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Intro to PeriOperative Medicine. Compiled by Tabitha Goring, MD Hospitalist Attending/Assistant Professor of Medicine Jacobi Medical Center Albert Einstein College of Medicine. Perioperative Medicine. Cardiac Risk Assessment in non-cardiac surgery

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intro to perioperative medicine

Intro to PeriOperative Medicine

Compiled by

Tabitha Goring, MD

Hospitalist Attending/Assistant Professor of Medicine

Jacobi Medical Center

Albert Einstein College of Medicine

perioperative medicine
Perioperative Medicine

Cardiac Risk Assessment

in non-cardiac surgery

Goldman Cardiac Risk Index Points

Age > 70 yo 5

MI < 6 months ago 10

JVD or S3 gallop 11

Significant Aortic Stenosis 3

Non-sinus Rhythm, APCs or >5 PVC/min 7

PO2<60 or PCO2>50, K<3.0 or HCO3<20

BUN >50 or Cr>3.0, abnormal AST,

Signs of chronic liver disease, or bedridden pt. 3

Intraperitoneal, intrathoracic or aortic procedure 3

Emergent Operation 4

perioperative medicine1
Perioperative Medicine

Goldman Risk Assessment

Class Points Risk

(Complication/Death Risk)

I 0-5 0.7%/ 0.2%

II 6-12 5% / 2%

III 13-25 11% / 2%

IV >26 22% / 56%

perioperative medicine severity of perioperative stress
Perioperative MedicineSeverity of Perioperative Stress

Aortic Cross Clamp

Intrathoracic

Infrainguinal Vascular

Orthopedic

Head & Neck

Carotid

Amputation

TURP

Superficial

Cataract

perioperative medicine2
Perioperative Medicine

Perioperative Stress Hormone

  • Norepinephrine/Epinephrine
  • Most anesthetics suppress many elements of the stress response

therefore, most problems occur postoperatively

  • Complications

Tachyarrythmias Hyperglycemia

Hypertension Protein Metabolism

Myocardial ischemia CHF (Na retention)

Vasoconstriction (wound failure) HypoNa, K, Mg

Hypercoaguability SIRS

perioperative medicine3
Perioperative Medicine

Non-invasive Pre-op Cardiac Testing

Exercise Treadmill

Exercise Thallium

Dipyridamole Thallium

Holter Monitor

Dobutamine Echocardiogram

peri operative medicine
Peri-Operative Medicine

Dobutamine Stress Echo

(Shaw et al 1996- Metaanalysis)

  • Highest positive predictive value(45-65%)
  • Well Tolerated
  • Predictive Value increases with number of walls imaged.
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Perioperative Medicine

Post-op Pulmonary Complications

Diaphramatic dysfunction

Hypoxemia

Pneumonia

Bronchospasm

Respiratory Failure

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Perioperative Medicine

Pulmonary

  • No need for routine pre-op PFTs
  • No data that routine pre-op CXR improves outcome
perioperative management
Perioperative Management

Asthma Rec’s

  • Consider Oral Streoids 24-48h in mod-severe asthmatics (better than inhaled steroids to prevent periop flares)

studies show no increased wound infections, impaired wound healing or hyperglycemia.

Kabalin, Arch Intern Med 1995; 155

  • Inhaled Albut/Atrov for wheezing
  • Smoking Cessation 8 wks prior to surgery
perioperative management1
Perioperative Management

Asthma Rec’s cont’d

  • Consider use of regional anesthesia
  • Nebulizers intra-op for flares
  • IV lidocaine + inhaled salbutamol have synergy

pretreat prior to airway irritation

  • Propofol, ketamine useful in asthmatics

(bronchodilators).

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PeriOperative Medicine

What does the anesthesiologist know?

Cancel a case….

Well versed in IV meds not PO meds

(HTN, DM, MI, CHF, BrSpasm, Oliguria, Pain)

Choice of anesthestic agent

Choice of invasive or non-invasive monitoring

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PeriOperative Medicine

What doesn’t the anesthesiologist know?

Long term management of chronic problems…

-HTN

-CAD

-Renal Failure

-Malnutrition

-Hepatic Dysfunction

-Endocrinologic Conditions

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PeriOperative Medicine

What does the anesthesiologist want to know?

Regarding Drug Regimens….

