clinical conundrum in perioperative evaluation
DESCRIPTION
Perioperative evaluation of difficult clinical scenarios which prompted to delay of surgery: - Undiagnosed aortic regurgitation - Pleural effusion with suspected TBTRANSCRIPT
- 1. Hospital Medicine Grand Rounds The role of the peri-operative evaluation in safe patient outcomes: an initial patient dissatisfaction with a happy ending Moises Auron MD FAAP Feb 11, 2009
2. Objectives
- Appraise the importance of the peri-operative assessment to detect unrecognized conditions that increase surgical risk.
- Describe the evaluation and management of aortic regurgitation and its peri-operative implications
3. Objectives
- Describe the evaluation and management of pleural effusion and its perioperative implication.
- Describe the peri-operative implications of active tuberculosis.
- Describe the initial peri-operative assessment of Rheumatoid arthritis.
4. Case presentation
- 55 y/o male
- CC: Tracheostomy and subglotic stenosis
- Referred for pre-operative evaluation for a laser dilatation of the subglottic stenosis
- Surgery scheduled for the next day.
- Patient travelled from Boston, MA.
5. PMH
- HTN (10 years)
- Tracheostomy
- G-tube on enteral feeding
- MVA 4 months ago with complicated ICU stay: prolonged intubation.
- D/C to SNF, and recent D/C to home 1 week prior to preoperative visit.
6. PSH
- Evacuation of subdural hematoma
- Pleural tube placement for closed chest injury
- Exploratory laparotomy with splenectomy and small bowel resection.
- ORIF hip fracture
- Tracheostomy
- Gastrostomy
7. Medications
- Esomeprazole 20 mg daily
- Polyethilen-glycol 17 g daily
- Indapamide 2.5 mg daily
- Aliskiren 150 mg daily
- Clonidine 0.2 mg bid
- Gabapentin 600 mg tid
- Aspirin 81 mg daily
- Oxycodone 10 mg po q6h prn (pain)
8. Social
- Smokes 1 ppd for 30 years (not smoking currently since accident 4 months ago).
- No EtOH intake.
- No Drugs.
- Prosecution lawyer, married for 25 years, 2 children.
9. Pre-operative assessment
- Able to walk indoors with a walker (2.5 mets) but is mostly in wheelchair
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- Chest discomfort when straining (because I had a chest tube)
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- Needs 4 pillows to sleep, orthopnea, no PND
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- Edema managed with indapamide
- Denied any complications with anesthesia.
10. Circulation.2007;116:1971-1996 11. Physical examination
- BP 205/70HR 90RR 16
- Gen: anxious, head tremors
- Neck: Carotid pulsations appreciated. Trach.
- Cor: S4, 3/6 diastolic murmur in Right 2 ndIC space with presence of diastolic murmur (rumble) in apical area
- Chest: CTA BL
- Abd: S, NT, ND, BS+, pulsatile liver, GT
- Ext: brisk pulses, pulsating capillary nail bed
12.
- What do you think?
13. Signs of aortic insufficiency
- Austin Flint murmur
- Corrigans pulse
- de Musset's sign
- Quinckes sign
- Traube's sign
- Duroziezs sign
- Lighthouse sign
- Landolfis sign
- Beckers sign
- Mllers sign
- Mayens sign
- Rosenbachs sign
- Gerhardts sign
- Hills sign
- Lincolns sign
- Shermans sign
- Ashrafians sign
Babu AN, et al. Ann Intern Med.138(9): 73642.Ashrafian H. Int J Cardiol. 2006 Mar 8;107(3):421-3. 14. Signs of aortic insufficiency
- Austin Flint murmur
- Large-volume, 'collapsing' pulse
- Bounding peripheral pulses (waterhammer)
- Low diastolic BP and increased pulse pressure
- Corrigans pulse (rapid upstroke and collapse of the carotid artery)
- de Musset's sign (head nodding in time with the heart beat)
- Quinckes sign (pulsation of the capillary bed in the nail)
- Traube's sign (systolic and diastolic murmurs described as 'pistol shots' heard over the femoral artery when it is gradually compressed)
- Duroziezs sign (double sound heard over the femoral artery when it is compressed distally)
Babu AN, et al. Ann Intern Med.138(9): 73642.Ashrafian H. Int J Cardiol. 2006 Mar 8;107(3):421-3. 15.
