1he preop" remalns a common and lmporLanL role for Lhe medlcal consulLanL. 1he medlcal hlsLory ls Lhe same as any medlcal hlsLory and physlcal (P&), buL Lhere are addlLlonal facLors Lo conslder.
!"#$ &'( )**+ $' ,)'-. 1. WhaL ls Lhe surglcal rlsk? 2. WhaL are Lhe paLlenL's rlsk facLors? 3. Pow urgenL ls Lhe surgery?
./012345 02678 1he APA/ACC guldellnes caLegorlze surglcal rlsk lnLo low, lnLermedlaLe, and hlgh rlsk, wlLh ambulaLory surgery belng low rlsk, and ma[or vascular surgery belng hlgh rlsk. Powever, Lhese guldellnes do noL llsL Lhe hundreds of Lypes of surgery ln exlsLence, and Lherefore one musL use cllnlcal [udgmenL Lo esLlmaLe Lhe surglcal rlsk. AddlLlonally, Lhe APA/ACC guldellnes' surglcal rlsk caLegorles refer Lo Lhe rlsk of cardlovascular compllcaLlons, noL overall morbldlLy or morLallLy. lacLors Lo Lake lnLo conslderaLlon lnclude: uuraLlon of general anesLhesla-surgery longer Lhan 8 hours has been assoclaLed wlLh lncreased rlsk of compllcaLlons Lmergency surgery-generally consldered hlgher rlsk 8lood loss LocaLlon and posslble compllcaLlons-e.g. abdomlnal surgery may be more rlsky ln a paLlenL wlLh clrrhosls %492:;9<6 0267 =439>068 Cardlovascular rlsk ls well descrlbed ln Lhe APA/ACC guldellnes. Conslder also Lhe rlsk of perloperaLlve aLrlal flbrlllaLlon. A Lhorough medlcal hlsLory wlll help ldenLlfy paLlenLs aL rlsk for pulmonary compllcaLlons, or have bleedlng dlaLheses, or hypercoagulable sLaLes, or lncreased rlsk of dellrlum. 1he secLlons ln Lhls handbook LhaL follow are useful guldes for speclflc condlLlons. 8ecommended ls Lo read ?40@2>A463/540 &267 .90492=23492>;" and %/5B>;40C &267 (66:66B:;9" for all paLlenLs, and oLher secLlons as perLlnenL.
,01:;3C >= 6/01:0C8 CfLen underesLlmaLed, Lhe urgency of surgery ls a crlLlcal parL of Lhe preoperaLlve evaluaLlon. lor example, a paLlenL wlLh slgnlflcanL cardlovascular rlsk mlghL reasonably undergo sLress LesLlng for a ma[or elecLlve procedure, buL would llkely forego such LesLlng prlor Lo a necessary, urgenL surgery for cancer. ln Lhe laLLer case, medlcal managemenL may be preferred, as a poslLlve preoperaLlve sLress LesL ls unllkely Lo lead Lo coronary surgery or revascularlzaLlon prlor Lo Lhe cancer surgery.
!"#$ &'( )**+ $' +'. ./BB402D: C>/0 =2;@2;16 Cnce Lhese elemenLs are known, Lhe preoperaLlve evaluaLlon, lncludlng recommendaLlons, should be summarlzed ln a conclse buL Lhorough noLe.
llrsL, sLaLe wheLher Lhe paLlenL ls of accepLable rlsk Lo undergo surgery. As menLloned prevlously, avold Lhe Lerm clearance"-Lhls Lerm lmplles LhaL noLhlng wlll go wrong. 1here may be compllcaLlons wlLh !"# surglcal procedure-Lhe key assessmenL ls wheLher Lhe anLlclpaLed beneflLs ouLwelgh Lhe rlsks.
The Preoperative Evaluation The Medicine Consult Handbook 2011 %&!'()*+ Mr. ____ presenLs for elecLlve LoLal hlp arLhroplasLy. Pe ls an accepLable candldaLe for Lhls surgery."
Pe has lncreased cardlovascular rlsk due Lo cllnlcal rlsk facLors of dlabeLes and a prlor 1lA. Powever, hls exerclse Lolerance ls good and l do noL recommend any furLher cardlac LesLlng prlor Lo Lhls lnLermedlaLe rlsk procedure.
Pe has lncreased rlsk of pulmonary compllcaLlons due Lo Lhe presence of CCu and obsLrucLlve sleep apnea. CCu remalns sLable, and hls CSA ls well LreaLed wlLh CA.
Pe ls aL rlsk for posLoperaLlve dellrlum."
