Pre/Perioperative Care

1
Pre/Perioperative Care

• John Holman, MD, MPH
• Captain, USN
• Naval Hospital
• Camp Pendleton, CA

2
Take-Home Messages

• Risk stratify for heart disease
• Type of surgery
• Presence of unstable disease
• Evaluate current illnesses
• Reduce peri-operative adrenergic burden
• Screen for dementia in the elderly

3
Introduction

• Purpose of preoperative evaluation
• Identify high-risk patients
• Recommend strategies to minimize risks
• Risks during surgery
• CARDIAC, pulmonary, endocrine, heme etc.

4
Stepwise Approach

• Indices
• Dripps-ASA - too general
• Goldman - No angina or CHF
• Detsky - Goldmans with angina CHF
• ACC/AHA guideline-2002 update (1996)
• Validated clinically and anatomically
• Level B evidence

5
Dripps - ASA

• Classification of physical status
• Class 1 Healthy without systemic disturbance
• Class 2 Mild-moderate systemic disease
• Class 3 Severe systemic disease limits activity
• Class 4 Incapacitating and life threatening
  systemic disease
• Class 5 Moribund patient with little chance of
  survival.

6
Dripps ASA

• Patient undergoing emergency surgery considered
  in poorer condition
• Letter E placed after classification
• Too general and subjective
• Does not identify patients who need further
  evaluation

7
Goldman

• Multifactorial scoring index to estimate cardiac
  risk
• S3 or JVD 11
• MI within 6 mos 10
• gt5 PVCs/min 7
• PACs or non-sinus 7
• Agegt70 5
• Emergency 4
• Chest, abd, aorta 3
• Valvular stenosis 3
• Poor general health 3

8
Goldman

• Developed in 1983
• Criticized for
• Lack of points for angina pectoris
• Lack of points for CHF
• Further refinements led to ..

9
Detsky

• Basically Goldmans with CHF Angina
• MI lt 6 mos 10
• MI gt 6 mos 5
• Class 3 angina 10
• Class 4 angina 20
• Unstable angina lt 3 mos 10
• Pulm edema lt 1 weeks 10
• Pulm edema evern 5
• Critical AS 20
• Age gt 70 5
• PACs, non sinus 5
• gt 5 PVCs/ min 5
• Poor general health 5
• Emergency surgery 5

10
Detsky

• Improvement but
• Still subjective
• Not evidence based
• Did not give clear recommendations for further
  evaluation
• Led to development of ACC guideline in 1996

11
ACC/AHA Guidelines

• Evidence based Level B
• Anatomically validated
• Clinically validated
• More objective
• Easy, stepwise approach

12
Step 1Is the surgery emergent?
yes
Is the surgery emergent?
Operating room
no
(Next Step)
Consider beta-blockade, pain control and other
peri-operative management
13
Step 2 Prior revascularization?
Has patient had revascularization in past 5 years?
yes
Any recurrent symptoms?
no
no
yes
Operating Room
Recent coronary evaluation? (next step)
14
Step 3 Recent Coronary Evaluation?
yes
Operating room
Recent Coronary Evaluation?
reassuring
None or Not reassuring
Search for Clinical Predictors
15
Step 4 Clinical Predictors
Delay for risk modification or revasculariztion
Major predictors
Intermediate predictors
(see next step)
Operating room unless high risk procedure
Minor or no predictors
16
Step 4 Clinical Predictors
If functional capacity less than 4 mets by
history, do noninvasive testing. Otherwise, go to
operating room.
17
Step 5 After testing
Coronary Assessment (ETT, MPS, Stress ECHO or
cath)
Low Risk
Operating Room
High Risk
Consider Revascularization Prior to other surgery
18
Two Patients
John
Mary

• 63 yo man with prior CABG 6 years ago.
• Walks 3 miles/day without angina
• HTN, High cholesterol and COPD on meds
• Undergoing laminectomy

• 63 yo female without known coronary dx.
• Has diabetes for 22 years, no complication
• Sedentary, mild obese
• Undergoing Fem-Pop bypass

19
Pre-op RecommendationsACC/AHA Task Force

• John should go to surgery without any ischemic
  evaluation--revascularized without recurrent
  symptoms
• Mary should have noninvasive testing--Diabetes is
  an intermediate risk factor, high risk procedure
  and poor functional capacity

20
Step 1 Define the Surgery

• Is it emergent/urgent? Risk stratification of
  the procedure
• High risk Major vessels, prolonged surgery with
  major fluid/blood loss gt5 events
• Intermediate Head and Neck, Endarterectomy,
  Orthopedic, Prostate, Thoracic or peritoneal
  
• 1-5 events
• Low risk Breast, cataract, endoscopic
  lt1 events

21
Step 2 Define the Patient

• Has patient undergone revascularization in the
  past 5 years?
• Has the patient undergone coronary evaluation in
  the past 2 years?
• By history, does the patient have a major or
  intermediate clinical predictor of risk?

