Transcript: Preoperative Exam for Nurse Practitioners

​Liz Rohr:
Well, hey there, it's Liz Rohr from Real World NP and you're watching NP Practice Made Simple, the weekly videos to help save you time, frustration and help you learn faster so you can take the best care of your patients. So today I'm going to be talking about pre-operative exams. It's kind of a big topic, but I'm going to do my very best to give you an overview of guidance of how I conduct my exams and how I recommend you do, based on the available guidelines. A couple disclaimers I want to make from the beginning is that if you are an algorithm-loving, tool-loving kind of girl like I am, or boy, that you might be a little bit disappointed for pre-op exams because they're a little bit complicated. So really one of the take homes I want you to take away from this is that each pre-op exam is for that patient at that time, with those chronic conditions for that type of surgery, unfortunately.

So it's really hyper individualized and that's for a very good reason is because it's just there's a lot to think about. So with that in mind, I think it's really important that, I really want to stress that you ask questions whenever you're not sure, right? So there's a spectrum of the different types of pre-ops you're seeing, right? There's healthy patients undergoing low-risk surgeries all the way through very complicated, multiple chronic comorbidities, very ill patients trying to undergo high-risk surgeries or asking for your clearance. And so I'm going to be talking a little bit more towards the kind of second one I mentioned just because that's kind of come up as a question a lot. But one other kind of disclaimer I want to add is that I'm a family nurse practitioner and I've been doing this for four years. However, the patients that I'm seeing are generally on the healthier side or are having lower risk surgeries that they have some chronic comorbidities.

I think that's actually a benefit for making this video though, because if I were to switch over to that type of practice in internal medicine doing those kind of higher risk patients, this is what I would do. So just one other thing to say before we start is that you kind of want to have a discussion with your supervisor. I'm going to be going over the steps that I recommend that I would take if I was transitioning into that practice of a more intense internal medicine position. In terms of doing, I mean, my job is intense, but it's just not doing that intense skill. This is kind of the approach that I would take, but I would also present this to my collaborating physician or my supervisor and talk about, "Here's my approach and is this something that you recommend? Do you have other protocols in the clinic? Do you have other forms that patients fill out?" Things like that.

Just having that kind of discussion first. Now, that those disclaimers are all out of the way, actually this is one more kind of disclaimer, is that people talk about pre-op clearance. It's not clearance, don't say clearance. I don't say clearance anymore. You can never erase the risk somebody has of having a surgery. But what you're doing is you're optimizing their health so that the surgery is as low-risk as possible. And you're talking about the risks and benefits and alternatives and deciding if the risks outweigh the benefits, right? Because there is always the option of not clearing somebody or not recommending them to have surgery. But optimizing is the kind of buzzword to use in perioperative medicine it sounds like. So I first start my assessment with this, is it a low-risk surgery, moderate or high-risk surgery? And that kind of frames the workup and the history questions and all the stuff that I'm doing.

So a low-risk surgery for example, is a cataract surgery. Not a whole lot that you have to do to kind of clear them for surgery, to optimize them for surgery, because the biggest risk for complication is having an uncontrolled high blood pressure. Whereas if you have some sort of GI surgery or brain surgery, things like that, those have different risks. And so, the risk is based on how long the surgery is, how much blood loss there is and the fluid shifts. And unfortunately there's no comprehensive list that I've found. I've found a pretty solid one. And actually I should have mentioned that I have a handout down below of this video with a cheat sheet of the information I'm going to be giving you in this video. So talking about the risk and the risks of the different types of surgeries is on there.
If you find that there's a surgery that's not listed, this is again, if I was in your shoes, I would discuss with one of my collaborating providers and I would say, "Are you familiar with the surgery? How long it is, how it involved it is, and would you assess it to be a low, moderate or high-risk?" And again, I also as another kind of direction pointer, you can kind of search and see if there's specific information for the evaluation, pre-op evaluation for cataract surgery for example, or pre-op evaluation for cholecystectomy or something like that. They may or may not exist, but that's another kind of path to go down. So once I've kind of determined if it's low, moderate, or high, if it's a low-risk cataract surgery, I'm not necessarily going to get into the full thing necessarily.

But if I've determined it's a moderate to high-risk, this is the typical path that I would go down. So the framework is that I'm assessing their chronic conditions, I'm assessing their cardiac and pulmonary risk scores, risk factors, and taking it from there, as well as recapping their medications, getting an accurate social history, doing the full physical exam, and then deciding what testing to do. So the main risks of having a surgery are death, cardiac complications and pulmonary complications. There's others of course, but those are the main ones you want to think about in terms of framing your pre-op exam. So for assessing the cardiac risk, I'm just going to kind of go through that, there's the most to talk about with that one. The two scenarios that we're talking about are somebody who has established cardiovascular disease, aortic stenosis, A-fib, history of an MI.

