Perioperative Care:  Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006
Workshop learning objectives <ul><li>Learn the indications for preoperative testing and preparation for a healthy patient ...
Outline <ul><li>Preoperative risk stratification </li></ul><ul><li>Perioperative cardiac risk reduction </li></ul><ul><li>...
Case #1 <ul><li>74 y.o. woman with CAD s/p stent in 1998, hypertension, osteoporosis, GERD, scheduled for cataract surgery...
Case #1 <ul><li>What do you recommend prior to cataract surgery? </li></ul><ul><li>CBC, lytes, creatinine, glucose, EKG </...
Routine Preoperative Testing  before Cataract Surgery N Engl J Med 2000;342;168 <ul><li>19,557 cataract surgeries </li></u...
ASA Physical Status Brain dead organ donor VI Ruptured AAA Will die within 24 hours without surgery V COPD on home 02,  Cl...
Routine Preoperative Testing  before Cataract Surgery N Engl J Med 2000;342;168 *Events = Cardiac, Hyper/hypotension, Stro...
Case #2: Preop Risk Stratification <ul><li>55 y.o. woman scheduled for hysterectomy  </li></ul><ul><li>PMH: hypertension, ...
What preoperative cardiac evaluation do you recommend? <ul><li>None. Proceed with surgery </li></ul><ul><li>Add a beta-blo...
Preventing Perioperative Cardiac Complications <ul><li>What are we trying to prevent? </li></ul><ul><ul><li>Perioperative ...
Risk of Cardiac Complications Based on Type of Surgery <ul><li>High (>5%) </li></ul><ul><ul><li>Major aortic, peripheral v...
Clinical Predictors of Perioperative Cardiac Complications Eagle, JACC 2002;39:542 Advanced age Abnormal ECG or rhythm not...
Assessing Functional Capacity Swimming Singles tennis 10+  METs Climb flight of stairs Scrub floors Golf Short run 4-10 ME...
Case #3: Preop  Hypertension Management <ul><li>55 y.o. woman arrives for hysterectomy  </li></ul><ul><li>PMH: hypertensio...
Outline <ul><li>Preoperative risk stratification </li></ul><ul><li>Perioperative cardiac risk reduction </li></ul><ul><li>...
Case #4 <ul><li>68 y.o. woman with type 2 diabetes, osteoarthritis of the knees, and hypothyroidism, scheduled for right h...
Case #4 <ul><li>What preoperative assessment do you recommend? </li></ul><ul><li>Proceed with surgery </li></ul><ul><li>Ex...
Preoperative Stress Testing Eagle ACC/AHA 2002 <ul><li>Indications: 2 or more of the following </li></ul><ul><ul><li>Inter...
Perioperative Beta Blockers <ul><li>In what clinical settings would you prescribe a perioperative beta-blocker? </li></ul>...
Benefits of Perioperative  Beta Blockers <ul><li>Reduce perioperative myocardial ischemia </li></ul><ul><li>Decrease perio...
Perioperative Beta Blockers in Noncardiac Surgery <ul><li>Patients: 200 Veterans w/ CAD or 2 CAD risk factors </li></ul><u...
Perioperative Beta Blockers in Noncardiac Surgery Mangano, NEJM, 1996
Which Beta Blocker? <ul><li>Cardioselective (atenolol, metoprolol)  </li></ul><ul><ul><li>Effective </li></ul></ul><ul><ul...
Dosing Perioperative  Beta Blockers <ul><li>Already taking a Beta Blocker: </li></ul><ul><ul><li>Adjust previous dose to a...
Outline <ul><li>Preoperative risk stratification </li></ul><ul><li>Perioperative cardiac risk reduction </li></ul><ul><li>...
Case # 5 <ul><li>A 70 year old man with diabetes, hypertension, CAD, and COPD is admitted with right upper quadrant pain. ...
Case #5 <ul><li>Which of the following is most likely to reduce the risk of perioperative pulmonary complications? </li></...
Perioperative Pulmonary Complications <ul><li>As common as postop cardiac complications; similar morbidity and mortality <...
<ul><li>Risk assessment and strategies to reduce perioperative pulmonary complications after noncardiothoracic surgery:  <...
Patient risk factors for postop pulmonary complications 4.87 ASA class > I 2.51 (total); 1.65 (partial) Functional depende...
Surgery risk factors for postop pulmonary complications <ul><li>Surgery type: abdominal, thoracic, neuro, head/neck, vascu...
