The
goal of preoperative evaluation is to serve the patient,
anesthesiologist, and surgeon so that the patient has the best chance of
going through surgery safely and successfully. The agenda of what to do
during preop eval is different enough from the agenda of acute care,
chronic disease management, and health maintenance that it bears
discussion of what that agenda should be. I suggest there are four
activities which serve the patient and surgical team:
- report medical issues,
- optimize medical issues,
- consider cardiac status, and
- suggest/implement perioperative interventions
1)
Report medical issues. As primary care physician or hospitalist, you
know medicine and you know the patient. You are in the best position to
explore, uncover, clarify, and then report all the information that the
surgical team needs to know about the patient. Get a complete and
accurate PMHx, PSHx, Allergy list with reactions, Med list, Social Hx,
etc., and report them to the surgical team. Old paper charts and new
EMR’s alike are often filled with outdated or vague information and may
be missing information. Now is the time to clean it all up, interpret
what is known of the patient’s conditions and background, and report it
clearly to the surgical team.
2) Optimize medical issues. Now that
you know the patient’s medical issues from step 1, if you find
conditions under poor control, optimize them. If an asthmatic ran out of
their inhaled steroid months ago and has uncontrolled asthma, don‘t
send the patient to surgery. Get the asthma under better control and
then head to the challenges of surgery. Same goes for uncontrolled
hypertension or heart failure or renal insufficiency which aren't at
their best. Get them to their best. Trivial problems don’t need to be
optimized, just the big ones which might impact ability to endure
surgery and recovery. And some problems are bad but cannot be further
optimized, and that’s ok. Improve the ones which can be optimized. Part
of this step 2 is to look for conditions which need to be optimized via
preop testing. A large section of this app addresses preop testing.
3)
Consider cardiac status. The biggest non-surgical complication during
and after surgery is myocardial infarction. Thus an entire activity of
preop eval is to consider the readiness of the heart to endure the
challenges of surgery. The American College of Cardiology has
promulgated a stepwise cardiac evaluation algorithm in each of its
guidelines starting in 1997, 2002, 2007, and now 2014. Each time the
algorithm gets a bit easier as evidence clarifies what makes a
difference for patients doing well or poorly. The algorithm is built
into this app as a decision tree.
4) Suggest/implement
perioperative interventions. There are a variety of acute perioperative
measures which might help the patient get through surgery, such as
quitting smoking or getting a Foley catheter out early. But this fourth
activity is mainly about medications to be started, adjusted, or stopped
around the time of surgery. Medicines which promote surgical bleeding
like anticoagulant and antiplatelet agents are first among those with
recommendations for periop mgmt. Then there are diabetic meds to be
adjusted while patients eat little to nothing before and for a time
after surgery. Then there are blood pressure meds and psych meds which
warrant attention. The ICSI guideline gives a good general rule of
thumb: continue meds which contribute to a patient’s homeostasis
(stability of physiology and medical conditions) and withhold meds which
do not.