E47: 0:3>BB:;@492>;6 aLlenLs are senL Lo Lhe lnLernlsL noL [usL for an assessmenL, buL for recommendaLlons. 8ecommendaLlons should go beyond Lhe APA/ACC guldellnes. Cur role as a medlcal consulLanL ls also Lo provlde guldance on perloperaLlve medlcaLlon managemenL, managemenL of chronlc medlcal condlLlons, anLlclpaLe and mlLlgaLe poLenLlal perloperaLlve compllcaLlons, and recommend approprlaLe prophylacLlc measures.
l recommend Lhe followlng: 1. roceed wlLh surgery wlLhouL furLher cardlac LesLlng. 2. ConLlnue hls beLa-blocker posLoperaLlvely. Pe ls anLlclpaLed Lo be Laklng oral meds lmmedlaLely posLop, so he may be glven meLoprolol 30 mg C 8lu, hls home dose, holdlng lf hls S8 ls <110 or P8 <60, as ofLen paLlenLs are relaLlvely hypoLenslve lnlLlally posLop. 3. uv1 prophylaxls should be provlded posLop per Lhe 2008 ACC guldellnes, for hlp replacemenL Lo lnclude low molecular welghL heparln, fondaparlnux, or warfarln. Cf Lhese opLlons, glven our lnsLlLuLlonal formulary, l recommend dalLeparln 3000 unlLs subcuLaneously once dally for aL leasL 10 days. 4. Pls posLoperaLlve paln should be LreaLed, buL psychoacLlve medlcaLlons should be mlnlmlzed Lo avold dellrlum. 3. osLoperaLlve lncenLlve splromeLry. 6. ConLlnue hls usual LloLroplum lnhaler posLop, and have albuLerol nebullzers 8n. Should he develop a CCu exacerbaLlon, l would favor corLlcosLerolds. 7. SLarL a low dose supplemenLal correcLlon algorlLhm wlLh premeal llspro posLop. 8esLarL meLformln when paLlenL ls eaLlng and renal funcLlon has been conflrmed Lo be accepLable. 8. lollow up wlLh hls C 2-4 weeks posLop." ?>BB/;2349: C>/0 :A45/492>; 1he paLlenL should be lnformed of your recommendaLlons. 1hls noLe should be communlcaLed Lo Lhe surgeon, Lhe prlmary care provlder, and Lo any speclallsLs as approprlaLe. 1he anesLhesla Leam should have access Lo Lhls noLe. SLaLe how you may be reached. Make sure you know who ln your The Preoperative Evaluation The Medicine Consult Handbook 2011 lnsLlLuLlon wlll be seelng Lhe paLlenL posLop-lL may be you, Lhe surgery Leam alone, or an lnLenslvlsL.
( =:F F>0@6 >; 54G>049>0C 4;@ 4;325540C 9:692;18 1here are many sLandard" preoperaLlve LesLs LhaL do noL need Lo be done rouLlnely. ln some cases, Lhere ls no consensus.
1, 11 noL requlred unless personal or famlly hlsLory of bleedlng dlaLhesls CbLaln 1/ln8 ln paLlenLs Laklng warfarln LCC (APA/ACC guldellnes) Class l: vascular surgery and ! 1 Cllnlcal 8lsk lacLor* lnLermedlaLe rlsk surgery ln paLlenLs wlLh CAu, Au, or cerebrovascular dlsease. Class lla: vascular surgery and no cllnlcal rlsk facLors Class llb: lnLermedlaLe rlsk surgery and ! 1 cllnlcal rlsk facLor ChesL x-ray As a general rule, noL necessary. 9!# be helpful for paLlenLs >30 years old undergolng Lhoraclc, upper abdomlnal, or AAA surgery, or who have slgnlflcanL cardlac or resplraLory dlsease (AC guldellnes 2006) ulmonary luncLlon 1esLs (l1s) CbLaln only lf needed Lo dlagnose prevlously unknown obsLrucLlve lung dlsease. used ln some surgery speclflc proLocols (e.g. Lhoraclc surgery) ArLerlal 8lood Cas (A8C) CbLaln only lf susplclon for CC2 reLenLlon LhaL would affecL posLop managemenL *Cllnlcal 8lsk lacLors: ulabeLes, lschemlc PearL ulsease, PlsLory of CongesLlve PearL lallure, Cerebrovascular ulsease, Chronlc kldney ulsease
Many preoperaLlve proLocols, wheLher from anesLhesla or Lhe surgeon, requlre cerLaln preoperaLlve LesLs LhaL Lhe medlcal consulLanL may noL feel are requlred. 1he LCC and coagulaLlon LesLs are common examples of LesLs LhaL are consldered overused. Cood communlcaLlon beLween Lhe medlcal consulLanL, paLlenL, surgeon, and anesLhesla Leam ls essenLlal-lf Lhe LesLlng ls requlred, we wlll ofLen go ahead and order lL so LhaL Lhe paLlenL's surgery wlll noL be cancelled, buL also Lake Lhe slLuaLlon as an opporLunlLy Lo have a dlalogue wlLh Lhose requesLlng Lhe LesLs.