Episode 269: New Frontiers in Preop Assessment and Optimization with Dr. Jeanna Blitz
Nov 19, 2023
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Dr. Jeanna Blitz, an expert in preoperative assessment and optimization of patients, discusses the use of biomarkers, alternatives to RCRI, and assessment of frailty, nutritional and psychological status. They also discuss the importance of preoperative optimization, biomarkers in perioperative risk assessment, assessing surgical risk with prediction models, considerations for different surgical scenarios, anemia in surgical patients, and recent rule changes in baseball.
Assessing a patient's functional capacity before surgery can help identify areas for improvement and interventions to enhance their readiness for surgery.
Integrating risk prediction models and considering the level of surgical risk helps determine the overall risk profile of a patient preoperatively.
Biomarkers like NT-proBNP and troponins play a crucial role in risk assessment, but further investigations may be necessary to determine their underlying cause and severity.
Deep dives
Preoperative Functional Capacity Assessment
Assessing a patient's functional capacity before surgery is crucial in determining the potential risks and optimizing outcomes. One key aspect is evaluating the patient's ability to perform daily activities, such as climbing stairs or walking. Tools like the Duke Activity Status Index (DASI) or the Met Repair can provide standardized and validated measures of functional capacity. Understanding a patient's functional limitations helps identify areas for improvement or interventions to enhance their readiness for surgery.
Importance of Surgical Risk Assessment
Considering the level of surgical risk is essential when evaluating patients preoperatively. Different types of surgeries carry varying degrees of risk, ranging from low-risk procedures like cataract surgery to high-risk surgeries like vascular procedures. Balancing the patient's individual risk factors with the surgical severity helps in determining the overall risk. Clinicians can integrate risk prediction models, such as the NISQIP calculator or Gupta MICA, to assess the global risk and guide decision-making. This multidimensional approach ensures a comprehensive evaluation of the patient's overall risk profile.
Assessing and Interpreting Biomarkers
Biomarkers like NT-proBNP or troponins play an important role in risk assessment. Elevated levels of NT-proBNP can indicate underlying cardiac issues, pulmonary hypertension, or other conditions. Troponins, on the other hand, can show myocardial injury after non-cardiac surgery. Interpreting these biomarker results must consider the patient's clinical context, history, and other diagnostic tests. However, further investigations like echocardiograms may be necessary to determine the underlying cause and severity of elevated biomarker levels.
Prehabilitation and Optimizing Functional Capacity
Prehabilitation involves improving a patient's functional capacity before surgery. It typically focuses on enhancing exercise capacity through tailored exercise programs. Patients can engage in activities like cardiac conditioning, strength training, or increasing daily physical activity. Prehabilitation also encompasses interventions like dietary modifications, smoking cessation, mental health support, and optimizing comorbidities. These holistic approaches aim to enhance overall health and fitness, reduce the risk of complications, and improve the patient's ability to recover post-surgery.
Pre-habilitation for Patients with Frailty Syndrome
Pre-habilitation is a multifaceted approach to improving the outcomes of patients with frailty syndrome before surgery. It involves focusing on three main domains: physical preparation, nutrition optimization, and psychological readiness. Physical preparation includes exercises like chair sit-to-stand and marching in place to improve functional capacity. Nutrition optimization focuses on providing nutritionally dense foods, with an emphasis on high protein intake. Psychological preparation is essential, as depression and anxiety can impact functional capacity. Prioritizing these domains depends on the patient's vulnerability and specific needs.
Assessing Frailty and Anemia in Surgical Patients
Frailty is an aggregate expression of vulnerability to stress, particularly in the perioperative period. The clinical frailty scale is a useful tool for assessing physical frailty in patients. However, it is important to also screen for cognitive function to refine the risk assessment, such as using the mini-cog test. Anemia is common in surgical patients and should not be overlooked. The cause of anemia should be determined, as it may indicate underlying health issues. Treatments for anemia, including iron deficiency anemia, should be considered preoperatively to improve patient outcomes. Treating anemia can range from iron supplementation to investigating the underlying cause of the anemia.
In this 269th episode I welcome Dr. Jeanna Blitz to the show to discuss the newest, most evidence based approach to preoperative assessment and optimization of patients. We discuss the use of biomarkers, alternatives to RCRI and using METS alone and assessment and optimization of frailty, nutritional status, anemia, psychological status and functional status.
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