Anaesthesia for Non-Cardiac Surgery in Patients with Coronary Stents Directorate of Anaesthetics Audit Reference 130108

1. Anaesthesia for Non-Cardiac Surgery in Patients with Coronary Stents Directorate of AnaestheticsAudit Reference 130108 AUDIT RESULTS Dr. Anthony Parsons Anaesthetic Department Audit Meeting 16/04/08

2. Aims + Objectives Review literature & identify best practice Assess current practice at BHR No. of patients managed? Attitudes and concerns of staff Clinical knowledge Define the �gold standard� we should achieve Produce action plan for improvement

3. Audit Format Internal survey of anaesthetic department Anonymous questionnaire, Feb � Mar 2008 22 questions 1 case history with 3 questions Responses Consultant Anaesthetists 24 NCCG�s 8 SpR�s + ST3�s 6 Pre-op Assessment Nurses 2

4. Question Format A Likert-type scale A pyschometric response scale Respondents specify their degree of agreement with a statement Scale of 1 � 7 strongly disagree � strongly agree Individual answers combined to maintain anonymity Bipolar scaling method � either positive or negativeBipolar scaling method � either positive or negative

5. Question Format Each question has a �correct� answer Responses 5-7 combined for �yes� 1 -3 combined for �no� 4 = �neutral� - added to correct answer Percentage of correct answers calculated to provide �department� result

6. Defining the gold standard A �traffic light� assessment [Based on NICE pre-op Ix guidelines] > 90% correct GREEN 75 � 90% correct YELLOW < 75% correct RED

9. Current Guidelines and Evidence

10. Coronary artery stents and non-cardiac surgery Br J Anaesth 2007 98:560-74 Perioperative management of antiplatelet agents in patients with coronary stents: recommendations of a French Task Force. Br J Anaesth 2006 97 580-2 ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery Circulation. 2007;116:e418-e499

11. Antiplatelet agents and surgery

12. Catheterisation and Cardiovascular Interventions 2004;63:141-5 - Up to 86% mortality when clopidogrel stopped for surgery within 3 weeks of PCI Eur Heart J 2005;26:576-83 - no difference in surgical outcome or operative mortality when clopidogrel continued J Am Coll Cardiol 2003;42:234-40 - transfusion rate 38.5% controls vs 42.6% on clopidogrel � vascular/ortho/visceral surgery Crit Care Med 2001;29:2271-5 - increased rate of re-operation for haemorrhage control in patients on clopidogrel

15. Stroke 2002;33:1916-19 7 deaths from intra-cerebral haemorrhage during neurosurgery Br J Anaesth 2007;99:316-28

17. British National Formulary (51) Section 2.9; 127 - based on t� of platelet + drug pharmacokinetics

18. Anti-platelet agents and surgery

19. Long lesions, larger or multi-vessel lesions,CRF, D.M., low LVEF suggest high risk for thrombosis Incidence, Predictors, and Outcome of Thrombosis After Successful Implantation of Drug-Eluting Stents JAMA, May 4, 2005�Vol 293, No. 17 Aspirin should never be stopped Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients With Coronary Artery Stents: A Science Advisory From the American Heart Association. Circulation 2007;115;813-818 Clopidogrel takes 3 � 5 days to maximally inhibit platelets without loading dose Clinical Pharmacokinetics 2004;43:963-81 Hypercoagulability occurs for at least 7 days post-op Anaesthesia & Analgesia 2001;92:572-7

20. Neuraxial blockade

21. Regional Anesthesia in the Anticoagulated Patient: Defining the Risks (The Second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation) Regional Anesthesia and Pain Medicine, Vol 28, No 3 (May�June), 2003: pp 172�197

22. Bare metal stents versus drug eluting stents

23. Incidence, Predictors, and Outcome of Thrombosis After Successful Implantation of Drug-Eluting Stents JAMA, May 4, 2005�Vol 293, No. 17 Sirolimus versus paclitaxel stents Circulation.2006; 113:e166-286 BJA 2006;96:686-93 Heparin alone does not provide adequate protection against thromboembolism Journal of Extra-Corporeal Technology, Sep 2006, 38/3(230-4) Heparin alone does not provide adequate protection against thromboembolism and may actually increase it by reducing thrombus cohesive strengthHeparin alone does not provide adequate protection against thromboembolism and may actually increase it by reducing thrombus cohesive strength

26. Case History You see a 68 year old male on the day of surgery for elective Abdominal Aortic Aneurysm repair. Past Medical History Hypertension COPD Good exercise tolerance MET > 6� Class II A.A.A. diagnosed 8 months ago� Diagnostic coronary angiography 4 months ago. x 1 B.M.S. inserted. CXR: N.A.D. ECG: sinus rhythm, no acute ischaemia �ECHO: satisfactory cardiac function � D.H.� Anti-hypertensives Analgesics Aspirin 75mg o.d. �The patient has taken all his medications today. (Not taking clopidogrel)

27. Case History

28. Summary

29. Comments Anaesthetists �some questions are ambiguous� �Patients must be assessed individually� �huge uncertainty - numbers needed for an RCT are vast� �guidelines for practice would be very useful� Nurses �Irrelevant to my practice � I always ask the surgeon & anaesthetist� �Wide variation exists between different surgeons / anaesthetists�

30. Conclusions There is a significant case-load of patients with coronary stents presenting for surgery Practice varies Scope exists for improvement in management Evidence-based guidelines are necessary to guide and standardise care

31. Limitations Highly complex topic in which yes / no answer may be impossible Patient management not directly assessed Defining a gold standard is difficult � no clear precedents exist Not relevant to some anaesthetists area of practice (e.g. Obs / paeds)

32. Action Plan Produce formal guidelines for BHR Involve stakeholders Surgeons Cardiology Haematology Pre-op assessment nurses Repeat audit ? prospective study of patients Revise guidelines as appropriate