evaluation of operative risk for non cardiac surgery ;for anesthesia and surgery.Cardiac conditions,including heart failure ,use of betablockers,stains.Diabetes risk,including difficult intubation.Thromboembolic risk,

1. La valutazione del rischio in
anestesia
Claudio Melloni
Libero professionista
Consulente di anestesia per Villa Torri,Villa Chiara,Poliambulatorio
Gynepro
Bologna

2. Rischio in anestesia

3. Limitazioni della lettura
• Non si parla del rischio tecnico,legato alle
attrezzature o alle diverse tecniche di
anestesia
• La lettura è piuttosto focalizzata alla
valutazione preoperatoria,con excursus nella
dinamica operatoria (presunta almeno….)
• Ci si riferisce alla chir.noncardiaca

4. Critical Elements for Risk Stratification in
Patients Undergoing Noncardiac Surgery
• Risk-assessment tool must be accurate
• Predicts perioperative events (positive likelihood ratio 10)
• Predicts absence of perioperative events (negative likelihood
ratio 0.2)
• Risk-assessment tool must influence outcome
• Identifies subgroups in which surgery should be cancelled or
treatment changed
• Identifies subgroups that do or do not benefit from proven
therapy to reduce risk
• Risk-assessment tool must have a favorable harms–benefit
tradeoff

5. Cardiac Risk Index in Noncardiac Surgery
Criteria Finding
Age (yr) >70 5
Cardiac status MI within 6 mo 10
Ventricular gallop or jugular venous distention (signs of heart
failure)
11
Significant aortic stenosis 3
Arrhythmia other than sinus or premature atrial contractions 7
≥5 premature ventricular contractions/min 7
General medical condition Po2 < 60 mm Hg, Pco2 > 50 mm Hg, K < 3 mmol/L, HCO3 <20
mmol/L, BUN > 50 mg/dL, serum creatinine > 3 mg/dL, elevated
AST, a chronic liver disorder, or bedbound
3
Type of surgery needed Emergency surgery 4
Intraperitoneal, intrathoracic, or aortic surgery 3
*Risk is based on the total number of points:
Level I: 0–5
Level II: 6–12
Level III: 13–25
Level IV: >25
Adapted from Goldman L et al: Multifactorial index of cardiac risk in noncardiac surgical procedures. New
England Journal of Medicine 297:845–850, 1977.

6. Revised cardiac risk index(RCRI)
. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF,
Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L:
Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac
Risk of Major Noncardiac Surgery. Circulation 1999; 100: 1043-1049
• • High risk surgery
• – intraperitoneal, intrathoracic or
suprainguinal vascular procedures
• • Ischemic heart disease
• • H/O CHF
• • H/O Cerebrovascular disease
• • Insulin therapy for DM
• • Preop Cr>2.0mg/dl

7. • Circulation. 1999 Sep 7;100(10):1043-9. Links
• Derivation and prospective validation of a
simple index for prediction of cardiac risk of
major noncardiac surgery.
• Lee TH, Marcantonio ER, Mangione CM,
Thomas EJ, Polanczyk CA, Cook EF,
Sugarbaker DJ, Donaldson MC, Poss R, Ho KK,
Ludwig LE, Pedan A, Goldman L.
• Department of Medicine, Brigham and
Women's Hospital and Harvard Medical

8. • Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA,
Fleischmann KE, Fleisher LA, Froehlich JB, Gusberg RJ,
Leppo JA, Ryan T, Schlant RC, Winters WL, Jr., Gibbons
RJ, Antman EM, Alpert JS,Faxon DP, Fuster V,
Gregoratos G, Jacobs AK, Hiratzka LF, Russell RO, Smith
SC, Jr.: ACC/AHA guideline update for perioperative
cardiovascular evaluation for noncardiac surgery---
executive summary a report of the American College of
Cardiology/American Heart Association Task Force on
Practice Guidelines (Committee to Update the 1996
Guidelines on Perioperative Cardiovascular Evaluation
for Noncardiac Surgery). Circulation 2002;105: 1257-67

9. • Importance of Surgical Procedure
• The surgical procedure influences the extent of the preoperative
evaluation required by determining the potential range of changes
in perioperative management. There is little hard data to define the
surgery specific incidence of complications, and the rate may be
very institution depedendent. Eagle et. al. published data on the
incidence of perioperative myocardial infarction and mortality by
procedure for patients enrolled in the coronary artery surgery study
(CASS).6 Higher risk procedures for which coronary artery bypass
grafting reduced the risk of noncardiac surgery compared to
medical therapy include major vascular, abdominal, thoracic, and
orthopedic surgery. Ambulatory procedures denote low risk.
Vascular surgery represents a unique group of patients in whom
there is extensive evidence regarding preoperative testing and
perioperative interventions.

10. • Importance of exercise tolerance
• Exercise tolerance is one of the most important determinants of
perioperative risk and the need for invasive monitoring. If a patient
can walk a mile without becoming short of breath, than the
probability of extensive coronary artery disease is small.
Alternatively, if patients become dyspneic associated with chest
pain during minimal exertion, then the probability of extensive
coronary artery disease is high. Reilly and colleagues demonstrated
that the likelihood of a serious complication occurring was inversely
related to the number of blocks that could be walked or flights of
stairs that could be climbed.7 Exercise tolerance can be assessed
with formal treadmill testing or with a questionnaire that assesses
activities of daily living.

11. • Reilly DF, McNeely MJ, Doerner D, Greenberg
DL, Staiger TO, Geist MJ, Vedovatti PA, Coffey
JE, Mora MW, Johnson TR, Guray ED, Van
Norman GA, Fihn SD: Self-reported exercise
tolerance and the risk of serious perioperative
complications. Arch Intern Med 1999; 159:
2185-92

12. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman
WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jr., Jacobs
AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL,
Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B:
ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for
noncardiac surgery: focused update on perioperative beta-blocker therapy:
a report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines
on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in
collaboration with the American Society of Echocardiography, American Society of
Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular
Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and
Society for Vascular Medicine and Biology.
Circulation 2006; 113: 2662-74.

