Pre-Operative Medical Assessment :
in Healthy Patients
Mazen Badawi
Medical Resident
1/2010
Introduction
Goal : decrease risk of surgery :
Identify unrecognized co-morbid disease
and risk factors for medical complications
of surgery
Optimize preoperative medical condition
Understand, recognize, and treat potential
complications
Work as a team with surgeon and
anesthesiologist
Questions to answer in each case
Why was the consult requested?
What is the benefit to the patient of the
proposed procedure?
May one substitute a lower risk
procedure?
What are the known risks?
What is the balance of risk-benefit?
What are the patient's goals?
Things to remember
Keep no. of recommendations to a minimum
Clarify the specific reason for the consult
request
Adherence to recommendations is greater for
consults requested early
Follow patients through the postoperative
period
Dont say cleared , say Average risk
Anesthesia factor
Patient and surgical factors are more
important risk predictors than anesthetic
considerations (JAMA 1988;260:2859)
ASA (Dripps) Classification is a
powerful predictor of overall
perioperative mortality. It also predicts
cardiac and pulmonary morbidity
ASA classification
Class Sys. Disturb. Mortality
1 Healthy patient with no disease outside of the surgical process <0.03%
2 Mild-to-mod. systemic disease caused by the surgical condition or by other 0.2%
pathologic processes
3 Severe disease process which limits activity but is not incapacitating 1.2%
4 Severe incapacitating disease process that is a constant threat to life 8%
5 Dying patient not expected to survive 24 hours with or without an 34%
operation
E Suffix to indicate an emergency surgery for any class Increased
Anesthesia risk
Drugs : Stress response, interaction,
SE
Mechanical and operational errors
Cardiac :
Inhalational agents are mycardial depressant
Accentuated hypotensive response
Anesthesia risk
Pulm. :
Vital capacity decreased by 50%
Decreased Fun.Resd.C below closing volumes
atelectasis and V/Q mismatch
Decreased mucociliary clearance
Depression of response to hypoxia and
hypercarbia
Diaphragmatic dysfunction
Anesthesia risk
Spinal vs. epidural :
No difference in cardiac mortality.
Probable decrease in the risk of pulm.
complications
Assessment of healthy indiv.
High false +ve , ?
Questionnaire
If all answered NO no need for
complete Hx, Ex
Wilson, ME, Williams, MB, Baskett, PJ, et al.
Assessment of fitness for surgical procedures and the variability of anaesthetists' judgments.
Br Med J 1980; 1:509
Questionnaire for healthy people
13 questions
General : past serious illnesses
Resp, CVS: exertional SOB, anginal chest
pain, cough, wheeze, ankle swelling
Rx: pills in the last 3 months (incl. excess
alcohol)
Allergies
Anesthetic in last 2 months, problem with
anesthesia (pt. or relative)
Q. To determine need for anesth. App.
17 Q
Resp, CVS : SOB, chest pain when climbing 2 flight
of stairs, hx of heart attack, angina, HF, asthma,
bronchitis
Renal disease
Neuro: stroke, epilepsy
Anesthesia : previous problems in family
Thyroid disease
Liver disease
Joint pain, stiffness esp. neck and jaw
DM and insulin use
Clinical assessment
1- Exercise capacity :
poor if symptomatic with walking 4
blocks or climbing 2 flights of stairs
doubles the risk for post op.
complications, CVS complications but
not pulm.
Clinical assessment
2- Medication use :
Including OTC, complementary,
alternative
Clinical assessment
3- Obesity : surprisingly, it is not a risk
factor for most major adverse
postoperative outcomes
there was no difference in postop.
complication rates between patients whose
BMI was > or < 30 incl. pulm.
But it still a major risk for postop. DVT &
PE
Clinical Assessment
3- Age: <60 yr 1.3% mortality
80-89 yr 11.3%
Age 70 as turning point
Labs
Routine lab inv. Arent usually recommended
in healthy indiv.
