Pre-Operative Assessment and Optimisation of the Older Surgical Patient

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1 Pre-Operative Assessment and Optimisation of the Older Surgical Patient Hypertension, arrhythmias, pacemakers and anticoagulant drugs in the surgical patient

2 Hypertension It s common Control rates are not great Major Risk for CVD Treatment is beneficial

3 Attributable Risk of Hypertension able Heart Failure Stroke Dementia AMI PVD Cataract IHD Percentage

4 Questions to Consider 1. Is diagnosis of hypertension bad for you? 2. Is elevated BP at the time of admission bad for you? 3. Is poorly controlled hypertension bad for you? 4. Does treatment make a difference?

5 Diagnosis is bad for you? Howell SJ et al. Br J Anaeth (2004)

6 Admission BP Little data Early studies no increase risk Lacked statistical power Used specific cut offs Howell et al Data mostly for SBP below 180 mmhg s Data suggest increased risk if SBP over 180 mmhg

7 Cardiovascular Lability Hypertensives greater BP lability periop Poor control, greater lability Impact uncertain Possible more intra-operative ischaemia Possible more arrhythmias Greater impact for protracted surgery

8 Treatment If SBP < 180 mmhg + no complications no reason to delay If > 180 mmhg possible benefits from delay continue antihypertensive medications Debate about ACE-Is Post-op Pain control important Restart ACE-I when euvoleamic

9 Arrhythmias Common peri-operatively (60-80%) Usually clinically insignificant Numerous pre-op predictors reported Most consistent for AF age 60 Sinus tachy & bradycardia common

10 Pre-op search for underlying co-morbidities Asymptomatic ventricular arrhythmias no increase in cardiac complications after non-cardiac surgery. no intervention required AF commonest supraventricular tachycardia Cause Rate v rhythm Antithrombotics Amiodarone associated with respiratory failure post-op Chronic bifascular block rarely progresses

11 Peri-op Treatments Correct precipitants Sinus tachy AF/Flutter No clear guidelines for Rx post non-cardiac surgery Heamodynamically stable? B-blockers better than digoxin AVNRT/AVRT Consider valsalva/ CSM adenosine

12 Pacemakers and AICDs Why was it put in? What type? Pacemaker dependent Get it tested Problems uncommon Problem is EMI

13 1. Is EMI likely? 2. Preoperative reprogramming or disabling special algorithms needed? 3. Suspend antitachyarrhythmia functions 4. Advising bipolar electrocautery /ultrasonic scalpel 5. Assuring availability temporary pacing/ defibrillation equipment 6. Evaluating possible effects of anaesthetic techniques Anaesthesiology Feb 2011

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15 Anticoagulants Pre-op ALL patients last dose of warfarin 4 days pre-op antithrombin deficiency or antiphospholipid antibodies? low risk, intermediate risk, high risk or very high risk?

16 Low risk: Target INR unless VTE with: active cancer intermediate risk VTE within last 3 months - intermediate risk VTE within last 6 weeks - high risk: ideally avoid surgery, temporary IVC filter non valvular AF target INR unless: TIA/CVA within the last 3 months (ideally avoid surgery) - intermediate risk Intermediate risk: DVT/PE target INR but VTE 6-12 weeks ago Valvular AF (even if INR target ) TIA/CVA within the last 3 months (ideally avoid surgery) High risk: VTE within the last 6 weeks ideally avoid surgery, temporary IVC filter Any indication with target INR , unless mechanical cardiac valves very high risk Very high risk: Mechanical cardiac valves

17 Anticoagulants Pre-op ALL patients last dose of warfarin 4 days pre-op antithrombin deficiency or antiphospholipid antibodies? low risk, intermediate risk, high risk or very high risk? Low risk Pre-op: No alternative required Intermediate risk Pre-op: Enoxaparin 40 mg 9am (day -3, -2-1) Omit morning of surgery High risk Pre-op: Enoxaparin1.5mg/kg 9am (day -3, -2-1) Omit morning of surgery Very high risk Pre-op: Admit patient day -3. IV UFH when INR <2.0 Stop 4 hours pre-op Post-op: Enoxaparin 40 mg 6-12 hrs post-op Post-op: Enoxaparin 40 mg 6-12 hours post-op Post-op: Enoxaparin 1.5mg/kg 6 hours post-op Post-op: Restart IV UFH immediately post-op Continue till target INR TWO consecutive occ.

18 Re-starting oral anticoagulant If no excessive bleeding (and epidural catheter has been removed), ideally evening of surgery once oral intake established INR less than 1.5 loading dose: 1.5 x usual dose 3 days then usual dose If INR more than 1.5 seek advice Consider interactions Refer local anticoagulation clinic within 3 days of d/c: only one INR in range pre d/c within 5 days if 2 consecutive INR s in range

19 Conclusions Pre-op assessment opportunity for screening SBP < 180 mmhg not a independent risk Arrhythmia consider why Pacemakers consider fixed rate if EMI Anticoagulants establish clear SOPs Area needs further research