Which Patients are Too High Risk for Ambulatory Surgery?

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1 Which Patients are Too High Risk for Ambulatory Surgery? BobbieJean Sweitzer, M.D. Director, Anesthesia Perioperative Medicine Clinic Professor of Anesthesia and Critical Care Professor of Medicine University of Chicago I have no disclosures Unanticipated admission: 2.67% Most common reasons: Surgical 40%; anesthetic 20%; medical 19% Predictors: LOS 1 3 hr: OR LOS > 3 hr: OR 4.26 ASA class 3: OR 4.60 LOS= length of surgery ASA class 4: OR 6.51 Age >80 yrs: OR 5.41 BMI 30 35: OR 2.81 OR PACU ASU Elderly had less pain and PONV but more intraoperative events 1

Elderly had more cardiovascular events OR PACU

pending evaluation or stabilization Elective

deferred for 12 m after DES and 1 m after BMS

potentially catastrophic risks of premature

2006;355:1949 52 Stents Relative Risk of

Minute Interval Associated with Increases in

Treatment within 90 Minutes Perform surgery

2 Elderly had more cardiovascular events OR PACU 2007 ACC/AHA Cardiac Evaluation for Noncardiac Surgery Update (within 30 days) ASU Postpone surgery pending evaluation or stabilization Elective procedures with risk of bleeding should be deferred for 12 m after DES and 1 m after BMS Healthcare providers must be aware of potentially catastrophic risks of premature discontinuation of anti platelet therapy 2006;355: Stents Relative Risk of In-Hospital Death with Each Additional 15- Minute Interval Associated with Increases in Door-to-Balloon Time as Compared with Treatment within 90 Minutes Perform surgery where 24 hour interventional cardiology coverage is available Nallamothu B et al. N Engl J Med 2007;357:1631 2

Significant multivariate predictors of adverse postoperative outcome Characteristic Odds Ratio 95% CI p Value Age > 65 yrs 1.58 1.13 2.23 0.008 CAD 1.52 1.17 1.97 0.002 HF 2.72 2.21 3.34 <0.

001 Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery 8.5 fold increased risk Kertai.

yr) have aortic sclerosis Risk factors for aortic sclerosis/stenosis: Same as for CAD Sclerosis (stiff, calcified valve w/o hemodynamic compromise) stenosis (stiff, calcified valve WITH hemodynamic

3 Significant multivariate predictors of adverse postoperative outcome Characteristic Odds Ratio 95% CI p Value Age > 65 yrs CAD HF <0.001 Hypertension <0.001 Diabetes AS <0.001 Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery 8.5 fold increased risk Kertai. Am J Med 2004;116:8 Am J Cardiol 2005;96:436 2% of persons > 65 yr have significant aortic stenosis 9% of nursing home residents 1 out of 5 of patients w/systolic murmurs 25% of yo (50% > 84 yr) have aortic sclerosis Risk factors for aortic sclerosis/stenosis: Same as for CAD Sclerosis (stiff, calcified valve w/o hemodynamic compromise) stenosis (stiff, calcified valve WITH hemodynamic compromise) The murmurs sound similar MOST COMMON symptom of aortic stenosis: Decrease in exercise tolerance & dyspnea (insidious onset) Perioperative adverse event rates within 3 months of valve replacement (mechanical) Impact of Heart Failure on Patients Undergoing Major Noncardiac Surgery Hammill BG. 2008;108:559 Increased risk CAD HF Left Ventricular Assist Devices (LVADs) These patients need care in a center with LVAD support 3

