Download Perioperative Management

Perioperative Management
Gretchen E. Twork MD
October 25, 2013
Section of Hospital Medicine
Objectives
Review the ACC/AHA guidelines
published September 2007 for cardiac
risk stratification
Pulmonary risk stratification
Epidemiology
Aging population
Rise 6  12 million non-cardiac
surgical procedures
1/4th of these intermediate or higher
risk
Symptomatic MI (plaque rupture)
after surgery –increased risk of death
(40-70% in some studies)
Consultants role
We do not medically “clear”
Manage risk throughout course
Identify risk factors that can be
modified prior to OR
“No further risk stratification
indicated”
Common sense is underrated
“intervention is rarely necessary to
simply lower the risk of surgery
unless such an intervention is
indicated irrespective of the
preoperative context”
JACC Vol. 50 Nov 17, 2007
Use common sense
Preoperative Evaluation
Setting?
Urgency?
Risk of not intervening?
History:
Functional status
4 Mets: flight of stairs, level ground 4 mph
Other risks: delirium, pulmonary,
diabetes,cirrhosis, anticoagulation
History –Red flags
Major clinical risk: MANDATE delay
unless emergent surgery
new or worsening anginal sx’s
decompensate CHF
severe valvular disease *
Significant arrhythmias *
Recent MI
JACC Vol. 50 Nov 17, 2007
AHA guidelines
CARP: routine revascularization pt’s
stable sx’s: no short/long term risk
benefit
DECREASE II: major risk, vascular,
+Bbl. Extensive CAD risk; not
powered for effect PCI/CABG
DECREASE-V: high risk vascular. No
difference in 30 day, 1 year
revascularization vs medical therapy
Cardiac Assessment
Step I: Emergency
Step II: active cardiac conditions
JACC Vol. 50 Nov 17, 2007
Further Cardiac Evaluation
Unstable coronary syndrome
Recent Myocardial infarction
Decompensated CHF
Significant arrhythmia:
Mobitz II, 3rd degree HB, Vtach, afib if
uncontrolled rate, sx bradycardia
Severe valve disease:
AS severe (mean >40 mmHg, valve area
<1, sx)
MS (sx, presyncope, CHF)
Aortic stenosis
if severe/critical AS with an acute fracture
or any other non emergent surgery: FIX
THE VALVE FIRST
Guidelines: severe AS: pt refuse or not
valve candidate: surgery mortality risk:
10%
Balloon may help/TAVR not so much
acutely
No Spinal anesthesia
JACC Vol. 50 Nov 17, 2007
Mitral stenosis
Increased risk of HF
Pre-op correction generally not
indicated (unless indicated
independently or high risk surgery)
Balloon valvuloplasty may be
efficacious
JACC Vol. 50 Nov 17, 2007
Non-cardiac surgery specific
risk
High: Vascular (5%), some
neurosurgical
Intermediate: (1-5%) intra-peritoneal,
intra-thoracic, ENT, CEA,
Orthopedic, prostate
Low (<1%) endoscopy, cataract,
breast, ambulatory
JACC Vol. 50 Nov 17, 2007
Patient specific risk
Clinical risk factors (replace
intermediate risk)
h/o CAD
h/o compensated or previous HF
Cerebrovascular disease, PVD
Diabetes mellitus
Renal insufficiency (Cr >2)
Originally these + major- revised CI
1 or more is indication for Beta-blocker and statin
Beta-Blockers –Friend or foe?
POISE: 8351 patients, RCT, fixed higher
dose metoprolol. POD 0.
1st dose: 100 mg Toprol: 2-4 hr prior OR.
2nd dose: 100 mg within 6 hours HR >80
and SBP >100.
3rd dose 200 mg po 12 hours after OR
Decreased cardiac M & M: 5.8% vs 6.9%.
HR 0.84 p=0.0399
Higher risk of stroke/overall mortality: 1%
vs 0.5%. HR 2.17 p=0.0053
Beta blockers
Caveats to POISE:
High dose, long acting
Day of surgery
No dose titration
Lack of common sense!
