Perioperative Cardiac Risk Assessment

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Perioperative Cardiac Risk Assessment

• Chuck Albrecht
• Assistant Professor, Johns Hopkins University
  School of Medicine
• Associate Program Director JHU/Sinai Residency
  Program in Internal Medicine
• Director, General Internal Medicine Division

2

• You are consulted regarding the preoperative
  assessment of a 68 yo diagnosed with
  adenocarcinoma prior to resection.
• Hx () inoperable CAD, EF 35, HTN,
  Hyperlipidemia, asymptomatic while walking 2
  miles 3 times/ week and while carrying groceries
  up the stairs to his apartment
• Medications include Lisinopril, Carvedilol,
  Furosemide, Simvastatin, and ASA
• PE notable for bp 120/64, hr 64 and regular, no
  JVD, lungs clear.
• ECG unchanged, sinus rhythm and evidence of old
  inferior infarct

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Which of the following is the most appropriate
next step in the preoperative evaluation of this
patient?

• Plasma B-type natriuretic peptide measurement
• Echocardiography
• Exercise Stress Testing
• Nuclear Stress Testing
• No further evaluation

4
Overconfident Consultant
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The Ten Commandments

• Determine the Question
• Establish Urgency
• Look for Yourself
• Be as brief as possible
• Be Specific

6
The Ten Commandments

• Provide Contingency Plans
• Honor Thy Turf (thou shalt not covet thy
  neighbor's patient)
• Teach With Tact
• Talk is Cheap. And Effective
• Follow-up
• Effective Consultations. Goldman et al. Arch
  Intern Med-Vol 143, Sept 1983

7
Internists
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Role of the Medical Consultant

• Not to clear which suggests no problems will
  occur
• 1) Determine current health status
• 2) Establish surgical-risk profile
• 3) To decide whether further cardiac testing is
  necessary
• 4) To identify actions or recommendations that
  might reduce the patients perioperative risk

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Abnormal Test Results

• Usually 2 standard deviations from the mean (2.5
  above or below reference)
• Single lab test in population without known
  disease, 5 can be expected to have an abnormal
  value
• 20 lab tests, such as a chemistry panel increases
  the likelihood of one abnormal value to 64, of
  which we know clinicians ignore 30-60.

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The Humble Origin of Defensive Medicine
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Diagnostic Ability of Tests

• Sensitivity of ECG for CAD .27
• Specificity of ECG for CAD .81
• Assuming a prevalence of 20 in 2000 patients
  screened
• 162 positives
• 108 of which would be false (more testing)
• 146 false negatives ( occult CAD)

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Issues

• More is generally not better when discussing the
  clinical value of testing
• 10 of the more than 30 billion spent on lab
  testing each year is for preoperative evaluation

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Current Approach for Low Risk/ Low Blood Loss
Surgery

• lt40 YEARS
• 40-59 YEARS
• gt60 YEARS

• Consider Hemoglobin
• ECG, Hemoglobin, BMP
• Above and Consider CXRY

2 points for the boards Lab testing is
unnecessary in healthy patients without a history
suspicious for bleeding disorders before low-risk
surgery. Lab testing is unnecessary in patients
undergoing routine cataract replacement and
intraocular lens implant.
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Electrocardiogram

• GOLDMAN
• FRAMINGHAM
• VELANOVICH

• MI lt 6 months
• 28 infarcts are silent
• Abnormal ECG increases risk of surgery and 10
  had abnormal ECG

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ELECTROCARDIOGRAM

• GOLDMAN

• Rhythm other than sinus, APCs, PVCs raise the
  risk of cardiac complications by 7

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ELECTROCARDIOGRAM

• Men over 40, Women over 50
• History or Physical Exam suggestive of heart
  disease, or Pt. Unable to provide hx
• Systemic disease which increase risk of heart
  disease such as DM, HTN, PVD, Malignancy
• Major or Emergency surgery
• Cardiotoxic Meds TCA, Doxorubicin etc...

