Perioperative assessment of
- CV risk and complications
- Pulmonary Complication Assessment
- Medication use assessment
- Smoking use assessment
- Pain management in peri-operative period
- VTE prophylaxis in perioperative Period
- Management of Post-operative Cardiac Complication
- Anti-coagulation management in peri-operative period
- Perioperative Diabetes / Hyperglycemia management
- Delirium managemnet in peri-operative period
Any other system related evaluation based on patients individual profile- Hematology: For patient who is bleeding or has significant anemia
- Endocrinolgy: Some one chronic steroid therapy, and or on thyroid supplement
- Liver Disease:
- Kidney Disease:
- Neurological Diseases:
References:
Peri-operative CV complication risk Assessment- Following questions needs to be answered.
- Surgery related questions:
- Urgency of the surgery
- How complex is the surgery
- Patient related questions:
- Cardiovascular Assessment:
- Cardiac Complications of non-cardiac surgery
POISE I trial : BB in Perioperative Period: POISE II : ASA in peri-operative period ; Alpha-2 adrenergic agnosits therapy CARP: Coronary revascularization before vascular surgery FOCUS: Liberal strategy for Hgb Trasnfusion
RCRI predicts cardiac complications but NSQIP does not. Hence, probably, RCRI is better. Use lab.
Peri-operative Pulmonary complication risk Assessment - Risk Assessment
- Smoking
- Pulmonary Assessment:
- OSA
- Screen all patients for OSA before surgery
- STOP BANG: Senstivity 81 %; Specificiaty in 30s
- Score of 3 or more . But not all patients with score > 3 have post-op complications.
- HCO3 of 28 or more increases the specificity; but will decrease the sensitivity
- Treat patients with OSA or suspected patients like OSA until confirmed.
Peri-operative Medication Management - ASA
- Continue for secondary stroke prevention if at all possible
- BB:
- Do not start on same day
- If previously on it, then monitor for HR and BB. Most complication due to Hypotension, and Bradycardia. Hypotension often lead to stroke.
- Target Blood Pressure (<130) and HR (60-75). Some clinicians follow more on heart rate than BB. More sensitive BB dosing change. In terms of BB, try to compare it to the baseline BP to decide on hypotension.
- BB
- Perioperative BB started within 1 day decreases preoperative MI, but causes more harm with increased sepsis.
- References: POISE -1
- Continue BB for appropriate indication if patient has been on it before.
- If patient has appropriate indications to start BB, start at least > 3 days prior to surgery
- Cardiac Stents:
- After 2008, all stents are second generation DES
Second generation stent have much less risk of DES than first generation stent - See AHA/ACC has recommendation (5 weeks ago NEW GUIDELINE on DAPT)
- Stop 1 meds: Median stent thrombosis in 122 days, Stop both : Median day of stent thrombosis: 7 days
- When to resume?
- Review of medications:
- Immunomodulator
- MTX:
- Hold for 1-2 weeks preoperatively and resume when wound healing is over or 2 weeks Post-op
- Adalimubab (for surgery) : Hold 3 weeks Preop
- Anakinra : Hold 2 days preop; check CBC
- Cimzia: Hold 6 weeks Preop.
- Estrogen
- Keep Estrogen, and do appropriate VTE prophylaxis
- SERM (Tamoxifen or Raloxifen)
- Anastrazole (Aromatase Inhibitor)
- Continue it. Appropriate DVT prophylaxis.
