Perioperative assessment

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
• 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