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Challenges in Pre-Operative Evaluation
Geoff Stetson, MDAssistant Professor of Medicine, UCSFHospitalist, San Francisco VA Medical Center
I have no disclosures
Special Thanks
Heather Nye, MD, PhD• Professor of Medicine UCSF
• Director of Co-Management Service and Veterans Integrated Preoperative Clinic at San Francisco VA Medical Center
Henry Crevensten, MD• Associate Professor of Medicine UCSF
• Director of Quality Improvement at San Francisco VA Medical Center
Challenges in Pre-Operative Evaluation3
Roadmap
Overview of pre-op evaluation
Case 1 – 10 Minutes
• Cardiac risk-stratification in pre-operative evaluation
• High-risk medications
Case 2 – 10 Minutes
• Pulmonary risk-stratification in pre-operative evaluation
• OSA considerations
Case 3 – 5 Minutes
• An approach to geriatric pre-operative evaluation
4 Challenges in Pre-Operative Evaluation
Learning Objectives
Understand the risks and benefits of pre-operative evaluation
Appropriately risk-stratify a patient from a cardiac standpoint
Explain how to modify use of certain high-risk medications in the perioperative period
Describe PPCs and their role in perioperative care
Appropriately risk-stratify a patient from a pulmonary standpoint
Understand the role of OSA in the perioperative period
Develop a holistic framework for approaching the pre-operative evaluation of a geriatric patient
5 Challenges in Pre-Operative Evaluation
Goals of Pre-Op Evaluation
Evaluate risk of a procedure to a particular patient
• Allows for informed decision-making
Optimize medical conditions
Minimize unnecessary testing
Minimize complications
6 Challenges in Pre-Operative Evaluation
Prevalence and Costs
~30 million people/yr undergo surgery in US, most ambulatory1
~18% of cataract surgery patients had preoperative consultation2
~ 50% of preoperative consultants recommended an unnecessary test3
Preoperative testing costs ~$18 Billion annually in the U.S.4
7
1. Onuoha OC, Arkoosh VA, Fleishre LA. JAMA Int Med. 2014; 174(8):1391-13952. Thilen S, Treggiari M, Lange J et al. JAMA Int Med. 2014; 173(3):380-3883. Kachalia A, Berg A, Fagerlin A, et al. Ann Intern Med. 2015; 162(2):100-1084. Kumar A, Srivastava U. J Anaesthesiol Clin Pharmacol. 2011 Apr;27(2):174-9
Challenges in Pre-Operative Evaluation
Risks of Unnecessary PreOp Testing
Worse Patient and System Outcomes
Harm
CostDelay
8 Challenges in Pre-Operative Evaluation
Case 110 Minutes
9 Challenges in Pre-Operative Evaluation
Question 1
10
ClearanceRisk
Stratification
Challenges in Pre-Operative Evaluation
General Approach
Update H&P Cardiac Risk Assessment
Pulmonary Risk
Assessment
Medication History
Substance Abuse and
EtOH Screen
Optimize Medical Co-Morbidities
11 Challenges in Pre-Operative Evaluation
Source of Guiding Principles
12 Challenges in Pre-Operative Evaluation
ACC/AHA Flowchart
13 Challenges in Pre-Operative Evaluation
ACC/AHA Flowchart
14
CAD = Coronary Artery Disease, ACS = Acute Coronary Syndrome, GDMT = Guideline-Directed Medical Therapy, MACE = Major Adverse Cardiac Events
Challenges in Pre-Operative Evaluation
Risk Calculators
Revised Cardiac Risk Index (RCRI)
American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP)
15 Challenges in Pre-Operative Evaluation
RCRI
Revised Cardiac Risk Index (RCRI)
• 6 Predictors of MACE (MI, V.fib, Cardiac Arrest, Complete Heart Block, Pulm Edema)
• 0-1 predictors = low risk
• 2+ predictors = high risk
• One center; thoracic, vascular, ortho over-represented
• Retrospectively validated numerous times
16
Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999;100:1043-9.
