Presentation Details
| Zero to Sixty: The Perioperative Visit that went from Risk Stratification to Crisis Management Sarah Khan, Kaylee Lewis, Heather Lander. University of Rochester, Rochester, NY, USA |
Abstract
CASE PRESENTATION: A 65-year-old man presented to the University of Rochester Center for Perioperative Medicine for preoperative optimization prior to a scheduled colonoscopy. His medical history included severe idiopathic angioedema with episodic flares, heart failure with preserved ejection fraction, obstructive sleep apnea, and obesity. During rooming, he appeared acutely ill with notable facial and neck swelling, dyspnea, and hoarse speech, symptoms consistent with prior flares. Examination revealed diffuse inspiratory wheezes bilaterally. He was placed on supplemental oxygen and treated with diphenhydramine, his rescue subcutaneous icatibant (bradykinin B2 receptor antagonist), and intramuscular epinephrine per his established flare protocol. Emergency Medical Services were called, and he received additional epinephrine and corticosteroids en route to the hospital, where he was admitted to the intensive care unit for airway monitoring.
DISCUSSION: This case illustrates how a routine perioperative evaluation can transition into acute care. Following stabilization, the patient required further optimization prior to proceeding with surgery. His Revised Cardiac Index indicated a 1.3% risk of major cardiac complications, and his ARISCAT score placed him at high risk (42%) for postoperative pulmonary complications. Given his high-risk airway and comorbidities, it was recommended the procedure be performed at an inpatient facility rather than an ambulatory surgery center where it was originally scheduled to better match available resources. The patient had previously undergone surgery (IR mediport placement) complicated by a postoperative angioedema flare. During that evaluation, communication between the clinic, anesthesia coordinators, and pharmacists ensured the availability of his emergency medications in PACU and outlined a plan for managing a potential flare.
CONCLUSIONS: This case highlights the critical role of perioperative clinics in not only identifying and optimizing patients with complex conditions prior to surgery, but also detecting acute illness and decompensation. Comprehensive assessment, interdisciplinary communication, and early risk recognition can prevent adverse events, guide proper resource matching for surgical location, and improve perioperative safety and outcomes.
No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the author.
DISCUSSION: This case illustrates how a routine perioperative evaluation can transition into acute care. Following stabilization, the patient required further optimization prior to proceeding with surgery. His Revised Cardiac Index indicated a 1.3% risk of major cardiac complications, and his ARISCAT score placed him at high risk (42%) for postoperative pulmonary complications. Given his high-risk airway and comorbidities, it was recommended the procedure be performed at an inpatient facility rather than an ambulatory surgery center where it was originally scheduled to better match available resources. The patient had previously undergone surgery (IR mediport placement) complicated by a postoperative angioedema flare. During that evaluation, communication between the clinic, anesthesia coordinators, and pharmacists ensured the availability of his emergency medications in PACU and outlined a plan for managing a potential flare.
CONCLUSIONS: This case highlights the critical role of perioperative clinics in not only identifying and optimizing patients with complex conditions prior to surgery, but also detecting acute illness and decompensation. Comprehensive assessment, interdisciplinary communication, and early risk recognition can prevent adverse events, guide proper resource matching for surgical location, and improve perioperative safety and outcomes.
No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the author.
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