section name header

Info


A. Preoperative Questionnaire for Adults (Panel 1, Ref [1]) navigator

  1. Medical history diseases of concern (obtain details for any of the following):
    1. Heart disease of any kind
    2. Chest pain, palpitations or blackouts
    3. Hypertension (HTN)
    4. Rheumatic fever
    5. Pulmonary: asthma, bronchitis, other chest disease
    6. Dyspnea on exertion
    7. Diabetes, hyperglycemia, sugar in urine
    8. Kidney or urinary trouble
    9. Convulsions, seizures, epilepsy, fits
    10. Anemia, polycythemia or other blood disorders [36]
    11. Bruising of bleeding problems
    12. Blood clots in legs or lungs
    13. Jaundice
    14. Indigestion or heartburn or reflux
    15. Any other serious illness
  2. Smoking: current or historically
  3. Alcohol: how much per week
  4. Dental: false, capped or crowned teeth
  5. Sight: glasses or contact lenses
  6. Hearing Aid
  7. Pacemaker, implantable cardioverter defibrillator (ICD)
  8. Women: pregnancy potential, oral contraceptive pill (OCP), hormone replacement therapy
  9. Weight and Height
  10. Medications, Over the Counter, Herbal Agents, Illicit Drugs
  11. Allergies: drugs, other materials (latex, others)
  12. Previous operations or anesthetics
  13. Previous problems with anesthetics for you or your family
  14. Other things surgeon or anesthetist should know

