Transcript Planning for perioperative medicine

Optimizing the surgical patient
Dana Doll D.O.
Chair of Anesthesia
St Michaels Hospital
Stevens Point, WI
Surgery statistics
 40 million anesthetics are administered each year in
this country. Anesthesiologists provide or participate
in more than 90 percent of these anesthetics
 10 percent of the United States population
undergoes non-cardiac surgery annually.
 Over 8 million have known CAD or cardiac risk
factors.
 Over 50,000 will suffer a perioperative myocardial
infarction. (0.2%)
What are You Really Being Asked
to Do?
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Assess risks of anesthesia
Assess the risks of the procedure
Manage “complicated” medical problems
Predict the future
objectives
 Review the AHA/ACC guidelines for the cardiac
evaluation for a non-cardiac surgery
 Discuss OSA and anesthesia
 Discuss NPO status
 Medications to have and to hold
 Expectations for surgical procedures
 Anesthesia planning
ASA Physical Status Classification System
For emergent operations, you have to add the letter ‘E’ after the classification.
Surgical risk
ACC/AHA 2007 Guidelines on Perioperative
Cardiovascular Evaluation and Care for Noncardiac
Surgery
“The purpose of preoperative evaluation is not to give
medical clearance, but rather to perform an
evaluation of the patient’s current medical status;
make recommendations concerning the evaluation,
management, and risk of cardiac problems over the
entire perioperative period; and provide a clinical
risk profile that the patient, primary physician,
anesthesiologist, and surgeon can use in making
treatment decisions…”
Kim A. Eagle, FACC, Chair, ACC/AHA Task Force on Practice
Guidelines for Perioperative Cardiovascular Evaluation for
Noncardiac Surgery
ACC/AHA 2007 Guidelines on Perioperative
Cardiovascular Evaluation and Care for Noncardiac
Surgery
 The overriding theme of this document is that
intervention is rarely necessary to simply lower the
risk of surgery unless such intervention is indicated
irrespective of the preoperative context.
Cardiac optimization
 Optimizing the patient is optimizing the oxygen supply and demand.
 HR and BP control
 Slower less O2 demand
 Lower BP less work for heart less o2 demand
 Respiratory optimization
 Less O2 dissolved less to deliver
 Pulmonary HTN to CHF
 Renal optimization
 Acidosis
 Fluid overload
 Hematologic optimization
 O2 carrying capacity
 Neurologic optimization
 Cushing reflex
Cardiac evaluation and care algorithm for
noncardiac surgery
Cardiac evaluation and care algorithm for
noncardiac surgery
Unstable coronary syndromes
Recent MI
Decompensated HF
Significant arrhythmias
Severe valvular disease
Cardiac evaluation and care algorithm for
noncardiac surgery
Endoscopic procedures
Superficial procedure
Cataract surgery
Breast surgery
Ambulatory surgery
Cardiac evaluation and care algorithm for
noncardiac surgery
Cardiac evaluation and care algorithm for
noncardiac surgery
History Of Ischemic Heart Disease
History Of Compensated Or Prior HF
History Of Cerebrovascular Disease
Diabetes Mellitus
Renal Insufficiency
Pre operative testing
Echocardiography
 Assessment of LV Function
 Recommendations for Preoperative Noninvasive Evaluation of LV
Function
 Class IIa
 Dyspnea of unknown origin ( Level of Evidence: C )
 Current or prior HF with worsening dyspnea if not performed within
12 months. ( Level of Evidence: C )
 Class IIb
 Stable patients with previously documented cardiomyopathy ( Level
of Evidence: C )
 Class III
 Routine perioperative evaluation ( Level of Evidence: B )
EKG
 Resting 12-Lead ECG
 Class I
 1 clinical risk factor undergoing vascular procedures. (Level of
Evidence: B)
 known CAD, peripheral arterial disease, or cerebrovascular disease
undergoing intermediate-risk procedures. ( Level of Evidence: C )
 Class IIa
 no clinical risk factors undergoing vascular surgical procedures.
(Level of Evidence: B )
 Class IIb
 1 clinical risk factor and undergoing intermediate-risk procedures.
