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Preoperative Risk Evaluation: An Old School Approach With a Few New Tools. David Chamberlain MD. “Clear the Patient for Surgery”. What Causes Perioperative Mortality?. 0.7 – 0.8% All cause (4,038 out of 485,850 pts) 1:2680 Anesthesia 1:420 Surgical error

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Preoperative Risk Evaluation: An Old School ApproachWith a Few New Tools

  • David Chamberlain MD

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What Causes Perioperative Mortality?

0.7 – 0.8% All cause (4,038 out of 485,850 pts)

1:2680 Anesthesia

1:420 Surgical error

1:95 Underlying medical condition(s)

67% Progression/complication of presenting disease

44% Progression/complication of underlying disease

30% Surgery contributed to mortality

< 1/3 Cardiac

> 1/3 Pulmonary

1/3 Other medical conditions

Fleischer, L, J Am Soc Anesthesiology, May 2002,Vol 96, Issue 5, p.1039-1041

Are internists really worth it l.jpg
Are Internists Really Worth It?

More likely to identify and intervene on medical conditions related to surgical outcomes.

Devereaux, PJ, et al, Clin Invest Med 2000: 23:116

Decreased length of stay post thoracic and hip surgery.

Phy, MP, et al, Arch Intern Med 2005; 165:796

No improvement of glucose control, perioperative Beta Blockers, DVT prophylaxis.

Auerbach, AD, et al, Arch Intern Med 2007; 167:2338

Higher 30 day and 1 year mortality rate, but in multi-variable analysis consulted patients had a significantly higher disease burden. Rates similar when adjusted.

Wijeysundera, DN, et al, Arch Intern Med 2010: 170:1365

No study has shown a decrease in perioperative mortality.

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Preoperative Risk Evaluationan Old School Approach

  • Risk Assessment

    • Global Assessment of Risk

    • Cardiac Perioperative Risk

      • Goldman Risk Index, Functional capacity, Surgical risk

    • Pulmonary Perioperative Risk

      • Risk Factor Evaluation

    • DVT Risk

      • Risk Factor Evaluation

    • Endocarditis Risk

      • Sanford Guidelines

    • Risk from Medical Conditions

    • Risk from Medications

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Global Assessment of Riskor“Looks good from door”

  • American Society of Anesthesiologists Preoperative Patient Classification

    • Created in 1941

    • Purpose was to assess the degree of a patient’s “sickness”

    • NPV far exceeds PPV – better at defining healthy than incapacitated

    • Not originally intended to predict operative risk, but …… (millions of patients later)

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ASA Patient Classification

Class 48hr Mortality

1 Healthy 0.07%

2 Mild Systemic Disease 0.24%

3 Severe Systemic Disease, limits 1.4%

activity, but not incapacitating

4 Incapacitating systemic disease, 7.5%

which is a constant threat to life

5 Moribund, not expected to survive 34%

24 hours with or without surgery

Emergent Surgery Risk Doubles

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Who is Too Sick or the “Are You Nuts?” Assessment

Predictors of Risk for MI, Heart Failure, Death

  • Unstable Coronary Syndrome

    angina, acute or recent MI

  • Decompensated Heart Failure

    new onset, worsening HF, NYHA Class IV

  • Significant Arrhythmias

    high grade AV block, symptomatic or new ventricular arrhythmia,

    tachycardia with rate > 100, symptomatic bradycardia

  • Severe Valvular Disease

    severe aortic stenosis, symptomatic mitral stenosis

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Predictors of Risk

  • Any one has high positive predictive value for MI, Heart failure, Death

  • Risk and severity of complications likely greater than benefit of surgery

  • Recommend delay or cancel surgery unless emergent

  • Those patients removed from subsequent cardiac risk assessments

    ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for non-cardiac surgery.

    J Am Coll Cardiol. 2007; OCT 23;50(17):e159-241

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Cardiac Perioperative RiskUpdated Old School Tools

  • Revised Goldman Cardiac Risk Index

  • Functional Capacity

  • Risk Specific to Type of Surgery

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Beyond the Goldman Cardiac Risk Index

  • 2893 patients

  • Elective non-cardiac surgery

  • Monitored for cardiac complications

    • MI

    • Pulmonary Edema

    • Ventricular Fibrillation

    • Cardiac Arrest

    • Complete Heart Block

      NOT all cause mortality

      Lee, TH, et al, Circulation 1999; 100:1043.

