Perioperative Medical Management

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Perioperative Medical Management

• Mark C. Wilson, M.D., M.P.H.

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You Should Expect Questions About ...

• Characteristics of Effective Consultations
• Appropriate Routine Preoperative Testing
• Cardiopulmonary Risk Assessment
• Perioperative Care of the Elderly
• Prevention of Venous Thromboembolism

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Role of the Medical Consultant is ...

• to identify the problems, correct the
  correctable, and then point out the
  uncorrectable to the unsuspecting.
• G. E. McElwain

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Factors that Enhance Compliance

• Focus on the Central Issue/Question
• Be Brief and Specific
• Emphasize Therapeutic Over Diagnostic
• Limit Number of Recommendations (lt 5)
• Direct Verbal Contact

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Routine Preoperative Testing

• Appropriate testing for an asymptomatic 43y/o
  woman who takes HCTZ and is scheduled for
  elective hysterectomy
• a) Chest X-ray
• b) Hematocrit
• c) PT PTT
• d) Electrolytes, BUN, Cr
• e) Electrocardiogram

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Preoperatively, Dont Do This ...
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Or You Could End Up Like This ...
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Preoperative Testing Driven By

• A. The History Physical Exam
• - Age
• - Sex
• - Medications
• - Chronic Diseases / Functional Impact
• - Exercise Tolerance
• - Nutritional Status
• B. The Type of Surgery

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Routine Preoperative Testing

• 1) BEWARE!!!
• 2) Routine Testing of Unselected, Asymptomatic
  Adults Does NOT Improve Outcomes
• 3) Most Important Step is Thorough HP
• 4) Evidence Supports that Prior Normal Testing
  Rarely Evolves into Significant Abnormality

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Value of Previous Tests

• 1,100 patients had 7,500 preoperative tests in VA
• 47 were duplicated tests performed within 1 year
• 70 of duplicates were performed in prior 4
  months
• 0.4 of previously normal tests evolved into an
  abnormality that could alter perioperative care
• Most importantly, the rare abnormal values were
  predictable from clinical assessment of patient
• Macpherson, Ann Int Med 1990

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Reasonable Situations to CONSIDER

• Test
• Hgb/Hct
• Lytes, BUN, Cr
• Coags, Platelets
• Electrocardiogram
• Chest X-Ray

• Setting
• All Women Men gt60yrs
• Renal Disease Diuretics DM HTN Age gt60yrs
• Liver Disease Coumadin Easy Bruising
  Malignancy
• History CAD Age gt50yrs
• Acute Pulm Sx Age gt60yr

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Routine Preoperative Testing

• Appropriate testing for an asymptomatic 43y/o
  woman who takes HCTZ and is scheduled for
  elective hysterectomy
• a) Chest X-ray
• b) Hematocrit
• c) PT PTT
• d) Electrolytes, BUN, Cr
• e) Electrocardiogram

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So, Be Discerning with Interventions
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Cardiopulmonary Case

• 67 y/o male referred to you for pre-op
  clearance before elective repair of a large
  inguinal hernia.
• Active farmer with h/o HTN, BPH, and angina since
  his inferior MI 2yrs ago. Smokes 1 ppd.
• Meds Metoprolol, ASA, Terazosin, NTG
• What Further Do You Need to Ask???

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Cardiopulmonary Risk Assessment

• Goal is to Assess Whether EXCESS Risk Exists
• History and Physical Examination are KEY
• Any Recent Change in Chronic Disease Status?
• Assess Exercise Tolerance
• Does Patient Have a Low, Moderate, or High
  Cardiac Risk Profile?
• What is the Risk Associated with the Surgery?

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Cardiopulmonary Case

• Works sun-up to sun-down. Reports good
  compliance with meds. Occasional SSCP when he
  overdoes it like when uses the rototiller
  longer than 30 minutes at a time. Prompt pain
  relief when stops to rest. Last used NTG 1 month
  ago.
• Can walk 1/2 mile without DOE. No PND,
  orthopnea, or palpitations.
• Small amount of tan sputum each morning.

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Cardiopulmonary Case

• Physical Exam
• 148/95 HR - 70 R - 12
• Gen vigorous male with yellow fingernails
• Lungs clear with coarse BS bilaterally
• Heart regular without murmur or gallop
• Abd benign without bruit
• Ext no edema, pulses intact
• bilateral femoral bruits

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Cardiopulmonary Risk Assessment

• The most appropriate preoperative testing
  strategy for this active farmer is
• a) Electrocardiogram
• b) Exercise Treadmill Testing
• c) Dobutamine Echocardiogram
• d) Pulmonary Function Testing

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Cardiac Risk Assessment

• Consistently Important Predictive Variables
• Recent MI
• Unstable Angina
• Congestive Heart Failure
• Aortic Stenosis
• Advanced Arrhythmias
• Emergency Surgery
• Aged

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1996 ACC/AHA Guidelines

• intervention is rarely necessary to lower the
  risk of surgery.
• In general, indications for further cardiac
  testing and treatments are the same as those in
  the nonoperative setting.

