36
Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Embed Size (px)

Citation preview

Page 1: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Perioperative Care: Preventing

ComplicationsSalim D. Islam, MDKaren E. Hauer, MD

2006

Page 2: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Workshop learning objectives

1. Learn the indications for preoperative testing and preparation for a healthy patient having elective surgery

2. Learn the indications for cardiac stress testing and beta blockade prior to noncardiac surgery

3. Understand new recommendations for preventing postoperative pulmonary complications

Page 3: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Outline

• Preoperative risk stratification

• Perioperative cardiac risk reduction

• Preventing postoperative pulmonary complications

Page 4: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Case #174 y.o. woman with CAD s/p stent in 1998, hypertension, osteoporosis, GERD, scheduled for cataract surgery. Able to walk 2 blocks, no chest pain or dyspnea. Meds: enalapril, lovastatin, ranitidine, aspirin.

PE: BP 128/70 HR 80

Surgeon asks you to perform routine preoperative tests and clear for surgery. What do you recommend?

Page 5: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Case #1What do you recommend prior to

cataract surgery?

A. CBC, lytes, creatinine, glucose, EKGB. Stress testC. A & BD. Recommend against surgeryE. Proceed with surgery

Page 6: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Routine Preoperative Testing before Cataract Surgery

N Engl J Med 2000;342;168

19,557 cataract surgeries• Randomized to preop testing

or no testing• Average age 74• 89% ASA class II or III• Outcome = perioperative

events

Page 7: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

ASA Physical StatusI Healthy DJD, Glaucoma

II Asymptomatic systemic disease

Hypertension,diabetes

III Symptomatic systemic disease

Stable angina, chronic renal insufficiency

IV Systemic disease - constant threat to life

COPD on home 02, Class III CHF

V Will die within 24 hours without surgery

Ruptured AAA

VI Brain dead organ donor

Page 8: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Routine Preoperative Testing before Cataract Surgery

N Engl J Med 2000;342;168

No testing

Routine testing

Relative risk (95%

CI)

Intraop events* 1.9% 2% 0.97

(0.8-1.2)

Postop events* 1.3% 1.2% 1.04

(0.8-1.3)*Events = Cardiac, Hyper/hypotension, Stroke/TIA, respiratory distress requiring treatment, hypoglycemia, DKA

Page 9: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Case #2: Preop Risk Stratification

55 y.o. woman scheduled for hysterectomy

PMH: hypertension, on hydrochlorothiazide

PE: BP 135/90 HR 85 Normal exam

EKG: Normal sinus rhythm, left ventricular hypertrophy

Page 10: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

What preoperative cardiac evaluation do

you recommend?A. None. Proceed with surgeryB. Add a beta-blockerC. Exercise stress testD. Exercise-thallium stress

test

Page 11: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Preventing Perioperative Cardiac

Complications•What are we trying to prevent?•Perioperative MI (mortality up to 15%)

•Mortality (all cause)•Other - CHF, ischemia, nonfatal arrhythmia

Page 12: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Risk of Cardiac Complications Based on Type

of Surgery• High (>5%)• Major aortic, peripheral vascular

surgery• Emergent major surgery• Long case - large fluid shifts, blood

loss

• Intermediate (<5%)• Carotid, head, neck• Abdominal, thoracic, pelvic• Orthopedic

• Low (<1%)• Endoscopic, skin, breast

Page 13: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Clinical Predictors of Perioperative Cardiac ComplicationsEagle, JACC 2002;39:542

Major MI within 1 month, unstable anginaDecompensated CHF, severe valve diseaseSignificant arrhythmia

Intermediate

Prior MIMild anginaCHFDiabetesCreatinine > 2.0 mg/dl

Minor Advanced ageAbnormal ECG or rhythm not sinusPrior strokeUncontrolled hypertensionFunctional capacity < 4 METs

Page 14: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Assessing Functional Capacity

1-4 METs EatDressWalk in house

4-10 METs Climb flight of stairsScrub floorsGolfShort run

10+ METs SwimmingSingles tennis

Page 15: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Case #3: Preop Hypertension Management

55 y.o. woman arrives for hysterectomy PMH: hypertension, on hydrochlorothiazide

PE: BP 185/100 HR 85 Normal exam

EKG: Normal sinus rhythm, left ventricular hypertrophy

How does your management change?

Page 16: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Outline

• Preoperative risk stratification

• Perioperative cardiac risk reduction

• Preventing postoperative pulmonary complications

Page 17: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Case #468 y.o. woman with type 2 diabetes, osteoarthritis of the knees, and hypothyroidism, scheduled for right hemicolectomy. Meds: glyburide, metformin, levothyroxine, acetaminophen. Non-smoker.

PE: BP 130/70 HR 88 98% RA 02 Sat

Page 18: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Case #4

What preoperative assessment do you recommend?

