Download How to Keep Your Surgeon Out of Trouble

How to Keep Your Surgeon Out of
Trouble: Perioperative Medicine:
Risk Stratification
Jalal K. Ghali, M.D., F.A.C.C.
Professor of Medicine
Associate Chair for Clinical Research
Chief, Division of Cardiology
Department of Medicine
Mercer University School of Medicine
Macon, GA
How to Make Your Surgeon
Happy
Dear Dr. GS,
Your patient Mr. MC has been “cleared” for
the planned surgery.
I would like to assure you that no medical
complications will arise from the planned
surgery and furthermore, should they arise, I
take full responsibility for managing them.
Our commitment extends for full 30 days post
op.
How to Keep Your Surgeon Out of
Trouble:
Impossible
Disclosures
Internists:
Know everything and do no
procedures
Surgeons:
Know nothing and do everything
Psychiatrists: Have no clue
Pathologists: Know everything, do everything…
one day late
Definition of the
Medical Consultant
Perioperative Medicine
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Magnitude of the problem
Is there a need for medical consultation?
Pathophysiology
Predictive models
 Revised Cardiac Risk Index
 Thoracic Revised Cardiac Risk Index
 Vascular Study Group of New England
 Surgical Mortality Probability Model
 Risk Calculator for Prediction of Cardiac Risk
Perioperative Medicine
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Clinical Recommendations
Special considerations
 Biomarkers
 Hypertension
 PCI
 Statins
 Beta Blockers
Summary
Definition of the medical consultant
10 million major noncardiac surgery
 4 million in patients ≥65 years
 High risk account for 80% of death
 250 million procedures worldwide
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Common preventable complications after non-cardiac surgery
that may be prevented by enhanced perioperative care
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Pneumonia
Superficial and deep wound infection
Myocardial infarction
Arrhythmias
Severe pain
Pulmonary embolism
Acute kidney injury
Stroke
Respiratory failure
Acute confusion or delirium
Cardiac arrest
Pearse RM, et al. BMJ 2011;343:d5759.
84,730 patients who had undergone inpatient
general and vascular surgery 2005 - 2007
Very low mortality
3.5%
Ghaferi AA. N Engl J Med 2009;361:1368-75
Very high mortality
6.9%
Rates of All Complications, Major Complications,
and Death after Major Complications
Ghareri AA, et al. N Engl J Med 2009;361:1368-1375.
Patients surviving beyond
30 days postop
Survival Probability
All Patients
Days
Patients with no complications
Patients with 1 or more 30-day postop complications
Khuri SF, et al. Ann Surg 2005;242(3):326-343.
Hospital-specific rates of preoperative medical
consultation for major elective noncardiac surgery
Wijeysundera DN, et al. Anesthesiology 2012;116:25-34.
Associations Between Perioperative Consultation,
Quality of Care, and Subsequent Complications
Auerbach AD, et al. Arch Intern Med 2007;167:2338-2344.
217,082 39% (n = 104,716) underwent
anesthesia consultations
- Reduced mean hospital length of stay
8.17 vs 8.52 day
- No reduction of 30 day or 1 year mortality
Wijeysundera DN, et al. Arch Intern Med 2009;169(6):595-602.
1994 – 2004
269,866
n = 104695 (38.8%) underwent consultation
30 day mortality
1 year mortality
RR 1.16 (1.07 – 1.25)
Number needed to harm
516
RR 1.08 (1.04 – 1.12)
Number needed to harm
227
Wijeysundera DN, et al. Arch Intern Med 2010;170(15):1365-1374.
Pathophysiology
Emotional stress
 Pain
 Surgical trauma
 Tissue injury
 Hypothermia
 Hypoxemia
 Immobility
 Bleeding and anemia
 Fasting

Landesberg G et al. Circulation 2009;119:2936-2944.
Landesberg G et al. Circulation 2009;119:2936-2944.
Potential triggers of states associated with perioperative
elevations in troponin levels, arterial thrombosis and fatal
myocardial infarction
Devereaux PJ, et al. CMAJ 2005;173(6):627-634.
Risk Prediction Models
Revised Cardiac Risk Index
Lee TH, et al. Circulation 1999;100:1043-1049.
