Download Preoperative Considerations for the Elderly Patient Undergoing Non

Preoperative Considerations for the Elderly
Patient Undergoing Non-Cardiac Surgery:
A Hospitalist’s Perspective
Luis C. Camarillo, MD
Assistant Professor of Internal Medicine
Division of Inpatient Medicine
3/17/06*
1
Mission:
Provide a general overview or primer
of pertinent studies & guidelines that
assist the medical consultant in
preoperatively assessing the elderly
patient having non-cardiac surgery.
2
Outline
Elderly Issues
Focus on Current Guidelines
Review of Preoperative Literature
Role of Hospitalist as a Medical Consultant
3
Mrs. Clinical Vignette**
„
71 year old woman with a history of:
„
„
„
„
„
„
„
„
diet controlled DM2, HTN, Hyperlipidemia, Hypothyroidism,
Osteoporosis, CKD (baseline BUN/creatinine of 32/2.1mg/dL),
GERD, and fibromyalgia
Playing with her grandchildren in the park & tripped over a rock.
She fell and could not get up.
She fell onto her right side, and now c/o severe right sided hip
pain.
Once in the ED - hemodynamically stable.
3 views of the right hip shows a non-displaced, right-sided
intertrochanteric fracture.
Orthopedics was consulted, and they recommended an open
reduction & internal fixation (ORIF).
After reviewing her reviewing her medical history and physical
examination, the admission orders included the following:
4
S&W Orthopedic Hip Fracture Admit Orders
5
What is our role and
responsibility here?
6
Our Role and Responsibility – New Strategy
LOW RISK
Hospitalist
PATIENT
Intermediate
RISK
Noninvasive testing/
Medical therapy
Postoperative
M&M
High RISK
7
Hospitalists’ Role in Consultative Medicine
„
Hospitalist - Physicians primarily dedicated to the care of
hospitalized patients
„
„
„
Term first coined by Drs. Robert Wachter and Lee Goldman
“The Emerging Role of “Hospitalists” in the American Health
Care System”. NEJM. August 1996
Hospitalists are strongly committed to:
„
„
„
„
„
Inpatient care
Teaching of residents & students
improving hospital quality
patient safety
systems improvements and efficiency
8
Hospitalists’ Role in Consultative Medicine
„
„
„
„
Although a fair amount of preoperative
medicine takes place in outpatient setting, a
considerable amount is occurring more in
hospital setting.
Especially since patients are becoming more
medical complex as well as more elderly.
Hospitalists are leading the charge in caring for
patients undergoing surgery.
Preoperative medicine is in itself - complicated
& ever-so changing.
9
Traditional Consult Model
„
„
„
„
„
Internist sees the patient, and leaves the
recommendations for the surgeons
Not involved in minute-to-minute management
of the patient.
Recommendations may be not be seen until end
of the day - delay in treatment.
Given the complexity of some patients, the
importance or urgency of said suggestions may
be outside the realm of the surgeon’s area of
expertise.
May be reluctant to implement such suggestions
due to unfamiliarity.
10
New Consult Model
„
„
„
„
„
„
„
„
„
Surgeons & internists form a partnership
Co-manage the shared patient
Make recommendations
Write orders
Establish an effective line of communication between
internists, surgeons, and nurses.
JCAHO safety goal: Improve effectiveness of
communication among caregivers.
Hospitalist is entrusted to care for patients
Embrace them as their own
Potential of improving outcomes
11
New Consult Model
„
„
„
„
„
Favored both by orthopedists and nurses.
Readily available to help address patients’ and
nurses’ questions and general concerns.
Help patient transition from inpatient to
outpatient setting
JCAHO safety goal: Accurately and completely
reconcile medications across the continuum of
care.
Maintain communication with patient’s primary
care physician – requires time
12
New Challenges call for Novel Health Care Delivery Systems
13
Hallmarks of Co-management Service
Quite
Similar
To
Our
Practice.
14
Paradigm Shift
„
Hospitalists:
„
„
„
„
„
assume a major role of educating medical residents in the field
of perioperative medicine.
However, a number of changes have occurred in
medicine residency training over the last 20 years.
Changes in curriculum design with focus on outpatient
care
Resulted in reduced time for medical consultation.
Internists spend 30% of time on medical consults.
15
Plauth et al. “Hospitalist’s Perceptions of Their Residency
Training Needs: Results of National Survey.” American
Journal of Medicine. 2001.
„
Those surveyed were asked to:
„
“1” = VERY INADEQUATE to “5” =
VERY ADEQUATE
„
„
„
„
Grade the importance of training
in the skills of medical
consultation:
Mean score of 4.6 + 0.7
Rate the emphasis on medical
consultation in their residencies:
Mean score of 3.4 + 1.1
(p=<0.001)
„
„
„
„
„
„
„
About 79% of the hospitalists
surveyed <1month of medical
consultation training
(p=<0.00001)
Consultative skills needed by a
myriad of other specialists….
Not Just Internists or Hospitalists.
IM residencies across the country
should allocate more time in their
respective curriculums.
Full month in the PGY-2.
AND
With the creation of additional
elective time available for those
entering fellowships whereby
consults are vital to their practice
(i.e. Cardiology, Pulmonary, etc…)
16
Helpful Quote
“ We don’t clear patients
for surgery…we correct the
correctable and hope for
the best.”
17
Initial Approach to the Patient
„
History:
„
„
„
„
„
„
„
„
„
Age
Prior cardiac disease (MI,
angina, CHF, arrhythymias,
valvular disease)
Prior cardiac intervention
Prior cardiac evaluation
(noninvasive test,
angiography)
Risk factors ( HTN, DM ,
Tobacco abuse,
hyperlipidemia)
Associated diseases ( PVD,
stroke, CKD, COPD)
Current state (CP, dyspnea)
Functional capacity
Thorough review of
medications/Allergies or
Intolerances
„
Physical Exam:
„
„
„
„
„
„
„
„
„
„
„
„
„
„
„
Vital signs
Mucosa (hydration/nutrition)
Lymph nodes, thyroid masses
Carotid bruits
JVD
Mumur (Aortic Stenosis,
Mitral Stenosis)
S3 gallop
Crackles/wheezes
Hepatosplenomegaly/Pulsatil
e masses/Rectal
exam/hernias
Edema
Peripheral pulses/bruits
Neurologic deficits
Mental status
MMSE
Skin (hydration/nutrition)
18
Initial Lab data:
19
Are there any preoperative
literature or essential guidelines
that may help in evaluating this
patient?