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Electrolytes

• Goldman
• Kaplan

• Electrolytes not associated with greatly
  increased risk
• 2800 tests drawn on asymptomatic patients. Four
  results changed management at a cost of 4.2
  million dollars to change mngmnt. (price 20
  YEARS AGO)

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Electrolytes

• Patients over 40
• Patients on diuretics
• Patients with SIADH, DI, severe liver disease,
  diabetes, renal disease, pancreatitis, adrenal
  disease

• CMP, SMA-12 ordered in a low risk population
  results in more false positives than true
  positives and delays surgery

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Bleeding Disorders Most evidence shows that
these tests do not add clinical value unless the
patient has a history of abnormal bleeding

• Prevalence of a prolonged pt/ ptt in a healthy
  population is 2.28
• To find one case (per thousand tested) of an
  asymptomatic person would cost 1,100,000
• Robbins-Mushin 1979

• ORDER IF
• history of abnl bleeding
• liver disease
• malabsorption
• use of anticoagulants
• surgery high risk for bleeding complications

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CHEST XRAY

• 30 Million chest x-rays done in the US in 1990
  costing 1.5 BILLION dollars
• Royal College of Radiologists Study
• 10,619 patients undergoing nonacute, noncardiac
  surgery

• 96.2 with normal findings went to surgery
• 92 with abnormal findings went to surgery
• 26 went to surgery before a report was available

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MEDICOLEGAL CONSIDERATION

• YOUR RISK OF BEING SUED IS MUCH GREATER IF YOU
  ORDER A TEST AND DO NOT LOOK AT IT AS COMPARED TO
  NOT ORDERING IT IN THE FIRST PLACE (or if tests
  are ordered they need to be checked)
• DO NOT ORDER UNECESSARY TESTS!

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CHEST XRAY

• 21 Studies between 1966 and 1992
• Meta-Analysis (Archer et. Al 1993)
• 14,390 patients

• Abnormalities detected 10 of the time
• 9 of abnormalities already known
• ONLY 1/10 abnormalities resulted in ANY change in
  patient management

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PREVIOUS TESTS

• MCPHERSON STUDY
• 3096 patients
• CBC, BMP, COAGS
• COMPARED REPEAT TESTS OVER 4 MONTH PERIOD

• IF THE TEST WAS NORMAL INITIALLY, only 0.4
  Changed over a 4 month period
• None of the 0.4 of lab changes impacted on
  asymptomatic patients!!

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Urine analysis

• Orthopods like urine
• 1989 cost analysis for routine preop UA
• nonprosthetic knee procedures, baseline wound
  infection 1
• 10 UA infection, UTI increases wound infection
  by 1, routine UA prevents infection in 0.001 of
  screened patients
• 1.5 million per wound prevented
• LOW PREDICTIVE VALUE/ HIGH COST

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Pulmonary Function Tests

• Little clinical utility EXCEPT
• assessment prior to CABG
• assessment prior to lung resection

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Other tests as Dictated by hp

• CV disease
• Pulmonary disease
• Hepatic disease
• Malignancy
• Renal Disease
• Bleeding Disorder
• Diabetes
• Thyroid Disease

• Prescription drug usage

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SUMMARY

• Less than 40
• 40-59
• gt60

• Consider HGB
• ECG, HGB, BMP
• ECG, HGB, BMP, (consider cxry)

For all ages, add tests as needed depending on
preexisting conditions
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• You are asked to evaluate a previously heatlhy
  26-year-old man before an elective repair of an
  inguinal hernia. He has no personal or family
  history of easy bruising, bleeding disorders, or
  thromboembolic disease. He takes occasional
  acetaminophen for pain.
• On physical exam, he is well developed with
  normal vital signs. Notable only for a reducible
  indirect right inguinal hernia. No petechiae,
  ecchymoses or telangiectasia.
• What is the most appropriate laboratory
  evaluation before the planned surgery?
• Prothrombin time, activated partial
  thromboplastin time, and platelet count
• No laboratory testing is necessary
• Prothrombin time, activated partial
  thromboplastin time, platelet count, and bleeding
  time
• Bleeding time
• Complete blood count with platelet count

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DOC, Ive been healthy for years, why did I have
a heart attack after surgery?

