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Intro to PeriOperative Medicine

Intro to PeriOperative Medicine. Compiled by Tabitha Goring, MD Hospitalist Attending/Assistant Professor of Medicine Jacobi Medical Center Albert Einstein College of Medicine. Perioperative Medicine. Cardiac Risk Assessment in non-cardiac surgery

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Intro to PeriOperative Medicine

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  1. Intro to PeriOperative Medicine Compiled by Tabitha Goring, MD Hospitalist Attending/Assistant Professor of Medicine Jacobi Medical Center Albert Einstein College of Medicine

  2. Perioperative Medicine Cardiac Risk Assessment in non-cardiac surgery Goldman Cardiac Risk Index Points Age > 70 yo 5 MI < 6 months ago 10 JVD or S3 gallop 11 Significant Aortic Stenosis 3 Non-sinus Rhythm, APCs or >5 PVC/min 7 PO2<60 or PCO2>50, K<3.0 or HCO3<20 BUN >50 or Cr>3.0, abnormal AST, Signs of chronic liver disease, or bedridden pt. 3 Intraperitoneal, intrathoracic or aortic procedure 3 Emergent Operation 4

  3. Perioperative Medicine Goldman Risk Assessment Class Points Risk (Complication/Death Risk) I 0-5 0.7%/ 0.2% II 6-12 5% / 2% III 13-25 11% / 2% IV >26 22% / 56%

  4. Perioperative MedicineSeverity of Perioperative Stress Aortic Cross Clamp Intrathoracic Infrainguinal Vascular Orthopedic Head & Neck Carotid Amputation TURP Superficial Cataract

  5. Perioperative Medicine Perioperative Stress Hormone • Norepinephrine/Epinephrine • Most anesthetics suppress many elements of the stress response therefore, most problems occur postoperatively • Complications Tachyarrythmias Hyperglycemia Hypertension Protein Metabolism Myocardial ischemia CHF (Na retention) Vasoconstriction (wound failure) HypoNa, K, Mg Hypercoaguability SIRS

  6. Perioperative Medicine Non-invasive Pre-op Cardiac Testing Exercise Treadmill Exercise Thallium Dipyridamole Thallium Holter Monitor Dobutamine Echocardiogram

  7. Peri-Operative Medicine Dobutamine Stress Echo (Shaw et al 1996- Metaanalysis) • Highest positive predictive value(45-65%) • Well Tolerated • Predictive Value increases with number of walls imaged.

  8. Perioperative Medicine Post-op Pulmonary Complications Diaphramatic dysfunction Hypoxemia Pneumonia Bronchospasm Respiratory Failure

  9. Perioperative Medicine Pulmonary • No need for routine pre-op PFTs • No data that routine pre-op CXR improves outcome

  10. Perioperative Management Asthma Rec’s • Consider Oral Streoids 24-48h in mod-severe asthmatics (better than inhaled steroids to prevent periop flares) studies show no increased wound infections, impaired wound healing or hyperglycemia. Kabalin, Arch Intern Med 1995; 155 • Inhaled Albut/Atrov for wheezing • Smoking Cessation 8 wks prior to surgery

  11. Perioperative Management Asthma Rec’s cont’d • Consider use of regional anesthesia • Nebulizers intra-op for flares • IV lidocaine + inhaled salbutamol have synergy pretreat prior to airway irritation • Propofol, ketamine useful in asthmatics (bronchodilators).

  12. PeriOperative Medicine What does the anesthesiologist know? Cancel a case…. Well versed in IV meds not PO meds (HTN, DM, MI, CHF, BrSpasm, Oliguria, Pain) Choice of anesthestic agent Choice of invasive or non-invasive monitoring

  13. PeriOperative Medicine What doesn’t the anesthesiologist know? Long term management of chronic problems… -HTN -CAD -Renal Failure -Malnutrition -Hepatic Dysfunction -Endocrinologic Conditions

  14. PeriOperative Medicine What does the anesthesiologist want to know? Regarding Drug Regimens…. -1st line, 2nd line, initial dose, titration, expected SEs -Further tests might be indicated preoperatively -Management suggestions -Help to optimize the underlying disease p/t the surgical insult -Never “clear” for a certain type of anesthesia (may need to convert to GA anyway) -Stent info; Type; Location; When placed; Antiplatelet Agents -Pacer/AICD (date last checked) - ?magnet -Suggest Cardiology when needed

  15. Perioperative Medicine Internists primary goal is not simply to “clear” pts for surgery, but to 1. establish and optimize the pts risk for cardiopulmonary complications, based on the pts current medical status in conjunction with the degree of perioperative stress caused by a particular procedure. 2. provide management recommendations which pertain to pts underlying medical problems

  16. Perioperative Medicine ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Cardiac Surgery (J Am Coll Cardiology 2007;50e159-241) The bottom line………. ****Intervention is rarely necessary to simply lower risk……unless it is indicated irrespective of the planned procedure.

