Intro to PeriOperative Medicine

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Intro to PeriOperative Medicine

• Compiled by
• Tabitha Goring, MD
• Hospitalist Attending/Assistant Professor of
  Medicine
• Jacobi Medical Center
• Albert Einstein College of Medicine

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Perioperative Medicine

• Cardiac Risk Assessment
• in non-cardiac surgery
• Goldman Cardiac Risk Index
  Points
• Age gt 70 yo 5
• MI lt 6 months ago 10
• JVD or S3 gallop 11
• Significant Aortic Stenosis 3
• Non-sinus Rhythm, APCs or gt5 PVC/min 7
• PO2lt60 or PCO2gt50, Klt3.0 or HCO3lt20
• BUN gt50 or Crgt3.0, abnormal AST,
• Signs of chronic liver disease, or bedridden
  pt. 3
• Intraperitoneal, intrathoracic or aortic
  procedure 3
• Emergent Operation 4

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Perioperative Medicine

• Goldman Risk Assessment
• Class Points Risk
• (Complication/Death Risk)
• I 0-5 0.7/ 0.2
• II 6-12 5 / 2
• III 13-25 11 / 2
• IV gt26 22 / 56

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Perioperative MedicineSeverity of Perioperative
Stress
Aortic Cross Clamp Intrathoracic Infrainguinal
Vascular
Orthopedic Head Neck Carotid Amputation
TURP Superficial Cataract
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Perioperative Medicine

• Perioperative Stress Hormone
• Norepinephrine/Epinephrine
• Most anesthetics suppress many elements of the
  stress response
• therefore, most problems occur
  postoperatively
• Complications
• Tachyarrythmias Hyperglycemia
• Hypertension Protein Metabolism
• Myocardial ischemia CHF (Na retention)
• Vasoconstriction (wound failure) HypoNa, K, Mg
• Hypercoaguability SIRS

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Perioperative Medicine

• Non-invasive Pre-op Cardiac Testing
• Exercise Treadmill
• Exercise Thallium
• Dipyridamole Thallium
• Holter Monitor
• Dobutamine Echocardiogram

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Peri-Operative Medicine

• Dobutamine Stress Echo
• (Shaw et al 1996- Metaanalysis)
• Highest positive predictive value(45-65)
• Well Tolerated
• Predictive Value increases with number of walls
  imaged.

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Perioperative Medicine

• Post-op Pulmonary Complications
• Diaphramatic dysfunction
• Hypoxemia
• Pneumonia
• Bronchospasm
• Respiratory Failure

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Perioperative Medicine

• Pulmonary
• No need for routine pre-op PFTs
• No data that routine pre-op CXR improves outcome

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Perioperative Management

• Asthma Recs
• Consider Oral Streoids 24-48h in mod-severe
  asthmatics (better than inhaled steroids to
  prevent periop flares)
• studies show no increased wound infections,
  impaired wound healing or hyperglycemia.
• Kabalin, Arch Intern Med 1995 155
• Inhaled Albut/Atrov for wheezing
• Smoking Cessation 8 wks prior to surgery

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Perioperative Management

• Asthma Recs contd
• Consider use of regional anesthesia
• Nebulizers intra-op for flares
• IV lidocaine inhaled salbutamol have synergy
• pretreat prior to airway irritation
• Propofol, ketamine useful in asthmatics
• (bronchodilators).

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PeriOperative Medicine

• What does the anesthesiologist know?
• Cancel a case.
• Well versed in IV meds not PO meds
• (HTN, DM, MI, CHF, BrSpasm, Oliguria, Pain)
• Choice of anesthestic agent
• Choice of invasive or non-invasive monitoring

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PeriOperative Medicine

• What doesnt the anesthesiologist know?
• Long term management of chronic problems
• -HTN
• -CAD
• -Renal Failure
• -Malnutrition
• -Hepatic Dysfunction
• -Endocrinologic Conditions

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PeriOperative Medicine

• What does the anesthesiologist want to know?
• Regarding Drug Regimens.
• -1st line, 2nd line, initial dose, titration,
  expected SEs
• -Further tests might be indicated preoperatively
• -Management suggestions
• -Help to optimize the underlying disease p/t the
  surgical insult
• -Never clear for a certain type of anesthesia
  
• (may need to convert to GA anyway)
• -Stent info Type Location When placed
  Antiplatelet Agents
• -Pacer/AICD (date last checked) - ?magnet
• -Suggest Cardiology when needed

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Perioperative Medicine

• Internists primary goal is not simply to clear
  pts for surgery, but to
• 1. establish and optimize the pts risk for
  cardiopulmonary complications, based on the pts
  current medical status in conjunction with the
  degree of perioperative stress caused by a
  particular procedure.
• 2. provide management recommendations which
  pertain to pts underlying medical problems

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Perioperative Medicine

• ACC/AHA 2007 Guidelines on Perioperative
  Cardiovascular Evaluation and Care for Cardiac
  Surgery (J Am Coll Cardiology 200750e159-241)
• The bottom line.
• Intervention is rarely necessary to simply
  lower riskunless it is indicated irrespective
  of the planned procedure.