• Physiologic response to Anesthesia
• Increased Myocardial Oxygen consumption
  (catecholamine release, increased peripheral
  vascular resistance, increased salt and fluid
  retention)
• Decreased myocardial oxygen supply
• Hypoventilation, Atelectasis, Anemia, Hypotension

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Pearls

• Most MIlt 24 hours post op (Badner, 1998)
• This corresponds with the time of maximal
  atelectasis, hence the rec for incentive
  spirometry
• Most periop MI without angina
• However think of this with arrhythmia (brief),
  chf, hypotension, hyperglycemia, mental status
  change
• Perioperative ischemia/infarction is a marker of
  increased cardiac risk over next two years

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Preoperative Evaluation of Patients Prior to
Noncardiac Surgery
PAUL DUDLEY WHITE
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Heart disease 1931

• There is no treatment for aortic valve disease
• There is no specific treatment for mitral valve
  disease
• The treatment of hypertension is a difficult and
  almost hopeless task
• There is no specific treatment for coronary
  disease

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Heart Disease 1931

• Patients with heart disease of nearly all types
  go through anesthesia and operations
  surprisingly well But marked congestive
  failure, very recent coronary thrombosis, severe
  angina pectoris, and luetic aortitis add very
  appreciably to the operative risk, sudden death
  being a common ending for all of these
  conditions except in rare cases, however, the
  presence of heart disease should not deter one
  from emergency operations.

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ASA 1961

• Class 1-6 No medical history (1) to moribund,
  not expected to survive 24 hours without surgery
  (5), brain dead organ donor (6), emergency (e)
• ASA newsletter current classification is a
  ceremonial exercise in memory of pioneer
  physicians, with little meaningful clinical
  application in todays practice of anesthesia

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Goldman
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9 factors (goldman)
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Cardiac Risk Index
39
1977 Risk Index Found the following factors NOT
to increase cardiac risk

• HTN with diastolic lt110
• S4
• Diabetes that was controlled
• Hyperlipidemia
• Chronic stable angina
• Anesthesia type

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Insert lubdub picture
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What came next?

• Refined Risk Factors including Eagle and Detsky
• Managed care the over-riding theme in 1996
• Intervention is rarely necessary to lower the
  risk of surgery
• Rational use of testing in an era of cost
  containment

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ACC/AHA Task Force
43
ACC/AHA guidelines 1996

• Clinical Predictors
• Major, Intermediate, Minor
• Functional Capacity
• METS
• Surgical Risk
• High, Intermediate, Low (gt5,lt5,lt1)

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1999
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4Cs, 1D, and a Surgery

• Chf
• Cva
• Cad
• Cri
• D (insulin requiring)
• High risk surgery

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ACC/AHA Guideline 2002Philosophy

• Preoperative intervention is rarely necessary to
  simply lower operative risk
• Identify most appropriate testing and treatment
  strategies to optimize patient care and assess
  short and long term risk

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ACC/AHA Guideline 2002Philosophy

• the concept of medical clearance for surgery
  is short sighted..
• Goals of the preoperative consult
• Evaluate medical status
• Advise on disease management in the periop period
• At times recommend preventive measures for the
  future

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Acc/aha 2002 picture
Review of 400 new articles since 1996 of
prospective/ randomized studies remains
small Available on the web _at_ www.acc.org and
americanheart.org
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Whats new in the ACC/AHA Guideline Revision?