- Lower risk than Tamoxifen
Peri-operative pain management - Decide on the nature of pain
- Nociceptive
- Visceral
- Neuropathic
- Inflammatory
- Muscle Spasm
- Post-operative pain medications management
- Analgesics Adjuncts in Acute Pain
- Acetaminophen
- IV form use decreases opiote use by 80 %
- 1 gm Q6 h is used
- Okay to use 4 gm / day in hospital ( 3gm / day is OTC rec)
- NSAIDs (peripheral drugs)
- COX1
- COX2 Inhibitor
- Some controversies in wound healing, but nothing proven
- NMDA receptor antagonists
- Alpha 2 agonists
- ANticonvulsants (alpha-2-delta)
- Gabapentin
- Pregabalin: 150 mg before and 12 hr after the surgery decreases opiate use
- Opiod receptor antagonists
- Corticosteroids
- Tramadol (not the best for acute pain)
- NNT for at least 50 % maximum pain
- Ibuprofen (400 mg ) + Paracetamol 1000 (NNT < 2)
- Is it the oxycodone that helps, or is it the acetaminophen component of percoet that helps
- Opioids in OSA
- Its the Central Sleep Apnea that opiates causes is what they will dye from, and not from airway obstruction
- Opiates: Affects REM sleep . REM sleep is suppressed.
Pain Control - Shoulder surgery are painful. Ongoing postoperative pain control is important.
Perioperative VTE prophylaxis - Compression Stockings: Intermittent Pneumatic Compression. They do not always wear it.
- Combining with pharmacological therapy 44 % reduction of VTE
- Home uses: Special device.
- Orthopedics IPC : In clinical studies, used this at least for 18 hrs / day
- IVC Filters
- No recommendation on when should IVC filter be placed prior to surgery. No literature on this are available.
- Extended prophylaxis for 30 days after Abdominal and Pelvic Surgery in oncologic patients with some risk of increased bleeding.
- No need of prophylaxis in arthoscopy patients
Management of Post-operative Cardiac Complication - HF
- Presence of HF is a risk factor for post-operative cardiac complication and worse outcome. Its contribution is more than the prior history of CAD
- Candian study confirmed this
- Manage like any other EF
- Post-operative ACS
- Is managed similar as any ACS
- 55 % of post-op MI are asymptomatic
- Usually occur within 48 hr
- MINS: Myocardial Injusry after Non-cardiac Surgery
- No idea on how to monitor it
- Atrial Fibrillation
- Prior A fib is associated with increased incidence of MACE in peri-operative period
- New-onset A fib during peri-operative priod (Data from North Carolina : A Herat J 2012)
- California study ; JAMA 2014: 0.81 % of patients had A fib when it was non-cardiac surgery.
- These post-opt a fib in non-cardiac surgery were associated with increased 1 yr CVA. They may need to be managed like paroxysmal atrial fibrillation
Management of Post-operative Complication after Neurosurgical intervention - Hyponatremia
- 70 % SIADH
- Restrict fluid (compare with cerebral salt wasting)
- 7 % Cerebral Salt Wasting
- It is hypovolumic hyponatremia unlike SIADH which is euvolumic hyponatremia
- Steroid induced hyperglycemia
- Post-operative Fever
Perioperative Management of Anti-coagulation. - When to stop the anti-coagulation medication? Below is the Manufacturer label. Depends on half life, and the risk of bleeding during the surgery?
Peri-procedural management of patients taking oral anticoagulants BMJ 2015- Do they need Bridging (based on risk of VTE risk - moderate or high risk, and risk of bleeding risk during surgery if moderate risk), and if they are bridged when should birding anti-coagulation be stopped prior to surgery?
- Assess the thrombotic risk, and find if it is low, moderate or high risk?
The table below is based on the definition derived from surgical / subspecialties societies in anti-coag bridging or anti-coat management studies : - When to restart the anti-coagulation?
- Additional References:
Perioperative Diabetes / Hyperglycemia Management
A1C prior to surgery - Underestimates the risk in Sickle Cell disease.
- > 8, its a arbitrary number, some patients has to be in this range.
- Some data to say some complication when A1C > 8
EKG in periop eval - Yes for high risk. No for low risk.
Aortic Stenosis - Physical exam is unreliable to assess the Severe AS
- If suspected, get an ECHO.
Hip Fracture - Fix hip in 48 hr. If delayed by 48-72 hr, leads to increased mortality, pneumonia, pressure sores.
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