Preoperative Assessment and Optimisation

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					Preoperative Assessment and
       Optimisation
           Paul Hersch
     Consultant Anaesthetist
    Royal United Hospital Bath
                   Summary

• The overriding theme of this document is
  that intervention is rarely necessary
  simply to lower the risk of surgery unless
  such intervention is indicated irrespective
  of the preoperative context.
• Indications for angiography and CABG
  are independent of surgery.
• Intervention is not just to “get patients
  through” surgery.
Preoperative Assessment

• Evaluate current medical status
• Recommend treatment to improve
  medical condition („optimisation‟)

• Provide clinical risk profile
   – informed consent
   – patient choice
• Plan management of risk over entire
  perioperative period
           Hypertension
• BP 140/85
• BP 179/109

• BP 180/110
            Coronary Heart Disease
Class I: Ordinary physical activity does not cause angina. Angina
   occurs on strenuous exercise only.
Class II: Slight limitation of ordinary activity. Angina occurs on walking
   or climbing stairs rapidly, walking uphill, walking or stair climbing
   after meals, or in cold, or in wind, or under emotional stress, or only
   during the first few hours after wakening. Angina occurs on walking
   more than 150 yards on the level and climbing more than one flight
   of ordinary stairs at a normal pace and in normal conditions.

Class III: Marked limitation of ordinary activity. Angina occurs on
   walking 75–150 yards on the level or climbing one flight of stairs in
   normal conditions and at normal pace.
Class IV: Angina on slight exertion; possible at rest.
              Heart Failure
• Previous echocardiography
• Compensated heart failure
  – No signs (elevated JVP, basal crackles)
  – No symptoms (orthopnoea, PND)
• New York Heart Association Classification
  Class I-II
        New York Heart Association
              Classification
Class I: No limitation of physical activity. Symptoms
  (shortness of breath, fatigue or palpitations) on
  strenuous exercise only.
Class II: Slight limitation of physical activity. Symptoms on
  moderate exertion eg climbing 2 flights of stairs, long-
  distance walking.

Class III: Marked limitation of activity. Symptoms on
  minimal exertion eg climbing 1 flight of stairs, walking
  short distances on the flat.
Class IV: Severe to complete limitation of activity.
  Symptoms with any physical exertion and may appear
  even at rest.
         Respiratory Disease
• Asthma
  – Acute attacks less than once a month
  – PEFR variability < 20%
• COPD
  – Moderate limitation of ordinary physical activity
  – Able to climb one flight of stairs without stopping
  – Able to walk 50–100 yards on the level without
    stopping
  – Only occasional episodes of acute chest infection
                   Functional Capacity
All patients for major surgery should have METs > 4


Duke Activity Index

1 MET    Can you take care of yourself?      4 METs   Climb a flight of stairs or walk up a hill?
         Eat, dress, or use the toilet?               Walk on level ground at 4 mph or 6.4 km/h?
         Walk indoors around the house?               Run a short distance?
         Walk a block or two on level ground
         at 2 to 3 mph or 3.2 to 4.8 km per h?        Do heavy work around the house like scrubbing
                                                      floors or lifting or moving heavy furniture?
         Do light work around the house like
4 METs   dusting or washing dishes?                   Participate in moderate recreational activities
                                                      like golf, bowling, dancing, doubles tennis, or
                                                      throwing a baseball or football?

                                           >10 METs Participate in strenuous sports like swimming,
                                                    singles tennis, football, basketball, or skiing?
     Derivation and Prospective Validation of a Simple Index for
      Prediction of Cardiac Risk of Major Noncardiac Surgery
                              Lee et al
                   Circulation 1999;100:1043-1049


Risk factor                                       Criteria
High-risk surgery                AAA repair, thoracic, abdominal surgery
IHD                              MI, Q on ECG, angina, nitrates, EST+
CCF                              History, examination, CXR
Cerebrovascular disease          Stroke, TIA
Diabetes                         Insulin treatment
Renal impairment                 Creatinine >177 mol/L

Number of factors         % population   Major cardiac complications
0                         36%                    0.5%
1                         39%                    1%
2                         18%                    5%
3                         7%                     10%
4                                                15%
5                                                30%
Cardiac risk assessment indices
• Goldman
  – Larsen
  – Detsky
     • www.vasgbi.com
  – Lee
• POSSUM
     • Physiological & Operative Severity Score for the
       enUmeration of Mortality & Morbidity
  – P-POSSUM
  – CR / OG / Vascular – POSSUM
     • www.riskprediction.org.uk
                Case example
• 70 year old man
• Severe Parkinsons Disease on Rx
• Admitted for elective inguinal hernia repair
   – also under investigation for change in bowel habit
• Two recent episodes of angina whilst walking to
  keep up with his son
   – stable class III angina
   – start β-blocker (or rate-limiting calcium channel
     blocker) prior to major surgery
Discussion

				
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