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title: Perioperative

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# Perioperative 
# Assessment
### in non-CV surgery
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Presenter: R2林協霆
Supervisor: 王詠醫師

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## Goal: 
* characterize risk of Pt & procedure → 
* appropriate testing (ie, results will Δ management) and interventions 
    * ie, reasonable probability of ↓ risk of MACE

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## REVISED CARDIAC RISK INDEX (RCRI)
![](https://i.imgur.com/LDevCzF.png)

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### CARDIAC RISK ASSOCIATED WITH SURGERY
![](https://i.imgur.com/BMTyFTQ.png)


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![](https://i.imgur.com/nM0QN77.png)

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![](https://i.imgur.com/crRQMoy.png)

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## Additional preoperative testing 
### (Circ 2014;130:e278)
* ECG if known cardiac disease and possibly reasonable in all, 
    * except if low-risk surgery
* TTE if any of following & prior TTE >12 month ago or prior to Δ in sx: 
    * dyspnea of unknown origin; 
    * hx of HF w/ ↑ dyspnea; 
    * suspect (eg, murmur) or known ≥ moderate valvular disease

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## Coronary artery disease
* If possible, wait ~60 day after MI in the absence of revascularization before elective surgery
* Coronary revasc guided by standard indications. 
    * Has not been shown to Δ risk of death or postop MI when done prior to elective vasc. surgery (NEJM 2004;351:2795).

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## Heart failure (JACC 2014;64:e77)
* Decompensated HF should be optimally treated prior to elective surgery
* 30-d CV event rate: 
    * symptomatic HF > asx HFrEF > asx HFpEF > no HF

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## Valvular heart disease
* If meet criteria for valve intervention, do so before elective surgery (postpone if necessary)
* If severe valve disease and surgery urgent, intra- & postoperative hemodynamic monitoring reasonable (espec for AS, because at ↑ risk even if sx not severe; be careful to maintain preload, avoid hypotension, and watch for atrial fibrillation)

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## Cardiac implantable electronic devices
* Discuss w/ surgical team need for device (eg, complete heart block) & consequences if interference w/ fxn, and likelihood of electromagnetic interference
* Consider reprogramming, magnet use, etc. as needed

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# Pre- & perioperative pharmacologic management

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### Anticoagulants
![](https://i.imgur.com/UY4eN5W.png)

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### Wafarin
![](https://i.imgur.com/uLAEuJd.png)

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### Antiplates
![](https://i.imgur.com/RQSbrZr.png)

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### Aspirin
![](https://i.imgur.com/MthLLJB.png)
* continue in Pts w/ existing indication. 
* Initiation prior to surgery does not ↓ 30-d ischemic events and ↑ bleeding (NEJM 2014;370:1494), but Pts w/ recent stents excluded.
* Hold 5-7 d: Neurosurgery, prostate, posterior eye chamber procedures


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### DAPT
![](https://i.imgur.com/RiJ10pN.png)

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### POST-PCI SURGERY AND DUAL ANTIPLATELET THERAPY
* ==Post-PTCA==: wait 2-4 weeks (then operate under ASA)
* ==Post-BMS==: dual antiplatelet therapy for a minimum of 2-4 weeks (then operate under ASA)
    * Discontinue Clopidogrel 5-7 days preoperatively
* ==Post-DES==: dual antiplatelet therapy for a strict minimum of 3 to 6 months with new generation stents 
    * consider bridging with IV tirofiban / eptifibatide / cangrelor if surgery required before this time then operate under ASA

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## β-blockers (JAMA 2015;313:2486)
* Continue βB in Pts on them chronically. Do not stop βB abruptly postop (may cause reflex sympathetic activation). Use IV if Pt unable to take PO.
* Reasonable to initiate if intermed- or high-risk ⊕ stress test, or RCRI ≥3, espec if vasc surgery. 
* Initiate ≥1 wk prior to surgery (not day of), use low-dose, shortacting βB, and titrate to achieve HR and BP goal (?HR ~55–65). Avoid bradycardia and HoTN.


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## High risk of thomboembolism
![](https://i.imgur.com/EKG6zOQ.png)


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## Moderate to low risk of thomboembolism
![](https://i.imgur.com/Z5UQeKQ.png)