20
Review of Cardiac Risk Indices
„
In the 1960’s:
„
„
In the 1970’s:
„
„
„
„
„
„
1986 – Detsky and colleagues
1987 – Larsen and colleagues
1989 – Eagle and colleagues
In the 1990’s:
„
„
„
„
„
„
1976 – New York Heart Association/Canadian Cardiovascular Society
(NYHA/CCS)
1977 – Goldman and colleagues
1979 – Cooperman and colleagues
In the 1980’s:
„
„
1963 – Dripp’s American Society of Anesthesiologists (ASA)
1990 – Pedersen and colleagues
1996 – Vanzetto and colleagues
1996 – American College of Cardiology/American Heart Association
(ACC/AHA)
1997 – American College of Physicians
1999 – Lee and colleagues
In 2002:
„
American College of Cardiology Update
21
Dripp’s American Society of Anesthesiologists
(ASA) 1963
„
„
„
„
„
„
Class I: a normal healthy patient.
Class II: a patient with mild systemic
disease
Class III: Those with severe systemic
disease limits activity but not
incapacitating
Class IV: incapacitating disease
Class V: Eminent death within 24
hours with or without the surgery
E – emergency surgical procedure
„
„
„
„
A Scale that is an excellent
predictor of which patients will do
poorly with anesthesia
Subjective in nature
Develop a safe anesthetic plan for
patients
All-cause Mortality:
„
„
„
„
„
I = 0.30 %
II = 0.2%
III = 1.2%
IV = 8%
V = 34%
22
Historical Review of Cardiac Risk Indices
„
In the 1970’s ***
„
„
1977 – Goldman and colleagues
In the 1980’s:
„
Discussing Cardiac
Risk Factors
1986 – Detsky and colleagues
23
Goldman et al. “Multifactorial Index of Cardiac Risk in Noncardiac
Surgical Procedures”. NEJM. 297:16. Oct 20, 1977.
„
„
„
„
„
„
Pioneered preoperative
cardiac risk index
Large, prospective
1001 consecutive, unselected
patients over 40 years old
Multivariate analysis
Identified 9 independent risk
factors
Correlated with end points of
„
„
„
„
cardiac death
VT
pulmonary edema
MI
24
25
Goldman et al. “Multifactorial Index of Cardiac Risk in Noncardiac Surgical
Procedures”. NEJM. 297:16. Oct 20, 1977.
„
„
„
„
„
Very Useful but not without its shortcomings
Inadequately differentiated patients in intermediate risk
category
Underestimated risk of vascular surgery patients
Decreased applicability to high risk surgeries
Criticized to be institutionally-dependent
„
„
„
Massachusetts General Hospital in Boston, MA
Insufficient numbers of patient with severe angina
Age independently predicted complications
„
19 of 21 patients who developed postop CHF were >60 yrs
26
Detsky et al. “Predicting Cardiac Complications in Paitents Undergoing Noncardiac Surgery.” Journal of General Internal Medicine. 1986.
„
„
„
„
455 patients referred to
consult service due to
known or suspected CAD
Enhanced Goldman’s
original multifactorial index
Added variables such as
angina & remote MI
Generating a cardiac risk
index included 13 factors
27
„
„
„
„
„
„
Stratified into 3 risk
categories based on
total points
Added predictive
information for patients
having:
Major surgeries such as
vascular, orthopedic,
intrathoracic,
intraperitoneal, and head
& neck
Minor surgeries such as
cataract procedures and
prostate surgery
Class I – Low risk
Class III – High risk
28
How do these indices compare?
Goldman’s Cardiac Risk Index
vs.
Detsky’s Cardiac Risk Index
Equally
Efficacious**
29
Historical Review of Cardiac Risk
Indices
„
In the 1990’s:
„
„
„
„
„
1990 – Pedersen and colleagues
1996 – Vanzetto and colleagues
1996 – American College of Cardiology/American
Heart Association (ACC/AHA)
1997 – American College of Physicians (ACP)
1999 – Lee and colleagues
Clinical data to determine
cardiac risk factors & subsequent
Noninvasive testing/medical tx
30
ACC/AHA Guidelines (1996 & 2002)
„
„
„
„
„
„
consensus paper on standards for
preoperative evaluation
patients having non-cardiac
surgery
A stepwise algorithm
This in turn provided an
organized assessment of
„ i) clinical markers (prior to
coronary evaluation and
treatment)
„ ii) functional capacity
„ iii) surgery specific risk.
Clinical predictors derived from
Goldman’s and Detsky’s criteria
Shown to reduce costs** of
preoperative evaluation
31
Cost of preoperative medical testing for all types of surgeries =
$30 billion annually
About 1 million patients will have a perioperative cardiac complication =
$20 billion annually
Preventing one postoperative complication
by obtaining a preoperative consult and/or
adhering to the ACC/AHA guidelines =
PRICELESS
32
(1) ACC/AHA Clinical Predictors
33
(2) Functional Status Assessment
„
Poor Status <4 METs
„
„
„
„
„
Moderate Status 4 to 7 METs
„
„
„
„
„
One MET – Oxygen consumption
Activites of Daily Living such as
of a 70-kg, 40 yo man at rest.
eating dressing, bathing
Walking 2 mph
Writing
Household chores such as vacuuming
Performing yardwork
Golfing w/o cart
Walking 4 mph
Climbing a flight of stairs
Excellent Status >7 METs
„
„
„
„
Jogging ( 10 minute mile)
Scrubbing floors
Singles tennis
Squash
34
(3) Cardiac Risks of Surgical Procedures
„
High cardiac risk Surgery - generally >5%
„
„
„
„
Intermediate cardiac risk Surgery - generally <5%
„
„
„
„
„
„
Emergency major operation - especially in elderly population
Major vascular procedures
Anticipated prolonged operations associated with large fluid shifts
or blood loss.
