Clinical conundrum in Perioperative Evaluation

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Perioperative evaluation of difficult clinical scenarios which prompted to delay of surgery:
- Undiagnosed aortic regurgitation
- Pleural effusion with suspected TB

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Clinical conundrum in Perioperative Evaluation

  1. 1. Hospital Medicine Grand Rounds “The role of the peri-operative evaluation in safe patient outcomes: an initial patient dissatisfaction with a happy ending” Moises Auron MD FAAP Feb 11, 2009
  2. 2. Objectives <ul><li>Appraise the importance of the peri-operative assessment to detect unrecognized conditions that increase surgical risk. </li></ul><ul><li>Describe the evaluation and management of aortic regurgitation and its peri-operative implications </li></ul>
  3. 3. Objectives <ul><li>Describe the evaluation and management of pleural effusion and its perioperative implication. </li></ul><ul><li>Describe the peri-operative implications of active tuberculosis. </li></ul><ul><li>Describe the initial peri-operative assessment of Rheumatoid arthritis. </li></ul>
  4. 4. Case presentation <ul><li>55 y/o male </li></ul><ul><li>CC: Tracheostomy and subglotic stenosis </li></ul><ul><li>Referred for pre-operative evaluation for a laser dilatation of the subglottic stenosis </li></ul><ul><li>Surgery scheduled for the next day. </li></ul><ul><li>Patient travelled from Boston, MA. </li></ul>
  5. 5. PMH <ul><li>HTN (10 years) </li></ul><ul><li>Tracheostomy </li></ul><ul><li>G-tube on enteral feeding </li></ul><ul><li>MVA 4 months ago with complicated ICU stay: prolonged intubation. </li></ul><ul><li>D/C to SNF, and recent D/C to home 1 week prior to preoperative visit. </li></ul>
  6. 6. PSH <ul><li>Evacuation of subdural hematoma </li></ul><ul><li>Pleural tube placement for closed chest injury </li></ul><ul><li>Exploratory laparotomy with splenectomy and small bowel resection. </li></ul><ul><li>ORIF hip fracture </li></ul><ul><li>Tracheostomy </li></ul><ul><li>Gastrostomy </li></ul>
  7. 7. Medications <ul><li>Esomeprazole 20 mg daily </li></ul><ul><li>Polyethilen-glycol 17 g daily </li></ul><ul><li>Indapamide 2.5 mg daily </li></ul><ul><li>Aliskiren 150 mg daily </li></ul><ul><li>Clonidine 0.2 mg bid </li></ul><ul><li>Gabapentin 600 mg tid </li></ul><ul><li>Aspirin 81 mg daily </li></ul><ul><li>Oxycodone 10 mg po q6h prn (pain) </li></ul>
  8. 8. Social <ul><li>Smokes 1 ppd for 30 years (not smoking currently since accident 4 months ago). </li></ul><ul><li>No EtOH intake. </li></ul><ul><li>No Drugs. </li></ul><ul><li>Prosecution lawyer, married for 25 years, 2 children. </li></ul>
  9. 9. Pre-operative assessment <ul><li>Able to walk indoors with a walker (2.5 mets) but is mostly in wheelchair </li></ul><ul><ul><li>Chest discomfort when straining (“because I had a chest tube”) </li></ul></ul><ul><ul><li>Needs 4 pillows to sleep, orthopnea, no PND </li></ul></ul><ul><ul><li>Edema managed with indapamide </li></ul></ul><ul><li>Denied any complications with anesthesia. </li></ul>
  10. 10. Circulation. 2007;116:1971-1996
  11. 11. Physical examination <ul><li>BP 205/70 HR 90 RR 16 </li></ul><ul><li>Gen: anxious, head tremors </li></ul><ul><li>Neck: Carotid pulsations appreciated. Trach. </li></ul><ul><li>Cor: S4, 3/6 diastolic murmur in Right 2 nd IC space with presence of diastolic murmur (rumble) in apical area </li></ul><ul><li>Chest: CTA BL </li></ul><ul><li>Abd: S, NT, ND, BS+, pulsatile liver, GT </li></ul><ul><li>Ext: brisk pulses, pulsating capillary nail bed </li></ul>
  12. 12. <ul><li>What do you think? </li></ul>
  13. 13. Signs of aortic insufficiency <ul><li>Austin Flint murmur </li></ul><ul><li>Corrigan’s pulse </li></ul><ul><li>de Musset's sign </li></ul><ul><li>Quincke’s sign </li></ul><ul><li>Traube's sign </li></ul><ul><li>Duroziez’s sign </li></ul><ul><li>Lighthouse sign </li></ul><ul><li>Landolfi’s sign </li></ul><ul><li>Becker’s sign </li></ul><ul><li>Müller’s sign </li></ul><ul><li>Mayen’s sign </li></ul><ul><li>Rosenbach’s sign </li></ul><ul><li>Gerhardt’s sign </li></ul><ul><li>Hill’s sign </li></ul><ul><li>Lincoln’s sign </li></ul><ul><li>Sherman’s sign </li></ul><ul><li>Ashrafian’s sign </li></ul>Babu AN, et al. Ann Intern Med. 138 (9): 736–42. Ashrafian H. Int J Cardiol. 2006 Mar 8;107(3):421-3.
