A few years ago my team was consulted to clear a patient for surgery. I said OK, let s get a pre-op consult note on the chart.

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Richard Clarke
6 years ago
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1 November 2016

2 A few years ago my team was consulted to clear a patient for surgery. I said OK, let s get a pre-op consult note on the chart. He consulted Cardiology.

3 No attempt should be made to prognosticate the effect of a surgical procedure upon a patient of a given physical state. - Saklad M. Grading of Patients for Surgical Procedures. Anesthesiology 1941; 2: (First proposed physical status classification)

5 33,224 patients who underwent surgery at The University of Pennsylvania from Each was assigned a physical status from 1 to 5 prior to anesthesia. PS 1, normal healthy patient, elective surgery PS 5, moribund patient The number of deaths related to anesthesia increases directly with deterioration of the preanesthetic condition of the patient.

7 1001 patients over 40 y.o. undergoing a variety of surgical procedures Looked at variables that correlated with post-op pulmonary edema, MI, ventricular tachycardia. S3 gallop or elevated JVP and MI within prior 6 months represented the highest risk factors. For the first time important valvular aortic stenosis (detected by physical exam) was also identified as a risk factor. Only 23 patients with important VAS were identified, but 3 of them (13%) died.

9 200 patients undergoing surgery at the San Francisco VA Medical Center. Given IV atenolol vs. placebo pre-op, and either IV or PO atenolol post-op and until discharge. No difference in event rates prior to D/C. No difference in use of beta blockers after D/C. Overall reduction in mortality and cardiac events at 6 months, 12 months, and 24 months after discharge.

11 Which patients are most likely to benefit from coronary assessment and treatment? The lack of adequately controlled or randomized clinical trials to define the optimal evaluation strategies led to the proposed algorithm based on collected observational data and expert opinion. Beta blockers Clearly this is an area where further research would be valuable.

14 Four class I and three class II recommendations for stress testing pre-op. Four class I and six class II recommendations for cardiac cath pre-op. Also noted the absence of trials demonstrating benefit of pre-op PCI or CABG? Specific recommendations regarding beta blockers appear.

16 In summary, the best approach on how to medically protect patients from cardiovascular complications during non-cardiac surgery is still unknown. They cited limitations in the literature: - Few randomized trials, inadequately powered - Few studies examining titration of therapy - Few studies in low to intermediate risk patients

18 Recommendations regarding statins appear. Specific statements regarding surveillance for post-op MI appear: - chest pain suggestive of ACS or ECG changes, troponin measurement is recommended. (Duh) - Stable after vascular surgery? (don t know) - Stable patients after low risk surgery (don t do it) Much discussion of what to do with BMS vs. DES

19 2002 Intermediate predictors - Mild angina - Prior MI - CHF - Diabetes - CKD 2007 RCRI risk factors - Ischemic heart disease - CHF - Stroke or TIA - DM requiring insulin - Serum Cr > 2

22 8351 patients with risk factors for MACE. Low risk surgeries excluded. Patients on beta blockers excluded. Metoprolol succinate 100 mg po 2-4h pre-op. Metoprolol succinate 100 mg po post-op. Metoprolol succinate 200 mg daily started 12h after first post-op dose. MI, HR 0.73 Stroke, HR 2.17 Death, HR 1.33

23 Patients who are unwilling to accept a probable increase in mortality are unlikely to want perioperative extended-release metoprolol. (duh)

26 10,010 patients with or at risk for atherosclerotic disease undergoing non-cardiac surgery. 2 x 2 design with ASA and clonidine vs. placebo Pre-op, clonidine 0.2 mg po and 0.2 mg clonidine patch placed on upper arm or chest. Patch left in place until 72 hours post-op. Hypotension, HR 1.32 Bradycardia, HR 1.49 Increase in non-fatal cardiac arrest.

28 Rosuvastatin vs. placebo and tranexamic acid vs. placebo. In view of the POISE and POISE-2 trial results, recruiting is not going very well

31 More language about risks / benefits after the POISE trial published. Beta blockers in vascular surgery pts with abnormal stress testing downgraded from class I to class IIa recommendation. The phrase beta blockers titrated to heart rate and blood pressure was added to all the IIa recommendations.