Those patients, me personally, this is the recommendation that I'm going to make is that they go see their cardiologist to have their input on the preoperative optimization. Are they optimized from their cardiologist perspective? Or at the very least get them on the phone and say, "What are your thoughts about this?" Once I've gathered all of my information so I can present the case, right? Which I talk about in, How to Ask Questions the Right Way. If you haven't seen that video yet, kind of getting all your stuff together before you're asking all the questions and asking very specific questions, especially of a specialist. And then you have the other patient who's coming in that you're kind of the detective and you're deciding, is there an underlying cardiovascular disease that we haven't discovered yet, that if we don't discover it is going to put them at risk for cardiovascular complications around their surgery or risk for death.

So here's the approach that I recommend. So you're asking a history, right? So you're talking about do you have any obvious signs of angina, shortness of breath, dyspnea on exertion, edema, things like that. Do they have a story of something that's coming that we haven't really assessed yet? And also we're going to look at functional capacity. So that's talking about what are they capable of doing in their day-to-day lives? Are they able to go grocery shopping, go up the stairs, walk around the block without any of those symptoms or are they not? And there's a couple of tools you can use. One is called the MET Score M-E-T-S. So this is where the scoring tools come in. Make your job a little bit easier, the MET Score and you can just ask them the questions and then fill that out.

And that gives them a score. And so if it's four or more, they're less likely to have cardiovascular complications. And so for those patients, depending on the history and what your assessment is, plus the functional capacity of that MET score, you can decide are they a risk for cardiovascular complications or not? Are they a risk for an underlying CAD or something like that? That's kind of what we're getting at here, but that's what I would do. The next thing is aside from assessing functional capacity is a cardiovascular risk specifically in a surgery. And there's a couple of tools for that. The NSQIP is one of them and N-S-Q-I-P and then the Revised Cardiac Risk Index, I believe is the other one. They don't overlap. So it's kind of you pick one or the other, they don't really compare it to each other.

And then again, it just depends on your conversation you've had with your supervisor of, "Should we be using the NSQIP?" Do you use this?" Et cetera. And using that kind of with a grain of salt, right? Because that's not perfect. I mean the METS isn't perfect either, but the NSQIP, again, which is a tool where you input the type of surgery they have, their age, their risk factors, the medications, things like that. It's a whole online thing. Again, it's in that handout. And you can kind of use that to inform your clinical judgment. And I think the main drawback for that is they don't have every surgery and it's not perfect. You can't just look at that and okay, you're done. It's really more complex than that. But it's helpful in terms of gathering a tool if that's something that your supervisor recommends.

So that's the main thing for cardiovascular and what your kind of conclusion about that is, do they have a less than 1% risk of death or complications, or greater than 1%? And if it's greater than 1%, then they need cardiovascular evaluation. And so, what does that look like? Personally, I really recommend you send them to cardiology because it's one thing to know to order a stress test, but it's another thing to be able to order the correct one and interpret it correctly and then to follow up and decide whether they need more testing because it's a false negative or something like that. I mean, you can do it if you want to, but never feel yourself pressured to do so, because I feel like I just hear and this is maybe a soapbox moment, but I just feel like I hear from so many new grads who put that pressure on themselves of, "I have to know it. I know to order a stress test, I'm going to do it."

But then again, you have to just be really careful with the things that you get back and maybe there's another test that they would recommend instead. Again, that's my own personal opinion, just to save yourself a little bit of sanity and it's a right thing to do. Both of them are right, but it's okay to send them to cardiology and that's what I recommend. And then pulmonology, that's kind of the cardiac risk assessment. So the pulmonology risk assessment is a little bit less algorithmic. I don't like it as much, less guideline based, but same moral of the story here goes is that, "Do they have an established COPD, asthma? Sleep apnea?" I keep forgetting about sleep apnea, but do they have those established already? Do they see a pulmonologist already? I'm going to have a conversation with a pulmonologist or have them see the pulmonologist to get their opinion about if this is a high-risk surgery or is it an appropriate risk for them.

Otherwise, are you assessing somebody who has an underlying lung disease that hasn't been uncovered yet? So do they have some risk factors for sleep apnea? There's that STOP-BANG scoring, which again, I'll put in the handout, which you can kind of guide and see if you have sleep apnea. Not necessarily that's going to bar you from having surgery, but it's just another factor to think about. Again, when you get all this data and this information, what I personally would do if I was in that situation was that I'd get all the information, do all the physical exam, the history, all that stuff, present it to my supervising physician or collaborator and then ask what they think. So again, do they have a long-term smoking history? Do they have dyspnea that hasn't been diagnosed yet? Do they have a cough that's not diagnosed yet? Things like that. Let's just make sure that that's optimized first.

So maybe you need to delay the surgery until they see pulmonology. Again, you could consider doing a chest x-ray versus pulmonary function tests. But again, do you feel confident with your PFT interpretation? I'm just going to be real right now that I don't feel that confident with PFTs. It's something that I'm working on. But again, I'm not a pulmonologist in terms of there's certain things that I understand about it, but do I feel confident differentiating between COPD versus interstitial lung disease versus other things that are going on, right? It's not just as simple as asthma and COPD, it's not. That's why there's pulmonary as a specialist. So anyway, I'm being on a soapbox, but it's for your benefit because I don't want you to feel that pressure of having to do all the things and be all the things at all at once. Because I definitely hear that over and over again and I felt that myself too.