  17. Perioperative Medicine Components of the Pre-op Evaluation ~History (chronic illnesses, meds, social hx) ~Physical ~Prior hx of cardiac w/u (echo, stress test, holter, AICD, cardiac cath) ~Assessment of functional status (METS) ~PSH/Anesthetic complications ~DI ~EKG (in moderate to high risk pts)

  18. Perioperative Medicine Establish Patient risk Establish Surgical risk

  19. Perioperative Medicine PATIENT RISK Who is High Risk?  Acute MI (<7 days) → Stress Testing → delay 4-6 weeks  Recent MI (8-30 days) → Stress Testing → delay 4-6 weeks  Unstable angina/severe angina  (+) stress test/echo with large ischemic burden  Decompensated CHF (+) S3 → ? Echocardiogram  Arrhythmia → high-degree HB → Cardiology Consult → symptomatic arrhythmia c CAD “  Severe valvular disease

  20. Perioperative Medicine Who is Intermediate Risk? • mild angina 1 -ADLeat,dress,toilet,walk around house(↑) • remote MI >1 month 2-3 -walks 1-2 blocks on level ground (↑ risk) • stable CHF METS 4 - light housework/climb 2 flights of stairs • creatinine >2.0 5-9 – heavy housework,golf,bowling,dancing • diabetes, uncontrolled 10 - strenuous exercise swimming, tennis • Qwaves on EKG football, basketball, skiing

  21. METS(Working metabolic rate relative to the resting metabolic rate) 4METS • Ability to perform a spectrum of common tasks correlate well with maximum O2 uptake by treadmill testing. (Mangano 1990) • Increased cardiac and long-term risks in pts unable to meet the 4-met demand • Perioperative ischemia more common in those with poor exercise tolerance.

  22. Perioperative Medicine Pts with low functional capacity <4 METS MAY benefit from preoperative stress testing to -identify preoperative ischemia -identify inducible cardiac arrythmias -to help estimate cardiac risk -help identify at risk territory after recent MI ***there is only real evidence to support stress testing in pts with 3 or more risk factors who have poor functional capacity AND require high risk surgery ONLY IF it will change management!!!

  23. Perioperative Medicine Who is Low Risk? • advanced age • abnormal EKG/old LBBB/LVH • low functional capacity • hx of CVA • uncontrolled HTN • frequent PVCs/NSVT **risk is not known to increase with accumulation of low risk factors….

  24. Perioperative Medicine SURGICAL RISK High Risk Open Aortic Surgery Peripheral vascular surgery XS blood loss estimated Large fluid shifts Prolonged Surgery

  25. Perioperative Medicine SURGICAL RISK Moderate Risk Intraperitoneal/Intrathoracic Surgery CEA/Endovascular AAA Head and Neck Surgery Orthopedic Procedures Open Prostate Resection

  26. Perioperative Medicine SURGICAL RISK Low Risk Superficial Procedures Endoscopic Procedures Cataract Surgery Breast Surgery Ambulatory Procedures

  27. Perioperative Medicine • Lee et al -(Circulation 1999;100:1043-1049) “simple index for prediction of cardiac risk” • Ischemic heart disease (MI, +stress test, NTG, active CP, abnormal Qwaves) • CHF (hx of HF, APE, PND, LE edema, rales, S3, PVC) • CVA (hx if TIA or stroke) • High risk surgery (AAA, vascular, thoracic sx) • Insulin-requiring DM • Creatinine >2.0

  28. Perioperative Medicine Who gets an EKG? Evidence supports: Anyone who is undergoing intermediate or high risk procedures who have at least one clinical risk factor…CAD, PAD, CVA, CRI, DM, CHF **low risk pts do not need EKGs (although we do them anyway)

  29. Perioperative Medicine Who gets PCI (preoperatively)? Balloon angioplasty- Plavix x 2 weeks +ASA Bare-Metal Stent – Plavix x 4 weeks + ASA Drug-eluting Stent – Plavix x 1 year (at least) + ASA **(expert-opinion only…no real evidence to support) **evidence reveals that PCI has no valve in prevention of cardiac events with except in those who PCI is indicated for ACS ***CABG for left main disease

  30. Perioperative Medicine Perioperative Beta-Blockers Who should be started? • Angina/Arrythmias/HTN – continue! • High Risk pt undergoing high risk procedures (evidence supports) • CHD + high risk procedure • High risk pt undergoing intermediate risk procedure **always use caution in pts in whom BBs are contraindicated (dCHF, severe valvular dx, IHSS, mod-pers asthma etc………

  31. Perioperative Medicine Perioperative B-blockers The Verdict is still out on…. • Intermediate Risk pts undergoing moderate risk procedures (although it is generally accepted that these pts are begun on BBs) • Low Risk pts undergoing high risk procedures • Low risk pts do not appear to benefit from and may be harmed by initiation of BBs. (Lindenauer et al (retrospective)NEJM 2005.)