ICD (Implantable Cardioverter Defibrillator)

tachycardia/fibrillation Cardiomyopathies with

placement for most ICDs Recommended that ICDs

reprogrammed preoperatively No interference if

drapes hold metal instruments on field during

4 ICD (Implantable Cardioverter Defibrillator) Healthy Hearts Don t Get ICDs Ventricular tachycardia/fibrillation Cardiomyopathies with EF <35% Hypertrophic cardiomyopathy Cautery above umbilicus may cause discharge No reliable way to detect appropriate magnet placement for most ICDs Recommended that ICDs be interrogated before and after procedures if magnet or cautery used If you need asynchronous pacing from ICD it MUST be reprogrammed preoperatively No interference if pacemaker 15 cm from magnetic drapes Magnetic drapes hold metal instruments on field during surgery Difficult Airway Obstructive Sleep Apnea (OSA) American Society of Anesthesiologists Task Force on Perioperative Management of Patients with OSA Postoperative Complications 4

5 Management of Sedation with OSA Semi recumbent position for sedation Use of personal CPAP devices Avoid deep sedation Monitor ETCO 2 during sedation Avoid or minimize opioids Be prepared for difficulty with masking and intubation Semi upright or lateral position for recovery General anesthesia preferable to deep sedation Intraoperative Fetal Monitoring 5

6 Ex Preemies Risk of apnea inversely related to post conceptual age (PCA) < 5% risk of apnea at 60 weeks PCA Preemie (32 36 weeks at birth) should be 52 weeks PCA (4 5 months old) Micro preemie (<32 weeks) should be 60 weeks PCA (at least 7 months old) Anemia increases risk Hct < 30% Those likely to need blood transfusions Severe anemia Sickle cell disease Procedures with significant blood loss Thrombocytopenia Hemophilia Coagulopathies >

Should surgery/anesthesia be postponed if a patient takes metformin on DOS? 1. Yes 2. No 3.

of metformin for > 48 72 hr most patients have significant GI upset upon resuming drug May protect against ischemia

44% 30 day VTE rates of highest risk outpatients: 1.18% Low risk inpatients: 0.61% 0.70% Risk factors: 1. Female 2.

Nausea in PACU # of risk factors PDNV Incidence Zero 10% 1 20% 2 30% 3 50% 4 60% 5 80% Severity of injury in

MAC death: 33% GA death: 27% Cataract Surgery is LOW risk Mortality: 0.01% (1:10:000); Morbidity (major): 0.

7 Should surgery/anesthesia be postponed if a patient takes metformin on DOS? 1. Yes 2. No 3. Depends on what the blood sugar is Should NEVER cancel case because patient took metformin DOS After interruption of metformin for > hr most patients have significant GI upset upon resuming drug May protect against ischemia Overall outpatient VTE rate: 0.15% Overall inpatient VTE rate: 1.44% 30 day VTE rates of highest risk outpatients: 1.18% Low risk inpatients: 0.61% 0.70% Risk factors: 1. Female 2. Age < 50 yr 3. History of PONV 4. Opioids in PACU 5. Nausea in PACU # of risk factors PDNV Incidence Zero 10% 1 20% 2 30% 3 50% 4 60% 5 80% Severity of injury in monitored anesthesia care (MAC), general, and regional anesthesia claims Bhananker: Anesthesiology, 2006;104:228 MAC death: 33% GA death: 27% Cataract Surgery is LOW risk Mortality: 0.01% (1:10:000); Morbidity (major): 0.04% Cochrane Review: 21,531 patients 707 adverse medical events (3.3%) 61 hospitalizations (0.28%) 3 deaths ( 0.014%) Limited (NO?) stress response (no major organ disruption; no fluid shifts; no blood loss; minimal postoperative pain)???avoidance of General Anesthesia??? 7

8 SUMMARY Which patients are too high risk depends on your type of facility Depends on the resources you have Depends on your willingness to accept risk If you don t like to gamble medicine isn t the job for you bsweitzer@dacc.uchicago.edu 8

I have no disclosures

I have no disclosures Preparing patients for out of hospital anesthesia BobbieJean Sweitzer, M.D. Director, Anesthesia Perioperative Medicine Clinic Professor of Anesthesia and Critical Care Professor of Medicine University