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Six Independent Predictors of Major Cardiac Complications

  • High Risk Surgery

  • History of Ischemic Heart Disease

    History MI, History positive stress test, angina, using NTG, Pathologic Q

    Not History CABG or PTCA or Stent

  • History of Heart Failure

  • History of Cerebrovascular Disease

  • DM treated with insulin

  • Serum Creatinine > 2.0

  • Lee, TH, Marcantonio, ER, Mangione, CM, et al, Circulation 1999; 100;1043

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Revised Goldman Cardiac Risk Indexvs.Rate of Cardiac Death, MI, Cardiac Arrest

Risk Factors Rate 95% CI

No Risk Factors 0.4% 0.1 – 0.8%

One Risk Factor 1.0% 0.5 – 1.4%

Two Risk Factors 2.4% 1.3 – 3.5%

Three Risk Factors 5.4% 2.8 – 7.9%

Devereaux, PJ, Goldman, L, Cook, DJ, et al. CMAJ 2005; 173:627

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Revised Goldman Cardiac Risk Indexvs. Cardiac Death, MI, Cardiac Arrest, Vfib, Pulmonary Edema, Complete Heart Block

Risk Factors Rate Rate with Beta Blockers

None 0.4 – 1.0% < 1%

One to Two 2.2 – 6.6% 0.8 – 1.6%

Three or More > 9% > 3%

Auerbach, A, Goldman, L. Circulation 2006; 113:1361

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Revised Cardiac Risk IndexMost Studied and Validated

  • Validated in Cohort of 1422 patients

  • Predictive value for cardiac complications and mortality significant in All types of non-cardiac surgery except AAA

  • Does Not Capture all-cause Mortality

    Ford, MK et al, Ann Intern Med 2010; 152:26

  • Better Predictive Value than original Goldman Criteria or Detsky Modified Risk Index

    Lee, TH, et al, Circulation 1999: 100:1043

  • Retrospective study; 663,665 pts; major non-cardiac Sx; 329 hospitals, 2000 – 2001

    RCRI likely underestimates risk of cardiac complications

    Increased mortality without Beta Blockers

    Devereaux, PJ, Goldman,L, et al, CMAJ 2005; 173:627

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Functional Capacityor “What’s the METs thing?”

  • 1 MET = 3.5 mL O2 uptake/KG per min

  • O2 uptake of a 40 y/o, 70 kg male sitting upright

  • Peak exercise capacity an independent predictor of all mortality in normals and subjects with cardiovascular dz

    < 5 METs : Poor Survival Prognosis (<50%)

    10 METs : Medical therapy = CABG (>75%)

    >= 13 METs : Good Survival Prognosis (>90%)

    (either category, data points at 10 year, linear separation as early as 1 year)

    For each 1 MET there is a 12% improvement in survival

    Myers, J, et al, N Engl J Med 2002; 346;793

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Can Complete Activity Without Stopping

Sit upright

Eat, dress, use toilet, make bed

Walk around house, shower

1 flight stairs, walk up hill, 2 block @ 2mph

Light house work, dust, wash dishes, golf, bowl

2 flights of stairs, walk on flat @ 4mph,


Scrubbing floors, weight lifting, moving furniture

Broke the bed/neighbors called the cops sex

Shovel snow

Doubles tennis, swing dancing

Recreational Sports: Singles tennis, soccer, basketball, skiing, jogging

Competitive sports

Specific Activity Scale

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How does this relate to Surgery?

  • < 4 METs Significantly Increases Risk MI, HF, Arrhythmia regardless of Surgical Risk

  • Functional Capacity Complication Rate

    < 4 METs > 5%

    4 – 10 METs 1 – 5%

    > 10 Mets < 1%

    Eagle, KA, et al, J Am Coll Cardiol, 2002; 39, 542-553

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What about Surgery Specific Risk?

Risk Cardiac death or nonfatal MI

High > 5 %

Intermediate 1 – 5 %

Low Risk < 1 %

Emergency 2 – 5 times the surgical risk

Fleischer, LA, Beckman, JA, Brown, KA, et al, ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiology 2007; 50:e159.