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Perioperative Medicine

• Components of the Pre-op Evaluation
• History (chronic illnesses, meds, social hx)
• Physical
• Prior hx of cardiac w/u (echo, stress test,
  holter, AICD, cardiac cath)
• Assessment of functional status (METS)
• PSH/Anesthetic complications
• DI
• EKG (in moderate to high risk pts)

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Perioperative Medicine

• Establish Patient risk
• Establish Surgical risk

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Perioperative Medicine

• PATIENT RISK
• Who is High Risk?
• ? Acute MI (lt7 days) ? Stress
  Testing ? delay 4-6 weeks
• ? Recent MI (8-30 days) ? Stress
  Testing ? delay 4-6 weeks
• ? Unstable angina/severe angina
• ? () stress test/echo with large ischemic burden
• ? Decompensated CHF () S3 ?
  ? Echocardiogram
• ? Arrhythmia ? high-degree HB ?
  Cardiology Consult
• ? symptomatic arrhythmia c
  CAD
• ? Severe valvular disease

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Perioperative Medicine

• Who is Intermediate Risk?
• mild angina 1
  -ADLeat,dress,toilet,walk around house(?)
• remote MI gt1 month 2-3 -walks 1-2
  blocks on level ground (? risk)
• stable CHF METS 4 - light
  housework/climb 2 flights of stairs
• creatinine gt2.0 5-9 heavy
  housework,golf,bowling,dancing
• diabetes, uncontrolled 10 - strenuous
  exercise swimming, tennis
• Qwaves on EKG football, basketball, skiing

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METS(Working metabolic rate relative to the
resting metabolic rate)

• 4 METS
• Ability to perform a spectrum of common tasks
  correlate well with maximum O2 uptake by
  treadmill testing. (Mangano 1990)
• Increased cardiac and long-term risks in pts
  unable to meet the 4-met demand
• Perioperative ischemia more common in those with
  poor exercise tolerance.

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Perioperative Medicine

• Pts with low functional capacity lt4 METS MAY
  benefit from preoperative stress testing to
• -identify preoperative ischemia
• -identify inducible cardiac arrythmias
• -to help estimate cardiac risk
• -help identify at risk territory after recent MI
• there is only real evidence to support stress
  testing in pts with 3 or more risk factors who
  have poor functional capacity AND require high
  risk surgery ONLY IF it will change management!!!

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Perioperative Medicine

• Who is Low Risk?
• advanced age
• abnormal EKG/old LBBB/LVH
• low functional capacity
• hx of CVA
• uncontrolled HTN
• frequent PVCs/NSVT
• risk is not known to increase with accumulation
  of low risk factors.

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Perioperative Medicine

• SURGICAL RISK
• High Risk
• Open Aortic Surgery
• Peripheral vascular surgery
• XS blood loss estimated
• Large fluid shifts
• Prolonged Surgery

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Perioperative Medicine

• SURGICAL RISK
• Moderate Risk
• Intraperitoneal/Intrathoracic Surgery
• CEA/Endovascular AAA
• Head and Neck Surgery
• Orthopedic Procedures
• Open Prostate Resection

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Perioperative Medicine

• SURGICAL RISK
• Low Risk
• Superficial Procedures
• Endoscopic Procedures
• Cataract Surgery
• Breast Surgery
• Ambulatory Procedures

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Perioperative Medicine

• Lee et al -(Circulation 19991001043-1049)
• simple index for prediction of cardiac risk
• Ischemic heart disease (MI, stress test, NTG,
  active CP, abnormal Qwaves)
• CHF (hx of HF, APE, PND, LE edema, rales, S3,
  PVC)
• CVA (hx if TIA or stroke)
• High risk surgery (AAA, vascular, thoracic sx)
• Insulin-requiring DM
• Creatinine gt2.0

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Perioperative Medicine

• Who gets an EKG?
• Evidence supports
• Anyone who is undergoing intermediate or high
  risk procedures who have at least one clinical
  risk factorCAD, PAD, CVA, CRI, DM, CHF
• low risk pts do not need EKGs (although we do
  them anyway)