• Preop Crgt 2.0 mg/dl intermediate risk
• Hctlt 28 increases ischemia risk in prostate and
  vascular surgery
• Elective surgery probably safe 4-6 weeks post MI
  if stress test reveals no residual ischemia
• BPgt 180/110 should be treated prior to elective
  surgery
• Beta Blockers
• Maintenance of normothermia in the high risk

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Risk of Surgery

• High Risk
• Emergency Surgery
• Vascular Surgery (Bypass)
• Anticipated Large Volume Blood Loss or Large
  Volume shifts

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Risk of Surgery

• Intermediate Risk Surgery
• Carotid surgery
• Head surgery
• Orthopedic surgery
• Prostate surgery
• Intraabdominal or intrathoracic surgery
• Neck surgery

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Risk of Surgery

• Low Risk
• Ambulatory
• Breast
• Cataract
• Dermatologic
• Endoscopic

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Major Clinical Predictors

• Unstable Coronary Syndrome
• Decompensated Heart Failure
• Significant arrhythmia
• High grade av block
• Symptomatic ventricular arryhthmia
• Supraventricular arryhthmia with high rate
• Severe Valvular Disease

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Intermediate Clinical Predictors

• Mild Angina
• Previous MI
• Compensated or hx of heart failure
• Diabetes mellitus (particularly insulin
  dependent)
• Renal insufficiency (CRTgt2) NEW

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Minor Clinical Predictors

• Advanced Age
• Abnl ECG (LVH, LBBB, ST-T abnormal)
• Rhythm other than sinus
• Low functional capacity
• History of Stroke
• Uncontrolled systemic hypertension

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Functional Capacity
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Algorithm

• 8 steps to preoperative assessment using surgical
  risk, clinical predictors, METS
• STEP 1 proceed with emergency surgery
• STEP 2 proceed if revascularized within 5 years
  without symptom changes
• STEP 3 proceed if cardiac evaluation done within
  2 years without change in symptoms

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Algorithm

• If you get to step 4 (assessing clinical
  predictors) remember the following general rule

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Algorithm

• Testing is indicated if any 2 of the following
  factors are present
• Intermediate Clinical Predictors
• Poor functional capacity
• High risk surgery
• For test purposes, and in most real life
  situations, however, please remember, these are
  still GUIDELINES, hence the Art

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Betablockade
200 patients with CAD known or RF, for elective
NC surgery Death prior to discharge 0 vs. 8
(plt.001) Death at 1 year 3 vs 14 (plt.005) Death
at 2 years 10 vs. 21 (plt.019) Principal effect
was a reduction in cardiac deaths/ morbidity in
first 6-8 months Atenolol IV prior and post
titrate to HR 55 (intensive)
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ANY PATIENT WITH INTERMEDIATE RF OR LOW
FUNCTIONAL CAPACITY RECEIVED STRESS ECHO Persons
with ischemia (112) were randomized to trial,
HOWEVER. Patients were eliminated for echo
findings of evidence of left main of severe 3v
disease HIGH RISK PATIENTS WERE ELIMINATED AT one
month DEATH 3.4 vs. 17 (p0.02) MI (nonfatal) 0
vs. 17 (plt0.001)
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When does empirical therapy render preoperative
noninvasive testing unnecessary? Retrospective,
again major vascular surgery with cad or RF, high
risk echo eliminated Investigators concluded that
patient with a revised cardiac risk index score
less than 3 had a cardiac risk less than 2 as
long as they received perioperative betablocker
therapy
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Beta-blockers Reduce Cardiac Morbidity and
Mortality in all but the highest risk patients

• Auerbach and Goldman (Jama 2002) metaanalysis
• Heterogenous group of studies
• NNT 2.5-8.3
• Experts routinely recommend perioperative
  betablocker for 1 MAJOR CRITERIA (Lee cardiac
  risk index)
• Or 2 MINOR advanced age, HTN, smoker,
  hypercholesterolemia, DM not requiring insulin

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No cardiac testing for intermediate risk patients
on beta blockers noninferior to testing before
vascular surgery for preventing death and
nonfatal MI

• J Am Coll Cardiology 2006 48964-9
• 770 patients (mean age 68, 75 men)
• Intermediate cardiac risk 1 or 2 of age gt70,
  angina, MI, CHF, DM, Crt gt1.6, CVA, TIA
• No testing or preop dob. Echo
• Bisoprolol 2.5 titrated to HR 60-65
• Time to surgery 34 vs. 53 days
• No cardiac testing 1.8 composite endpoint
• Cardiac testing 2.3 composite endpoint
• NONINFERIOR APPROACH

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Prevention of Perioperative Complications Beta
Blockers

• Start Days or weeks in advance
• Titrate resting heart rate to 50-60 bpm
• Continue for extended period of time (?)

