Pre/Perioperative Care

1. Pre/Perioperative Care John Holman, MD, MPH Captain, USN Naval Hospital Camp Pendleton, CA

2. Take-Home Messages • Risk stratify for heart disease: • Type of surgery • Presence of unstable disease • Evaluate current illnesses • Reduce peri-operative adrenergic burden • Screen for dementia in the elderly

3. Introduction • Purpose of preoperative evaluation • Identify high-risk patients • Recommend strategies to minimize risks • Risks during surgery • CARDIAC, pulmonary, endocrine, heme etc.

4. Stepwise Approach • Indices • Dripps-ASA - too general • Goldman - No angina or CHF • Detsky - Goldmans with angina + CHF • ACC/AHA guideline-2002 update (1996) • Validated clinically and anatomically • Level B evidence

5. Dripps - ASA • Classification of physical status • Class 1 – Healthy without systemic disturbance • Class 2 – Mild-moderate systemic disease • Class 3 – Severe systemic disease limits activity • Class 4 – Incapacitating and life threatening systemic disease • Class 5 – Moribund patient with little chance of survival.

6. Dripps – ASA • Patient undergoing emergency surgery considered in poorer condition • Letter “E” placed after classification • Too general and subjective • Does not identify patients who need further evaluation

7. Goldman • Multifactorial scoring index to estimate cardiac risk • S3 or JVD 11 • MI within 6 mos 10 • >5 PVCs/min 7 • PACs or non-sinus 7 • Age>70 5 • Emergency 4 • Chest, abd, aorta 3 • Valvular stenosis 3 • Poor general health 3

8. Goldman • Developed in 1983 • Criticized for • Lack of points for angina pectoris • Lack of points for CHF • Further refinements led to …..

9. Detsky • Basically Goldman’s with CHF + Angina • MI < 6 mos 10 • MI > 6 mos 5 • Class 3 angina 10 • Class 4 angina 20 • Unstable angina < 3 mos 10 • Pulm edema < 1 weeks 10 • Pulm edema evern 5 • Critical AS 20 • Age > 70 5 • PACs, non sinus 5 • > 5 PVCs/ min 5 • Poor general health 5 • Emergency surgery 5

10. Detsky • Improvement but…… • Still subjective • Not evidence – based • Did not give clear recommendations for further evaluation • Led to development of ACC guideline in 1996

11. ACC/AHA Guidelines • Evidence – based – Level B • Anatomically validated • Clinically validated • More objective • Easy, stepwise approach

12. Step #1:Is the surgery emergent? yes Is the surgery emergent? Operating room* no (Next Step) Consider beta-blockade, pain control and other peri-operative management

13. Step #2: Prior revascularization? Has patient had revascularization in past 5 years? yes Any recurrent symptoms? no no yes Operating Room Recent coronary evaluation? (next step)

14. Step #3: Recent Coronary Evaluation? yes Operating room Recent Coronary Evaluation? reassuring None or Not reassuring Search for Clinical Predictors

15. Step #4: Clinical Predictors Delay for risk modification or revasculariztion Major predictors Intermediate predictors (see next step) Operating room unless high risk procedure Minor or no predictors

16. Step #4: Clinical Predictors *If functional capacity less than 4 mets by history, do noninvasive testing. Otherwise, go to operating room.

17. Step #5: After testing Coronary Assessment (ETT, MPS, Stress ECHO or cath) Low Risk Operating Room High Risk Consider Revascularization Prior to other surgery

18. 63 yo man with prior CABG 6 years ago. Walks 3 miles/day without angina HTN, High cholesterol and COPD on meds Undergoing laminectomy 63 yo female without known coronary dx. Has diabetes for 22 years, no complication Sedentary, mild obese Undergoing Fem-Pop bypass Two Patients John Mary

19. Pre-op RecommendationsACC/AHA Task Force • John should go to surgery without any ischemic evaluation--revascularized without recurrent symptoms • Mary should have noninvasive testing--Diabetes is an intermediate risk factor, high risk procedure and poor functional capacity

20. Step 1: Define the Surgery • Is it emergent/urgent? Risk stratification of the procedure: • High risk: Major vessels, prolonged surgery with major fluid/blood loss >5% events • Intermediate: Head and Neck, Endarterectomy, Orthopedic, Prostate, Thoracic or peritoneal • 1-5% events • Low risk: Breast, cataract, endoscopic <1% events

21. Step 2: Define the Patient • Has patient undergone revascularization in the past 5 years? • Has the patient undergone coronary evaluation in the past 2 years? • By history, does the patient have a major or intermediate clinical predictor of risk?

