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