Transcript Perioperative Medical Evaluation for Gynecological Surgery

Perioperative Medical
Evaluation for Gynecological
Surgery
Cullen Archer, MD
Obstetrics and Gynecology
June 2006
6 Key Elements to Medicine Preop
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Cardiac Risk
Pulmonary Risk
DVT Risk and Prevention
Endocarditis Prophylaxis
Perioperative Delirium
Steroids
Topics
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Preoperative Cardiovascular Evaluation
Antibiotic Prophylaxis
Endocarditis Prophylaxis
DVT Prophylaxis
Preoperative Cardiac Evaluation
• Evaluation tailored to circumstances
• H+P and ECG should identify potentially
serious cardiac disorders
• Define disease severity, stability, and prior
treatment
Clinical Predictors of Increased Perioperative Cardiovascular Risk
(Myocardial Infarction, Heart Failure, Death)
• Major
– Unstable coronary syndromes
• Acute or recent myocardial infarction* with evidence of
important ischemic risk by clinical symptoms or
noninvasive study
• Unstable or severe† angina (Canadian class III or IV)‡
– Decompensated heart failure
– Significant arrhythmias
• High-grade atrioventricular block
• Symptomatic ventricular arrhythmias in the presence of
underlying heart disease
• Supraventricular arrhythmias with uncontrolled
ventricular rate
– Severe valvular disease
*The American College of Cardiology National Database Library defines recent MI as greater than 7
days but less than or equal to 1 month (30 days); acute MI is within 7 days.
†May include “stable” angina in patients who are unusually sedentary.
‡Campeau L. Grading of angina pectoris. Circulation. 1976;54:522–523.
Clinical Predictors of Increased Perioperative Cardiovascular Risk
(Myocardial Infarction, Heart Failure, Death)
• Intermediate
– Mild angina pectoris (Canadian class I or II)
– Previous myocardial infarction by history or
pathological Q waves
– Compensated or prior heart failure
– Diabetes mellitus (particularly insulindependent)
– Renal insufficiency
Clinical Predictors of Increased Perioperative Cardiovascular Risk
(Myocardial Infarction, Heart Failure, Death)
• Minor
– Advanced age
– Abnormal ECG (left ventricular hypertrophy, left
bundle-branch block, ST-T abnormalities)
– Rhythm other than sinus (e.g., atrial fibrillation)
– Low functional capacity (e.g., inability to climb
one flight of stairs with a bag of groceries)
– History of stroke
– Uncontrolled systemic hypertension
Functional Capacity
1 MET Can you take care of yourself?
Eat, dress, or use the toilet?
Walk indoors around the house?
Walk a block or two on level ground at 2-3 mph (4.8kph)
4 MET Do light work around the house like dusting or washing
dishes?
Climb a flight of stairs or walk up a hill?
Run a short distance?
Do heavy work around the house like scrubbing floors or
lifting or moving heavy furniture
Participate in moderate recreational activities like golf,
bowling, dancing, doubles tennis, or throwing a
baseball or football?
>10
Participate in strenuous sports like swimming, singles
tennis, football, basketball, or skiing?
Cardiac Risk* Stratification for Noncardiac Surgical Procedures
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High (Reported cardiac risk often greater than 5%)
• Emergent major operations, particularly in the elderly
• Aortic and other major vascular surgery
• Peripheral vascular surgery
• Anticipated prolonged surgical procedures associated with large fluid
shifts and/or blood loss
Intermediate (Reported cardiac risk generally less than 5%)
• Carotid endarterectomy
• Head and neck surgery
• Intraperitoneal and intrathoracic surgery
• Orthopedic surgery
• Prostate surgery
Low† (Reported cardiac risk generally less than 1%)
• Endoscopic procedures
• Superficial procedure
• Cataract surgery
• Breast surgery
*Combined incidence of cardiac death and nonfatal myocardial infarction.
†Do not generally require further preoperative cardiac testing.