32 a prolific researcher in the field of perioperative medicine and beta blockers in particular. In 2011 fired from his position at Erasmus University in the Netherlands due to allegations of academic fraud and misconduct. So toss all his studies

34 Use of online calculators for cardiac risk. Specific systematic review on beta blockers.

35 Class IIa Use of either a volatile anesthetic agent or total intravenous anesthesia is reasonable. Class III Routine use of PA catheters in patients, even those with elevated risk, is not recommended. Class I Measurement of troponin levels is recommended in the setting of signs or symptoms suggestive of MI. (duh)

39 1. High risk surgery 2. Ischemic heart disease 3. CHF 4. Stroke or TIA 5. Diabetes requiring insulin 6. Serum Cr > 2

40 Major cardiac complications: - myocardial infarction (CK-MB, EKG changes) - pulmonary edema ( CXR ) - ventricular fibrillation or cardiac arrest - 3 rd degree AV block (?) Zero points 0.4% 1 point 0.9% 2 points 6.6% 3 or more 11%

41 62 yo lady with HFpEF going for total hip arthroplasty. 88 yo lady with ESRD, severe claudication, going for fem-pop bypass graft. 1 1

42 43 yo gentleman with type 2 DM, insulin requiring going for rouxen-y gastric bypass. He walks his dogs every day for 20 to 30 minutes with some DOE. 78 yo gentleman, STEMI three years ago, EF 10-15%, cath with horrid 3 vessel disease not amenable to CABG or PCI. Chest pain provoked by changing TV channels with the remote control, going for TKA. 2 2

43 50 yo lady with type 2 DM, insulin requiring, TIA, CKD with Cr 2.1, prior NSTEMI with stent to distal RCA presents for right hemi-colectomy due to large dysplastic polyp seen on screening colonoscopy. She walks 3 miles daily without symptoms yo gentleman with type 2 DM, insulin req., stroke with right hemiparesis, ESRD, prior NSTEMI with multiple stents, presents for right hemi-colectomy due to colon CA. He is bed bound and resides in a skilled nursing facility. 5

45 Since the original study in 1999, only 5 high quality studies including 2046 patients have been published. Our study suggests that it is reasonable that clinicians use the RCRI to discriminate between patients who are at low versus high risk for perioperative cardiac complications after mixed non-cardiac surgery. Nonetheless, the findings are limited by a lack of high-quality validation studies and by moderate statistical heterogeneity.

46 The RCRI did not discriminate between low-risk and high-risk patients having vascular noncardiac surgery specifically AAA repair. As indicated previously, more high quality research is needed in this field. Clinicians should therefore interpret the moderate pooled predictive accuracy of the RCRI in mixed non-cardiac surgery, as well as its low accuracy in vascular non-cardiac surgery, with some caution.

48 10,081 patients who underwent elective CEA, lower extremity bypass, open and endovascular AAA repair between 2003 and Noted that only 21% of the patients in the initial RCRI derivation and validation cohorts underwent vascular surgical procedures. Higher RCRI scores predicted higher numbers of cardiac events. But it underestimated the risk of post-op cardiac events by 6 to 7 fold in low risk patients, and by 2 fold in high risk patients.

50 Population based study in Denmark looking at all patients 25 years who underwent elective noncardiac surgery between 2005 and A total of 447,352 surgeries. Divided patients into five age groups by 10 year increments from 55 to > 85. RCRI predicted increased MACE in each group. But underestimated the risk in elderly patients and overestimated the risk in younger patients. Zero points = greater than 98% NPV for MACE.

54 68 yo patient Cr 1.8 ASA class 3 (CAD, CHF, type 2 DM) Totally independent Hemicolectomy for colon CA

58 Is the patient cleared? I cannot read a long note Is the patient cleared?

65 University of Michigan study Patients undergoing aortic surgery Educational initiatives and Pre-op clinic centered around ACC / AHA guidelines. Nuclear stress tests 88% 47% Cardiac caths 24% 11% Coronary revascularization 24% 2% Post-op death/ MI 11% 4% Overall pre-op costs $1087 $171 (2002)

66 Among the silliest thing I ve seen lately 56 yo lady who played doubles tennis three times per week without symptoms. Had nuclear stress prior to outpatient blepharoplasty at Plastic Surgeon s office. Why did this happen?

68 Chronic pressure overload leads to LVH, limited coronary flow reserve. A fall in vascular resistance during anesthesia causes hypotension inadequate compensation due to fixed obstruction from AS. Hypotension decreased coronary perfusion myocardial ischemia reduced contractility hypotension decreased coronary perfusion hypotension etc MI, death

69 Originally described as a risk factor for MACE and death in Goldman s 1977 Cardiac Risk Index. Not found to be associated with MACE in the 1999 RCRI, but a very low number of patients. Advances in anesthesia and intra-op hemodynamic monitoring have greatly reduced the incidence of post-op events in patients with AS ( e.g. arterial lines, PA catheters, intra-op TEE, phenylephrine )

71 256 Mayo Clinic pts ( ) with severe AS undergoing intermediate to high risk surgeries. Death, MI, stroke, VT/VF, new / worsening CHF. 30 day post-op mortality: 5.9% vs. 3.1% (P = 0.13) No sig differences in MI, stroke, VT/VF. New / worsening CHF: 18.8% vs. 10.5% (P = 0.01) Asymptomatic AS patients had outcomes similar to controls and 3% risk of death at 30 days. Emergency surgeries (strongest predictor of death) excluded, all severe AS pts had <5% risk of death at 30 days.