Risk of Cardiac Death and Nonfatal Myocardial
Infarction for Noncardiac Surgical Procedures
Risk of
procedure
High (> 5%)
Aortic and major vascular surgery, peripheral
vascular surgery
Intermediate
(1 to 5%)
Intraperitoneal or intrathoracic surgery, carotid
endarterectomy, head and neck injury,
orthopedic surgery, prostate surgery
Low (< 1%)
Ambulatory surgery, breast surgery,
endoscopic procedures, superficial
procedures, cataract surgery
Thoracic Revised Cardiac
Risk Index
Thoracic Revised Cardiac Risk Index
Ischemic Heart Disease
CVA or TIA
Pneumonectomy
Creatinin >2 mg/DL
Brunelli A, et al. Ann Thorac Surg 2011;92:445-8.
1.5
1.5
1.5
1.0
Distribution of Patients in Each Class of the Recalibrated
Revised Cardiac Risk Index (ThRCRI)
ThRCRI
Score
Risk Class
No. of Cases
Major Cardiac
Complications
0
A
1,909
18 (0.9%)
1-1.5
B
616
26 (4.2%)
2-2.5
C
25
2 (8%)
>2.5
D
71
13 (18%)
p < 0.0001
Brunelli A, et al. Ann Thorac Surg 2011;92:445-8.
.
Rates of cardiac complication according to the Thoracic
Revised Cardiac Risk Index classes A, B, C, D
Brunelli A , et al. Ann Thorac Surg 2011;92:445-8.
.
Vascular Study Group of
New England(VSG-CRI)
Vascular Surgery Group Cardiac Risk Index (VSG-CRI) scoring
system and predicated risk of adverse cardiac events
Bertges, et al. J Vasc Surg 2010;52(3):674-83.
Surgical Mortality Probability
Model
ASA PS Classification
ASA PS
Definition
I
A normal healthy patient
II
A patient with mild systemic disease
III
A patient with severe systemic disease
IV
A patient with severe systemic disease that
is a constant threat to life
A moribund patient who is not expected to
survive without the operation
V
Glance LG, et al. Ann Surg 2012;255:696-702.
S-MPM Scoring System for Estimating Risk of 30-Day
Mortality After Noncardiac Surgery
Glance LG, et al. Ann Surg 2012;255:696-702.
S-MPM Class Levels and Associated Risk of Mortality
Class
Point Total
Mortality
I
0-4
<0.50%
II
5-6
1.5%-4.0%
III
7-9
>10%
Glance LG, et al. Ann Surg 2012;255:696-702.
Risk Calculator for Prediction
of Cardiac Risk After Surgery
Calculator to Predict the risk of
myocardial infarction or cardiac arrest
(MICA)
Type of surgery
 Functional status
 Abnormal creatinine
 American Society of Anesthesiologists class
 Increasing age
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The MICA risk calculator is available at www.surgicalriskcalculator.com
Gupta PK, et al. Circulation 2011;124:381-387.
Clinical Recommendations
CCS
ACC/
AHA
ESC
HFSA
CCS
ACC/AHA
ESC
HFSA
Definition
Something that provides direction or
advice as to a decision or course of
action;
 A detailed plan or explanation to guide
you in setting standards or determining a
course of action

Collins English Dictionary http://www.thefreedictionary.com/guideline
Definition


Systematically developed statements to assist
practitioner and patient decisions about
appropriate health care for specific clinical
circumstances1
To assist health care providers in clinical
decision making by describing a range of
generally acceptable approaches2
1. Institute of Medicine. Washington, DC: National Academy PR; 1992
2. Hunt S, et al. Circulation 2005;112:1825-52.
Electrocardiogram
Recommendations for Preoperative Resting
12-Lead ECG
Class I
1. Patients with at least 1 clinical risk factor who are
undergoing vascular surgical procedures.
2.
patients with known CHD, peripheral arterial disease,
or cerebrovascular disease who are undergoing
intermediate-risk surgical procedures.
Fleisher LA, et al. Circulation 2009;120:e169-e276.
Recommendations for Preoperative Resting
12-Lead ECG
Class III
1. Preoperative and postoperative resting 12-lead
ECGs are not indicated in asymptomatic persons
undergoing low-risk surgical procedures.
