty (427 but 563 m), Consider clinical risk factors and magnitude of surgery in the decision* less than 300 m -poor prognosis following aortic valve replacement >350 m for lung volume reduction surgery for management of significant COPD <200 m predict high 6-month mortality

*Br. J. Anaesth., January 1, 2012; 108(1): 30 - 35.

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Stepwise approach to preoperative pulmonary assessment

Age, BMI Dyspnea, COPD, OSA Inhaled tobacco use IHD, arrhythmia, NYHA class II pul hypertension, Nutrition status, lower albumin, DM, alk PO4 level of 125 U/L, high complexity scores, and decreased functional status, pancuronium,surg site duration,GA

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Stepwise approach to preoperative pulmonary assessment

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Risk assessment of liver diseases

Child-Turcotte-Pugh Classification of liver disease

Criterion
Ascites Encephalopathy Total bilirubin,
mol/L (N= 17.1) mg/dL (N= 1.0)

1 point each
None None < 34 (0-2) >35 (>3.5 g/dL) < 1.7

2 points each 3 points each

Controlled with diuretics Grade I-II 34 50 (2-3) Poorly controlled Grade III-IV > 50 (> 3)

Albumin, g/L INR

25-35 (2.5-3.5 g/dL) < 25 (< 2.5 g/dL) 1.72.2 >2.2

CTP A points = 5-6 , B = 7-9 , C = 10-15 Mortality rate(abdominal surgery.) : class A 10% class B : 30-31% class C- 76-82%

Integrated MELD Score

More recently, "integrated MELD" score (iMELD):

iMELD = MELD(3.8 ln bilirubin value) + (11.2 X ln INR) + (9.6 ln creatinine value), + (0.3 X age) - (0.7 X serum sodium [mEq/L]) + 100. ),

bilirubin and creatinine values in (mg/dL) ;ln- natural ogarithm

Scores of < 35, 35-45, and >45 associated with periop

mortality rates of 4%, 16%, and 50%, respectively.

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To summarise
Preoperative evaluation should be a team approach History and physical examination History-taking and the physical examination are still

the best means of preop screening, and Avoid unindicated lab tests Weigh the risk benefit ratio of surgery Provide optimal perioperative care by triage according to risk stratification Patients should have access to easily understood

information
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