  14. 14. Signs of aortic insufficiency <ul><li>Austin Flint murmur </li></ul><ul><li>Large-volume, 'collapsing' pulse </li></ul><ul><li>Bounding peripheral pulses (waterhammer) </li></ul><ul><li>Low diastolic BP and increased pulse pressure </li></ul><ul><li>Corrigan’s pulse (rapid upstroke and collapse of the carotid artery) </li></ul><ul><li>de Musset's sign (head nodding in time with the heart beat) </li></ul><ul><li>Quincke’s sign (pulsation of the capillary bed in the nail) </li></ul><ul><li>Traube's sign (systolic and diastolic murmurs described as 'pistol shots' heard over the femoral artery when it is gradually compressed) </li></ul><ul><li>Duroziez’s sign (double sound heard over the femoral artery when it is compressed distally) </li></ul>Babu AN, et al. Ann Intern Med. 138 (9): 736–42. Ashrafian H. Int J Cardiol. 2006 Mar 8;107(3):421-3.
  15. 15. <ul><li>Lighthouse sign (blanching & flushing of forehead) </li></ul><ul><li>Landolfi’s sign (alternating constriction & dilatation of pupil) </li></ul><ul><li>Becker’s sign (pulsations of retinal vessels) </li></ul><ul><li>Müller’s sing (pulsations of uvula) </li></ul><ul><li>Mayen’s sign (diastolic drop of BP>15 mm Hg with arm raised) </li></ul><ul><li>Rosenbach’s sign (pulsatile liver) </li></ul><ul><li>Gerhardt’s sign (enlarged spleen) </li></ul><ul><li>Hill’s sign- a ≥ 20 mmHg difference in popliteal and brachial systolic cuff pressures. </li></ul><ul><li>Lincoln’s sign (pulsatile popliteal) </li></ul><ul><li>Sherman’s sign (dorsalis pedis pulse is quickly located & unexpectedly prominent in age>75 yr) </li></ul><ul><li>Ashrafian’s sign (Pulsatile pseudo-proptosis) </li></ul>Signs of aortic insufficiency
  16. 16. Pre-operative optimization <ul><li>EKG: NSR, left axis deviation, LVH, PVC’s </li></ul><ul><li>Labs: creatinine 1.5 (GFR 51 by MDRD) </li></ul><ul><li>IS HE OPTIMALLY PREPARED? </li></ul>
  17. 17. Circulation. 2007;116:1971-1996
  18. 18. Circulation. 2007;116:1971-1996
  19. 19. Circulation. 2007;116:1971-1996
  20. 20. Clinical risk factors: RCRI Lee, et al. Circulation. 1999; 100: 1043 – 1049.
