perioperative medicine pearls

Perioperative Pearls l Alraies l May 17, 2010

Perioperative Pearls, What Is Necessary And What is Appropriate

M Chadi Alraies, MD FACPCleveland Clinic FoundationCleveland, Ohio, USA

Saturday, April 8, 2023


Disclosure

• None


Overview

•M

edical consultant role perioperative care

–N

uts and bolts of the preop assessm

ent

•P

reoperative risk stratification

–C

ardiopulmonary risk

–R

isk reducing interventions

•P

erioperative anticoagulation in patients on V

KA

or those w

ith coronary stents


Scope of the problem •

33 million surgeries every

year

•C

ost > $450 billion

•~

1 million pts/yr sustain

medical com

plications

–50,000 suffer perioperative M

IAM

I accounts for 40% of

perioperative mortality.

•In the next tw

o decades 25%

increase in number of

surgeries and 50% increased

in surgery related cost.


Pathophysiology •

Stress

–O

xygen demand/supply

imbalance

–F

luctuation in heart rate and blood pressure from

volume shift

and blood loss

–G

eneration of a prothrombotic

state

•H

istopathologic studies of fatal perioperative M

I

–P

laque rupture accounted for less than 55%

of the cases

–S

everity of the lesion didn’t predict the site of the infarction

–A

significant proportion of infarcts occurred distal to non-critical stenosis.


Surgery is Like a Plane Flight

Patient

Surgeon is the Pilot

Anesthesia is the Co-

Pilot

Michota F, Jaffer A. Clev Clin J Med 2006


Medical Consultant = Mechanic

•W

hat is th

e co

nditio

n o

f the

p

lan

e?

•Is th

e pla

ne in th

e best

cond

ition to fly?

•U

nd

er the b

est cond

ition

s, w

ha

t can the

plane

h

and

le?

•Is th

e long

-term

m

ainte

nan

ce pro

gram

a

deq

uate

?


•P

recise medical

diagnoses

•E

valuate the extent of organ disease

•O

ptimize all m

edical conditions

•A

ssess and describe physiologic lim

itations

•E

nsure adequate post-operative follow

-up

Medical Consultant = Mechanic


Medical Consultant Role

•S

hou

ld not tell th

e p

ilot o

r the

co-p

ilot w

hen

or h

ow

to fly

•D

o no

t CL

EA

R pa

tients

for surge

ry “op

timize

”

•S

hou

ld not m

ake

ane

sthe

tic re

com

me

nda

tion

s


Preoperative Evaluation•

Focus on

the history

–C

omplete

RO

S,

functional class, m

edications

•E

xam does

not need to be com

prehensive

•Laboratory testing should be selective, not routine


Perioperative Cardiac Risk Assessment


Case 1

•A

75-yo p

rese

nts pre

op fo

r a

radical prostate

ctom

y for

prosta

te ca

nce

r. PM

Hx

include

s CA

D w

ith h/o 3

V-

CA

BG

ab

out 2

yea

rs ag

o, HT

N

and

Typ

e 2 D

M. H

is current

me

ds in

clude

: insu

lin, a

teno

lol,

AS

A. H

e is ve

ry active

swim

min

g several la

ps fo

r

abo

ut 3

0 m

inu

tes at lea

st 3

time

s per w

ee

k; no C

P b

ut he

doe

s ge

t SO

B.

•E

xam: P

=6

8, BP

=1

30

/75

,

RR

=1

8

•L

ung

s=C

TA; h

eart exa

m is

norm

al e

xcept fo

r a

para

do

xical sp

lit S2

; LE p

ulses

are n

orm

al.


Question•

According to the current

AC

C/A

HA

guidelines, is an E

CG

recomm

ended for this patient?

A.

Ye

s

B.

No


Question•

According to the current

AC

C/A

HA

guidelines, is an E

CG

recomm

ended for this patient?

A.

Ye

s

B.

No

EKG is normal sinus with left anterior hemiblock


What is the most appropriate next step in regards to his cardiovascular risk?

A.

Ga

ted

trea

dm

ill e

xercise

test

B.

Exe

rcise th

alliu

m

scintig

rap

hy

C.

Do

bu

tam

ine

e

cho

card

iog

rap

hy

D.

