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Preoperative Medical Evaluation

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Preoperative Medical Evaluation Colin McMahon, MD. Division of Combined Internal Medicine and Pediatrics University at Buffalo, School of Medicine – PowerPoint PPT presentation

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Title: Preoperative Medical Evaluation


1
Preoperative Medical Evaluation
  • Colin McMahon, MD.
  • Division of Combined Internal Medicine and
    Pediatrics
  • University at Buffalo, School of Medicine

2
What are You Really Being Asked to Do?
  • Assess risks of anesthesia
  • Assess the risks of the procedure
  • Manage complicated medical problems
  • Predict the future

3
General Considerations
  • Limit number of recommendations
  • Focus on critical problems
  • Be specific about drugs, dosage and intervals
  • Dont ask the surgeon to think

4
General Approach
  • Diagnosis
  • Develop a problem list
  • Treatment
  • Directed toward decreasing surgical risk
  • Prognosis
  • Anesthesia complications
  • Procedural complications

5
Misconceptions
  • Advise on type of anesthesia
  • General, local or spinal
  • Change ongoing treatment plans
  • Initiate diagnostic work-ups

6
Risk Evaluation
  • Overall perioperative mortality 0.3
  • Anesthesia induction 10
  • Intraoperatively 35
  • Postoperatively (48 hours) 55

7
ASA Classification
8
Procedure Risk
  • Low risk
  • Eye surgery, oral surgery, DC, hysterectomy,
    herniorrhaphy
  • High risk
  • Craniotomy and cardiovascular

9
Specific Risks
  • Pulmonary
  • Cardiac
  • Hematologic
  • Endocrine
  • Thromboembolism Prophylaxis

10
Pulmonary Risks
  • Complications
  • Hypoventilation
  • Pneumonia
  • Atelectasis
  • Occur in about a third of patients
  • Accounts for half of perioperative mortality

11
Whos at Risk
  • Smokers
  • COPD
  • Obesity
  • Age gt 70
  • Thoracic surgery
  • Upper abdominal surgery
  • Anesthesia gt 2 hours

12
Risk Assessment
  • FEV1 gt 2L, probably safe
  • FEV1 between 1 and 2L, increased risk
  • FEV1 lt1L, high risk

13
Risk Management
  • Quit smoking
  • Bronchodilator therapy
  • CPT
  • Early treatment of bronchitis
  • Early mobilization

14
Cardiac Risks
  • Complications
  • Myocardial Infarction
  • CHF
  • Hypertension
  • 50 fatal, 60 silent
  • Increased mortality post-op day 3

15
Whos at Risk
  • Recent MI
  • Valvular heart disease
  • CHF
  • Unstable angina
  • Diabetes

16
Risk Assessment
  • Goldman Cardiac Risk-Index for Noncardiac Surgery
  • American College of Cardiology Risk Assessment

17
Risk Management
  • Monitor for perioperative ischemia
  • Repair severe aortic stenosis first
  • Treat CHF aggresively preoperative
  • Postpone non-emergent procedures for at least 6
    months after an MI

18
Hemetologic Risks
  • Complications
  • Thromboembolic
  • Bleeding

19
Whos at Risk
  • Polycythemia vera
  • Thrombocytopenia

20
Risk Assessment
  • Hematocrit
  • Platelet count
  • Bleeding time
  • PT/PTT

21
Risk Management
  • Phlebotomy to decrease hct lt 45
  • Maintain plts gt 50,000

22
Endocrine Risks
  • Thyroid storm
  • Diabetic complications

23
Risk Management
  • Good control of thyroid function for at least 3
    months prior
  • Hold oral hypoglycemics
  • Reduce insulin by half

24
Thrombembolic Prophylaxis
  • Specific to surgery
  • Increased risk
  • Elderly
  • Obesity
  • Prolonged anesthesia
  • Immobility

25
Other Considerations
  • Antibiotic prophylaxis
  • Herbal medicines
  • Geriatric patient
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