Carotid endarterectomy
Head & Neck procedures
Orthopedic procedures
Urologic procedures
Intraperitoneal and intrathoracic procedures
Low cardiac risk Surgery - generally <1%
„
„
„
„
„
Ambulatory procedures
Breast procedures
Cataract procedures
Dermatologic procedures
Endoscopic procedures
35
Big Picture:
Cardiac Risk Assessment Begins
with a Good History & Physical
Stepwise Algorithm
USE IN CONJUNCTION
Sound Clinical
Judgment
36
37
MAJOR Clinical predictors
Recent Coronary Evaluation – within past 2 yrs
38
Intermediate Clinical predictors
39
Minor or NO Clinical predictors
40
American College of Physicians (1997)
„
Similar to ACC/AHA:
„
„
„
„
Differences:
„
„
„
„
„
„
„
„
Emergent surgery to OR
Utilize Detsky’s index
Stratified into 3 risk categories
Detsky’s criteria are first stage of
risk stratification
Minor clinical predictors derived
from Eagle & Vanzetto criteria
Functional status not used
Patients having vascular surgery
need non-invasive stress testing
Superseded by
Lee et al and other studies using
exercise capacity
Studies on DSE in non-vascular
surgery
Data on the benefits of
perioperative beta blockers.
41
Lee et al.”Derivation and Prospective Validation of a Simple Index for
Prediction of Cardiac Risk of Major Non-cardiac Surgery”. Circulation.
1999.
„
„
„
„
„
„
Prospective study of 4,315
patients > 50 year old
Revised Cardiac Risk Index
6 independent predictors of
periop cardiac complications
„ High-risk type of surgery
„ Ischemic heart disease
„ Congestive heart failure
„ Cerebrovascular disease
„ Preoperative treatment with
insulin
„ Preoperative serum creatinine
> 2.0 mg/dL
Very Accurate
Helped identify patients for further
tests/interventions
Superior to Goldman’s & Detsky’s
Rate of adverse
perioperative cardiac events
Independent
predictors of
complications
Derivation
(2893 pts)
Validation
(1422 pts)
0
0.5%
0.4%
1
1.3%
0.9%
2
4%
7%
>3
9%
11%
Merits:
Simple Clinical tool, strong study, &
well-validated by ROC analysis,
as well as Modern.
42
ACC 2002 Update
„
„
Minimize unnecessary interventions while
enhancing cardiac risk assessment
Offered recommendations on beta-blockers,
arrhythmias, and coronary evaluation/
interventions.
43
Which Noninvasive Test to Choose?
Exercise stress testing
???
Myocardial perfusion imaging
Dobutamine stress echocardiography
44
“To Test or To Not Test – Only if Impacting Care”
45
Noninvasive testing - CONTROVERSIAL
„
„
„
Resting Echocardiography
Exercise Treadmill Test (ETT)
Chemical stress testing
„
„
Myocardial perfusion imaging (Dipy. Thallium)
Dobutamine stress echocardiography (DSE)
46
Resting Echocardiography
„
Left Ventricular Ejection Fraction <35%
„
„
„
„
„
Predictive of Postoperative heart failure
Mortality in severely ill patients
Degree of LV dysfunction - informational
Not predictive of postoperative ischemic events
Suggested if:
„
„
„
„
No prior echocardiogram
Deteriorated clinical status since last echocardiogram
Suspected valvular disease
Hypertrophic cardiomyopathy
47
Exercise stress testing
„
„
„
„
„
„
„
„
„
Preferred to pharmacologic stress testing
Exercise Treadmill Test (ETT) – High NPV, but low PPV
Eagle et al (2004)
Vascular surgery patients
Peak exercise heart rate goal of >75% of age-predicted maximum
Only 50% patients able to achieve this.
Inability to achieve target HR fails to exclude ischemia
Vast number of candidates for vascular surgery or possessing
diseases that impair their ability to perform this test.
Patient population seen infrequently.
48
Preoperative Chemical stress testing
„
„
„
„
Myocardial perfusion
imaging
Dobutamine stress
echocardiography
Suggested for those that
can’t exercise
Positive study is a weak
predictor of perioperative
cardiac events.
„
Indicated only if it
impacts the management
of patients in this setting.
„
„
intermediate-risk group.
Uncertainty of which
patients most likely
benefit from noninvasive
testing.
„
Paucity of evidence
49
Myocardial Perfusion Imaging
„
„
„
„
„
„
Sensitive for detecting CAD
Fixed or reversible defects.
Those with a fixed defect have
a higher risk of perioperative
cardiac events than those with
a normal scan.
However, still significantly
lower than patients with
thallium redistribution.
Reversible perfusion defects
predict perioperative events,
and a fixed defect predicts
long-term cardiac events
Avoid in patients with active
symptoms of asthma or COPD
„
„
„
Eagle and associates (2002)
„ 2834 patients
„ Vascular surgery
„ Negative predictive value of
99%
„ 189 perioperative events (MI
or cardiac death)
Also pooled data for:
„ 674 patients
„ Nonvascular surgery
„ Negative predictive value of
99%
„ 49 perioperative events (MI or
death)
Useful when assessing
Intermediate clinical risk patients
„ Not with patients with a high
or low pretest probability for
CAD
50
Dobutamine Stress Echocardiography (DSE)
„
„
„
„
„
„
„
Help assess LV regional wall motion at rest and dobutamine
stress
Provides adrenergic stimulus physiologically similar to stress
of the perioperative period more than vasodilators.
Fewer published studies than myocardial perfusion imaging
Poldermans (1993) et al - normal DSE has a negative
predictive value of 93% to 100%.
Eagle (2002) et al - demonstrated a negative predictive value
of 99% among 1,657 patients with 83 cardiac events.