So low, medium or high-risk, cardiac risk assessment, pulmonology risk assessment. There's no tools that I'm aware of. Deciding what testing they need to do if they need to do anything. And then the next thing is once you met those things is thinking about what are their chronic conditions? So you're kind of optimizing those. So they have diabetes. I'm just doing a recap in the history of diabetes A1C in October 2019 was 6.8. They take metformin twice a day. Blood sugars have been this and this. Nothing less than 70, greater than 300. Here are the symptoms. They are asymptomatic. Same thing for hypertension, just a recap of their chronic conditions. And you don't necessarily have to do the full laundry list. I mean it really depends, again, conversation with your supervisor.

But if they've got seven chronic conditions, if you can do your best to do a very quick recap of all that stuff, that can be really helpful for the surgeon and the medical team that's taking care of them 'cause they don't know the baseline like you do. And then in terms of the ROS and the physical exam, the main thing is respiratory and cardiovascular. So cough, shortness of breath, dyspnea on exertion, chest pain, syncope, or syncope edema. But then also relevant to the type of surgery they're having. Are they having eye surgery? Maybe do an RIOS right? But the full physical exam, I default, because again there's a lot of complex moving parts and if they've got something cardiac or respiratory, they could have something in their abdomen they could have distended...

I just do the full thing and maybe you do something different and maybe your supervisor tells you to do something different, in which case do that. But that's what I'm going to start with. I'm going to get all that information, do my exam, present it. The other history questions you want to think about are really good social history. So are they drinking alcohol? How much? How often? Things like that, because they could go into alcohol withdrawal, that's pretty serious. How much do they smoke? Again, nicotine withdrawal, things like that. And then do they have any history of malignant hypothermia having had surgery before? Have they ever had surgery before? And then the medications, what are they taking for meds? That's actually a whole discussion in and of itself. So I don't really have good rules for that.

But that really is case by case dependent and surgery-dependent, whether or not they continue aspirin or stop aspirin, continue beta blockers, et cetera. So again, I'd either talk with a surgeon or I'd collaborate with my physician depending on the case. So I think that's it. And I didn't really touch a ton on the healthy patient with a low-risk surgery very much. But I want to keep this short and sweet if I can. There's a list of history questions that are included in the handout down below that I give to my students to do a pre-op exam on somebody that's healthier. Again, just elicits any history of cardiovascular disease or liver disease or stuff like that. You're just trying to uncover what else is going on under there, right?
So you have any surprises around the time of having that surgery. One other thing actually I want to add is about the testing. So one quick thing before I wrap up is that for testing, we over-test in the United States for preoperative exams. For the healthy adult with a low-risk surgery, there really isn't very much that's recommended at all. Again, please look at your case-by-case situation, but the main testing I want you to think about, is if they have any cardiac risk factor, hypertension, high cholesterol, other cardiac abnormalities, consider doing an EKG. Also considering that in diabetes and CKD. The rationale for that being you're getting a baseline because they're at higher risk for complications. But also you can help detect anything that's abnormal that they need to have investigated before their surgery, right?

Chest x-rays, one to consider maybe case by case dependent if they're a long-term smoker, things like that. If they have an older age, things like that, higher risk surgery. Hemoglobin is recommended for adults over the age of 65, like a CBC. Or people who are under 65 if they have a higher blood loss surgery. And then again, it depends on the surgery. Are they having a GU surgery? They should probably have a urinalysis, right? But urinalysis for everybody? There isn't really enough evidence to recommend that. So again, always collaborate, always ask questions, case by case dependent. But those are kind of the main ones to think about. I think the most important is the EKG for people who have cardiac risk factors. Because again, you're just digging to find if there are any cardiac abnormalities.

And if you have any question about somebody with pulmonary abnormalities and you're not quite sure, do a chest x-ray, do they have any abnormalities? Feel free to send him to pulm. So that's it. I'm sorry that was so much information. I tried to keep it short and sweet as possible. Hopefully it was more helpful than it was confusing. And I hope that there were some helpful tips you can take away into your practice because again, it's such case by case dependent that you just have to be as careful as you can and then just ask for help when you need it and just don't push yourself too hard because it's okay to ask for help and it's okay to refer out when you need to. And I say this a lot, but I just got to keep saying it because I keep hearing it over and over again.

So I hope that makes you feel a little bit better. Definitely leave a comment below, if this video is helpful, I'd love to hear from you. Also, if you have a difference of opinion about what testing we should be doing, definitely let me know. Maybe that's a little controversial. Hopefully it's not. Hopefully it's reassuring. And yeah, any other screening tools you use or other suggestions that you have or recommendations, things like that. And hopefully there's nothing I left out. Don't forget to grab your copy of the Ultimate Resource Guide from the New NP over at realworldnp.com, if you haven't grabbed one already. And you'll get these videos sent straight to your inbox with notes from me, bonus content that I just don't share anywhere else. So thank you so much for watching. Hang in there and I'll see you next time.