Perioperative assessment
From IDWiki
Background
- The complexity of surgical patients is increasing
- Risks of surgery include bleeding, sepsis, and myocardial injury, all three of which have a risk of death
- Risks increase with age, and are highest with thoracic surgery, followed by vascular surgery, neurosurgery, and general surgery
- Purpose is to assess and communicate perioperative risk and to attempt to decrease that risk as much as possible
Mnemonic: RAMS IDLE C
- Risk assessment
- RCRI (4C's HD): CAD, CHF, CVD, creatinine>176, high-risk OR, diabetes on insulin
- Surgical risk: high (>5%) for aortic and peripheral vascular OR, intermediate (1-5%) for ortho, HEENT, prostate, low risk (<1%) for endoscopy, breast, dental
- Anticoagulation
- Aspirin: assess indication; stop 7 days preop, restart 1-2 days postop
- Unless recent stenting
- Assess need for bridging anticoagulation
- Aspirin: assess indication; stop 7 days preop, restart 1-2 days postop
- Medication management
- Continue β-blockers
- Hold non-essential
- See perioperative medication management for details
- Stress dose steroids
- <5 mg/d: continue home dose
- 5-20 mg/d
- Minor: double home dose for morning of OR
- Moderate: 50 mg IV on call to OR, then 25 mg IV TID for 1-2 days
- Major: 100 mg IV on call or OR, then 50 mg IV TID for 1 day, then 25 mg IV TID for 1 day
- > 20 mg/d: same as above
- Insulin
- For T1DM, or for T2DM with OR >3 hours, consider IV insulin
- For CABG, do IV insulin
- Insulin dose:
- Take 1/2 home dose of long-acting the night before, and monitor blood sugars regularly with prn rapid-acting
- See perioperative insulin management for details
- Delirium
- Prevention (non-pharm and pharm)
- Counselling
- Lungs (Pulmonary)
- OSA: STOP-BANG
- Surgical site: closer to the diaphragm is riskier
- Smoking cessation, ideally 4 weeks before
- Incentive spirometry postop
- Consider need for preop CXR or PFTs
- Endocarditis prophylaxis
- High risk patient (prior endocarditis, transplant with valvular disease, CHD, prosthetic material), AND
- High risk procedure (dental manipulation, incision of respiratory tissue)
- Consults
- Rheumatology: for rheumatoid arthritis or APLA
- Cardiology: if ischemic chest pain
- Anesthesia: if AS murmur or other high risk
- Endocrinology: T1DM needing IV insulin
Risk Assessment
- Calculators
- See http://perioperativerisk.com/
- For geriatrics, consider the GSCRI
Cardiovascular Risk Assessment
- RCRI: ischemic heart disease, CHF, stroke/TIA, insulin, creat>177, high risk surgery
| RCRI | Risk of major cardiovasular event |
|---|---|
| 0 | 4% |
| 1 | 6% |
| 2 | 10% |
| ≥3 | 15% |
- BNP
- Routine screening should be done for patients with RCRI ≥1, age ≥65 years, age 45-64 years with significant cardiovascular disease
- Considered elevated if preoperative NT-proBNP ≥300 ng/L or BNP ≥92 mg/L
- For these high-risk patients, follow troponin and ECG daily after surgery, with for 48 to 72 hours or until peak
Delirium Risk Assessment
- Age ≥70, alcohol abuse, TICS score <30, SAS class IV, markedly abnormal preoperative sodium, potassium, or glucose, aortic aneurysm surgery (2 points), and noncardiac thoracic surgery
- See the Best Practices Guideline from the ACS NSQIP and American Geriatrics Society 2012