-1st line, 2nd line, initial dose, titration, expected SEs

-Further tests might be indicated preoperatively

-Management suggestions

-Help to optimize the underlying disease p/t the surgical insult

-Never “clear” for a certain type of anesthesia

(may need to convert to GA anyway)

-Stent info; Type; Location; When placed; Antiplatelet Agents

-Pacer/AICD (date last checked) - ?magnet

-Suggest Cardiology when needed

perioperative medicine9
Perioperative Medicine

Internists primary goal is not simply to “clear” pts for surgery, but to

1. establish and optimize the pts risk for cardiopulmonary complications, based on the pts current medical status in conjunction with the degree of perioperative stress caused by a particular procedure.

2. provide management recommendations which pertain to pts underlying medical problems

perioperative medicine10
Perioperative Medicine

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Cardiac Surgery (J Am Coll Cardiology 2007;50e159-241)

The bottom line……….

****Intervention is rarely necessary to simply lower risk……unless it is indicated irrespective of the planned procedure.

perioperative medicine11
Perioperative Medicine

Components of the Pre-op Evaluation

~History (chronic illnesses, meds, social hx)

~Physical

~Prior hx of cardiac w/u (echo, stress test, holter, AICD, cardiac cath)

~Assessment of functional status (METS)

~PSH/Anesthetic complications

~DI

~EKG (in moderate to high risk pts)

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Perioperative Medicine

Establish Patient risk

Establish Surgical risk

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Perioperative Medicine

PATIENT RISK

Who is High Risk?

 Acute MI (<7 days) → Stress Testing → delay 4-6 weeks

 Recent MI (8-30 days) → Stress Testing → delay 4-6 weeks

 Unstable angina/severe angina

 (+) stress test/echo with large ischemic burden

 Decompensated CHF (+) S3 → ? Echocardiogram

 Arrhythmia → high-degree HB → Cardiology Consult

→ symptomatic arrhythmia c CAD “

 Severe valvular disease

perioperative medicine14
Perioperative Medicine

Who is Intermediate Risk?

  • mild angina 1 -ADLeat,dress,toilet,walk around house(↑)
  • remote MI >1 month 2-3 -walks 1-2 blocks on level ground (↑ risk)
  • stable CHF METS 4 - light housework/climb 2 flights of stairs
  • creatinine >2.0 5-9 – heavy housework,golf,bowling,dancing
  • diabetes, uncontrolled 10 - strenuous exercise swimming, tennis
  • Qwaves on EKG football, basketball, skiing
mets working metabolic rate relative to the resting metabolic rate
METS(Working metabolic rate relative to the resting metabolic rate)

4METS

  • Ability to perform a spectrum of common tasks correlate well with maximum O2 uptake by treadmill testing. (Mangano 1990)
  • Increased cardiac and long-term risks in pts unable to meet the 4-met demand
  • Perioperative ischemia more common in those with poor exercise tolerance.
perioperative medicine15
Perioperative Medicine

Pts with low functional capacity <4 METS MAY benefit from preoperative stress testing to

-identify preoperative ischemia

-identify inducible cardiac arrythmias

-to help estimate cardiac risk

-help identify at risk territory after recent MI

***there is only real evidence to support stress testing in pts with 3 or more risk factors who have poor functional capacity AND require high risk surgery ONLY IF it will change management!!!

perioperative medicine16
Perioperative Medicine

Who is Low Risk?

  • advanced age
  • abnormal EKG/old LBBB/LVH
  • low functional capacity
  • hx of CVA
  • uncontrolled HTN
  • frequent PVCs/NSVT

**risk is not known to increase with accumulation of low risk factors….

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Perioperative Medicine

SURGICAL RISK

High Risk

Open Aortic Surgery

Peripheral vascular surgery

XS blood loss estimated

Large fluid shifts

Prolonged Surgery

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Perioperative Medicine

SURGICAL RISK

Moderate Risk

Intraperitoneal/Intrathoracic Surgery

CEA/Endovascular AAA

Head and Neck Surgery

Orthopedic Procedures

Open Prostate Resection

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Perioperative Medicine

SURGICAL RISK

Low Risk

Superficial Procedures

Endoscopic Procedures

Cataract Surgery

Breast Surgery

Ambulatory Procedures

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Perioperative Medicine
  • Lee et al -(Circulation 1999;100:1043-1049)

“simple index for prediction of cardiac risk”

  • Ischemic heart disease (MI, +stress test, NTG, active CP, abnormal Qwaves)
  • CHF (hx of HF, APE, PND, LE edema, rales, S3, PVC)
  • CVA (hx if TIA or stroke)
  • High risk surgery (AAA, vascular, thoracic sx)
  • Insulin-requiring DM
  • Creatinine >2.0
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Perioperative Medicine

Who gets an EKG?