B. Preoperative Cardiac Assessment [5,29] navigator

  1. General Cardiac Evaluation
    1. History and Physical (H and P) examinations targeted to cardiovascular (CV) system
    2. Smoking is a major perioperative risk and should prompt further evaluations
    3. HTN is also a risk for poor outcomes
    4. Electrocardiography (ECG) may be reserved for patients with abnormal H and/or P
    5. Stress Testing (exercise, nuclear medicine, echocardiogram) generally not indicated
    6. Noninvasive cardiac testing is recommended in patients with 3 or more risk factors [29]
    7. Pre-operative chest radiograph is not cost effective in asymptomatic persons
    8. Routine preoperative evaluation does not affect outcomes of cataract surgery [25]
    9. Routine right heart catheterization prior to major non-cardiac surgery does not improve outcomes and leads to procedure-related side effects [28]
  2. Smoking [30]
    1. Contributes to perioperative complications, morbidity, mortality
    2. Perioperative smoking intervention 6-8 weeks prior to surgery reduced complications from 52% in control to 18% in intervention group
    3. Perioperative smoking intervention strongly recommended
  3. HTN [3]
    1. Mild to moderate HTN (systolic BP <180 mm, diastolic BP <110 mm) little operative risk
    2. Severe HTN (diastolic BP >110 mm) is a risk for poor outcomes
    3. Recommending delaying surgery for diastolic BP >110 mm
    4. Blood pressure (BP) medications should be continued until day of surgery
    5. Caution maintaining ACE inhibitors up until surgery (associated with hypotension)
    6. ß-blockers for at least 7 days titrating heart rate to ~60 per minute recommended
    7. However, caution with ß-blockers as perioperative use in suspected or definite atherosclerosis prior to noncardiac surgery reduced cardiac events but increased mortality [37]
  4. Echocardiography
    1. Not routinely indicated in preoperative assessment
    2. However, any murmur should be evaluated with echocardiography
    3. This is essential, at least for endocarditis prophylaxis [12]
    4. Echocardiography with dobutamine or persantine for all intermediate risk persons [3]
  5. Non-Cardiac Vascular Surgery Patients
    1. Usual practice is cardiac evaluation prior to non-cardiac vascular surgery
    2. Peripheral vascular disease suggests that other vascular disease will be present
    3. Likely that coronary angiography should be reserved for patients with high surgical risk
    4. If coronary angiography shows inoperable coronary artery disease (CAD), then vascular surgery should probably be canceled
    5. If vascular surgery were very risky, then cardiac angiography can help with assessment
  6. Risk Stratification [3,4,26]
    1. A variety of indices have been developed to risk-stratify patients prior to surgery
    2. None of these indices are substantially superior and room for improvement remains [26]
    3. Points are assigned (see below) for each parameter present
    4. Patient is stratified by number of points
    5. Vascular surgery patients can also be risk-stratified by thallium imaging or dobutamine echocardiography and these methods have similar accuracy
    6. In clinically low-risk vascular patients on ß-blockers undergoing surgery, dobutamine echocardiography [27] or catheterization [28] can generally be withheld
    7. Higher risk patients on ß-blockers with negative pharmacologic stress test can proceed to surgery [27]
    8. ß-blockers associated with up to 40% reduced risk of death in high risk [18] but apparent increased risk of death in low or moderate risk [8,37] non-cardiac surgery patients
  7. Perioperative Major Cardiac Events Rates By Cardiac Risk Factors [5]
    1. No Risk Factors: 0.4% event rate
    2. 1 Risk Factor: 0.9%
    3. 2 Risk Factors: 6.6%
    4. 3 or More Risk Factors: 11%
  8. Hematocrit (HCT) and Operative Outcomes [36]
    1. Abnormal HCT associated with inferior post-operative outcomes
    2. HCT >51% or <39% in males >65 years associated with poor outcomes
    3. For each 1% HCT deviation above or below normal range, 1.6% increase in mortality
  9. Prevention of Perioperative Cardiovascular Events [17]
    1. ß-Blockers provide reduction in risk for all cardiovascular events in cardiac surgery patients
    2. Evidence for benefit of perioperative ß-blockers in noncardiac surgery is unreliable [8]
    3. alpha2-adrenergic agonists have shown some benefit in meta-analysis and should be considered in patients intolerant to ß-blockers [17]
    4. Diltiazem and nitroglycerin have shown no benefit in preventing cardiac events in undergoing noncardiac surgery [29]
    5. Clonidine may provide some benefit in patients intolerant of ß-blockers [14]
  10. ß-Blockers in Patients with CAD Undergoing Surgery [3,8,29]
    1. Controversial whether all non-cardiac surgery patients with likely or known CAD should be given perioperative ß-blockers [18,37]
    2. Bisoprolol given perioperatively to high risk patients undergoing vascular surgery reduced death and MI by >80% [24]
    3. ß-blockers provide clear reduction of cardiac events in noncardiac surgery in patients with predicted >10% event rate, even without angiographically proven CAD [31,32]
    4. ß-blockers provide 20% reduction in mortality in patients with left ventricular ejection fraction >30% underoing coronary artery bypass grafting (CABG) [7]
    5. Metoprolol extended release given perioperatively to non-cardiac surgery patients reduced cardiac events but increased mortality in a large prospective study [37]
    6. Atenolol (5mg iv bid or 50mg po bid) given just perioperatively (<8 d) lead to reduction in mortality at 6, 12, and 24 months compared with placebo
    7. In low to moderate noncardiac surgery patients, ß-blockers provide unclear benefits and increase the risk of hypotension and bradycardia requiring treatment [8,37]
  11. Invasive Strategies for Reducing Coronary Events [29]
    1. Percutaneous transluminal coronary angioplasty done >90 days prior to noncardiac surgery appears to reduce risk of subsequent cardiac complications
    2. Similarly, in noncardiac surgery patients with CAD, preoperative CABG as appropriate likely reduces risk of subsequent cardiac complications
  12. Temperature Regulation and Surgery
    1. Standard anesthesia and surgical techniques do not maintain normal body temperature
    2. Hypothermia is a potential major contributor to severe morbidity perioperatively [10]
    3. Perioperative normothermia (~36.7°C) reduces serious cardiac events in patients with cardiac risk factors [13]
  13. Perioperative hypotension and/or hypoxemia contribute to cognitive decline in elderly

