Surgery Clearance

Template

HPI:
Patient is here for surgical clearance.
Planned surgery is:
Functional status:
Cardiac/pulmonary history: ; _no_ arrhythmias, recent MI / unstable angina, valve disease
Previous general anesthesia tolerance:
Social: __ ; recovery phase support planned:

AP
- Patient risk is ___; surgery risk is ___
- METS equivalent __; RCRI Risk __


• Patient + Surgery = Risk Stratification => Management.
• Urgent / emergent surgical patients don’t follow the risk stratification and are higher risk (2-3x baseline).
• A question: what does it take for this pt to make it / recover?
surgery of risks are:

hemostasis
cardiac strain
infection
tissue repair
anesthesia cx


1. Patient Risk
• Functional Status, Primary RFs, Secondary RFs, Fhx, Recent events.
• Metabolic Equivalents : METs; functional status
- can take care of self (eat, dress, toilet) = 1MET.
- can walk-up stairs / hill, walk 3-4 mph = 4METs
- heavy work (scrub floors, move heavy furniture, 2 flights stairs) = 4-10 METs
- sports (swimming, tennis, football, basketball) = >10 METs
> poor indicator is if can’t walk 4 blocks or 2 flights stairs.
• Primary Co-morbidities: key are hx cardiac dz, afib, hx HTN, DM, CKD, CVA/TIA, PAD
• Secondary : obesity, smoker, etoh abuse, age.
• Fhx: malignant hyperthermia or other intolerance to anesthesia.
• Social: recovery phase support.
• Recent MI / UA, decomp HF, high-grade arrythmias, valve dz (aortic stenosis) = very high risk for ACS/arrest; optimize management and likely refer for cardiology.


2. Surgery Risk
• Low Risk Procedures: <1% risk ACS:
- minimal invasive. min EBL
- office setting
- Breast bx, skin bx/excision, myringotomy, hysteroscopy. arthroscopy.
• Intermediate Risk Procedures: 1-5%:
- min-mod invasive. EBL 500-1500cc.
- dx laparoscopy, D&C, BTL, hernias, lysis adhesions, tonsillectomy, percutaneous lung bx, hysterectomy, myomectomy, chole’s, lapasroscopic, GI resection, hip/knee replacements.
• High Risk Procedures: >5%:
- highly invasive. EBL >1500cc.
- major ortho-spinal reconstruction, GI major reconstruction, major vascular, major GU (RRP), thoracic procedures, intracranial, major oropharynx, skeletal, neuro, total joint revisions.
• Emergent Procedures: 2-5x risk of elective.


3. Risk Stratification
• MICA, RCRI, ACS-NSQIP

MICA: intraop/postop MI or cardiac arrest: Gupta MICA Peri-operative Cardiac Risk calculator
- 5 variables: type surgery, dependent functional status, abnormal cr, ASA class, increased age.

RCRI : MDCalc RCRI
6 variables: - rate of cardiac death / MI: 0= 0.4%, 1=1.0%, 2=2.4%, >3 = 5.4%
-
High-risk type of surgery (examples include vascular surgery and any open intraperitoneal or intrathoracic procedures)
- History of ischemic heart disease (history of MI or a positive exercise test, current complaint of chest pain considered to be secondary to myocardial ischemia, use of nitrate therapy, or ECG with pathological Q waves; do not count prior coronary revascularization procedure unless one of the other criteria for ischemic heart disease is present)
- hx HF
- hx CVA/TIA
- DM insulin-dependent
- pre-op serum cr.

ACS-NSQIP: 20 pt factors + surgical procedure; NSQIP Calculator


4. Management
• Management based on risk
> low-risk: <1% risk = no further cardiac testing
> high-risk: >1% risk = often known CAD/valve dz. -> need stress / echo / holter / cards consult if <4 METS.

• Options: post-pone (w/ cardiac w/u-tx); ∆ procedure / alternative; cancel.
• Cardiac hx begets pre-op EKG. Why? Comparison during surgery EKG ∆s.

• Female patients get preg test.
• Interm-high risk: BMP (Cr) if >50 yo, H/H in high blood loss procedures
• EKG in known CAD/arrythmias/PAD/ hx CVA/TIA/ structural heart dz. (ACC/AHA 2014)

• Algorithm: emergency vs elective (low vs elevated risk {METS <4 vs >4})
- Stepwise Algorithm 2014 ACC/AHA Guideline
> low risk : go to surgery
> elevated risk : if METS >4 or >10 : go to surgery
> elevated risk : if METS <4 or unk: workup / cards vs ∆ tx options.



Stepwise Algorithm 2014 ACC/AHA Guideline
Step_app_peri_card_ases_CAD