Evidence supports:

Anyone who is undergoing intermediate or high risk procedures who have at least one clinical risk factor…CAD, PAD, CVA, CRI, DM, CHF

**low risk pts do not need EKGs (although we do them anyway)

perioperative medicine22
Perioperative Medicine

Who gets PCI (preoperatively)?

Balloon angioplasty- Plavix x 2 weeks +ASA

Bare-Metal Stent – Plavix x 4 weeks + ASA

Drug-eluting Stent – Plavix x 1 year (at least) + ASA

**(expert-opinion only…no real evidence to support)

**evidence reveals that PCI has no valve in prevention of cardiac events with except in those who PCI is indicated for ACS

***CABG for left main disease

perioperative medicine23
Perioperative Medicine

Perioperative Beta-Blockers

Who should be started?

  • Angina/Arrythmias/HTN – continue!
  • High Risk pt undergoing high risk procedures (evidence supports)
  • CHD + high risk procedure
  • High risk pt undergoing intermediate risk procedure

**always use caution in pts in whom BBs are contraindicated (dCHF, severe valvular dx, IHSS, mod-pers asthma etc………

perioperative medicine24
Perioperative Medicine

Perioperative B-blockers

The Verdict is still out on….

  • Intermediate Risk pts undergoing moderate risk procedures

(although it is generally accepted that these pts are begun on BBs)

  • Low Risk pts undergoing high risk procedures
  • Low risk pts do not appear to benefit from and may be harmed by initiation of BBs. (Lindenauer et al (retrospective)NEJM 2005.)
perioperative medicine25
PeriOperative Medicine

POISE Study

(PeriOperative ISchemic Evaluation)

Inclusion Criteria

  • Undergoing non-cardiac surgery
  • > 45 yo
  • LOS 24 hours
  • CAD/PVD/hx of CHF/major vascular surgery or
  • Any 3 of the 7 thoracic/abdominal surgery/CHF/TIA/DM/CRF/>70yo/urgent surgery
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PeriOperative Medicine

POISE Study

(PeriOperative ISchemic Evaluation)

Exclusion Criteria

  • Bradycardia <50bpm
  • 2nd or 3rd degree HB
  • Asthma
  • Adverse rxn to a BB
  • CABG w/i 5 yrs
  • Low risk procedure
  • On Verapamil
perioperative medicine adapted from kate leslie md pp presentation royal melbourne hospital

406

3548

2005

1506

191 sites

23 countries

886

PeriOperative Medicine(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)
perioperative medicine27
PeriOperative Medicine

POISE Study

(PeriOperative ISchemic Evaluation)

  • 8,351 patients included in the analysis, 99.8% of pts completed 30day f/u
  • Metoprolol 200 mg (starting 2-4 hours prior to surgery)
  • Continued qD x 30 days
  • Held for HR below 45bpm or hypotension (drug restarted @ lower dose)
  • EKG post-op, first day, second day and 30 days after surgery

(biomarkers if MI is suspected)

perioperative medicine28
PeriOperative Medicine

POISE Study

(PeriOperative ISchemic Evaluation)

Primary Outcome

1. Cardiovascular death

2. Non-fatal MI

3. Non-fatal cardiac arrest 30 days after randomization

adapted from kate leslie md pp presentation royal melbourne hospital primary outcome non fatal mi
(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)Primary Outcome Non-fatal MI
perioperative medicine stroke adapted from kate leslie md pp presentation royal melbourne hospital
PeriOperative MedicineStroke(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)
slide39
PeriOperative MedicineAll Deaths(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)
perioperative medicine adapted from kate leslie md pp presentation royal melbourne hospital1
PeriOperative Medicine(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)

For every 1,000 treated patients, metoprolol would prevent

  • 15 MIs
  • 7 cases of new AF
  • 3 post-op CABGs

And there would be

  • 8 excess deaths
  • 5 excess strokes
  • 53 patients with significant hypotension
perioperative medicine adapted from kate leslie md pp presentation royal melbourne hospital2
PeriOperative Medicine(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)
  • Significant decrease in the risk of non-fatal MI
    • Pooled OR = 0.68 (0.53-0.87)
  • Significant increase in the risk of perioperative stroke
    • Pooled OR = 2.16 (1.04-4.50)
  • No effect on total mortality
perioperative medicine29
Perioperative Medicine

Beta-Blockers

Evidence suggests:

  • Longer-Acting (Atenolol) appears to be superior to shorter acting (Metoprolol).
  • The dose should be started at least 7 days prior to surgery and titrated up to target HR 60-65 (which is often not feasible in-house)
perioperative medicine30
Perioperative Medicine

Post-op R/O MIs

The evidence does not support serial Troponin measurements in pts who are clinically stable and hv undergone intermediate or high risk surgery!!!!!!!!

