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Koshy
- 1. PREOPERATIVE EVALUATION OF CARDIAC PATIENT (For Non-Cardiac Surgery) Dr Thomas Koshy Additional Professor Sree Chitra Tirunal Institute for Medical Sciences and Technology Trivandrum
- 25. Minor predictors
- 27. When and Which Test (For the cardiologist) No further preoperative testing recommended Preoperative angiography Ex ECG Exercise echo or perfusion imaging‡** Pharmacologic stress imaging (nuclear or echo) Dipyridamole or adenosine perfusion Dobutamine stress echo or nuclear imaging Other (eg, Holter monitor, angiography) Yes Prior symptomatic arrhythmia (particularly ventricular tachycardia)? Borderline or low blood pressure? Marked hypertension? Poor echo window? No Yes Prior symptomatic arrhythmia (particularly ventricular tachycardia)? Marked hypertension? Bronchospasm? II AV Block? Theophylline dependent? Valvular dysfunction? No No Resting ECG normal? Patient ambulatory and able to exercise?‡ Yes No Yes Yes Indications for angiography? (eg, unstable angina?) Yes Yes No No Testing is only indicated if the results will impact care. 2 or more of the following?†* 1. Intermediate clinical predictors 2. Poor functional capacity (less than 4 METS) 3. High surgical risk
Notas do Editor
- The purpose of preoperative evaluation is to perform an evaluation of the patient’s current medical status, make recommendations concerning the risk of cardiac problems over the entire perioperative period, and provide a clinical risk profile that the patient, his or her primary physician, anesthesiologist, and surgeon can use in making treatment decisions. No test should be performed unless it is likely to influence patient treatment .
- The consultant should review available patient data, obtain a history, and perform a physical examination pertinent to the patient's problem and the proposed surgery. A critical role of the consultant is to communicate the severity and stability of the patient's cardiovascular status and to determine if the patient is in the best reasonable medical condition, given the context of the surgical illness.
- Preoperative cardiac evaluation must be carefully tailored to the circumstances that have prompted the consultation and nature of the surgical illness. A careful history and cardiovascular examination are crucial. In addition, the consultant must evaluate the cardiovascular system within the framework of the patient's overall health. Ancillary studies may be minimal, but should include review of the electrocardiogram
- In this way, the separation of MI into the traditional 3 and 6 month intervals has been avoided. Although there are no adequate clinical trials on which to base form recommendations it appears reasonable to wait 4 to 6 weeks after MI to perform elective surgery.
- Cardiac complications are two to five times more likely to occur with emergency surgical procedures than with elective operations. In addition, the magnitude of the surgical procedure influences the cardiac risk. Major vascular procedures represent the highest risk, as well as those with prolonged duration and large fluid shifts.
- Test of choice is exercise ECG testing. Provides estimate of functional capacity, Detects myocardial ischemia through ECG changes and hemodynamic response
- Preoperative invasive monitoring in an intensive care setting can be used to optimize and even augment oxygen delivery in patients at high risk
- Further evaluation regarding the optimal strategy for surveillance and diagnosis of perioperative MI is required before one method is advocated. In patients without evidence of CAD, surveillance should be restricted to patients who develop perioperative signs of cardiovascular dysfunction. In patients with known or suspected CAD undergoing surgical procedures associated with a high incidence of cardiovascular morbidity, ECGs at baseline, immediately after the surgical procedure, and daily on the first 2 days postoperatively appear to be the most cost-effective strategy.