(Level of Evidence: B )
 Class III
 asymptomatic persons undergoing low-risk procedures. (Level of
Evidence: B )
Noninvasive Stress Testing
 Noninvasive Stress Testing
 Class I
 Active cardiac conditions in whom surgery is planned should be evaluated and
treated per ACC/AHA guidelines before surgery. (Level of Evidence: B)
 Class IIa
 3 or more clinical risk factors and poor functional capacity (less than 4 METs)
undergoing vascular surgery if it will change management. (Level of Evidence: B)
 Class IIb
 1 to 2 clinical risk factors and poor functional capacity (less than 4 METs)
undergoing intermediate-risk or vascular surgery if it will change management.
(Level of Evidence: B)
 Class III
 No clinical risk factors undergoing intermediate-risk surgery. ( Level of Evidence: C )
 Low-risk surgery. ( Level of Evidence: C )
Who gets Beta Blockers?
 Beta-Blocker Medical Therapy
 Class I
 Receiving beta blockers to treat angina, symptomatic arrhythmias, hypertension, or
other ACC/AHA class I guideline indications. ( Level of Evidence: C )
 Vascular surgery who are at high cardiac risk owing to the finding of ischemia on
preoperative testing. ( Level of Evidence: B )
 Class IIa
 Vascular surgery in whom preoperative assessment identifies CAD. ( Level of Evidence: B )
 vascular and 1 clinical risk factor. (Level of Evidence: B)
 CAD or 1 clinical risk factor, who are undergoing intermediate-risk or vascular surgery.
(Level of Evidence: B)
 Class IIb
 Intermediate-risk procedures or vascular surgery, in whom preoperative assessment
identifies a single clinical risk factor. (Level of Evidence: C)
 Vascular surgery with no clinical risk factors who are not currently taking beta blockers. (
Level of Evidence: B )
 Class III
 Absolute contraindications to beta blockade. ( Level of Evidence: C )
Who gets statins?
 Recommendations for Statin Therapy
 Class I
 currently taking statins and scheduled for noncardiac
surgery ( Level of Evidence: B )
 Class IIa
 vascular surgery (Level of Evidence: B )
 Class IIb
 1 clinical risk factor undergoing intermediate-risk
procedure (Level of Evidence: C )
Who gets coronary revascularization?
 CABG or Percutaneous Coronary Intervention
 Class I
 Any person who meets criteria according to ACC/AHA guidelines for revascularization ( Level
of Evidence: A )
 Class IIa
 Revascularization with PCI for mitigation of cardiac symptoms and elective noncardiac
surgery in the subsequent 12 months, balloon angioplasty or bare-metal stent placement
followed by 4 to 6 weeks of dual-antiplatelet therapy. ( Level of Evidence: B )
 drug-eluting coronary stents and who must undergo urgent surgical procedures that mandate
the discontinuation of thienopyridine therapy, it is reasonable to continue aspirin if at all
possible and restart the thienopyridine as soon as possible. ( Level of Evidence: C )
 Class IIb
 High-risk ischemic patients (e.g., abnormal dobutamine stress echocardiograph with at least 5
segments of wall-motion abnormalities). ( Level of Evidence: C )
 low-risk ischemic patients with an abnormal dobutamine stress echocardiograph (segments 1
to 4). ( Level of Evidence: B )
 Class III
 Prophylactic coronary revascularization in patients with stable CAD before noncardiac
surgery. ( Level of Evidence: B )
 Elective noncardiac surgery within 4 to 6 weeks of bare-metal coronary stent implantation or
within 12 months of drug-eluting coronary stent implantation in patients in whom
thienopyridine therapy, or aspirin and thienopyridine therapy, will need to be discontinued
perioperatively. (Level of Evidence: B )
 Elective noncardiac surgery is not recommended within 4 weeks of coronary
revascularization with balloon angioplasty. ( Level of Evidence: B )
A.T. Still
Labs
Pulmonary
 Formal spirometry rarely indicated
 Subjective response to bronchodilators
 Detailed H&P
 Smoking cessation
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24 hours will decrease carboxyhemoglobin levels
2-3 days will increase ciliary function but increase secretions
1-2 weeks will decrease secretions
4-8 weeks will decrease postop pulmonary complications
relative risk of pulmonary complications among smokers as
compared with nonsmokers ranges from 1.4 to 4.3
OSA
 Prevalence of sleep disordered breathing is 9% in women and
24% in men
 Overt OSA has been estimated to be 2% in women and 4% in men
 OSA is an independent risk factor for perioperative pulmonary
complications