- Lighthouse sign (blanching & flushing of forehead)
- Landolfis sign (alternating constriction & dilatation of pupil)
- Beckers sign (pulsations of retinal vessels)
- Mllers sing (pulsations of uvula)
- Mayens sign (diastolic drop of BP>15 mm Hg with arm raised)
- Rosenbachs sign (pulsatile liver)
- Gerhardts sign (enlarged spleen)
- Hills sign- a 20 mmHg difference in popliteal and brachial systolic cuff pressures.
- Lincolns sign (pulsatile popliteal)
- Shermans sign (dorsalis pedis pulse is quickly located & unexpectedly prominent in age>75 yr)
- Ashrafians sign (Pulsatile pseudo-proptosis)
Signs of aortic insufficiency 16. Pre-operative optimization
- EKG: NSR, left axis deviation, LVH, PVCs
- Labs: creatinine 1.5 (GFR 51 by MDRD)
- IS HE OPTIMALLY PREPARED?
17. Circulation.2007;116:1971-1996 18. Circulation.2007;116:1971-1996 19. Circulation.2007;116:1971-1996 20. Clinical risk factors: RCRI Lee, et al. Circulation. 1999; 100: 1043 1049. 21. Despite patients anger and yelling
- he was not cleared for surgery and was sent to the ER:
- Aortic regurgitation with severe symptoms
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- NYHA III-IV
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- Orthopnea
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- Hypertensive urgency with wide pulse pressure
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- Unclear evolution surprising that was not diagnosed in recent hospitalization
22. Aortic regurgitation: Etiology
- Idiopathic dilatation (annuloaortic ectasia)
- Congenital (bicuspid valves)
- Calcific degeneration (accompained by AS)
- Rheumatic disease
- Infective endocarditis
- Systemic hypertension (cystic medial necrosis)
- Myxomatous degeneration
- Dissection of the ascending aorta
- Marfan syndrome
- Traumatic injuries
- Ankylosing spondylitis
- Syphilitic aortitis (tertiary)
- Rheumatoid arthritis
- Osteogenesis imperfecta
- Giant cell aortitis
- Ehlers-Danlos syndrome
- Reiters syndrome
- Whipple disease
- Discrete subaortic stenosis
- Ventricular septal defects with prolapse of an aortic cusp.
- Anorectic drugs (Fenfluramine, dexfenfluramine)
Circulation2008;118;e523-e661 23. Natural history of AR Circulation2008;118;e523-e661 24. Natural history of chronic AR
- Asymptomatic Patients With Normal EF
- Variables associated with higher risk (likelihood of death, symptoms, and/or LV dysfunction):
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- Age
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- LV end-systolic dimension
-
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- > 50 mm had a dysfunction - 19% per year.
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-
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- 40 to 50 mm - 6% per year,
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-
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- < 40 mm 0%.
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- LV end-diastolic dimension
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- LV ejection fraction during exercise.
Circulation2008;118;e523-e661 25. TTE
- Dilated LV size (300 cc end-diastolic volume) with moderate LVH. EF=50%.
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- Left Ventricle ID(dia - cm):6.5
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- Left Ventricle ID(sys - cm):3.6
- Normal RV size and function
- Bicuspid aortic valve. Severe (4+) AR with holodiastolic flow reversal in the descending arch.
- Mildly dilated Aorta with effacement of the S-T junction. Aortic sinus(cm) - 4.3. Sino-tubular Junction(cm) - 3.5. Ascending Aorta(cm) - 3.8. Aortic Arch(cm) - 3.7.
- Bi-atrial enlargement. LA index=28ml.
- Trivial TR. RVSP=41mmHg c/w mild PHTN
26. LV Catheterization
- LEFT MAIN: Normal.
- LEFT ANTERIOR DESCENDING: 20-25% narrowing proximal mid and distal segment.
- CIRCUMFLEX ARTERY: Minimal irregularities.
- RIGHT CORONARY ARTERY: mild narrowing about 30% in the mid third.
- LEFT VENTRICLE: Dilated. End diastolic size is increased. End systolic size is significantly increased. EF 35-40%. There are some PVC's and some mild mitral regurgitation.
- AORTIC VALVE: Bicuspid. There is 4+aortic regurgitation. There is partial effacement of the sino-tubular junction on the right side. The ascending aorta is mildly dilated.
