07JUL22 Anesthesia Pre-op

Fonseca - Vol 1, Sect 2, Ch 13 - Preoperative Evaluation

Introduction
- UCSD Physical Exam Checklists
 Certain medications are indicated for perioperative adjustment or discontinuation, but
most should be continued
o Pts on aminoglycosides 
 Can potentiate nondepolarizing relaxants
 Monitor neuromuscular relaxants carefully
 Pts on Aspirin
 Bleeding risk, platelet dysfunction
 Consider discontinuation for 10-14 days, discuss risk of stroke, MI or
thrombosis with discontinuation
 Pts on clonidine
 Acute withdrawal of clonidine can cause HTN crisis, decrease anesthetic
requirements
 Clonidine can be continued
 Lithium patients
 Potentiate neuromuscular blockers, lithium-induced hypothyroidism,
watch Na+ levels as Na and Li levels are inversely related
 May need to get thyroid function test preoperatively and avoid Na+
wasting diuretics
 MAOis (monoamine oxidase inhibitors, i.e. phenelzine, tranylcypromine,
isocarboxazid)
 Increase serum catecholamine stores, hepatotoxicity, can cause fatal
reaction with opioids, especially meperidine
 Avoid indirect-acting sympathomimetics and use reduced doses of direct-
acting agents
 Avoid opioids, especially meperidine
 D/C 14-21 days before unless increased suicide risk
 Warfarin
 Excessive intraoperative bleeding
 Warfarin can be continued or switched to heparin which can be stopped
in the immediate pre-op and resumed in the immediate post-op
 The most-used risk stratification system is the American Society of Anesthesiologists
(ASA) physical status classification system
 ASA I = healthy patient
 ASA II = mild systemic disease - no functional limitation
 ASA III = Severe systemic disease - definite functional limitation
 ASA IV = Severe systemic disease, constant threat to life
 ASA V = Moribound pt, not expected to survive w/o procedure

Conducting the Preoperative Evaluation

 Cardiovascular
o RCRI (Revised cardiac risk index) identifies patients at risk for major
cardiovascular complication
 There is an updated RCRI
 6 main risk factors for adverse cardiovascular event:
 Cerebrovascular disease
  Congestive heart failure
 Creatine level > 2.0 mg/dL (176.80 umol/L)
 Diabetes mellitus requiring insulin
 Ischemic cardiac disease
 Suprainguinal vascular injury, intrathoracic surgery, or intra-
abdominal surgery
 Patients undergoing surgery with no risk factors have 0.5% of cardiovascular
complication vs. those with 3+ risk factors have 11% risk
 Major Clinical Predictors for cardiac complications
 Unstable angina, decompensated CHF, significant arrhythmia, severe
valvular disease
 Patients with any of these risk factors require subsequent care and
delaying non-cardiac surgeries until cardiac condition is stable
 Intermediate clinical predictors
 Mild angina, prior MI, compensated CHF, diabetes, renal insufficiency
 These patients can be operated on for low-mild risk procedures if >4
METs
 Patients with any of these <4 mets should undergo noninvasive testing or
coronary angiography
 What are METs? Total Metabolic equivalents
 Patients with >4 METs can usually:
 Walk up a flight of stairs
 Walk up a hill
 Walk on ground at 4 mph
 Perform physical activity around the house
 Patients with <4 METs typically:
 Difficulty with the tasks above
 Walk a block or 2 on level ground at 2-3 mph
 Light moderate work, i.e. dusting, washing dishes
 Golfing, unable to golf without a cart
 Preoperative beta-blockers
 Used to be recommended 1 day prior, but recent studies show that  short
term beta blockade can increase risk of stroke, death, hypotension, and
bradycardia, even if it decreases risk of nonfatal MI
 Preoperative antibiotics where abx prophylaxis is recommended
 Prosthetic heart valve
 Previous infective endocarditis
 Unrepaired cyanotic congenital heart disease
