pre-op evaluation - internal medicine | acp · pre-op evaluation medication ... take for her knee...

Pre-Op Evaluation

AL-ACP May 31, 2013 Eddie Mathews, MD University of AL Birmingham Hospitalist, Assistant Professor [email protected]

Pre-Op Evaluation

Medication Management and Adrenal Insufficiency Anticoagulation Orthopedics Pulmonary Cardiovascular

Med Management and AI • Majority of all patients undergoing surgery take

medication regularly – Important to give patients guidance on which medications they

should continue and which they should hold – Risk-benefit analysis should be done on each medication to

determine a perioperative plan • Adrenal Insufficiency can be a major cause of

perioperative morbidity if not recognized – Surgical stress is a powerful stimulator of the HPA axis – An inadequate corticosteroid response can result in:

hypotension, electrolyte abnormalities, poor rehab with delayed recovery, and prolonged hospitalization

Med Management and AI

65 yo FM scheduled to have orthopedic surgery in 1 week. Hx of HTN, HLD, and DM. Meds – Metoprolol, HCTZ, Gemfibrozil, and Glipizide. How should her meds be managed perioperatively?

A) Stop all medications morning of surgery B) Take all medications morning of surgery C) Take metoprolol morning of surgery and hold others D) Take metoprolol + gemfibrozil, hold HCTZ + glipizide


C) Take metoprolol and hold others • Betablockers have been shown to reduce myocardial

ischemia and perioperative myocardial infarctions. All patients currently taking them should continue them perioperatively to prevent rebound ischemia, HTN, and increased mortality

• Diuretics are typically held the morning of surgery to limit risk of hypovolemia/hypotension

• Niacine + fibrates held prior to surgery to limit risk of myopathy/rhabdomyolysis

• Sulfonylureas held morning of surgery to prevent hypoglycemia


Our same patient wants to know what she can take for her knee pain up until 24hrs preop.

A) Ibuprofen B) Aspirin C) Naproxen D) Meloxicam


A) Ibuprofen • NSAIDS antiplatelet effects are reversible and the

duration of their effect is dependent on their elimination ½ life

• Ibuprofen has a short elimination ½ life (2hrs) and can be taken up until 24hrs preop

• Naproxen (14hrs/3days) and Meloxicam (20hrs/5days) have longer elimination ½ lives

• Aspirin irreversibly inactivates cyclooxygenase for the life of the platelet, therefore it must be held for 7-10 days to restore normal platelet function


Just prior to leaving her preop appointment she remembers she also takes Ginkgo and asks if she can continue.

A) Yes, herbal medications have little to no periop risk and are safe to continue

B) Stop the Ginkgo 1-2 days before surgery C) Stop the Ginkgo 1-2 weeks before surgery D) Stop the Ginkgo now and start taking St.

John’s wort to prevent withdrawal


C) Stop the Ginkgo 1-2 weeks before surgery • Many patients take herbal medications, but they rarely

inform their physicians about them. It is important to inquire specifically about herbal medications when doing a preop evaluation.

• Ginkgo, along with several other herbal medications, may increase bleeding risk

• St. John’s wort induces cytochrome P450 and decreases the effectiveness of many drugs

• Recommended that all herbal medications be discontinued 1-2 weeks before surgery

Med Management and AI 4 patients are in preop holding awaiting their surgeries

today. Which 1 of these 4 is most at risk for developing postop complications from AI?

A) 65yo with COPD who takes prednisone 10mg daily having cataract surgery

B) 35yo who finished medrol dose pack 5d ago for an URI having abdominal hysterectomy

C) 79yo with PMR who takes prednisone 4mg daily having a cholecystectomy

D) 55yo with COPD currently on no steroids but he just finished his 4th standard prednisone taper in the last 3 months having prostate surgery


D) 55yo with COPD and multiple recent prednisone tapers having prostate surgery

• Patients taking equivalent of at least 5mg of prednisone daily for > 3 weeks in the previous year are at risk for AI

• Patients going for minor surgery do not need additional steroids

• Patients on continuous dose of <5mg of prednisone daily or who have received any steroids for < 3 weeks are low risk


Our 55yo with COPD should have been treated with what to decrease the risk of AI?