- DIAGNOSIS:1. Severe aortic regurgitation secondary to bicuspid aortic valve. 2. Moderately severe left ventricular dysfunction. 3. Mild coronary artery disease. 4. Mild dilatation of the ascending aorta.
27. http://www.med.yale.edu/intmed/cardio/echo_atlas/entities/aortic_regurgitation.html 28. Circulation2008;118;e523-e661 29. Immediate Postoperative TEE
- LV systolic function is normal.
- RV systolic function is normal.
- Bioprosthetic valve (Carpentier-Edwards #27). There is no aortic regurgitation.
30. 31. Case presentation
- 56 y/o eastern european male (living in USA for the past 5 years).
- CC: Sigmoid adenocarcinoma
- Referred for preoperative evaluation for sigmoidectomy and probable primary anastomosis
- Surgery scheduled for the next day.
32. HPI
- 2 months with several episodes of hematochezia - colonoscopy showed a villotubular adenomatous polyp with focal areas of adenocarcinoma in-situ.
33. ROS
- nocturnal diaphoresis
- pleuritic chest pain
- dry cough
34. Under further questioning:
- 5 months of nocturnal fever (100F) and diaphoresis,
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- generalized arthralgias and bilateral ankle edema.
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- A non-erosive arthritis was diagnosed and treated empirically with prednisone (PDN), but no definite diagnosis was made.
35. HPI.
- 2 months prior to visit was hospitalized for presumed pneumonia receiving i.v. antibiotics; PDN was stopped.
- A chest CT scan revealed intra-thoracic lymphadenopathy and interstitial lung infiltrates.
36. HPI
- PPD and IFN test for TB were positive
- BAL: Negative AFB stain and mycobacterial cultures
- Patient has history of BCG administration.
- An axillary lymph node biopsy showed benign hyperplasia.
37. PMH, FH and PSH
- PMH
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- Well controlled HTN for 5 years
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- No surgeries
- Social H
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- Smoker 16 ppy.
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- No EtOH or drugs.
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- Literature teacher
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- Wife is an internist physician trained in Poland and works as Physician assistant in US.
- FH
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- Colon CA.
38. Medications
- HCTZ 12.5 mg daily
- Atenolol 50 mg daily
- Centrum 1 tablet daily
- Fish oil 1 tablet daily
- Acetaminophen 1 g po qid prn
- Sildenafil 50 mg prn
39. Preoperative assessment
- Able to climb a flight of stairs (> 4 mets)
- No previous anesthetic complications
- No active cardiac symptoms
40. Physical exam
- BP 140/85HR 67RR 22SpO2 94% (RA)
- HEENT: PERRL, EOMI, MMM
- Neck: supple, anterior cervical LAD mobile, increased in consistency, no goiter
- Cor: RRR, normal S1, S2, no MRG
- Chest: Decreased left breath sounds, no egophony or fremitus, minimal dullness on percussion on L
- Abdomen: S, NT, ND, BS+, no masses
- Extremities: Limitation of ROM of elbows, with discrete swelling and erythema of ankles bilaterally, no palpable synovitis.
41. Pre-operative assessment
- EKG: NSR, HR 65
- Labs: WNL
- Is he optimally prepared?
42. 43. Despite angry complaints.
- Surgery was delayed
- Active symptoms suggestive of systemic inflammatory process warrant further assessment
- A CXR was required
- An urgent ID evaluation was requested
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- High risk for TB
44.
- WHAT TESTS WOULD YOU ORDER?
45. Further evaluation 46. Perioperative implications of pleural effusion
- Restrictive ventilatory defect
- VC
- FRC
- TLC
- V/Q mismatchHypoxemia
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- Atelectasis
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- ventricular diastolic collapse (tamponade)
-
- C.O.
Gilmartin, et al. Thorax 1985; 40:6065. Agusti, et al. Am J Respir Crit Care Med 1997; 156:12051209. 47. Pleural effusion and mechanical ventilation Graf J. Current Opinion in Critical Care 2009; 15:1017. 48.
