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Antonio Alan S. MangubatPreoperative Testing Guidelines

Clinical PathwayClinical Pathway

MEDICAL CONDITIONSCardiovascular SystemHypertensionCardiac MurmurAngina Pectoris, Arryhthmias, Cardiac failurePacemakerTriple vessel diseaseCV conditionsHypertensionNewly diagnosed: Refer to IMPoorly controlled: Refer to IMPostpone operation if BP > 180/110 with less than two weeks to optimizedInform surgeon, allow 2 weeks for BP controlHypertensionStage 1 or 2 hypertension is not an independent risk factor for perioperative cardiac complicationsMild/moderate hypertension with no associated CV/metabolic abnormalities not beneficial to delay surgery

HypertensionContinue all anti-hypertensive medications except ACE inhibitors and ARBs (controversial)Continue beta-blockers and clonidine up to the day of operation because of the risk of rebound hypertensionMay use IV beta-blockers or transdermal clonidine in patients unable to take oral medicationsHypertensionFor SBP > 180 and DBP > 110 without any other associated s/s risk benefit of postponing the surgery should be weighedEvidence is inconclusiveIV anti-hypertensives can bring down the BP to manageable levels in a few hoursIV beta-blockers seem to be the most effective agentsCV conditionsCardiac murmurRefer to cardio for 2D-echo if murmur is unlikely to be functional (functional murmurs are soft and change/disappear with changes in posture)Severe AS needs cardio assessmentCV conditionsAngina Pectoris, Arryhthmias, Cardiac failureFollow guidelines for referral to cardiologyCV conditionsPacemakerRefer to cardio to check function of pacemaker if on poor follow-up or asymptomaticRefer if pacemaker spikes are absent on ECGCV conditionsTriple vessel disease (refuses CABG)Refer to cardiologyInform of risk if proceeding with surgeryGuidelines for referral to cardiologyPatients with Major clinical predictorsRequire intensive management, and will result in delay or cancellation of surgery unless emergentRecent MI < 30 daysUnstable/severe anginaDecompensated congestive heart failureSignigicant arrhythmiaHigh-grade AV blockSevere valvular diseaseClinical Predictors(Risks of MI, heart failure, death)Major:Unstable coronary syndromesAMI < 7 days, recent MI < 30 daysUnstable/severe anginaDecompensated CHFSignificant arrhythmiasHigh-grade AV blockSymptomatic ventricular arrhythmias with underlying heart diseassSupraventricular arrhythmia with uncontrolled ventricular rateSevere valvular disease

Clinical PredictorsIntermediate (Increase periop cardiac risk and require careful assessment of current status)Mild angina pectorisPrior MI > 1 month by history of pathologic Q wavesCompensated or previous CHFDMRenal insufficiencyClinical PredictorsMinorElderlyAbnormal ECG (LVH, LBBB, ST-T changes)Rhythm other than sinusStrokeUncontrolled hypertensionEffort tolerancePoor (1-4 Mets)EatingDressingWalking around the houseWashing dishesModerate to Good (4-10 Mets)Climbing one flight of stairsWalking on level ground at 6.4 kms/hourRunning a short distanceScrubbing the floorPlaying a game of golfSurgical RisksHigh (reported death > 5%)Aortic/other major vascular surgeryPeripheral vascular surgeryProlonged procedures with massive fluid shifts and blood lossEmergent major operation, especially in the elderlySurgical RisksIntermediate (cardiac risk < 5%)Carotid endarterectomyHead and neck surgeryIntraperitoneal/ intrathoracic surgeryOrthopedic surgeryProstate surgeryLow (Cardiac risk < 1%)Endoscopic/superficial proceduresCataract surgeryBreast surgeryRespiratory ConditionsConditionActionAsthmaCOPDInterstitial lung diseasesRefer to pulmo for assessment and optimization if control is poorPneumoniaRefer to pulmo urgentlyPostpone operationCXR abnormalities lung nodules Consolidation/Active TB pulmonary congestion suggestive of CHF refer to pulmo. May not need to postpone refer to pulmo. Postpone. refer to guidelines for cardiology referralEndocrine SystemConditionActionHypothyroidism/HyperthyroidismRefer to endocrine for treatment/optimization if not well controlled. In general, euthyroid patients with normal free T4 levels can proceed with surgery.Poorly controlled DMKnown DM, CBG > 18 mmol/L, or undiagnosed DM CBG > 11 mmol/LRefer to endocrine for optimization. In general, patient can proceed with surgery if compliant with medication, no s/s of diabetic crisis and random DBG < 18 mmol/L. Emphasize compliance with medication and dietary control.Diabetes MellitusMild hyperglycemia is preferable to hypoglycemia.Patients should not take oral hypoglycemics on the day of the procedure.Patient should not take short-acting insulin bolus the morning of procedure.Long-acting or intermediate insulin may be used to cover basal insulin needs; 50%-100% of usual dose is often reasonable.Insulin pumps should be continued but only to provide basal insulin coverage.The details of the insulin recommendations are influenced by the insulin sensitivity of the patient, the timing of the procedure, the length of the procedure, and how long the patient will need to be NPO following the procedure.Hematologic SystemConditionActionRBC: severe anemia

