Download -click here for handouts (3 per page)

4/20/2015
Perioperative
Management
Matt Parks MD
Associate Program Director
Internal Medicine Residency Program
East Tennessee State University
I, Matt Parks, MD DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. Stepwise Approach to Perioperative Cardiac Assessment: Treatment Algorithm
From: 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2014;64(22):e77‐e137. doi:10.1016/j.jacc.2014.07.944
1
4/20/2015
Case #1
A 65 year old male with a history of CAD, CHF, DM, Anemia, and HTN presents to the hospital with severe right groin pain that woke him from sleep a couple of hours ago. He denies any injury. He is afebrile with a blood pressure of 80/50, heart rate 115, respiratory rate 22. On exam he is found to be in distress due to pain, is tachycardic, has lower abdominal tenderness, and diminished pedal pulses. Labs reveal a Hgb
of 8.7 (baseline Hgb 10‐11) with all other labs normal. Aortic aneurysm rupture is suspected and confirmed with CT imaging. What is the next best step in management?
A. Left heart catheterization to assess preoperative cardiac risk.
B. Transfuse PRBCs to increase Hgb above 10.
C. Emergency surgery to repair aortic rupture.
D. Normal saline infusion to correct hypotension.
E. Start pressors and admit to the ICU.
Case #1
A 65 year old male with a history of CAD, CHF, DM, Anemia, and HTN presents to the hospital with severe right groin pain that woke him from sleep a couple of hours ago. He denies any injury. He is afebrile with a blood pressure of 80/50, heart rate 115, respiratory rate 22. On exam he is found to be in distress due to pain, is tachycardic, has lower abdominal tenderness, and diminished pedal pulses. Labs reveal a Hgb
of 8.7 (baseline Hgb 10‐11) with all other labs normal. Aortic aneurysm rupture is suspected and confirmed with CT imaging. What is the next best step in management?
A. Left heart catheterization to assess preoperative cardiac risk.
B. Transfuse PRBCs to increase Hgb above 10.
C. Emergency surgery to repair aortic rupture.
D. Normal saline infusion to correct hypotension.
E. Start pressors and admit to the ICU.
2
4/20/2015
Case #1
The correct answer is C. The patient has known CAD and needs emergency surgery. By the algorithm you recommend proceed to surgery.
Case #2
A 67 year old female with a history of CAD and CHF who presents to the ER with RUQ abdominal pain, nausea and vomiting as well as chest pain, dyspnea and lower extremity edema. She has been feeling ill for a few days and has not taken her medications. She has a temperature of 99.7, blood pressure of 150/95, heart rate 111, respiratory rate 20. On exam she is found to be in distress due to pain. She is tachycardic with an S3, has bibasilar crackles, RUQ abdominal tenderness, and 2+ pitting bilateral lower extremity edema. Notable labs include a BNP of 49,000, WBC of 12.1, and troponin 3.4. CXR shows bilateral pleural effusions and cardiomegaly. EKG reveals ST elevation in the lateral leads (I, aVL, V5‐6). What is the next best step in management?
A.
B.
C.
D.
E.
Left heart catheterization to assess preoperative cardiac risk.
Normal saline and IV antibiotics.
Emergent cholecystectomy.
Thrombolysis then proceed with emergent cholecystectomy.
Admission to the ICU and treatment of ACS.
Case #2
A 67 year old female with a history of CAD and CHF who presents to the ER with RUQ abdominal pain, nausea and vomiting as well as chest pain, dyspnea and lower extremity edema. She has been feeling ill for a few days and has not taken her medications. She has a temperature of 99.7, blood pressure of 150/95, heart rate 111, respiratory rate 20. On exam she is found to be in distress due to pain. She is tachycardic with an S3, has bibasilar crackles, RUQ abdominal tenderness, and 2+ pitting bilateral lower extremity edema. Notable labs include a BNP of 49,000, WBC of 12.1, and troponin 3.4. CXR shows bilateral pleural effusions and cardiomegaly. EKG reveals ST elevation in the lateral leads (I, aVL, V5‐6). What is the next best step in management?
A.
B.
C.
D.
Left heart catheterization to assess preoperative cardiac risk.
Normal saline and IV antibiotics.
Emergent cholecystectomy.
Thrombolysis then proceed with emergent cholecystectomy.