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Perioperative Medicine

• Who gets PCI (preoperatively)?
• Balloon angioplasty- Plavix x 2 weeks ASA
• Bare-Metal Stent Plavix x 4 weeks ASA
• Drug-eluting Stent Plavix x 1 year (at least)
  ASA
• (expert-opinion onlyno real evidence to
  support)
• evidence reveals that PCI has no valve in
  prevention of cardiac events with except in those
  who PCI is indicated for ACS
• CABG for left main disease

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Perioperative Medicine

• Perioperative Beta-Blockers
• Who should be started?
• Angina/Arrythmias/HTN continue!
• High Risk pt undergoing high risk procedures
  (evidence supports)
• CHD high risk procedure
• High risk pt undergoing intermediate risk
  procedure
• always use caution in pts in whom BBs are
  contraindicated (dCHF, severe valvular dx, IHSS,
  mod-pers asthma etc

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Perioperative Medicine

• Perioperative B-blockers
• The Verdict is still out on.
• Intermediate Risk pts undergoing moderate risk
  procedures
• (although it is generally accepted that these
  pts are begun on BBs)
• Low Risk pts undergoing high risk procedures
• Low risk pts do not appear to benefit from and
  may be harmed by initiation of BBs. (Lindenauer
  et al (retrospective)NEJM 2005.)

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PeriOperative Medicine

• POISE Study
• (PeriOperative ISchemic Evaluation)
• Inclusion Criteria
• Undergoing non-cardiac surgery
• gt 45 yo
• LOS 24 hours
• CAD/PVD/hx of CHF/major vascular surgery or
• Any 3 of the 7 thoracic/abdominal
  surgery/CHF/TIA/DM/CRF/gt70yo/urgent surgery

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PeriOperative Medicine

• POISE Study
• (PeriOperative ISchemic Evaluation)
• Exclusion Criteria
• Bradycardia lt50bpm
• 2nd or 3rd degree HB
• Asthma
• Adverse rxn to a BB
• CABG w/i 5 yrs
• Low risk procedure
• On Verapamil

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PeriOperative Medicine(Adapted from Kate Leslie,
MD, PP presentation Royal Melbourne Hospital)
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PeriOperative Medicine

• POISE Study
• (PeriOperative ISchemic Evaluation)
• 8,351 patients included in the analysis, 99.8 of
  pts completed 30day f/u
• Metoprolol 200 mg (starting 2-4 hours prior to
  surgery)
• Continued qD x 30 days
• Held for HR below 45bpm or hypotension (drug
  restarted _at_ lower dose)
• EKG post-op, first day, second day and 30 days
  after surgery
• (biomarkers if MI is suspected)

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PeriOperative Medicine

• POISE Study
• (PeriOperative ISchemic Evaluation)
• Primary Outcome
• 1. Cardiovascular death
• 2. Non-fatal MI
• 3. Non-fatal cardiac arrest 30 days after
  randomization

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(Adapted from Kate Leslie, MD, PP
presentation Royal Melbourne Hospital)
Primary Outcome
Non-fatal MI
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PeriOperative MedicineStroke (Adapted from Kate
Leslie, MD, PP presentation Royal Melbourne
Hospital)
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PeriOperative MedicineAll Deaths (Adapted from
Kate Leslie, MD, PP presentation Royal Melbourne
Hospital)
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PeriOperative Medicine (Adapted from Kate
Leslie, MD, PP presentation Royal Melbourne
Hospital)

• For every 1,000 treated patients, metoprolol
  would prevent
• 15 MIs
• 7 cases of new AF
• 3 post-op CABGs
• And there would be
• 8 excess deaths
• 5 excess strokes
• 53 patients with significant hypotension

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PeriOperative Medicine (Adapted from Kate
Leslie, MD, PP presentation Royal Melbourne
Hospital)

• Significant decrease in the risk of non-fatal MI
• Pooled OR 0.68 (0.53-0.87)
• Significant increase in the risk of perioperative
  stroke
• Pooled OR 2.16 (1.04-4.50)
• No effect on total mortality

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Perioperative Medicine

• Beta-Blockers
• Evidence suggests
• Longer-Acting (Atenolol) appears to be superior
  to shorter acting (Metoprolol).
• The dose should be started at least 7 days prior
  to surgery and titrated up to target HR 60-65
  (which is often not feasible in-house)

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Perioperative Medicine

• Post-op R/O MIs
• The evidence does not support serial Troponin
  measurements in pts who are clinically stable and
  hv undergone intermediate or high risk
  surgery!!!!!!!!
• It is only recommended in pts with EKG changes or
  CP!!!
• WOW!!!!!

