Ep 154: A 58-Year-Old Going for Surgery

Evaluation needed for a patient preparing for elective surgery.

Read more on this topic in Harrison's.

Harrison's Principles of Internal Medicine, 22nd Edition

Transcript

[upbeat intro music] 

[Ms. Heidhausen] This is Katerina Heidhausen, executive editor of Harrison's Principles of Internal Medicine. Harrison's Podclass is brought to you by McGraw Hill's AccessMedicine, the online medical resource that delivers the latest content from the best minds in medicine. And now, on to the episode. 

[music continues] 

[Dr. Handy] Hi, everyone. Welcome back to Harrison's Podclass. We're your co-hosts. I'm Dr. Cathy Handy. 

[Dr. Wiener] And I'm Dr. Charlie Wiener, and we're joining you from the Johns Hopkins School of Medicine. Welcome to today's episode about a 58-year-old going for surgery. Cathy, today's patient is a 58-year-old woman with known cholelithiasis who's scheduled for an elective cholecystectomy and is referred by the surgeon for a preoperative clearance. 

[Dr. Handy] It's a very common reason for visits to the primary care physician. You'd want to start first with more history and a physical examination. 

[Dr. Wiener] Okay. She's a 58-year-old woman whose past history is only notable for mild obesity and hypercholesterolemia. Over the last two years, she's had three episodes of abdominal pain that were thought to be due to gallstones. She's not had any known episodes of acute cholecystitis. She now wants her gallbladder out, and the surgeon plans on doing an elective robotic cholecystectomy. 

[Dr. Handy] That sounds reasonable. How about her past medical history? 

[Dr. Wiener] She's post-menopausal and her only medication is atorvastatin. She's up to date with her cancer screening, and a recent DEXA scan showed no osteoporosis. Six months ago, her lipid panel, electrolytes, creatinine, and hemoglobin A1c were all normal. She's a never-smoker and her review of systems is negative outside the episodes of cholelithiasis. She exercises regularly and is able to carry her laundry from the basement to her room on the second floor without resting. She works as a grants analyst at a local NGO. Her family history is only notable for a father with COPD from smoking. She has three adult children, all of whom are healthy. 

[Dr. Handy] And her physical exam? 

[Dr. Wiener] It's entirely normal. 

[Dr. Handy] Okay. The major causes of morbidity and mortality in patients undergoing non-cardiac surgery are from cardiovascular and pulmonary complications. Evidence-based practices dictate that an internist should perform an individualized evaluation of the surgical patient to provide an accurate preoperative risk assessment and stratification that will guide optimal perioperative risk reduction strategies. We really no longer advocate a one-size-fits-all approach. What's the question asking? 

[Dr. Wiener] The question's asking, in this patient, which of the following should she have prior to her surgery? Option A. is a 12-lead electrocardiogram. Option B. is a 12-lead electrocardiogram and an echocardiogram. Option C. is a PA and lateral chest X-ray. Option D. is spirometry. And E. is none of these are needed. 

[Dr. Handy] Okay, this question focuses on understanding the cardiovascular and pulmonary risks here. Let's start with cardiovascular risk. In addition to a history and physical, simple, standardized preoperative screening questionnaires have been developed for the purpose of identifying patients who are at intermediate or high risk who may benefit from a more detailed clinical evaluation. 

[Dr. Wiener] What are these questionnaires focused on? 

[Dr. Handy] Focused on symptoms of occult cardiac or pulmonary disease. 

[Dr. Wiener] How about our patient? She seems pretty healthy. Does she need additional testing? Option E. says no additional testing's necessary. 

[Dr. Handy] So it turns out that females over the age of 55 or men over the age of 45 undergoing elective cholecystectomy should have a 12-lead ECG as part of their preoperative assessment. Assuming that's normal, then no additional cardiac testing is necessary. 

[Dr. Wiener] Okay, so that was quick. The answer's A. 

[Dr. Handy] Yeah. And I'll add that the recent creatinine less than two is also helpful in risk-stratifying her. 

[Dr. Wiener] Can we actually estimate her cardiovascular risk? 