Challenges in Pre-Operative Evaluation
RCRI
17
Revised Cardiac Risk Index (RCRI)
1. CAD (MI, + stress, use NTG, CP c/w angina, Q-waves)
2. CHF
3. CVA/TIA
4. DM (requiring insulin)
5. CKD (Cr > 2.0 mg/dL)
6. High Risk Surgery (suprainguinal vascular, intraperitoneal, intrathoracic)
Score % of MACE
0 0.4%
1 0.9%
2 6.6%
3+ 11%
Challenges in Pre-Operative Evaluation
ACS NSQIP
21 predictors, created in 2011
525 US hospitals, > 1 million operations
Calculates risk of: MACE, death, PNA, VTE, AKI, return to OR, unplanned intubation, discharge to rehab/nursing home, surgical infection, UTI
Limitations: Not validated outside NSQIP, unclear what to do with all the predictive information
18 Challenges in Pre-Operative Evaluation
ACS NSQIP – Inputs
19 Challenges in Pre-Operative Evaluation
Did anyone use a calculator?
Which one?
How did our patient do?
20 Challenges in Pre-Operative Evaluation
RCRI
21
Revised Cardiac Risk Index (RCRI)
1. CAD (MI, + stress, use NTG, CP c/w angina, Q-waves)
2. CHF
3. CVA/TIA
4. DM (requiring insulin)
5. CKD (Cr > 2.0 mg/dL)
6. High Risk Surgery (suprainguinal vascular, intraperitoneal, intrathoracic)
Score % of MACE
0 0.4%
1 0.9%
2 6.6%
3+ 11%
Challenges in Pre-Operative Evaluation
ACS NSQIP – Results
22 Challenges in Pre-Operative Evaluation
ACC/AHA Flowchart
23
METs = Metabolic Equivalents; CPG = Clinical Practice Guidelines; GDMT = Guideline-Directed Medical Therapy
Challenges in Pre-Operative Evaluation
Functional Capacity
1 MET (metabolic equivalent) = basal O2 consumption of a 70 kg 40-year-old man
>10 METs Excellent
7-10 METs Good
4-6 METs Moderate• Climbing 2 flights of stairs, walking up a hill, walking on level ground
at 4 mph, heavy work around the house
<4 METs Poor• Golfing with golf cart, playing a musical instrument, slow ballroom
dancing, walking at 2-3 miles per hour
24 Challenges in Pre-Operative Evaluation
Functional Capacity
Making Beds – 3-5
Ironing – 2
Archery – 4.3
Doubles Badminton – 3-4
Bocce – 2-3
Broomball – 6.3
Cricket – 6.1
Equestrianism (not horseback riding) – 7
Ringette – 12.6
Tobogganing – 7
25 Challenges in Pre-Operative Evaluation
ACC/AHA Flowchart
26
METs = Metabolic Equivalents; CPG = Clinical Practice Guidelines; GDMT = Guideline-Directed Medical Therapy
Challenges in Pre-Operative Evaluation
Now, what about those meds?
27 Challenges in Pre-Operative Evaluation
Medications
Diabetes Medications
Betablockers
ACEI/ARB
Statins
Anticoagulation
Aspirin
28 Challenges in Pre-Operative Evaluation
Diabetes Meds
Assuming patient is NPO at MN…
Stop oral meds (including metformin*)
Dose reduce long-acting insulin ~25%
Stop prandial insulin
Start sliding-scale insulin
29 Challenges in Pre-Operative Evaluation
β Blockers
In NON-CARDIAC surgery, β blockers:
• Reduce cardiac events perioperatively
• Higher risk of death and stroke
CONTINUE β blockers for other indications
DO NOT start β blocker solely for surgery (consider RCRI 3+)
30 Challenges in Pre-Operative Evaluation
ACEI/ARB
Continuation associated with hypotension, not worse CV outcomes
Many hold ACEI/ARB 2/2 concern for perioperative AKI
ACC/AHA: “Continuation of ACEIs or ARBs perioperatively is reasonable.”
