PREOP GUIDELINES
Preop guidelines are meant to guide the process, but ultimately the MD has to make a judgement in many cases, and should feel free to poll the group if in a gray zone.
ANTICOAGULATION
ASRA guidelines: Neuraxial anesthesia should not be performed until patient is OFF their anticoagulation for the following periods:
Warfarin INR < 1.5
Lovenox 12 or 24 hrs depending on dose
Plavix 7 days minimum
Xarelto 3 days
Eliquis 3 days
Pradaxa 5 days
full guideline list at the Univ of Washington (less conservative than ASRA- 2 days on most new anticoagulants). https://depts.washington.edu/anticoag/home/sites/default/files/Neuraxial%20Guidelines_1.pdf
ASRA guidelines: http://journals.lww.com/rapm/Fulltext/2010/01000/Regional_Anesthesia_in_the_Patient_Receiving.13.aspx
ASRA update (newer agents): https://www.asra.com/advisory-guidelines/article/1/anticoagulation-3rd-edition
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4531015/
CARDIAC GUIDELINES
STRESS TEST PROXIMITY TO SURGERY- ACC guideline summary pending.....(will attach pdf for full guidelines)
From the ABA 2017: "The decision whether or not to obtain preoperative cardiac stress testing is best determined in a step-wise fashion. If the surgery is nonemergent and the patient does not have signs of acute coronary symptoms, the next step is to estimate the risk of major adverse cardiac events (MACE) associated with the surgical procedure. This can be done using the American College of Surgeons NSQIP risk calculator: http://riskcalculator.facs.org.
If the risk for perioperative MACE is < 1%, no further testing is indicated. Only if the risk for MACE exceeds 1% and the patient has poor (< 4 METS) or unknown exercise tolerance, pharmacologic stress testing is indicated if it would impact decision making or perioperative care (e.g., referral for preoperative revascularization).
For the 2014 AHA ACC algorithm that succinctly summarizes the current recommendations for obtaining preoperative stress testing, visit the following link:
http://circ.ahajournals.org/content/130/24/e278/F1.large.jpg
http://circ.ahajournals.org/content/130/24/e278/F1.expansion.html
RECENT MI- must be 6 months post-MI for elective surgery (? we need to research current guidelines here).
STENTS- patients must be 4 weeks post stent placement (bare metal stent), or 6 months for a DEA (drug eluting stent), depending on which guidelines you go by.
The American College of Cardiologists guidelines on the management of patients with ICS recommend dual antiplatelet therapy (DAT) for minimal 14 days after balloon angioplasty, 30 days for bare metal stents, and 365 days (changed to 6 months in update link below from ACC) for drug-eluting stents. Postponement of elective surgery is advocated during this period.
http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2016/03/25/14/56/2016-acc-aha-guideline-focused-update-on-duration-of-dapt
cancel / defer to hospital
The following cases, either by group decision or national guidelines, are NOT considered safe to perform at an Ambulatory Care Surgery center (ASC).The case should be escalated to the MD for the decision. Examples:
moderate (or worse) AS or AI
severe MR or MS
recent/active CHF (Ef <40)
moderate-severeCOPD
ESRD on Dialysis
active Angina on nitrates
Throat CA history, XRT
Rapid Afib/ poorly controlled
Abnormal K+ or Na < 130
LBBB on ECG that has not been investigated (worked-up)
.....list in progress....
GRAy ZONe
The following are to be reviewed by the covering MD for a decision. In most cases, it is the patient AGE, COMORBIDITIES, AND TYPE OF SURGERY that all contribute to a global picture in making the judgement as to whether to point 6move the case to the Hospital.
MI in last 6 months
CVA less than 1 year old
BMI > 42
ANY Major organ disease
Age >80
MH history
Difficult Airway hx
CARDIAC DEVICE MANAGEMENT
AICD GUIDELINES- Magnet use intraop is recommended to avoid inadvertent defibrillation (this will inactivate the defibrillator, but have no effect on the pacemaker function). This is preferred for most surgeries, as it allows the Anesthesiologist the ability to remove the magnet in an emergency situation where defibrillation is needed, as EARLY defibrillation is key to successful outcomes (ie, waiting for a Rep to turn the AICD back on, if you had it programmed off pre-op, is not ideal and will force one to use an external defibrillation in the meantime, which is not as effective and can damage the AICD). Only case where preop Programming Off is warranted is when the surgical field is so close to the AICD that magnet placement is not feasible, or the patient is pacemaker dependent and VOO or DOO mode is sought from the start.
PACEMAKER GUIDELINES- magnet application is recommended if surgery using cautery interferes with the pacing, or is within 16 cm of the device, and post-op interrogation is warranted to ensure programming alteration has not occurred. Preop Rep presence is recommended in cases of pacemaker dependance so that it can be programmed into an appropriate fixed pacing mode. Bipolar cautery is always recommended over monopolar, for pacemakers and AICD's, and post-op interrogation is recommended if cautery is used within 16 cm of the device.