E. Admission to the ICU/CCU and treatment of ACS.
3
4/20/2015
Case #2
The correct answer is E. The patient has ACS and should be evaluated and treated according to Guideline Determined Medical Therapy.
Case #3
A 73 year old male presents to clinic at the request of his ophthalmologist. Last month you referred him to the ophthalmologist for evaluation of a cataract. He tells you the ophthalmologist recommended cataract surgery, but was concerned about his medical history. The patient has a history of CAD with CABG seven years ago. Since that time he has been doing well without chest pain, dyspnea, or any other complaints related to his cardiac condition. His vitals are stable and he has no significant abnormalities on physical examination. Recent routine labs were normal. The patient asks if it is safe to have cataract surgery. What do you tell the patient and ophthalmologist?
A. Cataract surgery is a low risk procedure. No further testing is recommended.
B. Recommend left heart catheterization.
C. Recommend stress testing.
D. Recommend that surgery not be done nor any cardiac testing as he is not a candidate for redo CABG.
E. Refer the patient to a Cardiologist.
Case #3
A 73 year old male presents to clinic at the request of his ophthalmologist. Last month you referred him to the ophthalmologist for evaluation of a cataract. He tells you the ophthalmologist recommended cataract surgery, but was concerned about his medical history. The patient has a history of CAD with CABG seven years ago. Since that time he has been doing well without chest pain, dyspnea, or any other complaints related to his cardiac condition. His vitals are stable and he has no significant abnormalities on physical examination. Recent routine labs were normal. The patient asks if it is safe to have cataract surgery. What do you tell the patient and ophthalmologist?
A. Cataract surgery is a low risk procedure. No further testing is recommended.
B. Recommend left heart catheterization.
C. Recommend stress testing.
D. Recommend that surgery not be done nor any cardiac testing as he is not a candidate for redo CABG.
E. Refer the patient to a Cardiologist.
4
4/20/2015
Case #3
The patient should proceed with cataract surgery. It is considered a low risk surgical procedure. Many plastic surgery procedures are also considered low risk. Some procedures carry lower risk depending on the technique used.
Case #4
A 68 year old female presents to clinic at the request of her orthopedic surgeon who recommended an elective total knee replacement. The patient has a history of CAD. He would like her evaluated prior to surgery. The patient has a history of NSTEMI seven years ago and received a stent at that time. She has had no cardiac issues since that time. Her vitals are stable and she has no significant abnormalities on physical examination. Recent routine labs were normal. The patient states she continues to do heavy work around the house and can climb a flight of stairs, but her knee is a bit sore afterwards. What do you tell the patient and orthopedic surgeon?
A. Total knee replacement is a low risk procedure. No further testing is recommended.
B. Recommend left heart catheterization.
C. Recommend stress testing.
D. Recommend that surgery not be done nor any cardiac testing as she is not a candidate for redo CABG.
E. She is low risk for cardiac complications from noncardiac surgery.
Case #4
A 68 year old female presents to clinic at the request of her orthopedic surgeon who recommended an elective total knee replacement. The patient has a history of CAD. He would like her evaluated prior to surgery. The patient has a history of NSTEMI seven years ago and received a stent at that time. She has had no cardiac issues since that time. Her vitals are stable and she has no significant abnormalities on physical examination. Recent routine labs were normal. The patient states she continues to do heavy work around the house and can climb a flight of stairs, but her knee is a bit sore afterwards. What do you tell the patient and orthopedic surgeon?
A. Total knee replacement is a low risk procedure. No further testing is recommended.
B. Recommend left heart catheterization.
C. Recommend stress testing.
D. Recommend that surgery not be done nor any cardiac testing as she is not a candidate for redo CABG.
E. She is low risk for cardiac complications from noncardiac
surgery.
5
4/20/2015
Case #4
The patient has a low risk for cardiac complications from noncardiac surgery. Her functional capacity is at least 4 METs. She can proceed with total knee replacement.
METS (metabolic equivalents)
• Functional capacity is often expressed in terms of metabolic equivalents (METs), where 1 MET is the resting or basal oxygen consumption of a 40–year‐old, 70‐kg man.
• In the perioperative literature, functional capacity is classified as excellent (>10 METs), good (7 METs to 10 METs), moderate (4 METs to 6 METs), poor (<4 METs), or unknown.