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Are Betablockers effective?
Does perioperative metoprolol have an effect on
the incidence of cardiac complications 30 days
and 6 months after vascular surgery?
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Are Betablockers effective?

• RCT prior to vascular surgery and 5 days post
• Composite Outcomes MI/death/ACS/CHF/ arrhythmia
• 496 randomized and Table 1 characteristics were
  the same
• 30 days 12 (placebo) versus 10.2 (metoprolol)
  (P.57)
• 6 months (-) significant difference
• Adverse events
• intraoperative bradycardia (22 versus 8)
• Hypotension (46 versus 34)

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Are Betablockers effective?

• 60 LRCRI 1
• 9 LRCRI gt3
• Although postop heart rates differed between
  metoprolol and placebo groups (69 versus 79 BPM)
  the dose was not titrated to the 55-70 as in
  trials showing a benefit

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Beta Blockers Harmful?

• Insertt lindenauer article here

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Beta Blockers Harmful?

• Retrospective cohort study 782,969 patients
• 14 RCI 0 beta blocked
• 44 RCI 4 beta blocked (in need of PI?)
• 0-1 day beta blocker assigned prophylaxis
• gt3 days beta blocker started, assigned no
  treatment group
• RCRI 0-1 no benefit and possible harm
• RCRI 2-4 clear benefit (OR .58-.88 for death)

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Are Betablockers effective?
Does perioperative beta blockade decrease
mortality or cardiac morbidity in patients with
diabetes undergoing major noncardiac surgery?
British Medical Journal Online first bmj.com
accessed 1/2007
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Are Betablockers effective?

• Major noncardiac surgery
• Extended release metoprolol 1 day prior to 8 days
  postop
• 921 patients with same characteristics
• 18 month (-) change in composite endpoint
• 20 versus 21 (P.57)
• All cause mortality 16 in both groups
• 5-6 30 day event rate in both groups
• HR mean 76 versus 83
• Insufficient evidence to support beta blockade as
  prophylaxis in diabetic patients

British Medical Journal Online first bmj.com
accessed 4/2007
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Are Betablockers effective?
Do higher doses of beta-blockers and tight heart
rate control reduce perioperative myocardial
ischemia, troponin t release, or all cause
mortality?
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Are Betablockers effective?

• 272 Vascular surgery patients
• Table 1 characteristics same except heart rate
  64-66 versus 76 in beta blocked groups
• All had DSE
• Observational Cohort study
• No beta-blocker versus Low dose (1-25) versus
  high dose (25-100)

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Are Betablockers effective?

• Higher Beta-blocker doses were associated with a
  lower incidence of
• Myocardial ischemia HR 0.62
• Troponin T release HR 0.63
• Long- Term Mortality HR 0.86
• Higher Heart Rates were associated with an
  increased incidence of
• Myocardial ischemia HR 2.49
• Troponin T release HR 1.53
• Long-term mortality HR 1.42

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Betablockers Conclusions?

• The degree of perioperative heart rate control
  influences cardiac complications.
• Hospitals need to develop aggressive protocols
  using dose titration that reaches the beneficial
  heart rate target in positive trials (55-70).
• We still have limited data in nonvascular
  surgery.
• The role and benefit of noninvasive testing with
  potential strategies for revascularization
  continue to come into question, and tight heart
  rate control is beneficial and may obviate the
  need for NIT in some patients.

84
Conclusions Beta Blockers

• Patients with a revised cardiac risk less than 3
  have a cardiac risk lt2 receiving betablocker tx
  stress unhelpful for modifying risk in this group
• Stress provides useful information for patients
  with a risk score of 3 or greater
• Negative results 0.4-1.2 risk (with BB)
• Positive stress (5 abnl segments on dobutamine
  stress) did not benefit from beta blockers and
  may need cardiac catheterization and
  revascularization, this strategy remains unproven

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Betablockers Conclusions?