22
Major Clinical Predictors

• Unstable Coronary syndromes
• Decompensated CHF
• Significant dysrhythmias
• Severe valvular disease

23
Intermediate Clinical Predictors

• Mild Angina (NYHA class I or II)
• Prior MI
• Compensated CHF
• Diabetes Mellitus

24
Minor Clinical Predictors

• Advanced Age
• Abnormal ECG
• Rhythm other than sinus
• History of stroke
• Uncontrolled hypertension
• Low functional capacity

25
Functional capacity

• Excellent greater than 7 mets (heavy outdoor
  work, walk briskly up stairs)
• Moderate 4-7 mets (gardening, walking 4 mph,
  leisure cycling)
• Poor Less than 4 mets (walking 2 mph,
  cooking, golf with cart)

26
Cardiac Testing

• Noninvasive test
• EST without perfusion imaging
• EST with perfusion imaging
• Pharmacological testing with imaging
• Radionuclide angiography
• Pharmacological testing with echo
• Cardiac Cath

27
Task Force Theme

• The overriding theme is that intervention is
  rarely necessary unless such intervention is
  indicated irrespective of the fact the patient is
  to undergo surgery.

28
Putting it all together
If functional capacity less than 4 mets by
history, do noninvasive testing. Otherwise, go to
operating room.
29
Perioperative Cardiac Risk Reduction

• Maintain normothermia
• 1997 RCT showed normal temps decrease cardiac
  morbidity
• Alpha blockade
• 2003 meta analysis showed trend towards decreased
  mortality
• Beta blockade
• 1996 RCT showed 50 reduction in mortality at two
  years. Confirmed by three other RCTs.. BUT
  WAIT!

30
Perioperative Cardiac Risk Reduction

• Two RCTs since 2004
• Metoprolol no benefit in vascular surgery
• Meta analysis encouraging for 30 day outcomes but
  not statistically significant
• Retrospective review of 600,000 patients
• Major non cardiac surgery
• Only helped for high risk patients
• Harmful for low risk patients

31
Perioperative Cardiac Risk Reduction

• Lindenauer 2004 (JAMA)
• RCRI 0 OR 1.43 (1.29-1.58)
• RCRI 1 OR 1.13 (0.99-1.30)
• RCRI 2 OR 0.90 (0.75-1.08)
• RCRI 3 OR 0.71 (0.56-0.91)
• RCRI gt 4 OR 0.57 (0.42-0.76)
• Best candidates for perioperative beta blockers
  have long term indications

32
Perioperative Cardiac Risk Reduction

• Statins
• Observational data is promising
• Lindenauer 2003 NNT for RCRI gt 2 is 30 and for
  lt 2 is 186 to prevent one death
• Kertai 2004 60 decrease in all cause mortality
  for 5 years
• Small RCT done in 2004
• Durazzo 70 reduction in combined endpoint of
  cardiac death, nonfatal MI, USA, CVA.
• Jury still out but promising!

33
The Rest of the Story
34
Pulmonary Disease-Risks

• Active lung disease and/or poor general health
  status.
• Age
• General anesthesia, particularly gt 3 hours
• Use of pancuronium
• Closer the incision is to the diaphragm, the
  greater the risk

35
Pulmonary-Reducing risk

• Stop smoking for 8 weeks pre-op
• Treat obstructive disease aggressively
• Treat infection if present
• Patient education for incentive spirometry
• Epidural analgesia and/or intercostal nerve
  blocks

36
Smoking Cessation

• RCT of smoking cessation education by nurses for
  8 weeks prior to lower extremity
  revascularization
• 60 in intervention group quit, 25 cut down
  significantly
• Complication rate (mostly wound healing) reduced
  from 52 to 18 (NNT 3)
• Lancet 2002 359114-7

37
DVT prophylaxis

• Risk of the surgery
• Risk of the patient
• Treatments range from early ambulation to LMWH
  with intermittent pneumatic compression
• (See Table from ACCP Guidelines)

38
Bridging therapy for anticoagulated patients

• Low risk procedure continue warfarin
• Dental procedures continue warfarin, use EACA
  mouthwash as necessary
• Low risk patient Stop warfarin 4 days prior to
  surgery, briefly give post-op heparin prophylaxis
  and restart warfarin post-op
• (2C not evidence-based, just opinion)

39
Bridging therapy, p 2

• Moderate risk patient D/C warfarin 4-5 days
  pre-op, operate at lt1.5 INR. Cover with low-dose
  heparin beginning 2 days pre-op and give full
  dose post-op
• High risk patient D/C Warfarin 3-5 days pre-op
  and begin full-dose heparin when INR lt2.0. Stop 6
  hrs pre-op (12-24 hrs if LMWH)
  Restart both post-op
  until therapeutic
• Prevention of Venous Thromboembolism, the 7th
  ACCP conference CHEST 2004

