Protecting the heart Preventing complications

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Protecting the heartPreventing complications

• A Review of pre-operative risk assessment and
  perioperative medical care
• Chris Manasseh, MD
• September 1, 2004

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Learning Objectives

• Know how to preoperatively
• assess patients for perioperative risks
• Able to make perioperative
• recommendations to reduce postoperative
• complications
• Manage postoperative medical problems

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Perioperative Risk Assessment

• Perform focussed Patient Evaluation
• History
• Physical
• Tests
• Blood work
• EKG
• Other tests
• Provide appropriate Risk Assessment
• Cardiovascular Risk
• Pulmonary Risk

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Patient Evaluation - History

• Past surgeries and outcomes
• Anesthetic complications
• h/o bleeding, - h/o poor wound healing
• Past Medical History - attention to heart and
  lungs
• Cardiac risk factors, - h/o MI
• h/o PE/DVT, - h/o Gout, - h/o bleeding
  disorders/tendency
• h/o blood transfusion
• Medication history
• Aspirin, - NSAIDS, - Insulin, - Coumadin,
• Inhalers, - steroids
• Social history
• ETOH, Tobacco or drug use

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Patient Evaluation - Physical Exam

• HEENT - neck ROM, teeth, abscesses
• Cardiovascular system
• new murmurs, bruit, all peripheral pulses
• Pulmonary system
• Air entry, signs of edema, presence of
  wheeze/rhonchi
• Abdomen - unknown liver disease
• organomegaly
• Skin
• hemorrhage, petechiae, incision site, edema

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Clinical Scenario

• A 34 y/o healthy, sexually active mother of 3
  children wants an
• elective bilateral tubal ligation. She has no
  significant personal or
• family history other than childbirth. Her
  physical exam is
• unremarkable. She has been using diaphragm for
  contraception and she takes no other medications.
• According to current guidelines for preoperative
  evaluation of healthy patients, which of the
  following tests need to be done preoperatively.
• Chest X-ray
• EKG
• Serum electrolytes and serum glucose
• Coagulation tests
• Pregnancy test
• Hemoglobin and hematocrit

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Patient EvaluationBlood Tests - (see handout)

• Testing is selective - NOT Routine
• Should be justified by specific sign, symptom or
  diagnosis
• CBC h/o exertional dyspnea,blood loss, fatigue,
  tachycardia
• Chemistry profile h/o hypertension,diabetes,
  renal disease, diuretic use, h/o COPD, h/o sleep
  apnea
• Coagulation profile h/o DVT, warfarin use, signs
  of chronic liver disease
• Liver enzymes h/o hepatitis, ETOH abuse, signs
  of chronic liver disease
• Urinalysis dysuria, signs of cystitis,prior h/o
  UTI, presence of indwelling catheters,

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Patient Evaluation - EKGsSelective Clinical
Indications

• Men gt45 years, women gt55 years
• h/o Clinically important heart disease
• CAD, Arrhythmia, CHF
• Condition associated with heart disease
• peripheral vascular disease, hyperlipidemia
• Conditions predisposing to heart disease
• hypertension, diabetes
• Intrathoracic, Intraperitoneal, aortic or
  emergency surgery
• Predisposition toward electrolyte abnormalities

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Patient Evaluation - Other Diagnostic tests

• Chest X ray All patients over 60 years of age
• 2D Echocardiogram
• Evaluation of new murmur
• Pulmonary Function Tests
• ACP Guidelines for Preoperative PFTs
• Lung resection
• CABG Tobacco
• Upper abdominal surgery Tobacco
• Any surgery uncharacterized lung disease

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Perioperative Risk Assessment

• Perform focussed Patient Evaluation
• History
• Physical
• Tests
• Blood work
• EKG
• Other tests
• Provide appropriate Risk Assessment
• Cardiovascular Risk
• Pulmonary Risk

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Cardiovascular Risk AssessmentPredicting cardiac
complications in patients undergoing non cardiac
surgery

• American Society of Anesthesiology, Anesth 1963
• Goldman, N Eng. J Med. 1977
• Cooperman, Surgery 1978
• Detsky modified index, Arch Internal Medicine
  1986
• Larson, European Heart Journal 1987
• Eagle, Annals of Internal Medicine 1987
• LItalien, J American College of Cardiology 1996
• ACP, Annals of Internal Medicine 1997
• ACC/AHA Task force, Practice guidelines, revised
  2002

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Lee Index for prediction of Cardiac events in a
non cardiac surgery
1 point each

