Preop risk calculators

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ryanjmy

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We have RNs and an APN in our preop clinic that gather information and start our notes. The APN has access to the call anesthesiologist for questions about pt readiness but it seems that things get lost in translation. Was thinking about making them do the Duke Activity Status Index and NSQIP Surgical Risk Calculator to aid in risk stratification. Was wondering what other practices do to estimate exercise tolerance/MACE risk.

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We have RNs and an APN in our preop clinic that gather information and start our notes. The APN has access to the call anesthesiologist for questions about pt readiness but it seems that things get lost in translation. Was thinking about making them do the Duke Activity Status Index and NSQIP Surgical Risk Calculator to aid in risk stratification. Was wondering what other practices do to estimate exercise tolerance/MACE risk.

I use the AHA RCRI score system. After seeing co-morbidities, labs, ekg I commonly ask if pt can climb a flight of stairs or walk 2 City blocks without cp/sob. If RCRI score 2 or more and METS<4, I determine if further stress testing would change management. I think it’s a pretty good system.

I recall gomerblog having a preop clinic on the second floor only accessible by stairs. But when pt got to 2nd floor, there would only be a sheet of paper saying “you climbed a flight of stairs, there is no preop clinic, but take this paper with you to your surgery.”
 
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+1 for RCRI.
most of these score estimators suck anyways and provide widely variable % risk for the same patient
and many of these score estimators fail to consider RV dysfunction and pulmonary hypertension as a risk factor
 
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Preop calculators suck. self reported exercise tolerance sucks.
RCRI sucks.
If i get another 'cleared for anesthesia and surgery based on rcri=1' from some ****ing nitwit cardiologist i will lose it.
Even airway exams suck. We got one 'colleague' that labels everyone as MP1

Calculators are ok if the patient is low risk but as soon as theres any severe illness/complexity in the patient the numbers included in the trials that were used to create said calculator are so low that you cant really extrapolate out from that to your patient. Once mortality is over 10% for any of these calculators thats basically all you can say to the patient. So there we go


I actually really like the gomerblog idea!
 
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That's why I just do the case and don't worry about most of the crap they teach in residency.
 
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Riiiight. Cause you're gonna be cathing/stenting or doing that 3v cabg before that appy (which won't even help anyway btw)

Maybe or maybe not. But I don't think you should take upon yourself the medicolegal burden of anesthetizing a patient for elective surgery who has poor mets, multiple risk factors, and might potentially benefit from cardiac consultation. Of course the higher risk the surgery the more concerning. When you look at the guidelines it does specifically say to refer if it might change perioperative management. That is a large part of what we do. Optimize patients to reduce their risk burden.

Also how do you address risk with this patient? To provide meaningful informed consent?? "Sorry sir or ma'am you might have a major cardiac event during your surgery today, but im not sure and I don't think you should see anyone about it either."
 
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Maybe or maybe not. But I don't think you should take upon yourself the medicolegal burden of anesthetizing a patient for elective surgery who has poor mets, multiple risk factors, and might potentially benefit from cardiac consultation. Of course the higher risk the surgery the more concerning. When you look at the guidelines it does specifically say to refer if it might change perioperative management. That is a large part of what we do. Optimize patients to reduce their risk burden.

Also how do you address risk with this patient? To provide meaningful informed consent?? "Sorry sir or ma'am you might have a major cardiac event during your surgery today, but im not sure and I don't think you should see anyone about it either."

The patient isn't going to get better. If their pcp is halfway decent, they should already be on a bblocker, statin etc. A fat patient with crap mets and lots of medical problems will still be a fat patient with crap mets and lots of medical problems if you cancel them, just they will have wasted 2+ days now on getting the surgery they were going to get anyway. And you dumped it on your partner instead. Btw even if they get some kind of cardiac intervention, outcomes end up the same in vascular patients. Meanwhile stress tests have zero predictive value. So what exactly are you getting out of preop testing? I make sure that people see the cardiologist as cya and want to see the results of any tests they do but at least I do it knowing that the patient gets no added value whatsoever.

Avoid hypoxia, hypotension and tachycardia. Yeah ok thanks.
 
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The patient isn't going to get better. If their pcp is halfway decent, they should already be on a bblocker, statin etc. A fat patient with crap mets and lots of medical problems will still be a fat patient with crap mets and lots of medical problems if you cancel them, just they will have wasted 2+ days now on getting the surgery they were going to get anyway. And you dumped it on your partner instead. Btw even if they get some kind of cardiac intervention, outcomes end up the same in vascular patients. Meanwhile stress tests have zero predictive value. So what exactly are you getting out of preop testing? I make sure that people see the cardiologist as cya and want to see the results of any tests they do but at least I do it knowing that the patient gets no added value whatsoever.

Avoid hypoxia, hypotension and tachycardia. Yeah ok thanks.

You don’t find “medically cleared” by NP or PA helpful?
 
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Even airway exams don't always correlate to airway difficulty. I do a lot of bariatric and they actually tend to be very easy intubation even if mallampati poor and huge necks, etc.
 
FWIW, I've done research in this space and the definition of a CV event in most trials wouldn't be remotely close to being clinically significant. The one major trial that attempted to answer if revascularization (eg the thing everyone really wants) improves outcomes was stone cold negative (CARP 2008).

CV events can be anything from an asymptomatic EKG change, any chest pain, biomarker elevation, afib, VT, CHF, and death. The really only clinically significant events are afib, CHF, and death, all of which perioperative testing and risk stratification won't capture. Most patients being risk stratified for surgery have enough risk factors for afib. It's rarely an issue pre-op and post-op may need some rate control or a cardioversion, hardly deal breakers. VT is rare enough that you can't risk stratify it. CHF we all try to avoid by resuming diuretics and avoiding excessive fluids. Everything else is clinically meaningless or doesn't improve outcomes (eg abnormal stress for ischemia and not have similar perioperative outcomes).

The original paper was by Goldman in the 70s and it was patients actively infarcting, having uncontrolled arrhythmias, or in active heart failure undergoing surgery. Nowadays, no surgery, unless truly an emergency, would happen under these circumstances. Correct the acute stuff (eg active ACS, control the arrhythmia, get them out of a CHF exacerbation, address severe valvular lesions) otherwise, all that perioperative risk stratification is mental masturbation. You can eyeball most patients and accurately predict their risk.
 
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Even airway exams don't always correlate to airway difficulty. I do a lot of bariatric and they actually tend to be very easy intubation even if mallampati poor and huge necks, etc.
In this age of glidescopes mallampati means nothing. If they can open their mouth, I can intubate.
agree that preop clearance is mostly for medicolegal reasons. That’s why I don’t care if a PA or NP wrote it. It will serve its purpose regardless.....
 
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