Interventions to reduce postop pulmonary complications:  Preop <ul><li>Identify and target high risk patients </li></ul><u...
Interventions to reduce postop pulmonary complications:  Post op <ul><li>Lung expansion </li></ul><ul><ul><li>Deep breathi...
Interventions that might reduce postop pulmonary complications:  <ul><li>Laparoscopic instead of open surgery </li></ul><u...
Summary <ul><li>Preoperative risk stratification </li></ul><ul><li>Perioperative cardiac risk reduction </li></ul><ul><li>...
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Pre-operative and Peri-operative Care: New Strategies to ...

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Pre-operative and Peri-operative Care: New Strategies to ...

  1. 1. Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006
  2. 2. Workshop learning objectives <ul><li>Learn the indications for preoperative testing and preparation for a healthy patient having elective surgery </li></ul><ul><li>Learn the indications for cardiac stress testing and beta blockade prior to noncardiac surgery </li></ul><ul><li>Understand new recommendations for preventing postoperative pulmonary complications </li></ul>
  3. 3. Outline <ul><li>Preoperative risk stratification </li></ul><ul><li>Perioperative cardiac risk reduction </li></ul><ul><li>Preventing postoperative pulmonary complications </li></ul>
  4. 4. Case #1 <ul><li>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. </li></ul><ul><li>Meds: enalapril, lovastatin, ranitidine, aspirin. </li></ul><ul><li>PE: BP 128/70 HR 80 </li></ul><ul><li>Surgeon asks you to perform routine preoperative tests and clear for surgery. What do you recommend? </li></ul>
  5. 5. Case #1 <ul><li>What do you recommend prior to cataract surgery? </li></ul><ul><li>CBC, lytes, creatinine, glucose, EKG </li></ul><ul><li>Stress test </li></ul><ul><li>A & B </li></ul><ul><li>Recommend against surgery </li></ul><ul><li>Proceed with surgery </li></ul>
  6. 6. Routine Preoperative Testing before Cataract Surgery N Engl J Med 2000;342;168 <ul><li>19,557 cataract surgeries </li></ul><ul><li>Randomized to preop testing or no testing </li></ul><ul><li>Average age 74 </li></ul><ul><li>89% ASA class II or III </li></ul><ul><li>Outcome = perioperative events </li></ul>
  7. 7. ASA Physical Status Brain dead organ donor VI Ruptured AAA Will die within 24 hours without surgery V COPD on home 02, Class III CHF Systemic disease - constant threat to life IV Stable angina, chronic renal insufficiency Symptomatic systemic disease III Hypertension, diabetes Asymptomatic systemic disease II DJD, Glaucoma Healthy I
  8. 8. Routine Preoperative Testing before Cataract Surgery N Engl J Med 2000;342;168 *Events = Cardiac, Hyper/hypotension, Stroke/TIA, respiratory distress requiring treatment, hypoglycemia, DKA 1.04 (0.8-1.3) 1.2% 1.3% Postop events* 0.97 (0.8-1.2) 2% 1.9% Intraop events* Relative risk (95% CI) Routine testing No testing
  9. 9. Case #2: Preop Risk Stratification <ul><li>55 y.o. woman scheduled for hysterectomy </li></ul><ul><li>PMH: hypertension, on hydrochlorothiazide </li></ul><ul><li>PE: BP 135/90 HR 85 Normal exam </li></ul><ul><li>EKG: Normal sinus rhythm, left ventricular hypertrophy </li></ul>
  10. 10. What preoperative cardiac evaluation do you recommend? <ul><li>None. Proceed with surgery </li></ul><ul><li>Add a beta-blocker </li></ul><ul><li>Exercise stress test </li></ul><ul><li>Exercise-thallium stress test </li></ul>
  11. 11. Preventing Perioperative Cardiac Complications <ul><li>What are we trying to prevent? </li></ul><ul><ul><li>Perioperative MI (mortality up to 15%) </li></ul></ul><ul><ul><li>Mortality (all cause) </li></ul></ul><ul><ul><li>Other - CHF, ischemia, nonfatal arrhythmia </li></ul></ul>