C. Cardiac Risk Assessment Stratification Scheme [3,4]navigator

  1. Based on American College of Physicians recommendations
  2. All candidates for surgery should have basic evaluation
  3. Points are assigned and added up based on characteristics below
  4. Total points will risk stratify patient for post-operative outcomes
  5. CAD
    1. Myocardial infarction (MI) within 6 months 10 points
    2. MI >6 months 5 points
  6. Angina Scoring (Canadian System)
    1. Angina with walking 1-2 blocks or climbing 1 flight of stairs 10 points
    2. Angina with performance of any physical activity (not at rest) 20 points
  7. Alveolar Pulmonary Edema
    1. Within 1 week 10 points
    2. Ever 5 points
  8. Suspected (history/physical) critical aortic stenosis [15] 20 points
  9. Arrhythmias
    1. Rhythm other than sinus (±APB) 5 points
    2. More than 5 PVC's on ECG 5 points
  10. Poor General Medical Status 5 points (presence of any of the following):
    1. pO2 < 60 mm Hg
    2. pCO2 > 50 mm Hg
    3. Potassium < 3.0mM
    4. BUN > 18mg/dL
    5. Creatinine >260 µM
    6. Bedridden
  11. Age >70 years 5 points
  12. Emergency Surgery 10 points
  13. Classification:
    1. Low Risk (Class I) 0-15 points
    2. Intermediate Risk 20-30 points
    3. High Risk (Class III) >30 points
  14. Acting on Risk Assessment
    1. Patients at low risk require no other evaluation
    2. Patients at intermediate risk should have echocardiographic evaluation
    3. Patients at high risk should consider postponing surgery
  15. Obesity alone is probably not a risk factor for postoperative complications of general surgery; comorbid conditions are likely main contributors [16]
  16. Routine coronary artery revascularization before major vascular surgery does not affect long term outcomes and is not routinely recommended [6]

D. Overall Risk of Major Cardiac Events [1,2]navigator

  1. Major Events include death or nonfatal MI
  2. High Risk (>5%)
    1. Emergency surgery (mainly in elderly patients)
    2. Aortic or other major vascular surgery
    3. Peripheral vascular surgery
    4. Prolonged surgery with major fluid shifts
  3. Intermediate (1-5%)
    1. Carotid Endarterectomy
    2. Head and Neck surgery
    3. Intraperitoneal or intrathoracic surgery
    4. Major orthopedic surgery
    5. Prostate surgery
  4. Low (<1%)
    1. Endoscopy
    2. Surgical procedure
    3. Breast surgery
    4. Cataract surgery

