1. Spotlight Case June 2007 Beeline to Spine

2. 2 Source and Credits This presentation is based on June 2007 AHRQ WebM&M Spotlight Case –See full article at http://webmm.ahrq.govhttp://webmm.ahrq.gov –CME credit is available online Commentary by: Gerald W. Smetana, MD, Harvard Medical School, Beth Israel Deaconess Medical Center –Editor, AHRQ WebM&M: Robert Wachter, MD –Spotlight Editor: Tracy Minichiello, MD –Managing Editor: Erin Hartman, MS

3. 3 Objectives At the conclusion of this educational activity, participants should be able to: Understand the elements of preoperative medical evaluation Appreciate the limited role for preoperative laboratory testing Appreciate the importance of communication and collaboration between providers before surgery Discuss the value of preoperative clinics

4. 4 Case: Beeline to Spine An 83-year-old man with CAD, mild heart failure, history of repaired AAA, and prior lumbar disk disease (status post L5-S1 fusion) was scheduled for a fusion-augmentation surgery by orthopedics. Although the patient noticed a bulging mass on his abdomen a few months earlier, he did not mention it to providers. Laboratory tests sent for a voluntary medical research study showed an elevated alkaline phosphatase to nearly 800 U/L. His primary physician reviewed these lab results, but no action was taken.

5. 5 Case: Beeline to Spine The patient proceeded to surgery, where he was examined by both the anesthesiology and surgery teams. He underwent surgery in the supine position, given his history of AAA repair. The fusion augmentation was uneventful, and he was discharged home.

6. 6 Risks and Benefits of Major Surgery Risk-benefit analysis critical prior to any major surgery Mean 30-day mortality rate in recent study of 5878 patients undergoing major surgery was 1.5% Preoperative evaluation should consider risk of postoperative medical complications including cardiac, pulmonary, and thromboembolic Davenport DL, et al. Ann Surg. 2006;243:636-644.

7. 7 Mortality Stratified by ASA Physical Status Class American Society of Anesthesiologists Web site. ClassMortality I—A normal healthy patient0% II—A patient with mild systemic disease0.2% III—A patient with severe systemic disease2.2% IV—A patient with severe systemic disease that is a constant threat to life 15.2% V—A moribund patient who is not expected to survive without the operation 70%

8. 8 Preoperative Evaluation Identify factors that would increase risk of perioperative complications above baseline Stratify risk for principal complications Determine if preoperative laboratory testing necessary Recommend strategies to reduce these risks to the extent that they are modifiable

9. 9 Preoperative Evaluation Opportunity for collaboration between medicine, surgery, and anesthesia colleagues –Sharing information regarding previously unrecognized risk factor –Determining that risks of surgery may potentially exceed the benefits –Recommendation for intraoperative and postoperative risk reduction strategies

10. 10 Preoperative Evaluation History –Identify major risk factors for medical complications –Identify factors that would influence anesthetic technique and management

11. 11 Preoperative Evaluation Tools Standardized checklist forms to facilitate the anesthesiologist’s preoperative evaluation Specific guidelines to estimate risk of cardiac, pulmonary, and venous thromboembolic complications –Cardiac: AHA/ACCAHA/ACC –Pulmonary: ACPACP –Venous thromboembolic disease: ACCPACCP See Notes for complete references.

12. 12 Preoperative Evaluation: Are Laboratory Tests Necessary? Abnormal tests uncommon; can be predicted on basis of known medical problems Incidence of abnormalities that influenced preoperative management ranged from 0%-3% Normal test result within 4 months can be used, as long as there has been no change in clinical status of the patient Smetana GW, Macpherson GS. Med Clin N Amer 2003;87:7-40. Macpherson DS, et al. Ann Intern Med. 1990;113:969-973.

13. 13 Preoperative Evaluation: Are Laboratory Tests Necessary? Guidelines available from National Institute for Clinical Excellence (NICE) in Great BritainGuidelines Carlisle J, et al. Br J Anaesth. 2004;93:495-497.

14. 14 Preoperative Laboratory Evaluation Smetana GW, Macpherson GS. Med Clin N Amer 2003;87:7-40. TestIndications HemoglobinAnticipated major blood loss or symptoms of anemia White blood cell countSymptoms suggest infection, myeloproliferative disorder, or myelotoxic medications Platelet countHistory of bleeding diathesis, myeloproliferative disorder, or myelotoxic medications Prothrombin time (PT)History of bleeding diathesis, chronic liver disease, malnutrition, recent or long term antibiotic use Partial thromboplastin time (PTT) History of bleeding diathesis ElectrolytesKnown renal insufficiency, congestive heart failure, medications that affect electrolytes

15. 15 Preoperative Laboratory Evaluation TestIndications Renal functionAge > 50 years, hypertension, cardiac disease, major surgery, medications that may affect renal function GlucoseObesity or known diabetes Liver function testsNo indication. Consider albumin measurement for major surgery or chronic illness UrinalysisNo indication. ElectrocardiogramMen > 40 years, women > 50 years, known CAD, diabetes, or hypertension Chest radiographAge > 50 years, known cardiac or pulmonary disease, symptoms or exam suggest cardiac or pulmonary disease Smetana GW, Macpherson GS. Med Clin N Amer 2003;87:7-40.