• \

• Future Recommended Reading
• NEW ACC/AHA guidelines due out anytime
• NEW ACC/AHA endocarditis prophylaxis guidelines
  available

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Coronary Artery Revascularization Prophylaxis
Trial (CARP)
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CARP

• VA study
• 510 men
• Stable CAD, mean lvef 54
• Determined by a cardiologist to be high risk
• Cardiac cath
• Randomized to revasc vs. no revasc
• Exclusions
• Left main
• Lveflt20
• USA
• Critical AS
• Urgent/ Emergent surgery
• i.e. SICKEST OF THE SICK

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CARP

• Eligible if one or more major coronaries gt 70
  stenosis
• Local investigator decided CABG/PTCA
• 5859 patients scheduled for vascular surgery
• 1654 insufficient cardiac risk
• 1025 urgent surgery
• 626 prior revasc without residual ischemia
  (FIXED)
• 731 severe coexisting illness
• 633 refused
• 363 non obstructing cad
• 215 cad not amenable to revasc
• 54 left main
• 11 Eflt20
• 8 severe AS
• 500 patients

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CARP

• 240 revascularized and 252 not revascularized
• 2.7 years post vascular surgery
• 22 mortality Revasc Grp
• 23 mortality No revasc grp
• SIMILAR OUTCOMES!

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CARP

• The findings support the opinions of the ACC/AHA/
  ACP task force which have recommended that CABG
  or PCI be reserved for patients with Unstable
  cardiac disease or advanced cardiac disease, for
  whom a survival benefit with revascularization
  has been proved.

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CABG

• gt50 stenosis of Left Main
• Left main equivalent (gt70 LAD/CX)
• gt50 3 vessel disease
• The poorer the LVF, the greater the benefit

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Statins

• Retrospective studies suggestive of benefit of
  statins
• Poldermans et a. Statins are associated with a
  reduced incidence of perioperative mortality in
  patients undergoing major noncardiac surgery.
  Circulation. 2003107 1848-1851
• Lindenauer PK et al. Lipid lowering therapy and
  in hospital mortality in major non cardiac
  surgery. JAMA 2004 291(17) 2092-9.

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Statins

• Durazzo AE et al. Reduction in cardiovascular
  events after vascular surgery with atorvastatin
  a randomized controlled trial. J Vasc Surg
  200439967-76
• 100 patients randomized 20mg atorvastatin
• vascular surgery 31 days post start
• lower composite cardiac events (death, mi,
  angina, cva) no difference individual endpoints
• 1/2 each group betablocked, sample not large
  enough to determine if this contributed to
  composite benefit.

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Clonidine has been found to be beneficial in a
scattered group of heterogenous, low powered,
mostly retrospective trials, but if ABSOLUTE CI
to beta-blocker, its worth a shot
95
40 pts stent placement lt 6 weeks before
noncardiac surgery 7 MIs, 11 major bleeds, 8
deaths All deaths, MIs, 8/11 bleeds in pts
surgery lt 14 days post stent
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Stents

• These were bare metal stents (approximately 1
  month dual tx in 2000)
• 80 stents today are drug eluting

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STENTS

• Sirolimus (Cypher) ASA 325 Clopidogrel 75mg
  daily/ three months uninterrupted
• (NEJM Oct. 2, 2003 Sirolimus Eluting Stents
  versus Standard Stents in Patients with Stenosis
  in a Native Coronary Artery)
• Paclitaxel (Taxus) ASA 325 Clopidogrel 75 mg/
  daily six months uninterrupted
• (NEJM January 15, 2004 A Polymer-Based,
  Paclitaxel-Eluting Stent in Patients with
  Coronary Artery Disease)

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Lancet Case Reports
LANCET case reports 2004
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Stop Clopidogrel?
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Perioperative pulmonary assessment

• There are validated risk assessments
• ACP new guidelines 2006 defining risk factors

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Perioperative pulmonary assessment

