Pre-Op Primary Care

PRE-OP Primary Care

1. What patients need this? Basically anyone high risk, so anyone over >65 yo. Cardiac events #1 case of post-op mortality. 

2. What Calculators can we use for Mortality risk? (Check them on MD Calc) 

   1. 1. Preoperative Mortality Predictor Score

      2. Revised Cardiac Risk Index (RCRI)

      3. Gupta Perioperative Risk (Depending on who you work with this I've heard is less validated.

3. What Calculators can we use for Functional Capacity? 

   1. 1. Duke Activity Status Index (DASI)

4. General testing:

   1. 1. CBC if >65 or anyone with potential significant blood loss

      2. BUN/Cr (>2 RCRI) or patients >50 yo with elevated surgical risk

      3. Pregnancy testing for reporductive age women. 

      4. EKG: Reasonable with known CAD,arrhythmia, PAD, cerebrovasc dz unless low risk surgery

      5. CXR: If hx of cardiopulmonary disease and >50yo undergoing major surgery, particularly upper abd or thoracic surgery or obese (BMI >40). 

      6. Typically lytes, coags, LFT's, PFT's not generally recommended. 

5. Tobacco: QUIT 4-8 weeks prior to surgery. Lower risk of respiratory complications, improved wound healing. (Less than 2 weeks does not improve outcomes, though should still recommend quitting anytime). 

6. Continuing medications? 

   1. 1. B-Blocker: In general Continue, dont's start within 1 day of surgery. 

      2. Statins: Continue preop, and post-op. 

      3. ACE/ARB: Continue, though be careful in CHF. Reasonable to hold day of surgery due to risk intra-operative hypotension. 

      4. CCB: Continue

      5. Diuretics: HOLD at least day of surgery (consider 24-72 hours)

      6. ASA: HOLD 7-10 days in low risk patients. Continue in pts with stents or taking for secondary prevention. 

      7. Coumadin: HOLD 3-7 days before surgery in low risk patients. 

      8. DOAC's: HOLD 48-72 hours before in low risk patients (those WITHOUT A-fib without valve disease)

      9. Clopidogrel: HOLD 5 days prior

      10.  NSAIDS: HOLD 3 days prior (24 hours prior if Ibuprofen OK) 

      11. Estrogens: consider HOLD 2-6 wks prior

      12. H2 Blocker and PPI: Continue

      13. Bisphosphonates: HOLD AM of surgery (risk esophagitis supine)

      14. PDE-5: HOLD 3 days prior to surgery

      15. DIABETES Meds

          1. Metformin: HOLD 24-72 hrs prior

          2. Sulfonylureas, Pioglitazone, and DPP-4 inhibitors (Januvia): HOLD the AM of surgery

          3. SGLT-2 (Jardiance): HOLD at least 3 days before surgery

          4. GLP-1 agonist: HOLD Morning of surgery

          5. Lantus: Dose 60-80% usual dose the evening before surgery

      16. Supplements? 

          1. Fish oil: HOLD as inhibits platelets

          2. Herbals "G's": HOLD as inhibits platelets

             1. Garlic

             2. Ginkgo

             3. Ginseng

             4. Ginger

7. Last minute tips:

   1. Avoid phrase "cleared for surgery". Instead say "medically optimized for surgery." 

All credit goes to Dr. Roberts for presentation. Tried to distill some key points to bullets above. 

• Brad, NOV 27, 2022.