• Ischemic Heart disease
• H/o CHF
• H/o CVA
• On Insulin for diabetes
• Serum Creatinine gt2mg/dl
• High risk surgery
• Intraperitoneal
• Intrathoracic
• Suprainguinal vascular

• Cardiac Complication Rates
• 0 points 0.5
• 1 point 0.9
• 2 points 7
• 3 or more points 11

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Goldman Scale for Cardiac Risk
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Cardiovascular Risk AssessmentRole of Cardiac
Testing

• Preoperative Risk stratification should be based
  on clinical data(Lee, Magnano, Gilbert)
• Exercise stress test and other non invasive tests
  for myocardial ischemia should not be routinely
  used for perioperative risk stratification
• Decision to perform non invasive testing is based
  on the presence of clinical risk factors, the
  patients functional status and the type of
  surgery scheduled
• Coronary revascularization before non-cardiac
  surgery should be recommended only for patients
  with unstable myocardial ischemic syndromes or
  results indicating a high risk on non-invasive
  tests or ischemia
• Therapeutic doses of beta-adrenergic blockers
  should be used in patients with an intermediate
  or high risk for cardiac complications

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Decision tree for Non invasive cardiac testing
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Stepwise approach to preoperative cardiac
assessment (see handout)
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Estimated Energy requirement for various
activities
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 to 3 mph
4 METs Do light work around the house like
dusting or washing dishes? Climb a flight of
stairs or walk up a hill? 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? Walk on level ground at 4 mph? Run a
short distance? Greater than 10 METs
Participate in strenuous sports like swimming,
singles tennis, football, basketball, or skiing?
MET indicates metabolic
equivalent. Adapted from the
Duke Activity Status Index and AHA Exercise
Standards.
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Pulmonary Risk AssessmentPatient history - best
screening tool

• Patient related risk factors
• Smoking history
• COPD
• Asthma(peak flow lt80 predicted/any value below
  personal best)
• Procedure related risk factors
• Surgical site(most important predictor of
  pulmonary risk) upper abdominal and thoracic
  surgery carry highest risk about 20-25 of
  pulmonary postoperative complication.
• Surgery duration gt3 hours
• Use of general anesthesia
• Use of long acting neuromuscular blockade -
  pancuronium

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Preoperative Risk assessmentClinical scenario
73 year old female with h/o hypertension and s/p
left hip arthroplasty presents with sudden onset
of epigastric pain x 1 day, soon after eating
dinner (beef, bean, rice and milk). Home
medications include procardia XL 60mg once daily
and vioxx for knee pain. Patient denies using
ETOH, tobacco and drugs. Patient is afebrile T99,
P 94, and BP 160/104, R20 96 RA. On exam
patient is in moderate distress due to pain, very
hard of hearing. Exam is significant for soft
abdomen but with RUQ tenderness without rebound
or guarding. Rest of the exam is unremarkable.
RUQ u/s done in the ED shows stones in the
gallbladder with dilated CBD to 1.0cm with
pericholecystic fluid, negative sonographic
Murphys sign. Admission labs show WBC of 11.3
but normal diff, HCT of 40, platelets 223.
Chemistry is unremarkable with normal gap,
Bun/Cr.. 15/0.6. LFT with TB 0.0, Alt/AST 19/38,
ALP 93, amylase and lipase are within normal
limits. LFT continues to be normal except slight
elevation in TB/DB to 1.5/0.5. RUQ MRCP is done
to evaluate the ductal system, which shows no
stones in the ductal system. Patient is placed
on Levaquin/Flagyl, and kept NPO. Surgery and GI
are consulted. Patient becomes afebrile after the
second HD, and WBC also remains normal at 7-8
(normal diff). LFT continues to remain normal,
TB/DB continues to fall, and ALP remains normal
throughout the hospitalization. Because her MRCP
shows no stone in the ductal system, surgery
recommends laparoscopic cholecystectomy within
the next 48 hours.
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Clinical Scenario Pre-operative Risk Assessment

• Risk Assessment
• Cardiovascular
• Does the patient need preoperative stress
  testing?
• If so, what would be the appropriate test?
• Pulmonary
• Does the patient need CXR?
• Does the patient need PFT?

