Preoperative Evaluation

Question 1

46yo F dx w/ gallstones. Generally healthy, no chronic health problems. She is obese. Potential LETHAL surgical complication given her hx?

Answer 1

Cardiac complications

Pulmonary complications most likely seen in children and obese, but less likely to be lethal.

Question 2

52yo generally healthy F dx w/ breast cancer. Risk category of breast biopsy?

Answer 2

Low risk

Three categories: High, Moderate, Low

Low - risk of cardiac death <1%
Breast surgery, cataract, superficial derm, endoscopy

Moderate - risk of cardiac death 1-5%
Endarterectomy, head & neck surgeries, intrathoracic and intraperitoneal, orthopedic, prostate surgeries

High - risk of cardiac death >5%
Aortic or peripheral vascular surgeries

Question 3

58yo F preop H&P for thyroidectomy. She is obese, sedentary w/ T2DM and hyperlipidemia. Unable to walk two blocks w/o stopping to rest. Denies chest pain. What type of cardiac eval prior to surgery?

Answer 3

Noninvasive stress test prior to surgery

Need to look for clinical predictors of heart disease.

Major clinical predictors - requires coronary artery evaluation
(unstable coronary syndromes, decompensated HF, arrhythmias, valvular disease)

Intermediate clinical predictors - require eval of functional capacity
(mild angina, prior MI, compensated HF, DM, renal insufficiency)

This patient has DM (an intermediate clinical predictor) and poor functional capacity, and therefore stress testing is recommended.

Question 4

60yo M preop eval for elective knee replacement. He has DM, HLP, h/o MI 4 months ago. After MI, he had triple vessel bypass. What next?

Answer 4

Surgery should be deferred.

People w/ clinically important coronary artery disease should defer noncardiac procedures until 6 months after revascularization. If surgery is necessary within 6 months of revascularization, repeated eval of coronary arteries is necessary prior to surgery.

Question 5

59yo M patient is presenting for preop testing before underoging a hernia repair. He has hx of CAD and HLP, but nothing else. He had a positive stress test 4 yrs ago that was followed by angioplasty. Asx since. What type of cardiac eval is warranted prior to hernia repair?

Answer 5

No cardiac eval necessary

Asx pts w/ normal stress test in past 2 years, bypass surgery in past 5 yrs, or angioplasty in past 5 yrs are unlikely to have developed new disease.

Question 6

Preop eval on 66yo M for prostate surgery, HTN, but nothing else. Smoked half pack for 40 yrs, denies dyspnea or cough. What type of preop eval?

Answer 6

No pulmonary evaluation is necessary.

Pulmonary complications are most common in surgeries close to diaphragm.

Pre-existing respiratory disease increases the chance of bad outcomes, and smoking is a risk factor for pulmonary problems after surgery.

CXR indicated only in abnormal PE findings, or sxs of dyspnea and cough.

PFT useful in demonstrating status of asthma or COPD, but not be an effectice routine test in the absence of these symptoms.

Pulse oximetry or ABG are rarely useful in preop eval when they dont have sxs.