Perioperative Medicine Pearls

Perioperative Pearls, What Is
Necessary And What is

Appropriate
Saturday, 08 October 2011
M Chadi Alraies, MD FACP

Cleveland Clinic Foundation
Cleveland, Ohio, USA
Perioperative Pearls l Alraies l May 17, 2010

Disclosure
• None

Overview
Medical consultant role perioperative care

 Nuts and bolts of the preop assessment

Preoperative risk stratification

 Cardiopulmonary risk
 Risk reducing interventions
Perioperative anticoagulation in patients on VKA or those with

coronary stents

Scope of the problem

Pathophysiology

Surgery is Like a Plane Flight
Patient
Surgeon is the Anesthesia is

Pilot the Co-Pilot
Michota F, Jaffer A. Clev Clin J Med 2006

Medical Consultant = Mechanic
 What is the condition of the

plane?
 Is the plane in the best condition
to fly?
 Under the best conditions, what
can the plane handle?
 Is the long-term maintenance
program adequate?

Medical Consultant = Mechanic
Precise medical diagnoses


Evaluate the extent of organ disease


Optimize all medical conditions


Assess and describe physiologic limitations


Ensure adequate post-operative follow-up



Medical Consultant Role
 Should not tell the pilot or the

co-pilot when or how to fly
 Do not CLEAR patients for
surgery “optimize”
 Should not make anesthetic
recommendations

Preoperative Evaluation
Focus on the history


 Complete ROS, functional class, medications

Exam does not need to be comprehensive

Laboratory testing should be selective, not routine



Perioperative Cardiac
Risk Assessment

Case 1
 A 75-yo presents preop for a radical prostatectomy for prostate cancer.

PMHx includes CAD with h/o 3V-CABG about 2 years ago, HTN and
Type 2 DM. His current meds include: insulin, atenolol, ASA. He is
very active swimming several laps for about 30 minutes at least 3
times per week; no CP but he does get SOB.
 Exam: P=68, BP=130/75, RR=18
 Lungs=CTA; heart exam is normal except for a paradoxical split S2; LE

pulses are normal.

Question
According to the current ACC/AHA guidelines, is an


ECG recommended for this patient?


A.Yes
B.No

Question
According to the current ACC/AHA guidelines, is an


ECG recommended for this patient?

A.Yes
B.No
EKG is normal sinus with left

anterior hemiblock

What is the most appropriate next step in
regards to his cardiovascular risk?
A.Gated treadmill exercise test

B.Exercise thallium scintigraphy
C.Dobutamine echocardiography
D.Coronary angiography
E.No additional tests

regards to his cardiovascular risk?
A.Gated treadmill exercise test

B.Exercise thallium scintigraphy
C.Dobutamine echocardiography
D.Coronary angiography
E.No additional tests

ACC/AHA Guidelines
Preop ECG recommended

 Class I
 Vascular surgery patients with 1 risk factor*
Known CAD, PVD, CVD going for intermediate risk

surgery
Class IIa
Ischemic heart disease
Heart failure
 Vascular surgery Diabetes
Renal impairment
Class IIb
Cerebrovascular disease
 Intermediate risk surgery
 with 1 risk factor*
Fleisher LA et al. JACC 2007

J Am Coll Cardiol. 2007 Oct 23;50(17):1707-32.

Fleisher LA et al. J Am Coll Cardiol. 2007 Oct 23;50(17):1707-
32.
Perioperative
Perioperative Pearls Pearls
l Alraiesl May 17,17,
l May 2010
2010l
Factors Leading to Cumulative Risk for
Perioperative Cardiac Events
Fleisher LA et al. J Am Coll Cardiol. 2007 Oct 23;50(17):1707-

