risk assessment in noncardiac surgery

Risk assessment in noncardiac surgery

Lee’s Revised cardiac risk index

High risk surgery h/o IHD h/o CHF h/o CVA Preop insulin tmt Creat >2

Some include age also.

Zero- low

One or two –intermediate

Three or more- high

Risk of surgery

Aortic, major vascular, peri. vascular- high

Intraperitoneal,intrathoracic, carotid endarterectomy, head&neck, orthopedic, prostate- intermediate

Endoscopy, superficial, cataract, breast, ambulatory- low.

Step 1

Emergency Sx

Op.room Periop surveillance, postop risk stratification & mmt.

Step 2

Elective

yes

Active cardiac conditions

Evaluate & treat, consider OR

Active cardiac conditions Acute MI / Recent MI Unstable angina,

recent MI Decompensated HF Significant

arrhythmias

Severe valve d/s- severe AS, severe MS

High grade AV blockSymtomatic ventricular ASVT HR > 100Symptomatic brady

Step 3

No ACC

Low risksurgery Proceed with sx

Step 4

Intermediate or high risk

Functional capacity > 4 mets without symptoms

yes

proceed

Functional capacity

1 met: taking care of self, eat, dress, use toilet, indoor walking.

4 met: light work, climb a flight of stairs, golf, dancing.

>10 met: strenuous sports.

Step 5

No or unsure of functional capacity

No clinical risk factors

proceed

Step 5

No clinical risk factors Proceed with planned surgery

1 or 2 RF(vascular / intermediate risk sx)

Proceed with HR control or consider noninvasive testing If it will change mmt.

Step 5

3 or more RF intermediate

Proceed with HR control or noninvasive testing If it will change mmt.

High

Testing if it change mmt

Management changes

Cancellation of sx for prohibitive risk

Delay of sx for further medical mmt.

Coronary interventions before sx.

Use of ICU.

Changes in monitoring.

Noninvasive testing

Exercise ECG

Phamacologic stress imaging

Stress echocardiography

Role of MRI, multislice CT, coronary calcium scores, PET is rapidly evolving.

IHD

ACS & decompensated HF of ischaemic origin high risk of periprocedural further worsening.

Highest risk cohort: within 30 days of

MI.

SHTN

Htve crisis postop: DBP>120 and end organ damage- papilloedema, myocardial ischaemia, ARF.

Withdrawal of antiHTve tmt may ppt.

SHTN

SX need not be postponed in uncomplicated mild to moderate HTN.

Severe HTN DBP >110, benefits of delaying sx Vs risk of delaying sx. IV drugs may be used.

HF

Assessment help to adjust periop fluid & vasopressor mmt.

HOCM: thought to be high risk, but major sx under GA– low risk. Relative C.I for SA

Valvular HD

Aortic systolic murmurs require full eva’n. MV d/s less risk. Prosthetic heart valve: I.E. pxis. Stop Oral AntiCoagulants 5 days prior, INR < 1.5, restart pop day 1. Conversion to heparin periop period. LMWH cost effective, residual anticoagulant effect in two

thirds.

Prosthetic valve- AHA/ACC guidelines

Heparin in only•Mechanical MV/TV.•Mechanical AV with AF Prev. thromboembolism Hypercoagulable state Older gen. valve EF < 30% > 1 mech. valve

Cong. HD in adults

Presence of PHT & Eisenmenger

Avoid regional anasthesia, sympathetic blockade , worsening R to L shunt.

Preop coronary revasc

Class 1 1. Stable angina with LMCA d/s. 2. SA with TVD esp. if EF < 50 3. SA, DVD with prox. LAD d/s &

either EF < 50% or demonstrable

ischaemia 4. High risk UA or NSTEMI 5. Acute STEMI

Sx in prior revasc

CABG in last 5 yrs- sent for sx without delay

Bare Metal Stent- minimum of 6 wks, optimum of 3 mths.

Drug Eluting Stent- one yr.

Balloon Angioplasty- 2 wks

Previous PCI

Balloon Angioplasty < 14 days- delay for elective sx.

> 14 days- proceed with asp.

Previous PCI

BMS

>30-45 days : proceed with asp. < 30-45 days : delay sx

Previous PCI

DES

< 1 yr : delay sx

> 1 yr : proceed with asp.

Beta blockers

Continuation of BB : class 1

Use of BB titrated to HR & BP : class 11-A in Vascular sx with CAD Ishaemia on preop testing.

Routine high dose BB without dose titration maybe harmful.