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Peri-operative Recommendations

• Prophylactic measures
• DVT Prophylaxis
• SBE Prophylaxis
• Risk reduction strategies
• Cardiovascular risk reduction
• Pulmonary risk reduction
• Medical management of chronic problems
• Hypertension
• Diabetes

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Cardiovascular risk reductionUsing Beta blockers
in high risk patients

• Evidence for benefit
• Mangano et al., N Eng.. J Med.1996Effect of
  atenolol on mortality and Cardiovascular
  morbidity
• Wallace et al., Anes. 1998 Prophylactic atenolol
  reduces postop MI
• Polderman et al., N Eng. J Med. 1999 Effect of
  bisoprolol on perioperative mortality and MI
• Eligibility criteria
• CAD(previous MI, Typical.atypical angina)
• Meets Mangano criteria for bet blocker therapy
• Absence of CHF, 3rd degree heart block,
  bronchospasm on exam
• Vital signs in the desired range
• heart rate gt55/minute and systolic blood pressure
  gt100 mm Hg
• Dosing schedule similar to study group
• Atenolol 5mg IV 30 min before surgery and
  immediately postop followed by a 2nd infusion if
  SBPgt100 HR gt55. Therapy needs to be started
  ideally several days prior to surgery.
• Continue atenolol as tolerated 50-100 mg/day for
  maximum of 7 days
• Shorter acting beta-selective blockers are
  preferred like metoprolol 25mg to 50mg bid
  titrated to a resting heart rate goal of
  between 55 and 65 beats per minute

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Mangano Beta Blocker Criteria

• Aged 65 years or older
• Hypertension
• Current smoker
• Cholesterol gt 240 mg/dl
• DM not requiring insulin therapy

Use Beta Blockers in patients meeting any 2 of
the above criteria
Mangano et al, N Engl. J Med, 335, 1713,1996
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Pulmonary Risk Reduction - Some strategies

• Preoperative
• Stop smoking at least 8 weeks prior to surgery
• Treat active lung disease
• antibiotics for infection
• steroids for optimizing asthma(does not increase
  risk of surgical site infection
• Preop. Lung expansion education- deep breathing
  exercises
• Limiting duration of anesthesia
• Using laparoscopic techniques
• Postoperative
• Incentive spirometry
• CPAP(Continuous positive airway pressure)
  indicated if patient unable to do lung expansion
  maneuvers
• Postoperative Pain control
• Intercostal nerve blocks
• Epidural analgesia

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Peri-operative management of Hypertension(see
handout)

• Increased surgical risk
• Systolic BPgt180 and/or diastolic BP gt110
• Newly diagnosed hypertensives
• Start treatment with beta blocker
• Avoid diuretics before surgery to preclude volume
  depletion and electrolyte disturbances
• Established hypertensives
• Maintain usual antihypertensive regimen except
  hold diuretics 24 hours prior, some studies favor
  holding ACEI and ARBS on day of surgery
• when patients NPO
• Parenteral metoprolol, labetalol, diltiazem,
  enalapril
• Patch Clonidine

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Peri-operative management - Diabetes(see handout)

• Increased surgical risk Poor wound healing and
  wound infections
• particularly at blood glucose levels above
  250mg/dl
• Specific preoperative assessment
• Recent log of blood sugars to determine control,
  also obtain A1C
• ROS symptoms of hypo/hyperglycemia
• Special preoperative recommendations
• For all diabetics
• Fast for 12 hours prior to surgery to minimize
  aspiration of gastric contents
• Optimal goal for preoperative blood glucose
  levels between 120 and 180
• Diabetics on oral agents should hold medications
• 24 hours prior for glipizide
• 36 hours prior for glyburide
• 48 hours prior for metformin
• on the day of surgery for thiazolidinediones(Actos
  and Avandia)
• Diabetics on insulin regimen - on day of
  surgery(check FSBG Q hourly) D51/2NS_at_100ml/hr
• Type I continuous insulin infusion _at_1unit/hour
• Type II requiring insulin 1/3 to 1/2 total
  daily insulin given as NPH

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Managing postoperative problems

• Pain control
• Managing problems
• Nausea
• Nutrition

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Final Assessment and Recommendation to surgical
team

• Identify all medical problems relevant to surgery
• State current status of problem - HTN Good
  control
• Comment on the risk the patients medical
  problems add to the surgical morbidity and
  mortality
• Conclude by stating if the medical problems are
  currently optimized for surgery
• Please DO NOT CLEAR patient for surgery, only
  provide the surgical team with risk assessment
  based on patients acute and chronic clinical
  conditions and current activity status
• Ultimately the surgical team will weigh the risks
  and benefits of the proposed procedure and make a
  final decision