  12. 12. Risk of Cardiac Complications Based on Type of Surgery <ul><li>High (>5%) </li></ul><ul><ul><li>Major aortic, peripheral vascular surgery </li></ul></ul><ul><ul><li>Emergent major surgery </li></ul></ul><ul><ul><li>Long case - large fluid shifts, blood loss </li></ul></ul><ul><li>Intermediate (<5%) </li></ul><ul><ul><li>Carotid, head, neck </li></ul></ul><ul><ul><li>Abdominal, thoracic, pelvic </li></ul></ul><ul><ul><li>Orthopedic </li></ul></ul><ul><li>Low (<1%) </li></ul><ul><ul><li>Endoscopic, skin, breast </li></ul></ul>
  13. 13. Clinical Predictors of Perioperative Cardiac Complications Eagle, JACC 2002;39:542 Advanced age Abnormal ECG or rhythm not sinus Prior stroke Uncontrolled hypertension Functional capacity < 4 METs Minor Prior MI Mild angina CHF Diabetes Creatinine > 2.0 mg/dl Intermediate MI within 1 month, unstable angina Decompensated CHF, severe valve disease Significant arrhythmia Major
  14. 14. Assessing Functional Capacity Swimming Singles tennis 10+ METs Climb flight of stairs Scrub floors Golf Short run 4-10 METs Eat Dress Walk in house 1-4 METs
  15. 15. Case #3: Preop Hypertension Management <ul><li>55 y.o. woman arrives for hysterectomy </li></ul><ul><li>PMH: hypertension, on hydrochlorothiazide </li></ul><ul><li>PE: BP 185/100 HR 85 Normal exam </li></ul><ul><li>EKG: Normal sinus rhythm, left ventricular hypertrophy </li></ul><ul><li>How does your management change? </li></ul>
  16. 16. Outline <ul><li>Preoperative risk stratification </li></ul><ul><li>Perioperative cardiac risk reduction </li></ul><ul><li>Preventing postoperative pulmonary complications </li></ul>
  17. 17. Case #4 <ul><li>68 y.o. woman with type 2 diabetes, osteoarthritis of the knees, and hypothyroidism, scheduled for right hemicolectomy. </li></ul><ul><li>Meds: glyburide, metformin, levothyroxine, acetaminophen. Non-smoker. </li></ul><ul><li>PE: BP 130/70 HR 88 98% RA 0 2 Sat </li></ul>
  18. 18. Case #4 <ul><li>What preoperative assessment do you recommend? </li></ul><ul><li>Proceed with surgery </li></ul><ul><li>Exercise treadmill test </li></ul><ul><li>Persantine-thallium test </li></ul><ul><li>Cardiac catheterization </li></ul><ul><li>Add atenolol </li></ul>
  19. 19. Preoperative Stress Testing Eagle ACC/AHA 2002 <ul><li>Indications: 2 or more of the following </li></ul><ul><ul><li>Intermediate clinical predictor (Eagle 2002) </li></ul></ul><ul><ul><ul><li>Stable cardiac disease, DM, Cr > 2 </li></ul></ul></ul><ul><ul><li>High risk surgery </li></ul></ul><ul><ul><li>Poor functional status (< 4 METs) </li></ul></ul><ul><li>Which test? </li></ul><ul><ul><li>Ambulatory, normal ECG exercise treadmill </li></ul></ul><ul><ul><li>Ambulatory, abnormal ECG exercise + imaging </li></ul></ul><ul><ul><li>Can’t exercise P-Thal or Dobutamine echo </li></ul></ul><ul><li>Better for ruling out than ruling in cardiac disease </li></ul>
  20. 20. Perioperative Beta Blockers <ul><li>In what clinical settings would you prescribe a perioperative beta-blocker? </li></ul><ul><li>A. Hypertension </li></ul><ul><li>B. Major vascular surgery </li></ul><ul><li>C. History of CAD </li></ul><ul><li>D. CAD risk factors </li></ul><ul><li>E. All surgical patients </li></ul>
  21. 21. Benefits of Perioperative Beta Blockers <ul><li>Reduce perioperative myocardial ischemia </li></ul><ul><li>Decrease perioperative cardiac complications </li></ul><ul><li>Improve survival </li></ul>
  22. 22. Perioperative Beta Blockers in Noncardiac Surgery <ul><li>Patients: 200 Veterans w/ CAD or 2 CAD risk factors </li></ul><ul><li>Atenolol one hour prior to surgery until hospital discharge, unless HR < 55, vs. placebo </li></ul><ul><li>Operations: major vascular, abdominal, ortho, neurosurg </li></ul><ul><li>Outcomes: mortality, cardiac complications over 2 years </li></ul>Mangano, NEJM, 1996
  23. 23. Perioperative Beta Blockers in Noncardiac Surgery Mangano, NEJM, 1996
