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Perioperative Care: Preventing
ComplicationsSalim D. Islam, MDKaren 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
Outline
• Preoperative risk stratification
• Perioperative cardiac risk reduction
• Preventing postoperative pulmonary complications
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?
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
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
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
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
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
What preoperative cardiac evaluation do
you recommend?A. None. Proceed with surgeryB. Add a beta-blockerC. Exercise stress testD. Exercise-thallium stress
test
Preventing Perioperative Cardiac
Complications•What are we trying to prevent?•Perioperative MI (mortality up to 15%)
•Mortality (all cause)•Other - CHF, ischemia, nonfatal arrhythmia
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
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
Assessing Functional Capacity
1-4 METs EatDressWalk in house
4-10 METs Climb flight of stairsScrub floorsGolfShort run
10+ METs SwimmingSingles tennis
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?
Outline
• Preoperative risk stratification
• Perioperative cardiac risk reduction
• Preventing postoperative pulmonary complications
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
Case #4
What preoperative assessment do you recommend?
A. Proceed with surgeryB. Exercise treadmill testC. Persantine-thallium test D. Cardiac catheterizationE. Add atenolol
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
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
Benefits of Perioperative Beta Blockers
• Reduce perioperative myocardial ischemia
• Decrease perioperative cardiac complications
• Improve survival
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
Perioperative Beta Blockers in Noncardiac
Surgery
Mangano, NEJM, 1996
0
5
10
15
20
25
6 month mortality 2 year mortality
AtenololPlaceob
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
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
Outline
• Preoperative risk stratification
• Perioperative cardiac risk reduction
• Preventing postoperative pulmonary complications
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.
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.
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
Risk assessment and strategies to reduce
perioperative pulmonary complications after
noncardiothoracic surgery: A guideline from the ACP
Ann Intern Med 2006;144:575
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)
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.
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
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.
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
Summary
• Preoperative risk stratification
• Perioperative cardiac risk reduction
• Preventing postoperative pulmonary complications