Co

ron

ary a

ng

iog

rap

hy

E.

No

ad

ditio

na

l tests


ACC/AHA GuidelinesP

reop

EC

G reco

mm

end

ed

•C

las

s I

–V

ascu

lar su

rge

ry patien

ts with

1

risk facto

r*

–K

now

n CA

D, P

VD

, CV

D g

oin

g

for inte

rmed

iate risk surg

ery

•C

las

s IIa

–V

ascu

lar su

rge

ry

•C

las

s IIb

–Inte

rme

dia

te risk surg

ery

with 1

risk facto

r*

Fleisher LA et al. JACC 2007

Ischemic heart diseaseHeart failure

DiabetesRenal impairment

Cerebrovascular disease


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

Perioperative Pearls l Alraies l May 17, 2010 Perioperative Pearls l May 17, 2010 l

Fleisher LA et al. 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.

Factors Leading to Cumulative Risk for Perioperative Cardiac Events


Case 2•

65 year old postmenopausal

female w

ith medical history of

HT

N, C

AD

, atrial fibrillation and dyslipidem

ia presents to the em

ergency department

complaining of acute onset of

leg pain.

•F

urther testing and evaluation reveals that she has an acute arterial em

boli and needs im

mediate em

bolictomy.

• H

er heart rate is 85 bpm.

Perioperative Pearls l May 17, 2010 l


As the medical consultant, what is the MOST APPROPRIATE next step?1.

Com

plete a full preoperative evaluation, including a stress test, because she w

ill need a vascular procedure.

2.A

sk the patient about her physical activity so you can calculate her m

etabolic equivalents because she w

ill have an interm

ediate-risk surgery.

3.E

valuate her postoperatively for signs and sym

ptoms of a

myocardial infarction (M

I).

4.A

sk for surgery to be delayed for 2 days until a β

blocker low

ers her heart rate to betw

een 55 and 65 bpm

slowly.



Tailoring the Perioperative Evaluation Based on the Urgency of Surgery


Emergent surgery?

No

Further risk stratification

Proceed to OR and evaluate

postoperatively

Yes


As the medical consultant, what is the MOST APPROPRIATE next step?1.

Com

plete a full preoperative evaluation, including a stress test, because she w

ill need a vascular procedure.

2.A

sk the patient about her physical activity so you can calculate her m

etabolic equivalents because she w

ill have an interm

ediate-risk surgery.

3.E

valuate her postoperatively for signs and sym

ptoms of a

myocardial infarction (M

I).

4.A

sk for surgery to be delayed for 2 days until a β

blocker low

ers her heart rate to betw

een 55 and 65 bpm

slowly.



Is surgery emergent? Operating RoomYes


Cardiovascular Risk Assessment


Is surgery emergent? Operating RoomYes

Active cardiac condition?

NoEvaluate and TreatCardiac condition

Yes




ACC/AHA Guidelines•

Unstable coronary

syndromes

•D

ecompensated H

F

•S

ignificant arrhythm

ias–

High grade A

V block,

Mobitz II A

V block,

3rd degree AV

block, new

VT, sym

ptomatic

bradycardia, sym

ptomatic V

T, SV

T

with R

VR

•S

evere valvular heart disease


Active cardiac conditions that require evaluation and treatment before noncardiac surgery


Is surgery emergent? Operating Room

Low-risk surgery?

Yes



Yes

No





Low-risk surgery?

Yes



Yes

No

Operating RoomYes




Is surgery emergent?

Low-risk surgery?


No

No

Operating RoomYes

• Endoscopic procedures

• Superficial procedure

• Cataract• Breast





Low-risk surgery?

Good (>4 METs)Functional capacity?

Yes



Yes

No

Operating RoomYes

No

Operating RoomYes




Is surgery emergent?

Low-risk surgery?