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Surgery Specific Risk for Cardiac Death or Nonfatal MI

High Risk ( > 5% )

Aortic, Major vascular, Cardiothoracic, Emergent,

long with large blood loss/fluid shifts

Intermediate Risk ( 1 – 5% )

CEA, Head, Neck, Intraperitoneal, Intrathoracic, Orthopedic, Prostate

Low Risk ( < 1% )

Ambulatory surgery, Endoscopy, Superficial Procedure, Cataract surgery, Breast surgery

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The New School Uses:2007 ACC/AHA Cardiac Evaluation and Care Algorithm

  • Step 1 Emergency Surgery

  • Step 2 Global Assessment of Risk

    Too Sick for Surgery

  • Step 3 Global Assessment of Risk

    Low Risk and Low risk Surgery

  • Step 4 Assess Functional Capacity

  • Step 5 Calculate RCRI and Surgical Risk

    Looks like the old school and the new school are the same school

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Step 1

Need Emergent Sx?

Step 2

Active Cardiac Condition?


Proceed to OR

Post Op risk stratification

Risk Factor Management


Evaluate and Treat

Consider OR when stable

Evaluating Cardiac Risk2007 ACC/AHA Algorithm

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Step 3

Low Risk Surgery?

Step 4

Good Functional Capacity?

Step 5

Poor or Unknown


Proceed to OR


Proceed to OR


Compute RCRI

Evaluating Cardiac Risk 2007 ACC/AHA Algorithm

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Step 5 continued

Zero Risk Factors

1 – 2 Risk Factors or

3 or more Risk Factors and

Intermediate Risk Surgery


Proceed to Surgery


Proceed to OR

Rate Control with Beta


Consider Non-Invasive

Cardiac Testing if will change management

Evaluating Cardiac Risk2007 ACC/AHA Algorithm

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Step 5 continued

3 or more Risk Factors


High Risk Surgery


Consider Non-Invasive or Invasive testing

if will change management

Rate control with Beta


Evaluating Cardiac Risk2007 ACC/AHA Algorithm

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Evaluating Pulmonary RiskIt’s No Longer Just a Guess

Pulmonary Complications

MORE COMMON than Cardiac Complications

Cause Significantly LONGER Hospital Stays

Lawrence, VA, Hilsenbeck, SG, et al. J Gen Intern Med 1995; 10:671

MOST COSTLY Complications

Dimick, JB, Chen, SL, et al. J Am Coll Surg 2004; 199:531

Pulmonary Complications 6.8% across all types Sx

Atelectasis, Pulmonary Infection,

Prolonged Mechanical Ventilation, Respiratory Failure,

Chronic Lung Disease Exacerbation, Bronchospasm

Smetana, GW, Lawrence, GA, et al, Ann Intern Med 2006; 144:581

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Patient Related

Age > 50, 60, 70, 80

Chronic Lung Disease



Heart Failure



Functional Dependence

ASA Class >= 2

Qasam, A, et al, Ann Intern Med, 2006; 144:575

Odds Ratio of Complications

1.5, 2.28, 3.9, 5.63


Uncontrolled 3, Controlled 1

Current 5.5, 2 mo Cessation 1.26




Total 2.51 Partial 1.65


Predictors of Pulmonary Complications

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Procedure Related

Surgical Site

Duration > 3 – 4 hr

Type of Anesthesia


Qasam, A, et al, Ann Intern Med, 2006, 144:575

Odds Ratio

Upper Abdominal 2.8


General 1.83 vs. Spinal


Predictors of Pulmonary Complications

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Other Conditions That May Require Special Attention

  • Obesity Inconsistent data

  • OSA Probable

  • Pulmonary HTN Probable, Limited data

  • URI Data limited, usually defer Sx

    Smetana, G, Ann Intern Med, 2006; 144:581

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Recommendations for Assessment of Pulmonary Risk

  • History and Physical Exam

  • Identify Pulmonary Risk Factors

  • American Society of Anesthesiologists -

    Global Assessment of Pulmonary Risk

  • Arozulla Multifactorial Risk Index for Postoperative Respiratory Failure

    Smetana, G, et al, Ann Intern Med, 2006; 144:581

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ASA Postoperative Pulmonary Complications

Class Pulmonary Complications

1 Healthy 1.2%

2 Mild Systemic Disease 5.4%

3 Severe Systemic Disease, limits 11.4%

activity, but not incapacitating

4 Incapacitating systemic disease, 10.9%

which is a constant threat to life

5 Moribund, not expected to survive NA

24 hrs with or without surgery

Qasim, A, et al. Ann Intern Med, 2006; 144:575-580

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Type of Surgery



Neurosurgery, Upper Abdominal PeripheralVascular, Neck

Emergency Surgery

Albumin < 3.0 g/dL

BUN > 30 mg/dL

Partial/Full Dependence

History of COPD

Age > 70

Age 60 - 69

Point Value











Arozullah Respiratory Failure Risk Index

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Arozullah Respiratory Failure Index Scoring