- ID requested evaluation by Thoracic surgery
- Unsuccessful US-guided thoracentesis
- Thoracoscopy with pleural fluid drainage and pleural biopsy were done
http://www.thoracicmedicine.org 49. Perioperative air safety
- Each cough = 600,000 droplets
- Subsequently evaporate to form much smaller invisible droplet nuclei of up to 5 microns in size
- Particles < 10 microns can reach the alveoli
- Most concerning microorganism is Mycobacterium tuberculosis
Hickle R. Acta Anaesthesiol Scand Suppl. 1997;111:241-7. 50.
- Cough inducing procedures
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- Extubation
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- Suctioning
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- Average cough in PACU = 32 times during first 40 minutes of recovery
- Cost analysis study estimated the expense associated with an episode of unprotected exposure to TB in the PACU:
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- $57,000to$74,000
Perioperative air safety Hickle R. Acta Anaesthesiol Scand Suppl. 1997;111:241-7. 51. Perioperative air safety
- N95 respirator prevents passage of 95% of particles>0.3 microns
- Minimize personnel exposed
- Isolation with negative pressure
- Direct transfer to OR
- Bacterial filter in ETT
- Careful cleansing of OR and leaving room closed until air is completely changed
Neil J. AORN J. DEC 2008; 88 (6): 942-958 52. Perioperative air safety
- Schedule aerosol-generating procedure at the end of the day
- Attempt to do the procedure in the patients room
- Use disposable anesthesia equipment
Neil J. AORN J. DEC 2008; 88 (6): 942-958 53. Patient with active pulmonary TB
- Higher risk for temperature disregulation, hypoxemia and hypoventilation.
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- Fever metabolic rate and cardiac output
- Hypoxemia and hypoventilation occur due to anatomical lesions and necrotic lung parenchyma; atelectasis; pleural effusion
- Malnutrition and weakness secretions clearance and ineffective cough
- inspiratory and expiratory efforthypoventilation.
Neil J. AORN J. DEC 2008; 88 (6): 942-958 54. Pleural biopsy
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- Fibrinous pleuritis with mesothelial hyperplasia.
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- AFB stain was negative as well as mycobacterial cultures. Fungal serologies were negative.
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- Pleural fluid is an exudate
55. Light RW. NEJM. 2002; 346 (25): 1971-1977 56. Yataco JC, Dweik R. CCJM. 2005; 72(10): 854-872. 57. Ancillary testing
- ESR 99
- CRP 11
- Positive Rheumatoid factor
- Positive anti-CCP antibodies
- ANA, ANCA and hepatitis serology: negative
- Complement was normal.
- Pleural fluid Rheumatoid factor positive
58. Pleural rheumatoid factor
- Can be elevated in:
- Rheumatoid arthritis
- SLE
- Malignancy
- Pneumonia
- Tuberculosis
Yataco JC, Dweik R. CCJM. 2005; 72(10): 854-872. 59. Rheumatology consult
- Considered that patient could undergo surgery.
- Treatment would be started after surgery.
- C-spine flexion and extension X-Rays were normal.
60. Preoperative lateral flexion-extension C-spine X-Rays
- Progression of peripheral joint erosion parallels cervical spine disease
- RF seropositivity associated with higher incidence of cervical spine involvement
- C-spine involvement affects 15-86% of patients with RA
- Patients with erosive RA 30-40% have C-spine disease
Macarthur A, et al. Can J Anaesth. 1993; 40: 154-9. Crosby ET. Can J Anaesth. 1990; 37: 77-93. 61.
- Patient underwent sigmoidectomy with primary colorectal anastomosis. No further chemotherapy was advised.
http://nyp.org/masc/colorectal.htm 62. Post-operative
- Prednisone and methotrexate were started with progressive improvement of articular and pulmonary symptoms.
- Subsequently hydrocloroquine was added and prednisone dose was decreased.
- ESR and CRP normalized after 3 months and symptoms improved dramatically.
63. Clinical conundrum
- Pleuritis and interstitial lung disease are the most frequent pleuropulmonary manifestations of rheumatoid arthritis.
- Co-existence of constitutional symptoms in a smoker patient with presumed TB as well as with a recent diagnosis of sigmoid cancer.
64. Take home message
- Make precise diagnoses
- Evaluate the extent of organ disease
- Optimize medical diagnoses
- Assess and describe physiologic limitations
- Ensure adequate post-operative follow-up
- Regardless of the patient's desire to "proceed with surgery" - we have an obligation to do what is in the patient's best interest and to provide the surgical team with the service that they expect....
65.