22. Major Clinical Predictors • Unstable Coronary syndromes • Decompensated CHF • Significant dysrhythmias • Severe valvular disease

23. Intermediate Clinical Predictors • Mild Angina (NYHA class I or II) • Prior MI • Compensated CHF • Diabetes Mellitus

24. Minor Clinical Predictors • Advanced Age • Abnormal ECG • Rhythm other than sinus • History of stroke • Uncontrolled hypertension • Low functional capacity

25. Functional capacity • Excellent: greater than 7 mets (heavy outdoor work, walk briskly up stairs) • Moderate: 4-7 mets (gardening, walking 4 mph, leisure cycling) • Poor: Less than 4 mets (walking 2 mph, cooking, golf with cart)

26. Cardiac Testing • Noninvasive test • EST without perfusion imaging • EST with perfusion imaging • Pharmacological testing with imaging • Radionuclide angiography • Pharmacological testing with echo • Cardiac Cath

27. Task Force Theme • The overriding theme is that intervention is rarely necessary unless such intervention is indicated irrespective of the fact the patient is to undergo surgery.

28. Putting it all together *If functional capacity less than 4 mets by history, do noninvasive testing. Otherwise, go to operating room.

29. Perioperative Cardiac Risk Reduction • Maintain normothermia • 1997 RCT showed normal temps decrease cardiac morbidity • Alpha blockade • 2003 meta analysis showed trend towards decreased mortality • Beta blockade • 1996 RCT showed 50% reduction in mortality at two years. Confirmed by three other RCTs…………….. BUT WAIT!

30. Perioperative Cardiac Risk Reduction • Two RCTs since 2004 • Metoprolol no benefit in vascular surgery • Meta analysis encouraging for 30 day outcomes but not statistically significant • Retrospective review of 600,000 patients • Major non cardiac surgery • Only helped for high risk patients • Harmful for low risk patients

31. Perioperative Cardiac Risk Reduction • Lindenauer 2004 (JAMA) • RCRI = 0 OR = 1.43 (1.29-1.58) • RCRI = 1 OR = 1.13 (0.99-1.30) • RCRI = 2 OR = 0.90 (0.75-1.08) • RCRI = 3 OR = 0.71 (0.56-0.91) • RCRI > 4 OR = 0.57 (0.42-0.76) • Best candidates for perioperative beta blockers have long term indications OR for death in hospital

32. Perioperative Cardiac Risk Reduction • Statins • Observational data is promising • Lindenauer 2003 – NNT for RCRI > 2 is 30 and for < 2 is 186 to prevent one death • Kertai 2004 – 60% decrease in all cause mortality for 5 years • Small RCT done in 2004 • Durazzo – 70% reduction in combined endpoint of cardiac death, nonfatal MI, USA, CVA. • Jury still out but promising!

33. The Rest of the Story

34. Pulmonary Disease-Risks • Active lung disease and/or poor general health status. • Age • General anesthesia, particularly > 3 hours • Use of pancuronium • Closer the incision is to the diaphragm, the greater the risk

35. Pulmonary-Reducing risk • Stop smoking for 8 weeks pre-op • Treat obstructive disease aggressively • Treat infection if present • Patient education for incentive spirometry • Epidural analgesia and/or intercostal nerve blocks

36. Smoking Cessation • RCT of smoking cessation education by nurses for 8 weeks prior to lower extremity revascularization • 60% in intervention group quit, 25% cut down significantly • Complication rate (mostly wound healing) reduced from 52% to 18% (NNT 3) • Lancet 2002; 359:114-7

