1. Perioperative Risk Assessment - Can You Get It Right?
From the Publishers of
Perioperative Risk Assessment - Can You Get It Right?
COPYRIGHT © 2013, ALL RIGHTS RESERVED

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3. Need Advice – How Low is Low?
Dear Consult Sages;
I need your help and guidance to provide better service to my referring surgeons and their patients. I’ve attended your Consult Guys presentation at the annual meeting of the ACP for years.
You have helped me abandon the use of the term “Cleared for Surgery” and to instead really hone in on the patient’s perioperative risk as well as approaches to reduce that risk.
I recently saw a patient who I assessed to be at low cardiac risk. The surgeon wanted me to be more precise in risk determination. Here is the case and I’d appreciate your sage advice.

4. Case:
The patient is a 60 year old man for resection of a pulmonary nodule.
Hx: hypertension, hypercholesterolemia
Smokes 2ppd many years.
Does not exercise but climbs 1 flight stairs daily without difficulty
Bp 120/70 HR 60
Exam unremarkable.
ECG: Normal sinus rhythm. Within normal limits
“By current guidelines his risk is low but help me be more precise.”

5. ACC / AHA Guideline 2002 Philosophy
“… the concept of “medical clearance” for surgery is short sighted.
Goals of the preoperative consult:
Evaluate current medical status
Advise on disease management in the periop period.
At times recommend preventive measures for future.
Define your role in care (Co-manager?, subspecialty consultant?, etc.)

6. “Clearance 2007” ACC / AHA Guideline: Circulation 2007;116:e418-e500
Free at:

7. Anesthesia for the Consultant: Summary
ACC / AHA Guideline: Circulation 2007;116:e418-e500
Free at:

8. October 23, 2007
400 new articles reviewed since 2002 guideline

9. Key Elements of Risk Stratification
Emergency surgery
Active cardiac conditions
Low risk surgery
Functional capacity
Clinical risk factors
Will testing – preop intervention change management ?

10. Step 1 Step 1 Perioperative surveillance and Need for emergency
postoperative risk
stratification
Need for emergency
noncardiac surgery?
YES
Operating
room NO
Step 2

11. Step 2 Active Cardiac Conditions Unstable coronary syndromes
Evaluate and treat
per ACC/AHA
guidelines
Active cardiac
conditions
Consider
operating room
YES NO
Active Cardiac Conditions
Unstable coronary syndromes
Unstable or severe angina
Recent MI
Decompensated HF
Significant arrhythmias
Severe valvular disease
Step 3
Acute or Recent MI—Acute MI (within 7 days); Recent M (7-30 days). WITH evidence of important ongoing ischemic risk as evidenced by continued clinical symptoms or by non-invasive study
Heart Failure—ischemic or non-ischemic
Significant Arrhythmias:
High grade A-V block
Symptomatic ventricular arrhythmias in presence of underlying heart disease
Supraventricular arrhythmias with uncontrolled ventricular rate
Severe valvular disease: Mostly talking about AS

12. Step 3 Low Risk Surgery Endoscopic procedures Superficial procedures
Proceed with
planned surgery
YES NO
Low Risk Surgery
Endoscopic procedures
Superficial procedures
Cataract surgery
Breast surgery
Step 4
Low risk surgery with combined incidence of cardiac death and nonfatal MI of < 1%

13. Good functional capacity
Step 4
Step 4
Good functional capacity
(METS > 4)
without symptoms
Proceed with
planned surgery
YES
No or Unknown
Step 5

14. Step 5 History of ischemic heart disease
Clinical Risk Factors
History of ischemic heart disease
History of compensated or prior HF
History of cerebrovascular disease
Diabetes
Renal insufficiency

15. Step 5 Step 5 Clinical Risk Factors 3 or more 1 or 2 None Vascular
(Isch HD, CHF hx, Cereb vasc dx, DM, Cr >2
3 or more
1 or 2
None
Vascular
surgery
Intermediate
Risk surgery
Proceed with
planned surgery
Vascular or
intermediate
risk surgery
Consider testing
if it will change
management
Proceed with planned surgery with HR control or consider
Noninvasive testing if it will change management

17. Revised Cardiac Risk Index Lee, Circulation 1999
4315 patients, > 50 years old
Major elective noncardiac surgery
Six independent risk factors
High risk surgery AAA, vascular,thoracic, abdominal, ortho
History ischemic heart disease
History CHF
History cerebrovascular disease
Preoperative insulin use
Preoperative serum Cr > 2.0 mg/dl

18. = patients

19. = patients

20. National Surgical Quality Improvement Database
>250 hospitals >200,000 pts/year
Predictors of perioperative (up to 30 day) MI, Arrest
ASA Class
Functional status
Age
Serum Cr
Type of surgery
Article (Free) Circulation. 2011;124:
= patients

21. Problems - Limitations
MI (one or more of the following)
STEMI; new LBBB, new Q waves Tn
> 3 times top normal

28. Gupta vs ACC/AHA

29. = patients

30. = patients

31. State Farm Arena, Hidalgo Texas
Seating 5,500

32. Yankee Stadium, Bronx NY
Seating 50,082

33. State Farm Arena, Hidalgo Texas

36. Problems - Limitations
Outcomes dominated by 30 day death
NSQIP does not record all cardiac complications
Pulmonary edema
Preop stress test
Echo
Arrhythmia history / occurrence
Aortic valve disease
Beta blocker use
Remote history of CAD (except prior PTCA or CABG)
Most perioperative MI’s NSTEMI
Revised Cardiac Risk Index still helpful in predicting cardiac complications

37. Consults Guys’ Replies
Gupta cardiac risk assessment
30 day MI, Cardiac arrest
MI: STEMI, Tn 3X elevation
Not all cardiac arrests due to periop MI
NSQIP database does not include
Pulmonary edema
NSTEMI
Robust data base
Data on procedure not previously known
Bedside calculation

38. Produced by
and
COPYRIGHT © 2013, ALL RIGHTS RESERVED