It is only recommended in pts with EKG changes or CP!!!

WOW!!!!!

perioperative medicine31
Perioperative Medicine

Rather…..

Charlston et al (1988)…Obtain EKG

*Immediately post-op

*Day 1 post-op

*Day 2 post-op

If changes, (ST-T wave changes) or symptoms then obtain Cardiac enzymes

(What do we do with all these slightly positive troponins? Do they affect outcomes? What is the role of revascularization?)

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Perioperative Medicine

Why Give Stress Dose steroids???

Chronic Steroid use suppresses the hypothalamic-pituitary-adrenal axis…

What constitutes chronic use?

perioperative medicine33
Perioperative Medicine

Normal Daily Corticol Production

10 mg Hydrocortisone PO

Endogenous Cortisol levels rise to

50 mg – Minor Surgery

75-150 mg – Major Surgery

(at induction of anesthesia, with return to baseline within 24-48 h)

perioperative medicine34
Perioperative Medicine

Time to recovery of HPA axis

- as short as 2-5 days or as long as 9-12 months

Therefore, recommendations have been to administer steroids toany pt who has received more than 10 mg of prednisone for more than 7 days consecutive within the last year. (or 3 months depending on the author)

perioperative medicine35
Perioperative Medicine
  • Asthmatics
  • Chronic Rheumatologic/Autoimmune Diseases
  • Certain Neurologic Diseases
  • HIV (PCP)
  • Dematologic Diseases (include high potency topicals)
  • GI (UC)
perioperative medicine36
Perioperative Medicine

Traditional dose

100 mg of hydrocortisone q8h

(With a quick taper over 1-3 days if uncomplicated.)

Technically, dose should be administered based on the surgical risk

Minor - 25 mg Hydrocortisone at induction x 1

Moderate - 25 mg Hydrocortisone q8h x 24 h

Major - 50 mg Hydrocortisone q6h x 48-72h

perioperative medicine37
PeriOperative Medicine

A Question…….

A 68 yo man recently diagnosed with AdenoCa of the cecum undergoes preoperative evaluation before surgical resection. His PMH includes inoperable CAD, heart failure with LVSF 35%, HTN, hyperlipidemia. Angina is stable, occurring approx monthly, and he has no orthpnea or PND. Medications include lisinopril, carvedilol, lasix, zocor and daily ASA. He plays golf weekly and carries groceries up a flt of stairs to his apt.

On physical, P 64, 120/64, JVD 6 Lungs CTA S1S2 no S3. No LE edema

CBC, Chem are WNL

EKG – NSR, Qwaves in II, III, AVF (old)

perioperative medicine38
PeriOperative Medicine

Which of the following is the most appropriate next step in the preop eval of this pt?

a. Order plasma BNP

b. Echo

c. Exercise stress test

d. Nuclear imaging for LVEF

e. No further evaluation

What is his risk category??????

perioperative evaluation
PeriOperative Evaluation

Question #2

A 68 yo male with a PMH of CAD, HTN, chol, presents for a perioperative evaluation before AAA repair (open). His meds include lisinopril, HCTZ, Zocor, ASA. He has not had angina since undergoing a 3V CABG 4 yrs ago. He plays gold weekly, walking and carrying his clubs on a hilly course, walks two miles in 35-40 minutes 3w weekly and vacuums the house.

PE – P 78 BP 140/87. The remainder of the exam is unremarkable. Results of the electrocardiography are c/w his most recent electrocardiogram, with evidence of an old inferior infarction. CBC, Chem are WNL.

perioperative medicine39
Perioperative Medicine

Which of the following is the most appropriate perioperative management in this pt?

a. Atenolol

b. Exercise stress testing

c. Echocardiography

d. Intraoperative Rt heart Cath (Swan)

perioperative medicine40
Perioperative Medicine

Diabetes

Anticoagulation

DVT Prophylaxis

Delirium

HTN in Pregnancy