A. Proceed with surgeryB. Exercise treadmill testC. Persantine-thallium test D. Cardiac catheterizationE. Add atenolol

Page 19: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Preoperative Stress Testing

Eagle ACC/AHA 2002•Indications: 2 or more of the following–Intermediate clinical predictor (Eagle 2002)

• Stable cardiac disease, DM, Cr > 2–High risk surgery–Poor functional status (< 4 METs)

•Which test?–Ambulatory, normal ECG exercise treadmill–Ambulatory, abnormal ECG exercise + imaging

–Can’t exercise P-Thal or Dobutamine echo

•Better for ruling out than ruling in cardiac disease

Page 20: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Perioperative Beta Blockers

In what clinical settings would you prescribe a perioperative beta-blocker?

A. HypertensionB. Major vascular surgeryC. History of CADD. CAD risk factorsE. All surgical patients

Page 21: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Benefits of Perioperative Beta Blockers

• Reduce perioperative myocardial ischemia

• Decrease perioperative cardiac complications

• Improve survival

Page 22: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Perioperative Beta Blockers in Noncardiac

Surgery• Patients: 200 Veterans w/ CAD or 2 CAD risk factors

• Atenolol one hour prior to surgery until hospital discharge, unless HR < 55, vs. placebo

• Operations: major vascular, abdominal, ortho, neurosurg

• Outcomes: mortality, cardiac complications over 2 years

Mangano, NEJM, 1996

Page 23: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Perioperative Beta Blockers in Noncardiac

Surgery

Mangano, NEJM, 1996

0

5

10

15

20

25

6 month mortality 2 year mortality

AtenololPlaceob

Page 24: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Which Beta Blocker?• Cardioselective (atenolol, metoprolol)

– Effective– Fewest side effects

• Non-cardioselective (propranolol, nadolol)– Equally effective– More side effects - pulmonary, hypotension– Use only if patient already taking

• Avoid beta blockers with intrinsic sympathomimetic activity

• Consider clonidine if beta blockers contraindicated

Page 25: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Dosing Perioperative Beta Blockers

• Already taking a Beta Blocker:– Adjust previous dose to a target HR of 60

• New prescriptions:– Begin treatment with atenolol 25-50 mg q day within one month of surgery

– Consider a follow-up appt for HR check and dose adjustment 1-7 days before surgery

Page 26: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Outline

• Preoperative risk stratification

• Perioperative cardiac risk reduction

• Preventing postoperative pulmonary complications

Page 27: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Case # 5A 70 year old man with diabetes, hypertension, CAD, and COPD is admitted with right upper quadrant pain. He smokes 1 pack/day. Ultrasound reveals acute cholecystitis, and cholecystectomy is recommended. In addition to preoperative cardiac risk stratification, you consider the risk of pulmonary complications.

Page 28: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Case #5Which of the following is most likely to reduce the risk of perioperative pulmonary complications?

A.Preoperative CXRB.Incentive spirometryC.Laparoscopic techniqueD.Smoking cessation

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Page 29: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Perioperative Pulmonary

Complications• As common as postop cardiac complications; similar morbidity and mortality– Pulmonary complications may better predict long term mortality

• Most important and morbid:– Atelectasis– Pneumonia– Respiratory failure– Exacerbation of chronic lung disease

Page 30: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Risk assessment and strategies to reduce

perioperative pulmonary complications after

noncardiothoracic surgery: A guideline from the ACP

Ann Intern Med 2006;144:575

Page 31: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Patient risk factors for postop pulmonary

complicationsRisk factor Odds ratio

Age > 60 2.09 - 3.04

COPD 1.79

Current smoking 1.26

CHF 2.93

ASA class > I 4.87

Functional dependence

2.51 (total); 1.65 (partial)

Page 32: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Surgery risk factors for postop pulmonary

complications• Surgery type: abdominal, thoracic, neuro, head/neck, vascular, AAA

• Surgery > 3 hours• Emergency surgery• General anesthesia

QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.

Page 33: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Interventions to reduce postop

pulmonary complications: Preop

• Identify and target high risk patients– Patient and surgery risk risk factors

• Preop - consider:– Spirometry - only with COPD– CXR - for age > 50, high risk surgery, known cardiopulmonary disease

Page 34: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Interventions to reduce postop

pulmonary complications:

Post op• Lung expansion–Deep breathing exercises or –Incentive spirometry or–CPAP

• Selective use of NG tube after abdominal surgery–for nausea/emesis, inability to take p.o., abdominal distention

QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.

Page 35: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Interventions that might reduce postop

pulmonary complications:

• Laparoscopic instead of open surgery–Improves pain, spirometry, oxygenation

–Unclear benefit on clinically important pulmonary complications

• Epidural anesthesia/analgesia - unclear benefit

• Smoking cessation: > 2 months preop

Page 36: Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

Summary

• Preoperative risk stratification

• Perioperative cardiac risk reduction

• Preventing postoperative pulmonary complications