preop 28 mil 2025.pdf

28: Preoperative Evaluation Duminda N. Wijeysundera, and Emily Finlayson 1 perioperative medical specialists 2 3 5 6 Evolution of Pre-Anesthesia Evaluation ...

28: Preoperative Evaluation Duminda N. Wijeysundera, and Emily Finlayson 1 perioperative medical specialists 2 3 5 6 Evolution of Pre-Anesthesia Evaluation  7 8 3 5 Frailty, Geriatric Conditions, and The Older Surgical Patient 1 9 10 11 12 17 Goals and Benefits of Pre-Anesthesia Evaluation Fig. 28.1 18 19 21 22 23 24 26 23 25 26 27 Clinical Examination During Preoperative Evaluation clinical examination 28 29 31 11 32  FIG. 28.1 Components of The Medical History Fig. 28.2 Obstructive Sleep Apnea 33 35  FIG. 28.2 ECG, TB, TMJ, Assessment of Functional Capacity 12 14 36 37 38 41 42 43 44 45 subjective assessment Table 28.1 41 41 46 47  48 49 Table 28.2 Table 28.3 50 41 50 51 41 52 53 38 41 53 54 55 56 Table 28.1 Functional Capacity as Expressed in Metabolic Equivalents of Task METs Equivalent Level of Exercise 1 2 3 4 5 6 7 8 9 10 11 12 Clin Cardiol Table 28.2 Duke Activity Specific Index Questionnaire Can you: Points 1. Take care of yourself: that is, eat dress, bathe, or use the toilet? 2. Walk indoors, such as around your house? 3. Walk 200 yards on level ground? 4. Climb a flight of stairs or walk up a hill? 5. Run a short distance? 6. Do light work around the house like dusting or washing dishes? 7. Do moderate work around the house like vacuuming, sweeping floors, or carrying groceries? 8. Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture? 9. Do yard work like raking leaves, weeding, or pushing a power mower? 10. Have sexual relations? 11. Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a ball? 12. Participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing? Total score: Am J Cardiol Physical Examination Table 28.4 57 58 59 Table 28.3 MET-REPAIR Questionnaire Can you do ANY of the listed activities in each within the last month? If you can Able to Corresponding perform ANY of the activities listed, please check yes. perform? METs Stair climbing at rapid pace; carrying a suitcase (10–20 kg or 20–40 lbs) upstairs; ☐ running Moving furniture or household items; lifting light loads; running or playing with ☐ children or animals at vigorous effort; recreational swimming Carrying groceries up stairs; jogging; recreational soccer or tennis ☐ Descending stairs; making beds; vacuuming or sweeping floors; walking the dog ☐ for pleasure; play with children at moderate effort Stair climbing at slow pace; hanging laundry; cleaning the bathroom; mowing ☐ lawn (power mower); raking lawn or sweeping outside the house; leisure bicycling; walking for exercise on level ground at moderate pace Sitting; reading; watching TV; listening to music ☐ Moving household items up stairs, carrying boxes (up stairs); climbing hills ☐ carrying ≥20 kg or ≥40 lbs; swimming fast Hiking cross country; walking for exercise up hill; biking to/from work at self- ☐ selected pace; scrubbing floors on hands and knees with vigorous effort; mowing lawn (hand mower); shoveling snow; chopping wood with vigorous effort. Walk indoors, such as around your house; dressing/undressing. ☐ Carrying loads ≥25 kg or ≥50 lbs (e.g., furniture, 2 suitcases) up stairs; running at ☐ 10 km/h or 6 miles/h (faster than a bicycle at leisure pace) MET, MET-REPAIR, J Clin Anesth Table 28.4 BMI http://www.cdc.gov Chapter 40 Box 28.1 60 Fig. 28.3 61 Fig. 28.4 difficult 62 difficult or impossible 63 impossible 64  32 Box 28.1 Components of the Airway Examination FIG. 28.3 J Emerg Med  FIG. 28.4 Frailty, Geriatric Conditions, and the Older Surgical Patient 65 66 65 67 68 https://cpoc.org.uk/guidelines-and-resources Geriatric-Focused Assessment in The Older Surgical Patient Function and Mobility 65 69 70 71  72 