Perioperative assessment: Difference between revisions
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− | == |
+ | == Background == |
+ | * The complexity of surgical patients is increasing |
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+ | * Risks of surgery include bleeding, sepsis, and myocardial injury, all three of which have a risk of death |
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+ | ** Risks increase with age, and are highest with thoracic surgery, followed by vascular surgery, neurosurgery, and general surgery |
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+ | * Purpose is to assess and communicate perioperative risk and to attempt to decrease that risk as much as possible |
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+ | |||
+ | == Mnemonic: RAMS IDLE C == |
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* '''Risk assessment''' |
* '''Risk assessment''' |
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− | ** RCRI |
+ | ** [[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 |
** Surgical risk: high (>5%) for aortic and peripheral vascular OR, intermediate (1-5%) for ortho, HEENT, prostate, low risk (<1%) for endoscopy, breast, dental |
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* '''Anticoagulation''' |
* '''Anticoagulation''' |
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− | ** |
+ | ** Aspirin: assess indication; stop 7 days preop, restart 1-2 days postop |
*** Unless recent stenting |
*** Unless recent stenting |
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+ | **Assess need for bridging anticoagulation |
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− | ** Bridge? |
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* '''Medication management''' |
* '''Medication management''' |
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− | ** Continue |
+ | ** Continue β-blockers |
** Hold non-essential |
** Hold non-essential |
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+ | **See [[perioperative medication management]] for details |
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* '''Stress dose steroids''' |
* '''Stress dose steroids''' |
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** <5 mg/d: continue home dose |
** <5 mg/d: continue home dose |
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** > 20 mg/d: same as above |
** > 20 mg/d: same as above |
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* '''Insulin''' |
* '''Insulin''' |
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− | ** For T1DM, or for T2DM with OR >3 hours, consider IV insulin |
+ | ** For [[T1DM]], or for [[T2DM]] with OR >3 hours, consider IV insulin |
− | ** For CABG, do IV insulin |
+ | ** For [[CABG]], do IV insulin |
+ | ** Insulin dose: |
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− | ** |
+ | ***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 |
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* '''Delirium''' |
* '''Delirium''' |
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** Prevention (non-pharm and pharm) |
** Prevention (non-pharm and pharm) |
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** Counselling |
** Counselling |
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* '''Lungs''' (Pulmonary) |
* '''Lungs''' (Pulmonary) |
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− | ** OSA: STOP-BANG |
+ | ** [[OSA]]: STOP-BANG |
** Surgical site: closer to the diaphragm is riskier |
** Surgical site: closer to the diaphragm is riskier |
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** Smoking cessation, ideally 4 weeks before |
** Smoking cessation, ideally 4 weeks before |
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** Consider need for preop CXR or PFTs |
** Consider need for preop CXR or PFTs |
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* '''Endocarditis prophylaxis''' |
* '''Endocarditis prophylaxis''' |
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− | ** High risk patient (prior |
+ | ** High risk patient (prior [[endocarditis]], transplant with valvular disease, CHD, prosthetic material), AND |
** High risk procedure (dental manipulation, incision of respiratory tissue) |
** High risk procedure (dental manipulation, incision of respiratory tissue) |
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* '''Consults''' |
* '''Consults''' |
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− | ** Rheumatology: for |
+ | ** Rheumatology: for [[rheumatoid arthritis]] or [[APLA]] |
** Cardiology: if ischemic chest pain |
** Cardiology: if ischemic chest pain |
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** Anesthesia: if AS murmur or other high risk |
** Anesthesia: if AS murmur or other high risk |
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− | ** Endocrinology: T1DM needing IV insulin |
+ | ** Endocrinology: [[T1DM]] needing IV insulin |
+ | |||
+ | == Risk Assessment == |
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+ | |||
+ | * Calculators |
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+ | ** See http://perioperativerisk.com/ |
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+ | ** For geriatrics, consider the [https://qxmd.com/calculate/calculator_448/geriatric-sensitive-perioperative-cardiac-risk-index-gscri GSCRI] |
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+ | |||
+ | === Cardiovascular Risk Assessment === |
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+ | |||
+ | * [https://www.mdcalc.com/revised-cardiac-risk-index-pre-operative-risk RCRI]: ischemic heart disease, CHF, stroke/TIA, insulin, creat>177, high risk surgery |
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+ | |||
+ | {| class="wikitable" |
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+ | !RCRI |
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+ | !Risk of major cardiovasular event |
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+ | |- |
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+ | |0 |
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+ | |4% |
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+ | |- |
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+ | |1 |
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+ | |6% |
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+ | |- |
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+ | |2 |
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+ | |10% |
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+ | |- |
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+ | |≥3 |
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+ | |15% |
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+ | |} |
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+ | |||
+ | * BNP |
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+ | ** Routine screening should be done for patients with RCRI ≥1, age ≥65 years, age 45-64 years with significant cardiovascular disease |
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+ | ** Considered elevated if preoperative NT-proBNP ≥300 ng/L or BNP ≥92 mg/L |
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+ | ** For these high-risk patients, follow [[troponin]] and [[ECG]] daily after surgery, with for 48 to 72 hours or until peak |
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+ | |||
+ | === Delirium Risk Assessment === |
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+ | |||
+ | * 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 |
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+ | * See the Best Practices Guideline from the ACS NSQIP and American Geriatrics Society 2012 |
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[[Category:Perioperative medicine]] |
[[Category:Perioperative medicine]] |
Latest revision as of 14:21, 27 February 2022
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