Preoperative care

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Preoperative care is defined as "Care given during the period prior to undergoing surgery when psychological and physical preparations are made according to the special needs of the individual patient. This period spans the time between admission to the hospital to the time the surgery begins."[1]

Components of preoperative care

Cardiac risk reduction

Guidelines[2] by the American College of Cardiology (ACC) and American Heart Association (AHA) recommend (as summarized by Journal Watch:[3]

  • "Patients scheduled for low-risk noncardiac surgery should proceed to surgery."
  • "Patients with good functional capacity should proceed to surgery."
  • "Patients with poor or unknown functional capacity who are scheduled for non-low-risk surgery should be stratified according to the Revised Cardiac Risk Index[4] (Journal Watch Sep 17 1999). Patients with no risk factors should proceed to surgery. For those with one or more risk factors, clinicians are given the option of proceeding with surgery or performing noninvasive stress testing; the decision should be influenced by the type of noncardiac surgery (vascular vs. other), and by whether the clinician believes that noninvasive testing "will change management."
  • "For patients with risk factors, clinicians should consider perioperative ß-blockade."
  • "The algorithm does not apply to patients who require emergency noncardiac surgery, or to patients with active cardiac problems that mandate urgent intervention (e.g., unstable coronary syndromes, decompensated heart failure, important arrhythmias, severe valvular disease)."

Pulmonary risk reduction

Clinical practice guidelines by the American College of Physicians state:[5]

  1. "All patients undergoing noncardiothoracic surgery should be evaluated for the presence of the following significant risk factors for postoperative pulmonary complications in order to receive pre- and postoperative interventions to reduce pulmonary risk: chronic obstructive pulmonary disease, age older than 60 years, American Society of Anesthesiologists (ASA) class of II or greater, functionally dependent, and congestive heart failure."
  2. "Patients undergoing the following procedures are at higher risk for postoperative pulmonary complications and should be evaluated for other concomitant risk factors and receive pre- and postoperative interventions to reduce pulmonary complications: prolonged surgery (>3 hours), abdominal surgery, thoracic surgery, neurosurgery, head and neck surgery, vascular surgery, aortic aneurysm repair, emergency surgery, and general anesthesia."
  3. "A low serum albumin level (<35 g/L) is a powerful marker of increased risk for postoperative pulmonary complications and should be measured in all patients who are clinically suspected of having hypoalbuminemia; measurement should be considered in patients with 1 or more risk factors for perioperative pulmonary complications."
  4. "All patients who after preoperative evaluation are found to be at higher risk for postoperative pulmonary complications should receive the following postoperative procedures in order to reduce postoperative pulmonary complications: 1) deep breathing exercises or incentive spirometry and 2) selective use of a nasogastric tube (as needed for postoperative nausea or vomiting, inability to tolerate oral intake, or symptomatic abdominal distention)."
  5. "Preoperative spirometry and chest radiography should not be used routinely for predicting risk for postoperative pulmonary complications."
  6. "The following procedures should not be used solely for reducing postoperative pulmonary complication risk: 1) right-heart catheterization and 2) total parenteral nutrition or total enteral nutrition (for patients who are malnourished or have low serum albumin levels)."

For patients with asthma, more aggressive clinical practice guidelines by the U.S. National Asthma Education and Prevention Program recommend:[6]

  • "Patients who have asthma should have an evaluation before surgery that includes a review of symptoms, medication use (particularly the use of oral systemic corticosteroids for longer than 2 weeks in the past 6 months), and measurement of pulmonary function".
  • "If possible, attempts should be made to improve lung function preoperatively (FEV1 or peak expiratory flow rate [PEFR]) to either their predicted values or their personal best level. A short course of oral systemic corticosteroids may be necessary to optimize lung function".

Smoking cessation may reduce pulmonary complications according to the results of a randomized controlled trial.[7]

Incentive spirometry does not clearly help reduce pulmonary complications during the perioperative care after coronary artery bypass grafting according to a meta-analysis of randomized controlled trials by the Cochrane Collaboration. [8]

Benefits of preoperative medical consultation

The benefits of consultation are not clear in an observational study.[9]

References

  1. ↑ National Library of Medicine. Preoperative care. Retrieved on 2007-11-21.
  2. ↑ Fleisher LA, Beckman JA, Brown KA, et al (2007). "ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery". Circulation 116 (17): 1971–1996. DOI:10.1161/CIRCULATIONAHA.107.185700. PMID 17901356. Research Blogging.
  3. ↑ Brett AS (2007-11-20). Guidelines for Perioperative Cardiovascular Evaluation for Patients Considering Noncardiac Surgery. Retrieved on 2007-11-21.
  4. ↑ Lee TH, Marcantonio ER, Mangione CM, et al (1999). "Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery". Circulation 100 (10): 1043–9. PMID 10477528. [e]
  5. ↑ Qaseem A, Snow V, Fitterman N, et al (2006). "Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians". Ann. Intern. Med. 144 (8): 575–80. PMID 16618955. [e]
  6. ↑ NHLBI, Diagnosis and Management of Asthma. National Heart, Lung, Blood Institute. Retrieved on 2008-01-24.
  7. ↑ Møller AM, Villebro N, Pedersen T, Tønnesen H (2002). "Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial". Lancet 359 (9301): 114–7. PMID 11809253. [e]
  8. ↑ Freitas ER, Soares BG, Cardoso JR, Atallah AN (2007). "Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft". Cochrane Database Syst Rev (3): CD004466. DOI:10.1002/14651858.CD004466.pub2. PMID 17636760. Research Blogging.
  9. ↑ Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli J (2007). "Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery". Arch. Intern. Med. 167 (21): 2338–44. DOI:10.1001/archinte.167.21.2338. PMID 18039993. Research Blogging.

See also

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