32.
Perioperative
l May 2010
2010l
Case 2
Perioperative
l May 2010
2010l
As the medical consultant, what is the MOST APPROPRIATE next
step?
1.Complete a full preoperative evaluation, including a

stress test, because she will need a vascular
procedure.
2.Ask the patient about her physical activity so you can
calculate her metabolic equivalents because she
will have an intermediate-risk surgery.
3.Evaluate her postoperatively for signs and symptoms
of a myocardial infarction (MI).
4.Ask for surgery to be delayed for 2 days until a β
blocker lowers her heart rate to between 55 and 65
bpm slowly.
Perioperative
l May 2010
2010l
Tailoring the Perioperative Evaluation
Based on the Urgency of Surgery
Perioperative
l May 2010
2010l
As the medical consultant, what is the MOST APPROPRIATE
next step?
1.Complete a full preoperative evaluation, including a
stress test, because she will need a vascular
procedure.
2.Ask the patient about her physical activity so you can
calculate her metabolic equivalents because she
will have an intermediate-risk surgery.
3.Evaluate her postoperatively for signs and symptoms
of a myocardial infarction (MI).
4.Ask for surgery to be delayed for 2 days until a β
blocker lowers her heart rate to between 55 and 65
bpm slowly.
Perioperative
l May 2010
2010l
Cardiovascular Risk Assessment
Is surgery emergent?
Yes Operating Room

Yes Operating Room
No
Active cardiac condition?
Yes Evaluate and Treat
Cardiac condition

ACC/AHA Guidelines
Active cardiac conditions that require evaluation and
treatment before noncardiac surgery
Unstable coronary syndromes


Decompensated HF

Significant arrhythmias

 High grade AV block, Mobitz II AV block, 3rd degree

AV block, new VT, symptomatic bradycardia,
symptomatic VT, SVT with RVR
Severe valvular heart disease


Yes Operating Room
No
Cardiac condition
No
Low-risk surgery?

Yes Operating Room
No
Cardiac condition
No
Low-risk surgery?
Yes Operating Room

No
No
Low-risk surgery?
Yes Operating Room
•Endoscopic procedures
•Superficial procedure
•Cataract
•Breast
Fleisher LA et al. JACC
2007

Yes Operating Room
No
Cardiac condition
No
Low-risk surgery?
Yes Operating Room
No
Good (>4 METs) Yes Operating Room
Functional capacity?
2007
No Dress, toilet independently 1 METs

Walk indoors around the house 2 METs
Active cardiac condition? Light housework, vacuum, laundry 3 METs
Walk up a hill or a flight of stairs 4 METs
Golf, bowling, dancing 6 METs
No
Tennis, running, swimming, basketball 8 METs
Low-risk surgery?
No
2007
No
1-2 Risk No Risk

+3 Risk Factors
Factors Factors
Ischemic heart disease

Heart failure
Diabetes
Renal impairment
Cerebrovascular disease
High risk surgery

2007
* Lee Cardiac Risk Index (RCRI)
Risk Category
 Event
Rate %
 Class I (0 pts) 0.5
 Class II (1 pt) 1.3
 Class III (2 pts) 3.6
 Class IV (>3 pts) 9.1
*Comprised of 6 factors: High-risk type surgery, ischemic heart

disease, h/o CHF, h/o Stroke, Diabetes on Insulin, Cr>2.0mg/dl
Lee et al. Circulation 1999;100:1043

Procedure Related Stress
 High (Reported cardiac risk >5%)
Emergent major operations
Surgical Stress Level

Aortic/vascular surgery
Prolonged surgical procedures; large fluid shifts/blood loss
 Intermediate (Reported cardiac risk =1-5%)

Carotid endarterectomy
Head and neck Surgery
Intraperitoneal and intrathoracic Surgery
Orthopedic Surgery
Prostate Surgery (other than TURP)
 Low (Reported cardiac risk <1%)

Endoscopic procedures
Superficial procedure
Cataract
Breast
TURP (based on most studies, but not included by ACC/AHA)
Michota F, Frost S; Med Clin N Am

2002

No
1-2 Risk No Risk

+3 Risk Factors
Factors Factors
Yes
Vascular Intermediate Vascular
surgery Risk surgery surgery
Operating Room
Coronary
Assessment Operating Room with heart rate control or
noninvasive testing if it will change management

What is the role for beta blockers
and/or statins?
Depends on patient risk and type of surgery

 Vascular surgery patients benefit from both

 Intermediate risk patients do not benefit from
statins (DECREASE-IV)
 Data is conflicting on the role of beta-blockers in
intermediate risk patients (POISE vs.
DECREASE-IV)