  32. PeriOperative Medicine POISE Study (PeriOperative ISchemic Evaluation) Inclusion Criteria • Undergoing non-cardiac surgery • > 45 yo • LOS 24 hours • CAD/PVD/hx of CHF/major vascular surgery or • Any 3 of the 7 thoracic/abdominal surgery/CHF/TIA/DM/CRF/>70yo/urgent surgery

  33. PeriOperative Medicine POISE Study (PeriOperative ISchemic Evaluation) Exclusion Criteria • Bradycardia <50bpm • 2nd or 3rd degree HB • Asthma • Adverse rxn to a BB • CABG w/i 5 yrs • Low risk procedure • On Verapamil

  34. 406 3548 2005 1506 191 sites 23 countries 886 PeriOperative Medicine(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)

  35. PeriOperative Medicine POISE Study (PeriOperative ISchemic Evaluation) • 8,351 patients included in the analysis, 99.8% of pts completed 30day f/u • Metoprolol 200 mg (starting 2-4 hours prior to surgery) • Continued qD x 30 days • Held for HR below 45bpm or hypotension (drug restarted @ lower dose) • EKG post-op, first day, second day and 30 days after surgery (biomarkers if MI is suspected)

  36. PeriOperative Medicine POISE Study (PeriOperative ISchemic Evaluation) Primary Outcome 1. Cardiovascular death 2. Non-fatal MI 3. Non-fatal cardiac arrest 30 days after randomization

  37. (Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)Primary Outcome Non-fatal MI

  38. PeriOperative MedicineStroke(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)

  39. PeriOperative MedicineAll Deaths(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)

  40. PeriOperative Medicine(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital) For every 1,000 treated patients, metoprolol would prevent • 15 MIs • 7 cases of new AF • 3 post-op CABGs And there would be • 8 excess deaths • 5 excess strokes • 53 patients with significant hypotension

  41. PeriOperative Medicine(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital) • Significant decrease in the risk of non-fatal MI • Pooled OR = 0.68 (0.53-0.87) • Significant increase in the risk of perioperative stroke • Pooled OR = 2.16 (1.04-4.50) • No effect on total mortality

  42. Perioperative Medicine Beta-Blockers Evidence suggests: • Longer-Acting (Atenolol) appears to be superior to shorter acting (Metoprolol). • The dose should be started at least 7 days prior to surgery and titrated up to target HR 60-65 (which is often not feasible in-house)

  43. Perioperative Medicine Post-op R/O MIs The evidence does not support serial Troponin measurements in pts who are clinically stable and hv undergone intermediate or high risk surgery!!!!!!!! It is only recommended in pts with EKG changes or CP!!! WOW!!!!!

  44. Perioperative Medicine Rather….. Charlston et al (1988)…Obtain EKG *Immediately post-op *Day 1 post-op *Day 2 post-op If changes, (ST-T wave changes) or symptoms then obtain Cardiac enzymes (What do we do with all these slightly positive troponins? Do they affect outcomes? What is the role of revascularization?)

  45. Pt Risk vs. Surgical Risk

  46. Perioperative Medicine Why Give Stress Dose steroids??? Chronic Steroid use suppresses the hypothalamic-pituitary-adrenal axis… What constitutes chronic use?

  47. Perioperative Medicine Normal Daily Corticol Production 10 mg Hydrocortisone PO Endogenous Cortisol levels rise to 50 mg – Minor Surgery 75-150 mg – Major Surgery (at induction of anesthesia, with return to baseline within 24-48 h)

  48. Perioperative Medicine Time to recovery of HPA axis - as short as 2-5 days or as long as 9-12 months Therefore, recommendations have been to administer steroids toany pt who has received more than 10 mg of prednisone for more than 7 days consecutive within the last year. (or 3 months depending on the author)

  49. Perioperative Medicine • Asthmatics • Chronic Rheumatologic/Autoimmune Diseases • Certain Neurologic Diseases • HIV (PCP) • Dematologic Diseases (include high potency topicals) • GI (UC)

  50. Perioperative Medicine Traditional dose 100 mg of hydrocortisone q8h (With a quick taper over 1-3 days if uncomplicated.) Technically, dose should be administered based on the surgical risk Minor - 25 mg Hydrocortisone at induction x 1 Moderate - 25 mg Hydrocortisone q8h x 24 h Major - 50 mg Hydrocortisone q6h x 48-72h

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