Positive predictive value < 20% - poorly predictive of adverse
events
Avoid in significant arrhythmias, LBBB, marked hypertension,
and suspected critical aortic stenosis
51
52
What if noninvasive test is abnormal or high risk?
„
„
Options for reducing perioperative
cardiovascular risk
Revascularization:
Preoperative Coronary Artery Bypass Grafting
„ Preoperative Percutaneous Coronary
Intervention (PCI)
„
53
Preoperative Coronary Artery Bypass Grafting
„
„
„
„
Retrospective analysis of 3,368 patients
Coronary Artery Surgery Study (CASS) registry data
Eagle & associates (1997)
Major surgery after CABG:
„
„
„
„
„
„
Vascular, abdominal, thoracic, or head & neck
Fewer perioperative deaths or MI’s than those treated
medically alone.
However, did not account for outright mortality of CABG
No short term benefit when accounting for risk of death,
nonfatal MI, stroke, and cognitive dysfunction.
Prior CABG maintains cardioprotection for 4-6 yrs.
ACC/AHA recommends no further noninvasive testing if
„
symptom-free with CABG within the past 5 years.
54
Preoperative Percutaneous Coronary Intervention
(PCI)
„
„
„
Lower procedural risk than
CABG
„ more appealing in this
setting
Reserved for those with
obvious indication:
„ Acute coronary syndrome
or angina refractory to
medical therapy
„ ACC/AHA recommends
after high-risk noninvasive
testing
Further research needed for
drug-eluting stents further
complicates issue
„
„
„
„
„
„
„
Dual antiplatelet therapy of ASA
and clopidigrel prescribed for 3-6
months after PCI.
Most literature suggest delaying
noncardiac surgery 6 weeks after
stenting.
Allows for completion of
antiplatelet therapy.
May be impractical for some
patients who need surgery
Patients who have had PCI within
6 months to 5 years
Remained symptom-free
May proceed to non-cardiac
surgery without further testing.
55
Retrospectively analyzed data from BARI trial. Patients receiving
PCI within months to years prior to non-cardiac surgery had
similar outcomes to those patients who received CABG prior to undergoing surgery.
56
Preoperative Percutaneous Coronary Intervention
„
„
„
„
Stent placement may increase perioperative
cardiovascular risk at least some time after it’s placed.
Kaluza et al (2000) advised caution with non-cardiac
surgery after coronary artery stenting
40 consecutive patients receiving stents < 6 weeks prior
to surgery.
Within 6 weeks after stenting:
„
„
„
27.5% major bleeding
16.8% nonfatal myocardial infarction
20% died
„
„
Stent thrombosis accounted for the majority of fatal events
Similar findings by Wilson et al (2003)
57
Perioperative Medical Management
„
„
„
„
„
Beta Blockers
Alpha-2 agonists
Nitroglycerin
Calcium Channel Blockers
Statins
58
59
Mangano, et al. “”Effect of Atenolol on Mortality and Cardiovascular
Morbidity after Non-cardiac Surgery. Multicenter Study of Perioperative
Ischemia Research Group”. NEJM. 1996.
„
„
„
„
„
„
„
200 patients with known CAD or 2 risk factors
Randomized, Double-blind, and Placebo-controlled trial
Started preoperatively (IV) & continued (PO) duration of
hospital stay (at least 7 days)
Atenolol – NO perioperative deaths
Placebo – 1 perioperative death
Thus, no difference in mortality @ hospital discharge
But, significant reduction of overall mortality @ 6 mons:
„
„
„
8 deaths in patients in the placebo group
Zero deaths in patients in the treatment group (P<0.001)
Same difference noted even at 24 month follow-up
60
Poldermans, et al.” The Effect of Bisoprolol on Perioperative Mortality and
Myocardial Infarction in High-risk Patients Undergoing Vascular Surgery.”
NEJM. 1999.
„
„
„
Randomized placebo-controlled
unblinded trial
112 patients assigned to either
bisoprolol or placebo
High-risk
„
„
„
1 or more clinical risk factors
ischemia by DSE
Major Vascular surgery
„
„
AAA repair
Infra-inguinal arterial
reconstruction
„
„
„
„
„
„
7 days preop & at least 30
days postop
Terminated early
Significant reduction:
Incidence of Perioperative
Mortality from 17% vs. 3.4%
(p=0.02)
Incidence of Myocardial
Infarction 17% vs. 0%
(P<0.001)
Beta-blocker dose was titrated
to achieve optimal beta
blockade in both Mangano’s
and Polderman’s articles.
61
On the Horizon…
„
„
„
„
„
„
Perioperative Ischemia Evaluation (POISE)
Large, Multi-center, blinded, randomized
controlled group trial of metoprolol vs. placebo
10, 000 patients undergoing noncardiac surgery
Determine the actual efficacy of beta blockers
Determine optimal treatment doses and
regimens
Potentially identify patient population most likely
to benefit from beta blockers in this setting
62
Big Picture: Perioperative Beta Blockers
„
„
Class I: Conditions for which
there is evidence and
consensus opinion that the
procedure/therapy is useful &
effective.
Patients w/ severe LV
dysfunction excluded –
management uncertain
„
„
„
„
„
If patient is on regimen
already, then continue it.
Inexpensive
Low incidence of severe side
effects
Duration of treatment/ titration
of drug – unclear
Target pulse of 50-60
beats/min
63
Newer Strategies - Juxtaposing RCRI, Beta-Blockers, &
Noninvasive Testing in Intermediate-risk patients
„
„
„
Boersma et al (2001)
Observational study of 1,351 patients
Goal of determining the relationship of
perioperative cardiac risk to the following:
„
„
„
„
clinical risk score
DSE results
beta-blockers use.