No

No

No

Operating RoomYes

Dress, toilet independently 1 METsWalk indoors around the house 2 METsLight housework, vacuum, laundry 3 METs Walk up a hill or a flight of stairs 4 METsGolf, bowling, dancing 6 METsTennis, running, swimming, basketball 8 METs





+3 Risk Factors 1-2 Risk Factors No Risk Factors

Operating RoomYes

No

Ischemic heart diseaseHeart failure

DiabetesRenal impairment

Cerebrovascular diseaseHigh risk surgery




*Lee Cardiac Risk Index (RCRI)R

isk Ca

teg

ory

Even

t Rate

%C

lass I (0

pts)

0.5

Cla

ss II (1 pt)

1.3

Cla

ss III (2 pts)

3.6

Cla

ss IV (>

3 p

ts) 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

Hig

h (R

epo

rted card

iac risk >5%

)

•E

merg

ent m

ajor o

peratio

ns

•A

ortic/vascu

lar surg

ery

•P

rolo

ng

ed su

rgical p

roced

ures; larg

e fluid

sh

ifts/blo

od

loss

Interm

ediate (R

epo

rted card

iac risk =1-5%

)

•C

arotid

end

arterectom

y

•H

ead an

d n

eck Su

rgery

•In

traperito

neal an

d in

tratho

racic Su

rgery

•O

rtho

ped

ic Su

rgery

•P

rostate S

urg

ery (oth

er than

TU

RP

)

Lo

w (R

epo

rted card

iac risk <1%

)

•E

nd

osco

pic p

roced

ures

•S

up

erficial pro

cedu

re

•C

ataract

•B

reast

•T

UR

P (b

ased o

n m

ost stu

dies, b

ut n

ot in

clud

ed

by A

CC

/AH

A)

Michota F, Frost S; Med Clin N Am 2002

Su

rgical S

tress Level




Operating RoomYes

No

Operating Room

Yes

Operating Room with heart rate control or noninvasive testing if it will change management

IntermediateRisk surgery

Vascularsurgery

Vascularsurgery

CoronaryAssessment




What is the role for beta blockers and/or statins?

Depends on patient risk and

type of surgery

–V

ascular surgery patients

benefit from both

–Interm

ediate risk patients

do not benefit from statins

(DE

CR

EA

SE

-IV)

–D

ata is conflicting on the

role of beta-blockers in

intermediate risk patients

(PO

ISE

vs. DE

CR

EA

SE

-IV)


POISE vs. DECREASE IV•

Both studies show

ed a

reduction in CV

events

•P

OIS

E had excess strokes

and overall mortality

•B

eta blocker doses and

timing w

ere different

–P

OIS

E (started just before surgery

with m

aximum

therapeutic dose

within 24 hours of surgery)

–D

EC

RE

AS

E (started 30 days

before surgery using 12.5% of

maxim

um therapeutic dose

Dunkelgrun M et al. Ann Surg 2009




Operating RoomYes

No

Operating Room

Yes

Operating Room with heart rate control or noninvasive testing if it will change management


Vascularsurgery

Vascularsurgery

CoronaryAssessment


BB

SBB = Beta Blocker = Statin

S

BB

S





Operating RoomYes

No

Operating Room

Yes

Operating Room with heart ratecontrol or noninvasive testing


Michota FA. Ohio ACP 2009

BB

BB = Beta Blocker

>2 weeks preop

<2 weeks preop

Noninvasive testingif it will change management



Case 3 •A

75-yo p

rese

nts pre

op fo

r a

radical prostate

ctom

y for prostate

cancer. P

MH

x inclu

des C

AD

with

h/o

2-ve

ssel P

TC

A w

ith D

ES

sten

ting

8 m

on

ths

ag

o, H

TN

an

d

Typ

e 2

DM

. His curre

nt m

eds

include

: Insu

lin, A

teno

lol, AS

A, a

nd

clo

pid

og

rel. H

e is ve

ry active

swim

min

g several la

ps fo

r ab

out

30 m

inu

tes a

t lea

st 3 time

s per

we

ek; no

CP

but h

e doe

s ge

t SO

B.

•E

xam: P

=6

8, BP

=1

30

/75

, RR

=1

8

Lun

gs=

CTA

; hea

rt exam

is norm

al

exce

pt for a p

ara

doxica

l split S2

;

LE

pu

lses a

re no

rma

l.

•E

KG

= N

SR

, LA

HB


Which of the following is the most appropriate recommendation at this time?

A.

Pro

cee

d to su

rgery o

n

clop

ido

grel an

d a

spirin

B.

Disco

ntinue

clopid

ogre

l an

d

proce

ed to surg

ery o

n a

spirin

C.