ACC/AHA PRACTICE GUIDELINES:ACC/AHA Guideline Update for Perioperative Cardiovascular
Evaluation for Noncardiac Surgery—Executive Summary. J Am Coll Card. 2002; 39: 542-553.
ACC/AHA PRACTICE GUIDELINES:ACC/AHA Guideline Update for Perioperative Cardiovascular
Evaluation for Noncardiac Surgery—Executive Summary. J Am Coll Card. 2002; 39: 542-553.
ACC/AHA PRACTICE GUIDELINES:ACC/AHA Guideline Update for Perioperative Cardiovascular
Evaluation for Noncardiac Surgery—Executive Summary. J Am Coll Card. 2002; 39: 542-553.
Specific Preoperative Conditions
Hypertension
– ≥ 180/110 should be controlled preoperatively
– Perioperative  antagonists
Valvular Heart Disease
Myocardial Disease
Arrhythmias
Specific Preoperative Conditions
• Implantable Pacemakers and Interventricular
Conduction Devices
– unipolar or bipolar pacemaker leads
– Electrocautery: bipolar or unipolar ?
• ICD devices should be programmed off
immediately before surgery and then on
again postoperatively
Surgical Site Prophylaxis
Antimicrobial Prophylactic Regimens by Procedure
Procedure
Antibiotic
Vaginal/abdominal
cefazolin
hysterectomy*
Cefoxitin
Cefotetan
Metronidazole
Laparoscopy
None
Laparotomy
None
Hysteroscopy
None
Hysterosalpingogram
Doxycycline†
IUD insertion
None
Endometrial biopsy
None
Induced abortion/D&C
Doxycycline
Metronidazole
Urodynamics
Dose
1 or 2 g single dose IV
2 g single dose IV
1 or 2 g single dose IV
500 mg single dose IV
100 mg po BID x 5 days
100 mg orally 1 hour
before and 200 mg orally
after the procedure
500 mg po BID for 5 days
None
*A convenient time to administer antibiotic prophylaxis is just before induction of anesthesia
†If hysterosalpingogram demonstrates dilated tubes. No prophylaxis is indicated for a normal study.
ACOG Practice Bulletin 23, January 2001
Endocarditis Prophylaxis
Endocarditis prophylaxis recommended
Respiratory tract
Tonsillectomy and/or adenoidectomy
Surgical operations that involve respiratory mucosa
Bronchoscopy with a rigid bronchoscope
Gastrointestinal tract1
Sclerotherapy for esophageal varices
Esophageal stricture dilation
Endoscopic retrograde cholangiography with biliary
obstruction
Biliary tract surgery
Surgical operations that involve intestinal mucosa
Genitourinary tract
Prostatic surgery
Cystoscopy
Urethral dilation
1Prophylaxis
is recommended for high-risk patients; it is optimal for medium-risk patients.
Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association. Circulation. 1997;96:358-366.
Endocarditis Prophylaxis
Endocarditis prophylaxis not recommended
Respiratory tract
Endotracheal intubation
Bronchoscopy with a flexible bronchoscope, with or without biopsy2
Tympanostomy tube insertion
Gastrointestinal tract
Transesophageal echocardiography2
Endoscopy with or without gastrointestinal biopsy2
Genitourinary tract
Vaginal hysterectomy2
Vaginal delivery2
Cesarean section
In uninfected tissue:
Urethral catheterization
Uterine dilatation and curettage
Therapeutic abortion
Sterilization procedures
Insertion or removal of intrauterine devices
Other
Cardiac catheterization, including balloon angioplasty
Implanted cardiac pacemakers, implanted defibrillators, and coronary stents
Incision or biopsy of surgically scrubbed skin
Circumcision
2Prophylaxis
is optional for high-risk patients
Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association. Circulation. 1997;96:358-366.