Incorporated data from:
„
„
Poldemans et al (1999)
Lee et al (1999) Revised Cardiac Risk Index (RCRI)
64
Newer Strategies - Juxtaposing RCRI, Beta-Blockers, &
Noninvasive Testing in Intermediate-risk patients
„
„
„
1) Beta-blockers offer protection
across the spectrum of risk in
general
„ Fewer risk factors and/or
absent or fewer segments of
inducible ischemia on DSE
2) Inadequate protection of beta
blockers against perioperative
death or MI in the highest
predicted risk group
„ 3 or more cardiac risk factors
„ large wall motion
abnormalities on DSE (>/= 5
segments)
3) Perioperative cardiac events
cannot be predicted in the LOW
risk patient by noninvasive testing
such as DSE.
65
Perioperative Alpha-2 agonists
„
„
„
Somewhat promising data
Possible alternative in those high risk patients unable to tolerate
beta-blockers
Class IIb recommendation
„
„
Nishina et al demonstrated
„
„
„
„
Efficacy less well established by evidence/opinion
decrease in incidence of myocardial ischemia
study of 297 patients having vascular surgery
24% vs. 39%
Multicenter Study of Perioperative Ischemia Research Group
„
„
„
„
300 patients having non-cardiac surgery
Less myocardial ischemia in Mivazerol-treated arm vs. placebo
Mivazerol – alpha agonist unavailable in US
No differences in perioperative cardiac death or MI
66
Nitroglycerin in Non-cardiac Surgery
„
„
Very limited data
Coriat et al (1984)
„
„
„
„
„
45 patients undergoing CEA
Decreased ischemia but not MI or death
Lead to hypotension during anesthesia
Cannot be used prophylactically
Calcium Channel Blockers - Few studies and
data inconclusive
67
Statins (HMG Co-A reductase inhibitors)
„
„
„
„
„
„
Lindenauer et al (2004)
Large, Retrospective trial
reviewed database
Patients having high-risk noncardiac surgery
Discovered those on statins
had reduced mortality than
those not receiving statins
Odds ratio for death of 0.62
(95% CI 0.58-0.67)
Consider in all high-risk
patients having non-cardiac
surgery.
„
„
„
„
„
„
„
Durazzo et al (2004)
Small, prospective study
100 pts randomized to
atorvastatin or placebo prior to
vascular surgery
Randomized @ 14 days prior &
continued for 45 days total
Primary end-points of cardiac
death, non-fatal MI, &
ischemic stroke
End points noted in 8% statin
group vs. 26% placebo group
(p</=0.018)
68
Famous Quote
„
“In 1927, as a young professor of surgery,
I taught and practiced that an elective
operation for an inguinal hernia in a
patient older than 50 years was not
justified.”
69
Famous Quote
„
„
„
„
„
„
„
Dr. Alton Ochsner - Surgeon
One of the founders of Ochsner
Clinic (1942)
Contributions in fields of medicine
and surgery.
1939 – co-wrote with Dr. Debakey
first paper exposing hazards of
smoking relative to lung cancer
Surgery, Gynecology, and
Obstetrics.
Seeing patients until age of 85
years old.
70
Given the patient’s age, are there
any special considerations?
71
Geriatric Issues
US Elderly Population
„
Preoperative evaluations
are paramount:
„
„
Age
1999
(multiple)
2020
> 65
years
35 million
(1.5x)
53
million
40% of admissions for the
elderly are to surgical
services.
>85
years
4.3 million
(1.5x)
6.3
million
3) Higher surgical mortality
when compared to younger
cohorts.
>100
years
75, 000
(>2x)
200, 000
1) Rapidly, enlarging
subset of population
2) Surgeries are more
common in the elderly
„
„
72
% of Population 65yrs or older for the State of Texas & Counties in Texas
(254 counties total)
S&W Referral Counties
Rank
County
1990 (%)
2000 (%)
State of Texas
10.11
9.94
1
Llano
34.09
30.66
13
Hamilton
27.22
23.58
70
Milam
18.72
17.22
73
Robertson
18.38
16.97
128
Lampasas
15.72
14.52
133
Lee
15.90
14.38
239
Bell
8.76
8.77
248
Williamson
7.62
7.36
251
Coryell
5.58
5.70
Texas State Data Center and Office of the State Demographer – October 2003
73
Geriatric Issues
„
Until 1980’s „
„
„
„
„
„
Surgery on elderly met with much hesitation
For even common, elective procedures
Exhaust all non-surgical choices first
Only then was surgery performed on an
emergent/urgent basis.
Problem – much higher morbidity & mortality
Before 1960, mortality >30% for emergent cases
74
Geriatric Issues
„
„
„
About 33% of older patients have 3 or more
pre-existing medical conditions.
Very heterogeneous group.
Elderly patients of even the same age may vary
in:
„
„
„
„
„
„
„
functional status
underlying illnesses
social support
No simple algorithm available.
Preoperative management - KEY
Annually, 50,000 patients will have a perioperative MI.
„ 40% will die
Elderly account for 75% of all postoperative deaths.
75
Geriatric Issues
„
„
„
„
„
Last 25yrs, changes in attitudes
Declining overall surgical mortality
In 1950’s, patients with cardiac disease:
„ surgical mortality of 9.2% to 18%
Currently, patients with cardiac disease:
„ Surgical mortality 0.9% to 2.4%
Contributing in this decline...
„
„
„
On the average:
„
„
„
„
Enhancements in surgical techniques, better anesthesia, and enhanced
monitoring systems
Increased benefit vs. risk ratios
**70 year old man can survive another 11 years
**70 year old woman another 14 years
Surgeons more apt to consider benefits of surgery.
Older patients who survive surgery have a better prognosis &
generally live longer than their age-match controls.
76
“Fix what you can and
acknowledge the things you
can’t.”
77
Elderly Preoperative Model
„
Patient-specific risk factors
„
„
„
„
„
Age
Overall Functional Status
Nutritional Status
Preoperative Cognitive Status
Organ system-specific factors
„
„
„
Cardiovascular issues
Pulmonary issues
Renal issues
78
Age
„
„
„
„
„
„
„
„
„
Looks like a risk factor …but how much?
In surgical literature - independent risk factor
But considered a confounding variable.
Marker of sub-clinical disease
Declining functional status & diminishing organ function
Severity of disease is a much better clinical predictor than AGE.