40
Diabetes Mellitus

• Aim for 150-200 mg/dl glucose (8-11mmol)
• Set specific management based on
• Patients current diabetic regimen
• Anticipated time of day of surgery
• Anticipated duration of surgery

41
Diabetes and surgery

• Diabetics undergoing CABG who had
  Glucose/Insulin/Potassium infusion for tight
  (125-200) control had
• Lower incidence of atrial fibrillation
• Decreased wound infections
• Shorter length of stay
• Survival advantage that lasted for 2 years
• Newest trials suggest even tighter control

42
Adrenal Suppression

• Consider suppression for patients who have taken
  more than 10 mg prednisone for greater than 2
  weeks or 5 mg for longer term.
• May do stimulation testing or just treat
• Coverage for surgical stress can be lower than
  the traditional dosing.

43
Adrenal SuppressionReplacement

• Surgical stress Steroid dose
• Minor (herniorraphy) 25 mg HC pre-op
• Moderate (TAH, vas bypass) 20 mg HC Q8 x 2
  days
• Major (Whipple, CABG) 25-50 mg HC Q8 x 2
  days

44
Delirium in Hospitalized Elderly
Baseline Risks for Delirium

• Dementia 5.2 4.2-6.3
• Severe medical illness 3.8 2.2-3.4
• Alcohol abuse 3.3 1.9-5.5
• Depression 1.9 1.3-2.6

45
Post-operative Delirium
Precipitants for post-op Delirium

• Physical restraints 4.4 2.5-7.9
• Malnutrition 4.0 2.2-7.4
• More than 3 new meds 2.9 1.6-5.4
• Meperidine, benzodiazepines, anti-cholinergics
• Bladder catheter 2.4 1.2-4.7
• Any iatrogenic event 1.9 1.1-3.2

46
Managing Delirium

• Screen for dementia and prepare the family
• Reduce need for restraints
• Avoid precipitant medications
• Control pain
• Consider hypoxemia, electrolyte disturbance,
  withdrawal syndromes

47
Other Geriatric issues

• Clarify the handling of DNR status
• Early attention to nutrition-use enteral route if
  at all possible
• When to stop DVT prophylaxis?

48
Other Miscellaneous topics

• Adequate Post-operative analgesia reduces cardiac
  stress
• Normothermia reduces wound infections
• Appropriate timing of prophylactic antibiotics
• Which medications cannot be withheld?

49
Other Miscellaneous topics

• ACC recommendations on SBE prophylaxis
• Pre-op fluids (15ml/kg) reduces post-op nausea in
  cholecystectomy patients
• Excludes heart failure patients
• Dexamethasone (8 mg IV) given at time of
  operation reduces nausea in laparoscopic
  cholecystectomy

50
Other Miscellaneous topics

• Supplemental oxygen reduces wound infection rates
• Immediate v delayed repair of hip fracture
  reduces wound complications but not mortality or
  eventual functional status
• Early enteral feedings improve outcomes v
  prolonged NPO status

51
Summary

• Cardiac evaluation focusing on unstable disease
• Reduce adrenergic burden
• Manage other illnesses
• Screen for and manage delirium in the elderly

52
Case 1

• 68yo female with ovarian mass
• Diabetic, HTN, sedentary
• On Metformin, Lisinopril, Glyburide
• BP 155/98

53
Putting it all together
If functional capacity less than 4 mets by
history, do noninvasive testing. Otherwise, go to
operating room.
54
Case 2

• 68 yo man for prostatectomy
• COPD, on prednisone
• Prior CABG, prior stroke
• Retired, reclusive
• Multiple meds
• EKGRightward terminal forces, old inferior
  infarct

55
Case 3

• 67 yo for emergency surgery for AAA
• HTN, high cholesterol, smoker
• Possible alcoholic
• EKG LVH, tachycardia

56
Case 4

• 78 yo with post-op delirium post hip fx
• COPD, a fib, diabetes, Rheumatoid arth
• Lots of meds
• Exam fever

57
Single point cases

• Juvenile diabetic for mid AM surgery
• Chronic steroid use
• Hip fracture in patient with multiple illness
• Mitral valve prolapse-SBE prophylaxis?
• Orthopedic hardware- SBE prophylaxis?
• Medications on day of surgery
• Dental procedures on warfarin

58
Diabetes cases

• 73 yo with poorly controlled type II
• 43 yo with type I for 32 years
• 42 yo with type II physiology but taking insulin,
  elevated sugar before surgery
• Post-op CABG on insulin drip