Perioperative assessment

Mnemonic: RAMS IDLE C

• Risk assessment
  • RCRI: 4C's HD: CAD, CHF, CVD, creat>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
  • ASA: indication?; stop 7 days preop, restart 1-2 days postop
    • Unless recent stenting
  • Bridge?
• Medication management
  • Continue beta-blockers
  • Hold non-essential
• 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
• 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 IE, transplant with valve dz, CHD, prosthetic material), AND
  • High risk procedure (dental manipulation, incision of respiratory tissue)
• Consults
  • Rheumatology: for RA or APLA
  • Cardiology: if ischemic chest pain
  • Anesthesia: if AS murmur or other high risk
  • Endocrinology: T1DM needing IV insulin