Living longer, more functional, and demanding more aggressive
intervention
Treat & assess patients individually and not on AGE alone
But don’t ignore the age either.
79
Overall Functional Status
„
„
„
„
„
Dripp’s American Society of Anesthesiologists (ASA)
Physical status scale
Help gauge the degree of systemic illness before
anesthesia
Premise – The more functional patient will have a
better outcome after undergoing physiologic stresses
of surgery & anesthesia
However, Good functional status does not exclude
underlying heart disease.
80
Nutritional status
„
„
Predictor of postoperative
morbidity & mortality
Increased mortality
„
„
„
>20% weight loss
Albumin < 3.2 g/dL (six
fold increase)
Preoperative nutritional
supplementation
„
„
Controversial
Inconclusive
„
„
„
„
„
Detsky et al (1999)
Veterans Adminstration
Total Parenteral Nutrition
Cooperative Study
TPN versus non-TPN – no
overall difference in M&M
Increased infections in
TPN cohorts
Possibly beneficial in
severely malnourished
patients
81
Preoperative Cognitive Status
„
Informed consent - a challenge
„
„
„
„
Preoperative Folstein MMSE help determine baseline & detect occult
dementia
Postoperative Delirium - Extreme predictor of poor outcome
30-50% patients develop postoperative delirium
„
„
Increases in-hospital morbidity
Common precipitants:
„
„
„
„
„
„
„
Patients must understand risks & benefits of surgery
Pain – the most common precipitant
Physical restraints
Urinary catheters
Iatrogenic medical conditions
Beginning >3 NEW medicines
malnutrition
Benefits of using analgesics> risk of prescribing analgesics
„ Caveat - In the elderly, analgesics may reduce tidal volume, impair
cough, & deep breathing
82
Elderly Preoperative Model
„
Patient-specific risk factors
„
„
„
„
„
Age
Overall Functional Status
Nutritional Status
Preoperative Cognitive Status
Organ system-specific factors
„
„
„
Cardiovascular issues
Pulmonary issues
Renal issues
83
Age-related Cardiovascular changes
„
„
„
„
„
„
Increased wall thickness of intimal layer of
larger caliber arteries
Increase systemic vascular resistance (SVR)
Systolic pressure increases gradually starting at
30 or 40 years
Left Ventricular wall tension increases
LV thickening
Blunted heart rate response to stress and
noxious stimuli
84
Age-related Cardiovascular changes
„
„
„
„
„
„
„
Age-related decline in Beta-adrenergically mediated
vasodilation
Decreased Inotropic & chronotropic response to
catecholamines
Prone to develop CHF with modest volume
Hypotension with mild decreases in intravascular volume
Impaired diastolic filling
Increased afterload due increased SVR
Prevalent conduction abnormalities, tachyarrhythymias,
& bradyarrhythymias
85
Age-related Pulmonary changes
„
Lung & chest wall
„
„
„
„
Diminished elastic recoil
Decrease compliance of
chest wall
Decreased thoracic muscle
mass
Decreased intervertebral
space
„
„
Smaller chest height
Increased A-P diameter
„
Gas exchange
„
„
„
„
„
Decreased maximal minute
ventilation
Decreased pulmonary
capillary blood volume
Decreased lung surface
area
Increase anatomic &
functional dead space
Increased closing volume
„
Within tidal breathing
range, airway collapse
causes V/Q mismatch
86
Age-related Pulmonary changes
„
Ventilatory control:
„
„
Lower resting Pao2
Blunted central response of hypoxia
„
„
„
„
„
Pronounced with analgesics & anesthetics
Decreased sensitivity to elastic and resistive loads
Decreased protective reflexes in airway
Ciliary function & cough responses reduced
Limited pharyngeal sensation & motor function
„
Prone to aspiration
87
Predicting Perioperative Pulmonary Complications
„
„
„
Occur as Often as Cardiac Complications
Increasing Length of Stay (LOS)
Over past few years, investigators have
expanded risk indices to include
preoperative pulmonary assessment
88
Predicting Perioperative Pulmonary Complications
„
„
„
„
„
„
„
„
Arozullah et al (2000)
Validated, multifactorial risk index
for PPPC’s
Large database of veterans
undergoing non-cardiac surgery
Derived & validated risk indices for
predicting postoperative
respiratory failure and pneumonia
Contributing to Postop. Pulmonary
Complications:
„ procedure-related risk factors
„ Patient-related risk factors
Confirmed most significant risk
„ surgical site - closer incision to
diaphragm
Odds ratios of 3.6 patients > 70
yrs
Odds ratios of 5.6 patients > 80
yrs
89
Predicting Perioperative Pulmonary Complications
„
Highest Risk:
„
„
„
„
„
Cardiothoracic procedures
Open abdominal Aortic
Aneurysm repairs
Upper Abdominal procedures
Head & Neck
Lowest Risk:
„
„
„
„
„
„
Opthalmologic
Ear, nose, mouth
Nonvascular – humerus, wrist,
hip, or knee
Urogenital
Spine and Back (i.e.
