challenges in pre-operative evaluation - ucsf cme · 2018. 6. 20. · challenges in pre-operative...

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


• Pulmonary risk-stratification in pre-operative evaluation

• OSA considerations


• 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


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


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


Risks of Unnecessary PreOp Testing

Worse Patient and System Outcomes

Harm

CostDelay


Case 110 Minutes


Question 1

10

ClearanceRisk

Stratification


General Approach

Update H&P Cardiac Risk Assessment

Pulmonary Risk

Assessment

Medication History

Substance Abuse and

EtOH Screen

Optimize Medical Co-Morbidities


Source of Guiding Principles


ACC/AHA Flowchart


ACC/AHA Flowchart

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CAD = Coronary Artery Disease, ACS = Acute Coronary Syndrome, GDMT = Guideline-Directed Medical Therapy, MACE = Major Adverse Cardiac Events


Risk Calculators

Revised Cardiac Risk Index (RCRI)

American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP)


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.


RCRI

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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%


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


ACS NSQIP – Inputs


Did anyone use a calculator?

Which one?

How did our patient do?


RCRI

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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%


ACS NSQIP – Results


ACC/AHA Flowchart

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METs = Metabolic Equivalents; CPG = Clinical Practice Guidelines; GDMT = Guideline-Directed Medical Therapy


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


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


ACC/AHA Flowchart

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METs = Metabolic Equivalents; CPG = Clinical Practice Guidelines; GDMT = Guideline-Directed Medical Therapy


Now, what about those meds?


Medications

Diabetes Medications

Betablockers

ACEI/ARB

Statins

Anticoagulation

Aspirin


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


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+)


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


Statins

Continue statins if patient already taking one

Consider starting statin if patient to undergo vascular procedure


Anticoagulation


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].


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


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

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• 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


Quick Note About Labs

Laboratory testing should be dictated by H&P

Normal results within 4 months should be sufficient


Case 210 Minutes


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


Postoperative Pulmonary Complications (PPCs)

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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


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


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


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

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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


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


Husband’s Collateral

What diagnosis are we considering?

Do we care?

What are our next steps?


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

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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


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

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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.


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.



Diagnostic Studies


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


PFTs

Rarely indicated in non-CT surgery

No FEV1 cutoff that would absolutely cancel non-CT surgery

Consider in patients with otherwise unexplained dyspnea


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

🚬


Case 35 Minutes



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



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



STANDARD

• Update H&P






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GERIATRICS PATIENTS









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

�


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


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


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


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


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


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

�



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


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


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

�



71

BODY

BRAINBIG PICTURE



STANDARD

• Update H&P






72

GERIATRICS PATIENTS









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


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


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


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


Thank you!


challenges in pre-operative evaluation - ucsf cme · 2018. 6. 20. · challenges in pre-operative...

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