Preoperative Assessment Clinic

Question 1

Scheduling High-Risk patients

Answer 1

PAC triage Nurse
Surgeon

Question 2

Low risk

Answer 2

Triage nurse performs

Comprehensive History Review
Medication Reconciliation/Instructions
Pharmacy Consult for High-Risk meds
(e.g. blood thinners)
Pre-op Instructions given
& sent via mail or electronically
Documents a progress note summary

Question 3

High risk

Answer 3

Surgeon perform

Comprehensive History Review
Medication Reconciliation/Instructions (by pharmacy)
APP/Anesthesiology Review

Pre-op Instructions given
& sent via mail or electronically
Documents Anesthesia Pre-op Note

Question 4

limitations for telehealth visits

Answer 4

Poor Physical Exam
Labs/Studies must be done elsewhere

Question 5

Purpose of PAC

Answer 5

Identifies areas for optimization
Alerts us to the need for additional resources
Better communicate the risks to the patient

Question 6

Cardiac reason for surgical delay: Unstable coronary syndromes

Answer 6

Unstable coronary syndromes:
CCS III/IV (Angina/symptoms with everyday living, moderate limitation or worse)

Question 7

Cardiac reason for surgical delay: Significant arrythmia

Answer 7

Mobitz II AV block
3rd degree block
Symptomatic or newly recognized ventricular arrythmia
Afib + SVR with HR>100 at rest
Symptomatic bradycardia

Question 8

Cardiac reasons for surgical delay: Severe Valvular disease

Answer 8

If adults meet standard indication for valvular intervention, intervention before elective surgery is effective in reducing perioperative risk. (LOE C)
Severe AS (Mean gradient >40 mmHg, aortic valve area <1 cm2, or symptomatic)

Question 9

Cardiac reasons for surgical delay: recent myocardial infarction

Answer 9

≤ 60 days (in the absence of a coronary intervention) for non-elective procedures (ACC/AHA 2014)
≤ 6 months for completely elective procedures (ACC/AHA 2014)

Question 10

Cardiac reasons for surgical delay (5)

Answer 10

unstable coronary syndromes
Decompensated heart failure
Significant arrythmia
Severe valvular disease
Recent myocardial infarction

Question 11

Post operative MI rate

Answer 11

0-30 days = 32.8%
31-60 days = 18.7%
61-90 days = 8.4%
91-180 days = 5.9%

Question 12

30 Day mortality rates

Answer 12

0-30 days = 14.2%
31-60 days = 11.5%
61-90 days = 10.5%
91-180 days = 9.9%

Question 13

4 C’s for cardiac risk

Answer 13

CVA, CAD, CKD, CHF

Question 14

RCRI: Hx of Ischemic Heart Disease

Answer 14

Hx of MI
(+) stress test
current angina
use of nitrates
ECG w/ Q waves

Question 15

RCRI: Hx of CHF

Answer 15

Pulmonary Edema
Bilateral Rales or S3 gallop
Paroxysmal nocturnal dyspnea
CXR showing pulmonary vascular redistribution

Question 16

RCRI: Hx of cerebrovascular disease

Answer 16

TIA
Stroke (CVA)

Question 17

RCRI: creatinine

Answer 17

> 2mg/gL (CKD)

Question 18

RCRI DM

Answer 18

diabetic on insulin

Question 19

RCRI: high risk surgery

Answer 19

intraperitoneal
intrathoracic
suprainquinal vascular

Question 20

Total Risk score

Answer 20

0 = 0.4%
1 = 0.9%
2 = 6.6%
3+ = at least 11% risk