TIPS FOR MEDICINE CONSULT AFTERHOURS:

 

• Please respond to urgent requests promptly.  Lead by example!
• Attempt to see all consults within 4 hours. 
• PAMF patients are seen by PAMF hospitalists for medicine consults.
• Cardiology consults are seen by on call cardiology fellow.
• Discuss all consults with on call stanford ward attending
• Verbally communicate with primary team and prioritize recommendations.
• Use EPIC H&P template, assign med consult (200) to treatment team, and signout to medicine consult resident by 8 AM the following day.

 

PRE-OP CARDIAC ASSESSMENT FOR NON-CARDIAC SURGERY

(Assess: · Patient risk   · Surgery Risk   · Functional status [METS] · Stress test/beta blockade   ·Urgency of procedure )

Clinical judgment and individual patient factors should influence recommendations

 

 

STEP I: ASSESS NEED FOR FURTHER STRESS TESTING

1)If emergency surgery --> go directly to surgery

2)If non emergent surgery AND

• Low risk surgery OR
• Good functional capacity (>4 mets) without symptoms OR
• No clinical risk factors

Then “no contraindication to surgery” -->  proceed with planned surgery

 

3) If NONE OF ABOVE TRUE, assess

• Active cardiac condition                                                  àsend for stress/cath
• ≥3 clinical risk factors (RCRI) AND High Risk Surgery àsend for stress/cath

4) Otherwise “no contraindication to surgery” --> proceed with planned surgery with HR control or consider stress testing if it will change management.

 

 

STEP II:  RISK STRATIFY and DETERMINE NEED FOR BETA BLOCKADE 2,3

REVISED CARDIAC RISK INDEX (RCRI) or Clinical Risk Factors  (1 pt for each)
1) Ischemic Heart Disease (hx MI, Q’s on EKG, hx +stress test, ischemic chest pain,
use of sl NTG)
2) Congestive Heart Failure (hx CHF, pulmonary edema, PND, rales or S3, CXR c/w CHF)
3) Hx CVA/TIA
4) Diabetes treated with insulin
5) Creatinine > 2
6) High risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular procedures)

 

 

 

aMI, pulmonary edema, ventricular fibrillation, primary cardiac arrest, complete heart block
bHigher threshold to beta block and/or stress test if high functional capacity, low risk surgery
cLower threshold to beta block and/or stress test if poor functional capacity, high risk surgery, Consider stress testing if PVD or history of angina combined with poor functional status
dDobutamine stress echo PPV=14-24%, LR+ 3-6: NPV=98-100%, LR- 0-0.4
eUnclear evidence whether beta blockade beneficial when RCRI=1

Titrate beta blocker to HR 60-65. Continue through hospitalization and up to 30 days postop.   Relative contraindications are HR<60, SBP<90, PR int>250, advanced heart block, 
significant bronchospasm 

 

 

CLASSIFICATION OF PTS

                                                                               
Active Cardiac Condition                           
Recent MI A

Unstable or severe angina B

Decompensated CHF

Significant arrhythmias C

Severe valvular disease

 

Intermediate Predictors
Mild angina D
Prior MI E
Compensated or prior CHF
Diabetes
Creatinine > 2

 

Minor Predictors
Advanced Age F
Abnormal ECG G
< 4 METS
Hx of stroke
Uncontrolled hypertension H

 

 

 

CLASSIFICATION OF SURGERIES

High (cardiac event rate >5)
Emergency Procedures
Aortic/major vascular surgery
Long surgery, large fluid shifts/blood loss
Peripheral vascular surgery

 

Intermediate (cardiac event rate 1-5%)
Carotid endarterectomy
Head and neck surgery
Intraperitoneal and intrathoracic surgery
Orthopedic surgery
Prostate surgery

 

Low (cardiac event rate <1%)
Endoscopic procedures
Superficial procedure
Cataract surgery
Breast surgery

 

 

A <30 days;  Bangina walking 1-2 blocks or climbing one flight of stairs or less; Chigh-grade AV block, symptomatic ventricular arrhythmias with underlying heart disease, supraventricular arrhythmias with uncontrolled rate;  D angina with moderate exertion;  E by history or ECG;  F Undefined - ?>70; G LVH, LBBB, ST-T-wave abnormalities, rhythm other than sinus (e.g., atrial fibrillation);  H DBP >110

 

 

ESTIMATE FUNCTIONAL STATUS:
> 4 METS:  Climb a flight of stairs or walk up a hill.  Walk on level ground at 4mph.  Run a short distance.  Heavy work around the house.

 

 

ASSESS AND DOCUMENT KEY POINTS:
1) Patient Risk  

2) Surgery risk  

3) Functional status

4) Need for stress test 
5) Need for beta blockade 

6) Urgency of surgery

 

 

OTHER COMMON PERIOPERATIVE RECOMMENDATIONS:

• DVT prophylaxis with pharmacologic therapy
• Consider stress dose steroids if pt > 2 wks of steroids in past year or > 5 mg prednisone/day:
  1) Low risk procedure: 25mg IV Hydrocortisone x 1 dose
  2) Intermediate risk: 50 mg IV q8, taper over 1-2 days 
  3) High risk: 100mg IV q8, taper over 2-3 days

• No oral hypoglycemics on AM of surgery, reduce NPH or lantus insulin dose by ½

• Prophylactic antibiotics prior to surgery

 

1Eagle et al., ACC/AHA Guideline Update, Circulation, J Am Coll Cardiol.
2007 Oct 23;50(17):1707-32
2Lee et al., Circulation, 1999; 100: 1043-1049
3Wesorick and Eagle, American Journal of Medicine, 2005; 118: #12, 1413

 

(Phil Pang and Lisa Shieh ©2008)