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Perioperative Medicine

• Rather..
• Charlston et al (1988)Obtain EKG
• Immediately post-op
• Day 1 post-op
• Day 2 post-op
• If changes, (ST-T wave changes) or symptoms then
  obtain Cardiac enzymes
• (What do we do with all these slightly positive
  troponins? Do they affect outcomes? What is the
  role of revascularization?)

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Pt Risk vs. Surgical Risk
Low Risk pt. Intermediate Risk pt. High Risk pt.
Low Risk Surgery Proceed with Surgery Proceed with Surgery Proceed with caution
Moderate Risk Surgery Proceed with Surgery Assess METS Assess of risk factors ??BB Possible BB Post-op EKG/?Trop
High Risk Surgery Proceed with Caution Possible BB Post-op EKG/?Trop Definite BB ?Intervention - PCI Post-Op EKG/?Trop
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Perioperative Medicine

• Why Give Stress Dose steroids???
• Chronic Steroid use suppresses the
  hypothalamic-pituitary-adrenal axis
• What constitutes chronic use?

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Perioperative Medicine

• Normal Daily Corticol Production
• 10 mg Hydrocortisone PO
• Endogenous Cortisol levels rise to
• 50 mg Minor Surgery
• 75-150 mg Major Surgery
• (at induction of anesthesia, with return
  to baseline within 24-48 h)

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Perioperative Medicine

• Time to recovery of HPA axis
• - as short as 2-5 days or as long as 9-12 months
• Therefore, recommendations have been to
  administer steroids to any pt who has received
  more than 10 mg of prednisone for more than 7
  days consecutive within the last year. (or 3
  months depending on the author)

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Perioperative Medicine

• Asthmatics
• Chronic Rheumatologic/Autoimmune Diseases
• Certain Neurologic Diseases
• HIV (PCP)
• Dematologic Diseases (include high potency
  topicals)
• GI (UC)

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Perioperative Medicine

• Traditional dose
• 100 mg of hydrocortisone q8h
• (With a quick taper over 1-3 days if
  uncomplicated.)
• Technically, dose should be administered based on
  the surgical risk
• Minor - 25 mg Hydrocortisone at induction x
  1
• Moderate - 25 mg Hydrocortisone q8h x 24 h
• Major - 50 mg Hydrocortisone q6h x 48-72h

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PeriOperative Medicine

• A Question.
• A 68 yo man recently diagnosed with AdenoCa of
  the cecum undergoes preoperative evaluation
  before surgical resection. His PMH includes
  inoperable CAD, heart failure with LVSF 35, HTN,
  hyperlipidemia. Angina is stable, occurring
  approx monthly, and he has no orthpnea or PND.
  Medications include lisinopril, carvedilol,
  lasix, zocor and daily ASA. He plays golf weekly
  and carries groceries up a flt of stairs to his
  apt.
• On physical, P 64, 120/64, JVD 6 Lungs CTA S1S2
  no S3. No LE edema
• CBC, Chem are WNL
• EKG NSR, Qwaves in II, III, AVF (old)

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PeriOperative Medicine

• Which of the following is the most appropriate
  next step in the preop eval of this pt?
• a. Order plasma BNP
• b. Echo
• c. Exercise stress test
• d. Nuclear imaging for LVEF
• e. No further evaluation
• What is his risk category??????

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PeriOperative Evaluation

• Question 2
• A 68 yo male with a PMH of CAD, HTN, chol,
  presents for a perioperative evaluation before
  AAA repair (open). His meds include lisinopril,
  HCTZ, Zocor, ASA. He has not had angina since
  undergoing a 3V CABG 4 yrs ago. He plays gold
  weekly, walking and carrying his clubs on a hilly
  course, walks two miles in 35-40 minutes 3w
  weekly and vacuums the house.
• PE P 78 BP 140/87. The remainder of the exam
  is unremarkable. Results of the
  electrocardiography are c/w his most recent
  electrocardiogram, with evidence of an old
  inferior infarction. CBC, Chem are WNL.

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Perioperative Medicine

• Which of the following is the most appropriate
  perioperative management in this pt?
• a. Atenolol
• b. Exercise stress testing
• c. Echocardiography
• d. Intraoperative Rt heart Cath (Swan)

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Perioperative Medicine

• Diabetes
• Anticoagulation
• DVT Prophylaxis
• Delirium
• HTN in Pregnancy