Perioperative Medical Evaluation for Gynecological Surgery

1
Perioperative Medical Evaluation for
Gynecological Surgery

• Cullen Archer, MD
• Obstetrics and Gynecology
• June 2006

2
6 Key Elements to Medicine Preop

• Cardiac Risk
• Pulmonary Risk
• DVT Risk and Prevention
• Endocarditis Prophylaxis
• Perioperative Delirium
• Steroids

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Topics

• Preoperative Cardiovascular Evaluation
• Antibiotic Prophylaxis
• Endocarditis Prophylaxis
• DVT Prophylaxis

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Preoperative Cardiac Evaluation

• Evaluation tailored to circumstances
• HP and ECG should identify potentially serious
  cardiac disorders
• Define disease severity, stability, and prior
  treatment

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Clinical Predictors of Increased Perioperative
Cardiovascular Risk (Myocardial Infarction,
Heart Failure, Death)

• Major
• Unstable coronary syndromes
• Acute or recent myocardial infarction with
  evidence of important ischemic risk by clinical
  symptoms or noninvasive study
• Unstable or severe angina (Canadian class III
  or IV)
• Decompensated heart failure
• Significant arrhythmias
• High-grade atrioventricular block
• Symptomatic ventricular arrhythmias in the
  presence of underlying heart disease
• Supraventricular arrhythmias with uncontrolled
  ventricular rate
• Severe valvular disease
• The American College of Cardiology National
  Database Library defines recent MI as greater
  than 7 days but less than or equal to 1 month (30
  days) acute MI is within 7 days.
• May include stable angina in patients who are
  unusually sedentary.
• Campeau L. Grading of angina pectoris.
  Circulation. 197654522523.

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Clinical Predictors of Increased Perioperative
Cardiovascular Risk (Myocardial Infarction,
Heart Failure, Death)

• Intermediate
• Mild angina pectoris (Canadian class I or II)
• Previous myocardial infarction by history or
  pathological Q waves
• Compensated or prior heart failure
• Diabetes mellitus (particularly
  insulin-dependent)
• Renal insufficiency

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Clinical Predictors of Increased Perioperative
Cardiovascular Risk (Myocardial Infarction,
Heart Failure, Death)

• Minor
• Advanced age
• Abnormal ECG (left ventricular hypertrophy, left
  bundle-branch block, ST-T abnormalities)
• Rhythm other than sinus (e.g., atrial
  fibrillation)
• Low functional capacity (e.g., inability to climb
  one flight of stairs with a bag of groceries)
• History of stroke
• Uncontrolled systemic hypertension

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Functional Capacity

• 1 MET Can you take care of yourself?
• Eat, dress, or use the toilet?
• Walk indoors around the house?
• Walk a block or two on level ground at 2-3 mph
  (4.8kph)
• 4 MET Do light work around the house like dusting
  or washing
• dishes?
• Climb a flight of stairs or walk up a hill?
• Run a short distance?
• Do heavy work around the house like scrubbing
  floors or
• lifting or moving heavy furniture
• Participate in moderate recreational activities
  like golf,
• bowling, dancing, doubles tennis, or throwing
  a
• baseball or football?
• gt10 Participate in strenuous sports like
  swimming, singles
• tennis, football, basketball, or skiing?

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Cardiac Risk Stratification for Noncardiac
Surgical Procedures

• High (Reported cardiac risk often greater than
  5)
• Emergent major operations, particularly in the
  elderly
• Aortic and other major vascular surgery
• Peripheral vascular surgery
• Anticipated prolonged surgical procedures
  associated with large fluid shifts and/or blood
  loss
• Intermediate (Reported cardiac risk generally
  less than 5)
• Carotid endarterectomy
• Head and neck surgery
• Intraperitoneal and intrathoracic surgery
• Orthopedic surgery
• Prostate surgery
• Low (Reported cardiac risk generally less than
  1)
• Endoscopic procedures
• Superficial procedure
• Cataract surgery
• Breast surgery
• Combined incidence of cardiac death and
  nonfatal myocardial infarction.

10

• ACC/AHA PRACTICE GUIDELINESACC/AHA Guideline
  Update for Perioperative Cardiovascular
  Evaluation for Noncardiac SurgeryExecutive
  Summary. J Am Coll Card. 2002 39 542-553.

11

• ACC/AHA PRACTICE GUIDELINESACC/AHA Guideline
  Update for Perioperative Cardiovascular
  Evaluation for Noncardiac SurgeryExecutive
  Summary. J Am Coll Card. 2002 39 542-553.

12

• ACC/AHA PRACTICE GUIDELINESACC/AHA Guideline
  Update for Perioperative Cardiovascular
  Evaluation for Noncardiac SurgeryExecutive
  Summary. J Am Coll Card. 2002 39 542-553.