Class Point Total % Respiratory Failure

One <= 10 0.5

Two 11 – 19 1.8

Three 20 – 27 4.2

Four 28 – 40 10.1

Five > 40 26.6

Arozullah, AM, Daley, J, et al, Ann Surg 2000; 232:242

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Put It All Together

Step 1 ASA 1 and To OR

Low Risk Arozulla 1

Step 2 ASA 2 or Consider Further Testing

Arozulla 2 - 3 CXR, PFT if will change


Step 3 ASA >= 3 or Reconsider Surgery

High Risk Arozulla >= 4 Shorter Procedure

Spinal or Epidural

For all: Deep Breathing Exercises/Incentive Inspirometry Treat Identified Risk Factors & “Special” Conditions

Smetana, G, et al, Ann Intern Med, 2006; 144:581

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What Works

Pre-op Asthma Evaluation

Aggressive Tx. For COPD

Inspiratory Muscle Training

Pre-op Patient Education

Selective Post-op NG decompression

Median Length of Stay 1 day shorter

Complication rate vs controls 18% vs.35%

Hulzebos, EH, et al, JAMA, 2006; 296:1851

What Doesn’t

Smoking Cessation

Pre-op Antibiotics

Tube Feed or TPN

Strategies to Reduce Postoperative Pulmonary Complications

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DVT Risk

  • Low Risk ( < 2% )

    Age < 40 and Duration < 60 min and No Risk Factors

    Calf DVT 2% Proximal DVT 0.4%

    Significant PE 0.2% Fatal PE < 0.01%

    Tx: Ted Hose, early ambulation

  • Moderate Risk ( 10 – 40% )

    Age 40 – 60 or Duration > 60 min or Risk Factor

    Calf DVT 10 – 20% Proximal DVT 2 – 4%

    Significant PE 1 – 2% Fatal PE 0.1 – 0.4%

    Tx: LMWH, SCD

    Additional Risk Factors: Advanced Age, Cancer, Prior Venous Thromboembolism, Obesity, HF, Paralysis, Hypercoagulable State

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DVT Risk

  • High Risk ( 40 % )

    Age > 60

    Age 40 – 60 With Additional Risk Factor

    Calf DVT 20 – 40% Proximal DVT 4 – 8%

    Significant PE 1 – 2% Fatal PE 0.4 – 1.0%

    Tx: LMWH, SCD, Consider Prolonged Anticoagulation

  • Highest Risk ( 40 – 80% )

    Age > 40 with Multiple Additional Risk Factors or

    THR, TKR, Hip Fracture, Major Trauma, Spinal Cord

    Calf DVT 40 – 80% Proximal DVT 10 – 20%

    Significant PE 4 – 10% Fatal PE 0.2 – 5%

    Tx: Long Term LMWH/Anticoagulation,

    Vena Caval Interruption

    Geerts, WH, et al, Chest 2004; 126:3385

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Column A: Procedure


Skin and Soft Tissue Infection


AHA, April 2007

Column B: Abnormality

Prosthetic Cardiac Valve

History of Endocarditis

Congenital Heart Disease

Unrepaired Cyanotic

Repaired <= 6 months

Cardiac Transplant Valvulopathy

Endocarditis ProphylaxisOne from Column A and Column B

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Endocarditis Prophylaxis

  • None for GI

  • None for GU

  • None for MVP

  • None for ASD

    AHA, April 2007

  • None for bad hair day

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Medication ConsiderationsAspirin and Clopidogrel

  • When possible delay non-cardiac surgery in patients with recent coronary stenting

    • 4 to 6 weeks for bare metal stent

    • At least 12 months for drug-eluting stent

  • Optimize antiplatelet therapy with aspirin and clopidogrel by continuing it or reinstating it ASAP after procedure

    Fleischer, L, et al, Circulation, 2007, 118:418

    MKSAP Item 95,

    ACP IM Board Review Course October, 2010

    I’m not saying this was on the IM Boards, but it sure does come up a lot lately. You didn’t hear nothing from me.

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Medication Considerations andSpecific Medical Conditions

Expertise comes from residency and years of clinical experience.

We are the experts in these areas.

Consider assuming care. This is where an Internist is really worth it.