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Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006.

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Presentation on theme: "Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006."— Presentation transcript:

1 Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

2 Workshop learning objectives 1.Learn the indications for preoperative testing and preparation for a healthy patient having elective surgery 2.Learn the indications for cardiac stress testing and beta blockade prior to noncardiac surgery 3.Understand new recommendations for preventing postoperative pulmonary complications

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

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?

5 Case #1 What do you recommend prior to cataract surgery? A.CBC, lytes, creatinine, glucose, EKG B.Stress test C.A & B D.Recommend against surgery E.Proceed with surgery

6 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

7 ASA Physical Status IHealthyDJD, Glaucoma IIAsymptomatic systemic disease Hypertension, diabetes III Symptomatic systemic disease Stable angina, chronic renal insufficiency IVSystemic disease - constant threat to life COPD on home 02, Class III CHF VWill die within 24 hours without surgery Ruptured AAA VI Brain dead organ donor

8 Routine Preoperative Testing before Cataract Surgery N Engl J Med 2000;342;168 No testingRoutine testing Relative risk (95% CI) Intraop events* 1.9%2%0.97 ( ) Postop events* 1.3%1.2%1.04 ( ) *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 135/90HR 85 Normal exam EKG: Normal sinus rhythm, left ventricular hypertrophy

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

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

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

13 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 IntermediatePrior 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

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

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

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

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 88 98% RA 0 2 Sat

18 Case #4 What preoperative assessment do you recommend? A.Proceed with surgery B.Exercise treadmill test C.Persantine-thallium test D.Cardiac catheterization E.Add atenolol

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 ECGexercise treadmill –Ambulatory, abnormal ECGexercise + imaging –Cant exerciseP-Thal or Dobutamine echo Better for ruling out than ruling in cardiac disease

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

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

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 Mangano, NEJM, 1996

23 Perioperative Beta Blockers in Noncardiac Surgery 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

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

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

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.

28 Case #5 Which of the following is most likely to reduce the risk of perioperative pulmonary complications? A.Preoperative CXR B.Incentive spirometry C.Laparoscopic technique D.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

30 Risk assessment and strategies to reduce perioperative pulmonary complications after noncardiothoracic surgery: A guideline from the ACP Ann Intern Med 2006;144:575

31 Patient risk factors for postop pulmonary complications Risk factorOdds ratio Age > COPD1.79 Current smoking1.26 CHF2.93 ASA class > I4.87 Functional dependence2.51 (total); 1.65 (partial)

32 Surgery risk factors for postop pulmonary complications Surgery type: abdominal, thoracic, neuro, head/neck, vascular, AAA Surgery > 3 hours Emergency surgery General anesthesia

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

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

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

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


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