• AGE
• 60-69 OR 2.09
• 70-79 OR 3.04
• Patient Related Risks
• COPD 1.79
• Tobacco 1.26
• CHF 2.93
• lt4 METS 1.65-2.5

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Perioperative pulmonary assessment

• Procedure related
• Abdominal surgery
• Surgery gt 3hours OR 2.14

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Perioperative pulmonary assessment

• THE MOST POWERFUL PREDICTOR ALBUMIN lt3.5
• May or may not contribute
• OSA
• ETOH
• Delerium
• Low Weight

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Preoperative Pulmonary testing

• Generally proven to be ineffective for risk
  prediction

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Risk of Postoperative Pneumonia
AROZULLAH
106
Risk of Respiratory Failure
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Summary

• Many tests unneeded
• ACC/AHA 2002 guidelines due for update
• Think of beta blockade, Think of beta blocking
  and sending patients to surgery with Lees
  revised cardiac index lt3
• Stress still meaningful in some patients
• Bare metal stents vs. drug eluting stents

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Postoperative Fever

• Wind (NOT atelectasis)
• Water
• Wound
• What did We do?

110
Postoperative Fever

• Fevers lt48 hours rarely infectious (lt10)
• Magnitude of fever has NO correlation with
  infection
• After 5 days gt90 are infectious
• 42 wounds
• 29 UTI
• 12 Pneumonia

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Why is fever common POD 1?

• Interleukin 1,6
• TNF
• Interferon

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Atelectasis

• NOT SUPPORTED BY THE LITERATURE
• Engoren 100 patients followed 2 days post CT
  surgery no correlation between fever and
  atelectasis on xray
• Roberts et al 270 patients post abdominal
  surgery no correlation between fever and
  atelectasis on xray

113
Most Common Causes?

• Drugs
• Gout
• VTE
• Hematoma
• ETOH withdrawal
• Transfusion
• Pancreatitis

• IV/Catheter
• C.Diff
• Sinusitis
• Acalculous cholecystitis

114
Emergent Causes of Postop Day One fever

• Pulmonary Embolus
• Myonecrosis
• Adrenal Insufficiency
• DTs
• Malignant Hyperthermia

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Perioperative Medication Debates

• Antiparkinsonian Agents
• Stress Dose Steroids
• Ace inhibitors
• Blood pressure sustained by 3 vasopressor
  systems sympathetic nervous system, RAS, and
  vasopressin

116
Perioperative Steroid Use

• Initial 1952 report (steroid dependent patient
  stopped 2 days prior to surgery died during an
  orthopedic procedure)
• 1976 Kehlet revealed only 57 worldwide cases of
  postop hypotension secondary to AI
• 2/104 patients with postop steroids held
  completely had AI hypotension in a review by
  Brown and Buie

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Perioperative Steroid Use

• Abnormal response to ACTH after 5 days at
  Prednisone 20 mg or greater
• For lt20 about 1 month for HPA suppression to
  occur
• ACTH testing often not practical, studies have
  shown patients with evidence of suppression when
  testing may have a normal clinical course
  perioperatively without steroids, false negatives

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To Stress Dose or Not

• lt/ 5 prednisone no treatment
• Alternate day steroids no treatment
• gt5mg-20 dependent of surgical stress
• gt20 adrenally insufficient
• gt1 week therapy 20mg or more in last 6-12 months

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Treatment

• Local anesthesia 25 mg hydrocortisone or regular
  prednisone dose
• Moderate stress 50 mg q 8 hours
• Large stress surgery (cardiac, aortic,
  intraabdominal) 100 mg q 8 hours
• Maximum physiologic response?

