PREOPERATIVE EVALUATION (NONCARDIAC SURGERY)

56 PREOPERATIVE EVALUATION (NONCARDIAC SURGERY)



General Discussion


The effective preoperative evaluation seeks to perform several tasks which include (1) decreasing surgical morbidity; (2) minimizing expensive delays and cancellations on the day of surgery; (3) evaluating and optimizing patient health status; (4) facilitating the planning of anesthesia and perioperative care; and (5) reducing patient anxiety through education. The complete consultation should include recommendations for evaluation and treatment, including prophylactic therapies to minimize the perioperative risk.


Surgical complications occur frequently and generally include cardiac, respiratory, and infectious complications. The overall risk for surgical complications depends on individual factors and the type of surgical procedure being considered. Diseases associated with an increased risk for surgical complications include respiratory disease, cardiac disease, diabetes mellitus, and malnutrition. Cardiac complications are the most common cause of morbidity and mortality in the surgical patient.


Ideally, the patient should be evaluated several weeks before the planned surgical procedure. Emergency surgery requires expedited preoperative cardiac assessment and management. Patients undergoing elective or semielective procedures can proceed with preoperative cardiac testing if indicated.


The patient’s medical history usually is the most important component of the preoperative evaluation. The value of routine medical testing before elective surgery is unclear because most abnormalities in laboratory values can be predicted from the patient’s history and findings on the physical examination. Current recommendations call for fewer routine tests and instead recommend selective ordering of laboratory tests based on the specific indication in a given patient.


Aspirin and NSAIDs should be discontinued 1 week before surgery to minimize the risk of excessive bleeding. If the patient smokes, the patient should quit smoking at least 8 weeks before surgery to minimize the surgical risks associated with smoking.


Recommendations do not call for preoperative cardiac testing in all patients. The need for cardiac evaluation is determined by the clinical risk factors identified from the patient’s history, physical examination, functional status, EKG, and the risks inherent to the procedure being considered. Figure 56.1 provides the guidelines of the American College of Cardiology and the American Heart Association.


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Figure 56-1 Stepwise approach to preoperative cardiac assessment. Steps are discussed in text. *Subsequent care may include cancellation or delay of surgery, coronary revascularization followed by noncardiac surgery, or intensified care. CHF indicates congestive heart failure; ECG, electrocardiogram; MET, metabolic equivalent; MI, myocardial infarction.


The role for preoperative pulmonary function testing remains controversial. The American College of Physicians recommends spirometry in patients with a history of dyspnea and tobacco use who are undergoing upper abdominal or coronary artery bypass surgery. For any patient with cough or dyspnea, a work-up should be performed to evaluate for the underlying etiology. Asthma should be under control before surgery if possible. Any pulmonary infection should be treated preoperatively.


All patients with coronary artery disease (CAD) and possibly those with risk factors for CAD should receive perioperative beta blockers unless a strong contraindication exists.

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Aug 17, 2016 | Posted by in PEDIATRICS | Comments Off on PREOPERATIVE EVALUATION (NONCARDIAC SURGERY)

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