Recommend: if patient on ACEI/ARB for CHF or difficult to control HTN, continue
31 Challenges in Pre-Operative Evaluation
Statins
Continue statins if patient already taking one
Consider starting statin if patient to undergo vascular procedure
32 Challenges in Pre-Operative Evaluation
Anticoagulation
33 Challenges in Pre-Operative Evaluation
Aspirin
Aspirin for primary/secondary prevention (excluding prior PCI):
• No decrease in death or non-fatal MI
• Increased Hemorrhage
Stop ASA 5-10 days before procedure, restart 7-10 days later
In patients with previous PCI and intervention, should continue ASA if possible
34
Devereaux PJ et al for the POISE-2 Investigators. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014 Mar 31; [e-pub ahead of print].Graham MM et al. Aspirin in patients with previous percutaneous coronary intervention undergoing noncardiac surgery. Ann Intern Med 2017 Nov 14; [e-pub].
Challenges in Pre-Operative Evaluation
Medications
Diabetes Medications – Reduce Glargine by 25% + SSI
Betablockers – Continue
ACEI/ARB – Controversial…+/-
Statins – Continue
Anticoagulation – Hold, restart when surgeons deem safe, usually POD 1-3
Aspirin – Hold
35 Challenges in Pre-Operative Evaluation
How about that ?
Patient Characteristics
Procedure Characteristics
Perform EKG?
Low Risk Low Risk NO
Low Risk Int. or High Risk NO
High Risk Low Risk NO
High Risk Int. or High Risk YES
36
• Low risk patients – asymptomatic, <10% 10-year risk of CAD• High risk patients – coronary artery, peripheral artery, or cerebrovascular
disease, structural heart disease, or arrhythmia• Optimal timing of EKG is unknown, consensus 1-3 months
Challenges in Pre-Operative Evaluation
Quick Note About Labs
Laboratory testing should be dictated by H&P
Normal results within 4 months should be sufficient
37 Challenges in Pre-Operative Evaluation
Case 210 Minutes
38 Challenges in Pre-Operative Evaluation
Postoperative Pulmonary Complications (PPCs)Incidence 2.0-5.6%
PPCs associated with poor outcomes:
• ↑LOS, rehospitalization, and mortality rates
Under-appreciation for PPCs and their consequences
39 Challenges in Pre-Operative Evaluation
Postoperative Pulmonary Complications (PPCs)
40
More Morbid/Serious Less Morbid/Serious
Respiratory Failure* Pneumothorax
Prolonged Mechanical Ventilation Pleural Effusion
Infection Atelectasis
Exacerbation of Underlying Lung Disease Bronchospasm
Prolonged Cough*Respiratory Failure has various definitions, most: PPV, NiPPV
Challenges in Pre-Operative Evaluation
PPC Risk Factors
Risk Factor Odds Ratio
Functional Dependence in ADLs Partial 1.93-2.16 Total 4.07-4.22
Age 60-69y 2.09 70-79y 3.04
CHF, NYHA class II 2.20
OSA 1.86-2.46
COPD 1.79
Smoking 1.26
Recent URI/LRI -
Patient Specific
41
Qaseem et al Ann Int Med 2006; 144; 575-580.Gupta et al Chest 2011; 140: 1207-1215Johnson et al J Am Coll Surg 2007; 204: 1188-1198.Canet et al Anesthesiology 2010; 113:1338-1350.Smetana et al Ann Int Med 2006;144:582-595
*Obesity and mild-moderate asthma are not consistently associated with increased PPC risk
Challenges in Pre-Operative Evaluation
PPC Risk Factors
Risk Factor Odds Ratio
Emergency surgery 2.21
Surgery > 3-4 hours 2.14
General anesthesia 1.83
Aortic 2.94
Foregut/hepatobilliary 2.64
Brain 2.08
Other abdominal 1.27-1.78
ENT 1.11
Procedure Specific
42
Qaseem et al Ann Int Med 2006; 144; 575-580.Gupta et al Chest 2011; 140: 1207-1215Johnson et al J Am Coll Surg 2007; 204: 1188-1198.Canet et al Anesthesiology 2010; 113:1338-1350.Smetana et al Ann Int Med 2006;144:582-595
Challenges in Pre-Operative Evaluation
ARISCAT Risk IndexAssess Respirator Risk in Surgical Patients in Catalonia
Risk Factor Risk Score
Age (years)51-80 3
>80 16
PreOp SpO2 (%)91-95 8
<91 24
Respiratory infection in past month 17
Location of surgeryUpper abdominal 15
Thoracic 24
Duration of surgery2-3 hours 16
>3 hours 23
Emergency surgery 8
Preop hemoglobin ≤ 10 g/dL 11
43
Risk Class Risk Score PPCs (%)
Low <26 1.6-3.4
Intermediate 26-44 13-13.3
High >44 38-42.1
Derived in 2010, Validated in 2014
Wide variety of surgeries Southern European population Defined PPCs: respiratory
infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, aspiration
Challenges in Pre-Operative Evaluation
What to do with this data?