 Repaired congenital heart defect with prosthetic device 
 Repaired congenital heart defect with residual effects or cardiac
transplant
 New ABX Guidelines
 2g amox
 Allergy no test = Keflex/Ancef IV
 Allergy w/ anaphylaxis or positive test = Clindamycin
 Pulmonary
 Introduction
 Postoperative pulmonary conditions are as high as 5% in general surgical
patients and as high as 20% in patients that are high-risk
 Most severe complications include atelectasis, pneumonia, respiratory
failure, or exacerbation of underlying disease
  Tests to rule out pulmonary disease include O2 sat, chest radiograph,
ABG, and PFTs
 No data supports chest x-ray as standard of pulmonary screening
BUT MAY BE CONSIDERED in smokers, pts with recent
pulmonary infection, COPD, or carddiac disease
 Main risk factors for perioperative pulmonary complications:
 Age > 60
 Hx of COPD
 ASA >2
 Functional dependence
 Hypoalbuminemia
 CHF
 Procedure-related risk factors that are correlated to pulmonary
complications
 Long surgery duration
 Head and neck surgery
 Emergency surgery
 Use of general anesthetics
 Chronic Obstructive Pulmonary Disease
 COPD is characterized by airflow limitation that is usually progressive and
associated with enhanced chronic inflammatory response in the airways
and lung
 Risk of complication of COPD patients correlates with disease
severity 
 COPD patients should have bronchodilators used throughout the
perioperative period, avoid anything that causes bronchospasm
 Smoking
 Smoking increases the risk of pulmonary complications 4x
 Smoking impairs ciliary clearance, thickens mucus secretions, and
increases risk for aspiration, bronchospasm, hypoxemia, pneumonia
 Smoking cessation in the immediate pre-op DOES NOT decrease
pulmonary factors because secretions are increased for 8 weeks after
cessation prior to decreasing
 *smoking 24h prior is beneficial for smokers because O2 monitors don’t
pick up carboxyhemoglobin*
 Nicoderm can be used (21, 14, 7 mg = 1 pack, ½ pack, <1/2 pack)
 Asthma
 Patients with well-controlled asthma are not at risk for pulmonary
complications
 Make sure to ask patient about what exacerbates asthma and frequency
of exacerbations
 Poorly controlled asthma patients may require oral systemic
corticosteiroids
 Renal
 Acute Kidney Injury (AKI)
 AKI is classified as a change in serum creatinine concentration, urine
output, or both
 AKI in the perioperative period is associated with relative hypoperfusion
of the kidneys, or exposure to nephrotoxic compounds like contrast,
ACEis, or aminoglycosides
  4 main risk factors for perioperative AKI: Age, diabetes, increased
RCRI, increased ASA
 Patients with AKI have 3x higher in-hospital mortality rate

 Chronic Kidney Disease

o CKD is defined as glomerular filtration rate (GFR) <60 mL/min/1.73m2 or
evidence of kidney damage (proteinuria, glomerular hematuria, abnormal
renal imaging or biopsy) and is staged by GFR
o CKD usually associated with patients with diabetes mellitus,
hypertension, and glomerulonephritis
o Stages of Chronic Kidney Disease
 Stage I - normal GFR with proteinuria/hematuria
 Stage II - decreased GFR (60-89 mL/min)
 Stage IIIa - GFR = 45-59 mL/min
 Stage IIIb - GFR = 30-44 mL/min
 Stage IV - severe CKD where GFR = 15-29 mL/min
 Stage V - established end stage renal disease, GFR <15 mL/min
or on dialysis
 Patients with CKD should have NSAIDs, morphine, and aminoglycoside
abx monitored or avoided completely
 Worry for risk of infection, low potassium
 NSAIDs cause constriction of the renal artery, decreased renal
perfusion and decreased excretion of drugs that are exclusively
cleared renally
 Gastrointestinal
o Introduction
 GI and hepatic disease can predispose many generalized hospital-
associated complications, i.e. poor wound healing, excessive  bleeding,
electrolyte imbalance, anemia, etc.
