Responding to a colleague’s work

Preoperative Risk Stratification

Case 1 A 60-year-old female with no previous cardiac history, except for preoperative for stratification for a new murmur, is sent to you. An echocardiogram is performed demonstrating an ejection fraction of 60%, and severe aortic stenosis. Her proposed surgery is a total knee replacement.

The patient has no past medical history, does not take any medications and generally healthy. However, the patient has a new diagnosis of Aortic Stenosis. Step one of the perioperative evaluations is assessing the patient for cardiac stability. Aortic stenosis falls in the category of cardiac instability. This finding alone will postpone the surgery and require cardiac consultation possibly resulting in a cardiac procedure to help resolve the aortic stenosis. Studies show that patients with a history of aortic stenosis do not necessarily have a higher incidence of mortality, however they do show higher rates of adverse cardiovascular events compared to non-aortic stenosis patients (Kwok et al., 2017). Once cardiac issues have been managed, the procedure can be reconsidered. Total knee replacement surgery is still considered an elective surgery, meaning that it can be delayed up to a year before risk of any problems. Total knee replacements are orthopedic procedures, orthopedic procedures are generally intermediate risk procedures. (Cohn & Fleisher, 2019) This translates into an elevated risk procedure, meaning that the risk of MACE is greater than one percent. From there a functional capacity should be determined using the METs score. If the patients score is less than 4, per AHA the procedure can either proceed with heart rate regulations or non-invasive stress testing can be performed if management will change. (Fleisher et al., 2007) And per the patients Revised Cardiac Risk Index (RCRI) with the combined assessment the patient is a high risk surgery patient pending cardiac treatment.

Case 2: A 25-year-old male is sent to you for preoperative risk stratification. His proposed surgery is an emergency cholecystectomy. He is active and has no exertional symptoms playing basketball for over an hour 3 times weekly. He has no previous cardiac, medical, or surgical history.

Assessment of this patient shows that he is young, healthy with no medical history and taking no medication. He also has no signs and symptoms of cardiac instability clearing him for the next step in the evaluation process. In the case of emergent cholecystectomies, the risk of waiting to perform the procedure can lead to various problems. Acute calculous cholecystitis on the other hand is an acute inflammatory process from unrelieved gallbladder obstruction that often progresses to gallbladder necrosis if left untreated. (Yacoub et al., 2010, Discussion section) This places the procedure in the urgent category due to the risk of further complications. Cholecystectomies are placed in the elevated risk categories of procedures. Based on the information given the patients METs score is greater than ten, due to the fact that he participates in strenuous activity for over an hour three times weekly. His risk stratification score is zero, making him a low-risk surgical patient. Informed consent for him should include: information on the risk of possible perforation if the surgery is delayed, the importance and role of antibiotic therapy for cholecystitis, the different modes of surgical therapy ( open cholecystectomy vs laparoscopic cholecystectomy) , their benefits and their risk and recovery.

Case 3: A 75-year-old female with history of coronary artery disease with previous CABG and PCI, hypertension, and hyperlipidemia is sent to you for preoperative risk stratification. Her proposed surgery is hip replacement. You are unable to assess her functional status due to hip pain, which renders her mobility challenged. Her previous echocardiogram demonstrates an ejection fraction of 5560% with no wall motion abnormality. She has no active anginal or exertional symptoms.

Patient three has an extensive cardiac history. However, the patients cardiac condition is stable, allowing the progression of surgical evaluation. This being an elevated risk procedure, per the AHA Guideline levels of evidence (IIa) this patient will require preoperative electrocardiogram. Also, the patient might benefit from starting a beta-blocker and statin therapy (if not already prescribed) prior to surgery to help decrease cardiac demand. (Fleisher et al., 2007) Again, this procedure is classified as an elective surgery therefore, allowing for a delay of one year. The patient might need a delay to determine the efficacy of the newly started therapies. Due to the inability to determine the patients METs score, per guidelines, the procedure can be performed with close heart monitoring and control or a stress test can be performed to determined if management should change. Based on the information given, this pat

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