  21. 21. Despite patient’s anger and yelling… <ul><li>… he was “not cleared for surgery” and was sent to the ER: </li></ul><ul><li>Aortic regurgitation with severe symptoms </li></ul><ul><ul><li>NYHA III-IV </li></ul></ul><ul><ul><li>Orthopnea </li></ul></ul><ul><ul><li>Hypertensive urgency with wide pulse pressure </li></ul></ul><ul><ul><li>Unclear evolution – surprising that was not diagnosed in recent hospitalization </li></ul></ul>
  22. 22. Aortic regurgitation: Etiology <ul><li>Idiopathic dilatation (annuloaortic ectasia) </li></ul><ul><li>Congenital (bicuspid valves) </li></ul><ul><li>Calcific degeneration (accompained by AS) </li></ul><ul><li>Rheumatic disease </li></ul><ul><li>Infective endocarditis </li></ul><ul><li>Systemic hypertension (cystic medial necrosis) </li></ul><ul><li>Myxomatous degeneration </li></ul><ul><li>Dissection of the ascending aorta </li></ul><ul><li>Marfan syndrome </li></ul><ul><li>Traumatic injuries </li></ul><ul><li>Ankylosing spondylitis </li></ul><ul><li>Syphilitic aortitis (tertiary) </li></ul><ul><li>Rheumatoid arthritis </li></ul><ul><li>Osteogenesis imperfecta </li></ul><ul><li>Giant cell aortitis </li></ul><ul><li>Ehlers-Danlos syndrome </li></ul><ul><li>Reiter’s syndrome </li></ul><ul><li>Whipple disease </li></ul><ul><li>Discrete subaortic stenosis </li></ul><ul><li>Ventricular septal defects with prolapse of an aortic cusp. </li></ul><ul><li>Anorectic drugs (Fenfluramine, dexfenfluramine) </li></ul>Circulation 2008;118;e523-e661
  23. 23. Natural history of AR Circulation 2008;118;e523-e661
  24. 24. Natural history of chronic AR <ul><li>Asymptomatic Patients With Normal EF </li></ul><ul><li>Variables associated with higher risk (likelihood of death, symptoms, and/or LV dysfunction): </li></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>LV end-systolic dimension </li></ul></ul><ul><ul><ul><li>> 50 mm had a dysfunction - 19% per year. </li></ul></ul></ul><ul><ul><ul><li>40 to 50 mm - 6% per year, </li></ul></ul></ul><ul><ul><ul><li>< 40 mm – 0%. </li></ul></ul></ul><ul><ul><li>LV end-diastolic dimension </li></ul></ul><ul><ul><li>LV ejection fraction during exercise. </li></ul></ul>Circulation 2008;118;e523-e661
  25. 25. TTE <ul><li>Dilated LV size (300 cc end-diastolic volume) with moderate LVH. EF=50%. </li></ul><ul><ul><li>Left Ventricle ID(dia - cm):6.5 </li></ul></ul><ul><ul><li>Left Ventricle ID(sys - cm):3.6 </li></ul></ul><ul><li>Normal RV size and function </li></ul><ul><li>Bicuspid aortic valve. Severe (4+) AR with holodiastolic flow reversal in the descending arch. </li></ul><ul><li>Mildly dilated Aorta with effacement of the S-T junction. Aortic sinus(cm) - 4.3. Sino-tubular Junction(cm) - 3.5. Ascending Aorta(cm) - 3.8. Aortic Arch(cm) - 3.7. </li></ul><ul><li>Bi-atrial enlargement. LA index=28ml. </li></ul><ul><li>Trivial TR. RVSP=41mmHg c/w mild PHTN </li></ul>
