Transcript Nuts & Bolts of Perioperative Evaluation

Nuts & Bolts of
Perioperative Evaluation
What is Medical “Clearance”
Anyway?
The Cold Hard Truth
• A review of 146 medical consultations suggests
that the majority give little advice that truly
impacts either perioperative management or
outcome of surgery
• Too often reflex pre-op testing occurs which
increases costs and can lead to unnecessary
delays.
• To overcome this deficiency the ACC/AHA
developed guidelines to maximize patient benefit
and minimize delays in surgery.
ACC/AHA 2009 Guidelines
• Guideline recommendations reflect a consensus
of expert opinion after a thorough review of the
available, current scientific evidence, intended to
improve patient care.
• Assist doctors in clinical decision making
regarding the need for further cardiac evaluation
prior to surgery.
• Has been shown to reduce average costs of
“clearance” from $1000 to $170!!!
Role of the Consultant
• Determine the stability of the patient’s
cardiovascular status and whether the
patient is in optimal medical condition, in
the context of the surgical illness
• Obtain prudent testing: preoperative
tests are recommended only if the
information obtained will alter
management.
Role of the Consultant
• Intervention is rarely necessary to simply
lower the risk of surgery unless such
intervention is indicated irrespective of the
preoperative context.
• The medical consultant should avoid
"clearing" the patient for surgery, but rather
should establish risk and propose a plan
for reducing this risk.
The Consultant Should
• Review all medicines (including herbal and
OTC) and make specific recommendations
(particularly about timing and dosing of
medications)
• Identify true allergies and differentiate from
adverse affects
• Identify potential intra-op and post-op problems
(pulmonary, diabetic, renal, hematologic) and
make specific recommendations on
monitoring/managing potential problems.
• Know when it is appropriate to delay surgery
Role of History & Physical
The history/physical should seek to identify
serious active cardiac conditions such as:
• unstable coronary syndromes
• recent MI
• decompensated HF
• significant arrhythmias
• severe valvular disease
Other Pertinent Historical Data
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Pacemaker or implantable cardioverter
defibrillator (ICD)
History of bleeding diathesis or need for
transfusions
History of chronic steroid or benzodiazepine use
Prior operative/anesthetic complications
The presence Modifiable Risk Factors for
coronary heart disease (CHD)
Modifiable Risk Factors for
coronary heart disease (CHD)
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Peripheral vascular disease
Cerebrovascular disease
Diabetes mellitus
Renal impairment
Chronic pulmonary disease.
Indications for Specific
Pre-operative Tests
• Hematocrit for surgery with expected major
blood loss (increased ischemia <28%)
• Serum creatinine concentration if major surgery,
hypotension is expected, nephrotoxic drugs will
be used, or the patient is above age 50
• Chest x-ray “reasonable” for patients over 60, or
known chronic pulmonary disease, should be
performed in patients with suspected new or
unstable cardiac or pulmonary disease if it will
change mgt.
EKG recomendations
• Anyone with suspected active cardiac
conditions
• Anyone going for “high risk” surgery
• Anyone with at least one cardiac risk
factor going for “intermediate risk surgery”
Patients in Whom Routine Preoperative
ECGs may be Considered
• Men older than 45 years
• Women older than 55 years
• Patients at risk for electrolyte
abnormalities, such as diuretic use
Tests That are Not Routinely
Recommended
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Urinalysis
PT/INR or Bleeding Time
Blood glucose, A1c
Electrolytes
Pulmonary function tests
Echocardiography
When Should Consultants Obtain a
2D Echo?
• Patients with current or poorly controlled
heart failure
• Patients with dyspnea of unknown origin
(Should not obtain as a routine test of LV
function in patients without history of CHF)
Now to the 3 Key Nuts & Bolts!
3 Critical Determinants for Deciding
When Further Cardiac Evaluation is
Warranted
1. Surgical Risk Category (High,
Intermediate, or low)
2. Patient’s Clinical Risk Factors
(adapted from the Revised Cardiac Risk
Index)
3. Patient’s Functional Status
1. Surgical Risk Category
• High: Vascular (reported cardiac risk often
more than 5%) : Aortic and other major vascular
surgery, Peripheral vascular surgery
• Intermediate: (reported cardiac risk
generally 1% to 5%) : Intraperitoneal and
intrathoracic surgery, Carotid endarterectomy, Head and
neck surgery, Orthopedic surgery, Prostate surgery
• Low: (reported cardiac risk generally less
than1%): Endoscopic procedures, Superficial
procedure, Cataract, Breast, Ambulatory surgery
2. Clinical Risk Factors
(adapted from RCRI)
• History of ischemic heart disease (including
pathologic Q-waves on EKG)
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History of compensated or prior HF
History of cerebrovascular disease
Diabetes mellitus
Renal insufficiency (creatinine concentration
2.0 mg/dL)
Word on “Minor” Clinical Predictors
of Risk
• Advanced age (70)
• Minor EKG abnormalities (LVH, LBBB,
non-specific ST-T abnormalities)
• Rhythm other than sinus (ie A-fib)
• Uncontrolled HTN
(Minor predictors are recognized markers for
cardiovascular disease that have not been proven to
increase perioperative risk independently and therefore
have been eliminated from the decision making analysis)
3. Functional Status (METs)
• Based on the O2 consumption in ml/kg/min
of 70kg, 40 yr old male in resting state
• Excellent: >10
• Good: 7-10
• Moderate: 4-7
• Poor: <4
• Ask: can you walk 4 blocks, climb 2 flights
of stairs?
