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assessment
9 Juli 2016
Preanesthetic assessment (also called Preanesthesia
evaluation, Pre-anesthesia checkup (PAC)
http://www.clevelandclinicmeded.com/medicalpubs/
diseasemanagement/preventive-medicine/perioperative-
evaluation/
Patients limited in their activity from noncardiac causes, such
as severe osteoarthritis or general debility, are categorized
as having poor functional capacity, because one cannot
discern if significant cardiac conditions exist without the
benefit of a functional study (noninvasive testing).
- Postoperative pulmonary complications (PPCs) are equally
prevalent compared with cardiac complications and
contribute similarly to morbidity, mortality, and length of
postoperative hospital stay.
- Patient factors increasing the risk for PPCs include chronic
obstructive pulmonary disease, age older than 60 years,
American Society of Anesthesiologists (ASA) class II or
greater, functional dependence, and congestive heart
failure.
- Obesity and mild to moderate asthma have not been
consistently shown to predict PPCs.
- A low serum albumin level (<35 g/dL) has been found to be
a powerful predictor of PPCs, likely as a reflection of
impaired general health or immune compromise.
Surgical factors increasing PPC risk include thoracic or
abdominal surgical site (which can lead to splinting due to
pain and impaired diaphragmatic excursion); neurosurgery;
head and neck procedures; vascular procedures, especially
abdominal aortic aneurysm repair; any emergent procedures;
use of general anesthesia; and prolonged (>3 hr) procedures.
Routine pulmonary function testing and chest radiography:
- are not indicated preoperatively because they do not predict
PPCs
- the patient is symptomatic, has unexplained dyspnea, or is
undergoing lung volume reduction surgery or other
intrathoracic procedures.
Risk Index
0-5 Points: Class I 1% Complications
6-12 Points: Class II 7% Complications
13-25 Points: Class III 14% Complications
26-53 Points: Class IV 78% Complications
Revised Cardiac Risk Index
1. History of ischemic heart disease
2. History of congestive heart failure
3. History of cerebrovascular disease (stroke or transient
ischemic attack)
4. History of diabetes requiring preoperative insulin use
5. Chronic kidney disease (creatinine > 2 mg/dL)
6. Undergoing suprainguinal vascular, intraperitoneal, or
intrathoracic surgery
Compared to the original study, the revised version appears to be not only easier to
but also more accurate in clinical practice.
Major cardiac events or complications as they are referred to in both risk studies
include:
■ Myocardial infarction;
■ Pulmonary edema;
■ Ventricular fibrillation;
Routine preoperative tests for elective surgery’, NICE guideline NG45 (April 2016) ©
National Institute for Health and Care Excellence 2016. All rights reserved.
- Functional status is a reliable predictor of perioperative and
long-term cardiac events.
- Patients with reduced functional status preoperatively are at
increased risk of complications.
- Conversely, those with good functional status preoperatively
are at lower risk.
- If a patient has not had a recent exercise test before
noncardiac surgery, functional status can usually be
estimated from activities of daily living.
- Functional capacity is often expressed in terms of metabolic
equivalents (METs), where 1 MET is the resting or basal
oxygen consumption of a 40–year-old, 70-kg man.
©The European Society of Cardiology 2014. All rights reserved. For permissions please email:
journals.permissions@oup.com.
The functional status of the patient is a good predictor of both
the cardiac and overall risk of the patient for surgery and
hospitalization.
Thank You