2. Indication Of Cardiac Consultation In Noncardiac Surgery

3. 1-History And PE Findings 2-Type Of Surgery 3-Risk Factors 4-Emergency Or Elective Surgery DECISION GUIDELINE

4. 1-History And PE Findings

5. Metabolic Equivalent Of Task( MET)

6. Grading The Intensity Of Cardiac Murmurs

7. 2-Type Of Surgery

8. Rvised Cardiac Risk Index (RCRI) 1. High risk type of surgery 2. History of ischemic heart disease 3. History of congestive heart failure 4. History of cerebrovascular disease 5. Preoperative treatment with insulin 6. Preoperative serum creatinine concenteration greater than 2 mg/dl

9. DIFINATION OF RISK LEVEL Numbers of Risk factorsRisk level 0Low 1 to 2Intermediate More than 3high

10. continue National Surgical Quality Improvement Database >250 hospitals >200,000 pts/year Predictors of perioperative (up to 30 day) MI, Arrest ASA Class Functional status Age Serum Cr Type of surgery Article (Free) Circulation. 2011;124:381-387

11. 4-Emergency Or Elective Surgery An emergency procedure is one in which life or limb is threatened if not in the operating room where there is time for no or very limited or minimal clinical evaluation, typically within <6 hours An urgent procedure is one in which there may be time for a limited clinical evaluation, usually when life or limb is threatened if not in the operating room, typically between 6 and 24 hour

12. continue A time-sensitive procedure is one in which a delay of >1 to 6 weeks to allow for an evaluation and significant changes in management will negatively affect outcome. Most oncologic procedures would fall into this category An elective procedure is one in which the procedure could be delayed for up to 1 year

13. Key Elements of Risk Stratification Emergency surgery Active cardiac conditions Low risk surgery Functional capacity Clinical risk factors Will testing – preop intervention change management ?

14. “… the concept of “medical clearance” for surgery is short sighted. Goals of the preoperative consult:  Evaluate current medical status  Advise on disease management in the periop period.  At times recommend preventive measures for future.  Define your role in care (Co-manager?, subspecialty consultant?, etc.) ACC / AHA Guideline Philosophy

15. Decision Aalgorithm In Noncardiac Surgery

18. Step 1 Need for emergency noncardiac surgery? Operating room Perioperative surveillance and postoperative risk stratification YES NO Step 2 Step 1

19. Step 2 Active cardiac conditions Consider operating room Evaluate and treat per ACC/AHA guidelines YES NO Step 3 Active Cardiac Conditions Unstable coronary syndromes Unstable or severe angina Recent MI Decompensated HF Significant arrhythmias Severe valvular disease Step 2

20. Step 3 Low risk surgery Proceed with planned surgery YES NO Step 4 Low Risk Surgery Endoscopic procedures Superficial procedures Cataract surgery Breast surgery Step 3

21. Step 4 Good functional capacity (METS > 4) without symptoms YES Proceed with planned surgery No or Unknown Step 5 Step 4

22. Step 5 Clinical Risk Factors (Isch HD, CHF hx, Cereb vasc dx, DM, Cr >2 3 or more Vascular surgery Consider testing if it will change management Intermediate Risk surgery Proceed with planned surgery with HR control or consider Noninvasive testing if it will change management 1 or 2 Vascular or intermediate risk surgery None Proceed with planned surgery Step 5

26. آقایی 65 ساله کاندید جراحی فتق اینگواینال با سابقه فشار خون می باشد، هیچ گونه شکایتی از درد قفسه صدری یا خستگی رود رس را نمی دهد و دو طبقه پله را بدون علامت طی می کند MET>4 No active cardiac condition Type of surgery is low risk به آنستزیولوژیست جهت مشاوره پره آپ مراجعه می کند، تصمیم شما چیست؟

28. خانمی 60 ساله کاندید جراحی هیستراکتومی با سابقه فشار خون و دیابت ملیتوس وابسته به انسولین می باشد، میزان فعالیت بدنی او خوب است و بیش از دو طبقه پله را بدون مشکل طی می نماید MET>4 No active cardiac condition Type of surgery is Intermediate risk Risk factors=2 به آنستزیولوژیست جهت مشاوره پره آپ مراجعه می کند، تصمیم شما چیست؟

30. آقایی 50 ساله کاندید جراحی TURP می باشد،به علت آرتروز شدید میزان فعالیت بدنی او محدود است، دارای فشار خون و کراتینین سرمی mg/dl 2.5 است MET= نامشخص No active cardiac condition Type of surgery is Intermediate risk Risk factors=2 به آنستزیولوژیست جهت مشاوره پره آپ مراجعه می کند، تصمیم شما چیست؟

32. این جهان نیست چون هستان شده وان جهان هست بس پنهان شده اینکه بر کار است بیکار است و پوست آنکه پنهان است مغز و اصل اوست مولانا