Perioperative Assessment in the Older Adult. Sondra Vazirani, MD, MPH

Transcription

1 Perioperative Assessment in the Older Adult Sondra Vazirani, MD, MPH

2 The Preoperative Evaluation in the Older Adult Sondra Vazirani, MD, MPH, FACP* 33 rd UCLA Intensive Course in Geriatric Medicine & Pharmacy, 2016 Health Sciences Clinical Professor of Medicine, DGSOM at UCLA Hospitalist, Greater Los Angeles VA Healthcare System Director of Preoperative Medicine, VAGLAHS Dept of Surgery & PC Director of Inpatient Medicine Consult Service, VAGLAHS Dept of Medicine Member, Pharmacy & Therapeutics and Pharmacy Benefit Management Committees, GLA *Speaker Has No Conflicts of Interest

3 Take Home Points EBM guidelines Noncardiac Surgery Preoperative Evaluation is a unique process Knowledge base Risk/Benefit Analysis Perioperative Medication Management Cardiac Approach Interventions to optimize or risk stratify Every organ system is important

4 Geriatric Facts # of Americans > 65 years of age will double between 2010 and 2050 Higher rates per population of surgeries and procedures High rate of polypharmacy Higher likelihood of complications and prolonged recovery

5 2016 Focus on Mgt: Immediate Preop/Intraop/Post Op

6 2012

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8 Preoperative Assessment, Cont.

9 Outline for This Talk ACC/AHA Guidelines for Cardiac Evaluation for Non-Cardiac Surgery Selected Sub-Topics Medication Management Perioperative Beta-blockers Stents and Anti-platelet Agents Anticoagulation in setting of A-fib

10 Case Mr. Jones is a 72 yo M with h/o CAD, HTN, DM2, COPD, OSA and hyperlipidemia. He has poor functional capacity due to lumbar stenosis. He denies CP or SOB currently. You are asked to clear him. Does your cardiac evaluation differ if Mr. Jones is having cataract surgery vs. L3/4/5 laminectomy?

11 Purpose of Preop NOT to clear a patient

12 Purpose of Preop Summarize perioperative medical conditions relevant to medicine, anesthesia, and surgery Beyond a routine H&P Screen for OSA Post op hypoxia, respiratory failure, re-intubation Loose teeth Anesthetic history Adrenal axis suppression

13 Medications Purpose of Preop Reconciliation Eliminate non-essential medications Perioperative management of medications Not just take all cardiac meds the am of surgery Insulin, anticoagulants, steroids Perioperative effects of herbals G s cause bleeding

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15 Factors Influencing the Risk of Surgery Patient s Physical Status Preoperative Assessment/Treatment Type and Timing of Surgery Anesthetic and Surgical Skill OR and Hospital Competence

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17 ASA Physical Scale Class I: healthy Class II: mild systemic disease Class III: severe systemic disease, not incapacitating Class IV: incapacitating systemic disease, constant threat to life Class V: moribund, not expected to live >24 hours with or without surgery E: Emergent

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19 Operative Mortality in Colorectal CA

20 Goals of the Preoperative Evaluation Evaluate current medical status Determine medical candidacy Risk stratify the patient Optimize medical illnesses Offer perioperative recommendations for surgeon and anesthesiologist Provide patient education

21 Approach to Cardiac Pre-operative Evaluation ACC/AHA 2014 Guidelines on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery Update from 2007 Guidelines

22 ACC/AHA Approach to Preoperative Cardiac Assessment Emergent ACS CHF, VHD, arrhythmias (formerly Active Cardiac Conditions) MACE (Combined Clinical/Surgical Risk) Functional Capacity/METs Will Testing Impact Management?

23 Stepwise approach to perioperative cardiac assessment for CAD. Colors correspond to the Classes of Recommendations in Table 1. Fleisher L A et al. Circulation. 2014;130:e278-e333 Copyright American Heart Association, Inc. All rights reserved.

