medical evaluation of the surgical patient

1. Medical Evaluation of the Surgical
Patient
Dr Amit Kumar Shrestha
MDGP Resident
First Year
(NAMS)
Bharatpur Hospital

2. Surgery: Gradation of Risk of Common Noncardiac Surgical
Procedures
Higher
-Emergent major operations, especially elderly
-Aortic and other non carotid major vascular surgery
-Prolonged surgery associated with large fluid shift and/or blood loss
Intermediate
-Major thoracic surgery
-Major abdominal surgery
-Carotid end arterectomy surgery
-Head/neck surgery
-Orthopedic surgery
-Prostate surgery
Lower
-Eye, skin, and superficial surgery
-Endoscopic procedures

3. Standardized Preoperative Questionnaires
1. Age, weight, height
2. Are you:
Female and 55 years of age or older or male and 45
years of age of older?
If yes, are you also 70 years of age or older?
3. Do you take anticoagulant ("blood thinners")
medications?
4. Do you have or have you had any of the
following heart-related conditions?
-Heart disease
-Heart attack within the last six months
-Angina (chest pain)
-Irregular heartbeat
-Heart failure

4. 5. Do you have or have you ever had any of the following?
-Rheumatoid arthritis
-Kidney disease
-Liver disease
-Diabetes
6. Do you get short of breath when you lie flat?
7. Are you currently on oxygen treatment?
8. Do you have a chronic cough that produces any discharge or
fluid?
9. Do you have lung problems or diseases?
10. Have you or any blood member of your family ever had a
problem with any anesthesia other than nausea?
If yes, describe:
11. If female, is it possible that you could be pregnant?
Pregnancy test:
Please list date of last menstrual period:

5. Preoperative Cardiac Risk Assessment
Functional Status

6. Revised Cardiac Risk Index Clinical Markers
High-risk surgical procedures
-Vascular surgery
-Major intra peritoneal or intra thoracic procedures
Ischemic heart disease
-History of myocardial infarction
-Current angina considered to be ischemic
-Requiring sublingual nitroglycerin
-Positive exercise test
-Pathological Q-waves on ECG
-History of PTCA and/or CABG with current angina
considered to be ischemic

7. Congestive heart failure
-Left ventricular failure by physical examination
-History of paroxysmal nocturnal dyspnea
-History of pulmonary edema
-S3 gallop on cardiac auscultation
-Bilateral rales on pulmonary auscultation
-Pulmonary edema on chest x-ray
Cerebrovascular disease
-History of transient ischemic attack
-History of cerebrovascular accident
Diabetes mellitus
-Treatment with insulin
Chronic renal insufficiency
-Serum creatinine >2 mg/dL

8. - The risk of major cardiac events—defined as myocardial
infarction, pulmonary edema, ventricular fibrillation or
primary cardiac arrest, and complete heart block—can
then be predicted
-Based on the presence of none, one, two, three, or more
of these clinical predictors, the rate of development of one
of these major cardiac events is estimated to be 0.5, 1, 5,
and 10%, respectively

10. Risk Modification Using Preventive Strategies to
Reduce Cardiac Risk
Perioperative Coronary Revascularization
Perioperative Medical Preventive Therapies
B- Adrenergic Antagonists
(1) continued in high-risk patients who previously received these
drugs and undergo vascular surgery, and they should be
administered to high-risk patients identified by myocardial
ischemia on preoperative assessment who are scheduled to
undergo vascular surgery.
(2) recommended for high-risk patients defined by multiple clinical
predictors who undergo intermediate- or high-risk procedures.
(3) They may be considered for intermediate-risk patients who
undergo intermediate- or high-risk procedures and for low-risk
patients who undergo vascular surgery.

11. HMG-CoA Reductase Inhibitors (Statins)
-considered in intermediate- or high-risk patients with atherosclerotic
cardiovascular disease who are undergoing major noncardiac surgery.
Angiotensin-Converting Enzyme (ACE) Inhibitors
-discontinuation of ACE inhibitors and angiotensin receptor blockers
for 24 hours prior to noncardiac surgery due to adverse circulatory
effects after induction of anesthesia.
Oral Antiplatelet Agents
-If clinicians elect to withhold antiplatelet agents prior to surgery, they
should be restarted as soon as possible postoperatively
Calcium Channel Blockers
-Evidence is lacking to support the use of calcium channel blockers as a
prophylactic strategy to decrease perioperative risk in major
noncardiac surgery.

