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Perioperative Care: Preventing Complications

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Presentation on theme: "Perioperative Care: Preventing Complications"— Presentation transcript:

1 Perioperative Care: Preventing Complications
Salim D. Islam, MD Karen E. Hauer, MD 2006 SDI - intros, show of hands re: specialty

2 Workshop learning objectives
Learn the indications for preoperative testing and preparation for a healthy patient having elective surgery Learn the indications for cardiac stress testing and beta blockade prior to noncardiac surgery Understand new recommendations for preventing postoperative pulmonary complications KH

3 Outline Preoperative risk stratification
Perioperative cardiac risk reduction Preventing postoperative pulmonary complications KH

4 Case #1 74 y.o. woman with CAD s/p stent in 1998, hypertension, osteoporosis, GERD, scheduled for cataract surgery. Able to walk 2 blocks, no chest pain or dyspnea. Meds: enalapril, lovastatin, ranitidine, aspirin. PE: BP 128/70 HR 80 Surgeon asks you to perform routine preoperative tests and clear for surgery. What do you recommend? KH Ask for key features

5 Case #1 What do you recommend prior to cataract surgery?
CBC, lytes, creatinine, glucose, EKG Stress test A & B Recommend against surgery Proceed with surgery KH Sicker patient More minor surgery Stress test: minor clinical predictors, minor surgery per ACC/AHA; good fxn’l status We don’t “clear” for surgery; goal is to make a medical evaluation of current medical status that can influence management throughout periop period; worse to order tests and not react to them than not to order them

6 Randomized to preop testing or no testing Average age 74
Routine Preoperative Testing before Cataract Surgery N Engl J Med 2000;342;168 19,557 cataract surgeries Randomized to preop testing or no testing Average age 74 89% ASA class II or III Outcome = perioperative events KH 9 centers All got H & P Outcome = intra op or post op events in the 7 days following surgery

7 ASA Physical Status I Healthy DJD, Glaucoma II
Asymptomatic systemic disease Hypertension, diabetes III Symptomatic systemic disease Stable angina, chronic renal insufficiency IV Systemic disease - constant threat to life COPD on home 02, Class III CHF V Will die within 24 hours without surgery Ruptured AAA VI Brain dead organ donor SDI

8 Routine Preoperative Testing before Cataract Surgery N Engl J Med 2000;342;168
No testing Routine testing Relative risk (95% CI) Intraop events* 1.9% 2% 0.97 ( ) Postop events* 1.3% 1.2% 1.04 ( ) KH Most common events = hypertension, arrhythmia (bradycardia) No benefit to testing based on age, ASA status, sex, race, medical history Conclusion = test if you would have tested anyway - still do careful H & P and react to any abnormalities *Events = Cardiac, Hyper/hypotension, Stroke/TIA, respiratory distress requiring treatment, hypoglycemia, DKA

9 Case #2: Preop Risk Stratification
55 y.o. woman scheduled for hysterectomy PMH: hypertension, on hydrochlorothiazide PE: BP 135/90 HR 85 Normal exam EKG: Normal sinus rhythm, left ventricular hypertrophy SDI Difference here is bigger surgery HR 85, LVH

10 What preoperative cardiac evaluation do you recommend?
None. Proceed with surgery Add a beta-blocker Exercise stress test Exercise-thallium stress test SDI

11 Preventing Perioperative Cardiac Complications
What are we trying to prevent? Perioperative MI (mortality up to 15%) Mortality (all cause) Other - CHF, ischemia, nonfatal arrhythmia SDI

12 Risk of Cardiac Complications Based on Type of Surgery
High (>5%) Major aortic, peripheral vascular surgery Emergent major surgery Long case - large fluid shifts, blood loss Intermediate (<5%) Carotid, head, neck Abdominal, thoracic, pelvic Orthopedic Low (<1%) Endoscopic, skin, breast SDI