• In many instances, patient or surgery
specific factors dictate an obvious strategy
(eg, emergency surgery) that may not
allow for further cardiac assessment or
treatment – therefore just close
surveillance and post-op risk factor mgt.
• The presence of “active cardiac
conditions” (unstable coronary disease,
decompensated HF, severe arrhythmia or
valvular heart disease) usually leads to
cancellation or delay of surgery until the
cardiac problem has been clarified and
treated
• Low risk procedures are associated with a
combined morbidity and mortality rate less
than 1% even in high-risk patients
• interventions based on cardiovascular
testing, even with multiple cardiac risk
factors and poor functional status, rarely
results in a change in management
• ►►►PROCEED TO SURGERY
• Functional status is reliable for
perioperative and long-term prediction of
cardiac events
• Outcomes not influenced by further
cardaic work-up even in “high risk” surgery
• Should consider Beta Blocker
• ►►►PROCEED TO SURGERY
Poor or Unknown Functional Status
• For patients with poor/unknown functional
status proceed based on number of
Clinical Risk Factors and surgical type.
• (Clinical risk factors: ischemic heart disease,
compensated or prior HF, diabetes mellitus,
renal insufficiency, and cerebrovascular
disease.)
Poor Functional Status
• If the patient has no clinical risk factors
• ►►►PROCEED TO SURGERY
Poor functional status
• If the patient has 1 or 2 clinical risk factors,
then it is reasonable to proceed to surgery
(regardless of type), with heart rate
control.
• (perform non-invasive testing only if it will
change management.)
In patients with 3 or more clinical risk
factors:
• If “intermediate risk” surgery proceed to
surgery with tight heart rate control,
(consider further cardiovascular testing.)
• If “high risk” vascular surgery: STOP:
Perform non-invasive testing
Once Decided to Proceed to
Surgery, what other Patient Specific
Variables Should be Addressed?!!!
What about PPM and ICD’s?
• Should be evaluated before and after
surgical procedures
• Rate-responsive mode PM’s should be
inactivated
• ICD should be turned off immediately
before surgery
• Know if patient PM dependent
• Emergent cardioversion- avoid device!
What about Patients with Stents?
• Elective noncardiac surgery is not
recommended within 4 to 6 weeks of baremetal coronary stent implantation
• No surgery within 12 months of drugeluting coronary stent implantation.
Thienopyridine therapy imperative to
prevent in-stent thrombisis.
Stents Continued…
• Surgeons who are concerned about
periprocedural bleeding must be aware of the
potentially catastrophic risks of premature
discontinuation of thienopyridine therapy. Need
cardiology involvment!
• In patients who have received drug-eluting
stents requiring urgent surgical procedures that
mandate the discontinuation of thienopyridine
therapy, continue aspirin if at all possible and
restart the thienopyridine ASAP! (5-7 days)
Word on patients on Aspirin
• monotherapy with aspirin should not be
routinely discontinued for elective noncardiac
surgery.
• in the majority of surgeries, may result in
increased frequency of procedural bleeding
(relative risk 1.5) but not an increase in the
severity of bleeding complications or
perioperative mortality due to bleeding.
• If the decision is made to stop aspirin, seven to
ten days should elapse before surgery is
undertaken
• Resume approximately 24 hours (or the next
morning) after surgery when there is adequate
hemostasis
Word on Coumadin
• If High Risk patient (Atrial fibrillation associated
with valvular heart disease, Mechanical valve in the
mitral position, Mechanical valve and prior
Discontinue warfarin 3 to
5 days before procedure with “Bridge”
Heparin while INR is below therapeutic
level.
thromboembolic event)
Coumadin Cont…
• If low risk patient (Deep vein thrombosis,
Uncomplicated or paroxysmal nonvalvular atrial
fibrillation, Bioprosthetic valve, Mechanical valve in the
Discontinue warfarin 3 to 5
days before procedure. Reinstitute
warfarin after procedure.
aortic position)
Word on Steroids
• Patients taking prednisone at a dose greater
than 20 mg/day for three weeks or more, or a
Cushingoid appearance should be assumed to
have HPA axis suppression; give stress dose of
corticosteroids perioperatively
• Patients who have taken any dose of
glucocorticoids for less than three weeks, or
chronic alternate day therapy, are unlikely to
have a suppressed HPA axis and should
continue on their usual dose of
glucocorticoids perioperatively.
