PrePerioperative Care

1
Pre/Perioperative Care

• John Holman, MD, MPH
• Camp Pendleton, CA
• Dan Brewer, MD

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

5
ACC/AHA Guidelines

• Evidence based Level B
• Anatomically validated
• Clinically validated
• More objective
• Easy, 5 step approach

6
Step 1 Define the Surgery

• Is it emergent/urgent?
• If yes, then proceed to the OR
• Manage risk post-operatively
• Consider beta blockade
• If no, preoperative evaluation

7
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
8
Step 2 Determine Presence of Active Cardiac
Conditions

• If none are present, proceed with surgery
• Presence of one of these delays surgery for
  evaluation
• Many patients need a cardiac cath

9
Step 2

• Unstable coronary syndromes
• Decompensated heart failure
• Significant arrhythmias
• Severe valvular disease

10
Step 2 Active Cardiac Conditions
Evaluate and treat per current guidelines
yes
Active Cardiac conditions
no
Consider Operating Room
(Next Step)
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Step 3 Surgery Low Risk?

• Low risk surgery includes
• Endoscopic procedures
• Superficial procedures
• Cataract surgery
• Breast surgery
• Ambulatory surgery
• Cardiac risk lt1
• Testing does not change management

12
Step 3 Surgery Low Risk?
yes
Operating room
Low risk surgery
No
(Next Step)
13
Step 4 Determine Functional Capacity

• Excellent gt 10 METS (basketball, skiing, singles
  tennis)
• Good 7-10 METS (heavy house 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)

14
Step 4 Functional Capacity?
yes
gt 4 METS, no symptoms
Operating room
No
(Next Step)
15
Step 5 Unknown/Poor Functional Capacity

• Assess cardiac risk factors
• Ischemic heart disease history
• Compensated or prior heart failure
• Diabetes mellitus
• Renal insufficiency (Cr gt2 mg/ml)
• Cerebrovascular disease
• Similar to RCRI without surgery risk

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Step 5 Unknown/Poor Functional Capacity?
Assess risk factors
gt 3 risk factors
0 risk factors
1-2 risk factors
Vascular or Intermediate risk surgery
Vascular surgery
Operating room
Intermediate risk surgery
To OR with heart rate control or noninvasive
coronary assessment
Coronary assessment
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Step 5 (cont)

• Surgery specific risk
• Vascular 5 risk of intraoperative cardiac
  event
• Aortic Major vascular surgery
• Peripheral vascular surgery
• Intermediate 1-5 risk
• Head and neck incl carotid endarterectomy
• Orthopedic
• Prostate
• Intraperitoneal/Intrathoracic

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Step 5 (cont)

• Heart rate control for patients with risk factors
  using beta blockade (more to follow on this)
• Coronary assessment
• ONLY if results will change management

19
Cardiac Testing

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

20
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.

21
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!

22
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

23
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

24
RCRI scoring

• Hx of CAD 1
• Hx of TIA/CVA 1
• Creatinine gt 2mg/ml 1
• Hx of Diabetes mellitus 1
• High risk surgery 1
• Chest, abdomen, pelvic vascular
• Total points 5

25
Perioperative Cardiac Risk Reduction

• POISE study 2007 AHA meeting
• Over 8000 patients - vasculopaths
• Metoprolol CR preop and for 30 days
• Decrease in nonfatal MI, A fib and CABG
• Increase in all cause mortality, stroke,
  hypotension and bradycardia
• Decrease in composite endpoint of CV death,
  nonfatal MI and nonfatal arrest

26
Perioperative Cardiac Risk Reduction

• Issues
• Dose very high
• 100 mg preop, 100mg 6 hr postop, 200 mg 12 hours
  later and daily for 30 days
• Hypotension
• Not aggressively managed until below 100 mm
  systolic
• Dosage not titrated ip

27
Perioperative Cardiac Risk Reduction

• Recommendations
• Do not stop beta blockers for patients having
  surgery
• Prevent 15 MIs for every 1000 patients
• Cause 8 deaths and 5 severe strokes for every
  1000 patients
• Need to determine best patient, best beta blocker
  and best dosage

28
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!

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The Rest of the Story
30
Pulmonary Disease-Risks

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

31
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

32
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

33
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)

34
DVT risk assessment

• Low risk lt 40 yo, uncomplicated minor surgery,
  no clinical risk factors
• Moderate Age 40-60 for any surgery, Major
  surgery or minor surgery with risk factors lt 40
• High Major surgery gt 60yo, Major surgery with
  risk factors ages 40-60, recent MI
• Highest Known prior DVT, hypercoagulable state
  or cancer. Lower extremity orthopedics. Multiple
  trauma. Spinal cord injury

35
DVT prophylaxis

• Low risk Early ambulation
• Moderate SQ heparin Q 12 or low dose LMWH, and
  IPC or elastic stockings
• High risk SQ heparin Q8 or LMWH plus IPC
• Highest risk Full dose LMWH, oral warfarin, or
  full-dose heparin plus IPC

36
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)

37
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

38
Diabetes Mellitus

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

39
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

40
Postoperative Glycemic Control and Reduced
Cardiac-Related Mortality

14.5

Mortality ()
6.0


4.1
2.3
1.3
0.9
Average Postoperative Glucose (mg/dL)
Cardiac-related mortality was significantly
higher for patients with blood glucose levels
gt175 mg/dL (Plt.001). J Thorac Cardiovasc Surg.
20031251007-1021.
41
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.

42
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

43
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

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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

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Managing Delirium

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

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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?

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Other Miscellaneous topics

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

48
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

49
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

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Summary

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

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Case 1

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

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Case 2

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

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Case 3

• 67 year old male
• Leaking AAA
• No meds
• Strong FHx of CAD
• Smokes 2 ppd, 3-4 beers a day
• 180/85, 105, 16
• Recommendations?

54
Case 4

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