13 MI within 1 month, unstable angina
Clinical Predictors of Perioperative Cardiac Complications Eagle, JACC 2002;39:542 Major MI within 1 month, unstable angina Decompensated CHF, severe valve disease Significant arrhythmia Intermediate Prior MI Mild angina CHF Diabetes Creatinine > 2.0 mg/dl Minor Advanced age Abnormal ECG or rhythm not sinus Prior stroke Uncontrolled hypertension Functional capacity < 4 METs SDI Abnormal ecg = LVH, LBBB, St-T change

14 Assessing Functional Capacity
1-4 METs Eat Dress Walk in house 4-10 METs Climb flight of stairs Scrub floors Golf Short run 10+ METs Swimming Singles tennis SDI

15 Case #3: Preop Hypertension Management
55 y.o. woman arrives for hysterectomy PMH: hypertension, on hydrochlorothiazide PE: BP 185/100 HR 85 Normal exam EKG: Normal sinus rhythm, left ventricular hypertrophy How does your management change? SDI HTN: delay surgery for Stage 3 HTN (BP > 180/110)

16 Outline Preoperative risk stratification
Perioperative cardiac risk reduction Preventing postoperative pulmonary complications KH

17 Case #4 68 y.o. woman with type 2 diabetes, osteoarthritis of the knees, and hypothyroidism, scheduled for right hemicolectomy. Meds: glyburide, metformin, levothyroxine, acetaminophen. Non-smoker. PE: BP 130/70 HR % RA 02 Sat KH What are key issues in this case?

18 Case #4 What preoperative assessment do you recommend?
Proceed with surgery Exercise treadmill test Persantine-thallium test Cardiac catheterization Add atenolol KH What are the important risk factors that influence this patient’s risk of periop complications? --age, DM, mod risk surgery, unable to exercise; not on Bblocker

19 Preoperative Stress Testing Eagle ACC/AHA 2002
Indications: 2 or more of the following Intermediate clinical predictor (Eagle 2002) Stable cardiac disease, DM, Cr > 2 High risk surgery Poor functional status (< 4 METs) Which test? Ambulatory, normal ECG exercise treadmill Ambulatory, abnormal ECG exercise + imaging Can’t exercise P-Thal or Dobutamine echo Better for ruling out than ruling in cardiac disease SDI Alternate could be to give Bblocker

20 Perioperative Beta Blockers
In what clinical settings would you prescribe a perioperative beta-blocker? A. Hypertension B. Major vascular surgery C. History of CAD D. CAD risk factors E. All surgical patients SDI

21 Benefits of Perioperative Beta Blockers
Reduce perioperative myocardial ischemia Decrease perioperative cardiac complications Improve survival SDI

22 Perioperative Beta Blockers in Noncardiac Surgery
Patients: 200 Veterans w/ CAD or 2 CAD risk factors Atenolol one hour prior to surgery until hospital discharge, unless HR < 55, vs. placebo Operations: major vascular, abdominal, ortho, neurosurg Outcomes: mortality, cardiac complications over 2 years SDI 1/3 w/ CAD, 2/3 with CAD risk factors CRF: age > 65, chol > 240, HTN, DM, current smoking Mangano, NEJM, 1996

23 Perioperative Beta Blockers in Noncardiac Surgery
SDI The principle benefit was due to a reduction in cardiac deaths during the first six to eight months. NNT of 9. In studies with higher risk patients (known CAD based on positive DBA stress) NNT = 3 noteworthy differences in the atenolol and placebo populations with respect to preoperative cardiac risk factors, particularly diabetes mellitus, and postoperative cardiac medication administration Mangano, NEJM, 1996

24 Which Beta Blocker? Cardioselective (atenolol, metoprolol)
Effective Fewest side effects Non-cardioselective (propranolol, nadolol) Equally effective More side effects - pulmonary, hypotension Use only if patient already taking Avoid beta blockers with intrinsic sympathomimetic activity Consider clonidine if beta blockers contraindicated KH All B 1 selective B blockers equivalent Clonidine - another sympatholytic - lowers HR, BP, norepi levels, ischemia