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Guideline Comparison
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Hemodynamic Stress of Surgery

• High Risk (cardiac risk gt 5)
• Emergency operations
• Aortic or other major vascular surgeries
• Intermediate Risk (cardiac risk lt 5)
• Abdominal surgery
• Orthopedic surgery
• Head Neck surgery
• Low Risk (cardiac risk lt 1)
• Breast surgery
• Cataract surgery
• Herniorrhaphy ACC/AHA Guideline 1996

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Pulmonary Risk Assessment

• For Patients with Chronic Lung Diseases, Morbid
  Obesity, or Current Respiratory Infections
• Assess Tobacco Use
• Assess if Change in Dyspnea, Cough, Sputum
• Operative Site is Most Important Determinant
• Evidence Supports PFTs Only in Lung Resection
• PFTs May be Helpful by Increasing Vigilance
• pCO2 gt 45 Associated with Adverse Outcomes

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Cardiopulmonary Risk Assessment

• The most appropriate preoperative testing
  strategy for this active farmer is
• a) Electrocardiogram
• b) Exercise Treadmill Testing
• c) Dobutamine Echocardiogram
• d) Pulmonary Function Testing

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Perioperative Care of the Elderly

• Status Functional Impact of Chronic Diseases
• Exercise Tolerance
• Consider Preoperative MMSE
• Polypharmacy and Drug Metabolism
• Be Wary of Pre-op Medication Changes

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Postoperative Delerium

• It Is Common and Often Multifactorial. Consider
• Sun-Downing
• Infection
• Alcohol Withdrawal / New Medications
• Abnormal Electrolytes
• Hypoxemia
• Cardiac Ischemia
• Stroke

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Prevention of DVT

• 57 y/o obese woman scheduled for resection of
  ovarian cancer. Prior DVT and h/o CHF. Most
  appropriate prophylaxis would be
• a) Intermittent Pneumatic Compression Devices
• b) Warfarin and Low Molecular Weight Heparin
• c) Inferior Vena Cava Filter and Aspirin
• d) Low Molecular Weight Heparin and IPCDs

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Once Again, Look for Risk Factors
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Clinical Risk Factors for DVT

• Prior History of DVT or PE
• Congestive Heart Failure
• Prolonged Immobilization
• Malignancy

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Risk Stratification by ACCP Consensus

• Low Risk Patients
• Typically lt40yrs without risk factors minor
  surgeries
• Early ambulation
• Moderate Risk Patients
• Typically gt40yrs without risk factors major
  surgeries
• Low dose heparin q12hrs or IPCD
• High Risk Patients
• Typically gt40yrs with risk factors major
  surgeries
• Low dose heparin q8hrs or LMWH
• Chest 1995 108312S-334S

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Appropriate DVT Prophylaxis

• Hip Fracture or Replacement
• Total Knee Replacement
• Neurosurgery Patients
• Very High Risk
• Trauma / Recent DVT

• - LMWH or Warfarin
• - LMWH or IPCD
• - IPCD
• - Combination Strategies
• - IVC Filter

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Prevention of DVT

• 57 y/o obese woman scheduled for resection of
  ovarian cancer. Prior DVT and h/o CHF. Most
  appropriate prophylaxis would be
• a) Intermittent Pneumatic Compression Devices
• b) Warfarin and Low Molecular Weight Heparin
• c) Inferior Vena Cava Filter and Aspirin
• d) Low Molecular Weight Heparin and IPCDs

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Fun Consultative Pearls

• CV risk equal for general and spinal anesthesia
• Beware spinal anesthesia if fixed cardiac output
• Many postoperative MIs silent ... and subtle
• ASA irreversibly inhibits plts NSAIDs
  transiently
• Continue cardiac/anti-HTN meds on AM of surgery
• Diastolic BP lt 110 is not associated with
  increased perioperative MM

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So What Now???
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Session Objectives

• 1) Determine Components of Effective
  Consultation
• 2) Identify Appropriate Perioperative Testing
• 3) Review Cardiopulmonary Risk Assessment
• 4) Identify Unique Aspects of Consultation in
  Elderly
• 5) Determine Appropriate DVT Prophylaxis