KEY – Recognize Elevated Risk for PPC
Identify strategies to mitigate individual modifiable risk factors
Communicate risk to anesthesia, surgery, hospital medicine, and patient
44 Challenges in Pre-Operative Evaluation
Husband’s Collateral
What diagnosis are we considering?
Do we care?
What are our next steps?
45 Challenges in Pre-Operative Evaluation
Obstructive Sleep Apnea
Incidence Estimates:
~90% of patients with mod-severe OSA unaware of dx
Few controlled, prospective studies
Based on 2 meta-analyses, increased risk for:
• MI, Cardiac Arrest, Arrhythmias, ICU stay, reintubation
46
Age 30-49 Age 50-70
Women 9% 27%
Men 26% 43%
Kaw et al. Brit J Anesthes. 2012;109:897-106Hai et al. J Clin Anesthes. 2014;26:591-600
Challenges in Pre-Operative Evaluation
Assess Risk – STOP-BANG
Snoring: Do you snore loudly?
Tiredness: Do you often feel tired, fatigued, or sleepy during daytime?
Observed apnea: Has anyone observed you stop breathing during your sleep?
Pressure: Do you have or are you being treated for high BP?
BMI > 35 kg/m2
Age > 50
Neck circumference ≥ 17” M, ≥ 16” F
Gender (biologic sex) = male
47
Increased risk of OSA:
• Score ≥ 3
Increased risk of moderate-severe OSA:
• Score ≥ 5
High sensitivity, poor specificity (~30%)
STOP-BANG ≥ 3 + serum HCO3 ≥ 28 increases specificity to ~80%
Chung F et al. Anesthesiology. 2008;108(5):812-21.Chung F et al. Br J Anaesth. 2012;108(5):768–75.
Chung F et al. Chest. 2013;143(5):1284-93.
Challenges in Pre-Operative Evaluation
OSA Risk Management
Use a reliable screen in the pre-operative period
• The earlier the better
Insufficient evidence to delay surgery for full sleep study unless:
• Poorly controlled systemic disease (e.g. HTN, pulm HTN)
• Evidence of impaired gas exchange (↑pCO2, ↑HCO3)
48
Chung F et al. Anesthesia & Analgesia. 2016;123(2):452-73.ASA OSA Task Force. Anesthesiology. 2014;120(2):268-86.
Challenges in Pre-Operative Evaluation
49 Challenges in Pre-Operative Evaluation
Diagnostic Studies
50 Challenges in Pre-Operative Evaluation
Chest X-Ray
Large meta-analysis: 10% abnormal 87% were expected findings, 0.1% changed management
More recent study, found 20% CXRs with abnormalities, but only 3% changed management
Poor correlation of CXR abnormalities with risk/outcomes
Obtain only if active cardio-pulmonary (CP) symptoms, unstable CP disease, or CT surgery
51
C Archer et al, Can J Anaesth 1993; 40:1022Qaseem et al, Ann Int Med 2006; 144:575-580
Challenges in Pre-Operative Evaluation
PFTs
Rarely indicated in non-CT surgery
No FEV1 cutoff that would absolutely cancel non-CT surgery
Consider in patients with otherwise unexplained dyspnea
52 Challenges in Pre-Operative Evaluation
SMOKING CESSATION!!!