13
Specific Preoperative Conditions

• Hypertension
• 180/110 should be controlled preoperatively
• Perioperative ? antagonists
• Valvular Heart Disease
• Myocardial Disease
• Arrhythmias

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Specific Preoperative Conditions

• Implantable Pacemakers and Interventricular
  Conduction Devices
• unipolar or bipolar pacemaker leads
• Electrocautery bipolar or unipolar ?
• ICD devices should be programmed off immediately
  before surgery and then on again postoperatively

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Surgical Site Prophylaxis

• Antimicrobial Prophylactic Regimens by
  Procedure
• Procedure Antibiotic Dose
• Vaginal/abdominal cefazolin 1 or 2 g single
  dose IV
• hysterectomy Cefoxitin 2 g single dose IV
• Cefotetan 1 or 2 g single dose IV
• Metronidazole 500 mg single dose IV
• Laparoscopy None
• Laparotomy None
• Hysteroscopy None
• Hysterosalpingogram Doxycycline 100 mg po BID x
  5 days
• IUD insertion None
• Endometrial biopsy None
• Induced abortion/DC Doxycycline 100 mg orally 1
  hour
• before and 200 mg orally
• after the procedure
• Metronidazole 500 mg po BID for 5 days
• Urodynamics None
• A convenient time to administer antibiotic
  prophylaxis is just before induction of
  anesthesia
• If hysterosalpingogram demonstrates dilated
  tubes. No prophylaxis is indicated for a normal
  study.

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Endocarditis Prophylaxis

• Endocarditis prophylaxis recommended
•    Respiratory tract
•       Tonsillectomy and/or adenoidectomy
•       Surgical operations that involve
  respiratory mucosa
•       Bronchoscopy with a rigid bronchoscope
•    Gastrointestinal tract1
•       Sclerotherapy for esophageal varices
•       Esophageal stricture dilation
•       Endoscopic retrograde cholangiography with
  biliary
• obstruction
•       Biliary tract surgery
•       Surgical operations that involve intestinal
  mucosa
•    Genitourinary tract
•       Prostatic surgery
•       Cystoscopy
•       Urethral dilation
• 1Prophylaxis is recommended for high-risk
  patients it is optimal for medium-risk patients.

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Endocarditis Prophylaxis

• Endocarditis prophylaxis not recommended
•    Respiratory tract
•       Endotracheal intubation
•       Bronchoscopy with a flexible bronchoscope,
  with or without biopsy2
•       Tympanostomy tube insertion
•    Gastrointestinal tract
•       Transesophageal echocardiography2
•       Endoscopy with or without gastrointestinal
  biopsy2
•    Genitourinary tract
•       Vaginal hysterectomy2
•       Vaginal delivery2
•       Cesarean section
•       In uninfected tissue
•          Urethral catheterization
•          Uterine dilatation and curettage
•          Therapeutic abortion
•          Sterilization procedures
•          Insertion or removal of intrauterine
  devices
•    Other

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Endocarditis Prophylaxis

• ACC/AHA Recommendations for Antibiotic
  Prophylaxis to Prevent Bacterial Endocarditis
• ACOG Practice Bulletin No. 47, October 2003

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Prophylactic regimens for GI/GU Procedures

• Situation Agents Regimen
• High-risk patients Ampicillin plus Adults
  ampicillin 2.0 g IM or IV plus gentamicin 1.5
• Gentamicin mg/kg (not to exceed 120 mg)
  within 30 min of starting
• procedure 6 hr later, ampicillin 1 g IM/IV
  or amoxicillin 1
• g orally
• Children ampicillin 50 mg/kg IM or IV (not
  to exceed 2.0
• g) plus gentamicin 1.5 mg/kg within 30 min
  of starting
• the procedure 6 h later, ampicillin 25
  mg/kg IM/IV or
• amoxicillin 25 mg/kg orally
• High-risk patients allergic Vancomycin Adults
  vancomycin 1.0 g IV over 1-2 h plus gentamicin
• to ampicillin/amoxicillin plus gentamicin 1.5
  mg/kg IV/IM (not to exceed 120 mg) complete
• injection/infusion within 30 min of starting
  procedure
• Children vancomycin 20 mg/kg IV over 1-2 h
  plus
• gentamicin 1.5 mg/kg IV/IM complete
  injection/infusion
• within 30 min of starting procedure
• Moderate-risk patients Amoxicillin or Adults
  amoxicillin 2.0 g orally 1 h before procedure, or
• ampicillin ampicillin 2.0 g IM/IV within 30 min
  of starting procedure
• Children amoxicillin 50 mg/kg orally 1 h
  before
• procedure, or ampicillin 50 mg/kg IM/IV
  within 30 min of

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Infective Endocarditis

• Definition of Infective Endocarditis According to
  the Modified Duke Criteria
• Definite infective endocarditis
• Pathological criteria microorganisms
  demonstrated by culture or histological
  examination of a vegetation, a vegetation that
  has embolized, or an intracardiac abscess
  specimen or
• Pathological lesions vegetation or intracardiac
  abscess confirmed by histological examination
  showing active endocarditis
• Clinical criteria
• 2 major criteria or
• 1 major criterion and 3 minor criteria or
• 5 minor criteria
• Possible IE
• 1 major criterion and 1 minor criterion or
• 3 minor criteria
• Rejected
• Firm alternative diagnosis explaining evidence of
  IE or
• Resolution of IE syndrome with antibiotic therapy
  for lt 4 days or
• No pathological evidence of IE at surgery or
  autopsy, with antibiotic
• therapy for lt 4 days or
• Does not meet criteria for possible IE as above
• Modifications shown in boldface.