 Case report demonstrates hemodynamic changes associated
with apneic episodes
 Pulse increase of up to40 bpm coinciding with hypoxia
 Similar increases in SBP with levels above 180 mmHg coinciding with
arousal
 Hemodynamic instability did not respond to supplemental oxygen but
resolved with CPAP
 Postoperative nocturnal hypoxia precipitated myocardial
ischemia in patients undergoing major vascular surgery
OSA
 Length of Stay
 7.2 days in patients with Obstructive Sleep Apnea not using
CPAP
 6.0 days if patients on CPAP
 5.1 days for patients in the control group
 Unplanned transfer to the ICU
 33.3% in patients with undiagnosed Obstructive Sleep
Apnea
 12.3% in patients with known Obstructive Sleep Apnea
 6% in controls
OSA
 Screening
 STOP BANG
 Testing
 Polysomnography
 Home pulse oximitry
Snoring
Tired
Observed Obstruction
Pressure (HTN)
BMI
Age (greater than 50)
Neck circumference
Gender
 Treatment and recommendations
 CPAP
 Oral appliance
 Prolonged postoperative monitoring
Medications to take or not to take
 Take day of surgery
 CV meds
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Beta blockers
Antiarrythmics
Clonidine
Statins
Anti-reflux
Seizure/ Parkinson
Psych– inform anesthesiologist
Bronchodilators
OCP– unless stopped for DVT prevention
Steroids – will likely get stress dose
Thyroid replacement
Pain meds– inform anesthesiologist
Medications to take or not to take
 Do not take day of surgery
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Diuretics
ACE/ ARB
Potassium
Diabetes oral medications
 Metformin-- lactic acidosis
 Basal insulin ½ dose
 Hold bolus doses while NPO
 NSAIDs/ ASA *
 Herbal supplements – one week
Meds associated with bleeding
 NSAIDs
 Diclofenac, IBU, indomethacin, keto – 1 day hold
 Naproxen and sulindac –3 day hold
 Meloxicam, nabumetone, piroxicam – 10 day hold
 COX2 inhibitors –2 days (nephrotoxicity)
 Antiplatelet
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Clopidigrel and Brillanta – 5 day hold
Effient – 7 day hold
ASA – 5 days
Do not stop antiplatelet agents without carefully reviewing
indications and minimum duration from stenting and
discussing with anesthesia, surgeon, and cardiologist
 Warfarin – 5 days with bridging
Newer anticoagulants
 Dabigatran (pradaxa)
 Creatinine clearance > 50 then stop 2 days
 Creatinine clearance < 50 then stop 5 days
 Consider doubling days of cessation prior to surgeries with
high risk of bleeding
 Rivaroxaban (Xarelto)
 Stop at least 1-2 days before procedure
 longer if chronic kidney disease or very high risk of bleeding
 Ticlopidine (Ticlid)– stop 5 days before surgery
Fasting guidelines
 Rule: 2, 4, 6, 8 rule applies to all ages
 No clear liquids within 2 hours of surgery
 Clear liquid definition
 Water, Fruit juice without pulp (e.g. apple juice), Gatorade,
Pedialyte, Carbonated beverage, Clear tea, Black coffee
 Not allowed as clear liquid: Milk, milk products or Alcohol
 No breast milk within 4 hours of surgery
 No solid foods within 6 hours of surgery
 Includes orange juice with pulp, light meals (toast or crackers),
infant formula and milk
 No fried foods, fatty foods or meats within 8 hours of
surgery
 These foods are associated with delayed gastric emptying
Pediatric pearls
 Cough cold fever chills – is patient ever optimized?
 Fever never good
 If surgery will fix problem then usually reasonable
 ASA 3 should go to pediatric center
 Oral sedation available
 Prolongs wake up times and discharge times
 Mask induction until age 8-12 depending on maturity
level
 PIV needed otherwise
Planning for anesthetic technique
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Regional and anticoagulation
Talk with anesthesia providers
Give patients preview of what to expect
Talk about NPO
Tell them about general anesthesia, spinals, nerve
blocks, sedation
 Pain expectations
Summary
 Reviewed the AHA/ACC guidelines for the cardiac
evaluation/ preparation for a non-cardiac surgery
 Discussed respiratory optimization
 Talked about day of surgery planning
 Examined the benefit of really understanding the
surgical process to better inform our patients
conclusion
References
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ASA website patient information fast facts
J Am Coll Cardiol 2007; 50 p e159-e241
Anesthesiology 2012; 116 p 522-38
Anesthesia & Analgesia 2011; 112 p 113-121
Anesthesiology 2011; 114 p 495-511
Lancet 2008; 372: 139–44
Questions
A. T. Still