Make an Impact With Small Moves
Improvements in both workflow and staff attitudes are part of a leader’s responsibilities, but your interventions in these areas don’t need to be major to make...
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By: Adam Dorin
Published: 10/10/2007
We're not actuaries, but we know that the best practices in anesthesia often require calculating risk. No matter how much number-crunching we do for the pre-operative cardiac evaluation, though, our final assessment will likely rest more with the art than with the science of our clinical trade. It comes down to recognizing the signs and symptoms that can compromise our patient's health and determining if the procedure's benefits are worth the risks.
Figuring out the factors
To define the potential for harm from a cardiac perspective when a patient undergoes anesthesia and surgery, we must examine many factors, including the risk of a dangerous arrhythmia, the likelihood of a perioperative myocardial infarction and the possibility of blood loss or other operative stressors such as hypotension or hypertension.
Begin by considering the type of procedure and the context of the surgery itself. Any patient over 40 is at least potentially at risk for undiagnosed coronary artery disease, but without further information it doesn't seem reasonable or cost-effective to order a stress thallium exam. But if a patient presents with a vague history of angina and is in poor compliance with prescribed nitrates and beta-blockers, you should seriously consider delaying the surgery until after he receives a formal cardiology evaluation.
For the data, consult the American College of Cardiology/American Heart Association Guidelines, which were updated in 2002. These put the combined incidence of non-fatal MI or cardiac death at greater than five percent in cases which are prolonged, involve high blood loss, peripheral vascular surgery, major vascular surgery or emergency surgery - not the sort of work we typically do on an outpatient basis. Likewise, the intermediate category of cardiac risk (roughly one to five percent of non-fatal MI or cardiac death) includes carotid endarterectomy, prostate surgery and intra-thoracic surgery, as well as such more traditional same-day cases as intra-peritoneal, head and neck, and orthopedic surgery.
Other outpatient procedures, such as cataract or endoscopic operations, are considered low risk (a less than one percent association with non-fatal MI or cardiac death). This group doesn't need cardiac evaluation beyond the routine H & P and labs.
Points in the patient history
If after reviewing the patient's medical record and taking an H & P you decide a cardiac evaluation is called for, here's how to quantify the patient's risk:
Keep the type of surgery in mind when you weigh this information. Classify as high risk any procedure that involves the vascular system or has a propensity for excessive blood loss (including thoracic, abdominal and ENT procedures), especially if there is any suspicion of a compromised airway.
Picturing the layers of risk
Now that you have the data, it's time to put it all together. This algorithm from the American College of Cardiology can guide us through the "art" stage of assessing patients at risk:
Risk-reward
There will always be the question of whether pre-procedure coronary intervention, and pre-procedure non-invasive testing, in patients with known CAD will exceed the risk of elective surgery. Weigh the answer against the potential for an improved duration and quality of life if successful revascularization is achieved.
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