Disco

ntinue

clopid

ogre

l an

d

asp

irin an

d pro

ceed

to su

rgery

now

D.

Disco

ntinue

clopid

ogre

l an

d

asp

irin an

d pro

ceed

to su

rgery

with a

LM

WH

brid

ge

E.

Disco

ntinue

clopid

ogre

l an

d

asp

irin an

d pro

ceed

to su

rgery

afte

r a four m

on

th dela

y


ACC/AHA Guidelines

Previous PCI

Balloon BMS DES

Time since PCI

<14d >14d >30-45d

<30-45d

<365d >365d

Delay for electiveor nonurgent surgery

Proceed to surgery on aspirin

Delay for electiveor nonurgent surgery

Proceed to surgery on aspirin

Fleisher LA et al. JACC 2007Grines CL et al. JACC 2007


Case 4•

A 55

yo fe

male

with

h/o

CO

PD

(last FE

V1

=2L ~

1 yr a

go) H

TN

,

OA

and

obe

sity pre

sen

ts for p

reop

eva

luatio

n 2 w

ee

ks before

TAH

.

Sh

e has sm

oke

d 2

ppd

for the last

40yrs.

•H

er m

ed

s includ

e Ip

ratro

piu

m

/albute

rol inh

ale

r (wh

ich sh

e u

ses

spora

dically), HC

TZ

, an

d

ace

tamino

phe

n. S

he d

enie

s SO

B,

or co

ugh

.

•E

xam: P

=7

5, BP

= 1

30/8

0, RR

=1

8,

Sa

O2

=98

%. L

ung

s=d

ecre

ase

d a

ir

entry bilate

rally but n

o wh

eezing

.

He

art e

xam

is no

rma

l. Extre

mitie

s

are n

orm

al.


What is the most appropriate next step in regards to addressing her perioperative pulmonary risk?

A.

Preoperative spirom

etry

B.

Re-education about daily

inhaler use

C.

Preoperative arterial blood

gas (AB

G)

D.

Preoperative sm

oking

cessation

E.

Chest radiography

F.A

ll of the above


What is the most appropriate next step in regards to addressing her perioperative pulmonary risk?

A.

Preoperative spirom

etry

B.

Re-ed

ucatio

n ab

ou

t daily

inh

aler use

C.

Preoperative arterial blood

gas (AB

G)

D.

Preoperative sm

oking

cessation

E.

Chest radiography

F.A

ll of the above


Preoperative Spirometry

•N

o evidence for risk

prediction perioperatively

•N

o threshold of values for

which surgery is

contraindicated

•C

onsensus

–Lung R

esection

–C

AB

G

–U

nexplained dyspnea or lung

disease

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


Risk factors for Postoperative Pulmonary Complications

•P

atient–

CO

PD

–A

ge

>60

yrs

–A

SA

cla

ss >

II

–F

un

ctio

nal

de

pe

nd

enc

e

–C

HF

–A

lbu

min

<3

.5g/d

L

•P

rocedure–

>3

ho

urs

du

ratio

n,

ge

ne

ral a

ne

sthe

sia

, e

me

rge

nc

y su

rge

ry

–T

ho

racic, v

asc

ula

r, h

ead

and

nec

k,

ne

uro

su

rgic

al, a

nd

a

bd

om

ina

l p

roce

du

res

Qaseem A et al. Ann Intern Med 2006


Risk factors for Postoperative Pulmonary Complications

•P

atient–

CO

PD

–A

ge

>60

yrs

–A

SA

cla

ss >

II

–F

un

ctio

nal d

ep

en

de

nce

–C

HF

–A

lbu

min

<3

.5g/d

L

•P

rocedure–

>3

ho

urs

du

ratio

n, g

en

era

l a

nes

thes

ia, e

me

rge

nc

y

su

rge

ry

–T

ho

racic, v

asc

ula

r, he

ad

a

nd

ne

ck, n

eu

rosu

rgic

al, a

nd

ab

do

min

al p

roc

ed

ure

s

Qaseem A et al. Ann Intern Med 2006

Smoking data is mixed

Obesity and mild to moderate asthma are not associated with increased risk


Preoperative Pulmonary Risk-Reduction Strategies

•S

moking cessation (>

6-8

wks)