A) Hydrocortisone 100mg IV the night prior to surgery and at anesthesia induction, followed by 50mg IV q12 x 1 day

B) Hydrocortisone 50mg IV at induction, followed by 25mg iv q8 for 24hrs, then prednisone 10mg daily x 3days

C) Hydrocortisone 50mg IV at induction, then prednisone 10mg daily x 7 days

D) Dexamethasone 4mg IV at induction, then 2mg po daily x 7 days


B) Hydrocortisone 50mg IV at induction followed by 25mg IV q8 x 24-48hrs, then prednisone 10mg daily x 3 days

• Correct regiment for moderate surgical stress • Severe surgical stress – double doses of

hydrocortisone and start with prednisone 20mg x 3 days then 10mg x 3 days

• Dexamethasone does not have mineralocorticoid activity and should not be used


• Take a good medication history (including herbal medications) when doing a preop evaluation.

• Develop a perioperative medication plan with the patient based on a risk-benefit analysis

• Patients on or frequently treated with steroids should be screened for the risk of AI perioperatively and treated appropriately

Anticoagulation

• Many patients undergoing surgery are on some form of anticoagulation

• The risk of perioperative bleeding must be weighed with the risk of thromboembolism

• The indication for anticoagulation and the type of surgical procedure usually guide the perioperative managment

Anticoagulation

76yo M has a hx of HTN, DM, and Afib. He is scheduled for a craniotomy in 2 weeks. He takes warfarin for his Afib. Does he need preop bridging with enoxaparin?

A) No, CHADS2=2, safe to stop warfarin B) Yes, CHADS2=2, needs preop bridging C) No, bridging before craniotomy is too

dangerous D) Yes, CHADS2=3, needs preop bridging

Anticoagulation

D) Yes, CHADS2=3, needs preop bridging • Perioperative bridging of anticoagulation for

Afib recommended if CHADS2 ≥ 2 • Rates of thromboembolism secondary to Afib

are increased during 30day perioperative period

• Preoperative bridging regiments are not effected by surgical bleeding risk

Anticoagulation

His procedure goes well and there are no unexpected bleeding concerns postop. How should his anticoagulation be managed now?

A) 12-24hrs postop resume full dose enoxaparin and warfarin

B) 12-24hrs postop start low dose enoxaparin, @72hrs increase to full dose and resume warfarin

C) 72hrs postop resume full dose enoxaparin and warfarin

D) 12-24hrs postop resume warfarin

Anticoagulation

B) low dose enoxaparin followed by full dose with resumption of warfarin

• Following a high bleeding risk surgery initial anticoagulation is with low dose LMWH

• At 72hrs increase to full dose LMWH or depending on bleeding risk can use UFH infusion without a bolus

• Warfarin is resumed when starting full dose LMWH or when felt to be clinically appropriate

Anticoagulation

The following 4 patients have mechanical valves. Put them in order from highest risk for thromboembolism to lowest.

A) 55yo, bileaflet aortic valve placed 2yrs ago B) 77yo, caged-ball mitral valve placed 20yrs ago C) 60yo, tilting disk mitral valve placed 15yrs ago D) 45yo, bileaflet aortic valve placed 6m ago B-> C-> D-> A

Anticoagulation

• Type of valve – Caged-ball (5x) > tilting disk (1.5x) > bileaflet

• Position of valve – Mitral (2x) > aortic

• When placed – <3 months – high risk <1 year – mod risk

• Other factors: age, Afib, previous ATE, LV dysfunction, L atrial enlargement

Anticoagulation

75yo found to have a brain mass. NSG to operate in 7days. Request assistance re: anticoagulation because…2m ago a drug-eluting coronary stent was placed and the patient is taking aspirin & clopidogrel.

A) D/C both immediately and start full dose enoxaparin until 24hrs before surgery

B) Continue both until the day before surgery C) D/C both immediately and start a glycoprotein

IIb/IIIa inhibitor until surgery D) D/C both immediately, no other treatment

Anticoagulation

C. Use a glycoprotein IIb/IIIa inhibitor • After placement of a DES patients must remain on

dual antiplatelet treatment x 1yr • BMS - can stop dual antiplatelet treatment after 6

weeks (continue aspirin) • Bridging after stent placement to replace dual

antiplatelet treatment is with a IIb/IIIa inhibitor (heparin does not inhibit platelet aggregation)

Anticoagulation

• Perioperative bridging is needed for Afib if CHADS2 ≥ 2

• Caged-ball mitral valves are high risk for thromboembolism

• If bridging is indicated to replace dual antiplatelet treatment for stents use a IIb/IIIa inhibitor

