Preoperative Evaluation

Initial information

• Surgery to be performed:

• Date of surgery:

• Surgeon:

• Surgeon’s fax number:

History

• Identify CAD Risk factors that increased risk of MACE

  • Age 55 years or older

  • History of

    • Cigarette smoking within the previous 6 months

    • Unstable angina, i.e. chest discomfort/pain with exertion

    • HTN, HLD (LDL > 190), arrhythmia, HF, MI, CKD, DM, PAD, stroke

    • Cardiac revascularization within the previous 5 years

  • Family history of HLD, MI, stroke

• Functional capacity: Evaluate if any MACE risk factors are positive

  • < 4 METs: Cannot walk up 1 flight of stairs

  • 4-10 METs: Walk uphill for 1-2 blocks and/or 1 flight of stairs without stopping

  • > 10 METs: Strenuous sports (swimming, cycling, tennis, soccer)

• Additional history for consideration:

  • Allergies and medications

  • Current medical issues (including pregnancy) and/or history of

    • Asthma, COPD, lung disease

    • Sleep apnea including STOP-BANG score

    • Anemia, bleeding, and/or clotting disorders

  • Previous surgeries including dates and complications

  • Previous anesthesia and complications

  • Alcohol and/or recreational drug use

• Home environment and social support

  • Where and with whom does the patient live?

  • Are there stairs in the living environment or other potential hazards?

  • What are the patient’s plans for transportation to and from the surgery?

Physical Exam

• BP, BMP, O2 saturation

• Dental examination

• Cardiopulmonary examination

Assessment and Plan

Presence of CAD risk factors: Calculate Major Adverse Cardiac Event (MACE) Risk

• Risk of cardiac complication less than 1% or > 4 METS: Proceed to surgery

• < 4 METs: Refer for pharmacologic stress testing

Cardiac Risk Identified

• Unstable angina: Obtain EKG and refer for stress test

  • Negative stress test: Evaluate risk per surgical calculator

  • Positive stress test: Refer to cardiology for further evaluation

• Arrhythmia: Perform EKG and consider further workup pending rhythm

Delay elective surgery for

• Smoking within 8 weeks

• Recent CAD intervention including angioplasty (within 14 days), bare metal stent (30 days), or drug-eluting (1 year)

Medications:

• Stop

  • Now: OTC herbal supplements, bisphosphonates

  • 7 days before procedure:

    • Aspirin (unless indication is prior coronary artery stenting)

    • P2Y12 inhibitor (e.g. clopidogrel)

  • 5 days before procedure: Warfarin if no h/o mechanical heart valve and/or DVT/PE within previous 3 months (otherwise bridging with LMWH required)

  • 3 days before procedure: Dabigatran, COX-2 inhibitors, NSAIDs

  • 24 hours before surgery:

    • NOACs (e.g. apixaban, rivaroxaban)

    • Oral diabetes medications (administer 50% basal insulin dose morning of procedure)

• Continue

  • Continue dual antiplatelet therapy (e.g. clopidogrel and aspirin) if < 6 weeks s/p bare metal stent or < 1 year s/p drug eluting stent

  • Beta-blockers if started > 4 weeks before surgery

• Administer

  • Stress dose steroids for chronic prednisone > 5 mg/day: Hydrocortisone 75 mg IV q8 hours

  • Dental prophylaxis (administer 2g amoxicillin 1 hour prior to surgery) for h/o unrepaired congenital heart disease, infective endocarditis, prosthetic heart valve, heart transplant, major heart surgery within previous 6 months

Testing

Patient determined to be at above average risk by American College of Surgeons Surgical Risk Calculator

• PNA or pulmonary complications: Obtain CXR

• Surgical site infection: Obtain HbA1c

• U/A: Current s/sx UTI, planned urologic intervention, planned implantation of foreign material

• Renal failure: Consider nephrology consult

• Death: Reconsider surgery

Obtain for the following issues or if requested by the surgeon

• CBC: Age > 65, anemia, CKD, liver disease, cardiac/vascular surgery

• CMP

  • HTN, HF, CKD, DM, liver disease

  • Use of chronic NSAID, diuretics, ACE/ARB, digoxin

• HbA1c: DM

• PT/PTT/INR: Anemia or taking anticoagulants

• Urine pregnancy test: Female of childbearing age

• CXR: Age > 60, COPD, HF, planned intrathoracic surgery

• Cervical Spine x-ray: H/o rheumatoid arthritis due to risk for atlanto-axial subluxation during intubations

• EKG: Obtain for CAD, PAD, CVA, arrhythmia

  • LBBB: Refer for stress test

  • Other abnormalities: Consider obtaining echocardiogram/stress test vs. referral to cardiology

• Echocardiogram: Valvular disease with most recent study > 1 year prior

Counseling

• Patient counseled to stop smoking and consider delaying elective surgery until 8 weeks after successful smoking cessation

• H/o sleep apnea: Patient should bring oral appliance and/or CPAP machine on day of surgery

• NPO instructions (often institution-dependent): 2 hours for clear liquids, 4 hours for breast milk, 8 hours for meals

Notes

• Not required for healthy patients receiving topical/local anesthesia, nitrous oxide/oxygen for a dental procedure, and/or peripheral nerve blocks

• Previous MI risk classification for procedures included

  • Low (< 1%): Cataract, breast, EGD/colonoscopy

  • Intermediate (1-5%): Head/neck, intrathoracic, intraperitoneal including prostate, orthopedic

  • High (> 5%): Vascular surgery, emergent procedures

• Previous MI

  • Non-emergent surgery should not be performed within 60 days of MI

  • CVD risk increases if MI occurred within the previous 6 month

• Heart failure

  • Increases peri/postoperative mortality risk to 50 to 100%

  • Greater risk associated with HFpEF

• Risk for pulmonary complications is increases with length of surgery

• Medications

  • Statins reduce 30 day MI and death rates

  • Steps for warfarin bridge:

    • Stop warfarin 4 days before procedure and start LMWH

    • Stop LMWH 12 hours before procedure and restart 6 hours after procedure

    • Restart Warfarin when no longer NPO and stop LMWH when INR > 2.0

• Postoperative fever and complications

  • Fever mnemonic (7 Ws): Wind (see pulmonary below), water (UTI), wound (surgical site), walking (PE), wonder drugs, withdrawal, wonky gland (endocrine)

  • Pulmonary

    • Conditions: Atelectasis, PNA, PE

    • Prevention: Preoperative steroids, incentive spirometry, DVT ppx including ambulation

  • Infection: PNA, UTI, surgical site