To Betablock or not to Betablock
Class I: continue in patients already on
Class IIa:
Vascular: CAD, more then 1 RF, or + stress test
Intermediate: more then 1 risk factor
Class IIb:
Intermediate: 1 risk factor: uncertain
Vascular: 0 risk: uncertain
Class III: don’t give if absolute contraindication,
routine non-titrated high dose bblocker not useful
and possible harmful
Betablocker
Start days to weeks
Titrate dose for goal: HR 65-80
without hypotension
? 1 risk factor and intermediate risk
surgery
DECREASE IV: 1066 pt. bisprolol (2.5
mg), fluvastatin (80 mg), both, neither
Cardiac events 2.1 vs 6, HR 0.34
p=0.002, stroke 0.8 vs 0.6% p=0.65
Statins
NEJM: DECREASE III
summary of results: 250 pts fluvastatin (median
37 days prior to surgery) and 247 placebo
Post-op myocardial ischemia: 27 pt (10.8%) on
fluvastin and 47 (19%) in placebo (Hazard ratio
0.55, 95%CI 0.34-0.88 p=0.01) NNT 12
death due to CV causes: 12 pts (4.8%) fluvastatin
and 25% (10.1%) placebo (hazard ratio 0.47; 95%
CI, 0.24-0.94; p=0.03) NNT 19
no significant increase in rate of adverse events
NEJM 361;10 Sept 3, 2009
Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical
conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of
age or greater
Fleisher, L. A. et al. Circulation 2007;116:1971-1996
Copyright ©2007 American Heart Association
Which is true of noninvasive
testing
1. excellent negative predictive value
2. excellent positive predictive value
3. both 1 and 2
Noninvasive testing
Excellent negative predictive value
(90-100)
Horrible positive predictive value (667%)
P thal and DSE really equivalent in
most patients
Evaluation
Testing: only changes care 0-2.6% if
indiscriminate
+H/P findings: yield abn tests 81%
Labs: CBC (blood loss expected, infection),
lytes, BUN/Cr (medications, CRI and other
history)
EKG: men >40, woman >50, known CAD
CXR >50 + major surgery
Laine et al. In the clinic Preoperative Evaluation. Annals of
Internal Medicine 2009
Evaluation
Healthy patient risk <0.1% for serious
complication
Focused history and physical
Medications, substance abuse, tob
Exercise tolerance
Co-morbidities (CIRRHOSIS)
Identify procedure and patient
related risks
Laine et al. In the clinic Preoperative Evaluation. Annals of
Internal Medicine 2009
Perioperative Medicines
Ace inhibitor –consider pros/cons
Post operative hypotension. AHA and
Annals
AKI: volume depletion, blood loss
If HTN on multiple meds may make
sense
Can always give, can’t take back
Laine et al. In the clinic Preoperative Evaluation. Annals of
Internal Medicine 2009
Perioperative Medicines
Take your beta-blocker – HR 6o’s-80
Use judiciously –start low, go slow
Diuretics: consider pros/cons
Outpatient setting: known CAD
Known CAD
Level of jeopardized myocardium
Ischemic threshold
Optimal medical regimen
Risk factors, undefined disease
EKG suggests old infarct, poor
functional status
Would it change my management?
Inpatient setting
Risk of not-operating or delay (hip fx)
What happens if stress is positive?
Urgent surgery: initial risk
assessment –ID and stabilized cardiac
disease
Unless major cardiac condition
revascularization does not play a major
role
Delay in OR after PCI
Balloon angioplasty: wait >=14 days*
Bare metal stent: wait >= 30-45 days *
Drug eluting stent: wait 365 days*
*=aspirin
• Due to late in-stent thrombosis
• Arbitrary but based on expert opinion: II a
and b
Is cardiac morbidity is higher then
pulmonary morbidity in noncardiac
surgery
1. true
2. false
Is cardiac morbidity is higher then
pulmonary morbidity in noncardiac
surgery
False. The cardiac and pulmonary
morbidity and mortality are the same.
Pulmonary risk major better predict
long term outlook.