POISE vs. DECREASE IV
Both studies showed a reduction in CV events


POISE had excess strokes and overall mortality


Beta blocker doses and timing were different


 POISE (started just before surgery with maximum

therapeutic dose within 24 hours of surgery)
 DECREASE (started 30 days before surgery

using 12.5% of maximum therapeutic dose
Dunkelgrun M et al. Ann Surg 2009

B
= Beta Blocker = Statin
B

No
1-2 Risk No Risk

+3 Risk Factors
Factors Factors
Yes
Vascular Intermediate Vascular
B surgery Risk surgery B surgery
B B Operating Room
Coronary
Assessment Operating Room with heart rate control or
noninvasive testing if it will change management

B
= Beta Blocker
B

No
1-2 Risk No Risk

+3 Risk Factors
Factors Factors
Yes
Intermediate
Risk surgery
>2 weeks <2 weeks
Operating Room
B preop preop
B
Operating Room with heart rate Noninvasive testing
control or noninvasive testing if it will change management
Michota FA. Ohio ACP 2009

Case 3
 A 75-yo presents preop for a radical prostatectomy for prostate cancer.
PMHx includes CAD with h/o 2-vessel PTCA with DES stenting 8
months ago,
ago HTN and Type 2 DM. His current meds include: Insulin,
Atenolol, ASA, and clopidogrel.
clopidogrel He is very active swimming several
laps for about 30 minutes at least 3 times per week; no CP but he
does get SOB.
 Exam: P=68, BP=130/75, RR=18 Lungs=CTA; heart exam is normal

except for a paradoxical split S2; LE pulses are normal.
 EKG = NSR, LAHB

Which of the following is the most
appropriate recommendation at this time?
A.Proceed to surgery on clopidogrel and aspirin
B.Discontinue clopidogrel and proceed to surgery on aspirin
C.Discontinue clopidogrel and aspirin and proceed to surgery now
D.Discontinue clopidogrel and aspirin and proceed to surgery with

a LMWH bridge
E.Discontinue clopidogrel and aspirin and proceed to surgery after

a four month delay

Which of the following is the most
appropriate recommendation at this time?
A.Proceed to surgery on clopidogrel and aspirin
B.Discontinue clopidogrel and proceed to surgery on aspirin
C.Discontinue clopidogrel and aspirin and proceed to surgery now
D.Discontinue clopidogrel and aspirin and proceed to surgery with

a LMWH bridge
E.Discontinue clopidogrel and aspirin and proceed to surgery after

a four month delay

ACC/AHA Guidelines
Previous
PCI
Balloon BMS DES
Time <14d >14d >30-45d <30-45d <365d >365d

since
PCI
Delay for elective Proceed to surgery Delay for elective Proceed to surgery
or nonurgent surgery on aspirin or nonurgent surgery on aspirin

Grines CL et al. JACC 2007

Case 4
 A 55 yo female with h/o COPD (last FEV1=2L ~ 1 yr ago) HTN, OA and
obesity presents for preop evaluation 2 weeks before TAH. She has
smoked 2ppd for the last 40yrs.
 Her meds include Ipratropium /albuterol inhaler (which she uses

sporadically), HCTZ, and acetaminophen. She denies SOB, or
cough.
 Exam: P=75, BP= 130/80, RR=18, SaO2=98%. Lungs=decreased air

entry bilaterally but no wheezing. Heart exam is normal. Extremities
are normal.

regards to addressing her perioperative
pulmonary risk?
A.Preoperative spirometry
B.Re-education about daily inhaler use
C.Preoperative arterial blood gas (ABG)
D.Preoperative smoking cessation
E.Chest radiography
F.All of the above

regards to addressing her perioperative
pulmonary risk?
A.Preoperative spirometry
B.Re-education about daily inhaler use
C.Preoperative arterial blood gas (ABG)
D.Preoperative smoking cessation
E.Chest radiography
F.All of the above

Preoperative Spirometry
 No evidence for risk prediction perioperatively
 No threshold of values for which surgery is

contraindicated
 Consensus
 Lung Resection
 CABG
 Unexplained dyspnea or lung disease

