PREOP RISK ASSESSMENT- CARDIAC AND PULMONARY
CARDIAC
WHOM AND HOW TO ASSESS
Determine if the pt. has an active cardiac condition or has undergone recent PCI.
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Acute coronary syndromes
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Decompensated heart failure
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Uncontrolled arrhythmias
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Severe valvular disease ( AS or MS )
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Defer all but the most emergent procedures in these patients until the active cardiac condition has
been treated.
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If recent PCI, modify the timing of surgery and perioperative antiplatelet treatment accordingly.
Determine patient- and procedure-related risks in patients without an active cardiac condition.
Classify the procedure
• High-risk (>5% perioperative risk of death or MI)
Aortic and peripheral vascular surgery
• Intermediate-risk (1% to 5% perioperative risk of death or MI) Intraperitoneal and
intrathoracic surgeries, carotid endarterectomy, head and neck surgery, orthopedic
surgery, and prostate surgery
• Low-risk (<1% perioperative risk of death or MI)
Endoscopic and superficial procedures, cataract surgery, breast surgery, and ambulatory
surgery
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Obtain a history and do a physical examination in all patients.
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Order laboratory testing based on the patient's individual clinical condition.
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Order an ECG if vascular surgery, known heart disease, PAD or cerebrovascular disease
undergoing intermediate risk procedures
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Do not obtain preoperative CXR without clinical suspicion for intrathoracic pathology.
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Classify the patient as high-, intermediate-, or low-risk by using the Revised Cardiac Risk Index
(RCRI).
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Consider using the American College of Surgeons' National Surgical Quality Improvement
Program (ACS-NSQIP) Cardiac Risk calculator for a more precise estimate of perioperative risk.
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Consider using the Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) for
patients undergoing vascular surgery.
Do not do an extensive cardiac evaluation in:
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Patients who need emergency surgery
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Patients who do not have an active cardiac condition and need low-risk surgery
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Patients who do not have an active cardiac condition, have no cardiac symptoms, and
have good exercise capacity (≥4 METS)
Perform noninvasive cardiac testing in patients:
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With symptoms of coronary ischemia
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With three or more clinical cardiac risk factors and poor functional capacity (<4 METS)
who are undergoing intermediate- or high-risk surgery
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Consider testing patients with poor functional capacity but only one or two clinical risk
factors who are undergoing intermediate or high risk surgery
In patients requiring testing do one of the following
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Exertional stress testing/stress thallium
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Dipyridamole thallium or its equivalent (e.g., Cardiolite sestamibi)
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Dobutamine stress echocardiography
INTERVENTIONS TO DECREASE RISK
In patients with severe aortic stenosis:
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Aortic valve replacement in symptomatic patients
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For emergency surgery- prevent tachycardia with β-blockers, prevent decrease in
preload with adequate fluids, and prevent hypotension with α-adrenergic pressors.
Patients with recent coronary stenting.
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Delay elective noncardiac surgery 4 to 6 weeks for bare-metal stents and at least 12
months for drug-eluting stents.
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Continue antiplatelet therapy as soon as possible after the procedure
Preoperative coronary revascularization in selected patients
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If they are high risk or if they have unstable angina refractory to medical therapy
• CABG or PCI before planned surgery,
Perioperative β-blockers
In patients:
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With known coronary artery disease
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At high risk for coronary artery disease due to multiple risk factors
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Undergoing cardiac surgery
Allow adequate time (1 week or longer) for titration and to ensure tolerability, and use long-acting
(e.g., atenolol, bisoprolol, metoprolol succinate) over short-acting β-blockers (e.g., metoprolol
tartrate).
• Contraindications
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Heart rate <55 beats/min
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Systolic BP <100 mm Hg
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Active, decompensated heart failure
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Bronchospasm (e.g., asthma, COPD)
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High-degree AV heart block
Statins
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In patients who are at risk for postop MI.
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Continue statins in all patients already receiving them.
α2-adrenergic agonists
In patients with multiple risk factors for CAD in whom β-blockers are
contraindicated.
Other interventions in selected patient groups.
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Preoperative epidural anesthesia for patients with hip fracture.
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Maintaining normal temperature perioperatively in elderly patients undergoing major
surgery.
COUNSELING
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Review websites that provide information on types of surgery
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Ensure that patients understand that their personal risk may not be reflected accurately in
general publications and that they should direct specific questions to their clinician.
FOLLOW UP
Maintain a low threshold for testing patients for evidence of ischemia and MI in the
perioperative setting.
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For asymptomatic patients at high cardiac risk, consider obtaining serial ECGs and
cardiac enzymes for up to 1 week postoperatively.
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Evaluate all symptomatic patients for evidence of cardiac ischemia, even if their
symptoms are atypical.
PULMONARY
WHOM AND HOW TO ASSESS
Consider general health status
American Society of Anesthesiologists (ASA) Physical Status Classification
1- A normally healthy patient
2- A patient with mild systemic disease
3- A patient with severe systemic disease that is not incapacitating
4- A patient with an incapacitating systemic disease that is a constant threat to life
5- A moribund patient who is not expected to survive for 24 hours with or without an operation
E- Suffix to indicate an emergency surgery for any class
Consider age as a minor predictor of pulmonary risk.