• Perioperative cardiac and long‐term risks are increased in patients unable to perform 4 METs of work during daily activities.
• Examples of activities associated with <4 METs are slow ballroom dancing, golfing with a cart, playing a musical instrument, and walking at approximately 2 mph to 3 mph.
• Examples of activities associated with >4 METs are climbing a flight of stairs or walking up a hill, walking on level ground at 4 mph, and performing heavy work around the house.
Case #5
A 72 year old male presents to clinic at the request of his general surgeon who recommended an elective cholecystectomy. The patient has been experiencing symptoms consistent with biliary colic and US confirmed cholelithiasis. The patient’s surgeon would like him evaluated prior to surgery. The patient has no personal history of CAD, but his older brother and sister have both had CABG. He has no history of chest pain or dyspnea at rest. His vitals are stable and he has no significant abnormalities on physical examination other than mild RUQ tenderness with deep palpation. Recent routine labs were normal. The patient states he does not exercise and is mostly sedentary. He says he gets tired and short of breath when walking up a flight of stairs. What do you tell the patient and surgeon?
A. Cholecystectomy is a low risk procedure. No further testing is recommended.
B. Recommend left heart catheterization.
C. Recommend stress testing.
D. Recommend that surgery not be done nor any cardiac testing as he is not a candidate for redo CABG.
E. He is low risk for cardiac complications from noncardiac surgery.
6
4/20/2015
Case #5
A 72 year old male presents to clinic at the request of his general surgeon who recommended an elective cholecystectomy. The patient has been experiencing symptoms consistent with biliary colic and US confirmed cholelithiasis. The patient’s surgeon would like him evaluated prior to surgery. The patient has no personal history of CAD, but his older brother and sister have both had CABG. He has no history of chest pain or dyspnea at rest. His vitals are stable and he has no significant abnormalities on physical examination other than mild RUQ tenderness with deep palpation. Recent routine labs were normal. The patient states he does not exercise and is mostly sedentary. He says he gets tired and short of breath when walking up a flight of stairs. What do you tell the patient and surgeon?
A. Cholecystectomy is a low risk procedure. No further testing is recommended.
B. Recommend left heart catheterization.
C. Recommend stress testing.
D. Recommend that surgery not be done nor any cardiac testing as he is not a candidate for redo CABG.
E. He is low risk for cardiac complications from noncardiac surgery.
Case #5
The patient has poor functional capacity. Further testing will impact decision making so pharmacologic stress testing should be done.
Case #6
An 87 year old male is admitted to the hospital with a right hip fracture. The patient has a history of severe dementia and is a resident of a local nursing home. He has a history of CAD with CABG fifteen years ago. He has been stable on his current cardiac medications with no complaints of chest pain, but history is limited due to dementia. You are consulted by the orthopedic surgeon for medical evaluation prior to possible surgery. His vitals are stable and he has no significant abnormalities on physical examination other than right hip tenderness. Routine labs were normal. What do you tell the patient and surgeon?
A.
B.
C.
D.
E.
Hip repair is a low risk procedure. No further testing is recommended.
Recommend left heart catheterization.
Recommend stress testing.
Recommend that no cardiac testing be done as it will not change management.
He is low risk for cardiac complications from noncardiac surgery.
7
4/20/2015
Case #6
An 87 year old male is admitted to the hospital with a right hip fracture. The patient has a history of severe dementia and is a resident of a local nursing home. He has a history of CAD with CABG fifteen years ago. He has been stable on his current cardiac medications with no complaints of chest pain, but history is limited due to dementia. You are consulted by the orthopedic surgeon for medical evaluation prior to possible surgery. His vitals are stable and he has no significant abnormalities on physical examination other than right hip tenderness. Routine labs were normal. What do you tell the patient and surgeon?
A. Hip repair is a low risk procedure. No further testing is recommended.
B. Recommend left heart catheterization.
C. Recommend stress testing.
D. Recommend that no cardiac testing be done as it will not change management.
E.
He is low risk for cardiac complications from noncardiac surgery.
Case #6
The patient has poor functional capacity, but further testing will not impact decision making. Palliative care should be considered.