  26. 26. LV Catheterization <ul><li>LEFT MAIN: Normal. </li></ul><ul><li>LEFT ANTERIOR DESCENDING: 20-25% narrowing proximal mid and distal segment. </li></ul><ul><li>CIRCUMFLEX ARTERY: Minimal irregularities. </li></ul><ul><li>RIGHT CORONARY ARTERY: mild narrowing about 30% in the mid third. </li></ul><ul><li>LEFT VENTRICLE: Dilated. End diastolic size is increased. End systolic size is significantly increased. EF 35-40%. There are some PVC's and some mild mitral regurgitation. </li></ul><ul><li>AORTIC VALVE: Bicuspid. There is 4+aortic regurgitation. There is partial effacement of the sino-tubular junction on the right side. The ascending aorta is mildly dilated. </li></ul><ul><li>DIAGNOSIS: 1. Severe aortic regurgitation secondary to bicuspid aortic valve. 2. Moderately severe left ventricular dysfunction. 3. Mild coronary artery disease. 4. Mild dilatation of the ascending aorta. </li></ul>
  27. 27. http://www.med.yale.edu/intmed/cardio/echo_atlas/entities/aortic_regurgitation.html
  28. 28. Circulation 2008;118;e523-e661
  29. 29. Immediate Postoperative TEE <ul><li>LV systolic function is normal. </li></ul><ul><li>RV systolic function is normal. </li></ul><ul><li>Bioprosthetic valve (Carpentier-Edwards #27). There is no aortic regurgitation. </li></ul>
  30. 31. Case presentation <ul><li>56 y/o eastern european male (living in USA for the past 5 years). </li></ul><ul><li>CC: Sigmoid adenocarcinoma </li></ul><ul><li>Referred for preoperative evaluation for sigmoidectomy and probable primary anastomosis </li></ul><ul><li>Surgery scheduled for the next day. </li></ul>
  31. 32. HPI <ul><li>2 months with several episodes of hematochezia - colonoscopy showed a villotubular adenomatous polyp with focal areas of adenocarcinoma in-situ. </li></ul>
  32. 33. ROS <ul><li>nocturnal diaphoresis </li></ul><ul><li>pleuritic chest pain </li></ul><ul><li>dry cough </li></ul>
  33. 34. Under further questioning: <ul><li>5 months of nocturnal fever (100F) and diaphoresis, </li></ul><ul><ul><li>generalized arthralgias and bilateral ankle edema. </li></ul></ul><ul><ul><li>A non-erosive arthritis was diagnosed and treated empirically with prednisone (PDN), but no definite diagnosis was made. </li></ul></ul>
  34. 35. HPI…. <ul><li>2 months prior to visit was hospitalized for presumed pneumonia receiving i.v. antibiotics; PDN was stopped. </li></ul><ul><li>A chest CT scan revealed intra-thoracic lymphadenopathy and interstitial lung infiltrates. </li></ul>
  35. 36. HPI <ul><li>PPD and IFN test for TB were positive </li></ul><ul><li>BAL: Negative AFB stain and mycobacterial cultures </li></ul><ul><li>Patient has history of BCG administration. </li></ul><ul><li>An axillary lymph node biopsy showed benign hyperplasia. </li></ul>
  36. 37. PMH, FH and PSH <ul><li>PMH </li></ul><ul><ul><li>Well controlled HTN for 5 years </li></ul></ul><ul><ul><li>No surgeries </li></ul></ul><ul><li>Social H </li></ul><ul><ul><li>Smoker 16 ppy. </li></ul></ul><ul><ul><li>No EtOH or drugs. </li></ul></ul><ul><ul><li>Literature teacher </li></ul></ul><ul><ul><li>Wife is an internist physician trained in Poland and works as Physician assistant in US. </li></ul></ul><ul><li>FH </li></ul><ul><ul><li>Colon CA. </li></ul></ul>
  37. 38. Medications <ul><li>HCTZ 12.5 mg daily </li></ul><ul><li>Atenolol 50 mg daily </li></ul><ul><li>Centrum 1 tablet daily </li></ul><ul><li>Fish oil 1 tablet daily </li></ul><ul><li>Acetaminophen 1 g po qid prn </li></ul><ul><li>Sildenafil 50 mg prn </li></ul>