polycythemia (Hb greater than 17) may need transfusion pre-operatively if estimated intraop blood loss if moderate to high. May proceed with surgery of no s/s and anemia work-up is not urgent. refer to hematology if with no obvious secondary causesPlatelets thrombocytopenia

thrombocytosis (> 500,000) refer to hematology. May need to prepare platelet for transfusion pre-/intraoperatively refer to hematologyRenal DiseasesConditionActionNewly diagnosed renal failure with hyperkalemiaRefer to nephrology for assessment and optimization. Postpone operationKnown ESRD on dialysisAll patients should be dialyzed a day before the operation.Obesity/OSAClinical diagnosis of OSA Daytime somnolence (easily falls asleep during quiet times or Epworth score of > 14)Snoring with arousalBMI 30 or moreNeck circumference 42 cms. or moreSmall receding mandibleHypertension (> 140/90)Obesity/OSADetermination of Severity of OSA based on Clinical s/sNo. of S/SSeverityScore2Mild14Moderate26Severe3Determination of Severity of OSA based on Sleep StudyAHISeverityScore5-15Mild115-30Moderate2> 30Severe3Obesity/OSAScoring of Invasiveness of Anesthesia or SurgerySurgeryAnesthesiaScoreSuperficial or peripheralNo sedation0Superficial or peripheralSedation or RA1Superficial or peripheralGA2MajorGA3Scoring of Opioid RequirementOpioid RequirementScoreNone0Low dose oral1High dose oral2Parenteral/Neuraxial3Obesity/OSADetermination of Peri-Operative Risk of OSA

OSA severity + Invasiveness OR post-op opioids (1-3)(0-3)(0-3)

4 or less: OPD acceptable but inpatient preferable5 or more: significantly increased perioperative riskObesity/OSAPerioperative risk 4 or lessMonitoring in PACU for 3 hours longer than non-OSA patients in an unstimulated environmentSp02 should be at baseline and with no airway obstructionPerioperative risk 5 or moreContinuous postoperative Sp02 monitoring in ICU or high-dependency unitEpworth Sleepiness ScaleScoring of Chances of DozingSituations0No chance1Slight chance2Moderate chance3High chanceSitting and readingWatching TVSitting inactive in a public placeAs a passenger in a car for an hourLying down to rest in the afternoonSitting and talking to someoneSitting quietly after a lunch without alcoholIn a car, while stopped for a few minutes in trafficTOTALRheumatologyConditionActionRheumatoid ArthritisOrder cervical spine x-rays: 3 views(open mouth, flexion and extension) to assess for atlanto-axial dislocationCoagulation SystemConditionActionAnti-Platelet AgentsStop all anti-platelet agents 7-14 days before operation clopidogrel 7 days dipyridamole 10 days ticlopidine 14 days GP IIb/IIIa 4 weeks aspirin alone, not associated with increased riskNSAIDS/COX-2 inhibitorsAlone, not associated with significantly increased riskHerbal Medications garlic 7 days ginkgo 36 hours ginsent 24 hoursLMWH 10-12 hours after last doseWarfarin stop warfarin for 3 days. Check PT/INR. If INR is less than 2 start LMWH q12. Omit on day of surgery 10-12 hours after last doseAllergiesConditionActionDrug AllergiesAdverse ReactionsName of medications and type or reactions experiencedPreoperative Laboratory ExaminationsASA IAGERISK OF BLOOD LOSSCBCBUN/CreaElectrolytesGlucoseECGCXRPT/PTT< 50Eye/Low---------------ModerateY------------HighYYYYY50-64Eye---------------Low------Y------65-70Eye ---YY------LowYYY------50-70ModerateYYYYYHighYYYYYPreoperative Laboratory ExaminationsASA II and IIIASARISK OF BLOOD LOSSCBCBUN/CreaElectrolytesGlucoseECGCXRPT/PTTASA IIEye---YY------LowYYY------ModerateYYYYYHighYYYYYASA IIIor moreEye---YY------LowYYYY---ModerateYYYYYHighYYYYYGuidelines for Preop InvestigationsECGAge > 50 yearsASA II or moreHigh risk surgery

Cardio-respiratory symptoms or signsGuidelines for Preop InvestigationsCXRASA II with cardiorespiratory symptoms or signsASA III or moreHigh risk surgery

s/s of active respiratory diseaseHistory of pneumonia within the last 6 monthsHistory of pneumothoraxHistory of childhood tracheostomyLarge multinodular goitersThorascopic procedure or thoracotomyCervical lymph node biopsy under GAExtremes of age, smoking, stable pulmo/cardio disease, resolved recent URTI are not considered unequivocal indicationsGuidelines for Preop InvestigationsBiochemistryASA I and age > 65ASA II or moreModerate risk surgery and age >50High risk surgery

Drug history of:DiureticsTheophyllineDigitalis Systemic steroids

Guidelines for Preop InvestigationsCBCAge > 65ASA II or moreModerate and high-risk surgery

NSAID use within past 6 monthsHistory of anemia within the past yearPallor on PEPolycythemiaCADMalignancyRecent radiation or chemotherapySevere coexisting disease or unstable condition renal failure, liver disease, poorly controlled HPN, malnutritionFemale with menorrhagia

Guidelines for Preop InvestigationsCoagulation profileHigh risk surgeryModerate risk surgery (except for ASA I and age