 Gastroesophageal reflux Disease (GERD)
 Characterized by discreased lower esophageal sphincter tone,
causing reflux of gastric contents into the esophagus
 Chronic GERD is managed by H2 blockers or PPIs
 Continue H2 blockers and PPIs peroperatively
 Well-managed GERD patients treated like normal
 Poorly managed GERD patients may have procedures delayed
until  GERD is better managed
  Emergent procedures can be augmented by H2 blockers,
rapid sequence induction, and NG suction
 Peptic Ulcer Disease (PUD)
 Ulceration of the mucosal lining of the stomach or first part of the
duodenum
 Causes of PUD are usually Infection of H. Pylori or chronic NSAID
use.
 PUD is managed by PPIs or H2 blockers
 Avoid NSAIDs in PUD patients, exacerbations should be
managed  by immediately stopping NSAID and switching to other
analgesic and evaluation for PUD
 Hepatic Disease
 Risk factors for hepatic disease include: IV drug use, alcohol
abuse syndrome, hx of jaundice, blood transfusion
 Presenting factors of hepatic disease are: telangiectasia,
gynecomastia, ascites, pruritis, fatigue, and testicular atrophy in
males
 Surgical risk for hepatic disease is mesured through the Model for
End Stage Liver Disease (MELD) Score
 MELD score <10 should be able to undergo elective
surgery 
 MELD score >15 should not be considered for elective
surgery
 Endocrine
 Diabetes Mellitus
 Diabetes defined as fasting blood glucose >126 mg/dL or hgA1c >5.7%
 Type I Diabetes = insulin dependent
 Autoimmune process resulting in destruction of insulin-producing
beta-islet cells of the pancreas
 Type II Diabetes = Non-insulin dependent
 Begins as insulin resistant state with compensatory increase in
insulin production by beta cells
 Late stage Type II diabetes can result in beta cells
decompensating, requiring exogenous insulin
 Hyperglycemia in the peri-operative period can cause increased morbidity
and mortality due to dehydration and electrolyte disturbances, vascular
permeability, and pathogen growth
 Perioperative Blood glucose should be between 140-180 mg/dL
 Diabetes is the leading cause of kidney failure in america
 Chronic hyperglycemia can cause nephropathy, autonomic, and
peripheral neuropathy as well as peripheral vascular disease
 Operations for diabetic patients should be as early in the morning as
possible
 Delayed gastric emptying particular in DB patients
 Hyperthyroidism
 Typically a sequelae of Graves disease, multinodular goiter, or
exogenous thyroid hormone
 Symptoms of hypeprthyroidism = Fever, tremor, hyperdynamic cardiac
functioning, HTN, tachycardia
 Hyperthyroidism patients are at risk for sinus tachycardia and atrial
fibrillation or thyroid storm
  Thyroid storm is  diagnosed by symptoms including tachycardia,
hyperpyrexia, and delirium
 Treat with B-blockers, antipyretics, and thionamides
 Hyperthyroid patients should be made euthyroid prior to operations using
PTU, methimazole, or iodide tx up to 8 weeks prior
 For emergent procedures, propranolol is the main B-blocker of choice for
hyperthyroid patients
 Hypothyroid patients
 Usually due to hashimoto thyroiditis or primary hypothyroidism
 Patients usually present with lethargy, fatigue, anorexia, deepression,
weight gain, and cold intolerance
 Hypothyroidism patients have decreased CO secondary to decreased
stroke volume and heart rate and ventilation
 Hypothyroid patients can have hypoxia and hypercarbia
 Hypothyroid patients should have TH supplementation via levothyroxine
 Adrenal insufficiency
 Cortisol is the primary glucocorticoid in humans which potentiates the
effects of other catecholamines
 Hypothalamic-pitutiary-adrenal axis (HPA) regulated by a negative
feedback loop, regulates cortisol secretion.