73 74 Cognition 75 65 76 77 78 79 80 81 82 82 67 Nutrition 65 83 67 Document height, weight, and BMI Measure baseline serum albumin and prealbumin concentrations Inquire about unintentional weight loss in the last year 84 Frailty 85 86  87 88 65 89 93 94 95 96 97 98 99 99 100 101 102 103 Additional Considerations 104 In the past 12 months, have you ever had a time when you felt sad, blue, depressed, or down for most of the time for at least two weeks?” In the past 12 months, have you ever had a time, lasting at least two weeks, when you didn’t care about the things that you usually care about or when you didn’t enjoy the things that you usually enjoy?” 105 106 Patients with a History of Substance Use Disorder Preoperative Optimization for Older Patients with Frailty (Table 28.5) 107 Table 28.5 108  109 Chapter 86 4 4 110 111 Decision-Making for Surgery in Older Adults 112 Cognition http://www.teachbacktraining.org 113 114 Preoperative Evaluation of Patients with Coexisting Disease Chapter 29 Cardiovascular Disease 115 116 14 13 12 117 118 119 Hypertension 120 121 122 123 Chapter 29 123 14 59 124 125 126 Ischemic Heart Disease  127 127 128 129 130 131 132 133 132 134 135 136 137 138 115 116 Heart Failure Atrial Fibrillation 14 12 14 139 12 136 140 141 142 143  Fig. 28.5 12 Fig. 28.6 13 Fig. 28.7 14 emergency urgent time-sensitive 12 12 14 14 FIG. 28.5 ACS-NSQIP, MI, Circulation 12 14 144  12 Table 28.6 136 https://riskcalculator.facs.org/RiskCalculator 42 43 Box 28.2 FIG. 28.6 BNP, ECG, NT pro-BNP, PACU, Can J Cardiol 12 145 146 147 148 Assessment of Functional Capacity 41 41 46 47 Table 28.2 Table 28.3 149  49 52 FIG. 28.7 CV, ECG, TTE, Eur Heart J 13 150 41 151 153 151 152 Table 28.7 151 152 Table 28.7 Box 28.2  14 Table 28.6 Components of the Revised Cardiac Risk Index and Expected Cardiac Event Risk Components of Revised Cardiac Risk Index High-risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular procedure) Ischemic heart disease (by any diagnostic criteria) History of congestive heart failure History of cerebrovascular disease Diabetes mellitus requiring insulin Creatinine >2.0 mg/dL (176 μmol/L) Revised Cardiac Risk Index Score †‡ 0 1 2 ≥3 Circulation † Can J Cardiol ‡ Box 28.2 Classification Scheme for Procedure-Specific Cardiac Risk in the 2022 European Society of Cardiology Guidelines Low Cardiac Risk Intermediate Cardiac Risk High Cardiac Risk Eur Heart J Table 28.7 BNP MI NT pro-BNP † J Am Coll Cardiol ‡ Ann Intern Med 154 155 116 156 153 157 158 153 157 14 Table 28.6 136 https://riskcalculator.facs.org/RiskCalculator 42 43 159 137 160 136 161 162 162 163 164 Does this patient have IHD Is this patient optimized for planned radical nephrectomy? cleared for surgery diagnosis prognosis  12 165 145 166 167 168 169 14 170 171 172 173  174 175 176 177 178 179 12 14 13 not de novo 180 181 182 183 184 185 181 186 187 188 180 181 long-term 189 Hypertension 125 126 190 184 191 192 post hoc 193 selectively Atrial Fibrillation Preoperative Antiplatelet Therapy Coronary Stents 194 14 195 196 194  197 197 14 194 193 198 14 194 Heart Failure 199 127 200 199 199 201 202 203 203 199 199 204 205 206 symptomatic 206 206 asymptomatic 207 208 12 13 12 32 32 209 210 Ischemic Heart Disease 14 14 12 12 14 14 211 212 189 213 Hypertension 125 126 Atrial Fibrillation Cardiovascular Implantable Electronic Devices Murmurs and Valvular Abnormalities  Table 28.8 Table 28.9 214 14 12 Table 28.8 Grading the Intensity of Cardiac Murmurs Grade Description I II III IV V VI Table 28.9 Aortic Stenosis 214 Table 28.9 sclerosis 215 216  217 218 218 12 14 214 12 14 214 14 12 14 acquired Chapter 29 219 214 Aortic Insufficiency Table 28.9 220 221 32 222 12 14 214 14 214 Mitral Stenosis 214 214 Chapter 29  214 214 12 14 12 Mitral Regurgitation Table 28.9 32 223 12 214 