E. Preoperative Pulmonary Evaluation [20,21,22,23] navigator

  1. Guideline Recommendations [20,23]
    1. All patients undergoing noncardiothoracic surgery should be evaluated for significant risk factors for preoperative pulmonary complications in order to receive preventions:
    2. Chronic obstructive pulmonary disease (COPD)
      1. Age >60 years
      2. American Society of Anesthesiologists Class II or greater (see below)
      3. Functionally dependent
    3. Congestive Heart Failure (CHF)
    4. The following surgeries have increased pulmonary complication risks [20,21]:
    5. prolonged (>3 hour) surgery
      1. abdominal surgery
      2. thoracic surgery
      3. neurosurgery
    6. head and neck surgery
      1. vascular surgery
      2. aortic aneurysm repair
      3. emergency surgery
      4. general anesthesia
    7. Low serum albumen (<3.5gm/dL) is marker of increased pulmonary complication risk
    8. All patients with higher risk of pulmonary complications should postoperatively receive [22]:
    9. deep breathing exercises or incentive spirometry
      1. selective use of nasogastric tube
    10. Preopertive spirometry and chest radiography (CXR) should not be used routinely for predicting risk for pulmonary complications
    11. The following should not be used solely for reducing postoperative pulmonary risks:
    12. right heart catheterization
      1. total parenteral nutrition or total enteral nutrition
  2. American Society of Anesthesiologists Risk Classification (Complication Rate) [6,23]
    1. Class I: normally healthy patient (1.2%)
    2. Class II: patient with mild systemic disease (5.4%)
    3. Class III: Patient with systemic disease that is not incapacitating (11.4%)
    4. Class IV: patient with incapacitating systemic disease with constant threat to life (10.9%)
    5. Class V: moribund patient with <24 hours expected survival with or without operation
  3. Other Risks and Pulmonary Complications
    1. Obesity alone is probably not a risk factor for postoperative complications of general surgery [16]
    2. Well controlled asthma is not a risk factor for pulmonary complications [23]
    3. Pulmonary hypertension (P-HTN) is risk factor for postoperative pulmonary complications
    4. Impaired sensorium and alcohol use associated with 20-40% increased risks
  4. Significant postoperative pulmonary complications are as common as coronary complications
  5. Assessment
    1. Clinical findings are highly predictive of poor outcomes
    2. Pulmonary function tests (PFTs) recommended only for patients at increased risk
    3. PFTs are probably important in patients with chronic respiratory disease of any type
    4. PFTs (spirometry) help assess degree of airflow limitation
    5. Preoperative CXR is of limited benefit as a preditor of outcomes, but serves as baseline
    6. Preoperative cardiac evaluation is usually appropriate in patients with lung diseases
  6. Preoperative Pulmonary Risk Reduction [22]
    1. Discontinue smoking for at least 8 weeks
    2. Treat airflow limitation in patients with COPD (or asthma)
    3. Treat respiratory infections aggressively and delay surgery if possible
    4. Patient education regarding lung expansion
    5. Exercise training may also be beneficial
  7. Intraoperative Pulmonary Risk Reduction [23]
    1. Short acting neuromsuclar blockade
    2. Laparoscopic may be perferred over open abdominal surgery
    3. Neuraxial blockade
    4. Right sided heart catheterization (Swan-Ganz) of no benefit in good randomized trial
  8. Postoperative Pulmonary Risk Reduction [23]
    1. Deep breathing exercises / incentive spirometry
    2. Continuous positive airway pressure (CPAP) masks
    3. Epidural anesthesia if needed
    4. Intercostal nerve blocks to reduce pain on breathing
    5. Avoid opiates and other respiratory depressants
    6. Selective nasogastric tube decompression after abdominal surgery
    7. Patient controlled opioid analgesia
    8. Total parenteral nutrition is of no benefit over enteral nutrition

F. Perioperative Anticoagulation Management [11] navigator

  1. For patients taking warfarin, 3-4 days are usually required for INR to fall below 1.5
  2. Low dose vitamin K (1mg) can be given to reduce INR if operation is requred
  3. Goal INR < 1.5 prior to surgery
  4. Heparin
    1. May be given iv prior to surgery to maintain anticoagulation in high risk patients
    2. Heparin should be stopped 6 hours prior to surgery
    3. Heparin should not be restarted until at least 12 hours after major surgery
    4. Longer delays should be considered if surgical bleeding is occurring
  5. When possible, surgery should not be performed within 3 months of a deep vein thrombosis
  6. Elective surgery should also be avoided within 1 month of an arterial embolism
  7. All persons with immobilizing surgery should receive thromboembolism prophylaxis
    1. Low molecular weight heparin (LMWH) is generally preferred over standard heparin
    2. LMWH initiated preoperatively for elective hip replacement is more effective and causes less bleeding than post-operatively initiated LMWH

G. Maintenance of Hematocrit [9]navigator

  1. Need for maintaining minimal hematocrit and hemoglobin levels
    1. Required hemoglobin for oxygen transport and adequate tissue oxygenation
    2. Acute isovolumic hemoglobin (Hb) reduction (13 down to 5gm/dL) in young healthy adults at rest increases heart rate and cardiac index, but did not affect tissue oxygenation [19]
    3. Therefore, for healthy young persons undergoing elective surgery, it appears to be safe to maintain Hb levels levels in the 7gm/dL range
    4. However, in persons with atherosclerotis, particularly with cardiac disease, severe i drop the Hb will stress the heart and increase risk for major ischemic events
    5. Recommend maintenance of relatively high Hb (>9gm/dL) in persons at risk
  2. Etiology of HCT Drops in Surgery
    1. Bleeding
    2. Hemodilution (perioperative fluids)
  3. Prevention of HCT Drops in Surgery
    1. Classically, allo-RBC transfusions were used
    2. Autologous donation pre-surgery is now very common
    3. Erythropoietin may be used pre-op, peri-op and post-operatively to increase HCT [9]
    4. Recovery of blood during surgery with filtration/reinfusion systems (experimental)