Case #7
A 67 year old male presents to your office for pre‐operative evaluation for right knee replacement. He has a history of osteoarthritis of the right knee and his orthopedic surgeon has recommended replacement as soon as possible. The patient can walk with some discomfort, but it is tolerable. The patient recently had a cardiac evaluation for chest pain with a heart catherization and drug eluting stent placement. The stent was placed three weeks ago. He is on clopidogrel and aspirin.
Which of the following do you recommend?
A. Delay knee replacement for one year.
B. Delay knee replacement for one week.
C. Stop clopidogrel and aspirin and recommend knee replacement today.
D. Stop clopidogrel and aspirin for a week and proceed with knee replacement.
E. Continue clopidogrel and aspirin and proceed with knee replacement today.
8
4/20/2015
Case #7
A 67 year old male presents to your office for pre‐operative evaluation for right knee replacement. He has a history of osteoarthritis of the right knee and his orthopedic surgeon has recommended replacement as soon as possible. The patient can walk with some discomfort, but it is tolerable. The patient recently had a cardiac evaluation for chest pain with a heart catherization and drug eluting stent placement. The stent was placed three weeks ago. He is on clopidogrel and aspirin.
Which of the following do you recommend?
A. Delay knee replacement for one year.
B. Delay knee replacement for one week.
C. Stop clopidogrel and aspirin and recommend knee replacement today.
D. Stop clopidogrel and aspirin for a week and proceed with knee replacement.
E. Continue clopidogrel and aspirin and proceed with knee replacement today.
Case #7
• Algorithm for Antiplatelet Management in Patients With PCI and Noncardiac Surgery
Case #8
A 67 year old male presents to your office for pre‐operative evaluation for right knee replacement. He has a history of osteoarthritis of the right knee and his orthopedic surgeon has recommended replacement as soon as possible. The patient can walk with some discomfort, but it is tolerable. The patient recently had a cardiac evaluation for chest pain with a heart catherization and drug eluting stent placement. The stent was placed six months ago. He is on clopidogrel and aspirin.
Which of the following do you recommend?
A. Delay knee replacement for one year.
B. Delay knee replacement for six months.
C. Stop clopidogrel and aspirin and recommend knee replacement today.
D. Stop clopidogrel and aspirin for a week and proceed with knee replacement, then restart both as soon as possible.
E. Continue clopidogrel and aspirin and proceed with knee replacement today.
9
4/20/2015
Case #8
A 67 year old male presents to your office for pre‐operative evaluation for right knee replacement. He has a history of osteoarthritis of the right knee and his orthopedic surgeon has recommended replacement as soon as possible. The patient can walk with some discomfort, but it is tolerable. The patient recently had a cardiac evaluation for chest pain with a heart catherization and drug eluting stent placement. The stent was placed six months ago. He is on clopidogrel and aspirin.
Which of the following do you recommend?
A. Delay knee replacement for one year.
B. Delay knee replacement for six months.
C. Stop clopidogrel and aspirin and recommend knee replacement today.
D. Stop clopidogrel and aspirin for a week and proceed with knee replacement, then restart both as soon as possible.
E. Continue clopidogrel and aspirin and proceed with knee replacement today.
Case #8
• Algorithm for Antiplatelet Management in Patients With PCI and Noncardiac Surgery
Case #9
A 72 year old female presents to clinic in follow‐up after and admission for cholecystitis. She was treated conservatively with antiobitics and discharged home a week ago. Her surgeon referred her to you for pre‐operative assessment. She has a history of coronary artery disease and takes metoprolol, lisinopril, clopidogrel, and aspirin. She had a two stents placed two years ago. She had a stress test in the hospital that was completely normal with no signs of ischemia and a normal ejection fraction. She asks if there is anything she needs to do before her gallbladder is removed.
Which of the following do you recommend?
A. Delay cholecystectomy for one year.
B. Recommend that cholecystectomy not be performed due to high risk.
C. Stop clopidogrel and aspirin and recommend cholecystectomy in a week.
D. Stop clopidogrel, continue aspirin and proceed with cholecystectomy in a week.
E. Continue clopidogrel and aspirin and proceed with cholecystectomy today.
10
4/20/2015
Case #9
A 72 year old female presents to clinic in follow‐up after and admission for cholecystitis. She was treated conservatively with antiobitics and discharged home a week ago. Her surgeon referred her to you for pre‐operative assessment. She has a history of coronary artery disease and takes metoprolol, lisinopril, clopidogrel, and aspirin. She had a two stents placed two years ago. She had a stress test in the hospital that was completely normal with no signs of ischemia and a normal ejection fraction. She asks if there is anything she needs to do before her gallbladder is removed.
