Stepwise approach to PreOp eval in an easy way to remember. ECRF
- E-Emergency? -Yes–>Proceed with surgery, optimize risks preop and manage postoperatively.
- C-Cardiac conditions, active?-Yes–>Evaluate and treat per guidelines.
- R-Risk? -Low risk–>Proceed with surgery
- F-Functional Capacity->4METS–>Proceed with surgery. If F<4METS or Unknown, Do pharmacologic stress test ONLY IF changes the management.
Active cardiac issues are like ACS, Arrhythmias, acute CHF, severe valve issues or any other symptomatic heart issues.
LOW SURGICAL RISK conditions-ECBS
HIGH RISK surgeries-EC
INTERMEDIATE RISK surgeries
Almost all the other surgeries not mentioned above are Intermediate risk surgeries.
4 METS=Climb 2 flights of stairs or Walk more than 4 blocks without symptoms
Clinical Risk Factors–DICK Failure
I-Ischemic heart disease
K-Kidney disease/CKD stage 3 or worse
Revised Cardiac Risk Index [RCRI]=DICK Failure + High Risk Surgery
D-Diabetes Mellitus requiring Insulin
I-Ischemic heart disease or positive exercise stress test
High risk surgery
-Each condition above gets one point.
1 point–>1% MI, death or major cardiac event.
2 points–>2.4% “
3 points–>5.4% “
More than 3 points–>Reasonable to start Beta Blocker pre op. Beta blocker should not be started on day of surgery.
1 week for PTCA
1 month for BMS
1-2 months for CABG
1 year for DES
No need for delay in surgery for revascularization for stable CAD patients.
If patient has suspected Obstructive Sleep Apnea [OSA], that needs to be tested and treated prior to elective surgery.
Cirrhotic patients with MELD>15 or with Child Turcott Pugh class C, should not undergo elective surgery due to high mortality [upto 65% with MELD>15 and upto 75% with CPT class C].
MELD uses IBCD for scoring.
CTP uses IBAAHe for scoring
When to stop certain medications prior to surgery?
Antiplatelets-Ask cardiology if patient had recent stenting.
Warfarin -3-4days prior to surgery
Endocarditis Prophylaxis for patients with PECT: Amoxicillin 2g 1hr before surgery. Ampicillin IV, Azithromycin or Clindamycin can be given too.
ONLY for HIGH RISK patients undergoing HIGH RISK procedures.
P-Prosthetic heart valve
C-Congenital Cyanotic Heart disease
T-Transplanted heart with valvulopathy
Prophylactic antibiotics solely to prevent endocarditis is not recommended for patients who undergo GU or GI tract procedures
HIGH RISK procedures are dental extraction, dental implants, root canal treatments, periodontal procedures, broch with biopsy.
Stress dose steroids with Hydrocortisone 100mg IV Q8hrs for 48hrs can be given for patients who are on >20mg Prednisone/day or if patient has post op hypotension.
If AM Cortisol level is more than 10mcg/dL, PTA PO steroid dose can be continued.
Post Op fever
Fever in the first 48hrs probably due to inflammation from surgery. Do not order Pan-culture yet until there is fever beyond 48hrs.
If patient becomes unstable with fever, antibiotics covering MRSA and Psedomonas should be given.
Post Op Afib
Anticoagulation should only be started if AFib lasts more than 48hrs after it’s onset and if CHADS score >2.