H. Antimicrobial Prophylaxis [34,35] navigator

  1. May decrease incidence of infection, especially of surgical wound
  2. May also increase risk of resistant bacteria and superinfection
  3. Antibiotics Currently Recommended in High Risk Patients
    1. Age >70 years
    2. Morbid obesity
    3. Underlying immune dysfunction including diabetes, dialysis, immunosuppressants
    4. Chronic renal failure
    5. Presence of specific cardiac valve lesions such as congenital abnormalities
    6. Previous history of endocarditis
    7. Prosthetic heart valve
  4. Generally restricted to procedures with high infection rates
    1. Prosthetic implants
    2. Coronary bypass or other open heart surgery and other thoracic surgery
    3. Colorectal surgeries
    4. High risk upper gastrointestinal surgeries
    5. High risk genitourinary surgeries
    6. Hysterectomy and induced abortion
    7. Head and Neck surgery
    8. Neurosurgery
    9. Ophthalmic surgery
    10. Total joint replacement, internal fixation of fractures, hip fractures
    11. Vascular procedures
    12. Dental procedures
  5. Other Issues
    1. Direct prophylaxis at most likely organisms
    2. Dental, esophageal, and upper respiratory procedures use amoxicillin, clindamycin, cephalexin (Keflex®), cefadroxil (Duricef®), clarithromycin or azithromycin (Zithromax®)
    3. Cefazolin (Ancef®) IV is generally recommended for most surgeries
    4. Vancomycin should only be used if methacillin resistance is an issue
    5. Routine vancomycin use should be discouraged
    6. For colorectal surgery and appendectomy, cefoxitin or cefotetan
    7. Third and fourth generation cephalosporins should be avoided
    8. Non-esophageal gastrointestinal and genitourinary procedures use amoxicillin, ampicillin, ± gentamicin, or vancomycin ± gentamicin
    9. Dose of antibiotic usually given 30 minutes or less before skin incision
    10. Repeat dose for in prolonged (>4 hour) surgery
    11. Cefoxitin requires more frequent dosing due to short half life
  6. All contaminated surgeries, ruptured viscus, traumatic wounds are treated

I. Perioperative Evaluation in Alcohol Dependency navigator

  1. Major concern for underlying liver damage
    1. Clotting Abnormalities
    2. Abnormal drug metabolism
    3. Increased risk for delirium in perioperative setting
  2. Alcohol withdrawal syndromes are particularly problematic perioperatively
  3. Alcoholics are at increased risk for ARDS in a variety of settings
  4. Child's Classification of Preoperative Risk in Alcoholic Patient
    1. Group A - mortality 5-10%
    2. Group B - mortality 10-30%
    3. Group C - mortality 50-70%
  5. Child Group A Patients
    1. Bilirubin <2mg/dL
    2. Albumin >3.5gm/dL
    3. Ascites - none
    4. Encephalopathy - none
    5. Excellent nutritional status
  6. Child Group B Patients
    1. Bilirubin 2-3mg/dL
    2. Albumin 3.0-3.5gm/dL
    3. Ascites - easily controlled
    4. Encephalopathy - mild
    5. Good nutritional status
  7. Child Group C Patients
    1. Bilirubin <2mg/dL
    2. Albumin <3gm/dL
    3. Ascites - poorly controlled
    4. Encephalopathy - advanced
    5. Poor nutritional status
  8. Perioperative Alcohol Withdrawal
    1. Patients with active withdrawal should have surgery postponed
    2. Benzodiazepines should be used librally
    3. ß-blocking agents and/or clonidine may be used for sympatholytic activity

