Transcript Case

Perioperative Care:
Preventing Complications
Salim D. Islam, MD
Karen E. Hauer, MD
2006
Workshop learning objectives
1. Learn the indications for preoperative testing and
preparation for a healthy patient having elective
surgery
2. Learn the indications for cardiac stress testing
and beta blockade prior to noncardiac surgery
3. Understand new recommendations for preventing
postoperative pulmonary complications
Outline
• Preoperative risk stratification
• Perioperative cardiac risk reduction
• Preventing postoperative pulmonary
complications
Case #1
74 y.o. woman with CAD s/p stent in 1998, hypertension,
osteoporosis, GERD, scheduled for cataract surgery. Able to
walk 2 blocks, no chest pain or dyspnea.
Meds: enalapril, lovastatin, ranitidine, aspirin.
PE:
BP 128/70
HR 80
Surgeon asks you to perform routine preoperative tests and
clear for surgery. What do you recommend?
Case #1
What do you recommend prior to cataract surgery?
A.
B.
C.
D.
E.
CBC, lytes, creatinine, glucose, EKG
Stress test
A&B
Recommend against surgery
Proceed with surgery
Routine Preoperative Testing
before Cataract Surgery
N Engl J Med 2000;342;168
19,557 cataract surgeries
• Randomized to preop testing or no testing
• Average age 74
• 89% ASA class II or III
• Outcome = perioperative events
ASA Physical Status
I
Healthy
DJD, Glaucoma
II
Asymptomatic systemic disease
Hypertension,
diabetes
III
Symptomatic systemic disease
Stable angina,
chronic renal insufficiency
IV
Systemic disease - constant threat
to life
COPD on home 02,
Class III CHF
V
Will die within 24 hours without
surgery
Ruptured AAA
VI
Brain dead organ donor
Routine Preoperative Testing
before Cataract Surgery
N Engl J Med 2000;342;168
No testing
Routine
testing
Relative risk
(95% CI)
Intraop
events*
1.9%
2%
0.97 (0.8-1.2)
Postop
events*
1.3%
1.2%
1.04 (0.8-1.3)
*Events = Cardiac, Hyper/hypotension, Stroke/TIA,
respiratory distress requiring treatment, hypoglycemia, DKA
Case #2: Preop Risk
Stratification
55 y.o. woman scheduled for hysterectomy
PMH: hypertension, on hydrochlorothiazide
PE: BP 135/90
HR 85
Normal exam
EKG: Normal sinus rhythm, left ventricular
hypertrophy
What preoperative cardiac
evaluation do you recommend?
A.
B.
C.
D.
None. Proceed with surgery
Add a beta-blocker
Exercise stress test
Exercise-thallium stress test
Preventing Perioperative Cardiac
Complications
• What are we trying to prevent?
• Perioperative MI (mortality up to 15%)
• Mortality (all cause)
• Other - CHF, ischemia, nonfatal arrhythmia
Risk of Cardiac Complications Based on
Type of Surgery
•
High (>5%)
• Major aortic, peripheral vascular surgery
• Emergent major surgery
• Long case - large fluid shifts, blood loss
•
Intermediate (<5%)
• Carotid, head, neck
• Abdominal, thoracic, pelvic
• Orthopedic
•
Low (<1%)
• Endoscopic, skin, breast
Clinical Predictors of Perioperative Cardiac Complications
Eagle, JACC 2002;39:542
Major
Intermediate
Minor
MI within 1 month, unstable angina
Decompensated CHF, severe valve disease
Significant arrhythmia
Prior MI
Mild angina
CHF
Diabetes
Creatinine > 2.0 mg/dl
Advanced age
Abnormal ECG or rhythm not sinus
Prior stroke
Uncontrolled hypertension
Functional capacity < 4 METs
Assessing Functional Capacity
1-4 METs
4-10 METs
10+ METs
Eat
Dress
Walk in house
Climb flight of stairs
Scrub floors
Golf
Short run
Swimming
Singles tennis
Case #3: Preop
Hypertension Management
55 y.o. woman arrives for hysterectomy
PMH: hypertension, on hydrochlorothiazide
PE: BP 185/100
HR 85
Normal exam
EKG: Normal sinus rhythm, left ventricular
hypertrophy
How does your management change?
Outline
• Preoperative risk stratification
• Perioperative cardiac risk reduction
• Preventing postoperative pulmonary
complications
Case #4
68 y.o. woman with type 2 diabetes, osteoarthritis of
the knees, and hypothyroidism, scheduled for right
hemicolectomy.
Meds: glyburide, metformin, levothyroxine,
acetaminophen. Non-smoker.
PE:
BP 130/70 HR 88
98% RA 02 Sat
Case #4
What preoperative assessment do you
recommend?
A.
B.
C.
D.
E.
Proceed with surgery
Exercise treadmill test
Persantine-thallium test
Cardiac catheterization
Add atenolol
Preoperative Stress Testing
Eagle ACC/AHA 2002
• Indications: 2 or more of the following
– Intermediate clinical predictor (Eagle 2002)
• Stable cardiac disease, DM, Cr > 2
– High risk surgery
– Poor functional status (< 4 METs)
• Which test?