•R

educe airway obstruction

–S

trict ad

here

nce

to

prescrib

ed m

edica

tion

s

–P

reop

era

tive stero

ids a

s

nee

de

d

•A

ntibiotics for respiratory

infection

•P

reoperative lung

expansion education

–Ince

ntive sp

irom

etry

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


Postop Pulmonary Risk-Reduction Strategies•G

oo

d evid

ence

of b

en

efit

–P

osto

perative lu

ng

expan

sion

m

od

alities (A)

–Incentive spirom

etry, CP

AP

–S

elective po

stop

erative naso

gastric

deco

mp

ression

(B)

–S

ho

rt-acting

neu

rom

uscu

lar blo

ckade

(B)

•E

quivoca

ble e

vide

nce o

f ben

efit

–L

aparo

scop

ic (vs. op

en) o

peratio

n (C

)

•C

on

flicting evide

nce

of b

ene

fit vs. ha

rm

–S

mo

king

cessation

(I)

–In

traop

erative neu

raxial blo

ckade (I)

–P

osto

perative ep

idu

ral analg

esia (I)

–Im

mu

no

nu

trition

(I)

•C

lear e

viden

ce of h

arm

–R

ou

tine to

tal paren

teral or en

teral n

utritio

n (D

)

–R

igh

t-heart cath

eterization

(D)

Lawrence VA et al. Ann Int Med 2006


Anticoagulation and Surgery


Case 6•

72-ye

ar-old w

oman

with h

istory of

rheu

matic h

eart

dise

ase, a

trial

fibrilla

tion

an

d s/p

me

chan

ical a

ortic

valve is now

sche

duled

for an

ele

ctive sigm

oid

rese

ction fo

r colo

n

cancer.

•P

atie

nt is on w

arfarin

with targe

t INR

2.0-

3.0

.


What are your recommendations for perioperative anticoagulation?

A.

Stop w

arfarin 5 days before

surgery and resume w

arfarin on

the morning of surgery

B.

Stop w

arfarin 5 days before, use

SC

full dose LMW

H starting 3

days before surgery; resume full

dose LMW

H w

ith warfarin post-

operatively until the INR

is

between 2 - 3

C.

Use F

FP

and IV V

itamin K

to

reverse the effect of warfarin in

the AM

of surgery and then

proceed with surgery

D.

Stop w

arfarin 5 days before, start

IV U

FH

the same day; resum

e IV

UF

H w

ith warfarin post-operatively

until the INR

is between 2 - 3


Thrombosis Risk “Window”•

A therapeutic patient (IN

R 2-3)

will generally need 5 days off

OA

C to low

er the INR

to this level

–P

re-proce

dura

l “win

dow

” of

thrombo

sis risk

•T

herapeutic OA

C w

ill take

another 3-4 days after the

procedure

–P

ost-p

rocedu

ral “w

ind

ow” o

f

thrombo

sis riskWhite RH et al. Arch Intern Med. 1995


Who needs bridging therapy?


•N

o randomized

controlled trials

•E

xpert opinion



Anticoagulation and Surgery


Bleeding Thrombosis

surgery


Communication

•C

onsultant

•S

urgeon

•A

nesthesia

•N

ursing staffPerioperative Pearls l May 17, 2010 l


INR 1.5-2.0

INR>2.0 INR>2.0

INR 1.5-2.0

INR<1.5

Procedure

OAC stopped

OAC started

Days 0-5

1 5

Thrombosis Risk “Window”


CHADS2 Score:1. Recent CHF =12. Age ≥ 75 years =13. Diabetes mellitus =14. Prior stroke or TIA =2 Kearon C et al. N Eng J Med 1997

Gage J et al. JAMA 2001


UFH Bridge Protocol

INR>2.0 INR>2.0

Procedure

OAC stopped

OAC started

Days 0-5

1 5

Begin IVUFH

Stop IVUFH Begin IVUFH*

Stop IVUFH

1 Week LOS


LMWH Bridge Protocol

INR>2.0 INR>2.0

Procedure

OAC stopped

OAC started

Days 0-5

1 5

Begin LMWH

Stop LMWH* Begin LMWH*

Stop LMWH

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.



Thank you

Chadi Alraies, [email protected]

mailto:[email protected]

http://www.chadialraies.blogspot.com/

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