References navigator

  1. Garcia-Miguel FJ, Serrano-Aguilar PG, Lopez-Bastida J. 2003. Lancet. 362(9397):1749 abstract
  2. Wiklund RA and Rosenbaum SH. 1997. NEJM. 337(16):1132 abstract
  3. American College of Physicians. 1997. Ann Intern Med. 127(4):309 abstract
  4. Palda VA and Detsky AS. 1997. Ann Intern Med. 127(4):313 abstract
  5. Grayburn PA and Hillis LD. 2003. Ann Intern Med. 138(6):506 abstract
  6. McFalls EO, Ward HB, Moritz TE, et al. 2005. NEJM. 351(27):2795
  7. Ferguson TB, Coombs LP, Peterson ED. 2002. JAMA. 287(17):2221 abstract
  8. Devereaux PJ, Beattie WS, Choi PT, et al. 2005. BMJ. 331:313 abstract
  9. Goodnough LT, Monk TG, Andriole GL. 1997. NEJM. 336(13):933 abstract
  10. Sessler DI. 1997. NEJM. 336(24):1730 abstract
  11. Kearon C and Hirsh J. 1997. NEJM. 336(21):1506 abstract
  12. Dajani AS, Taubert KA, Wilson W, et al. 1997. JAMA. 277(22):1794 abstract
  13. Frank SM, Fleisher LA, Breslow MJ, et al. 1997. JAMA. 277(14):1127 abstract
  14. Nishina K, Mikawa K, Uesugi T, et al. 2002. Anesthesiology. 96:323 abstract
  15. Kertai MD, Bountioukos M, Boersma E, et al. 2004. Am J Med. 116(1):8 abstract
  16. Dindo D, Muller MK, Weber M, Clavien PA. 2003. Lancet. 361(9374):2032 abstract
  17. Wijeysundera DN, Naik JS, Beattie WS. 2003. Am J Med. 114(9):742 abstract
  18. Lindenauer PK, Pekow P, Wang K, et al. 2005. NEJM. 353(4):349 abstract
  19. Weiskopf RB, Viele MK, Feiner J, et al. 1998. JAMA. 279(3):217 abstract
  20. Qaseem A, Snow V, Fitterman N, et al. 2006. Ann Intern Med. 144(8):575 abstract
  21. Smetana GW, Lawrence VA, Cornell JE. 2006. Ann Intern Med. 144(8):581 abstract
  22. Lawrence VA, Cornell JE, Smetana GW. 2006. Ann Intern Med. 144(8):596 abstract
  23. Smetana GW. 2007. JAMA. 297(19):2121 abstract
  24. Poldermans D, Boersma E, Bax JJ, et al. 1999. NEJM. 341(24):1789 abstract
  25. Schein OD, Katz J, Bass EB, et al. 2000. NEJM. 342(3):168 abstract
  26. Gilbert K, Larocque BJ, Patrick LT. 2000. Ann Intern Med. 133(5):356 abstract
  27. Boersma E, Poldermans D, Bax JJ, et al. 2001. JAMA. 285(14):1865 abstract
  28. Polanczyk CA, Rohde LE, Goldman L, et al. 2001. JAMA. 286(3):309 abstract
  29. Fleisher LA and Eagle KA. 2001. NEJM. 345(23):1677 abstract
  30. Moller AM, Villeb ro N, Pedersen T, Tonnesen H. 2002. Lancet. 359(9301):114 abstract
  31. Auerbach AD and Goldman L. 2002. JAMA. 287(11):1435 abstract
  32. Auerbach AD and Goldman L. 2002. JAMA. 287(11):1445 abstract
  33. Fleisher LA. 2002. JAMA. 287(16):2043 abstract
  34. Antibacterial Prophylaxis. 2005. Med Let. 47(1213):59 abstract
  35. Antimicrobial Prophylaxis in Surgery. 1999. Med Let. 39(1060):75
  36. Wu W, Schifftner TL, Henderson WG, et al. 2007. JAMA. 297(22):2481 abstract
  37. POISE Study Group. 2008. Lancet. 371(9627):1839 abstract