Fleisher LA, et al. Circulation 2009;120:e169-e276.
Suggested algorithm for performing preoperative
electrocardiography
Feely MA, et al. Am Fam Physician 2013;87(6):414-8.
Echocardiography
264, 823 patients undergoing elective intermediate to
high risk noncardiac surgery 1998 - 2008
Echocardiography 40,084 (15.1%)
70,996
30 day mortality
1.14 (1.02-1.27)
Wijeysundera DN, et al. BMJ 2011;342:d3695.
1 year mortality
1.07 (1.01-1.12)
Recommendations for Preoperative Noninvasive
Evaluation of LV Function
Class IIa
1. It is reasonable for patients with dyspnea of unknown
origin.
2.
It is reasonable for patients with current or prior HF
with worsening dyspnea or other change in clinical
status if not performed within 12 months.
Fleisher LA, et al. Circulation 2009;120:e169-e276.
Recommendations for Preoperative Noninvasive
Evaluation of LV Function
Class IIb
1. Reassessment of LV function in clinically stable
patients with previously documented cardiomyopathy is
not well established.
Class III
1. Routine perioperative evaluation of LV function in
patients is not recommended.
Fleisher LA, et al. Circulation 2009;120:e169-e276.
Stress Testing
Association of preoperative stress testing with one year
survival in the subgroup analyses
Wijeysundera DN, et al. BMJ 2010;340:b5526.
Active Cardiac Conditions for Which the Patient
Should Undergo Evaluation and Treatment Before
Noncardiac Surgery
Unstable coronary symptoms
 Decompensated HF (NYHA functional
class IV: worsening or new-onset HF)
 Significant arrythmias
 Severe valvular disease

Fleisher LA, et al. Circulation 2009;120:e169-e276.
Recommendations for Noninvasive Stress Testing
Before Noncardiac Surgery
Class I
1. Patients with active cardiac conditions.
Class IIa
1.
3 or more clinical risk factors and poor functional
capacity (less than 4 METs) who require vascular
surgery is reasonable if it will change management.
Fleisher LA, et al. Circulation 2009;120:e169-e276.
Recommendations for Noninvasive Stress Testing
Before Noncardiac Surgery
Class IIb
1. may be considered for patients with at lease 1 to 2 clinical
risk factors and poor functional capacity (less than 4
METs) who require intermediate risk or vascular surgery if
it will change management.
Class III
1. Noninvasive testing is not useful for patients with no
clinical risk factors undergoing low or intermediate-risk
noncardiac surgery.
Fleisher LA, et al. Circulation 2009;120:e169-e276.
Long-Term Survival among Patients Assigned to Undergo
Coronary-Artery Revascularization or No Coronary-Artery
Revascularization before Elective Major Vascular Surgery
McFalls EO, et al. NEJM 2004;351:2795-2804.
American College of Cardiology (ACC)/ American
Heart Association (AHA) 2007 Guidelines
Open Vascular Surgery Required
Yes
Emergent
Proceed with planned procedure
No
Yes
Active Cardiac Condition
No
Class I: Non-Invasive Stress Testing
Class I: Coronary Revascularization indications
same as in patients not undergoing surgery
Known Functional Capacity
No
Yes
< 3 Clinical Risk Factors
No
Class I: No Further Testing
Class I: Continue β-blocker if currently prescribed
Class IIa: Consider Non-Invasive Stress Testing
Biomarkers
Postoperative NT-proBNP Thresholds and the Incidence of
Mortality or Nonfatal MI at 30 Days after Surgery
Rodseth et al. Anesthesiology 2013;119:270-83.
Postoperative BNP Thresholds and the Incidence of Mortality
or Nonfatal MI at 30 Days after Surgery
Rodseth et al. Anesthesiology 2013;119:270-83.
Risk of death for patients with estimated glomerular filtration
rate <60 ml-min-1.73 m-2 compared with ≥60 mil-min-1.73 m-2
at both short-term and long-term follow up
Mooney et al. Anesthesiology 2013;118:809-24.
Kaplan-Meier estimates of 30-Day mortality based on peak
Troponin T values
15,133 noncardiac surgery (2007 – 2011)
The Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION)
Study Investigators. JAMA 2013;307:2295-2304.
