Preoperative Risk Assessment

Geoffrey C Zarrella DO FACC

your late add ons

keep calm

use your tools

stick to your guns

PURPOSE OF THE PREOP EVAL

❖ ASSESS PERIOP RISK

❖ CAN INFORM DECISION TO PROCEED OR CHOICE OF SX

(INCLUDES PT PERSPECTIVE)

❖ DETERMINE NEED FOR CHANGES IN MANAGEMENT

❖ medicines/perform cv interventions/postop monitoring

❖ optimal location and timing of surgery

❖ alternative strategies

❖ IDENTIFY CV CONDITIONS AND/OR RISK FACTORS

REQUIRING LONGER-TERM MANAGEMENT

urgency

❖ emergency

❖ >> life or limb threatened if not in operating room

❖ >> NO or very limited time for clinical evaluation

❖ < 6 hours

❖ urgent

❖ time for limited clinical eval.

❖ life or limb threatened if not in OR soon

❖ 6-24 hours

urgency

❖ time sensitive

❖ a delay of 1-6 weeks to allow for evaluation and

significant changes in management will negatively

affect outcome

❖ elective

❖ procedure can be delayed for up to 1 year

?? ??

establishing risk

❖ previous phrasing : low risk patient for moderate risk

surgery

❖ current diction :

❖ low risk // mace < 1%

❖ elevated risk // mace >1%

risk calculators

risk estimators / tools

❖ RCRI (revised cardiac risk index)

❖ developed from stable pts / 50+ / elective major sx

❖ high risk surgery

❖ intrathoracic / intraperitoneal / suprainguinal vascular surgery

❖ cad

❖ chf

❖ cerebrovascular disease

❖ diabetes on insulin

❖ serum creatinine >2mg/dl

❖ if Y to 2 or more >> you are “high risk”

risk estimators / tools

❖ Surgeon’s NSQIP / Gupta score

❖ >400,000 pts - intended to supplement judgment - predictive ability C statistic 0.88

❖ age

❖ creatinine

❖ ASA classification

❖ preoperative functional status

❖ procedure site

❖ advantage to nsquip // higher degree of accuracy / more

detailed /granular tool

ready?

defining functional capacity

❖ excellent >10mets

❖ good 7-10 mets

❖ fair 4-6 mets

❖ poor <4 mets

❖ ?can you walk up a flight of stairs or a hill?

❖ can you walk 4mph on a treadmill for > 5 minutes

>10 mets

❖ strenuous sports

❖ swimming

❖ singles tennis

❖ basketball

❖ football

❖ skiing

4 mets

❖ light work around the house?

❖ climb a flight of stairs or walk up a hill?

❖ walk on level ground 4mph?

❖ run a short distance?

❖ heavy housework; scrub floor / lift - move furniture

❖ golf, bowling, dancing, doubles tennis, throw baseball /

football

1 met

❖ take care of yourself?

❖ eat, dress, toilet?

❖ walk indoors in the house?

❖ walk a block or two on level ground (2-3mph)

51

Shoulder surgery

hypertension hyperlipidemia

family hx ascvd

dyspnea with climbing stairs

lisinopril/hctz simvastatin toprol xl

normal ecg

4-6 mets

NSQIP/Gupta 0.12% mace….

RCRI 0.4%

55

❖ hernia surgery

❖ htn bmi34

❖ ecg >> sr lvh possible

inferior mi

❖ asx / can climb 2 flights /

mets >6

❖ NSQIP/Gupta 0.06%

❖ rcri / 0.4%

70yo M

prostate cancer / needs radical

prostatectomy

cad / htn / crcl 40 cr1.7 /

albuminuria

singles tennis / prefers scotch

stable angina w/ des lad 7yrs ago

NSQIP 0.11%

RCRI 0.9%

62yo M w/ adisopathy

htn + dm + met syndrome

sedentary>>can walk 1-2 flights of steps

bowel ischemia due to strangulated hernia >>

EMERGENT SURGERY

ecg: afib 120 / lvh / inferior q waves

Cr1.5

NSQIP 0.38%

RCRI 0.9% (counting emergent sx a high

risk)

64yo M

double whammy

cp x 24hrs >> late presenting

NSTEMI

acute cholecystitis

active angina / killip2 heart failure

creat 1.3

nsqip 1.28%

rcri >11%

60yo M

knee replacement

uncertain functional capacity

bmi 38

htn

osa

afib controlled V response

creat 1.6

nsqip 0.26%

rcri 0.4%

80yo M’s

subject A

afib on apixaban

htn

needs clearance for cataract

subject B

afib on warfarin / hx hfref / cva related to

afib

needs dental extraction and “periapical

scaling”

preoperative evaluation / Coronary Revascularization

Antiplatelet management in pci and noncardiac surgery

preoperative evaluation / Valve Disease

preoperative evaluation / Valve Disease

preoperative evaluation / Valve Disease

cied’s ?#$%?

❖ cardiac implantable electronic device

❖ put plan in place prior to OR

❖ complicated device > dump it on eps

preoperative evaluation / Pacemaker - ICD

pulmonary htn

❖ pt should be evaluated by phtn specialist prior to OR

❖ continue meds through procedure

❖ PVR>3wu’s

❖ PASPR > 70mmhg

❖ on phtn meds

preoperative evaluation / Pulmonary Vascular Disease

someone please reschedule this man,

(or send him to cardiology

as a same day consultation.)

preoperative evaluation

preoperative evaluation

preoperative evaluation

preoperative evaluation

preoperative evaluation / timing with previous PCI

preoperative evaluation / beta-blocker therapy

preoperative evaluation / beta-blocker therapy

preoperative evaluation / other meds

preoperative evaluation / antiplatelet therapy

preoperative evaluation / antiplatelet therapy

KEYS

Keys

Geoffrey C Zarrella DO FACC

Preoperative Risk Assessment