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s!s"s#s$s%s&s's(s)s*s+s,s-s.s/lls0‹‹s1@@s2AAs3s4 s5ŠŠs6s7s8 s9s:¦¦s;i€<i€= s>ÿs? s@ÿsA&&sBsC sDnnsEn@FÿsGÿsHsIsJsK//sL..sM..sN..sO--sP sQsR sS sTjjsUi€Vi€Wi€Xi€Yn@Zi€[n@\i€]i€^i€_s`sasbi€ci€di€ei€fi€gi€hi€ii€ji€ki€li€mi€ni€oi€pi€qi€ri€si€ti€ui€vi€wi€xi€yi€zs{i€|i€}i€~i€i€€i€i€‚i€ƒi€„i€…i€†i€‡i€ˆi€‰i€Ši€‹i€Œsi€Ži€i€i€‘i€’s“i€”i€•i€–i€—i€˜i€™i€šs›sœsÿsž sŸs s¡s¢s£s¤s¥s¦s§s¨s©sªs«s¬ss®""s¯s°s±s²s³s´sµs¶s·s¸s¹i€ºs»i€¼s½s¾s¿sÀsÁsÂsÃsÄsÅsÆsÇsÈsÉsÊ))sË sÌ sÍ¶¶sÎi€Ïi€Ði€Ñi€Òi€Ón@Ôi€ÕsÖ s×sØsÙsÚn@Ûn@Ün@Ýn@Þn@ßn@àn@án@â sã sä så**sæn@çi€èsésê sëi€ìsín@în@ïsðsñsò só sô&&sõ sös÷99sø sù66súsû33süse0f1g0h1i0j0k1l2m2n2o2p1q3r2s0t1u0v1w0x1y1{4†true‡emrgyesˆfalse‰emrgnoŠ crvascyes‹ crvascnoŒfavcathyes favcathnoŽminor pushminor intermediate‘pushint’major“ pushmajor”¨Guidelines were adopted from the ACC/AHA Guidelines For Perioperative Cardiovascular Evaluation ForNoncardiac Surgery (J Am Coll Cardiol 1996 Mar 15; 27[No. 4]:910-948–Minor Clinical Predictors—p1.Advanced Age 2.AbnormalEKG 3.NonSinus Rhythm 4.Low functional Capacity 5.HxStroke 6.Uncontrolled HTN˜0™OKš1œIntermed. Clinical Predictorsj1.Mild Angina 2.MI>6months ago 3.Compensated Or Prior CHF 4.DiabetesŸMajor Clinical Predictors ¢1.Unstable Coronary Syndrome(MI<6months, Unstable Or Severe Angina) 2.Decompensated CHF 3.Sig Arrythmia 4.Severe Valvular DZ¡empty¢page2£poor¤xpoor¥mod¦xmod§high¨ highrisk©lowªlowrisk« interrisk¬page1¯High Surgical Rx°¼Cardiac Rx >5%: 1.Emergency surgery 2.Aortic & other major vascular surgery 3.Peripheral vascular surgery 4.Prolonged surgical procedures associated with large fluid shifts or blood loss²Intermediate Surgical Rx³—Cardiac Rx <5%: 1. Carotid endarterectomy 2.Head And neck surgery 3.Intraperitoneal And intrathoracic surgery 4.Orthopedic surgery 5.Prostate surgeryµLow Surgical Rx¶qCardiac risk generally <1%: 1.Endoscopic procedures 2.Superficial procedures 3.Catarac surgery 4.Breast surgery.¸-Is this an Emergent or Nonemergent Operation¹(GO DIRECTLY TO OR For emergency surgeryº4HAS THE PT HAD A RECENT REVASCULARIZATION PROCEDURE»;Is This Patient a Minor/Intermediate/ Major Clinical Risk¼GO DIRECTLY TO OR½Consider delay or cancellation of noncardiac sugery. Further management depends on the etiology of the major risk factor (eg. ischemia vs valvular disease).¾,HAS THE PT HAD A RECENT CATH OR STRESS TEST¿(How Many Mets Can this Patient TolerateÀGThe patient needs noninvasive testing for further risk stratification.Á5Is the Procedure a Low/Intermediate/High Risk SurgerÂ[This patient is an intermediate risk for a Low Risk Surgical Procedure. Go directly to ORÃeThis patient is an intermediate risk for an Intermediate Risk Surgical Procedure. Go directly to ORÄUThis patient is a minor surgical risk for any surgical procedure. Go directly to ORÅRThis patient is an low risk For a Low Risk Surgical Procedure. Go directly to ORÆ[This patient is a low risk For an Intermediate Risk Surgical Procedure. Go directly to OrÇrecommendationÉPoor Tolerance <4metsÊÛAn individual can do 4 to >10 mets if 1.Climb a flight of stairs/walk up a hill 2.Walk at 4mph 3.Run short distances 4.Do heavy house work 5.Participate in moderate physical activity 6.Participate in strenuous sportsÌÛAn individual can do 4 to >10 mets if 1.Climb a flight of stairs/walk up a hill 2.Walk at 4mph 3.Run Short distances 4.Do heavy house work 5.Participate in moderate physical activity 6.Participate in strenuous sportsÍ mainmenuàsexmaleá sexfemaleâanginatypicalãanginaatypicalämiyesåminoæqyesçqnoèstyeséstnoêdiabetesyesëdiabetesnoì smokeyesísmokenoî hcholyesïhcholnoðñlabiòptageó2.581ô.976õcad2ö¼Pryor DB, Shaw L, et al. 