13. • Yang H, Raymer K, Butler R, Parlow J, Roberts R: The effects of perioperative beta-
blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized
controlled trial. Am Heart J 2006; 152: 983-90
• Juul AB, Wetterslev J, Gluud C, Kofoed-Enevoldsen A, Jensen G, Callesen T, Norgaard P,
Fruergaard K, Bestle M, Vedelsdal R, Miran A, Jacobsen J, Roed J, Mortensen MB,
Jorgensen L, Jorgensen J, Rovsing ML, Petersen PL, Pott F, Haas M, Albret R, Nielsen LL,
Johansson G, Stjernholm P, Molgaard Y, Foss NB, Elkjaer J, Dehlie B, Boysen K, Zaric D,
Munksgaard A, Madsen JB, Oberg B, Khanykin B, Blemmer T, Yndgaard S, Perko G, Wang
LP, Winkel P, Hilden J, Jensen P, Salas N: Effect of perioperative beta blockade in patients
with diabetes undergoing major non-cardiac surgery: randomised placebo controlled,
blinded multicentre trial. Bmj 2006; 332: 1482
• Wallace AW, Galindez D, Salahieh A, Layug EL, Lazo EA, Haratonik KA, Boisvert DM,
Kardatzke D: Effect of clonidine on cardiovascular morbidity and mortality after
noncardiac surgery. Anesthesiology 2004; 101: 284-93.
• Hindler K, Shaw AD, Samuels J, Fulton S, Collard CD, Riedel B: Improved postoperative
outcomes associated with preoperative statin therapy. Anesthesiology 2006; 105: 1260-
72.
Durazzo AE, Machado FS, Ikeoka DT, De Bernoche C, Monachini MC, Puech-Leao P,
Caramelli B: Reduction in cardiovascular events after vascular surgery with atorvastatin:
a randomized trial. J Vasc Surg 2004;39: 967-75

14. • (http://www.acc.org/qualityandscience/clinic
al/topic/topic.htm).

15. Key words
• perioperative risk
• cardiac risk,
• noncardiac surgery,
• intraoperative risk,
• postoperative risk,
• risk stratification,
• cardiac complication,
• cardiac evaluation,
• perioperative care,
• preoperative evaluation,
• preoperative assessment
• intraoperative complications.

16. Scopi della valutazione cardiaca preop
• 1)identificazione dei pazienti con rischio
cardiaco troppo alto,non accettabile
• 2)identificazione dei paz con malattia cardiaca
che possono essere migliorati o curati preop.
• 3)identificazione dei pazienti che possono
beneficiare di intervento di CABG

17. Come può la visita preop modificare il
trattamento?

18. Fattori che determinano il rischio
cardiaco periop
• Marcatori clinici
• Capacità funzionale
• Intervento chirurgico

19. I marcatori clinici
condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie:
• 1)instabilità coronarica;per esempio un MI recente o una
angina instabile o severa;
• 2)Insufficienza cardiaca scompensata;NYHA Classe IV o una
insufficienza in peggioramento o di nuova insorgenza;
• 3)aritmie significative;blocco AV di alto grado(Mobitz 2,BAV
3,aritmie ventricolari sintomatiche,aritmie sopraventricolari con
ritmo cardiaco non controllato,tachicardia
sintomatica,tachicardia ventricolare di nuova scoperta.
• 4)malattia valvolare severa,cioè stenosi aortica serrata o stenosi
mitralica sintomatica.

20. • The overriding theme of this document is that intervention is rarely
necessary to simply lower the risk of surgery unless such
intervention is indicated irrespective of the preoperative context.
• The purpose of preoperative evaluation is not to give medical
clearance but rather to perform an evaluation of the patient’s
current medical status; make recommendations concerning the
evaluation, management, and risk of cardiac problems over the
entire perioperative period; and provide a clinical risk profile that
the patient, primary physician, and nonphysician caregivers,
anesthesiologist, and surgeon can use in making treatment
decisions that may influence short- and long-term cardiac
outcomes.
• No test should be performed unless it is likely to influence patient
treatment.
• The goal of the consultation is the optimal care of the patient

21. Condizioni associate ad alto rischio per
complicanze cardiovascolari
perioperatorie
• Presenza dei fattori predittivi di aumentato
rischio cardiovascolare periop
• Scarsa capacità funzionale(<4 MET)
• Chirurgia ad alto rischio (rischio
cardiovascolare periop > 5%)

22. Active Cardiac Conditions for Which the Patient
Should Undergo Evaluation and Treatment Before Noncardiac
Surgery (Class I, Level of Evidence: B):major clinical predictors

23. Estimated Energy Requirements for Various Activities

24. MET: equivalenti energetici
indice delle possibilità energetiche per varie attività
• scaletta dei MET :risposta a domande semplici,quali:
• sei in grado di avere cura di te stesso?mangiare,bere,usare la toilette(MET 1)?;
• puoi camminare in casa (MET 2) ;
• puoi camminare 100-200m in piano alla velocità di 3-4.5 Km/h?(Met 3);
• puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti?(MET 4);
• puoi salire una rampa di scale o in salita?o camminare in piano a 6,5 Km/h o
correre per una breve distanza?(Met 5).
• Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere
mobilio pesante(Met 6-7)?
• Puoi partecipare a attività ricreative leggere come giocare a golf,a
bocce,ballare,giocare a tennis in doppio,o lanciare la palla a baseball o
calcio(MET 8-9)?
• Puoi partecipare a sport pesanti come il nuoto,tennis in
singolo,calcio,pallacanestro o sci?(Met 10).

25. Cardiac evaluation and care algorithm for noncardiac surgery based on active
clinical conditions, known cardiovascular disease,
or cardiac risk factors for patients 50 years of age or greater. *

26. • See Table 2 for active clinical conditions.
• †See Table 3 for estimated MET level equivalent.
‡Clinical risk factors include ischemic heart disease,
compensated or prior HF, diabetes mellitus, renal
insufficiency, and cerebrovascular disease. §Consider
perioperative beta blockade (see Table 11) for
populations in which this has been
shown to reduce cardiac morbidity/mortality.
ACC/AHA indicates American College of
Cardiology/American Heart Association; HR,
heart rate; LOE, level of evidence; and MET,
metabolic equivalent

27. La stratificazione chirurgica degli interventi dal punto di
vista del rischio cardiaco
• rischio di MI o morte cardiaca superiore al 5%:
– chirurgia vascolare maggiore(aortica) e quella periferica;
• a rischio intermedio ,compreso fra 1 e 5%:
la chirurgia intraperitoneale ed intratoracica
endoarterectomia carotidea
chirurgia della testa e del collo
chirurgia ortopedica maggiore
chir prostatica.
• rischio minore,inferiore all’1% :
– procedure endoscopiche,
– superficie corporea
– chirurgia per cataratta
– Chir mammaria.

28. Cardiac Risk* Stratification for Noncardiac
Surgical Procedures

29. Scopi dei test aggiuntivi
cardiovascolari
• Fornire una misura obbiettiva di capacità
funzionale
• Identificare una ischemia preop miocardica
importante
• Diagnosticare aritmie cardiache rilevanti
• Stimare il rischio cardiaco periop e definire una prognosi

31. Dipiridamolo tallio
• the presence of a redistribution defect on
dipyridamole thallium imaging in patients
undergoing peripheral vascular surgery is
predictive of postoperative cardiac events. In
order to increase the predictive value of the
test, several strategies have been suggested.
Lung uptake, left ventricular cavity dilation,
and redistribution defect size have all been
shown to be predictive of subsequent
morbidity.10

32. Dobutamine stress test
• Dobutamine stress echocardiography has been suggested as the best
preoperative test in several recent meta-analyses.11 The appearance of
new or worsened regional wall motion
abnormalities is considered a positive test. The
advantage of this test is that it is a dynamic assessment of ventricular
function. Dobutamine echocardiography has also been studied and was
found to have among the best positive and negative predictive values.
Poldermans et al. demonstrated that the group at greatest risk were those
who demonstrated regional wall motion abnormalities at low heart rates.12
The presence of 5 or more segments of new regional wall motion
abnormalities denotes a high risk group who did not benefit from
perioperative beta blockade in one trial.13 Beattie and colleagues
performed a meta-analysis of stress echocardiography versus thallium
imaging and demonstrate that stress echocardiography has better negative
predicative characteristics.11 A moderate-to-large perfusion defect by
either test predicted postoperative MI and death

33. Noninvasive Stress Testing
Recommendations for Noninvasive Stress Testing Before
Noncardiac Surgery
• CLASS I
• 1. Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be
evaluated and treated per ACC/AHA guidelines† before noncardiac surgery. (Level of Evidence: B)
• CLASS IIa
• 1. Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity
(less than 4 METs) who require vascular surgery‡ is reasonable if it will change management. (Level of
Evidence: B)
• CLASS IIb
• 1. Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor
functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change
management. (Level of Evidence: B)
• 2. Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good
functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery. (Level of
Evidence: B)
• CLASS III
• 1. Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk
noncardiac surgery. (Level of Evidence: C)
• 2. Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery. (Level of Evidence:
C)

34. Razionale dei test non invasivi preop
nella valutazione del rischio
Test non invasivi Paz con valori del
test anormali
Valori predittivi per morte o MI periop
Positivo : negativo
Monitoraggio ECG
ambulat
9-39% 4-15 1-16
Esercizio con
monitoraggio ECG
16-70% 5-25 90-100
Dipiridamolo-tallio
Chir vasc 22-69 4-20 95-100
Chir non vasc 23-47 8-27 98-100
Eco cardio grafia
stress dobutamina
23-50 7-23 93-100

35. EF preop e outcome cardiaco postop.
(Franco et al,J Vasc Surg 10;656:1989)
EF>55%
N=50
EF 35-55%
N=20
EF 20-35%
N=15
MI 19% 15% 20%
Morte 0 0 13%

36. Chir vasc dopo
precedente
rivascolarizzazio
ne
Chir vascolare
senza prec
edente
rivascolarizzazio
ne
Complicazioni % Mortalità % Complicazioni % Mortalità %
angiografia 0.2-0.5 0.1-0.5 - -
PTCA/CABG 3-13 1-5.5 - -
Chir vasc 0.3-2 0.3-0.4 0.6-11.7 0.6-10
Rischio globale 3.5-10.5 1.4-12.4 0.6-11.7 0.8-10
Ma…….. Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate
Diminuiscono il rischio
cardiovascolare a lungo termine
Aumentano il rischio cardiaco a
lungo termine
Rischio globale a ?? ??

37. Outcome cardiaco per chirurgia
maggiore non cardiaca Eagle et al,Circulation 1997 96
1892-7
N=395
N=582
N=964

38. Cardiac outcome in low risk
surgery:n=1297

39. Incidenza di mortalità periop in
pazienti con CAD(n=1632) Eagle et al
High risk surgery >=4% Low risk surgery<=4%
Abdominal 4% Urologic 1.8
Vascolare 11.3 Orthopedic 1.2
Thoracic 7.7 Skin 0
Head neck 7.3 Miscellaneous 3

40. Cardiac outcome in noncardiac surgery
following CABG

41. Class I indications for preop coronary
angiography in non cardiac surgery
• High risk results during non invasive testing
• Amgina pectoris unresponsive to adequate
medical therapy
• Most patients with unstable angina pectoris
• Nondiagnostic or equivocal noninvasive test
result in a high risk patient undergoing a high
risk noncardiac surgical procedure

42. Proposed approach to the management of patients with previous
percutaneous coronary intervention (PCI) who require noncardiac
surgery, based on expert opinion

43. BETA BLOCCANTI E CHIRURGIA
NON CARDIACA

44. Perioperative Beta-Blocker Therapy
Recommendations for Beta-Blocker Medical Therapy
• CLASS I
• 1. Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina,
symptomatic arrhythmias, hypertension, or other ACC/AHA class I guideline indications. (Level of Evidence: C)
• 2. Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the
finding of ischemia on preoperative testing. (Level of Evidence: B)
• CLASS IIa
• 1. Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative
assessment identifies CHD. (Level of Evidence: B)
• 2. Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery
identifies high cardiac risk, as defined by the presence of more than 1 clinical risk factor.* (Level of Evidence: B)
• 3. Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high
cardiac risk, as defined by the presence of more than 1 clinical risk factor,* who are undergoing intermediate-risk or
vascular surgery. (Level of Evidence: B)
• CLASS IIb
• 1. The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or
vascular surgery, in whom preoperative assessment identifies a single clinical risk factor.* (Level of Evidence: C)
• 2. The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who
are not currently taking beta blockers. (Level of Evidence: B)
• CLASS III
• 1. Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta
blockade. (Level of Evidence: C)

45. Indicazioni ai beta bloccanti
• i betabloccanti devono essere continuati nel periop per coloro che li assumono
per indicazione di angina,aritmie sitomatiche,ipertensione o altre indicazioni
delle linee guida ACC/AHA di classe I.
• i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad
alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza
B).
• I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia
vascolare nei quali la valutazione preop identifichi coronaropatia e/o un elevato
rischio cardiaco ,definito come la presenza di più di 1 fattore di rischio clinico
,anche se vanno incontro a chirurgia classificata come rischio intermedio .
• l’utilità dei betabloccanti rimane incerta in pazienti candidati a chirurgia di
rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di
evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non
stanno assumendo i farmaci( Livello di evidenza B).
• Ovviamente i betabloccanti non devono essere somministrati a coloro che
presentano controindicazioni assolute al loro impiego.
• In conclusione dosaggi terapeutici di betabloccanti devono essere
utilizzati in pazienti ad alto-intermedio rischio cardiaco

46. Bisoprolol and perioperative cardiac
outcome Poldermans et al NEJM 1999;341;1789-94
Bisoprolol n=59 Standard care n=53
Cardiac death 2(3,4%) 9(17%) *
Non fatal MI 0 9(17%) **
Total 2(3.4%) 18(34%) **
*=p<0.02 **=p<0.01

47. • N Engl J Med. 1999 Dec 9;341(24):1789-94.
Links
• Comment in:
N Engl J Med. 1999 Dec 9;341(24):1838-40.
N Engl J Med. 2000 Apr 6;342(14):1051-2; author r
N Engl J Med. 2000 Apr 6;342(14):1052; author rep
Rev Cardiovasc Med. 2001 Winter;2(1):25-6.
The effect of bisoprolol on perioperative
mortality and myocardial infarction in high-
risk patients undergoing vascular surgery.

48. Weksler N, Klein M, Szendro G, Rozentsveig V, Schily M, Brill S,
Tarnopolski A, Ovadia L, Gurman GM: The dilemma of immediate
preoperative hypertension: to treat and operate, or to postpone
surgery? J Clin Anesth 2003; 15: 179-83
• There is a great deal of debate regarding a trigger to delay or cancel a
surgical procedure in a patient with poorly or untreated hypertension
• In the absence of end-organ changes, such as renal
insufficiency or left ventricular hypertrophy with strain, it
would seem appropriate to proceed with surgery.
• A randomized trial of treated hypertensive patients without known
CAD who presented the morning of surgery with an elevated diastolic
blood pressure was unable to demonstrate any difference in
outcome between those who were actively treated versus those in
whom surgery was delayed.
• In contrast, a patient with a markedly elevated blood pressure and the new
onset of a headache should have surgery delayed for further evaluation and
potential treatment..

49. Howell SJ, Sear YM, Yeates D, Goldacre M, Sear JW, Foëx P.
Hypertension, admission blood pressure and perioperative
cardiovascular risk. Anaesthesia 1996;51:1000-1004.
• A retrospective case-controlled study which
found that a history of hypertension was an
important predictor for perioperative cardiac
death but not admission blood pressure.
• The study implies that end-organ damage
resulting from hypertension is the likely villain
in this group of patients.

50. • In the absence of major contraindications
therapeutic dosages of beta adrenergic
antagonists should be given to patients with
an intermediate or high risk of cardiac
complications

51. • Adrenergic Receptor Genotype but Not
Perioperative
• Bisoprolol Therapy May Determine Cardiovascular
Outcome
• in At-risk Patients Undergoing Surgery with Spinal
Block
• The Swiss Beta Blocker in Spinal Anesthesia (BBSA)
Study: A Double-blinded,
• Placebo-controlled, Multicenter Trial with 1-Year
Follow-up
• Michael Zaugg, M.D.,* Lukas Bestmann, Ph.D.,†

52. Periop statin therapy
• Recommendations for Statin Therapy
• CLASS I
• 1. For patients currently taking statins and scheduled for
noncardiac surgery, statins should be continued. (Level of
Evidence: B)
• CLASS IIa
• 1. For patients undergoing vascular surgery with or without
clinical risk factors, statin use is reasonable. (Level of
Evidence: B)
• CLASS IIb
• 1. For patients with at least 1 clinical risk factor who are
undergoing intermediate-risk procedures, statins may be
considered. (Level of Evidence: C)

53. terapia preoperatoria con statine
• La terapia preoperatoria con statine deve essere
continuata per coloro che le assumono già (livello
di evidenza B);
• la loro somministrazione è ragionevole per i
candidati a chirurgia vascolare con o senza fattori
di rischio clinici (livello di evidenza B):
• Le statine possono essere prese in considerazione
per i pazienti con almeno 1 fattore di rischio clinico
candidati a chirurgia di rischio intermedio (livello
di evidenza C)

54. • usinSchouten, Olaf MD a; Poldermans, Don MD, PhD b; Visser, Loes MD b;
Kertai, Miklos D. MD c; Klein, Jan MD, PhD b; van Urk, Hero MD, PhD a;
Simoons, Maarten L. MD, PhD c; van de Ven, Louis L. MD, PhD c;
Vermeulen, Maarten MSc c; Bax, Jeroen J. MD, PhD d; Lameris, Thomas
W. MD, PhD c; Boersma, Eric PhD c Fluvastatin and bisoprolol for the
reduction of perioperative cardiac mortality and morbidity in high-risk
patients undergoing non-cardiac surgery: Rationale and design of the
DECREASE-IV study. American Heart Journal. 148(6):1047-1052,
December 2004

55. Eur J Vasc Endovasc Surg. 2004 Oct;28(4):343-52. Links
A combination of statins and beta-blockers is independently associated with a reduction in
the incidence of perioperative mortality and nonfatal myocardial infarction in patients
undergoing abdominal aortic aneurysm surgery.
Kertai MD, Boersma E, Westerhout CM, Klein J, Van Urk H, Bax JJ, Roelandt JR, Poldermans D
.
• Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands.
• OBJECTIVE: To investigate the combined beneficial effect of statin and beta-blocker use on perioperative
mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA).
BACKGROUND: Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine
stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite
the use of beta-blockers. METHODS: We studied 570 patients (mean age 69+/-9 years, 486 males) who
underwent AAA-surgery between 1991 and 2001 at the Erasmus MC. Patients were evaluated for clinical risk
factors (age>70 years, histories of MI, angina, diabetes mellitus, stroke, renal failure, heart failure and
pulmonary disease), DSE, statin and beta-blocker use. The main outcome was a composite of perioperative
mortality and MI within 30 days of surgery. RESULTS: Perioperative mortality or MI occurred in 51 (8.9%)
patients. The incidence of the composite endpoint was significantly lower in statin users compared to
nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence interval (CI): 0.13-0.74; p=0.01). After
correcting for other covariates, the association between statin use and reduced incidence of the composite
endpoint remained unchanged (OR: 0.24, 95% CI: 0.10-0.70; p=0.01). Beta-blocker use was also associated
with a significant reduction in the composite endpoint (OR: 0.24, 95% CI: 0.11-0.54). Patients using a
combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across
multiple cardiac risk strata; particularly patients with 3 or more risk factors experienced significantly lower
perioperative events. CONCLUSIONS: A combination of statin and beta-blocker use in patients with AAA-
surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in
patients at the highest risk.

56. Eur J Vasc Endovasc Surg. 2004 Oct;28(4):343-52. Links
A combination of statins and beta-blockers is independently associated with a
reduction in the incidence of perioperative mortality and nonfatal myocardial
infarction in patients undergoing abdominal aortic aneurysm surgery.
Kertai MD, Boersma E, Westerhout CM, Klein J, Van Urk H, Bax JJ, Roelandt JR,
Poldermans D.
• 570 pazienti sottoposti a chirurgic dell’aorta addominale
• Perioperative mortality or MI occurred in 51 (8.9%) patients.
• Perioperative mortality or MI significantly lower in statin users compared
to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence
interval (CI): 0.13-0.74; p=0.01).
• Beta-blocker use was also associated with a significant reduction in the
composite endpoint (OR: 0.24, 95% CI: 0.11-0.54).
• Patients using a combination of statins and beta-blockers appeared to be
at lower risk for the composite endpoint across multiple cardiac risk strata;
particularly patients with 3 or more risk factors experienced
significantly lower perioperative events. CONCLUSIONS: A
combination of statin and beta-blocker use in patients with AAA-surgery is
associated with a reduced incidence of perioperative mortality and
nonfatal MI particularly in patients at the highest risk.
•

57. • Attenzione però che è necessario che il beta
bloccante sia effettivamente efficace nel
controllare la FC;infatti solo se la FC rimane <
100 bpm se ne dimostra l’efficacia………….

58. Anesth Analg 2008;106:1039 –48, Beattie WS,
Wijeysundera DN, Karkouti K, McCluskey S, Tait G.)
• Metanalisi:molti degli studi sull’argomento sono estremamente
eterogenei e solo quando la massima frequenza cardiaca
misurata era inferiore a 100 bpm, si aveva un significativo
effetto protettivo (OR 0.23; 95% CI 0.08–0.65; P=0.005), mentre
quando questo target non era raggiunto non vi era alcuna
efficacia dimostrabile (OR 1.17; 95% CI 0.79–1.80; P=0.43)
• Inoltre, con l’utilizzo di una meta-regressione si dimostra
un’associazione lineare tra l`effetto del Bbloccante sulla
frequenza cardiaca (media, massima, e sulla sua variazione) e
l`incidenza di IM (r2=0.63; P=0.001), dove una maggiore efficacia
del Bbloccante era associato ad una riduzione di incidenza di IM
postoperatorio

59. Anesthesiology. 2004 Aug;101(2):284-93.Effect of clonidine on
cardiovascular morbidity and mortality after noncardiac surgery.
Wallace AW, Galindez D, Salahieh A, Layug EL, Lazo EA, Haratonik KA,
Boisvert DM, Kardatzke D.
• Department of Anesthesia and Perioperative Care, University of California, USA.
awallace@cardiacengineering.com
• BACKGROUND: Perioperative myocardial ischemia occurs in 20-40% of patients at risk for cardiac
morbidity and is associated with a ninefold increase in risk of cardiac morbidity. METHODS: In a
prospective, double-blinded, clinical trial, we studied 190 patients with or at risk for coronary artery
disease in two study groups with a 2:1 ratio (clonidine, n = 125 vs. placebo, n = 65) to test the
hypothesis that prophylactic clonidine reduces the incidence of perioperative myocardial ischemia and
postoperative death in patients undergoing noncardiac surgery. Clonidine (0.2 mg orally as well as a
patch) or placebo (tablet and patch) was administered the night before surgery, and clonidine (0.2 mg
orally) or placebo (tablet) was administered on the morning of surgery. The patch or placebo remained
on the patient for 4 days and was then removed. RESULTS: The incidence of perioperative myocardial
ischemia was significantly reduced with clonidine (intraoperative and postoperative, 18 of 125, 14%
vs. placebo, 20 of 65, 31%; P = 0.01). Prophylactic clonidine administration had minimal hemodynamic
effects. Clonidine reduced the incidence of postoperative mortality for up to 2 yr (clonidine, 19 of 125
[15%] vs. placebo, 19 of 65 [29%]; relative risk = 0.43 [confidence interval, 0.21-0.89]; P = 0.035).
CONCLUSIONS: Perioperative administration of clonidine for 4 days to patients at risk for coronary
artery disease significantly reduces the incidence of perioperative myocardial ischemia and
postoperative death.

60. Wallace AW, Galindez D, Salahieh A, Layug EL, Lazo EA, Haratonik KA, Boisvert DM,
Kardatzke D .Effect of clonidine on cardiovascular morbidity
andmortality after noncardiac surgery.Anesthesiology. 2004
Aug;101(2):284-93.

61. Long term protection offered by 4 days of
perioperative clonidine in patients at risk of CAD

62. • Am J Med. 2009 Jan 28. [Epub ahead of print]
Links
• Perioperative Beta-blockers for Major
Noncardiac Surgery: Primum Non Nocere.
• Chopra V, Plaisance B, Cavusoglu E,
Flanders SA, Eagle KA.
• Division of General Medicine, Department of
Internal Medicine, University of Michigan
Health System, Ann Arbor.

63. • Lancet. 2008 Dec 6;372(9654):1962-76. Epub
2008 Nov 13. Links
• Comment in:
Lancet. 2008 Dec 6;372(9654):1930-2.
Perioperative beta blockers in patients
having non-cardiac surgery: a meta-analysis.
• Bangalore S, Wetterslev J, Pranesh S,
Sawhney S, Gluud C, Messerli FH.
• Division of Cardiology, Brigham and Women's
Hospital, Boston, MA, USA.

64. • Anesth Analg. 2007 Jan;104(1):27-41. Links
• Comment in:
Anesth Analg. 2007 Jan;104(1):1-3.
Perioperative beta-blockers for preventing
surgery-related mortality and morbidity: a
systematic review and meta-analysis.
• Wiesbauer F, Schlager O, Domanovits H,
Wildner B, Maurer G, Muellner M,
Blessberger H, Schillinger M.
• Department of Cardiology, Vienna General

65. • Diabetics share the same risks as patients with
cardiac ischemia,renal insufficiency or
cerebrovascular atherosclerotic
disease***(42 Haffner

66. • Risks of the diabtiecs;autonomic dysfunction
• Difficult intubation………..see lavoro Nova pub

67. • Anesth Analg. 2008 Dec;107(6):1919-23. Links
• The extended Mallampati score and a
diagnosis of diabetes mellitus are predictors
of difficult laryngoscopy in the morbidly
obese.
• Mashour GA, Kheterpal S, Vanaharam V,
Shanks A, Wang LY, Sandberg WS,
Tremper KK.
• Department of Anesthesiology, University of
Michigan Medical School, Ann Arbor,

68. • J Postgrad Med. 2000 Apr-Jun;46(2):75-9.
Links
• The palm print as a sensitive predictor of
difficult laryngoscopy in diabetics: a
comparison with other airway evaluation
indices.
• Vani V, Kamath SK, Naik LD.
• Department of Anaesthesiology, Seth G. S.
Medical College and K. E. M. Hospital, Parel,
Mumbai - 400 012, India.

69. • : Anesth Analg. 1998 Mar;86(3):516-9. Links
• Diabetes mellitus and difficult laryngoscopy
in renal and pancreatic transplant patients.
• Warner ME, Contreras MG, Warner MA,
Schroeder DR, Munn SR, Maxson PM.
• Department of Anesthesiology, Mayo Clinic
and Foundation, Rochester, Minnesota 55905,
USA.
• Limited mobility of the cervical spine or

70. • (44) while : Anesth Analg. 1998 Mar;86(3):516-9. Links
• Diabetes mellitus and difficult laryngoscopy in renal and pancreatic transplant patients.
• Warner ME, Contreras MG, Warner MA, Schroeder DR, Munn SR, Maxson PM.
• Department of Anesthesiology, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA.
• Limited mobility of the cervical spine or temperomandibular joint may contribute to increased difficulty of laryngoscopy in patients who have severe diabetes mellitus.
The frequency of difficult laryngoscopy in diabetics undergoing renal and/or pancreatic transplants has been reported to be as high as 32%. We retrospectively
reviewed the anesthetic records of all adult patients who underwent renal and/or pancreatic transplant and endotracheal intubation from January 1, 1985 to October
31, 1995. Characteristics specifically reviewed included the presence of diabetes mellitus, type of organ donor, age, gender, body mass index, previous difficult
laryngoscopy, known characteristics potentially related to difficult laryngoscopy, and degree of difficulty with laryngoscopy. Laryngoscopy was graded as easy,
minimally to moderately difficult, and moderately to extremely difficult to perform. Factors associated with any degree of difficult intubation were univariately
assessed by using Fisher's exact test. Of 725 patients, 15 (2.1%) were identified as having difficult laryngoscopies, although all underwent successful endotracheal
intubations. Factors associated with difficult laryngoscopy were diabetes mellitus (P = 0.002) and characteristics known to be related to difficult laryngoscopy (P =
0.02). These findings confirm an increase in the frequency of difficult laryngoscopy in diabetic patients undergoing renal and/or pancreatic transplant, although no
laryngoscopies were rated as moderately to extremely difficult. We conclude that the frequency of difficult laryngoscopy in these diabetic patients is much lower than
previous reports have suggested. IMPLICATIONS: Previous studies have suggested that airway management of many diabetic patients may be difficult. Our medical
record review of patients with severe diabetes undergoing organ transplants showed that extraordinary techniques were not required to successfully manage their
airways.
• Difficult Laryngoscopy and
• Diabetes Mellitus
• Key Words: INTUBATION, TRACHEAL-diabetes
• and COMPLICATIONS, DIABETES MELLITUS.
• METABOLISM, DIABETES MELLITUS.
• To the Editor:
• Like the authors, we too were surprised by the extremely
• high incidence (32!%) of difficult laryngoscopy in diabetic
• renal transplant patients reported by Hogan et al. (1). They
• suggested that "stiff joint syndrome," a condition occasionally
• seen in type I insulin-dependent diabetics, may have
• been a major cause of this finding. Because their results
• were so striking, we investigated the incidence of difficult
• laryngoscopy and intubation in similar patients at our
• institution.

71. Heart failure as a risk factor

72. Hammill BG,Curtis,LH,Bennett-Guerrior E,O’Connor,CM,Jollis
JC,Schulman KA,Hernandez AF.Impact of heart failure on patients
undergoing major noncardiac surgery.Anesthesiology 2008;108:559-
67
• Medicare 5% standard analytic files
• Inpatients fee for service claims 2000-20004
• Patients >65 for major noncardiac surgery:
– Carotid endarterectomy
– Lower extr bypass
– Open AAA
– Hip replacement
– Knee replacement
– Spinal fusion
– Above and below knee amputation
– Open and laparoscopic cholecystectomy
– Cancer resection abdominal,lung,colon

73. Hammill et al.Impact of heart failure on patients
undergoing major noncardiac surgery.Anesthesiology
• Main outcome :
– Operative mortality
– 30 days readmission

74. Hammill et al. Impact of heart failure on patients undergoing
major noncardiac surgery.Anesthesiology 2008;108(4): 559-567
• I pazienti di età ≥65 anni
• inseriti nel programma assicurativo statunitense Medicare
• sottoposti, tra il 2000 e il 2004, ad uno tra tredici tipi di chirurgia maggiore non-
cardiaca.
• esclusi dall’analisi i pazienti con insufficienza renale terminale e quelli che non
avessero soddisfatto, da almeno un anno, i criteri Medicare® per la sottoscrizione
di una polizza.
• 159.327 interventi,: 18% eseguiti in pazienti con insufficienza cardiaca e il 34% in
pazienti con cardiopatia ischemica.
• I rischi relativi corretti di mortalità e riammissione per i pazienti con insufficienza
cardiaca, rispetto a quelli che non presentavano né insufficienza cardiaca né
cardiopatia ischemica, erano 1.63 (intervallo confidenza 95%: 1.52-1.74) e 1.51
(intervallo confidenza 95%: 1.45-1.58), rispettivamente.
• I rischi relativi corretti di mortalità e riammissione per i pazienti con cardiopatia
ischemica, rispetto a quelli che non presentavano né insufficienza cardiaca né
cardiopatia ischemica, erano 1.08 (intervallo confidenza 95%: 1.01-1.16) e 1.16
(intervallo confidenza 95%: 1.12-1.20), rispettivamente.

75. Characteristics of the study population by disease group
heart
faliure Cad normal
età 79,4 75,3 75,6
Masch i% 42 48,8 34,4
nerii% 8,5 5,2 5,6
teaching hospitali% 16,9 19,7 16,3
admitted form a skilled nursing
facilityi% 1,5 0,4 0,4
urgent admissioni% 19,2 13,8 14,5
emergent admissionji% 30 19 16,7
COPDi% 45,1 31,1 22,2
CADi% 81 100 0
dementiai% 9,1 5,1 4,1
diabetesi% 43,4 30,5 19,6
histrory of strokei% 26,9 21,5 11,4
hypertensioni% 86,4 82,4 66,8
periph vasc.diseasei% 46,3 36,3 17,9
renal diseasei% 15,2 5,2 2,7

76. Operative mortality
HF CAD normal
total 8 3,1 2,4
> Knee amput 25.8 18 16
<knee amput 12.8 10.4 7.2
Carotid endarterec tomy 2,5 1,2 0,9
Colon cancer resection 11.9 6.3 5.4
Hip replacement 8.4 3.9 2.8
Knee replacement 0.9 0.4 0.3
Laparoscopic
cholecystectomy
5.6 2.1 1.8
Lower extremity bypass 8.1 3.7 4.1
Open AAA repair 10.3 5.8 4.8
Other abdominal cancer
resections
11.8 4.3 4.9
Pulmonary cancer
resection
10.2 6.0 4.1

77. 30 day readmission
HF CAD normal
total 17.1 10.8 8.1
> Knee amput 25.2 21.6 18.9
<knee amput 24.1ns 23.4ns 19.9 ns
Carotid endarterectomy 15.2 10.8 8.7
Colon cancer resection 18 13.2 10.5
Hip replacement 16.6 10.3 8.8
Knee replacement 9.9 6.2 4.7
Laparoscopic
cholecystectomy
16.4 10.1 8.4
Lower extremity bypass 27.2 18.2 16.2
Open AAA repair 14.8 10.3 11.4
Other abdominal cancer
resections
17.3 12.6 11.8
Pulmonary cancer
resection
17.4 15.5 11.3
Spinal fusion

78. Effect of heart failure and CAD on mortality per procedure

79. Operative mortality and readmission rate for HF patients with or
without CAD

80. Conclusion from the study of Hammil et al
• Heart Failure patients :
–mortality risk 63%
–Readmission risk 51%

81. Hernandez AF, Whellan DJ, Stroud S, Sun JL, O’Connor CM, Jollis JG.
Outcomes in heart failure patients after major noncardiac surgery. J
Am Coll Cardiol. 2004;44(7):1446-1453
• OBJECTIVES: The purpose of this study was to evaluate mortality and
readmission rates of heart failure (HF) patients after major noncardiac surgery.
BACKGROUND: There is a lack of generalizable outcome data on HF patients
undergoing major noncardiac surgery because previous studies have been
limited to a few academic centers or have not focused on this group of
patients. METHODS: Using the 1997 to 1998 Standard Analytic File 5% Sample
of Medicare beneficiaries, we identified patients with HF who underwent major
noncardiac surgery. A multivariable logistic regression model was used to
provide adjusted mortality and readmission rates in patients after noncardiac
surgery. Patients with coronary artery disease (CAD) and all other remaining
patients (Control) who had similar surgery served as reference groups.
RESULTS: Of 23,340 HF patients and 28,710 CAD patients, 1,532 (6.56%) HF
patients and 1,757 (6.12%) CAD patients underwent major noncardiac surgery.
There were 44,512 patients in the Control group with major noncardiac
surgery. After accounting for demographic characteristics, type of surgery, and
comorbid conditions, the risk-adjusted operative mortality (death before
discharge or within 30 days of surgery) was HF 11.7%, CAD 6.6%, and Control

82. PHILLIPS, FRANKLIN A. MICHOTA,W. H. WILSON TANG,
CHRISTOPHER M. WHINNEY, ASHOK PANNEERSELVAM, ERIC D.
HIXSON,MARIO GARCIA, GARY S. FRANCIS, AMIR K. JAFFER.
Outcomes of Patients With Stable Heart Failure Undergoing
Elective Noncardiac Surgery.Mayo Clin Proc. 2008;83(3):280-
288
• il rischio operatorio viene minimizzato dalla
ottimizzazione preoperatoria effettuata dal servizio
di medicina interna ,con abbattimento notevole della
mortalità e morbilità :solo la sopravvivenza ad un
anno è ridotta rispetto ai pazienti di controllo,come è
logico attendersi in ogni caso in pazienti portatori di
malattia cronica seria.

83. YE OLIVIA XU-CAI, DANIEL J. BROTMAN, CHRISTOPHER O. PHILLIPS, FRANKLIN A. MICHOTA,W. H. WILSON TANG,
CHRISTOPHER M. WHINNEY, ASHOK PANNEERSELVAM, ERIC D. HIXSON,MARIO GARCIA, GARY S. FRANCIS, AMIR
K. JAFFER. Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac Surgery.Mayo Clin
Proc. 2008;83(3):280-288

84. Postop survival time of HF patients after noncardiac major surgeryYE
OLIVIA XU-CAI, DANIEL J. BROTMAN, CHRISTOPHER O. PHILLIPS, FRANKLIN A. MICHOTA,W. H. WILSON TANG, CHRISTOPHER M.
WHINNEY, ASHOK PANNEERSELVAM, ERIC D. HIXSON,MARIO GARCIA, GARY S. FRANCIS, AMIR K. JAFFER. Outcomes of Patients
With Stable Heart Failure Undergoing Elective Noncardiac Surgery.Mayo Clin Proc. 2008;83(3):280-288

86. YE OLIVIA XU-CAI, DANIEL J. BROTMAN, CHRISTOPHER O. PHILLIPS, FRANKLIN A.
MICHOTA,W. H. WILSON TANG, CHRISTOPHER M. WHINNEY, ASHOK PANNEERSELVAM,
ERIC D. HIXSON,MARIO GARCIA, GARY S. FRANCIS, AMIR K. JAFFER. Outcomes of
Patients With Stable Heart Failure Undergoing Elective Noncardiac Surgery.Mayo Clin
Proc. 2008;83(3):280-288
• Our data suggest that perioperative mortality is surprisingly low
(<2%) in patients with clinically stable HF— regardless of EF—
undergoing elective noncardiac surgery.
• At 1 year, crude mortality rates for patients with HF with reduced
EF (13.5%) or with preserved EF (6.3%) were significantly higher
than for controls (3.1%). However, we found no evidence to suggest
that the immediate postoperative period was associated with a
significantly higher risk of death than the subsequent months. This
raises the possibility that the long-term postoperative mortality
rate that we observed in the patients with HF, particularly those
with low EF, represents the background mortality expected in
patients with chronic illnesses.
• Our findings contrast with previous studies that have focused on
the perioperative outcomes of patients with HF

87. Perioperative mortality and 30 days readmission rate
for patients with HF operated for noncardiac surgery
Preoperative evaluation at the
Internal
Medicine Preoperative
Assessment Consultation and T
reatment (IMPACT)
Center at the Cleveland Clinic

88. Unrecognized MI and silent myocardial
ischemia
• Unrecognized MI:, determined by rest wall motion
abnormalities in the absence of a history of MI.
• Silent myocardial ischemia ;stress-induced wall motion
abnormalities in the absence of angina pectoris
• 23 and 28% respectiverly in pts undergoing
major vascular surgery!
– Feringa HH, Karagiannis SE, Vidakovic R, Elhendy A, ten Cate FJ, Noordzij PG,
van Domburg RT, Bax JJ, Poldermans D. The prevalence and prognosis
of unrecognized myocardial infarction and silent myocardial
ischemia in patients undergoing major vascular surgery. Coron
Artery Dis. 2007 Nov;18(7):571-6.