Word on Beta Blockers
(Nov 2009 Update)
• Don’t start or stop abruptly, POISE trial
demonstrated likely harm if initiate high
fixed dose of ER Metoprolol day of
surgery. (Increased Strokes and Morbidity)
• Patients already on Beta Blockers should
be continued.
• If initiating for patients with multiple RF’s,
should be titrated up to desired HR (60-80)
over days to weeks!
Word on Statins
• Evidence that statins may prevent vascular
events through mechanisms other than
cholesterol lowering (eg, plaque stabilization,
reduction in inflammation, decreased
thrombogenesis) and may be of benefit in the
perioperative period.
• Based on the current evidence, statin therapy
should be continued in patients undergoing
surgery, particularly in patients at high risk for
cardiovascular events. (Dose adjust to limit
myopathy risk.)
Word on Diabetic Medications
• Patients with type 2 diabetes who take oral
hypoglycemic drugs should hold medicine on the
morning of surgery.
• All patients with diabetes should have their
surgery as early as possible to minimize the
disruption of their management routine while
being NPO.
• Most antidiabetic medications can be restarted
after surgery when patients resume eating,
except metformin, which should be delayed in
patients with suspected renal hypoperfusion until
documentation of adequate renal function.
Diabetic Medications Cont…
• Sulfonylureas should be started only after eating
has been well established.
• Thiazolidinediones should not be restarted if
patients develop congestive heart failure or
problematic fluid retention, or if there are any
liver function abnormalities.
• Basal metabolic needs utilize approximately one
half of an individual's insulin even in the absence
of oral intake; thus, patients should continue with
basal insulin even when not eating. This is
mandatory in type 1 diabetes to prevent
ketoacidosis (with maintenance D5).
Word on Other Meds
• Clonidine: Given the potential benefits of continuing
alpha 2 agonists perioperatively and the possible
negative consequences of withdrawal, these drugs
should be continued in the perioperative period.
• Calcium channel blockers should be continued in
patients who are already taking them preoperatively.
• ACE inhibitors should be continued in patients who
are taking them for the management of hypertension
• ARBs should be discontinued on the day of surgery
and resumed postoperatively as long as the patient
is not hypotensive and has normal renal function.
Other Meds Continued
• Diuretics should be held on the morning of
surgery, and resumed when the patient is taking
oral fluids.
• Stopping niacin, fibric acid derivatives, bile
sequestrants, and ezetimibe perioperatively is
recommended. They should be stopped the day
before surgery to allow for drug elimination.
• Both H2 blockers and proton pump inhibitors
decrease gastric volume and raise gastric fluid
pH, thereby reducing the risk of chemical
pneumonitis from aspiration and reduce the risk
of stress-related mucosal damage
Word on Inhaled Pulmonary Meds
• Inhaled medications used to control obstructive
pulmonary disease such as beta agonists and
anticholinergics have been found to reduce the
incidence of postoperative pulmonary
complications in patients with asthma and COPD
and should be continued perioperatively.
• Are normally administered on the morning of
surgery. The drugs can be administered through
a nebulizer or in the circuit of the ventilator when
compliance with inhalation technique is likely to
be poor.
Word on Infective Endocarditis
• Patients with infected skin, skin structures,
or musculoskeletal tissue may have
polymicrobial infections. When such
patients undergo a surgical procedure,
only bacteremia with staphylococci or
beta-hemolytic streptococci are likely to
cause IE.
Indications for IE prophylaxis
• Prosthetic heart valves including bioprosthetic
and homograft valves , Prosthetic material used
for cardiac valve repair
• A prior history of IE
• Complex cyanotic congenital heart diseases
• (or recently repaired in prior 6 months)
• Cardiac valvulopathy in a transplanted heart
Treatment Regimens SBE
Prophylaxis
• Amoxicillin 2 g 1 hr prior to surgery
• clindamycin (600 mg), cephalexin or
cefadroxil (2 g), or azithromycin (500
mg) for pen allergic
• NPO: 2 g of intravenous or intramuscular
ampicillin 30 minutes before the
procedure
• clindamycin (600 mg IV) or cefazolin (1
g IV) 30 minutes before for pen allergic
Remember Communication is Key!