37. DVT prophylaxis • Risk of the surgery • Risk of the patient • Treatments range from early ambulation to LMWH with intermittent pneumatic compression (See Table from ACCP Guidelines)

38. ‘Bridging therapy’ for anticoagulated patients • Low risk procedure: continue warfarin • Dental procedures: continue warfarin, use EACA mouthwash as necessary • Low risk patient: Stop warfarin 4 days prior to surgery, briefly give post-op heparin prophylaxis and restart warfarin post-op (2C: not evidence-based, just opinion)

39. Bridging therapy, p 2 • Moderate risk patient: D/C warfarin 4-5 days pre-op, operate at <1.5 INR. Cover with low-dose heparin beginning 2 days pre-op and give full dose post-op • High risk patient: D/C Warfarin 3-5 days pre-op and begin full-dose heparin when INR <2.0. Stop 6 hrs pre-op (12-24 hrs if LMWH) Restart both post-op until therapeutic Prevention of Venous Thromboembolism, the 7th ACCP conference CHEST 2004

40. Diabetes Mellitus • Aim for 150-200 mg/dl glucose (8-11mmol) • Set specific management based on: • Patient’s current diabetic regimen • Anticipated time of day of surgery • Anticipated duration of surgery

41. Diabetes and surgery • Diabetics undergoing CABG who had Glucose/Insulin/Potassium infusion for tight (125-200) control had: • Lower incidence of atrial fibrillation • Decreased wound infections • Shorter length of stay • Survival advantage that lasted for 2 years • Newest trials suggest even tighter control

42. Adrenal Suppression • Consider suppression for patients who have taken more than 10 mg prednisone for greater than 2 weeks or 5 mg for longer term. • May do stimulation testing or just treat • Coverage for surgical stress can be lower than the traditional dosing.

43. Adrenal Suppression:Replacement • Surgical stressSteroid dose • Minor (herniorraphy) 25 mg HC pre-op • Moderate (TAH, vas bypass) 20 mg HC Q8 x 2 days • Major (Whipple, CABG) 25-50 mg HC Q8 x 2 days

44. Delirium in Hospitalized Elderly • Dementia 5.2 [4.2-6.3] • Severe medical illness 3.8 [2.2-3.4] • Alcohol abuse 3.3 [1.9-5.5] • Depression 1.9 [1.3-2.6] Baseline Risks for Delirium:

45. Post-operative Delirium • Physical restraints 4.4 [2.5-7.9] • Malnutrition 4.0 [2.2-7.4] • More than 3 new meds 2.9 [1.6-5.4] • Meperidine, benzodiazepines, anti-cholinergics • Bladder catheter 2.4 [1.2-4.7] • Any iatrogenic event 1.9 [1.1-3.2] Precipitants for post-op Delirium:

46. Managing Delirium • Screen for dementia and prepare the family • Reduce need for restraints • Avoid precipitant medications • Control pain • Consider: hypoxemia, electrolyte disturbance, withdrawal syndromes

47. Other Geriatric issues • Clarify the handling of DNR status • Early attention to nutrition-use enteral route if at all possible • When to stop DVT prophylaxis?

48. Other Miscellaneous topics • Adequate Post-operative analgesia reduces cardiac stress • Normothermia reduces wound infections • Appropriate timing of prophylactic antibiotics • Which medications cannot be withheld?

49. Other Miscellaneous topics • ACC recommendations on SBE prophylaxis • Pre-op fluids (15ml/kg) reduces post-op nausea in cholecystectomy patients • Excludes heart failure patients • Dexamethasone (8 mg IV) given at time of operation reduces nausea in laparoscopic cholecystectomy

50. Other Miscellaneous topics • Supplemental oxygen reduces wound infection rates • Immediate v delayed repair of hip fracture reduces wound complications but not mortality or eventual functional status • Early enteral feedings improve outcomes v prolonged NPO status