16. 16 Laboratory Evaluation Indicated for this Patient Complete blood count* Renal function tests* Electrocardiogram* Chest x-ray ‡ * Carlisle J, et al. Br J Anaesth. 2004;93:495-497. ‡ Smetana GW, Macpherson GS. Med Clin N Amer 2003;87:7-40.

17. 17 Risk Assessment in this Case Higher cardiac risk given age and comorbidities –Revised Cardiac Risk Index yields risk of 6.6% Lower risk for pulmonary problems –Spinal surgery is an intrinsically low risk procedure for pulmonary complications Geerts WH, et al. Chest. 2004;126(suppl 3):338S-400S. Lee TH, et al Circulation. 1999;100:1043-1049.

18. 18 Preoperative Recommendations Pharmacologic strategies to reduce cardiac risk Prophylaxis to reduce the risk for surgical site infection Prophylaxis against venous thromboembolism Geerts WH, et al. Chest. 2004;126(suppl 3):338S-400S. Bratzler DW, Hunt DR. Clin Infect Dis. 2006;43:322-330.

19. 19 Case (cont.): Beeline to Spine One week later, the patient was admitted with frank jaundice, abdominal pain, and diarrhea. Physical examination revealed a 4x4 cm, easily palpable mass protruding from his mid- abdomen. CT scan revealed a widely metastatic pancreatic cancer. There was massive tumor burden along the peritoneum and adjacent to stomach, liver, and bowels. A CA 19-9 was extremely high.

20. 20 Case (cont.): Beeline to Spine When told of his diagnosis of metastatic cancer, the patient immediately said he wished he had never undergone the surgery.

21. 21 What Went Wrong Symptomatic abdominal mass with associated markedly elevated alkaline phosphatase not addressed prior to major elective surgery

22. 22 Case (cont.): Bee Line to the Spine Review of the preoperative assessment by anesthesia and orthopedics revealed no mention of an epigastric mass nor of the markedly abnormal alkaline phosphatase.

23. 23 How Could This Error Have Been Prevented? History –More careful history with open-ended question –“Do you have any other symptoms or concerns about your health that we didn’t discuss today?” Physical exam –Suggested minimum examination includes vital signs and assessment of airway, chest, and heart –Abdomen not normally examined before spinal surgery Laboratory data –Unclear whether alkaline phosphatase result was available to hospital staff Anesthesiology. 2002;96:485-496.

24. 24 How Could This Error Have Been Prevented? Alkaline phosphatase would never be a routine preoperative test, but result was markedly elevated prior to surgery Suspect cancer (pancreatic, biliary, liver primary or mets) in elderly asymptomatic patient Primary care physician would need to further evaluate patient and exclude cancer before any consideration of elective surgery

25. 25 Missed Opportunities ProviderPotential abnormal findings revealing diagnosis Primary MDHistory of abdominal mass Exam revealing abdominal mass Markedly elevated alkaline phosphatase AnesthesiologyHistory of abdominal mass SurgeonHistory of abdominal mass Physical exam

26. 26 Risk Factors for Poorly Coordinated Care Multiple physicians Care delivered by providers in different health delivery systems with separate information technology systems No actively involved primary care physician –“Primary care” received in emergency department Patient with low health literacy

27. 27 Improving Preoperative Assessment Detailed history and physical examination, using open-ended questions Communication among providers Dedicated preoperative assessment clinics Optimize medical conditions

28. 28 Communication Between Providers in Perioperative Period Especially challenging when physicians practice in different sites No access to each other’s medical records Each provider has responsibility to follow through on any identified factors that may increase risk May require telephone call/e-mail to confirm that all doctors are “on the same page”

29. 29 Preoperative Assessment Clinic Identify patients who need additional preoperative evaluation Optimize medical conditions Potentially improve outcomes

30. 30 Preoperative Assessment Clinic for Vascular Surgery Patients 26 of 234 required further evaluation or were unsuitable for surgery due to significant comorbidities Reduction in mortality rates among patients undergoing infrarenal aneurysm repair who visited preoperative clinic when compared with usual care (4.8% vs. 14.5%) Cantlay K, et al. Anaesthesia. 2006;61:234-239.

31. 31 Preoperative Assessment Clinic Findings 565 of 5083 patients seen in preoperative clinic required further information regarding known medical problems Additional 115 patients with new medical problems –20% required review of previous medical records or test results –80% required additional testing or consultation Correll DJ, et al. Anesthesiology. 2006;105:1254-1259.

32. 32 Take-Home Points Preoperative medical evaluation requires a thorough history and physical exam, using open-ended questions Laboratory testing plays a limited role in risk stratification Communication and collaboration between surgeons, anesthesiologists, and consulting primary care physicians before surgery is critical

33. 33 Take-Home Points Preoperative clinics may aid in identifying risk factors for postoperative complications and may improve outcomes Patients should proceed to surgery only if the benefits exceed the risk