  24. 24. Which Beta Blocker? <ul><li>Cardioselective (atenolol, metoprolol) </li></ul><ul><ul><li>Effective </li></ul></ul><ul><ul><li>Fewest side effects </li></ul></ul><ul><li>Non-cardioselective (propranolol, nadolol) </li></ul><ul><ul><li>Equally effective </li></ul></ul><ul><ul><li>More side effects - pulmonary, hypotension </li></ul></ul><ul><ul><li>Use only if patient already taking </li></ul></ul><ul><li>Avoid beta blockers with intrinsic sympathomimetic activity </li></ul><ul><li>Consider clonidine if beta blockers contraindicated </li></ul>
  25. 25. Dosing Perioperative Beta Blockers <ul><li>Already taking a Beta Blocker: </li></ul><ul><ul><li>Adjust previous dose to a target HR of 60 </li></ul></ul><ul><li>New prescriptions: </li></ul><ul><ul><li>Begin treatment with atenolol 25-50 mg q day within one month of surgery </li></ul></ul><ul><ul><li>Consider a follow-up appt for HR check and dose adjustment 1-7 days before surgery </li></ul></ul>
  26. 26. Outline <ul><li>Preoperative risk stratification </li></ul><ul><li>Perioperative cardiac risk reduction </li></ul><ul><li>Preventing postoperative pulmonary complications </li></ul>
  27. 27. Case # 5 <ul><li>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. </li></ul>
  28. 28. Case #5 <ul><li>Which of the following is most likely to reduce the risk of perioperative pulmonary complications? </li></ul><ul><li>Preoperative CXR </li></ul><ul><li>Incentive spirometry </li></ul><ul><li>Laparoscopic technique </li></ul><ul><li>Smoking cessation </li></ul>
  29. 29. Perioperative Pulmonary Complications <ul><li>As common as postop cardiac complications; similar morbidity and mortality </li></ul><ul><ul><li>Pulmonary complications may better predict long term mortality </li></ul></ul><ul><li>Most important and morbid: </li></ul><ul><ul><li>Atelectasis </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Respiratory failure </li></ul></ul><ul><ul><li>Exacerbation of chronic lung disease </li></ul></ul>
  30. 30. <ul><li>Risk assessment and strategies to reduce perioperative pulmonary complications after noncardiothoracic surgery: </li></ul><ul><li>A guideline from the ACP </li></ul><ul><li>Ann Intern Med 2006;144:575 </li></ul>
  31. 31. Patient risk factors for postop pulmonary complications 4.87 ASA class > I 2.51 (total); 1.65 (partial) Functional dependence 2.93 CHF 1.26 Current smoking 1.79 COPD 2.09 - 3.04 Age > 60 Odds ratio Risk factor
  32. 32. Surgery risk factors for postop pulmonary complications <ul><li>Surgery type: abdominal, thoracic, neuro, head/neck, vascular, AAA </li></ul><ul><li>Surgery > 3 hours </li></ul><ul><li>Emergency surgery </li></ul><ul><li>General anesthesia </li></ul>
  33. 33. Interventions to reduce postop pulmonary complications: Preop <ul><li>Identify and target high risk patients </li></ul><ul><ul><li>Patient and surgery risk risk factors </li></ul></ul><ul><li>Preop - consider: </li></ul><ul><ul><li>Spirometry - only with COPD </li></ul></ul><ul><ul><li>CXR - for age > 50, high risk surgery, known cardiopulmonary disease </li></ul></ul>
  34. 34. Interventions to reduce postop pulmonary complications: Post op <ul><li>Lung expansion </li></ul><ul><ul><li>Deep breathing exercises or </li></ul></ul><ul><ul><li>Incentive spirometry or </li></ul></ul><ul><ul><li>CPAP </li></ul></ul><ul><li>Selective use of NG tube after abdominal surgery </li></ul><ul><ul><li>for nausea/emesis, inability to take p.o., abdominal distention </li></ul></ul>
  35. 35. Interventions that might reduce postop pulmonary complications: <ul><li>Laparoscopic instead of open surgery </li></ul><ul><ul><li>Improves pain, spirometry, oxygenation </li></ul></ul><ul><ul><li>Unclear benefit on clinically important pulmonary complications </li></ul></ul><ul><li>Epidural anesthesia/analgesia - unclear benefit </li></ul><ul><li>Smoking cessation: > 2 months preop </li></ul>
  36. 36. Summary <ul><li>Preoperative risk stratification </li></ul><ul><li>Perioperative cardiac risk reduction </li></ul><ul><li>Preventing postoperative pulmonary complications </li></ul>
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