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Pre-operative assessment

History

 

  • Identify cardiac risk factors, note if these have been adequately controlled
  • Grade angina in terms of Canadian Cardiology Society Classification - Grade I-IV
  • Surgical outcome is improved if CCF is controlled before surgery
 
  1. Previous TIA / CVA
    • Carotid duplex doppler assessment
    • CT brain if CVA recent (exclude intracranial haemorrhage)
  2. Calf claudication
    • Defines risk from surgery
    • Saphenous vein should be harvested from the less symptomatic leg (wound healing is improved)
    • Saphenous vein may be later required for local bypass surgery
  3. Ongoing respiratory tract infection 
    • CXR, baseline ABG on air
  4. Bleeding diathesis
    • GI/GU/intracranial - contraindicates the use of anticoagulation required for mechanical valves
    • Peri-operative cover (PPI) should be used in patients with peptic ulcer disease
  5. Renal impairment
    • If pre-existing should be referred to the nephrologist
    • Consider need for post-operative renal replacement therapy
  6. Alcohol consumption
    • Potential for alcohol withdrawal
    • Determine the social circumstances to which the patient will be discharged
  7. Drugs
    • Aspirin should be stopped 1 week prior to surgery
    • Warfarin should be stopped 48 hours prior to surgery (and INR checked)
    • Patients on steroids must be covered peri-operatively with hydrocortisone to avoid addisonian crisis
    • Cardiac drugs - continue all cardiac drugs up til the day of surgery
    • Hypoglycaemics
      • NIDDM: Omit oral hypoglycaemic drugs on day of surgery; monitor glucose 4 hourly
      • IDDM: commence sliding scale on admission (if unstable); sliding scale 48 hours post surgery
    • Antibiotics - prescribe prophylactic antibiotics
      • CABG: Cefuroxime 1.5g iv on induction / Cefuroxime 750mg iv tds until lines removed
      • Valve: Flucloxacillin 500mg (or erythromycin 500mg qds) + Gentamicin 120mg iv on induction / Gentamicin 120mg iv bd + Flucloxacillin 500mg iv qds until lines removed
 
 
 
 
 
Examination
  • Thorough examination with emphasis on immediate relevant features
  • Note dental hygiene (urgent dental treatment arranged before valve surgery
  • Co-existing AAA; assess all peripheral pulses (esp femoral pulses in case of IABP)
  • Presence of varicose veins
  • Neurological examination will provide a baseline
 
 
 
Investigations 
  • FBC, U/E, LFTs, glucose, coag, CXM 4 units (2 for pulmonary resection)
  • ECG
  • BP
  • ABG
  • Echo
  • Carotid duplex to document the severity of carotid artery disease
  • CT Brain if CVA <6 weeks
  • Coronary angiogram within 12 months; more up-to-date angiogram if an infarct has occured in the interim

 

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