  38. 39. Preoperative assessment <ul><li>Able to climb a flight of stairs (> 4 mets) </li></ul><ul><li>No previous anesthetic complications </li></ul><ul><li>No active cardiac symptoms </li></ul>
  39. 40. Physical exam <ul><li>BP 140/85 HR 67 RR 22 SpO2 94% (RA) </li></ul><ul><li>HEENT: PERRL, EOMI, MMM </li></ul><ul><li>Neck: supple, anterior cervical LAD – mobile, increased in consistency, no goiter </li></ul><ul><li>Cor: RRR, normal S1, S2, no MRG </li></ul><ul><li>Chest: Decreased left breath sounds, no egophony or fremitus, minimal dullness on percussion on L </li></ul><ul><li>Abdomen: S, NT, ND, BS+, no masses </li></ul><ul><li>Extremities: Limitation of ROM of elbows, with discrete swelling and erythema of ankles bilaterally, no palpable synovitis. </li></ul>
  40. 41. Pre-operative assessment <ul><li>EKG: NSR, HR 65 </li></ul><ul><li>Labs: WNL </li></ul><ul><li>Is he optimally prepared? </li></ul>
  41. 43. Despite angry complaints…. <ul><li>Surgery was delayed </li></ul><ul><li>Active symptoms suggestive of systemic inflammatory process warrant further assessment </li></ul><ul><li>A CXR was required </li></ul><ul><li>An urgent ID evaluation was requested </li></ul><ul><ul><li>High risk for TB </li></ul></ul>
  42. 44. <ul><li>WHAT TESTS WOULD YOU ORDER? </li></ul>
  43. 45. Further evaluation
  44. 46. Perioperative implications of pleural effusion <ul><li>Restrictive ventilatory defect </li></ul><ul><li>↓ VC </li></ul><ul><li>↓ FRC </li></ul><ul><li>↓ TLC </li></ul><ul><li>V/Q mismatch  Hypoxemia </li></ul><ul><ul><li>Atelectasis </li></ul></ul><ul><ul><li>ventricular diastolic collapse (tamponade)  </li></ul></ul><ul><ul><li>↓ C.O. </li></ul></ul>Gilmartin, et al. Thorax 1985; 40:60–65. Agusti, et al. Am J Respir Crit Care Med 1997; 156:1205–1209.
  45. 47. Pleural effusion and mechanical ventilation Graf J. Current Opinion in Critical Care 2009; 15:10–17.
  46. 48. <ul><li>ID requested evaluation by Thoracic surgery </li></ul><ul><li>Unsuccessful US-guided thoracentesis </li></ul><ul><li>Thoracoscopy with pleural fluid drainage and pleural biopsy were done </li></ul>http://www.thoracicmedicine.org
  47. 49. Perioperative air safety <ul><li>Each cough = 600,000 droplets </li></ul><ul><li>Subsequently evaporate to form much smaller invisible droplet nuclei of up to 5 microns in size </li></ul><ul><li>Particles < 10 microns can reach the alveoli </li></ul><ul><li>Most concerning microorganism is Mycobacterium tuberculosis </li></ul>Hickle R. Acta Anaesthesiol Scand Suppl. 1997;111:241-7.
  48. 50. <ul><li>Cough inducing procedures </li></ul><ul><ul><li>Extubation </li></ul></ul><ul><ul><li>Suctioning </li></ul></ul><ul><ul><li>Average cough in PACU = 32 times during first 40 minutes of recovery </li></ul></ul><ul><li>Cost analysis study estimated the expense associated with an episode of unprotected exposure to TB in the PACU: </li></ul><ul><ul><li>$57,000 to $74,000 </li></ul></ul>Perioperative air safety Hickle R. Acta Anaesthesiol Scand Suppl. 1997;111:241-7.