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Modified Duke Criteria

• Major criteria
• Blood culture positive for IE
• Typical microorganisms consistent with IE from 2
  separate blood cultures Viridans streptococci,
  Streptococcus bovis, HACEK group, Staphylococcus
  aureus or community-acquired enterococci in the
  absence of a primary focus or
• Microorganisms consistent with IE from
  persistently positive blood cultures defined as
  follows At least 2 positive cultures of blood
  samples drawn gt 12 h apart or all of 3 or a
  majority of 4 separate cultures of blood (with
  first and last sample drawn at least 1 h apart)
• Single positive blood culture for Coxiella
  burnetii or antiphase 1 IgG antibody titer
  gt1800
• Evidence of endocardial involvement
• Echocardiogram positive for IE (TEE recommended
  for patients with prosthetic valves, rated at
  least possible IE by clinical criteria, or
  complicated IE paravalvular abscess TTE as first
  test in other patients) defined as follows
  oscillating intracardiac mass on valve or
  supporting structures, in the path of regurgitant
  jets, or on implanted material in the absence of
  an alternative anatomic explanation or abscess
  or new partial dehiscence of prosthetic valve
  new valvular regurgitation (worsening or changing
  or preexisting murmur not sufficient)
• Minor criteria
• Predisposition, predisposing heart condition, or
  IDU
• Fever, temperature gt 38C
• Vascular phenomena, major arterial emboli, septic
  pulmonary infarcts, mycotic aneurysm,
  intracranial hemorrhage, conjunctival
  hemorrhages, and Janeways lesions
• Immunologic phenomena glomerulonephritis,
  Oslers nodes, Roths spots, and rheumatoid
  factor
• Microbiological evidence positive blood culture
  but does not meet a major criterion as noted
  above or serological evidence of active
  infection with organism consistent with IE
• Echocardiographic minor criteria eliminated
• Modifications shown in boldface.
• Excludes single positive cultures for
  coagulase-negative staphylococci and organisms
  that do not cause endocarditis.

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DVT Prophylaxis

• Absolute Risk for DVT in Hospitalized Patients
• Patient Group DVT Prevalence,
• Medical patients 1020
• General surgery 1540
• Major gynecologic surgery 1540
• Major urologic surgery 1540
• Neurosurgery 1540
• Stroke 2050
• Hip or knee arthroplasty, hip fracture
  surgery 4060
• Major trauma 4080
• Spinal cord injury 6080
• Critical care patients 1080
• Rates based on objective diagnostic testing for
  DVT in patients not receiving thromboprophylaxis.

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DVT Prophylaxis

• Risk Factors for VTE
• Surgery
• Trauma (major or lower extremity)
• Immobility, paresis
• Malignancy
• Cancer therapy (hormonal, chemotherapy, or
  radiotherapy)
• Previous VTE
• Increasing age
• Pregnancy and the postpartum period
• Estrogen-containing oral contraception or hormone
  replacement therapy
• Selective estrogen receptor modulators
• Acute medical illness
• Heart or respiratory failure
• Inflammatory bowel disease
• Nephrotic syndrome
• Myeloproliferative disorders
• Paroxysmal nocturnal hemoglobinuria
• Obesity
• Smoking

24
ACCP Grading Recommendations

• Applying the Grades of Recommendation for
  Antithrombotic and Thrombolytic Therapy The
  Seventh ACCP Conference on Antithrombotic and
  Thrombolytic Therapy. CHEST 2004 126179S187S)

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DVT Prophylaxis - Recommendations

• Minor Surgery
• lt 30 minutes for benign disease
• Recommend against use if specific prophylaxis
  other than early and persistent mobilization
  (Grade 1C).
• Laparoscopy
• If VTE risk factors are present, we recommend the
  use of thromboprophylaxis with one or more of the
  following LDUH, LMWH, IPC, or GCS (all Grade 1C)

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DVT Prophylaxis - Recommendations

• Major Surgery
• Benign with no additional R.F.
• LDUH, 5,000 U bid (Grade 1A)
• once-daily prophylaxis with LMWH 3,400 U/d
  (Grade 1C), or
• IPC started just before surgery and used
  continuously while the patient is not ambulating
  (Grade 1B)
• Malignant, or with additional R.F.
• DUH, 5,000 U tid (Grade 1A), or
• higher doses of LMWH (i.e., gt 3,400 U/d) Grade
  1A
• Alternative considerations include IPC alone
  continued until hospital discharge (Grade 1A), or
• combination of LDUH or LMWH plus mechanical
  prophylaxis with GCS or IPC (all Grade 1C)

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DVT Prophylaxis - Recommendations

• Duration of Prophylaxis
• until discharge from the hospital (Grade 1C)
• if particularly high risk, including those who
  have undergone cancer surgery and are gt 60 years
  of age or have previously experienced VTE,
  prophylaxis for 2 to 4 weeks after hospital
  discharge (Grade 2C)