Assess functional status

  Standard metabolic equivalent (MET): unit used to estimate the amount of oxygen used by the body during physical activity

  1 MET: energy used at rest

  4 METs (classically associated with readiness to undergo stress of surgery): ability to climb a flight of stairs, vacuum, light housework

  Identify areas for further testing (see below)

  Social history

  Tobacco: associated with postoperative pulmonary complications and reactive airways

  EtOH: impaired liver function, risk of withdrawal

  Identify risk factors for perioperative complications (e.g., delirium, renal failure)

Testing

  Driven by findings on history and physical and type of surgery

  Routine testing generally not indicated; indications for the following:

  Labs

  Hemoglobin/Hematocrit: anemia; anticipated blood loss; premature infants

  Platelets: personal/family history of bleeding diathesis; liver disease

  Electrolytes: renal dysfunction, taking medications which affect Na⁺/K⁺ (antihypertensives/diuretics)

  Coagulation factors: patient taking anticoagulants; liver disease

  Transaminases: cirrhosis

  βHCG: controversial and institution specific—consider for all women of childbearing age

  Arterial blood gas: patient mechanically ventilated prior to surgery

  Type/Crossmatch: anticipated blood loss >500 cc

  Electrocardiogram: age > 60 years; major vascular surgery with at least one clinical risk factor (see ACC/AHA guidelines below) of any age; intermediate risk surgery with known coronary artery disease (CAD), peripheral vascular disease, or cerebrovascular disease; consider for patients undergoing major vascular disease with no risk factors

  Chest x-ray: cardiopulmonary disease; age > 50 years undergoing abdominal aortic aneurysm or upper abdominal/thoracic surgery

  C-spine films: Trisomy 21; rheumatoid arthritis with clinical signs; trauma

  PFTs: see below

  Echocardiography: age > 50 years with new murmur (r/o aortic stenosis (AS)); assessment of known/suspected heart failure; known AS with prior echo >12 months

Evaluation of the Cardiac Patient for Noncardiac Surgery

  ACC/AHA guidelines

  High risk surgery: major vascular

  Intermediate risk surgery: Intraperitoneal and intrathoracic surgery, carotid endarterectomy, head and neck surgery, orthopedic surgery, prostate surgery

  Low-risk surgery: endoscopic procedures, superficial procedure, cataract surgery, breast surgery, ambulatory surgery

  Active cardiac conditions: unstable coronary syndromes, decompensated heart failure, severe valvulopathy, significant arrhythmia

  Lee Revised Cardiac Risk Index

  Six independent risk factors for major postoperative complications

Related posts:

23. Point-of-Care Ultrasound in the ICU 31. ICU Administration 32. Ethics and Palliative Medicine 21. Pediatric Emergencies 15. Fluids and Electrolytes 16. Nutrition

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