  49. 51. Perioperative air safety <ul><li>N95 respirator prevents passage of 95% of particles > 0.3 microns </li></ul><ul><li>Minimize personnel exposed </li></ul><ul><li>Isolation with negative pressure </li></ul><ul><li>Direct transfer to OR </li></ul><ul><li>Bacterial filter in ETT </li></ul><ul><li>Careful cleansing of OR and leaving room closed until air is completely changed </li></ul>Neil J. AORN J. DEC 2008; 88 (6): 942-958
  50. 52. Perioperative air safety <ul><li>Schedule aerosol-generating procedure at the end of the day </li></ul><ul><li>Attempt to do the procedure in the patient’s room </li></ul><ul><li>Use disposable anesthesia equipment </li></ul>Neil J. AORN J. DEC 2008; 88 (6): 942-958
  51. 53. Patient with active pulmonary TB <ul><li>Higher risk for temperature disregulation, hypoxemia and hypoventilation. </li></ul><ul><ul><li>Fever ↑ metabolic rate and cardiac output </li></ul></ul><ul><li>Hypoxemia and hypoventilation occur due to anatomical lesions and necrotic lung parenchyma; atelectasis; pleural effusion </li></ul><ul><li>Malnutrition and weakness  ↓ secretions clearance and ineffective cough </li></ul><ul><li>↓ inspiratory and expiratory effort  hypoventilation. </li></ul>Neil J. AORN J. DEC 2008; 88 (6): 942-958
  52. 54. Pleural biopsy <ul><ul><li>Fibrinous pleuritis with mesothelial hyperplasia. </li></ul></ul><ul><ul><li>AFB stain was negative as well as mycobacterial cultures. Fungal serologies were negative. </li></ul></ul><ul><ul><li>Pleural fluid is an exudate </li></ul></ul>
  53. 55. Light RW. NEJM. 2002; 346 (25): 1971-1977
  54. 56. Yataco JC, Dweik R. CCJM. 2005; 72(10): 854-872.
  55. 57. Ancillary testing <ul><li>ESR 99 </li></ul><ul><li>CRP 11 </li></ul><ul><li>Positive Rheumatoid factor </li></ul><ul><li>Positive anti-CCP antibodies </li></ul><ul><li>ANA, ANCA and hepatitis serology: negative </li></ul><ul><li>Complement was normal. </li></ul><ul><li>Pleural fluid Rheumatoid factor positive </li></ul>
  56. 58. Pleural rheumatoid factor <ul><li>Can be elevated in: </li></ul><ul><li>Rheumatoid arthritis </li></ul><ul><li>SLE </li></ul><ul><li>Malignancy </li></ul><ul><li>Pneumonia </li></ul><ul><li>Tuberculosis </li></ul>Yataco JC, Dweik R. CCJM. 2005; 72(10): 854-872.
  57. 59. Rheumatology consult <ul><li>Considered that patient could undergo surgery. </li></ul><ul><li>Treatment would be started after surgery. </li></ul><ul><li>C-spine flexion and extension X-Rays were normal. </li></ul>
  58. 60. Preoperative lateral flexion-extension C-spine X-Rays <ul><li>Progression of peripheral joint erosion parallels cervical spine disease </li></ul><ul><li>RF seropositivity associated with higher incidence of cervical spine involvement </li></ul><ul><li>C-spine involvement affects 15-86% of patients with RA </li></ul><ul><li>Patients with erosive RA – 30-40% have C-spine disease </li></ul>Macarthur A, et al. Can J Anaesth. 1993; 40: 154-9. Crosby ET. Can J Anaesth. 1990; 37: 77-93.
  59. 61. <ul><li>Patient underwent sigmoidectomy with primary colorectal anastomosis. No further chemotherapy was advised. </li></ul>http://nyp.org/masc/colorectal.htm
  60. 62. Post-operative <ul><li>Prednisone and methotrexate were started with progressive improvement of articular and pulmonary symptoms. </li></ul><ul><li>Subsequently hydrocloroquine was added and prednisone dose was decreased. </li></ul><ul><li>ESR and CRP normalized after 3 months and symptoms improved dramatically. </li></ul>
  61. 63. Clinical conundrum <ul><li>Pleuritis and interstitial lung disease are the most frequent pleuropulmonary manifestations of rheumatoid arthritis. </li></ul><ul><li>Co-existence of constitutional symptoms in a smoker patient with presumed TB as well as with a recent diagnosis of sigmoid cancer. </li></ul>
  62. 64. Take home message <ul><li>Make precise diagnoses </li></ul><ul><li>Evaluate the extent of organ disease </li></ul><ul><li>Optimize medical diagnoses </li></ul><ul><li>Assess and describe physiologic limitations </li></ul><ul><li>Ensure adequate post-operative follow-up </li></ul><ul><li>Regardless of the patient's desire to &quot;proceed with surgery&quot; - we have an obligation to do what is in the patient's best interest and to provide the surgical team with the service that they expect.... </li></ul>

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