ACP Guidelines for PFT’s. Ann Intern Med 1990;112:793-4

Qaseem A et al. Ann Intern Med 2006

Risk factors for Postoperative
Pulmonary Complications
 Patient
 COPD
 Age>60 yrs
 ASA class > II
 Functional dependence
 CHF
 Albumin <3.5g/dL
 Procedure
 >3 hours duration, general anesthesia, emergency
surgery
 Thoracic, vascular, head and neck, neurosurgical,
Qaseem A et al. Ann Internand
Med 2006
abdominal procedures
Risk factors for Postoperative
Pulmonary Complications
 Patient
 COPD Smoking data is mixed
 Age>60 yrs Obesity and mild
to moderate asthma are
 ASA class > II
not associated with
 Functional dependence increased risk
 CHF
 Albumin <3.5g/dL
 Procedure
 >3 hours duration, general anesthesia, emergency
surgery
 Thoracic, vascular, head and neck, neurosurgical,
Qaseem A et al. Ann Internand
Med 2006
abdominal procedures
Preoperative Pulmonary
Risk-Reduction Strategies
Smoking cessation (>6-8 wks)

Reduce airway obstruction


 Strict adherence to prescribed medications
 Preoperative steroids as needed
Antibiotics for respiratory infection


Preoperative lung expansion education


 Incentive spirometry
Smetana GW et al. N Engl J Med 1999
Qaseem A et al. Ann Intern Med 2006

Postop Pulmonary Risk-Reduction Strategies
 Good evidence of benefit
 Postoperative lung expansion modalities (A)
 Incentive spirometry, CPAP
 Selective postoperative nasogastric
decompression (B)
 Short-acting neuromuscular blockade (B)
 Equivocable evidence of benefit
 Laparoscopic (vs. open) operation (C)
 Conflicting evidence of benefit vs. harm
 Smoking cessation (I)
 Intraoperative neuraxial blockade (I)
 Postoperative epidural analgesia (I)
 Immunonutrition
Lawrence VA(I)
et al. Ann Int Med 2006

Anticoagulation and Surgery

Case 6
 72-year-old woman with history of rheumatic heart disease, atrial
fibrillation and s/p mechanical aortic valve is now scheduled for an
elective sigmoid resection for colon cancer.
 Patient is on warfarin with target INR 2.0-3.0.

What are your recommendations for
perioperative anticoagulation?
A.Stop warfarin 5 days before surgery and resume warfarin on the morning of surgery
B.Stop warfarin 5 days before, use SC full dose LMWH starting 3 days before surgery;
resume full dose LMWH with warfarin post-operatively until the INR is
between 2 - 3
C.Use FFP and IV Vitamin K to reverse the effect of warfarin in the AM of surgery and
then proceed with surgery
D.Stop warfarin 5 days before, start IV UFH the same day; resume IV UFH with
warfarin post-operatively until the INR is between 2 - 3
7.

What are your recommendations for
perioperative anticoagulation?
A.Stop warfarin 5 days before surgery and resume warfarin on the morning of surgery
B.Stop warfarin 5 days before, use SC full dose LMWH starting 3 days before surgery;
resume full dose LMWH with warfarin post-operatively until the INR is
between 2 - 3
C.Use FFP and IV Vitamin K to reverse the effect of warfarin in the AM of surgery and
then proceed with surgery
D.Stop warfarin 5 days before, start IV UFH the same day; resume IV UFH with
warfarin post-operatively until the INR is between 2 - 3
7.

Thrombosis Risk “Window”
A therapeutic patient (INR 2-3) will generally need 5

days off OAC to lower the INR to this level

 Pre-procedural “window” of thrombosis risk
Therapeutic OAC will take another 3-4 days after the


procedure
 Post-procedural “window” of thrombosis risk
White RH et al. Arch Intern Med. 1995

Who needs bridging therapy?

No randomized controlled trials

Expert opinion

Perioperative
Perioperative
Pearls l Pearls
Alraies l l May
May17,
17,2010
2010 l
Anticoagulation and Surgery
Bleeding Thrombosis
surgery
Perioperative
Perioperative
Pearls l Pearls
Alraies l l May
May17,
17,2010
2010 l
Communication
 Consultant
 Surgeon
 Anesthesia
 Nursing staff
Perioperative
Perioperative
Pearls l Pearls
Alraies l l May
May17,
17,2010
2010 l
Thrombosis Risk “Window”
OAC stopped OAC started
Days -5 0 1 5
INR>2.0 INR<1.5 INR>2.0
INR INR
1.5-2.0 1.5-2.0
Procedure
CHADS2 Score:
1.Recent CHF =1
2.Age ≥ 75 years
=1
3.Diabetes mellitus Kearon C et al. N Eng J Med 1997
=1 Gage J et al. JAMA 2001
4.Prior stroke or TIA
=2 Perioperative
Perioperative
Pearls l Pearls
Alraies l l May
May17,
17,2010
2010 l
UFH Bridge Protocol
Days -5 0 1 5
INR>2.0 INR>2.0
Begin IVUFH Stop IVUFH