Which of the following do you recommend?
A. Delay cholecystectomy for one year.
B. Recommend that cholecystectomy not be performed due to high risk.
C. Stop clopidogrel and aspirin and recommend cholecystectomy in a week.
D. Stop clopidogrel, continue aspirin and proceed with cholecystectomy in a week.
E.
Continue clopidogrel and aspirin and proceed with cholecystectomy today.
Case #9
• Algorithm for Antiplatelet Management in Patients With PCI and Noncardiac Surgery
Case #10
A 75 year old female is admitted to the hospital after a fall resulted in a right hip fracture. The patient has a history of coronary artery disease. Your risk assessment determines a stress test is indicated. The stress test shows no evidence of ischemia and a normal ejection fraction. She is on aspirin, metoprolol, lisinopril, and amlodipine. She has no chest pain or dyspnea. Her vitals have been stable during the hospitalization. She asks if any of her medications will be changed prior to surgery to repair her hip. Which of the following do you recommend?
A. Stop all cardiac medications prior to surgery and restart them when in a few days if her blood pressure allows.
B. Recommend continuation of metoprolol as well as her other cardiac medications.
C. Hold metoprolol, but continue all of her other cardiac medications.
D. Increase the dose of metoprolol for better cardioprotective effects.
E. Decreased the dose of metoprolol for better cardioprotective effects.
11
4/20/2015
Case #10
A 75 year old female is admitted to the hospital after a fall resulted in a right hip fracture. The patient has a history of coronary artery disease. Your risk assessment determines a stress test is indicated. The stress test shows no evidence of ischemia and a normal ejection fraction. She is on aspirin, metoprolol, lisinopril, and amlodipine. She has no chest pain or dyspnea. Her vitals have been stable during the hospitalization. She asks if any of her medications will be changed prior to surgery to repair her hip. Which of the following do you recommend?
A. Stop all cardiac medications prior to surgery and restart them when in a few days if her blood pressure allows.
B. Recommend continuation of metoprolol as well as her other cardiac medications.
C. Hold metoprolol, but continue all of her other cardiac medications.
D. Increase the dose of metoprolol for better cardioprotective effects.
E. Decreased the dose of metoprolol for better cardioprotective effects.
Case #10
• Class I
• 1.Beta blockers should be continued in patients undergoing surgery who have been on beta blockers chronically. (Level of Evidence: B)
•
•
•
•
•
•
•
•
•
Class IIa
1.It is reasonable for the management of beta blockers after surgery to be guided by clinical circumstances, independent of when the agent was started. (Level of Evidence: B)
Class IIb
1.In patients with intermediate‐ or high‐risk myocardial ischemia noted in preoperative risk stratification tests, it may be reasonable to begin perioperative beta blockers. (Level of Evidence: C)
2.In patients with 3 or more RCRI risk factors (e.g., diabetes mellitus, HF, CAD, renal insufficiency, cerebrovascular accident), it may be reasonable to begin beta blockers before surgery. (Level of Evidence: B)
3.In patients with a compelling long‐term indication for beta‐blocker therapy but no other RCRI risk factors, initiating beta blockers in the perioperative setting as an approach to reduce perioperative risk is of uncertain benefit. (Level of Evidence: B)
4.In patients in whom beta‐blocker therapy is initiated, it may be reasonable to begin perioperative beta blockers long enough in advance to assess safety and tolerability, preferably more than 1 day before surgery. (Level of Evidence: B)
Class III: Harm
1.Beta‐blocker therapy should not be started on the day of surgery. (Level of Evidence: B)
Summary
Follow ACC guidelines to the letter.
Consulting Cardiology is probably not the correct answer.
Never say a patient is “cleared” for surgery.
Use terms like “low risk for cardiac complications”
Don’t start or stop beta blockers on the day of surgery.
Unstable cardiac disease: delay non‐emergent surgery
Pre‐existing chronic CV disease or symptoms not yet diagnosed: evaluate and manage per EBGs
• Stable or no CV disease: proceed with surgery without testing
• Emergent surgery: proceed with surgery
•
•
•
•
•
•
•
12