Determine clinical risk factors which may influence perioperative
management and proceed to surgery with appropriate monitoring and
management strategies based on the clinical assessment.
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If one
cannot do optimal preoperative evaluation as a patient departs for
emergency surgery, the 2007 ACC guideline reminds one to do risk
stratification and risk factor management postoperatively.
An emergency procedure is one in which life or limb is threatened if not in the operating room
where there is time for no or very limited or minimal clinical
evaluation, typically within <6 hours.
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An urgent procedure is one in which there may be time for a limited clinical evaluation,
usually when life or limb is threatened if not in the operating room,
typically between 6 and 24 hours.
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A time-sensitive procedure is one in which a delay of >1 to 6 weeks to allow for an evaluation
and significant changes in management will negatively affect outcome
(e.g. most oncologic procedures).
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An elective procedure is one in which the procedure could be delayed for up to 1 year.
ACC
notes that patient with CHF and history of CHF are at elevated risk for
poorer perioperative outcomes. Recognition of clinically evident CHF is
important. However, it is not yet clear whether assessment for
asymptomatic LV dysfunction leads to benefit for perioperative outcomes.
Significant valvular disease increases cardiac risk for surgical patients. ACC makes following recommendations:
–
echo for pts with clinically suspected moderate or greater valvular
stenosis or regurg if there has been (1) no prior echo within 1 year,
or (2) significant change in clinical status or physical exam since last
eval (I. C)
–
valvular disease interventions (replacement and
repair) based on standard indications improves perioperative risk when
performed before non-cardiac surgery (I, C)
–
appropriate
intraoperative and postop hemodynamic monitoring makes non-cardiac
surgery reasonable on those with asymptomatic severe aortic stenosis
(Ila, B), asymptomatic mitral stenosis when percutaneous mitral balloon
commissurotomy is not possible (llb, C), asymptomatic mitral regurg
(Ila, C). and asymptomatic aortic regurg and a normal LVEF (Ila, C).
Arrhythmias are common, and although they do not confer as much
risk as previously thought, they should prompt attention to management,
stability, and any underlying disorder.
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A-fib that is clinically stable does not require special management aside from considerations of periop anticoagulation.
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Ventricular arrhythmias, whether single PVC’s or nonsustained V-tach,
usually do not require therapy unless they result in hemodynamic
compromise or are associated with significant structural heart disease
or inherited electrical disorders.
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Although frequent PVC’s and
nonsustained V-tach are risk factors for the development of
intraoperative and postoperative arrhythmias, they are not associated
with an increased risk of nonfatal Ml or cardiac death in the
perioperative period. However, patients who develop sustained or
nonsustained V-tach during the perioperative period. However, patients
who develop sustained or nonsustained V-tach during the perioperative
period may require referral to a cardiologist for further evaluation,
including assessment of their ventricular function and screening for
CAD.
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High-grade conduction abnormalities, such as complete AV
block, if unanticipated, may increase operative risk and necessitate
temporary or permanent transvenous pacing. However, patients with
intraventricular conduction delays, even in the presence of a left or
right bundle-branch block, and no history of advanced heart block or
symptoms, rarely progress to complete AV block preoperatively. The
presence of some pre-existing conduction disorders, such as sinus node
dysfunction and AV block, requires caution if perioperative beta-blocker
therapy is being considered. Isolated bundle-branch block and
bifascicular block generally do not contraindicate use of beta blockers.
