What preoperative assessment do you recommend for a patient with a history of MI or one who is in renal failure?
—JEFFREY ARBOUR, PA-C, Saline, Mich.

The number and type of preoperative studies will vary with the surgery being performed. For cardiac surgery, obtain a baseline 12-lead ECG, stress test, posteroanterior and lateral chest x-rays, echocardiogram (transesophageal or transthoracic), and cardiac catheterization. Study results should then be used to optimize the patient prior to any surgical intervention. Barring contraindications, a post-MI patient should be on aspirin and a beta blocker. However, some surgical procedures require that the aspirin be discontinued one week prior (unless the patient has a stent in situ). Creatine kinase and troponin levels should be followed and serial ECGs obtained.

Patients in renal failure require dialysis performed in close coordination with the surgeon on the day of surgery. Monitor acid-base balance closely, and review any medications that will be used for possible nephrotoxicity. Follow blood urea nitrogen and creatinine levels. It is imperative that fluid management and electrolyte imbalances be monitored. The patient may have platelet dysfunction leading to bleeding tendencies. According to the American College of Cardiology and the American Heart Association, a noncardiac surgery patient with a creatinine level >2.0 mg/dL is considered to be at cardiovascular risk. For additional information, see Salifu MO, Otah KE, and Otah E. Perioperative management of the patient with chronic renal failure (accessed April12, 2009).
—Debra Kleinschmidt, PhD, PA

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