73 634 Cleveland Clinic pts ( ) with AS who underwent elective non-cardiac surgery. 30 day mortality: 2.1% vs. 1% (P=0.036) Post-op MI: 3% vs. 1.1% (P=0.001) Symptomatic vs. asymptomatic severe AS - 30 day mortality: 2.8% vs. 1.2% - Post-op MI: 5.6% vs. 3.5% Other predictors: high risk surgery (OR 7.3), mod or severe MR (OR 9.8), symptomatic severe AS (OR 2.7), pre-existing CAD (OR 2.7)

74 So what these two studies demonstrate is that the observed incidence of MACE and death in patients with severe AS is much lower than it used to be. If emergency surgeries are excluded, the 30 day mortality rate in patients with severe AS was <5% in both studies. So who s afraid of the big bad wolf? We still should be, but not nearly as much as we used to be.

75 If we have a patient with severe AS and a normal LVEF who is asymptomatic then no further w/u is really needed. If we have a patient with symptomatic severe AS then we must weigh the risks of postponing the proposed surgery to pursue AVR. Balloon valvuloplasty? (poo-poo d in 2014 ) TAVI? (No studies.) Not usually an option in hospitalized patients. We must talk to the anesthesiologist!

76 Should I get a routine pre-op CXR? NO! Only 1.3% show anything unexpected, and only 0.1% change management.

77 Post-op pulmonary complications: - Equal or greater importance than cardiac complications (morbidity, mortality, LOS). - Moving target. - Poor functional status - COPD, CHF - Low albumin ( < 3.5 ) - OSA - Aortic, upper abd, thoracic - Smoking - Duration / type of anesthesia - Age > 60 - Emergency surgery - Sepsis

78 S nore (louder than talking, another room?) T ired (or sleepy during daytime?) O bserved (stop breathing in your sleep?) P ressure (treated for high blood pressure?) Yes to 2 or more = high risk of OSA

79 Myth: quitting fewer than 8 weeks prior to surgery may increase pulmonary complications. Smoking increases the risk of: - Pulmonary complications - Wound complications - Infections Quitting decreases the risks in these categories.

81 NSQIP database, n 468,000 Failure to wean off vent within 48 hrs of surgery. Unplanned intubation or re-intubation. 60% abdominal surgeries 3% of patients had PRF Patients with PRF 30 day mortality 25%

85 Healthy person, not septic, going for lap CCX:

86 Bed bound SNF resident with COPD, CHF, DM, myelodysplasia presents with infected, ruptured AAA:

87 Lung expansion maneuvers Smoking cessation Selective NG decompression Laparoscopic procedures Epidural anesthesia

88 I ncentive spirometry C ough and deep breathing O ral care U nderstanding G etting out of bed H ead of bed elevation (Decreased post-op pneumonia and resp failure)

90 1884 patients with Afib who required interruption of warfarin therapy for surgery. Warfarin stopped 5 days prior, resumed the PM of or the AM after surgery. Dalteparin vs. placebo started 3 days prior, held 24 hours prior to the procedure, resumed hours after the procedure based on bleeding risk. No difference in arterial embolism, more major and minor bleeding in the dalteparin group.

91 But - Very low event rate in both groups (0.4 and 0.3%) - Low rate of major bleeding ( 3.2% ), none fatal - Mean CHADS 2 score % of patients had CHADS 2 score of 1 or 2 - Patients at high risk of bleeding or ATE (CEA, cancer surgery, CV or neurosurgical procedures) were not included. - In low risk patients, bridging is not needed.

92 By aggressively anticoagulating patients post-op are we causing more bleeding that results in withholding anticoagulation completely? Could this result in more strokes rather than fewer? How many major bleeding events do we tolerate per stroke? Medicolegal risk?

93 In a pilot trial 75% of the arterial embolic events in high risk patients were a result of anticoagulation being held due to bleeding pts with mechanical heart valve or atrial fibrillation / flutter and a major risk factor (prior stroke, HTN, diabetes, age >75, HFrEF). Warfarin held 5 days prior to surgery, resumed the PM after surgery. Dalteparin vs. placebo post-op. Results in 2017?

94 Class I troponin and EKG with signs / symptoms of myocardial ischemia. Class IIb usefulness of troponin and EKG in an asymptomatic patient at high risk of peri-op MI is uncertain in the absence of defined risk and benefits of a defined management strategy. Class III routine screening with troponin in unselected patients without symptoms.

95 77 yo gentleman admitted to surgery due to acute cholecystitis and sepsis. Surgery consulted Medicine and Cardiology. PMH: CAD, AAA repair (2005) ACS, eventual CABG, HFrEF (20-25%), NSVT but refused ICD. He had cooled off quite a bit with antibiotics and some cautious IV fluids. Had been more fatigued lately, but no CP or SOB.

96 I said leave him on his beta blocker and go take his gallbladder out. Cards ordered a nuclear stress. I asked why. We need to take a look if it shows ischemia. I asked whether revascularization prior to surgery has ever been shown to improve outcomes. No. (the correct answer)

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