In a study of 2000 patients undergoing
elective surgery, 60 %of routinely ordered
tests would not have been performed if
testing had only been done for recognizable
indications; only 0.22 % of these revealed
abnormalities that might influence
perioperative management
CBC
AST/A Sickle
Chest X- /Type /INR Urea Blood
ECG M F Lytes /LP Cell
Ray Screen PT Creat. glucose
BILI Screen
Surgical Procedure on
Type & Screen List
No of Units
Age:
<45
45-70
>70
Cvs, HTN
Pulmonary disease
Malignancy
Hepatic disease/ETOH
Renal disease
Blood disorders
Diabetes
Smoking >20 pack years
Use of Digoxin, Diuretics,
ACE inhib.
Use of Steroids
Use of Anticoagulants
CNS disease
Sickle Risk*
CBC
Anemia is present in 1% of
asymptomatic ppl
In a study of 2000 pt, 30 days
mortality=
Pre op. Hb >= 12 1.3% mort.
Pre op. Hb < 6 33.3% mort.
CBC
Conclusion:
CBC is recommended in:
All pt. >65 yr before major surgery
All pt. <65 yr before major surgery with
expected significant blood loss
All pt with symptoms of anemia before
minor surgery
Electrolytes
Frequency of unexpected electrolyte
abnormalities is low, 0.6%
No solid relation of abnormalities with
periop. complications
Hints easily collectable from hx
routine electrolyte determinations are
NOT recommended
Renal funct.
Mild to moderate renal impairment is
usually asymptomatic
High Cr among asymptomatic patients
with no history of renal disease is only
0.2% ,rises in > 46 yrs to reach 9.8%
Renal funct.
Ass. Of Cr >177 with cardiac, pulm.,
and post op mortality
Cr level is recommended esp. in
>50yr
Hypotension expected
Nephrotoxic Rx
B.S
25% of >60 yr have abnormal b.s level.
incidence of asymptomatic hyperglycemia is
unknown.
No relationship between op. risk and DM
except in vascular & CABG (but not asymp.
hyperglycemia)
routine measurement of b.s is not
recommended in healthy ppl before surgery
LFT
Only 0.3% of healthy ppl. Have
abnormal LFTs
routine LFT pre op. in healthy ppl
isnt recommended
Hemostasis
routine preoperative tests of
hemostasis are NOT recommended.
should be restricted to patients with a
known bleeding diathesis or an illness
associated with bleeding tendency
Urinalysis
Done to:
identify unsuspected renal disease
UTI
It is not necessary for the detection of
asymptomatic renal disease if a serum
creatinine measurement is Normal
relationship between asymptomatic UTI and
surgical infection is unclear
not recommended as routine
ECG
Guidelines :
Men > 45 years
Women > 55 years
Known cardiac disease
Clinical evaluation suggesting the possibility of
cardiac disease
Patients at risk for electrolyte abnormalities, such
as diuretic use
Systemic disease associated with possible
unrecognized heart disease, such as DM, HTN
Patients undergoing major surgical procedures
CXR
Recommended in:
>50 yr undergoing major surg.
Suspected cardiac or pulm. disease
PFT
not indicated for healthy patients prior to
surgery
reserved for patients who have SOB that
remains unexplained after careful clinical
evaluation
Clinical findings are more predictive of the risk
of postop. Pulm. complication than are
spirometric results :
decreased breath sounds,
prolonged expiratory phase,
added sounds.
Summary : for healthy pt.
screening questionnaire for all patients
Hx of exercise tolerance for all patients
Blood pressure and pulse for all patients
Hx + Ex if one of the above is abnormal, in patients
over 60 years, or in those undergoing major surgery
Pregnancy test for women who may be pregnant
HCT for all patients undergoing surgery with
expected major blood loss and for patients 65 years
or older undergoing major surgery irrespective of
potential for perioperative blood loss
Summary
Serum Cr if major surgery, hypotension is expected,
nephrotoxic drugs will be used, or the patient is
above age 50
ECG recommendations as above, unless obtained
within the previous month
Chest x-ray for patients over 50 years undergoing
major surgery, or those with suspected cardiac or
pulmonary disease, unless one has been performed
within the past six months
All other tests only if the clinical evaluation suggests
a likelihood of disease
Thank you..
