Transcript an_approach_to_pre-op_assessment

Cardiovascular
Pre-Operative Evaluation
for Non-Cardiac Surgery
Jessica Thom
PGY-1
2007 ACC/AHA Pre-Op Guidelines for
Cardiovascular Evaluation and Care for
Non-Cardiac Surgery
Heart disease and procedures
 1.3 million Canadians (4.3%) reported to have heart
disease
 The prevalence of heart disease increases with age
 The largest number of non-cardiac surgical procedures
performed in patients aged 65 and older.
Methodology & Evidence
 Literature searches in PubMed, MEDLINE and Cochrane
Library
 Searches limited to studies published in English between
2002-07
 Reviewed 400 relevant new articles focused on
perioperative risk for cardiac complications following
non-cardiac surgery
Role of the consultant
 Review available patient data
 Obtain a pertinent history
 Perform a thorough physical examination
 Suggest preoperative tests/procedures or higher levels of
post-op care
 Pre-op tests are generally only indicated if the information obtained will
change treatment
 Be weary of solely focusing on the question at hand. Aim
instead to provide a comprehensive evaluation of the
patient’s risk
History
 Cardiac history: unstable/stable angina, prior MI,
decompensated HF, arrhythmias, severe valvular disease,
presence of pacemaker/ICD
 If cardiac disease is present: any recent change in symptoms?
 Evidence of associated diseases: DM, CKD, stroke, PVD,
chronic pulmonary disease
 Record all medications (including herbals)
 Social habits: smoking history
 Determine the functional capacity
 As determined based on METS
What’s a MET?
What cardiac conditions should I work up and treat?
Physical Exam
 Vital signs
 General appearance
 Cardiac exam
 Pulmonary exam
 Examination of area undergoing surgery
Clinical risk factors for cardiac
complications in non-cardiac surgery
 High risk surgery
 Ischemic heart disease
 Heart failure
 Diabetes
 Renal insufficiency – Pre-op creatinine > 2.0mg/DL (175 mmol/L)
 Previous stroke
Relative risks of surgical
procedures
 Low risk: Opthalmologic procedures, superficial
procedures, endoscopy, breast surgeries
 Intermediate risk: Orthopedic surgeries, intraabdominal surgeries, intra-thoracic surgeries, ENT
surgeries, prostate surgery, carotid endarterectomies
 High risk: All other vascular surgeries
The all important algorithm
Figure 1. Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known
cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater. *See Table 2 for active clinical
conditions. †See Clas...
Fleisher L A et al. Circulation 2007;116:e418-e500
Copyright © American Heart Association
Additional Testing?
Role of a 12-lead EKG
 Indicated in:
 All patients undergoing vascular surgery
 Patients with at least 1 clinical risk factor undergoing
intermediate risk surgery
Non-invasive stress testing
 Reasonable in patients with 3+ clinical risk factors and poor
functional capacity (<4 METS) undergoing vascular surgery if it
will change management (IIa)
 Consider in patients with 2+ clinical risk factors and poor
functional capacity undergoing intermediate-risk surgery if it
will change management (IIb)
Pre-op Coronary Revascularization
with CABG or PCI
Class I:
 In patients with acute STEMI
 In patients with high-risk unstable angina or NSTEMI
 In patients with stable angina who have:
 Significant left main disease
 3-vessel disease (survival benefit greater in patients with EF <50%)
 2-vessel disease + significant proximal LAD stenosis + either EF
<50% or ischemia on non-invasive testing.
Class IIa:
 In patients whom PCI will mitigate cardiac symptoms and
who need elective non-cardiac surgery in the next 12 months
 Balloon angioplasty or bare-metal stent placement followed by
4 to 6 weeks of dual-antiplatelet therapy is indicated.
Beta blockers?
Limitations in the perioperative beta-blocker literature include
the following:
 Few randomized trials have examined the role of
perioperative beta-blocker therapy
 Most trials are inadequately powered.
 Studies to determine the optimal type of beta blockers are
lacking.
 Few studies addressing the optimal time at which beta
blockers should be started in the perioperative period.
What to do about those stents?
Figure 2. Proposed approach to the management of patients with previous percutaneous
coronary intervention (PCI) who require noncardiac surgery, based on expert opinion.
Fleisher L A et al. Circulation 2007;116:e418-e500
Copyright © American Heart Association
Figure 3. Proposed treatment for patients requiring percutaneous coronary intervention (PCI)
who need subsequent surgery.
Fleisher L A et al. Circulation 2007;116:e418-e500
Copyright © American Heart Association
For the full guidelines:
http://circ.ahajournals.org/content/116/17/e418.full
Pulmonary Pre-Operative
Evaluation for Non-Pulmonary
Surgery
Risk factors
 Age >50
 Chronic lung disease
 Asthma
 Smoking
 OSA
 Pulmonary HTN
 Poor functional status
 Upper respiratory infection
Procedural risk factors
 Site of surgery
 Highest risk – thoracic, upper abdominal surgeries, AAA
repair, ENT, neurosurgery
 Duration of surgery – greater than 3 to 4 hours
 Type of anesthesia?
Pulmonary Function Testing
 May be useful in the following cases:
 Identifying patients in whom risk of surgery does not justify
the benefit
 Identifying patients at high risk that may benefit from
aggressive pre-op optimization
Pulmonary Function Testing
 ACP recommendations:
 Do not obtain PFTs routinely to predict pulmonary post-op
complications
 PFTs should NOT deny a patient surgery
 Obtain PFTs:
 In patients with COPD or asthma if clinical evaluation cannot
determine is patient is at best baseline and would benefit
from pre-op optimization
 In patients with dyspnea and exercise intolerance that
remains unexplained after clinical evaluation
Chest X-Ray
 Add little to clinical evaluation of healthy patients
 Obtain CXR:
 In patients with known cardiopulmonary disease
 Unless CXR has been obtained in past 6 months
 In patients aged > 50 undergoing high risk procedures
(thoracic/upper abdominal surgeries, AAA repair, ENT
surgeries).
Arrouzullah Respiratory Failure Index
Pre-operative predictor
Point value
Type of surgery
AAA
27
Thoracic
21
Neurosurgery, upper abdominal
14
ENT
11
Emergency surgery
11
Albumin <3.0g/dL
9
BUN >30 mg/dL
8
Partially/fully dependent functional status
7
History of COPD
6
Age
>70
6
60-69
4
Arouzullah Respiratory Failure Index
Class
Point total
%Resp Failure
1
<10
0.5
2
11-29
1.8
3
20-27
4.2
4
28-40
10.1
5
>40
26.6