It is crucial that assessment and preparation for surgery starts as soon as possible adopting a multimodal , transdisciplinary approach
Optimising cardiac function Thorough assessment of cardiac morbidity is particularly important for high-risk surgical patients . The revised cardiac risk index is one of the most validated and widely used risk assessment tools for predicting peri-operative risk in patients with cardiac comorbidities . 7
Hypertension alone is only a minor independent risk factor for adverse cardiac events in noncardiac surgery . 7 Postponement of planned surgical procedures due to elevated blood pressure is a common reason to cancel necessary surgery .
The Joint Guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society have produced a consensus statement stating patients with clinic blood pressures below 180mmHg systolic and 110mmHg diastolic should not have their surgical procedure delayed . 8 Patients with stage 3 hypertension ( BP > 180mmHg systolic / 110mmHg diastolic ) should have their surgery delayed with BP optimisation and allowing a minimum of 4-6 weeks of treatment following the National Institute for Health and Care Excellence / British Heart Society CG127 algorithm . 8 Patients presenting with stage 1 ( BP 130 – 139mmHg systolic or 80 – 89mmHg diastolic ) or stage 2 hypertension ( BP > 140mmHg systolic or 90mmHg diastolic ) are considered safe to proceed to surgery . 8
It should be noted that patients with diastolic pressure ≥110mmHg immediately before surgery have been shown to have increased risk of complications including myocardial infarction and renal failure . 9
Heart failure is a global problem , with at least 26 million people affected . 10 The prevalence of heart failure is also increasing as the population ages , and more patients with congestive heart failure will present for surgery . 11 In patients with acutely decompensated heart failure ( New York Heart Association class IV ), surgery should be postponed , if possible , and the opinion of a cardiologist sought for titration of heart failure medication . 7 Pharmacists can play a vital role in up-titration of heart failure medication in this crucial period .
Optimising respiratory function Pre-operative optimisation of lung function helps to reduce post-operative pulmonary complications . 12 Patients are advised to stop smoking for a period of 4 – 6 weeks . This reduces airway reactivity , improves mucociliary function and decreases carboxy-haemoglobin . 12 Pharmacists can help promote smoking cessation advice to these ‘ at-risk ’ patients .
Incentive spirometry pre-operatively has also proved to be effective in reducing post-operative pulmonary complications . 13 Pharmacists can further support patients by providing the appropriate counselling on correct inhaler technique and checking compliance . Patients with symptomatic asthma should have their treatment increased until symptom control is achieved . 14 Approximately 4.5 % of the UK population aged over 40 years are affected by chronic obstructive pulmonary disease ( COPD ). 15 For the care of COPD , the updated National Institute for Health and Care Excellence ( NICE ) guidance emphasises ‘ five fundamentals ’ of chronic
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