Perioperative Assessment

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 
    • HF
    • ACS
    • Atrial Fibrillation 
  • 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: 


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:
  • 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

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 
    • J Pain 2016 (Guideline ) 
  • 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
      • Clonidine
    • 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
The table below is based on the definition derived from surgical / subspecialties societies in anti-coag bridging or anti-coat management studies : 

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.