'Value of the history And physical in identifying patients at increased risk For coronary artery disease.' Annals of Internal Medicine 1993 Jan 15;118(2):81-90.üMust Input Pt's Ageý.1126þ.328ÿ.03011.0931.213.7412.5961.845.694.637.0404.0251 .55 7.3762.7183100 pretestcad1 popstressekg2thal3echo.52.71 .87!.64".85#.77$sensfld%specfld&postposfld'postnegfld5dysp6 pleuritic7nonpain8sat9hemoptysis:rub; petypical>e1)Use of a Clinical Model for Safe Management of Patients with Suspected PE. AIM, 1998.;129:997-1005?2)PIOPED. JAMA, 263:2753-9@10E *syncopeFL*blood pressure less than 90mmHg with heart rate greater than 100 beats/minG2*requires oxygen supplementation greater then 40%HN*new onset right heart failure (elevated JVP and new S1,Q3,T3 or RBBB on ECG)IsevereJseveryKsevernLpecalcMperiskNpe1O alternateQtestpreSvqT negativeUintV4W27X59Y79Z98[13\29]84^.003_1.4`3.5a33c fieldpostd peseverej*Surgery within 12 weekskD*Immobilization (bedrest) for 3+days in 4 weeks before presentationl*Previous DVT or PEmF*Fracture of lower ext and immobilization of fracture within 12 weeksn6*Family hx of DVT or PE (2 members with known events)orisk1priskyqrisknv*Heart rate >90 beats/minw*Leg symptomsx*Low-grade fevery*Chest xray c/w PEztypicalfld{ typicaly| typicaln‡probiˆinfo‰coughŠstrep‹exŒnodesfcŽ9532‘temp’100.9“105”$Pt temperature>105 is this correct?•Must input a Temperature–95—'Pt temperature is <95 is this correct?˜-1™.16š4.61›No treatment, No cultureœ.61616ž'Culture and wait, or culture and treatŸ2.61 44¡4.34¢57£Treat and do not culture¤83¥lr¦prob§ recommendfld¨fAssuming a positive culture prevalence of 24% as calculated in a hospital-based inner city population©OSimplified Walsh Clinical Prediction Guide Arch Int Med 1975; 135:1493-1497ªstrep1²³1997 ACP, 'Guidelines for Assessing and Managing the Perioperative Risk from Coronary Artery Disease Associated with Major Noncardiac Surgery'. Ann Intern Med. 1997; 127:309-312.³surgy´Proceed Directly to Surgery¶Canadian Angina Classification·0=asymptomatic;¸"I=angina with strenuous exercise;¹"II=angina with moderate exertion;ºFIII=angina with walking 1 to 2 blocks or climbing 1 flight of stairs;»IV=angina with any activity.¼mi½angina¾20¿chfÀasyesÁrhythm1Ârhythm2Ãrhythm3Ärhythm4ÅvascÆnonvascÇsurgnÈacp2É3Go Back, Must Pick Emergent or Nonemergent SurgeryÊ9PO2<60mmhg, PCO2>50mmHg, K+<3, BUN>50, Cr>2.9, bedriddenÍmedyÎageyÏdiabyÔProceed directly to surgeryÕ19Ö=The patient is at high risk (>15%) for a perioperative event×ÜThis patient is at a low risk (<3%) for a perioperative event and may proceed directly to surgery without further noninvasive testing. There is no evidence that further testing will alter risk assessment in this group.ØÑThe patient is at intermediate risk (3-15%) for a perioperative event. Perform thallium imaging or dobutamine stress echo. A negative test places the patient at low risk (<3%) for a perioperative event and Ùvyou can proceed directly to surgery. A positive test puts the patient at high risk (>15%) for a perioperative event.Ú”This patient is at intermediate risk (3-15%) And is undergoing nonvascular surgery. No further testing is necessary. Proceed directly to surgery.