Preop Smoking cessation shown to:
• Decrease overall post-op complications
• Decrease PPC
• Fewer wound healing complications• No change in mortality
Risk eliminated with >1y cessation
Timeline controversial, >6-8 weeks
53
Mills et al Am J Med 2011; 124(2): 144-54Wong Et al Can J Anesth 2012;59(3): 268-279
Thompson et al Cochrane Database Mar 27 2014
🚬
Challenges in Pre-Operative Evaluation
Case 35 Minutes
54 Challenges in Pre-Operative Evaluation
55 Challenges in Pre-Operative Evaluation
Expert Panel in Geriatric Surgery
2010 Med-SurgPartnership
28 member multidisciplinary panel
Reviewed ~20 years of literature
Provide consensus recommendations based on best evidence
56
2012
2016Challenges in Pre-Operative Evaluation
PreOp EvalWhat’s Different?
57
BODY
BRAINBIG PICTURE
Challenges in Pre-Operative Evaluation
PreOp EvalWhat’s Different?
STANDARD
• Update H&P
• Cardiac Risk Assessment
• Pulmonary Risk Assessment
• Medication History
• Substance Abuse and EtOH Screen
• Optimize Medical Co-Morbidities
58
GERIATRICS PATIENTS
• Cognitive Baseline & Delirium Risk
• Functional Capacity
• Polypharmacy Screen
• Frailty Assessment
• Nutritional Assessment
• Advanced Directives, Goals, & Shared Decisions
• Education, Expectation Setting
Challenges in Pre-Operative Evaluation
PreOp EvalWhat’s Different?
STANDARD
• Update H&P
• Cardiac Risk Assessment
• Pulmonary Risk Assessment
• Medication History
• Substance Abuse and EtOH Screen
• Optimize Medical Co-Morbidities
59
GERIATRICS PATIENTS
• Cognitive Baseline & Delirium Risk
• Functional Capacity
• Polypharmacy Screen
• Frailty Assessment
• Nutritional Assessment
• Advanced Directives, Goals, & Shared Decisions
• Education, Expectation Setting
Challenges in Pre-Operative Evaluation
How about our patient (BODY)?
RCRI = 2 (CAD, CKD)
TTE – grade 1 diastolic dysfunction, rest normal
Myocardial perfusion normal
PM interrogation normal
ARISCAT = 3!
No absolute contraindications
Surgery time!!!! Right?
60
�
Challenges in Pre-Operative Evaluation
Need think about the �
~20% of adults >70 have cognitive impairment
Associated with increased:
• Postop LOS, delirium, functional decline, mortality
Difficult to assess postop cognitive status without baseline
61 Challenges in Pre-Operative Evaluation
How to evaluate the � ?
Mini-COG
• 3 item recall (🐸🌈 � ) – 1 point each
• 3 minute Clock draw (hands at 11:10) – 2 vs. 0 points
• If < 3, likely impairment do full MMSE
• Assess decision making capacity
62 Challenges in Pre-Operative Evaluation
Functional Screen
Functional dependence – one of strongest predictors of:
• postoperative mortality, delirium, surgical site infections, discharge to SNF
ADLs/IADLs (any “NO” may warrant discharge planning)
• Can you get out of bed or chair yourself?
• Can you dress and bathe yourself?
• Can you make your own meals?
• Can you do your own shopping?
63
Endicott et al J Vasc Surg 2017Scarborough et al Ann Surg 2015
Challenges in Pre-Operative Evaluation
Functional Screen
Falls?
