1. Surgery risk classes - ANS -Class 1: benefits outweigh risk, should
be done
Class 2a: reasonable to perform
Class 2b: should be considered
Class 3: rarely appropriate
2. General rules for surgery: testing - ANS -ECG before surgery only
if coronary disease, except when low risk surgery
Stress test not indicated before surgery
Do not do prophylactic coronary revascularization
, 3. Meds before surgery - ANS -- Diabetic agents: Use insulin therapy
to maintain glycemic goals(iii) Discontinue biguanides, alpha
glucosidase inhibitors, thiazolidinediones, sulfonylureas, and GLP-
1 agonists
- Do not start aspirin before surgery
- Stop Warfarin 5 days before surgery. May be bridged with Lovenox.
- Do not stop statin before surgery
- Do not start beta-blocker on day of surgery, but may continue
4. Assessment of surgical risk - ANS -- Unstable cardiac condition
(recent MI, active angina, active HF, uncontrolled HTN, severe
valvular disease), concern with CAD, CHF. arrhythmia, CVD
- patient stable or unstable?
- urgency of the procedure (oncology will be time sensitive)
- risk of procedure
,- nutritional status
- immune competence
- determine functional capacity (need to be more than 4 METS, more
than 10 METs makes low risk)
5. Low risk surgeries - ANS -cataracts
breast biopsy
cystoscopy, vasectomy
laparoscopic procedures
Plastic surgery
6. intermediate risk surgeries - ANS -Head/ neck surgery
thyroidectomy
Intraperitoneal
, Prostate
Laminectomy
Hip/ knee
Hysterectomy
cholecystectomy
nephrectomy
non-major intrathoracic
7. High risk surgeries - ANS -aortic/ cabg
transplants
spinal reconstruction
peripheral vascular surgery
8. Lee's revised cardiac risk index - ANS -6 points:
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