[Dr. Handy] Yeah, there are a variety of calculators available online. One common one is the Revised Cardiac Risk Index. It relies on the presence or absence of six identifiable predictive risk factors. One, is it a high-risk surgery? So an example of that would be a vascular surgery. Two, do they have any ischemic heart disease? Three, do they have congestive heart failure? Four, do they have cerebrovascular disease? Five, do they have diabetes mellitus that's treated with insulin? And the sixth factor, is their renal insufficiency with a creatinine over two milligrams per deciliter? Each of these predictors is assigned one point. The risk of major cardiac events can then be predicted. 

[Dr. Wiener] And how do you define the risk of cardiac events? 

[Dr. Handy] Well, the cardiac events that we're talking about are those defined as MI, pulmonary edema, ventricular fibrillation, or primary cardiac arrest, or complete heart block. 

[Dr. Wiener] And how high is the risk based on the factors you just mentioned? 

[Dr. Handy] If none of those factors are present, the rate of development of one of those four major cardiac events is estimated to be about half a percent. If more than three are present, the rate is over 11%. 

[Dr. Wiener] Wow, that's a huge difference. So our patient, as I read it, has the lowest risk, or less than 0.5%. 

[Dr. Handy] That's right. 

[Dr. Wiener] So option B. asks for an echocardiogram in addition to the ECG. Who merits an echocardiogram? 

[Dr. Handy] Patients with three or more of the RCSI risk factors merit further risk stratification for coronary disease. The next step is an evaluation of functional status. And participation in activities of daily living offers an expression of functional capacity that's often expressed in terms of metabolic equivalence or METs. For predicting perioperative events, poor exercise tolerance has been defined as fewer than 4 METs, and that's limited by dyspnea, excessive fatigue, or angina. 

[Dr. Wiener] What kind of activities of daily living get you above 4 METs? 

[Dr. Handy] It's things like being able to walk at least four blocks or climb two flights of stairs at a normal pace, or perform activities such as playing golf or doubles. Patients with moderate or greater functional capacity generally should not undergo further non-invasive cardiac testing prior to elective non-cardiac surgery. 

[Dr. Wiener] So it sounds like our patient has an excellent functional capacity and no more cardiac testing is indicated. What about the X-ray and spirometry? Who gets those? 

[Dr. Handy] Similar to preoperative assessment of cardiovascular risk, all patients undergoing elective surgery should be assessed for their risk of postoperative pulmonary complications. There are many published resources to help, but it includes the expected risks such as age, comorbidities, history of respiratory problems, active or past smoking, or sleep apnea. Preoperative spirometry and chest radiography should not be used routinely for predicting risk of postoperative pulmonary complications, but it may be appropriate for patients with chronic obstructive pulmonary disease or asthma. 

[Dr. Wiener] Okay. Again, it sounds like our patient's low-risk. Any other thoughts about the respiratory system? 

[Dr. Handy] Yes, several meta-analyses have shown that rates of pneumonia and respiratory failure are lower among patients receiving epidural or spinal anesthesia rather than general anesthesia. However, there were no significant differences in cardiac events between the two approaches. Also, evidence supports postoperative epidural analgesia for over 24 hours for the purpose of pain relief. And she should be advised to continue her atorvastatin. 

[Dr. Wiener] Great. So the teaching point of today's case is that the medical preoperative evaluation before elective surgery should be individualized based on the patient's surgery and the patient's overall health. A good history and physical is always indicated. Patients with low cardiac or pulmonary risk often do not need much if any additional testing prior to surgery. 

[Dr. Handy] You can find this question and other questions like it in Harrison's Self-Review. And the new 22nd edition of Harrison's is now available. You can find it online or in print and check out the show notes for more information. To learn more about the topic we discussed today, check out the chapter on medical clearance. Visit the show notes for links to helpful resources, including related chapters and review questions from Harrison's, available exclusively on AccessMedicine. If you enjoyed this episode, please leave us a review, so we can reach more listeners just like you. Thanks so much for listening. 

[upbeat outro music]