– Ambulatory, normal ECG
– Ambulatory, abnormal ECG
– Can’t exercise
exercise treadmill
exercise + imaging
P-Thal or Dobutamine echo
• Better for ruling out than ruling in cardiac disease
Perioperative Beta Blockers
In what clinical settings would you prescribe a
perioperative beta-blocker?
A. Hypertension
B. Major vascular surgery
C. History of CAD
D. CAD risk factors
E. All surgical patients
Benefits of Perioperative
Beta Blockers
• Reduce perioperative myocardial ischemia
• Decrease perioperative cardiac complications
• Improve survival
Perioperative Beta Blockers in
Noncardiac Surgery
• Patients: 200 Veterans w/ CAD or 2 CAD risk
factors
• Atenolol one hour prior to surgery until hospital
discharge, unless HR < 55, vs. placebo
• Operations: major vascular, abdominal, ortho,
neurosurg
• Outcomes: mortality, cardiac complications over 2
years
Mangano, NEJM, 1996
Perioperative Beta Blockers in
Noncardiac Surgery
25
20
15
Atenolol
Placeob
10
5
0
6 month mortality
2 year mortality
Mangano, NEJM,
1996
Which Beta Blocker?
• Cardioselective (atenolol, metoprolol)
– Effective
– Fewest side effects
• Non-cardioselective (propranolol, nadolol)
– Equally effective
– More side effects - pulmonary, hypotension
– Use only if patient already taking
• Avoid beta blockers with intrinsic
sympathomimetic activity
• Consider clonidine if beta blockers
contraindicated
Dosing Perioperative
Beta Blockers
• Already taking a Beta Blocker:
– Adjust previous dose to a target HR of 60
• New prescriptions:
– Begin treatment with atenolol 25-50 mg q day
within one month of surgery
– Consider a follow-up appt for HR check and
dose adjustment 1-7 days before surgery
Outline
• Preoperative risk stratification
• Perioperative cardiac risk reduction
• Preventing postoperative pulmonary
complications
Case # 5
A 70 year old man with diabetes,
hypertension, CAD, and COPD is admitted
with right upper quadrant pain. He smokes
1 pack/day. Ultrasound reveals acute
cholecystitis, and cholecystectomy is
recommended. In addition to preoperative
cardiac risk stratification, you consider the
risk of pulmonary complications.
Case #5
Which of the following is most likely to
reduce the risk of perioperative pulmonary
complications?
A. Preoperative CXR
QuickTime™ and a
TIFF (Uncompressed) decompressor
B. Incentive spirometry
are needed to see t his picture.
C. Laparoscopic technique
D. Smoking cessation
Perioperative Pulmonary
Complications
• As common as postop cardiac complications;
similar morbidity and mortality
– Pulmonary complications may better predict
long term mortality
• Most important and morbid:
– Atelectasis
– Pneumonia
– Respiratory failure
– Exacerbation of chronic lung disease
Risk assessment and strategies to
reduce perioperative pulmonary
complications after
noncardiothoracic surgery:
A guideline from the ACP
Ann Intern Med 2006;144:575
Patient risk factors for postop
pulmonary complications
Risk factor
Age > 60
COPD
Current smoking
CHF
ASA class > I
Functional dependence
Odds ratio
2.09 - 3.04
1.79
1.26
2.93
4.87
2.51 (total); 1.65 (partial)
Surgery risk factors for postop
pulmonary complications
• Surgery type: abdominal, thoracic, neuro,
head/neck, vascular, AAA
• Surgery > 3 hours
• Emergency surgery
• General anesthesia
Quic kTime™ a nd a
TIFF (Un co mp res se d) d ec ompre ss or
ar e n eed ed to see th is p ictu re.
Interventions to reduce postop
pulmonary complications: Preop
• Identify and target high risk patients
– Patient and surgery risk risk factors
• Preop - consider:
– Spirometry - only with COPD
– CXR - for age > 50, high risk surgery, known
cardiopulmonary disease
Interventions to reduce postop
pulmonary complications:
Post op
• Lung expansion
– Deep breathing exercises or
– Incentive spirometry or
– CPAP
• Selective use of NG tube after abdominal
surgery
– for nausea/emesis, inability to take p.o.,
abdominal distention
Quic kTime™ a nd a
TIFF (Un co mp res sed ) d ec ompre sso r
ar e n eed ed to see thi s p ictu re.
Interventions that might reduce
postop pulmonary complications:
• Laparoscopic instead of open surgery
– Improves pain, spirometry, oxygenation
– Unclear benefit on clinically important
pulmonary complications
• Epidural anesthesia/analgesia - unclear
benefit
• Smoking cessation: > 2 months preop
Summary
• Preoperative risk stratification
• Perioperative cardiac risk reduction
• Preventing postoperative pulmonary
complications