Pre-Surgery

//{Last name, First name}

{Above documentation reviewed.}

{Patient discussed with Dr. { }.}

{ Patient Phone #: ({ }) { }-{ }}

███ SUBJECTIVE ███

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(CC): Pre-Operative Evaluation

(HPI):

{ } is a { } year old {male}{female} who presents for risk stratification and medical optimization. Planned Surgery is {-type of surgery-}. This is a {low risk}{elevated risk} surgery.

//Low risk = endoscopic procedures, superficial procedures, cataract surgeries, breast surgery, ambulatory surgery. Risk of major adverse events < 1%

//Elevated risk = everything else.

--- Review of Systems ---

No history of {}MI, {}arrhythmias, {}cardiac catheterization, {}significant cardiac valvular disease, {}stroke, {}COPD or other significant lung disease.

No history of smoking.

No family history of {}early cardiac death, {}stroke, {}DM.

--- 4 Mets activities ---

{ } Can do light housework around the house like washing dishes.

{ } Can walk up a flight of stairs/hill without chest pain.

--- REVISED CARDIAC RISK INDEX ---

{ } High risk surgery

{ } Ischemic heart Dz

{ } History of CHF

{ } History cerebrovascular disease

{ } Insulin therapy for diabetes

{ } Pre-op creatinine > 2

-----

// 0 factors: .4% *LOW RISK*

// 1 factor: .9% *LOW RISK*

// 2 factors: 7%

// 3 factors: 11%

--- AMERICAN COLLEGE OF SURGEONS NSQIP NSQIP SURGICAL RISK CALCULATOR ---

//http://riskcalculator.facs.org/

░░░ PAST MED/SURG/SOC HISTORY ░░░

{}Reviewed in AHLTA

Significant for { }

(= ALLERGIES =)

{}NKDA

(= CURRENT MEDICATIONS =)

{ }

███ OBJECTIVE ███

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{ ,pe-cards }

███ ASSESSMENT & PLAN ███

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# {}Medically stable for surgery

Per the 2014 ACC/AHA perioperative guidelines for non-cardiac surgery, this patient is medically stable and at average risk for surgery. She has {}no active cardiac conditions and has a Revised Cardiac Risk Index of { }%, has {good} functional capacity exceeding 4 mets, and is undergoing {a low}{an elevated} risk procedure.

{-- Continue atenolol and lipitor during the pre and perioperative period if possible.}

{-- Hold ASA 7-10 days prior to procedure}

{-- Hold HCTZ 24hrs prior to procedure}

{-- Hold prempro 4-6 wks prior to surgery . Hold postoperatively until period of elevated risk for VTE has resolved}

{-- Hold metformin 48-72hrs prior to procedure and monitor glucose perioperatively, with sliding scale if necessary}

{-- DVT interventions per ortho}

{-- Because of age, care with CNS meds post-operatively to minimize risk of delirium}

// Meds:

// Continue B-blockers

// Evidence against beginning B-blockers unless high risk patients (POISE 2008) Addressed in 2014 guidelines in detail

// Continue statins, even post-op! (DECREASE III trial starts statins in vascular surgery)

// Continue ACE/ARB for htn. Careful for CHF

// Continue calcium channel blockers

// Hold diuretics at least day of surgery (consider 24-72 hrs)

// Hold ASA 7-10 days in low risk pts

// Continue ASA in patients with stents or using for secondary prevention unless risk is prohibitively high

// Stop coumadin 3-7 days before low risk pts*

// Stop factor Xa and thrombin inhibitors 48-72hrs before in low risk pts (Atrial fibrillation without valve disease)

// Hold clopidogrel 5 days

// Hold NSAID’s 3 days (24 hrs ibuprofen)

// Estrogens: consider d/c 4-6 weeks prior

// Continue H2 blockers and PPI’s

// Diabetics individualize. Tight control in low to intermediate risk surgery is NOT good

// Would hold metformin 24-72hrs prior to procedure, particularly if any nephrotoxic dyes to be considered

// Labs:

// Probably safe to use test results from prior 4 months if no interim health change

// Hb(CBC) >65yo or if surgery for anyone with potential significant blood loss

// BUN/Cr(>2 RCRI) patients >50yo intermediate or high risk surgery

// Pregnancy testing reproductive age women

// EKG: reasonable with known CAD, significant arrhythmia, PAD, cerebrovascular dz, or significant structural ht dz, EXCEPT those undergoing low risk surgery (class IIa)

// CXR: Pts with cardiopulmonary disease and >50yo undergoing major surgery, particularly upper abd or thoracic surgery, or obese with BMI > 40

// All else (lytes, coags, LFT’s, PFT’s not recommended)

{DUTY RECS:{ }}

FOLLOW-UP: { }

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