14 214 Mitral Valve Prolapse is 224 225 32 214 Tricuspid Regurgitation  32 Chapter 29 214 Prosthetic Heart Valves 214 214 214 214 214 Box 28.3 214 Infective Endocarditis Prophylaxis 214 Infective Endocarditis Prophylaxis Box 28.4 214 Box 28.3 Recommendations for Preoperative Bridging Anticoagulation Therapy in Patients with Mechanical Heart Valves AVR INR MVR Class I (recommended) Class IIa (is reasonable) Circulation. Rhythm Disturbances on the Preoperative Electrocardiogram Chapter 29 Box 28.4 Cardiac Conditions for Which Endocarditis Prophylaxis Is Recommended  Circulation. Chapter 29 Box 28.5 226 Box 28.5 Common Indications for a Permanent Pacemaker AV bpm Class I Indications Class II Indications Circulation  227 139 228 228 229 230 231 Chapter 29 Atrial Fibrillation 232 233 234 235 Table 28.10 236 237 238 238 Table 28.10 Chest 239 115 240 242 Box 28.6 Classification Scheme for Procedure-Specific Bleeding Risk in the 2022 American College of Chest Physicians Guidelines Minimal Bleeding Risk Low/Moderate Bleeding Risk High Bleeding Risk Chest  243 244 Box 28.6 244 243 244 Table 28.11 Box 28.6 244 245 Table 28.11 ASRA, DOAC, eGFR Chest † ‡ Reg Anesth Pain Med 246 244 Table 28.12 244 Box 28.3 214 Cardiovascular Implantable Electronic Devices Chapter 34 247 248 Table 28.13 249 250 Table 28.12 Patients at High Risk for Periprocedural Thromboembolism During Withdrawal of Vitamin K Antagonist Anticoagulation Indication for Anticoagulation with High-Risk Clinical Features Vitamin K Antagonist (e.g., warfarin) Mechanical heart valve Atrial fibrillation Venous thromboembolism Chest Table 28.13 Pacing Clin Electrophysiol Box 28.7 12 250 14 250 251 252 14 Box 28.8 Box 28.7 Proposed Principles for CIED Management CIED EMI Heart Rhythm Peripheral Artery Disease 253 254 255 256 257 115 116 Box 28.8 Preoperative Recommendations for CIEDs CIED EMI ICD  Heart Rhythm Ischemic Heart Disease Atrial Fibrillation Coronary Stents 184 180 258 Pulmonary Disorders Chapters 12 29 49 Asthma 259 260  261 Upper Respiratory Tract Infections 262 Chapter 29 Chronic Obstructive Pulmonary Disease 263 Chapter 12 common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases and influenced by host factors including abnormal lung development http://www.goldcopd.org mild moderate severe very severe 264 266 an acute worsening of respiratory symptoms that result in additional therapy http://www.goldcopd.org Postoperative Pulmonary Complications 267 Chapter 49 Tobacco Smokers, Second-Hand Tobacco Smoke Exposure, and Cannabis Consumption  Postoperative Pulmonary Complications Chapter 29 Obstructive Sleep Apnea 268 269 272 273 Fig. 28.8 274 275 274 276 277 275 278 279 Chapter 40 280 282 115 283 285 286 Tobacco Smokers, Second-Hand Tobacco Smoke Exposure, and Cannabis Consumption 287 289 290 291  292 https://www.cdc.gov/tobacco/quit_smoking/index.htm https://smokefree.gov FIG. 28.8 BiPAP, BMI, CPAP, Anesthesiology 293 294 295 296 297 298 5 5 5 299 300 301 302  303 304 305 306 307 308 309 309 311 305 305 Upper Respiratory Tract Infections Chapter 72 312 312 313 Chapter 72 314 Postoperative Pulmonary Complications 315 315 316 317 Box 28.9 267 267 316 318 320 261  267 320 Is dyspnea caused by lung disease or heart failure? Can dyspnea or wheezing be improved further? 15 267 267 316 Box 28.9 Selected Risk Factors for Postoperative Pulmonary Complications ASA-PS BUN Potential Patient-Related Risk Factor Potential Procedure-Related Risk Factor Potential Laboratory Test Risk Factor Ann Intern Med 44 45 316 318 319 44 45 318 319 44 45 316 Table 28.14 321 316 Tobacco Smokers, Second-Hand Tobacco Smoke Exposure, and Cannabis Consumption  322 325 4 23 326 327 Table 28.14 Scoring Scheme for the ARISCAT Perioperative Pulmonary Risk Index ARISCAT Score Risk of Pulmonary Complications Low risk: