Preoperative Risk Evaluation: An Old School Approach With a Few New Tools

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Preoperative Risk Evaluation An Old School
ApproachWith a Few New Tools

• David Chamberlain MD

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Clear the Patient for Surgery
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What Causes Perioperative Mortality?

• 0.7 0.8 All cause (4,038 out of 485,850
  pts)
• 12680 Anesthesia
• 1420 Surgical error
• 195 Underlying medical condition(s)
• 67 Progression/complication of presenting
  disease
• 44 Progression/complication of underlying
  disease
• 30 Surgery contributed to mortality
• lt 1/3 Cardiac
• gt 1/3 Pulmonary
• 1/3 Other medical conditions
• Fleischer, L, J Am Soc Anesthesiology, May
  2002,Vol 96, Issue 5, p.1039-1041

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Are Internists Really Worth It?

• More likely to identify and intervene on medical
  conditions related to surgical outcomes.
• Devereaux, PJ, et al, Clin Invest Med 2000
  23116
• Decreased length of stay post thoracic and hip
  surgery.
• Phy, MP, et al, Arch Intern Med 2005 165796
• No improvement of glucose control, perioperative
  Beta Blockers, DVT prophylaxis.
• Auerbach, AD, et al, Arch Intern Med 2007
  1672338
• Higher 30 day and 1 year mortality rate, but in
  multi-variable analysis consulted patients had a
  significantly higher disease burden. Rates
  similar when adjusted.
• Wijeysundera, DN, et al, Arch Intern Med 2010
  1701365
• No study has shown a decrease in perioperative
  mortality.

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Preoperative Risk Evaluationan Old School
Approach

• Risk Assessment
• Global Assessment of Risk
• Cardiac Perioperative Risk
• Goldman Risk Index, Functional capacity, Surgical
  risk
• Pulmonary Perioperative Risk
• Risk Factor Evaluation
• DVT Risk
• Risk Factor Evaluation
• Endocarditis Risk
• Sanford Guidelines
• Risk from Medical Conditions
• Risk from Medications

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Global Assessment of RiskorLooks good from
door

• American Society of Anesthesiologists
  Preoperative Patient Classification
• Created in 1941
• Purpose was to assess the degree of a patients
  sickness
• NPV far exceeds PPV better at defining healthy
  than incapacitated
• Not originally intended to predict operative
  risk, but (millions of patients later)

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ASA Patient Classification

• Class 48hr Mortality
• 1 Healthy 0.07
• 2 Mild Systemic Disease 0.24
• 3 Severe Systemic Disease, limits 1.4
• activity, but not incapacitating
• 4 Incapacitating systemic disease, 7.5
• which is a constant threat to life
• 5 Moribund, not expected to survive 34
• 24 hours with or without surgery
• Emergent Surgery Risk Doubles

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Who is Too Sick or the Are You Nuts? Assessment

• Predictors of Risk for MI, Heart Failure, Death
• Unstable Coronary Syndrome
• angina, acute or recent MI
• Decompensated Heart Failure
• new onset, worsening HF, NYHA Class IV
• Significant Arrhythmias
• high grade AV block, symptomatic or new
  ventricular arrhythmia,
• tachycardia with rate gt 100, symptomatic
  bradycardia
• Severe Valvular Disease
• severe aortic stenosis, symptomatic mitral
  stenosis

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Predictors of Risk

• Any one has high positive predictive value for
  MI, Heart failure, Death
• Risk and severity of complications likely greater
  than benefit of surgery
• Recommend delay or cancel surgery unless emergent
• Those patients removed from subsequent cardiac
  risk assessments
• ACC/AHA 2007 Guidelines on perioperative
  cardiovascular evaluation and care for
  non-cardiac surgery.
• J Am Coll Cardiol. 2007 OCT 2350(17)e159-241

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Cardiac Perioperative RiskUpdated Old School
Tools

• Revised Goldman Cardiac Risk Index
• Functional Capacity
• Risk Specific to Type of Surgery

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Beyond the Goldman Cardiac Risk Index

• 2893 patients
• Elective non-cardiac surgery
• Monitored for cardiac complications
• MI
• Pulmonary Edema
• Ventricular Fibrillation
• Cardiac Arrest
• Complete Heart Block
• NOT all cause mortality
• Lee, TH, et al, Circulation 1999 1001043.

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Six Independent Predictors of Major Cardiac
Complications

• High Risk Surgery
• History of Ischemic Heart Disease
• History MI, History positive stress test,
  angina, using NTG, Pathologic Q
• Not History CABG or PTCA or Stent
• History of Heart Failure
• History of Cerebrovascular Disease
• DM treated with insulin
• Serum Creatinine gt 2.0
• Lee, TH, Marcantonio, ER, Mangione, CM, et al,
  Circulation 1999 1001043

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Revised Goldman Cardiac Risk Indexvs.Rate of
Cardiac Death, MI, Cardiac Arrest

• Risk Factors Rate 95 CI
• No Risk Factors 0.4 0.1 0.8
• One Risk Factor 1.0 0.5 1.4
• Two Risk Factors 2.4 1.3 3.5
• Three Risk Factors 5.4 2.8 7.9
• Devereaux, PJ, Goldman, L, Cook, DJ, et al. CMAJ
  2005 173627

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Revised Goldman Cardiac Risk Indexvs. Cardiac
Death, MI, Cardiac Arrest, Vfib, Pulmonary Edema,
Complete Heart Block

• Risk Factors Rate Rate with Beta Blockers
• None 0.4 1.0 lt 1
• One to Two 2.2 6.6 0.8 1.6
• Three or More gt 9 gt 3
• Auerbach, A, Goldman, L. Circulation 2006
  1131361

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Revised Cardiac Risk IndexMost Studied and
Validated

• Validated in Cohort of 1422 patients
• Predictive value for cardiac complications and
  mortality significant in All types of non-cardiac
  surgery except AAA
• Does Not Capture all-cause Mortality
• Ford, MK et al, Ann Intern Med 2010 15226
• Better Predictive Value than original Goldman
  Criteria or Detsky Modified Risk Index
• Lee, TH, et al, Circulation 1999 1001043
• Retrospective study 663,665 pts major
  non-cardiac Sx 329 hospitals, 2000 2001
• RCRI likely underestimates risk of cardiac
  complications
• Increased mortality without Beta Blockers
• Devereaux, PJ, Goldman,L, et al, CMAJ 2005
  173627

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Functional Capacityor Whats the METs thing?

• 1 MET 3.5 mL O2 uptake/KG per min
• O2 uptake of a 40 y/o, 70 kg male sitting upright
• Peak exercise capacity an independent predictor
  of all mortality in normals and subjects with
  cardiovascular dz
• lt 5 METs Poor Survival Prognosis (lt50)
• 10 METs Medical therapy CABG (gt75)
• gt 13 METs Good Survival Prognosis (gt90)
• (either category, data points at 10 year, linear
  separation as early as 1 year)
• For each 1 MET there is a 12 improvement in
  survival
• Myers, J, et al, N Engl J Med 2002 346793

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Specific Activity Scale

• METs
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
• 12

• Can Complete Activity Without Stopping
• Sit upright
• Eat, dress, use toilet, make bed
• Walk around house, shower
• 1 flight stairs, walk up hill, 2 block _at_ 2mph
• Light house work, dust, wash dishes, golf, bowl
• 2 flights of stairs, walk on flat _at_ 4mph,
• Sex
• Scrubbing floors, weight lifting, moving
  furniture
• Broke the bed/neighbors called the cops sex
• Shovel snow
• Doubles tennis, swing dancing
• Recreational Sports Singles tennis, soccer,
  basketball, skiing, jogging
• Competitive sports

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How does this relate to Surgery?

• lt 4 METs Significantly Increases Risk MI, HF,
  Arrhythmia regardless of Surgical Risk
• Functional Capacity Complication Rate
• lt 4 METs gt 5
• 4 10 METs 1 5
• gt 10 Mets lt 1
• Eagle, KA, et al, J Am Coll Cardiol, 2002 39,
  542-553

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What about Surgery Specific Risk?

• Risk Cardiac death or nonfatal MI
• High gt 5
• Intermediate 1 5
• Low Risk lt 1
• Emergency 2 5 times the surgical risk
• Fleischer, LA, Beckman, JA, Brown, KA, et al,
  ACC/AHA 2007 Guidelines on perioperative
  cardiovascular evaluation and care for noncardiac
  surgery. J Am Coll Cardiology 2007 50e159.

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Surgery Specific Risk for Cardiac Death or
Nonfatal MI

• High Risk ( gt 5 )
• Aortic, Major vascular, Cardiothoracic,
  Emergent,
• long with large blood loss/fluid shifts
• Intermediate Risk ( 1 5 )
• CEA, Head, Neck, Intraperitoneal, Intrathoracic,
  Orthopedic, Prostate
• Low Risk ( lt 1 )
• Ambulatory surgery, Endoscopy, Superficial
  Procedure, Cataract surgery, Breast surgery

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The New School Uses2007 ACC/AHA Cardiac
Evaluation and Care Algorithm

• Step 1 Emergency Surgery
• Step 2 Global Assessment of Risk
• Too Sick for Surgery
• Step 3 Global Assessment of Risk
• Low Risk and Low risk Surgery
• Step 4 Assess Functional Capacity
• Step 5 Calculate RCRI and Surgical Risk
• Looks like the old school and the new school are
  the same school

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Evaluating Cardiac Risk2007 ACC/AHA Algorithm

• Step 1
• Need Emergent Sx?
• Step 2
• Active Cardiac Condition?

• Yes
• Proceed to OR
• Post Op risk stratification
• Risk Factor Management
• Yes
• Evaluate and Treat
• Consider OR when stable

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Evaluating Cardiac Risk 2007 ACC/AHA Algorithm

• Step 3
• Low Risk Surgery?
• Step 4
• Good Functional Capacity?
• Step 5
• Poor or Unknown

• Yes
• Proceed to OR
• Yes
• Proceed to OR
• Yes
• Compute RCRI

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Evaluating Cardiac Risk2007 ACC/AHA Algorithm

• Step 5 continued
• Zero Risk Factors
• 1 2 Risk Factors or
• 3 or more Risk Factors and
• Intermediate Risk Surgery

• Yes
• Proceed to Surgery
• Yes
• Proceed to OR
• Rate Control with Beta
• Blocker
• Consider Non-Invasive
• Cardiac Testing if will change management

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Evaluating Cardiac Risk2007 ACC/AHA Algorithm

• Step 5 continued
• 3 or more Risk Factors
• And
• High Risk Surgery

• Yes
• Consider Non-Invasive or Invasive testing
• if will change management
• Rate control with Beta
• Blockers

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Evaluating Pulmonary RiskIts No Longer Just a
Guess

• Pulmonary Complications
• MORE COMMON than Cardiac Complications
• Cause Significantly LONGER Hospital Stays
• Lawrence, VA, Hilsenbeck, SG, et al. J Gen
  Intern Med 1995 10671
• MOST COSTLY Complications
• Dimick, JB, Chen, SL, et al. J Am Coll Surg
  2004 199531
• Pulmonary Complications 6.8 across all types Sx
• Atelectasis, Pulmonary Infection,
• Prolonged Mechanical Ventilation, Respiratory
  Failure,
• Chronic Lung Disease Exacerbation, Bronchospasm
• Smetana, GW, Lawrence, GA, et al, Ann Intern
  Med 2006 144581

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Predictors of Pulmonary Complications

• Patient Related
• Age gt 50, 60, 70, 80
• Chronic Lung Disease
• Asthma
• Smoking
• Heart Failure
• Albumin
• BUN
• Functional Dependence
• ASA Class gt 2
• Qasam, A, et al, Ann Intern Med, 2006 144575

• Odds Ratio of Complications
• 1.5, 2.28, 3.9, 5.63
• 2.36
• Uncontrolled 3, Controlled 1
• Current 5.5, 2 mo Cessation 1.26
• 2.93
• 2.53
• 2.29
• Total 2.51 Partial 1.65
• 4.87

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Predictors of Pulmonary Complications

• Procedure Related
• Surgical Site
• Duration gt 3 4 hr
• Type of Anesthesia
• Emergency
• Qasam, A, et al, Ann Intern Med, 2006, 144575

• Odds Ratio
• Upper Abdominal 2.8
• 2.14
• General 1.83 vs. Spinal
• 2.21

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Other Conditions That May Require Special
Attention

• Obesity Inconsistent data
• OSA Probable
• Pulmonary HTN Probable, Limited data
• URI Data limited, usually defer Sx
• Smetana, G, Ann Intern Med, 2006 144581

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Recommendations for Assessment of Pulmonary Risk

• History and Physical Exam
• Identify Pulmonary Risk Factors
• American Society of Anesthesiologists -
• Global Assessment of Pulmonary Risk
• Arozulla Multifactorial Risk Index for
  Postoperative Respiratory Failure
• Smetana, G, et al, Ann Intern Med, 2006 144581

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ASA Postoperative Pulmonary Complications

• Class Pulmonary Complications
• 1 Healthy 1.2
• 2 Mild Systemic Disease 5.4
• 3 Severe Systemic Disease, limits 11.4
• activity, but not incapacitating
• 4 Incapacitating systemic disease, 10.9
• which is a constant threat to life
• 5 Moribund, not expected to survive NA
• 24 hrs with or without surgery
• Qasim, A, et al. Ann Intern Med, 2006
  144575-580

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Arozullah Respiratory Failure Risk Index

• Type of Surgery
• AAA
• Thoracic
• Neurosurgery, Upper Abdominal Peripheral
  Vascular, Neck
• Emergency Surgery
• Albumin lt 3.0 g/dL
• BUN gt 30 mg/dL
• Partial/Full Dependence
• History of COPD
• Age gt 70
• Age 60 - 69

• Point Value
• 27
• 21
• 14
• 11
• 9
• 8
• 7
• 6
• 6
• 5

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Arozullah Respiratory Failure Index Scoring

• Class Point Total Respiratory Failure
• One lt 10 0.5
• Two 11 19 1.8
• Three 20 27 4.2
• Four 28 40 10.1
• Five gt 40 26.6
• Arozullah, AM, Daley, J, et al, Ann Surg 2000
  232242

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Put It All Together

• Step 1 ASA 1 and To OR
• Low Risk Arozulla 1
• Step 2 ASA 2 or Consider Further Testing
• Arozulla 2 - 3 CXR, PFT if will change
• management.
• Step 3 ASA gt 3 or Reconsider Surgery
• High Risk Arozulla gt 4 Shorter Procedure
• Spinal or Epidural
• For all Deep Breathing Exercises/Incentive
  Inspirometry Treat Identified Risk Factors
  Special Conditions
• Smetana, G, et al, Ann Intern Med, 2006 144581

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Strategies to Reduce Postoperative Pulmonary
Complications

• What Works
• Pre-op Asthma Evaluation
• Aggressive Tx. For COPD
• Inspiratory Muscle Training
• Pre-op Patient Education
• Selective Post-op NG decompression
• Median Length of Stay 1 day shorter
• Complication rate vs controls 18 vs.35
• Hulzebos, EH, et al, JAMA, 2006 2961851

• What Doesnt
• Smoking Cessation
• Pre-op Antibiotics
• Tube Feed or TPN

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DVT Risk

• Low Risk ( lt 2 )
• Age lt 40 and Duration lt 60 min and No Risk
  Factors
• Calf DVT 2 Proximal DVT 0.4
• Significant PE 0.2 Fatal PE lt 0.01
• Tx Ted Hose, early ambulation
• Moderate Risk ( 10 40 )
• Age 40 60 or Duration gt 60 min or Risk Factor
• Calf DVT 10 20 Proximal DVT 2 4
• Significant PE 1 2 Fatal PE 0.1 0.4
• Tx LMWH, SCD
• Additional Risk Factors Advanced Age, Cancer,
  Prior Venous Thromboembolism, Obesity, HF,
  Paralysis, Hypercoagulable State

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DVT Risk

• High Risk ( 40 )
• Age gt 60
• Age 40 60 With Additional Risk Factor
• Calf DVT 20 40 Proximal DVT 4 8
• Significant PE 1 2 Fatal PE 0.4 1.0
• Tx LMWH, SCD, Consider Prolonged
  Anticoagulation
• Highest Risk ( 40 80 )
• Age gt 40 with Multiple Additional Risk Factors
  or
• THR, TKR, Hip Fracture, Major Trauma, Spinal
  Cord
• Calf DVT 40 80 Proximal DVT 10 20
• Significant PE 4 10 Fatal PE 0.2 5
• Tx Long Term LMWH/Anticoagulation,
• Vena Caval Interruption
• Geerts, WH, et al, Chest 2004 1263385

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Endocarditis ProphylaxisOne from Column A and
Column B

• Column A Procedure
• Dental
• Skin and Soft Tissue Infection
• Respiratory
• AHA, April 2007

• Column B Abnormality
• Prosthetic Cardiac Valve
• History of Endocarditis
• Congenital Heart Disease
• Unrepaired Cyanotic
• Repaired lt 6 months
• Cardiac Transplant Valvulopathy

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Endocarditis Prophylaxis

• None for GI
• None for GU
• None for MVP
• None for ASD
• AHA, April 2007
• None for bad hair day

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Medication ConsiderationsAspirin and Clopidogrel

• When possible delay non-cardiac surgery in
  patients with recent coronary stenting
• 4 to 6 weeks for bare metal stent
• At least 12 months for drug-eluting stent
• Optimize antiplatelet therapy with aspirin and
  clopidogrel by continuing it or reinstating it
  ASAP after procedure
• Fleischer, L, et al, Circulation, 2007, 118418
• MKSAP Item 95,
• ACP IM Board Review Course October, 2010
• Im not saying this was on the IM Boards, but it
  sure does come up a lot lately. You didnt hear
  nothing from me.

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Medication Considerations andSpecific Medical
Conditions

• Expertise comes from residency and years of
  clinical experience.
• We are the experts in these areas.
• Consider assuming care. This is where an
  Internist is really worth it.