Timed Up and Go Test (TUGT) > 15 sec
• Rise from chair without armrests (no pushing off)
• Walk 10 feet
• Turn around
• Return to chair
• Sit down
64
Endicott et al J Vasc Surg 2017Scarborough et al Ann Surg 2015
Challenges in Pre-Operative Evaluation
Back to the � – Delirium
Postop incidence: 10-51%
30-40% attributable to modifiable risk factors (i.e. PREVENTABLE)
Highest in hip fracture, vascular, and cardiac
Associated with:
• Increased mortality, increased LOS, higher costs, discharge to SNF, worse surgical outcomes, functional and cognitive decline
65
Ganai, Arch Surg 2007Inouye, Lancet 2014
Challenges in Pre-Operative Evaluation
How about our patient (� )?
Known MCI
MOCA score 18/30
Recites surgical indications & possible complications
Independent in ADLs, help for some IADLs (meds, $$$)
Has hearing aid & glasses
TUGT (with cane) = 30 secs
66
�
Challenges in Pre-Operative Evaluation
67 Challenges in Pre-Operative Evaluation
Delirium Prevention
Preop
• Eliminate, cut down EtOH
• Minimize offending meds, opiates (Beers)
• EDUCATE FAMILY
• Communicate with anesthesia and surgery
Intraop and Postop
• So many things, beyond scope, happy to discuss
68 Challenges in Pre-Operative Evaluation
Medication Review
Standard Med Review +
Screen for deliriogenicmeds (Beers)
Screen for polypharmacy
• >50% of patients >60 y/o on 5+ meds
• Associated with: delirium, ADEs, drug-drug interactions, non-adherence, functional decline
69
Dr. Seuss, “You’re Only Old Once” 1986
Challenges in Pre-Operative Evaluation
Back to our patient
On total of 17 meds, including apixaban
Off NSAIDs 2/2 recent UGIB
Recent severe delirium / MS changes in setting of Percocet
Chart lists codeine and hydrocodone as causing hives
70
�
Challenges in Pre-Operative Evaluation
PreOp EvalWhat’s Different?
71
BODY
BRAINBIG PICTURE
Challenges in Pre-Operative Evaluation
PreOp EvalWhat’s Different?
STANDARD
• Update H&P
• Cardiac Risk Assessment
• Pulmonary Risk Assessment
• Medication History
• Substance Abuse and EtOH Screen
• Optimize Medical Co-Morbidities
72
GERIATRICS PATIENTS
• Cognitive Baseline & Delirium Risk
• Functional Capacity
• Polypharmacy Screen
• Frailty Assessment
• Nutritional Assessment
• Advanced Directives, Goals, & Shared Decisions
• Education, Expectation Setting
Challenges in Pre-Operative Evaluation
Establish Goals and Preferences
Understand patient goals for surgery…consistent with likely outcome?
Review potential scenarios / set expectations
• Functional limitations, loss of independence, prolonged recovery, need for nursing facility, ICU stay, postoperative cognitive decline
• BEST case & WORST case
Advanced Directives / Health Care Proxy
73 Challenges in Pre-Operative Evaluation
Case Conclusion
Major concerns!!! (Very very high risk)
Extended conversations with patient and wife
Discussed with geriatrics, anesthesia, ortho, social work
Decision was made to proceed
74 Challenges in Pre-Operative Evaluation
Case Conclusion
Successful THA with epidural only
POD 1-2 clear MS, but suboptimal pain control with APAP + epidural
Gabapentin was added…
12 hours later, “saw bugs crawling on his skin.”
Later that evening, code blue hypoxia to 70s, hypotension
To ICU, intubated, on pressors
75 Challenges in Pre-Operative Evaluation
Learning Objectives
Understand the risks and benefits of pre-operative evaluation
Appropriately risk-stratify a patient from a cardiac standpoint
Explain how to modify use of certain high-risk medications in the perioperative period
Describe PPCs and their role in perioperative care
Appropriately risk-stratify a patient from a pulmonary standpoint
Understand the role of OSA in the perioperative period
Develop a holistic framework for approaching the pre-operative evaluation of a geriatric patient
76 Challenges in Pre-Operative Evaluation
Thank you!
77 Challenges in Pre-Operative Evaluation
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