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Postoperative Delerium

• 10-15 older general surgery patients
• 30-60 older orthopedic patients
• quiet confusion more pronounced in the evening
  (sundowning)
• Increase duration of hospitalization
• Increase 1 year mortality

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STOP Delerium

• Stop all sedative hypnotics or CNS active drugs
  (TCA, neuroleptics, GI meds, antihistamines,
  anticholinergics, Cipro, NSAIDS, meperidine)
• Treat infection if present
• Optimize the metabolic status
• Patience (if there is an altered mental status at
  baseline, it will take longer to return to
  baseline)

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Postoperative Delerium

• Restore Mental and Physical Function
• Mobilization/ Ambulation
• Sleep Hygiene (Restore circadian rhythm)
• Restoration of Vision or Hearing Devices
• Discontinue IV/ Foley
• Avoid Restraints
• Frequent orientation/ Social Visits

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Bridging Anticoagulation
124
An 82 year old woman with Afib, HTN, and CAD
presents with hip fracture. The INR is 5.5 and
surgery is scheduled in 18 hours. What is the
best strategy to reduce the INR to less than 1.5
in this time frame?

• Use FFP
• Use 10 mg VIT K subcutaneously
• Use 2.5 mg VIT K orally
• Use 2.5 mg VIT K intravenously

125
VIT K

• Route of administration that acts most rapidly
• IV, then PO, then subq (unpredictable absorption)
• FFP for surgeries within 12 hours
• Oral VIT K for surgeries gt24 hours
• Check INR early in the morning with FFP on stand
  by 2 units FFP generally enough to reduce from
  INR 2 to lt1.5

126
Bridging Anticoagulation

• 25,000 patients/ year
• NO RCT
• Generally poor quality studies

127
Why do we care?

• 5-10 of recurrent VTEs fatal
• 20 arterial thromboembolic events fatal
• 50 arterial thromboembolic events disabling
• Bridging anticoagulation reduces risk 70 (but at
  what risk?)

128
Bridging Anticoagulation

• 9-13 of patients with a major bleed will die!

129
gt10 year ATE gt10 month VTE
130
5-10/ year ATE 2-10 month VTE
131
lt5 year of ATE lt 2 month of VTE
132
Bridging Anticoagulation
133
Bridging with LMWH

• ACC/AHA guidelines 1998 state that LMWH NOT
  recommended for perioperative bridge therapy with
  valvular heart disease

134
(No Transcript)
135
Diabetic control in the operative patient

• Administration of Basal Insulin
• Administration of Bolus Insulin that is adjusted
  in anticipation of caloric needs
• Correction boluses to avoid marked hyperglycemia
• Incorporate correction insulin into basal or
  bolus as appropriate
• Goal?

136
Diabetic control in the pregnant patient

• Incidence 4-6
• 12 preexisting Diabetes
• 88 Gestational
• Pathogenesis
• Hormones associated with the pregnant state
  increases insulin resistance while decreasing
  insulin sensitivity

137
Diabetic control in the pregnant patient

• Risk of Developing DM
• 50 lifetime risk of type II DM
• Treatment
• Insulin (Regular)
• Glyburide (experimental)
• Contraindicated
• Insulin Glargine
• Metformin

138
Venous Thromboembolism

• 5-10 all hospital deaths are due to pulmonary
  embolus in autopsy studies
• It is a Failure to Prevent Syndrome
• The Agency for Healthcare Research and Quality
  published Making Health Care Safer A Critical
  Analysis of Patient Safety Practices ranked DVT
  prophylaxis as THE highest ranked safety practice
  due to a reduction in adverse patient outcomes
  while reducing overall cost

139
DVT PROPHYLAXIS

• USE IT

140
Endocarditis prophylaxis
141
HTN in Pregnancy

• Preeclampsia
• 140/90, gt20 weeks, gt300mg protein/24 hours,
  normalizes 6-16 days post delivery
• Eclampsia
• () seizures (TX MG to 4.5-8.5 and decreased
  DTRs
• Gestational HTN
• Transient, gt20 weeks, (-) protein
• Essential HTN with superimposed Preeclampsia
• Preexisting with new onset proteinuria post 20
  weeks
• Chronic HTN
• Preexisting

142
HTN in Pregnancy

• Treatment
• Labetalol (agent of choice with breastfeeding)
• Hydralazine
• Methyldopa
• Contraindicated
• ACE-inhibitor, ARB, Nitroprusside, Atenolol
• Second Line
• Nifedipine and Verapamil