Pulmonary risk stratification
No pulmonary risk index per se
Equally prevalent to cardiac
Inability to climb 2 flights stairs: PPV 82%
postop complications in
thoracotomy/upper abd surgery
Better predictor long-term mortality
Retrospective 8930 hip fx: 19% post-op
medical complications
2.6 pulmonary vs. 2.o cardiac
Major complications
Atelectasis
Pneumonia
Respiratory failure
Exacerbation chronic lung disease
Bronchospasm
Surgical site
With thoracic & upper abdominal:
Vital capacity reduced 50-60 % and can remain
so for 1 week
Functional residual capacity decreased 30%
below closing volumes increased risk
atelectasis, pneumonia, V/Q mismatch
also
Diaphragmatic dysfunction
Splinting
Preoperative strategies
Smoking cessation counseling
Classic: 8 weeks before
Prospective trial 200 pt CABG: stopped
smoking <2 months complication rate 4x
(57.1 vs. 14.5)
Annals: suggests 4 weeks similar benefit
Recent Meta-analysis: Doesn’t matter
Delay surgery if people are sick
Preoperative testing
ABG: resting hypoxia, suspected
chronic hypercapnia, lung resection
PFTS: undiagnosed lung disease—
unexplained dyspnea, lung resection
CXR:
chronic lung disease
major surgery – suspected cancer would
change management
abnormal exam
Preoperative strategies
COPD
Treat to best baseline level of treatment
 Ipratropium or tiotropium, Beta-agonists
if wheezing
 Don’t add theophylline unless you would
do it de novo

Asthma
If ET: 2-4 puffs or nebulizer within 30
minutes intubation
 Lack of evidence systemic glucocorticoids

Intraoperative Strategies
Alternative shorter procedure if
feasible <3 hours
Minimize duration anesthesia
Regional anesthesia
Laparoscopic vs. open has not been
shown to be benefit.
NO benefit from PA catheters
Postoperative strategies
Pain control
Can consider epidural analgesia
(decrease respiratory depression)
factors can build up: identify and be
aggressive pre/post-op
Consider CPAP, BIPAP in
appropriate patients.
Postoperative strategies
Incentive spirometry or Deep
Breathing
Incentive spirometer = pneumonia
prevention device
no one wants pneumonia
Prospective trial 172 patients: abdominal
surgery: 48% complication in untreated
controls vs. 22% incentive spirometry or
deep breathing
START TEACHING PREOP
Recruit family
Risk of respiratory failure
72 yo man with oxygen dependent
COPD ( 2 liters), who can walk 15 feet
for elective shoulder surgery
(laporoscopic)
What is his risk of respiratory
failure?
What is the greatest risk factor for
respiratory failure postoperatively
1.
2.
3.
4.
age
fully dependent functional status
site of surgery
oxygen dependence
What is the greatest risk factor for
respiratory failure postoperatively
3. site of surgery: on the Arouzalla
respiratory failure index
Arozullah respiratory failure index
Preoperative predictor
Type of surgery
Point value
Abdominal aortic aneurysm
Thoracic
Neurosurg, upper abd, peripheral vascular
Neck
27
21
14
11
Emergency surgery
11
Albumin <3.0 g/dL
9
BUN >30 mg/dL
8
Partially or fully dependent functional status 7
History of chronic obstructive pulmonary disease 6
Age >70 years
6
60 to 69 years
4
From Arozullah, AM, Daley, J, Henderson, WG, Khuri, SF,
Ann Surg 2000; 232:242.
Performance Arozullah RF index
Class Point total % respiratory failure
1
10
0.5
2
11 to 19
1.8
3
20 to 27
4.2
4
28 to 40
10.1
5
>40
26.6
Resources
AHA 2007: JACC Vol. 50 Nov 17, 2007
Arozullah, AM, Daley, J, Henderson, WG, Khuri, SF, Ann
Surg 2000; 232:242
http://content.onlinejacc.org/cgi/content/full/50/17/1707
CHEST 2008
Laine et al. In the clinic Preoperative Evaluation. Annals of
Internal Medicine 2009
Schouten et al. Fluvastatin and perioperative events in
patients undergoing vascular surgery. NEJM 361;10 Sept 3,
2009