Endocarditis Prophylaxis
ACC/AHA Recommendations for Antibiotic Prophylaxis to Prevent Bacterial Endocarditis
ACOG Practice Bulletin No. 47, October 2003
Prophylactic regimens for GI/GU Procedures
Situation
High-risk patients
Agents
Ampicillin plus
Gentamicin
High-risk patients allergic
to ampicillin/amoxicillin
Vancomycin
plus gentamicin
Moderate-risk patients
ampicillin
Amoxicillin or
ampicillin
Moderate-risk patients
allergic to ampicillin/
amoxicillin
Regimen
Adults: ampicillin 2.0 g IM or IV plus gentamicin 1.5
mg/kg (not to exceed 120 mg) within 30 min of starting
procedure; 6 hr later, ampicillin 1 g IM/IV or amoxicillin 1
g orally
Children: ampicillin 50 mg/kg IM or IV (not to exceed 2.0
g) plus gentamicin 1.5 mg/kg within 30 min of starting
the procedure; 6 h later, ampicillin 25 mg/kg IM/IV or
amoxicillin 25 mg/kg orally
Adults: vancomycin 1.0 g IV over 1-2 h plus gentamicin
1.5 mg/kg IV/IM (not to exceed 120 mg); complete
injection/infusion within 30 min of starting procedure
Children: vancomycin 20 mg/kg IV over 1-2 h plus
gentamicin 1.5 mg/kg IV/IM; complete injection/infusion
within 30 min of starting procedure
Adults: amoxicillin 2.0 g orally 1 h before procedure, or
2.0 g IM/IV within 30 min of starting procedure
Children: amoxicillin 50 mg/kg orally 1 h before
procedure, or ampicillin 50 mg/kg IM/IV within 30 min of
starting procedure
Vancomycin
Adults: vancomycin 1.0 g IV over 1-2 h
complete infusion within 30 min of starting procedure
Children: vancomycin 20 mg/kg IV over 1-2 h; complete
infusion within 30 min of starting procedure
IM indicates intramuscularly, and IV, intravenously.
1Total children’s dose should not exceed adult dose.
2No second dose of vancomycin or gentamicin is recommended.
Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association. Circulation. 1997;96:358-366.
Infective Endocarditis
Definition of Infective Endocarditis According to the Modified Duke Criteria
Definite infective endocarditis
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Pathological criteria: microorganisms demonstrated by culture or histological examination of a vegetation,
a vegetation that has embolized, or an intracardiac abscess specimen; or
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Pathological lesions: vegetation or intracardiac abscess confirmed by histological examination showing
active endocarditis
Clinical criteria
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2 major criteria; or
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1 major criterion and 3 minor criteria; or
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5 minor criteria
Possible IE
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1 major criterion and 1 minor criterion; or
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3 minor criteria
Rejected
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Firm alternative diagnosis explaining evidence of IE; or
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Resolution of IE syndrome with antibiotic therapy for < 4 days; or
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No pathological evidence of IE at surgery or autopsy, with antibiotic
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therapy for < 4 days; or
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Does not meet criteria for possible IE as above
Modifications shown in boldface.
Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications. A Statement for Healthcare
Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular
Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American
Heart Association. Circulation. 2005; 111:e394-e433.
Modified Duke Criteria
Major criteria
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Blood culture positive for IE
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Typical microorganisms consistent with IE from 2 separate blood cultures: Viridans streptococci, Streptococcus bovis, HACEK
group, Staphylococcus aureus; or community-acquired enterococci in the absence of a primary focus; or
Microorganisms consistent with IE from persistently positive blood cultures defined as follows: At least 2 positive cultures of blood
samples drawn > 12 h apart; or all of 3 or a majority of ≥ 4 separate cultures of blood (with first and last sample drawn at least 1 h
apart)
Single positive blood culture for Coxiella burnetii or anti–phase 1 IgG antibody titer >1:800
Evidence of endocardial involvement
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Echocardiogram positive for IE (TEE recommended for patients with prosthetic valves, rated at least “possible IE” by clinical
criteria, or complicated IE paravalvular abscess; TTE as first test in other patients) defined as follows: oscillating intracardiac
mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative
anatomic explanation; or abscess; or new partial dehiscence of prosthetic valve; new valvular regurgitation (worsening or changing
or preexisting murmur not sufficient)
Minor criteria
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Predisposition, predisposing heart condition, or IDU
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Fever, temperature > 38°C
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Vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm,
intracranial hemorrhage, conjunctival hemorrhages, and Janeway’s lesions
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Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, and
rheumatoid factor
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Microbiological evidence: positive blood culture but does not meet a major criterion as
noted above* or serological evidence of active infection with organism consistent with IE
Echocardiographic minor criteria eliminated
Modifications shown in boldface.