25 Dosing Perioperative Beta Blockers
Already taking a Beta Blocker: Adjust previous dose to a target HR of 60 New prescriptions: Begin treatment with atenolol mg q day within one month of surgery Consider a follow-up appt for HR check and dose adjustment 1-7 days before surgery KH Start early enough to achieve beta-blockade

26 Outline Preoperative risk stratification
Perioperative cardiac risk reduction Preventing postoperative pulmonary complications KH

27 Case # 5 A 70 year old man with diabetes, hypertension, CAD, and COPD is admitted with right upper quadrant pain. He smokes 1 pack/day. Ultrasound reveals acute cholecystitis, and cholecystectomy is recommended. In addition to preoperative cardiac risk stratification, you consider the risk of pulmonary complications. KH - COPD, smoker, lap choley

28 Case #5 Which of the following is most likely to reduce the risk of perioperative pulmonary complications? Preoperative CXR Incentive spirometry Laparoscopic technique Smoking cessation

29 Perioperative Pulmonary Complications
As common as postop cardiac complications; similar morbidity and mortality Pulmonary complications may better predict long term mortality Most important and morbid: Atelectasis Pneumonia Respiratory failure Exacerbation of chronic lung disease Post op pulm complic’s - around 6-7% Pulmonary complic’s contribute same amt as cardiac complic’s to morbid/mortal/LOS

30 A guideline from the ACP
Risk assessment and strategies to reduce perioperative pulmonary complications after noncardiothoracic surgery: A guideline from the ACP Ann Intern Med 2006;144:575 Applies to adults undergoing NON cardiopulm surgery Periop = 2-3 mo’s before and after surgery

31 Patient risk factors for postop pulmonary complications
Odds ratio Age > 60 COPD 1.79 Current smoking 1.26 CHF 2.93 ASA class > I 4.87 Functional dependence 2.51 (total); 1.65 (partial) All patients should be assessed for risk factors for post op pulm complic’s ASA american society of anesthesiologists class II = mild systemic disease Other lung dz - probably imprt but no lit to quantify the risk Smoking - start cessation very early in preop period Total dependence = no ADL’s, partial -= help or assistive device ALSO LOW ALBUMIN , altered mental status, BUN > 30 RR 2.09 for 60-69, 3.04 or Not obesity, mild-mod asthma

32 Surgery risk factors for postop pulmonary complications
Surgery type: abdominal, thoracic, neuro, head/neck, vascular, AAA Surgery > 3 hours Emergency surgery General anesthesia Bottom 3 all have odds ratio of about 2

33 Interventions to reduce postop pulmonary complications: Preop
Identify and target high risk patients Patient and surgery risk risk factors Preop - consider: Spirometry - only with COPD CXR - for age > 50, high risk surgery, known cardiopulmonary disease ID high risk patients’ based on hx, not testing Spirometry - no absolute cutoff below which surgical risk is unacceptable Smoking cessation - benefit if at least 2 mo before CT surgery

34 Interventions to reduce postop pulmonary complications: Post op
Lung expansion Deep breathing exercises or Incentive spirometry or CPAP Selective use of NG tube after abdominal surgery for nausea/emesis, inability to take p.o., abdominal distention Any method of lung expansion equally effective Symptomatic abd distention NGT reduces PNA and atelectasis, not PNA - in 2 prior meta-analyses

35 Interventions that might reduce postop pulmonary complications:
Laparoscopic instead of open surgery Improves pain, spirometry, oxygenation Unclear benefit on clinically important pulmonary complications Epidural anesthesia/analgesia - unclear benefit Smoking cessation: > 2 months preop Epidural - probably better, esp if short acting drugs vs. longer duration blockade Smoking - based on lit for CT surg. Quit for > 6 mo preop and risk of pulm complic is same as a never-smoker.

36 Summary Preoperative risk stratification
Perioperative cardiac risk reduction Preventing postoperative pulmonary complications KH

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