Pre Operative Clearance for Non Cardiac Surgery:
ALL CLEAR
Dominique Renee Abell, RN, MSN, CCRN, ACNP-BC
(ACLS, PALS, TNCC)
rbeckum@crossroadsdevelopers.com
OBJECTIVES
1. Outline evidence based practice
guidelines related to pre operative
evaluation for surgery
2. Describe conditions that require
pre operative diagnostic evaluations
3. Review the findings that would
postpone or cancel surgery
“The purpose of preoperative evaluation is
not simply to give medical clearance but rather
to perform an evaluation of the patient's current
medical status, make recommendations
concerning the evaluation, management and
risk of cardiac problems over the entire
perioperative period; and provide a clinical risk
profile that the patient, primary physician,
anesthesiologist and surgeon can use in making
treatment decisions that may influence short
term and long term cardiac outcomes”
.
Goals of Preoperative Evaluation

Documentation for which surgery is needed

Assessment of patient overall condition/health status




Uncovering issues that could cause problems during
and after surgery
Perioperative risk determination
Optimize medical condition to reduce morbidity and
mortality
Develop perioperative plan of care
Goals of Preoperative Evaluation

Education of patient and family

Surgery

Anesthesia

Intraoperative care

Post operative pain control

Reduce anxiety

Facilitate recovery
Goals of Preoperative Evaluation

Reduce cost

Decrease length of stay

Reduce cancellations day of surgery

Increase patient/family satisfaction
Nurse Practitioner Responsibilities

Perform complete History and Physical

Review/Order labs and ancillary studies

Assess risk related to patient's co-morbidities

Assess need for preoperative specialty consults

Communicate with anesthesia provider and surgeon

Assist with optimal timing of surgery

Medically optimize patient condition preoperatively
Situation for Surgery
Emergent: life threatening situation, risk of or
death of patient if not preformed
Urgent: life threatening or debilitating, needs to be
done sooner than later
Elective: patient may “need” procedure but can be
scheduled at any time
Cardiac Risk
Definition:
Combined incidence of cardiac death and nonfatal
myocardial infarction
Focus on cardiac and pulmonary risk factors that
can contribute to complications
Determine patient's functional capacity, Metabolic
equivalent (MET)
Cardiac Risk
ACC/AHA guidelines
ASA guidelines
Lee's Revised Cardiac Risk Index
http://www.statcoder.com/cardiac.htm
Cardiac Risk Indices
Factors associated with life threatening cardiac
complications/perioperative cardiac death

MI within 6 months

S3 gallop or jugular venous distention

Age >70

ECG other than Sinus Rhythm, >5 PVC's/min

Aortic Stenosis

Poor general health/medical status

Emergency surgery

Intraperitoneal, intrathoracic, aortic surgery
Different Levels of Risk
High:
Unstable Coronary Symptoms- acute or recent MI with
evidence of ischemia
Unstable or Severe Angina
Decompensated Heart Failure
Symptomatic/Significant Arrhythmias
High Grade Atrioventricular Block
Severe Valve Disease
Intermediate:
Mild Angina
Previous MI
Compensated or History of Heart Failure
Diabetes Mellitus
Renal Insufficiency
Minor:
Advanced Age
Abnormal ECG
Any other Rhythm besides Sinus
Low functional Capacity
History of Stroke
Uncontrolled Hypertension
Primary car provider
patient
surgeon
anesthesiologist
History and Physical




Medical history-past
and current
Review of Systemscardiac risk factors,
cardiac conditions,
associated diseases,
changes in symptoms
Medication
Vital signs
Central and Peripheral
pulses
Lungs/Cardiac
Auscultation/Palpation
Abdominal palpation
Examine Lower
Extremities
Alcohol, Tobacco, NonFunctional Capacity
Prescribed drugs
History and Physical

Surgical History

Allergies


Family History of
adverse reaction to
anesthesia
Studies- CBC, INR,
aPTT, BMP/CMP,ECG,
CXR, Stress Test, PFT,
ECHO, Cardiac Cath,
Children include birth
historypremature,perinatal
complications,
congenital,
chromosomal, anatomic
malformations
Functional Capacity

1 Metabolic Equivalent
(MET)
Can you take care of
yourself?
ADL's- eat, dress,toilet,
Walk indoors around the
house
Walk a block or two on
level ground 2-3 mph
Do light houseworkdusting, wash dishes
Functional Capacity

4 MET
Can you climb a flight of
stairs or walk up hill
Walk on level ground at
4mph
Run a short distance
Heavy housework-scrub
floors, lift or move
heavy furniture
Moderate recreational
activities-golf,throwing
a football
Functional Capacity

>10 MET
Swimming, singles tennis,
football, basketball,
skiing
Management of Cardiac Risk
Continue current medications
Cardio-protective Beta Blockade
Coronary angiography/revascularization
Pulmonary Complication

Definition: revised to clinically significant

Pneumonia

Respiratory failure with prolonged mechanical
ventilation

Bronchospasm

Atelectasis

Exacerbation of underlying lung disease
Pulmonary Complications

Decreased functional residual capacity/vital capacity

Cough

Aspiration pneumonia

Atelectasis

Pneumonia

Smoking- even in absence of lung disease
Pulmonary complications

Procedure specific risk factors

Surgical site- most important risk factor

Duration

Anesthesia

Neuromuscular blockade
Pulmonary Complications

COPD/Asthma

Goal is “Personal Best”

Poor PFT's do no exclude from surgery or correlate
with risk of post operative complications

Poor exercise capacity is probably best predictor

Along with type and duration of surgery

Age and obesity are not independent risk factors

Metabolic markers- BUN>30, albumin <3
Pulmonary Complications

Reducing Risk

Preoperative




smoking cessation 8 weeks prior
Treat airflow obstruction in patients with
COPD/Asthma
Administer antibiotics and delay surgery
Begin patient education regarding post op
lung expansion maneuvers
Pulmonary Complications

Intraoperative

Surgery less than 3 hours

Spinal or epidural

Regional or local blocks

Avoid pancuronium

Minimally invasive as possible

laparoscopic
Pulmonary Complications

Post Operative






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Turn, Cough, and Deep Breath
Early mobilization
Adequate analgesia
Incentive Spirometer/Acapella valve
Continuous Positive Airway Pressure
(CPAP)
Epidural analgesia
Intercostal nerve blocks
Hematologic Risk

Hematocrit < 24%

Thrombocytopenia <50,000

History of bleeding diathesis

Cirrhosis

Hematologic malignancy

Antiplatelet medication

Anti-coagulation therapy

DVT/VTE prophylaxis
Chronic Medications

Consider every medication/supplement

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Diabetes- adjust insulin or oral
hypoglycemics
Chronic steroids- stress dose
Hypertensive medications- PO or IV
Anti-ischemic medications- transdermal
or IV
Alcohol use and withdrawal
Chronic Medications



Monoamine oxidase inhibitors- taper and withdraw
2-3 weeks before surgery
Oral contraceptives- stopped 6 weeks before elective
surgery secondary to increased VTE risk
Herbal supplements discontinued 2 weeks before
surgery

Aspirin discontinued 7-10 days before

Thienopyridines (clopidogrel) 2 weeks before

Non-steroidal Anti-inflammatories 7-10 days before
Chronic Medications


Oral anticoagulants stopped 4-5 days
INR 1.2-1.5 before surgery

Evaluate for “bridge therapy”

Cox 2 inhibitors may be continued up to surgery
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