Le Manach, et al. Anesthesiology 2005;102:885-891.
Le Manach, et al. Anesthesiology 2005;102:885-891.
Kikura M, et al. J Thromb Haemost 2008;6:742-748.
Kikura M, et al. J Thromb Haemost 2008;6:742-748.
Statins
Effect of perioperative statins on myocardial
infarction, atrial fibrillation, and death.
Chopra V, et al. Arch Surg 2012;147(3):181-9.
Effect of perioperative statins on hospital and intensive
care unit length of stay.
Chopra V, et al. Arch Surg 2012;147(3):181-9.
Forest plot of comparison: I Statin versus
placebo/no treatment, outcome: 1.2 All-Cause
mortality
Sanders RD, et al. Cochrane Database Syst Rev 2013;7.
Forest plot of comparison: I Statin versus
placebo/no treatment, outcome: 1.4 Myocardial
Infarction (non-fatal)
Sanders RD, et al. Cochrane Database Syst Rev 2013;7.
PCI
The highest-risk period for ST after PCI with
either BMS or DES following NCS is the first 4
weeks. Therefore, it seems reasonable to
withhold NCS, if possible, for at least 4 weeks
after PCI.
Singla S, et al. JACC 2012;60:2005-2016.
Proposed approach to the management of patients
with previous PCI requiring noncardiac surgery
Fleisher LA, et al. Circulation 2009;120:e169-e276.
Proposed treatment for patients requiring
percutaneous coronary intervention (PCI) who need
subsequent surgery
Fleisher LA, et al. Circulation 2009;120:e169-e276.
Perioperative Hypertension
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No link between perioperative complications with
either preexistant hypertension or an elevated
blood pressure
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Types of surgery: CABG, AA, CEA, PVS,
intraperitoneal or intrathoracic
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Perioperative cardiac complications are
associated with hemodynamic lability (>20%
change in mean BP)
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Consider lowering the dose of ACE
inhibitors or AR antagonist 24 hours ( at
least 10 hours) before surgery
Perioperative Beta Blockers
8,351 patients with, or at risk of, atherosclerotic
disease received extended-release metoprolol
succinate (n=4174) or placebo (n=4177)
started 2-4 h before surgery and continued
for 30 days.
Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:1839-47.
Kaplan-Meier estimates of the primary outcome (A),
myocardial infarction (B), stroke (C) and death (D)
Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:1839-47.
Metoprolol
(n = 4179)
Placebo
(n = 4177)
Death
129
79
32
Strokes
41
19
32
Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:1839-47.
Meta-analysis of β-blocker trials in patients undergoing noncardiac surgery
Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:1839-47.
.
Comparison of effect of perioperative β-blockade on nonfatal strokes in secure and non-secure trials.
Bouri S et al. Heart 2013.
Meta-analysis of nine secure randomised controlled trials
showing a significant increase in mortality with
perioperative β-blockade.
Bouri S et al. Heart 2013.
Prevalence of hypotension in β-blocker and control
groups.
Bouri S et al. Heart 2013.
Thirty-Day Mortality Propensity Model
London MJ, et al. JAMA 2013;309(16):1704-13.
Beta Blockers
28,263 adults with IHD who underwent noncardiac
surgery 2004 - 2009
MACE
Mortality
Heart Failure
22%
18%
MI within 2 years
46%
20%
MI 2 – 5 years
29%
26%
MI > 5 years
35%
33%
No MI or HF
44%
30%
Anderson C et al. Annual Congress of the European Society of Cardiology. September 18, 2013.
Summary of ACC/AHA Guideline Recommendations
Beta-Blocker Medical Therapy
Class I
Class III
Beta-blockers should be continued in patients
undergoing surgery who are receiving betablockers to treat angina, symptomatic
arrhythmias, hypertension, or other ACC/AHA
class I guideline indications
Routine administration of high-dose betablockers in the absence of dose titration is not
useful and may be harmful to patients not
currently taking beta-blockers who are
undergoing noncardiac surgery
Fleisher LA. Cleve Clin J Med 2009;76:S9-15.
Fleisher LA. Cleve Clin J Med 2009;76:S9-15.
Medical Consultant
Provide informed clinical judgment based on
knowledge, experience and the individual
patient’s data to optimize short and long term
outcomes.