Stop IVUFH Begin IVUFH*
Procedure
1 Week LOS

LMWH Bridge Protocol
Days -5 0 1 5
INR>2.0 INR>2.0
Begin LMWH Stop LMWH

Stop LMWH* Begin LMWH*
Procedure
1-2 Day LOS

Post-operative AC management consideration
• Close communication with surgeon and patient

• Monitor hemostasis, hematology and chemistry lab closely
• Start warfarin and prophylactic AC as soon as feasible
(within 24 hours)
• Avoid LMWH with impaired renal function (CrCl < 30 ml/min)
/ high risk bleeding surgery (neuro and cardiac)
• Full dose AC with 24 hours for moderate risk and 48-72 for
high risk for bleeding surgery.
• Fondaparinux is not recommended for bridging AC.
Perioperative
l May 2010
2010l
Thank you
Chadi Alraies, MD
Alraies@hotmail.com
www.chadialraies.blogspot.com

Perioperative Medicine Pearls

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Perioperative Medicine Pearls

Enviado por

Direitos autorais:

Formatos disponíveis

Perioperative Pearls, What Is

Necessary And What is

Saturday, 08 October 2011

M Chadi Alraies, MD FACP

Perioperative Pearls l Alraies l May 17, 2010

Perioperative Pearls l Alraies l May 17, 2010

 Nuts and bolts of the preop assessment

Perioperative Pearls l Alraies l May 17, 2010

Perioperative Pearls l Alraies l May 17, 2010

Perioperative Pearls l Alraies l May 17, 2010

Surgeon is the Anesthesia is

Michota F, Jaffer A. Clev Clin J Med 2006

Perioperative Pearls l Alraies l May 17, 2010

 What is the condition of the

Perioperative Pearls l Alraies l May 17, 2010

Precise medical diagnoses

Evaluate the extent of organ disease

Optimize all medical conditions

Assess and describe physiologic limitations

Ensure adequate post-operative follow-up

Perioperative Pearls l Alraies l May 17, 2010

 Should not tell the pilot or the

Perioperative Pearls l Alraies l May 17, 2010

Focus on the history

 Complete ROS, functional class, medications

Laboratory testing should be selective, not routine

Perioperative Pearls l Alraies l May 17, 2010

Perioperative Pearls l Alraies l May 17, 2010

 A 75-yo presents preop for a radical prostatectomy for prostate cancer.

 Exam: P=68, BP=130/75, RR=18

 Lungs=CTA; heart exam is normal except for a paradoxical split S2; LE

Perioperative Pearls l Alraies l May 17, 2010

According to the current ACC/AHA guidelines, is an

ECG recommended for this patient?

Perioperative Pearls l Alraies l May 17, 2010

According to the current ACC/AHA guidelines, is an

ECG recommended for this patient?

EKG is normal sinus with left

Perioperative Pearls l Alraies l May 17, 2010

A.Gated treadmill exercise test

Perioperative Pearls l Alraies l May 17, 2010

A.Gated treadmill exercise test

Perioperative Pearls l Alraies l May 17, 2010

Fleisher LA et al. JACC 2007

Perioperative Pearls l Alraies l May 17, 2010

Perioperative Pearls l Alraies l May 17, 2010

Fleisher LA et al. J Am Coll Cardiol. 2007 Oct 23;50(17):1707-

1.Complete a full preoperative evaluation, including a

Fleisher LA et al. JACC 2007

Perioperative Pearls l Alraies l May 17, 2010

Fleisher LA et al. JACC 2007

Perioperative Pearls l Alraies l May 17, 2010

Unstable coronary syndromes

 High grade AV block, Mobitz II AV block, 3rd degree

Fleisher LA et al. JACC 2007

Perioperative Pearls l Alraies l May 17, 2010

Fleisher LA et al. JACC 2007

Perioperative Pearls l Alraies l May 17, 2010

Fleisher LA et al. JACC 2007

Perioperative Pearls l Alraies l May 17, 2010

Perioperative Pearls l Alraies l May 17, 2010

No Dress, toilet independently 1 METs

1-2 Risk No Risk

Ischemic heart disease