Preoperative Risk Assessment
By our dear and forever hospitalist leader Dr. Shalini Gupta!
Case: 85 yo M with CAD s/p DES 2 years ago, stroke 3 months ago, AFib, IDDM A1c 9%, COPD, mild cognition deficit, has rotator cuff tear and going for surgery? What next?
Philosophy: Risk assessment of each organ system and its physiologic reserve to tolerate the stress of a specific surgery
Cardiovascular, Pulmonary, Renal, Endocrine, Neuro-cognitive, Hematologic, Gastrointestinal
Know your patient (H&P and exam most important tool) -including anesthesia history
Major adverse cardiac event (MACE) risk calculator (low <1%, high >=1%)
RCRI score (may overestimate low-risk surgery, and underestimate high-risk surgeries)
Gupta/MICA score (age, functional status, ASA classification, Cr, procedure type)
NSQIP (takes account how patient is doing at this time)
Functional status
Epic built-in tool
[Q&A] What about patients who are unable to do these activities for years? —Get echo/stress test if there is concern, shared decision with patient and anesthesiologist
Cardiovasular testing is rarely indicated in low-MACE-risk patients, or METs>=4 patients.
Other complications
Pulm: OSA (STOP-BANG), COPD, Chronic O2 dependent, Asthma, Smoking, Age, ILD, PHTN, Recent respiratory infection (1 mo)
Neuro: Stroke after non-cardiac surgery 0.1-1.9%. Elective surgery should preferably be delayed for 9 months after a previous stroke
FRAIL Index (new area of discussion)
Surgical risk factors
Site near diaphragm (upper abd/thoracic/supra-inguinal vascular)
Length >2 hr
Type of anesthesia (general/spinal/epidural/monitored anesthesia care/peripheral blocks); type of NM block
Emergency surgery (emergent <6 hrs, urgent 6-24 hrs, time sensitive 1-6 weeks, elective>= 1 year)
High value labs and imaging (choose wisely)
Labs
EKG: may be helpful to establish baseline EKG (Q waves, LVH, arrhythmias)
Echo: for unexplained dyspnea, heart failure with a change in condition, or suspected valve disease (or known valvular disease overdue for imaging)
Drugs (briefly)
Additional Resources
Link to PPT