ÛmcifldÜ lriskfldÝ acpresultÞacp1ßmciàlrvíMI<6 months ago 10îMI>6 months ago 5ïClass III angina 10ðClass IV angina 20ñ!Pulmonary edema within 1 week 10òh/o pulmonary edema 5óCritical aortic stenosis 20ôFRhythm other than sinus Or sinus plus atrial premature beats on EKG 5õ>5 PVSs on EKG 5öPoor general medical status 5÷Age> 70 years 5øEmergency surgery 10ý>If the patient's MCRI is less than 20, he is either at low orþP intermediate risk For a cardiac event perioperatively. To determine whether heÿf is at low Or intermediate risk, you must determine the number of low risk variables the patient has.û The patient gets 1 point For each low risk variable. If the patient has 0 Or 1 low risk variables, Then he is at low risk For a perioperative cardiac event, however, If he has 2 Or more low risk variables Then he is at intermediate risk For an eventlrv1_Variables: Age>70, History of angina, Diabetes mellitus, Q's on EKG, Hx of ventricular ectopylrv2 ransonidageglucose wbc ldhsgothct buncabasefluid15%5%25%14%39%22%57%43%50%disease mortalityranson{Debernardinis M, et al. Automated selection of high-risk patients with acute pancreatitis. Crit Care Med 1989;17:318-323."anticoagid#‘Kuijer PM etal. Prediction of the risk of bleeding during anticoagulant treatment for venous thromboembolism. Arch Intern Med 1999; 159:457-460$ bleedfld%1.6& genderfem'1.3(maligy)2.2,4%-1%.8%/2%017%17%2 majorfld3anyfld4 bleeding67These rules are intended for educational purposes only7disc28ml9apache1:fib;fram1<6=7> dementia1?8@varicAlbb1B11C12D14EgailF15G coumadinIbutton1504J\SPAF Investigators. Predictors of thromboembolism atrial fib... Ann Int Med 1992; 116:1-5.LhtnMachfN previousO2.5%P7.2%Q17.6%RafibfldWbutton1516XzLe Moine etal. 'Factors related to early mortality in cirrhotic patients bleeding from varices...' Gut 1992; 33:1381-1385YencepZptfld[xfuse\2.75].1^.31_2.64b###.00%cmortsapachitgOrgan insufficiency or immune compromised state must have been evident prior to the hospital admissionvLiverw‹Biopsy proven cirrhosis and documented portal hypertension; episodes of past upper gi bleed; prior episode of hepatic failure/enceph/coma.yCardiovascularz%New York Heart Association class IV.|Respiratory}]Severe exercise restriction, Chronic hypoxia,hypercapnia, pulm htn(>40mmhg), vent dependenceRenal€Chronic Dialysis‚Immune-CompƒSPatient has received immune suppresive therapy or has a disease that is supressive„ apachage…liver†renal‡respˆic‰cvŠtfld‹mapfldŒhrfldrrfldŽoxfldphfldapache2‘hKnaus WA, etal. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13:818-829’na“kfld”crfld•hctfld–wbcfld—gcsfld˜41™39š40.9›38.5œ38.936ž38.4Ÿ34 35.9¡33.9¢30£31.9¤29.9¥Must input Patients age¦180§140¨179©110ª139«70¬10955®69¯40°54±Must input hr²160³130´159µ129¶50·49¸Must input MAP¹35º25»24¼Must input rr½500¾350¿499À200Á349ÂMust input pa02Ã7.7Ä7.6Å7.69Æ7.5Ç7.59È7.33É7.49Ê7.25Ë7.32Ì7.15Í7.24ÎMust input pHÏ155Ð150Ñ154Ò149Ó120Ô111Õ119ÖMust input na×6.9Ø5.5Ù5.9Ú5.4Û3.4Ü2.5Ý2.9Þ Must input kàarfá1.5â1.9ã.6äMust input Creatinineå60æ59.9ç46è49.9é45.9êMust input HCTë39.9ì19.9í14.9îMust input WBCïopstatð45ñ64ò65ó74ô75÷statusø42ù53ú71û88ü77ý18þ23ÿ2880###% apacheflddyeardseasonddatedday dstate!dcity"dfloor#dhosp$dcounty%dmonth&dflag'dball(dtree)dflag2*dball2+dtree2,dwatch-dpen.miniid/mList any three concrete images. Ask the patient to repeat them. Record the number the pt is able to repeat0ŒAsk the patient to count backwards by 7 from 100 and count how far patient can go. Alternatively spell world backwards/1pt for each letter1Aany concrete object will do as a suggestion use a watch or a pen2BAsk the patient to remember the objects listed above, No hinting.3correct4 dementia25‹Folstein M, etal. 