89. .N-TERMINAL PRO-BRAIN NATRIURETIC PEPTIDE
.ENDOGENOUS NITRIC OXIDE SYNTHASE INHIBITOR
ASYMMETRIC DIMETHYLARGININE
. POLYMORPHISMS IN PLATELET GLYCOPROTEIN
(GP) IIIA AND GPIB[ALPHA]
Laboratory markers for cardiac risk
after noncardiac surgery

90. Laboratory markers for cardiac risk after noncardiac surgery
• Elevated NT-proBNP levels are independently associated with an increase in the risk
of perioperative cardiovascular KO
– Yun KH, Jeong MH, Oh SK, Choi JH, Rhee SJ, Park EM, Yoo NJ, Kim NH, Ahn YK, Jeong JW.Preoperative plasma N-terminal pro-brain natriuretic
peptide concentration and perioperative cardiovascular risk in elderly patients.Circ J.2008 Feb;72(2):195-9.
– Leibowitz D, Planer D, Rott D, Elitzur Y, Chajek-Shaul T, Weiss ATBrain natriuretic peptide levels predict
perioperative events in cardiac patients undergoing noncardiac surgery: a prospective study.
Cardiology. 2008;110(4):266-70. Epub 2007 Dec 12.
• per 0.1-micromol/L increment in plasma ADMA
concentration, the odds ratio to experience the
primary end point increased by 1.26
– Maas R, Dentz L, Schwedhelm E, Thoms W, Kuss O, Hiltmeyer N, Haddad M, Klöss T, Standl T, Böger RH.Elevated plasma concentrations of the
endogenous nitric oxide synthase inhibitor asymmetric dimethylarginine predict adverse events in patients undergoing noncardiac surgery. Crit
Care Med. 2007 Aug;35(8):1876-81
• Polymorphisms in platelet glycoprotein (GP) IIIa and
GPIb[alpha]. Pro33 and Met145 genotypes were
independent predictors of composite ischemic
outcome
– Faraday, Nauder , Martinez, Elizabeth A. Scharpf, Robert B. Kasch-Semenza, Laura ; Dorman, Todd ; Pronovost, Peter J.
Perler, Bruce ; Gerstenblith, Gary Bray, Paul F. Fleisher, Lee A. Platelet Gene Polymorphisms and Cardiac Risk Assessment
in Vascular Surgical Patients. Anesthesiology. 101(6):1291-1297, December 2004.

91. Ma…..gli eventi avversi emodinamici intraoperatori come
vengono raccolti e definiti?
• Esame delle cartelle di anestesia scritte a
mano………………………………………..
• raccolta automatica dei dati
– Anesth Analg. 2004 Mar;98(3):569-77,The incidence and prediction of automatically detected
intraoperative cardiovascular events in noncardiac surgery.Röhrig R, Junger A, Hartmann B, Klasen J,
Quinzio L, Jost A, Benson M, Hempelmann G
– gli eventi cardiovascolari avversi si accompagnavano ad una
aumentata mortalità (2.1% versus 1.0%).
– Però questi eventi non erano previsti nè dalla classificazione ASA né dall’ indice di rischio cardiaco
riveduto e corretto Revised Cardiac Risk Index (RCRI)

92. Levels of Thromboembolism Risk in Surgical Patients
Without Prophylaxis

93. Livelli di rischio tromboembolico in pazienti senza profilassi
(Goertz et al 114 AHA/ACC
DVT PE
Livello di rischio polpac
cio
prossimale Evento
clinico
fatale Strategia di prevenzione con
successo
Basso:
Chir minore in paz <40 anni senza fattori di
rischio
2 0.4 0.2 <0.01 No profilassi,deambulazione
precoce,aggressiva
Moderata:
Chir minore in paz con fattori di rischio
aggiuntivi;
Chir in paz 40-60 anni senza fattori di
rischio aggiuntivi
10-20 2-4 1-2 0.2-
0.4
Hep(ogni 12 h),LMWH
<3400,GCS,IPC
Alta:
chir in paz>60 a tra 40-60 con fatt.di
rischio(VTE,cancro,ipercoagulabilità
molecolare)
20-40 4-8 2-4 0.4-1 HEP ogni 8
h,LMWH>3400,Ipc
Altissima:
Chir in paz con fattori di rischio multipli
Artroprotesi anca ,ginocchio
Frattura anca
Trauma maggiore
Trauma midollare spinale
40-80 10-20 4-10 0.2-5 LMWH>3400,fondaparinux,
Vit K antag p os(INR 2-3),IPC
o GCS+LMWH o Hep
IPC;cpmpressione penumatica intermittente,
Hep;eparina non frazionata

94. • J Am Coll Surg. 2007 Jun;204(6):1211-21. Links
• Multivariable predictors of postoperative
venous thromboembolic events after general
and vascular surgery: results from the patient
safety in surgery study.
• Rogers SO Jr, Kilaru RK, Hosokawa P,
Henderson WG, Zinner MJ, Khuri SF.
• Department of Surgery and Center for Surgery
and Public Health, Brigham and Women's
Hospital, Boston, MA 02115, USA.

95. • J Oral Maxillofac Surg. 2007 Jun;65(6):1149-
54. Links
• Oral surgery in patients on anticoagulant
treatment without therapy interruption.
• Ferrieri GB, Castiglioni S, Carmagnola D,
Cargnel M, Strohmenger L, Abati S.
• Department of Medicine, Università degli
Studi di Milano, Milano, Italy.
giovanni.ferrieri@unimi.it

99. Choice of Anesthetic Technique and
Agent
• Recommendations for Use of Volatile
Anesthetic Agents
• CLASS Iia 1. It can be beneficial to use volatile
anesthetic agents during noncardiac surgery
for the maintenance of general anesthesia in
hemodynamically stable patients at risk for
myocardial ischemia. (Level of Evidence: B)