Orthopedics

• Hospitalist co-management shown to decrease time to consultation, time to surgery, length of stay and cost

• Orthopedic patients have increased risk of VTE when compared to most other surgical patients

Orthopedics

70yo admitted overnight with a hip fracture. His surgery has been delayed until tomorrow. He is not on any anticoagulation. You now decide to order…

A) Nothing B) Intermittent pneumatic compression devices to

start now C) Physical therapy to get him out of bed D) Low dose enoxaparin to start now with plan to

hold 12hrs before surgery and resume 12hrs after

Orthopedics

D. Low dose enoxaparin to start now • VTE prophylaxis should be initiated on admit if

surgery is expected to occur in >12hrs • Risk of VTE starts at time of injury with trauma

and immobility rather than at time of surgery • Mechanical VTE prophylaxis is useful when

anticoagulation is contraindicated but has not been shown to be as effective

Orthopedics

12hrs after surgery enoxaparin is restarted. On postop day 3 our patient is discharged to rehab. VTE prophylaxis should now consist of:

A) Enoxaparin 40mg daily x 28d from surgery B) No meds, but early aggressive physical

therapy C) Enoxaparin 40mg daily x 10d from surgery D) Enoxaparin 40mg daily until ambulatory

Orthopedics

A. Enoxaparin x 28 days from surgery • Extending prophylaxis from 7d to 28d

decreased VTE rate from 35% to 1.5% • 2008 ACCP guidelines recommend that

prophylaxis be extended beyond 10d and up to 35d after surgery for hip fracture patients

Orthopedics

After he gets his last injection of enoxaparin prior to discharge the patient asks if he can take one of those new pills to prevent blood clots. You inform him…

A) The new oral drugs are not yet approved in the US for VTE prophylaxis

B) Rivaroxaban 10mg po daily is approved for VTE prophylaxis after hip surgery

C) Dabigatran 220mg po daily is approved for VTE prophylaxis after hip surgery

D) No new drugs but he can take aspirin instead

Orthopedics

B. Rivaroxaban 10mg po daily is approved • An oral direct Xa inhibitor that some research

shows is more effective than enoxaparin, however still some concerns re: bleeding

• In US, Dabigatran only approved for non-valvular afib

• Insufficient evidence to support use of aspirin over other options for VTE prophylaxis

Orthopedics

• VTE prophylaxis should be initiated on admission for acute orthopedic fractures if surgery is expected to occur in >12hrs

• Hip fracture patients should have prophylaxis extended for 28d postop

• Rivaroxaban 10mg po daily is an acceptable alternative to LMWH for prophylaxis

Pulmonary

• Perioperative pulmonary complications are equally as prevalent and contribute similarly to morbidity, mortality, and length of stay when compared to CV complications

• Include: atelectasis, acute respiratory failure, pneumonia, bronchospasm, and exacerbation of chronic lung disease

Pulmonary

70yo seen in clinic 2weeks before cholecystectomy. He still smokes and has mild COPD. Today he has no complaints and his lungs are clear. Re: his smoking you tell him…

A) The optimal time to quit smoking before surgery is at least 2m preop but he should quit now

B) Because he is doing well he can smoke up until the night before surgery

C) Quitting smoking now this close to surgery will increase his risk of pulmonary postop complications

D) Quit smoking now and change to chewing tobacco

Pulmonary

A. At least 2m preop is the optimal time to quit smoking

• Sputum production of smokers who quit return to level of nonsmokers after 2 full months of cessation

• No increase in complications in recent quitters • Anytime is a good time to quit smoking

Pulmonary

After you convince him to quit smoking what preoperative test should be ordered?

A) CXR and preoperative spirometry B) CXR only C) CXR, preoperative spirometry, and an ABG D) None

Pulmonary

B) CXR only • ACP guidelines support preop CXR for patients with

history of cardiopulmonary disease and for patients >50yo undergoing upper abdominal, thoracic, or abdominal aortic surgery

• Differences in spirometry measurements do not predict cardiopulmonary complications in noncardiothoracic surgery

• ACP guidelines recommend preop spirometry when the cause of a patient’s dyspnea is not known or there is concern that the patient’s lung disease is not optimized

Pulmonary

You check in on your patient the evening after surgery. His pain is well controlled and he is breathing comfortably on room air. What should you now order?