12. Preoperative Pulmonary Assessment
The guidelines from the American College of Physicians recommend the following:
• All patients undergoing non cardiac surgery should be assessed for risk of pulmonary
complications
• Patients undergoing emergency or prolonged (>3 h) surgery; aortic aneurysm repair;
vascular surgery; major abdominal, thoracic, neuro, head, or neck surgery; and general
anesthesia should be considered to be at higher risk for postoperative pulmonary
complications.
• Patients at higher risk of pulmonary complications should receive deep breathing
exercises and/or incentive spirometry as well as selective use of a nasogastric tube for
postoperative nausea, vomiting, or symptomatic abdominal distention to reduce
postoperative risk
• Routine preoperative spirometry and chest radiography are less helpful for predicting
risk of postoperative pulmonary complications, but may be appropriate for patients
with chronic obstructive pulmonary disease (COPD) or asthma.
• Pulmonary artery catheterization, total parenteral nutrition, and total enteral nutrition
are not encouraged for postoperative pulmonary risk reduction

13. Predisposing Risk Factors for Pulmonary
Complications
1. Upper respiratory tract infection: cough,
dyspnea
2. Age >60 years
3. COPD
4. American Society of Anesthesiologists Class 2
5. Functionally dependent
6. Congestive heart failure
7. Serum albumin <3.5 g/dL
8. FEV1<2 L
9. MVV <50% of predicted
10. PEF <100 L or 50% predicted value
11. PCO2>45 mmHg
12. PO2 <50 mmHg

14. Risk Modification to Reduce Perioperative Pulmonary
Complications
Preoperatively
-Cessation of smoking
-Training in proper breathing (incentive spirometry)
-Inhalation bronchodilator therapy
-Control of infection and secretion, when indicated
-Weight reduction, when appropriate
Intraoperatively
-Limited duration of anesthesia
-Select shorter acting neuromuscular blocking drugs
when indicated
-Prevention of aspiration
-Maintenance of optimal broncho dilation

15. Postoperatively
Continuation of preoperative measures, with particular
attention to
-inspiratory capacity maneuvers
-mobilization of secretions
-early ambulation
-encouragement of coughing
-selective use of a nasogastric tube
-adequate pain control without excessive narcotics

16. Diabetes Mellitus
• Many patients with diabetes mellitus have significant symptomatic
or asymptomatic CAD and may have silent myocardial ischemia due
to autonomic dysfunction.
• Evidence supports intensive perioperative glycemic control to
achieve near-normal glucose levels (90–110 mg/dL) versus
moderate glycemic control (120–200 mg/dL), using insulin infusion.
• This practice must be balanced against the risk of hypoglycemic
complications.
• Oral hypoglycemic agonists should be held on the morning of
operation.
• Perioperative hyperglycemia should be treated with intravenous
infusion of short-acting insulin or subcutaneous sliding-scale insulin.
• Patients who are diet-controlled may proceed to surgery with close
postoperative monitoring.

17. Prophylaxis for Infective Endocarditis
prophylactic antibiotics should be administered to patients with
congenital or valvular heart disease, prosthetic valves, mitral
valve prolapse, or other cardiac abnormalities in accordance
with ACC/AHA practice guidelines

18. Prophylaxis of Venous Thromboembolism
• Aspirin is not supported as a single agent for
thromboprophylaxis.
• Low-dose unfractionated heparin <5000 units subcutaneous
bid), low-molecular weight heparin (e.g., enoxaparin 30 mg
bid or 40 mg qd) or a pentasaccharide (fondaparinux 2.5 mg
qd) for patients at moderate risk,
• unfractionated heparin (5000 units subcutaneous tid) for
patients at high risk.
• Graduated compression stockings and pneumatic
compression devices are useful supplements to anticoagulant
therapy.

19. THANK YOU