*Excludes single positive cultures for coagulase-negative staphylococci and organisms that do not cause endocarditis.
Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications. A Statement for Healthcare Professionals From the Committee on
Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke,
and Cardiovascular Surgery and Anesthesia, American Heart Association. Circulation. 2005; 111:e394-e433.
DVT Prophylaxis
Absolute Risk for DVT in Hospitalized Patients
Patient Group
DVT Prevalence, %
Medical patients
10–20
General surgery
15–40
Major gynecologic surgery
15–40
Major urologic surgery
15–40
Neurosurgery
15–40
Stroke
20–50
Hip or knee arthroplasty, hip fracture surgery
40–60
Major trauma
40–80
Spinal cord injury
60–80
Critical care patients
10–80
*Rates based on objective diagnostic testing for DVT in patients not receiving thromboprophylaxis.
DVT Prophylaxis
Risk Factors for VTE
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Surgery
Trauma (major or lower extremity)
Immobility, paresis
Malignancy
Cancer therapy (hormonal, chemotherapy, or radiotherapy)
Previous VTE
Increasing age
Pregnancy and the postpartum period
Estrogen-containing oral contraception or hormone replacement therapy
Selective estrogen receptor modulators
Acute medical illness
Heart or respiratory failure
Inflammatory bowel disease
Nephrotic syndrome
Myeloproliferative disorders
Paroxysmal nocturnal hemoglobinuria
Obesity
Smoking
Varicose veins
Central venous catheterization
Inherited or acquired thrombophilia
ACCP Grading Recommendations
Applying the Grades of Recommendation for Antithrombotic and Thrombolytic Therapy The Seventh ACCP Conference on
Antithrombotic and Thrombolytic Therapy. CHEST 2004; 126:179S–187S)
DVT Prophylaxis - Recommendations
Minor Surgery
• < 30 minutes for benign disease
• Recommend against use if specific
prophylaxis other than early and persistent
mobilization (Grade 1C).
Laparoscopy
• If VTE risk factors are present, we
recommend the use of thromboprophylaxis
with one or more of the following: LDUH,
LMWH, IPC, or GCS (all Grade 1C)
DVT Prophylaxis - Recommendations
Major Surgery
• Benign with no additional R.F.
– LDUH, 5,000 U bid (Grade 1A)
– once-daily prophylaxis with LMWH ≤ 3,400 U/d (Grade
1C+), or
– IPC started just before surgery and used continuously while
the patient is not ambulating (Grade 1B)
• Malignant, or with additional R.F.
– DUH, 5,000 U tid (Grade 1A), or
– higher doses of LMWH (i.e., > 3,400 U/d) [Grade 1A]
– Alternative considerations include IPC alone continued until
hospital discharge (Grade 1A), or
– combination of LDUH or LMWH plus mechanical
prophylaxis with GCS or IPC (all Grade 1C)
DVT Prophylaxis - Recommendations
Duration of Prophylaxis
• until discharge from the hospital (Grade 1C)
• if particularly high risk, including those who have
undergone cancer surgery and are > 60 years of
age or have previously experienced VTE,
prophylaxis for 2 to 4 weeks after hospital discharge
(Grade 2C)