'Mini Mental State: a practical method for grading the cognitive status of patients..' J Psychiatr Res 1975; 12:129-198.6dno7dyes8 dsentence9dimage:§This tests the ability to follow a three step command. One point for each correct step. As a suggestion 'Take a piece of paper, fold it in half, put it on the table'= threestep? field1673A'A score<23 is consistent with dementiaBfldyCbutton1690DoSgarbossa EB, etal. Electrocardiographic diagnosis of evolving AMI in the presence of lbb. NEJM 1996;481-487.H checkbox1691I checkbox1694J checkbox1696K0In the study group 20/129 (16%) had an Acute MIL/In the study group 15/27 (56%) had an Acute MIM/In the study group 44/50 (88%) had an Acute MIN/In the study group 48/52 (92%) had an Acute MIO.In the study group 4/4 (100%) had an Acute MIP field1699Q36% Sens and 96% Spec for AMIR field1701Sbutton1709TkAnderson KW etal. An updated coronary risk profile: a statement of health professionals. Am Heart J; 1991_pushbutton1713`pushbutton1714afagefldb-12c31d-11e-9f-8g-6h-5i-4j37k-3l38m-2n43o47p48q51r52s56t61u67v68w62x17y73zftchol{151|152}166~167182€183199‚219ƒ220„239…240†262‡263ˆ288‰289Š315‹316Œfhdl26Ž668187‘-7’fsbp“104”112•113–121—161˜172™173š checkbox1724› checkbox1726œ checkbox1725ž field1728Ÿ<1 2¡5¢8£12¤13¥9¦3§6¨10©14ª16«21¬3024®#Average 10yr prob(%) of CAD for a ¯###y/o °Woman: ±Man: ²yr5³<2´yr10µ1¶4·7¸18¹21º19»22¼11½23¾25¿27À29Á17Â31Ã33Ä20Å36Æ22Ç38È40É42Ê*Your Patients Prob (%) at: 5yr 10yrË field1739Ìbutton1767Í·Gail MH, Brinton LA, Byar DP, et. al. Projecting individulized probabilities of developing breast cancer for white females who are being examined annually, J. NCI, 81:1989, 1879-1886ÕgageÖ gmenarche×gbiopsyØgaflbÙgfamilyÚ.09401Û.52926Ü.21863Ý.9583Þ.01081ß.28804à.19081á.74948âOdds Ratio: ã###.0#####ä field1769å+You must answer all of the above questionsènobleedébleedêunstablebleedìinrfldí4.6î9.9ïtherapyðnotesñNO treatment at this timeò field1783óHold Warfarinô'Consider Vit K if procedure is plannedõ field1790öVit K 0.5-1mgIV÷:Expect decrease in INR at 8hrs, INR should be2-3 in 24hrsøVit K 3-5mgIVù7Expect decrease in INR at 6hrs, Recheck INR in 6-12hrsúVit K 10mgIV +/- FFPû4Expect decrease in INR at 6hrs, Recheck INR in 6hrsüVit K 10mgIV +FFP 20-40cc/kg&²êë Ed;=HIJRUVWX\]`a€Š‹§¨©ª®°ÀÁÝÞåï1òø. ,"#245>CJOPQRTWapqstu‰Š‹Œ•Ÿ ±´µ¶¸¹¼ÌÍÎÓÔÞßàäèéêëìù CXDRW_Zabmrux|—~„‡Ž™š¨©ª¬¿ÉÊÎçèèvëíûü ëÈ Âê4J`’¨¾ä@Vlž¸Úô(>Perioperative Risk from CAD\êACC/AHA Guidelines "€ÿEmergency Surgery?\" éYl" éN0€ÿCorornary Revascularization <5yrs,”0éY”<éN(<€ÿand no currnet symptomsH€ÿFavorable Cath or Stress test <2yrs, T€ÿand no change in symptoms”HéY”TéNd€ÿClinical Predictors of Periop Riskp$éMinor0p<éIntermediate tp$éMajorEx$èNext -->b€ écH€ éd„€ é ;È°Ìæ Jf Ž¦Êàö.Np†œ=>$éRestartH,éHighI,,@éIntermediateJt,$éLowK €ÿRisk of Surgical ProcedureR$é<--BackSd€(Âôˆc(T€ U$PTéRecommendationV< éWD< éX„< é[€ÿExercise Tolerance\8éPoor<4mets]PDéMod-Ex>4mets`@ é a• é €x$éMenu ‹È ò(Pb~œ´Ìäü*BXpˆ ¸Ðèþ0LdxŽ¬Likelihood of Sig. 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