laminectomy)
Minimal even for high risk
patients
„
Other Surgical factors:
„
„
„
Duration> 3 hours
Emergency surgery
Laparoscopic vs. open
procedures
„
„
Quicker recovery time in
laparoscopic surgeries
Data inconclusive as to
differences in clinical
outcomes
90
Predicting Perioperative Pulmonary Complications
„
Patient-related risk factors
Poor Functional status
„ Current Tobacco use
„ Chronic Obstructive Pulmonary Disease
„ Advanced age
„ Obesity
„ Obstructive Sleep Apnea
„
91
Predicting Perioperative Pulmonary Complications
„
„
Poor Functional status
Reilly et al (1999)
„ Inability to climb 2 flights
of stairs (80% PPV)
„ 89% unable to climb 1
flight had complications
„ MORE PREDICTIVE THAN
SPIROMETRY
ASSESSMENT
„
„
„
„
Current Tobacco use:
Increases tracheobronchial
secretions & airway
reactivity
Decreases mucociliary
clearance
Smetana et al (1999)
„ Smoking w/in 2 weeks
of surgery
„ Increased risk of
pulmonary
complications
„ Irrespective of absence
of COPD
92
Predicting Perioperative Pulmonary Complications
„
COPD:
„
„
„
„
Associated with 4.7
odds ratio
Chronic sputum
production
Maximum laryngeal
height < 4cm
Suggestive of
hyperexpansive lung
fields
„
„
„
Obesity:
Reduced lung volumes
Complications were
similar for non-obese
(7.0% vs. 6.3%)
„
Smetana et al (2005)
93
Predicting Perioperative Pulmonary Complications
„
Obstructive Sleep Apnea:
Gupta (2001)
„ Retrospective study
„ Patients with OSA versus match control group
„ Hip or knee surgery
„ Those with OSA had more cardiac events, ICU
transfer, intubation, or urgent CPAP
„
„
„
24% versus 9% (p<0.004)
First 24 hours postoperatively
94
DVT Prophylaxis
„
„
„
„
Leading cause of
postoperative morbidity
& mortality.
Even with prophylaxis,
incidence of DVT is
about 20%
No data addressing the
actual duration of DVT
prophylaxis
Should be continued
until fully ambulatory
95
Pulmonary lab tests
„
CXR
„
„
ABG
„
„
Beneficial - may change preoperative plans
Routine test – not necessary unless potential of
contributing preoperative management
Spirometry:
„
„
Typically, does not add to management
No spirometric data available to distinguish patient as
inoperable vs. operable
96
Age-related Renal changes
„
Small decrease in renal mass
„
„
Renal blood flow diminished by
50%
„
„
Exaggerated in hypertensive
patients
Less efficient sodium conservation
w/ restriction
„
„
Mostly cortical
„
„
„
„
Prone to hypovolemia
Impaired natriuretic response w/
load
„
Slow fluid mobilization
„
„
„
„
Preoperative renal status
predictor of postoperative
renal failure.
Hou et al (1983)
Studied 2,262 consecutive
medical & surgical admissions
Risk of deterioration:
„ 2.9% creatinine
<1.2mg%
„ 4.4% creatinine >1.2mg%
Preventative considerations:
1) Conscientious of volume
Status
2) Treat infections aggressively
3) Avoid nephrotoxic drugs at
all costs
97
Surgical Rates for Elderly
2nd
250, 000 hip fractures annually.
Leading Reason for Hospital Admission in the Elderly.
98
Surgical Procedures Performed
February 1, 2005 through January 31, 2006
Raw Data provided by:
Scott & White Surgical data provided by
Department of Data Analysis and Reporting –
Judy Jacobs and Teresa Ponder.
99
Total # of Surgical procedures = 14, 334
# of
Complicat
ions
% for
Age
group
% of
Total
surgeries
# of
preop &
postop
consults
% for
Age
group
19%
281
10%
2%
4
0.15%
2, 096
15%
149
7%
1%
57
3%
85 years &
older
414
3%
20
5%
0.14%
77
19%
Totals
5, 225
36%
450
22%
3%
138
22%
Age Range
(10 yr
interval)
# of
patients
% of
Total
surgeries
65-74 years
2, 715
75-84 years
100
Reversal of Chronologic age vs. Physiologic age?
50-65 yr olds
65-80 yr olds
65-80 yr olds
50-70 yr olds
Severity of disease is a much better clinical predictor than AGE.
Age alone should not exclude surgery.
101
Interpretation of Data
„
„
„
„
„
„
„
„
„
Either insufficient consults for 65-74 years group or an abundance
of unnecessary consults for the much older age groups.
Selection bias of patient type as well as surgery risk in the >75
years group.
Much fewer surgeries in the >85 yrs group.
Preoperative care given to the >85 years group is skewed towards
higher standard given the class of patient.
Lowered expectations of postoperative complications in the 65-74
yrs group.
Older patients and their families expect more aggressive
intervention.
Greater workload for surgeons, internists and other consultants.
In order to accommodate this medical/surgical need, must have a
larger number of experienced (consultative medicine) physicians
willing to accept this challenge.
Have the potential of positively impacting ALL age groups by
utilizing consult services to help co-manage medically complex and
older patients.
102
Interpretation of Data
„
„
„
„
„
Beta-blockers are beneficial in elderly undergoing noncardiac surgery. Cardiac mortality reduced from 12% to
2%.(McGory et al 2005)
Optimizing glucose control pre-, peri-, & postoperatively
can reduce incidence of wound infections (usually labor
intensive)
Still much more research to be done.
Greater wealth of educational & research opportunities
for senior staff, residents, and students.
Additional challenges: No preexisting preoperative
guidelines addressing postoperative complications from
neurologic, hematologic, oncologic, renal, &
gastrointestinal systems.
103
Take Home Message:
Risk Factors for Elderly Postoperative Mortality
ASA physical status Class III and IV
Surgical procedure
Major or emergency procedures
Preexisting disease Cardiovascular, pulmonary, hepatic, renal, diabetes
mellitus
Functional status
<1-4 MET
Nutritional status
>20% weight loss, anemia, serum albumin < 3.2
mg/dL
Place of residence
Not living with family
Ambulation
Bedridden, immobilized
104
Take Home Message:
Risk Reduction Maneuvers
„
„
„
„
Cardiovascular:
„ Beta blockers
„ Attention to volume changes
Skin:
„ Early mobilization
„ Incontinence & nutrition issues
„ Positioning
Bowel/bladder:
„ Discontinue foley promptly
„ Conscientious of uti/constipation
„ Avoid anticholinergics
Thermoregulation
„ Elderly unable to maintain normothermia
„ Hypothermia increases incidence of surgical site infection
„ Warming blankets, warm fluids & ventilatory gas
„ Keep core temperature @ 36.5 degrees C
105
Take Home Message:
Risk Reduction Maneuvers
„
„
„
Pulmonary:
„
Smoking cessation > 8 wks prior to surgery
„
Bronchodilator therapy
„
Humidified oxygen
„
Aggressive pulmonary toilet
„
Incentive spirometry
„
PEP therapy
Medications
„
Attention to polypharmacy
„
Discontinue unnecessary meds
„
Reduce toxic meds
Cognition
„
Note preexisting dementia, ETOH use
„
Minimize or discontinue sedative-hypnotic drugs
„
Avoid anticholinergics
„
Use judicious chemical restraints:
„
„
Haloperidol 0.5mg-1mg orally or IV every 6-8hrs
Risperidone 0.25mg-0.5mg orally twice daily
106
Making Our World of Healing…Better
107
References
„
„
„
„
„
„
„
„
„
„
„
Barrett et al. “Perioperative Medicine: The Present and the Future”. Society of
Hospital Medicine supplement - Perioperative Care. 2005.