Do not deny surgery to patients based on age alone
Determine the presence and severity of COPD.
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Use H/P , labs, and when indicated, spirometry, to determine risk for postop pulmonary
complications.
Establish the presence of patient-related risk factors to classify risk as average, moderate, or
high.
Cigarette smoking
- Smoking is a risk factor for postop pulmonary complications among patients with and without
COPD. Patients who quit 2 months before surgery are at lower risk but patients who quit within 2
months of surgery may increase their risk
Patients with asthma
- Consider risk to be increased only if the patient is actively wheezing or if
the peak flow is <80% of personal best or predicted.
- If peak flow is >80% of personal best or predicted, consider recent stability of peak flow and
symptoms.
Inquire about exercise capacity
• Consider poor exercise capacity to be a risk factor for postop pulmonary complications.
Do not consider obesity to be a major risk factor for postoperative pulmonary complications.
Assess at-risk patients for OSA ( major risk factor for postop complications )
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The STOP questionnaire
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Do you Snore?
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Do you have daytime Tiredness?
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Have you had Observed apneas?
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Do you have high-blood Pressure?
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The STOP-Bang questionnaire includes four additional factors:
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BMI >35 kg/m2
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Age > 50 years
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Neck circumference >40 cm
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Male gender
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Identify high-risk patients for consultation with an anesthesiology and, if feasible, defer surgery
pending further evaluation and treatment.
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Consider CPAP ventilation or closer monitoring in high-risk patients.
Certain noncardiac, nonpulmonary surgeries increase risk for postoperative pulmonary
complications.
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E.g- aortic, upper abdominal, and nonresective thoracic (e.g., Nissen) procedures carry the
highest risk
Consider the duration of surgery
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Prolonged surgical procedures have an increased risk of complications
General anesthesia - minor risk factor for pulmonary complications when
compared to spinal anesthesia.
Preoperative spirometry - select patients with risk factors (e.g., smoking) or unexplained symptoms that
may represent undiagnosed pulmonary disease.
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Do not routinely obtain spirometry before surgery, even if high-risk procedures.
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Reserve for patients undergoing thoracic or upper abdominal surgery who have cough, dyspnea,
or poor exercise tolerance that remains unexplained after a careful H/P .
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Recognize that spirometry refers to the measurement of FEV1 and FVC, and that it is not
necessary to obtain additional pulmonary function tests for the purposes of estimating the risk of
postoperative pulmonary complications.
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In patients with known COPD or asthma to establish the degree of airway obstruction only when
the H/P do not allow a confident determination of their present status compared to their best
baseline
Do not routinely obtain preoperative arterial blood gas tests or chest radiographs before surgery.
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Obtain spirometry or chest radiographs only if another indication exists that is independent from
the need for surgery.
INTERVENTIONS TO DECREASE RISK
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Encourage smoking cessation for at least 8 weeks before elective surgery.
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Begin patient education efforts on lung expansion maneuvers.
Consult with surgery colleagues to reduce risk by
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Limiting duration of surgery to 2 hours if possible.
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Using laparoscopic techniques when possible.
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Substituting less ambitious surgical procedures in patients at high risk.
Encourage lung expansion maneuvers in the postop period
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In patients undergoing thoracic, abdominal, and aortic procedures, recommend deep breathing
exercises or incentive spirometry
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Consider CPAP for patients who cannot cooperate with effort-dependent techniques.
Patients with asthma or COPD,
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Treat patients who are not at their best baseline with a combination of inhaled bronchodilators,
systemic corticosteroids if necessary to optimally reduce airflow obstruction.
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Preoperative chest PT:
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Patients with an ineffective cough and upper airway secretions
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Patients with persistent sputum production despite other therapies
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Patients with poor functional capacity due to exertional dyspnea
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Treat bacterial bronchitis or pneumonia with antibiotics before proceeding to elective surgery.
( Indications for treatment, choice of antibiotics, and duration of therapy are identical to
those for patients with asthma or COPD who are not preparing for elective surgery)
Consult with anesthesiologists to develop intraoperative drug therapies to reduce risk in patients
at high risk for postoperative pulmonary complications.
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Consider the benefits of regional vs. general anesthesia on an individual basis.
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Avoid pancuronium in patients at high risk for postop pulmonary complications in the setting of
other important patient- and procedure-related risk factors.
Adequately treat pain in the postoperative period to reduce the risk of postoperative pulmonary
complications.
COUNSELING
• Provide patients with information and advice on prophylactic measures to avoid postoperative
pulmonary problems.
• Note that teaching lung expansion maneuvers before surgery leads to a greater reduction in
postoperative pulmonary complications than teaching that begins after surgery.
FOLLOW UP
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Evaluate high-risk patients after surgery for evidence of wheezing, unexplained dyspnea, fever, or
productive cough, which may be manifestations of atelectasis, bronchospasm, or pneumonia.