A) Morphine pca pump for improved pain control

B) NG tube placed to prevent vomiting C) Incentive spirometer D) Electronic cigarette

Pulmonary

C) Incentive spirometer • Among all possible postop risk reduction

strategies, lung expansion modalities are the most effective

• Routine placement of NG tubes after surgery increase the risk of atelectasis and pneumonia, recommend selective use only

Pulmonary

• Important to evaluate and address pulmonary risk prior to surgery

• Patients should quit smoking at any time • CXR are often an appropriate preop test,

however spirometry is rarely indicated • Use of an incentive spirometer is an effective

way to reduce postop pulmonary complications

Cardiovascular

• Cardiovascular complications are one of the most significant risk to patients undergoing major noncardiac surgery

• 3 elements assessed to determine perioperative cardiac risk – Patient’s history – Patient’s exercise capacity – Surgery specific risk

Cardiovascular

65yo FM hx of DM (on insulin), HTN, CVA, & CKD (creat=2.8) seen in clinic prior to knee surgery. She is able to walk up 1 flight of stairs and denies any CP/DOE history. What preop cardiac evaluation do you order?

A) None B) EKG C) EKG and cardiac stress test D) EKG and resting cardiac echo

Cardiovascular

B) EKG • EKG for all patients going for vascular surgery

or with ≥ 1 risk factor and intermed risk sg • Risk factors = Revised Cardiac Risk Index

– CAD, CHF, CVA, CKD, DM, + High Risk Sg

• ≥4 METs – no stress test needed • Echo – indicated to eval dyspnea of unknown

origin, hx of uncontrolled CHF

Cardiovascular

Her EKG is normal. Medications are lisinopril, insulin, and aspirin. BP 150/90, HR 85 Which medication should be added?

A) Amlodipine B) Atenolol C) Isosorbide Dinitrate D) None

Cardiovascular

B) Atenolol • Beta Blockers indicated for ≥2 risk factors and

intermediate risk surgery – Start weeks in advance and titrate to HR 60-65 – Concern with starting acutely because of

increased risk of CVA

• No data to support starting Ca Channel Blocker or nitrates

Cardiovascular

Which other medication should also be started? A) Aspirin/dipyridamole B) Diltiazem C) Atorvastatin D) None

Cardiovascular

C) Atorvastatin • Patients with ≥1 risk factor undergoing

intermediate risk procedure should be started on a statin (ACC/AHA guidelines)

• Best to start at least 2 weeks prior to surgery, however appears to be safe to start acutely

• No increased risk of perioperative myopathy or rhabdomyolysis

Cardiovascular

65yo hx of DM (on insulin), HTN, CVA, & CKD (creat=2.8). Her knee pain severely limits her mobility. She uses a cane to get across the room and thinks she might have walked up 2 stairs last year. What preop cardiac evaluation do you order?

A) EKG B) EKG and cardiac stress test C) EKG and cardiac arteriogram D) EKG and cardiac MRI

Cardiovascular

B) EKG and stress test • 1 MET • ‘Consider noninvasive testing if it will change

management’ – Patients with ≥1 risk factor and intermediate risk

surgery – Patient has 3 risk factors

• 10% risk of major cardiac complication

Cardiovascular

65yo hx of DM (on insulin), HTN, CVA, & CKD (creat=2.8) and severe right knee OA (essentially wheelchair bound) is admitted from ER with acute left hip fracture after a fall. What preop cardiac evaluation do you order?

A) EKG B) EKG and cardiac stress test C) EKG, cardiac stress test, and cardiac echo D) EKG and cardiac CT

Cardiovascular

A. EKG • In this acute situation cardiac stress test would

not change your management • Patient needs hip surgery for acute fracture • Add statin • Add Beta Blocker cautiously

Cardiovascular

• Patients with good physical activity levels (≥4 METs) without symptoms do not require preop cardiac stress test

• Patients with poor physical activity levels should only have a preop stress test if it will change management

• Beta Blockers should be added preop if ≥2 risk factors, however caution if adding acutely

Cardiac Evaluation and Care Algorithm

Pre-Op Evaluation

Medication Management and Adrenal Insufficiency Anticoagulation Orthopedics Pulmonary Cardiovascular

QUESTIONS?

• Eddie Mathews, MD • UAB Hospitalist • [email protected]

pre-op evaluation - internal medicine | acp · pre-op evaluation medication ... take for her knee...

Documents