Cohn, Steven L. Goldman, Lee. “Preoperative Risk Evaluation and perioperative
management of patients with coronary artery disease”. The Medical Clinics of
North America. 87. 111-136.2003
Das, et al. “Assessment of Cardiac Risk before nonvascular surgery: dobutamine
surgery echo in 530 pts”. Journal of American College of Cardiology. Volume
35. 2000.
Detsky, et al. “Predicting Cardiac Complications in Patients Undergoing Non-cardiac
Surgery”. Journal of Internal Medicine. Volume 1. 1986.
Eagle et al. “The Preoperative Cardiovascular evaluation of the intermediate-risk
patient: New data, changing strategies”. The American Journal of Medicine.
118. 1413e1-1413e9. 2005.
Eagle et al.” ACC/AHA Guidelines for perioperative Cardiovascular Evaluation for Noncardiac surgery – Executive Summary. Journal of the American College of
Cardiology. 39:3. 2002.
Egbert et al. “The value of the Preoperative Visit”. JAMA. 185:553. 1963.
Ersan, et al. “Perioperative Management of the Geriatric Patient”. EMedicine. 2005.
Fleisher et al. “Lowering Cardiac Risk in Non-cardiac Surgery”. NEJM. 345:23. 2001.
Goldman et al. “Multifactorial Index of Cardiac Risk in Non-cardiac Surgical
Procedures”. NEJM. 297:16. 1977.
Grayburn, et al. “Cardiac Events in Patients Undergoing Non-cardiac Surgery: Shifting
the Patadigm from Noninvasive Risk Stratification to Therapy”. Annals of Internal
Medicine. 138:6.2003.
108
References
„
„
„
„
„
„
„
„
„
„
Jin, et al. “Minimizing perioperative Adverse Events in the Elderly”. British Journal
of Anesthesia. 87:4. 2001.
Karcic, et al. “Perioperative Cardiovascular Evaluation”. Postgraduate Medicine.
108:6. 2000.
Karnath, Bernard. “Preoperative Cardiac Risk Assessment”. American Family
Physician. 66:10. 1889-1896. 2002.
Lee et al. “Derivation and Prospective Validation of a Simple Index for Prediction of
Cardiac Risk of Major Non-cardiac Surgery”. Circulation. 100:1043-1049. 1999.
Mangano, et al. “”Effect of Atenolol on Mortality and Cardiovascular Morbidity after
Non-cardiac Surgery.Multicenter Study of Perioperative Ischemia Research Group”.
NEJM. 1996.
Mangano, et al. “Preoperative Assessment of Patients with known or suspected
Coronary Disease”. NEJM. 333:26. 1995.
McKean, Sylvia. “The Comprehensive Role of the Hospitalist as Medical Consultant: A
Case Discussion”. Society of Hospital Medicine supplement - Perioperative
Care. 2005.
Merli, Geno. “The Hospitalist as Perioperative Expert: An Emerging Paradigm”.
Society of Hospital Medicine supplement - Perioperative Care. 2005.
Myers, Monica. “Preoperative Evaluation”. Jacksonville Medicine. December 1998.
Merli, Geno. “The Hospitalist as Perioperative Expert: An Emerging Paradigm”.
Society of Hospital Medicine supplement - Perioperative Care. 2005.
109
References
„
„
„
„
„
„
„
„
„
„
„
Plauth et al. “Hospitalist’s Perceptions of Their Residency Training Needs: Results of
National Survey.” American Journal of Medicine. 2001.
Poldermans, et al.” The Effect of Bisoprolol on Perioperative Mortality and Myocardial
Infarction in High-risk Patients Undergoing Vascular Surgery.” NEJM. 1999.
Schein, et al. “The Value of Routine Preoperative Medical Testing Before Cataract
Surgery”. NEJM. 342:3. 2000.
Sear, et al. “Issues in the Perioperative Management of the Elderly patient with
Cardiovascular Disease”. Drugs Aging. 19:6. 2002.
Smetana et al. “Estimating and reducing perioperative Pulmonary Risk for NonCardiothoracic Surgery”. Society of Hospital Medicine supplement Perioperative Care. 2005.
Smetana et al. “Preoperative Pulmonary Evaluation”. NEJM. 340:12. 937-944.1999.
Thomas, et al. “Preoperative Assessment of Older Adults”. Journal of the
American Geriatrics Society. 43:7. 1995.
Ventura, Hector O. “Alton Ochsner, MD: Physician”. The Ochsner Journal. 4:1. 4852.
Wesorick et al. “Hospitalist Co-management of Surgical patients: A partnership with
potential”. Society of Hospital Medicine supplement - Perioperative Care.
2005.
Winawer, et al. “Preoperative Cardiovascular Risk Evaluation”. Society of Hospital
Medicine supplement - Perioperative Care. 2005.
Scott & White Surgical data provided by Department of Data Analysis and
Reporting – Judy Jacobs and Teresa Ponder.
110
The End
„
„
„
„
Proceed to post test
Print post test
Complete post test
Return post test to
Dr. S.K. Oliver
„ 407I TMAUII
„
111
Post test 1
„
„
List one pulmonary risk reduction
maneuver to decrease elderly post
operative mortality.
_____________________________
112