 The most common causes of adrenal insufficiency are primary
autoimmune adrenalitis and withdrawal of chronic steroid use (secondary
AI)
 Patients that have chronic cortisol supplementation may need a stress
dose for operations
 Hematology
 Common tests to evaluate for hematologic deficiencies are Complete
blood count (CBC), prothrombin time (PT), partial thromboplastin time
(PTT), bleeding time, and fibrin split products
 Anemia
 Defined as hemoglobin concentration <14 g/dL in males and 12.3 g/dL in
females
 If anemia is detected, iron study and reticuloucyte counts should be
gained to identify etiology
 Iron deficiency may be addressed if time allows, however transfusion is
used for time-sensitive procedures in the postoperative face
 Transfusion should be considered at Hgb concentrations < 7 mg/dL for
hemodynamically stable patients
 Transfusions for unstable, symptomatic patients (angina, orthostatic
hypotension, tachycardia unresponsive to fluid resuscitation) should
begin at <8 mg/dL
 Sickle Cell Disease
 Caused by Genetic mutation substituting valine for glutamic acid in the
6th position of the beta chain of hemoglobin
 Patients with sickle cell trait have benign disease and no symptoms
 Homozygous HbS patients have sicklecell disease, causing anemia,
hemloysis, and vascular occlusion
 Vascular occlusion can lead to end-organ damage rapidly in sickle
cell crisis
 Hx should include last crisis, interval between crisis, inciting events for
crisis, and needs for transfusion
  Perioperative management of sicklecell = warm temperature, prophylactic
abx, patient comfort, managing anxiety, and hydration
 Bleeding Diatheses
 Predisposed to abnormal bleeding, usually due to abnormal platelet
function
 Thrombocytopenia
 Quantitative platelet disorder where there is increased platelet
destruction, decreased platel;et production, or abnormal distribution
 Common cause of thromboycytopenia is typically immunologic, due to an
autoimmune disorder, i.e. lupus or autoimmune hemolytic anemia, HIV, or
CLL
 Preoperative thrombocytopenia should be managed with corticosteiroids,
immunoglobulin, or platelet transfusions
 Normal patients have ⅓ of circulatory platelets sequestered by the spleen
 Patients with hepatosplenomegaly can have up to 80-90% of platelets
sequestered
 Platelet transfusion should be considered if platelet count is <50,000 / uL
or higher if expected blood loss is significant
 One single platelet transfusion usually increases platelet levels by
10,000 / uL
 Following transfusion, platelet count should be done after
an hour - pt with 60,000 - 100,000 / uL should tolerate
most routine procedures
 Coagulation Disorders
 Hemophilia
 Hemophilia A = Most common
 Deficiency in Factor VIII
 XLR inheritance
 Hemophilia B = 2nd most common
 Factor IX deficiency
 XLR inheritance 
 Both hemophilia A and B have increased aPTT (activated PTT)
 Patients with Hemophilia A with mild symptoms can be treated
with DDAVP (Deamino-D-arginine Vasopressin) 
 DDAVP increases circulating factor VIII
 Severe hemophilia A will require DDAVP and factor VIII
supplementation
 Von Willebrand Disease
 Most commonly inherited abnormality affecting platelet function, caused
by deficient or dysfunctional von Willebrand factor (vWF)
 vWF carries factor VIII
 When activated, vWF wild bind platelets to exposed collagen
 Von Willebrand Disease is characterized by severity, type I, 2, and 3
 DDAVP doesn’t work for Type III vWF disease because no
inherent vWF, give cryoprecipitate
 Common symptoms = mucosal  bleeding, GI bleeding, elevated PT
 Perioperative management for von willebrand disease is DDAVP, Factor
VIII, or vWF concentrate
 Anticoagulant and Antiplatelet therapy
 Patients on Warfarin should have INR measured 
  Patients on Heparin have aPTT measured or factor Xa inhibitors or direct
thrombin time
 Risk of bleeding in patients on anticoagulants
 Minimal risk = stop 18-24 h preop
 Minor risk = stop 24 h preop
 High risk = stop >48 h preop
 Neurology
 Seizures
 Hx for seizure patients should include inciting events, frequency, and any
antiepileptic medications
 Perioperative management of antiepileptics are minimal, reducing pro-
convulsive medications
 Cerebrovascular accident (CVA) or Stroke
 4th most common cause of death
 10% of strokes are hemorrhagic, 90% are ischemic
 Risk for another major CVA following CVA is most increased after 9
months
- Cardiology
o Bare metal stents
 30 days of clopidogrel and aspirin
o Drug eluting stents
 365 days if no risk of bleeding
o MI w/ no intervention
 No procedures for 60 days
o MedCalc