24 Step 1

25 Step 2: Risk of Major Adverse Cardiac Events (MACE)

26 Risk of Surgery

27 How do you estimate risk of MACE? Based on combined clinical/surgical risk RCRI calculator ACS NSQIP calculator

28 Lee Risk Index Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery Lee, et al. Circulation, 1999, 100:

29 Lee Risk Index Prospective Cohort of 4,315 pts > 50 years old Nonemergent, Noncardiac Surgery at a tertiary care hospital Logistic regression analysis of defined preoperative clinical variables that correlated with cardiac complications Lee, et al. Circulation, 1999, 100:

30 Lee Risk Index CAD CHF CVA/TIA DM (Insulin) Creatinine >2 High risk surgery Cardiac Complication Rates 0 = 0.4% 1 = 0.9% 2 = 7% 3+ = >11% **NOTE AGE IS NOT A RISK FACTOR *intraperitoneal, intrathoracic, or suprainguinal vascular Lee, et al. Circulation, 1999, 100:

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32 ACS NSQIP Calculator Procedure name or CPT code Other surgical or non-operative options 21 patient data points

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35 Step 2: Risk of Major Adverse Cardiac Events

36 Stepwise approach to perioperative cardiac assessment for CAD. Colors correspond to the Classes of Recommendations in Table 1. Fleisher L A et al. Circulation. 2014;130:e278-e333 Copyright American Heart Association, Inc. All rights reserved.

37 What is a MET? The Question

38 Estimated Energy Requirements for Activities Metabolic Equivalent (MET) VO2 at rest, sitting (3.5 ml O2/kg/min) 1 4 METs Can you take care of yourself (dress, toilet)? Walk around the house Walk a block or two at 2-3 mph Light work around the house

39 . Functional Status OH NO!

40 Estimated Energy Requirements for Activities 4-->10 METs Climb a flight of stairs or walk up a hill Walk on level ground at 4 mph Run a short distance Participate in moderate recreational activities Participate in strenuous sports like singles tennis, swimming I ask what is the most exertional activity you do?

41 Stepwise approach to perioperative cardiac assessment for CAD. Colors correspond to the Classes of Recommendations in Table 1. Fleisher L A et al. Circulation. 2014;130:e278-e333 Copyright American Heart Association, Inc. All rights reserved.

42 Will further testing impact decision making or perioperative care? Risk stratification Revascularization Is there evidence of benefit with preoperative revascularization? What are implications (time delay) of preoperative revascularization?

43 Noninvasive Stress Testing Exercise Treadmill Test (ETT) Nuclear ETT-thallium Adenosine-thallium (p-thal) sestamibiregadenoson Doubutamine-thallium Echo ETT-Echo Dobutamine Echo Make them run if they can..

44 How does ETT fare? Less sensitive for single vessel disease Difficult to interpret if baseline EKG abnormalities Poor test in females Implausible if unable to achieve low METs

45 Rationale for Preop Revascularization Perioperative MIs arise at areas of critical stenoses, elicited by stress Cytokines, catecholamines, vasospasm, reduced fibrinolysis, platelet activation. Rupture of insignificant lesions may cause up to 50% of periop MIs Dawood MM et al, Int J Cardiology 1996; 57:

46 Preop Revascularization Studies that support ACC/AHA position CARP, Vascular surgery at VA, NEJM 2004 No Difference in: Death within 30 days Perioperative MI (12% vs. 14%) LOS Mortality at 2.5 years [DECREASE-V]- Poldermans

47 Summary Revascularize if you would have done it anyway Indicated according to CPGs; and not exclusively to reduce perioperative cardiac events Fleisher, Lee, et. al, 2014

48 Cardiac Protection beyond Revascularization. Beta blockers Statins Continue them (I) Start them ASAP in vascular surgery patients (IIa)

49 Beta Blockers: The Pendulum

50 Perioperative beta-blockers: theoretical basis Prolonging coronary diastolic filling time Muting sympathetic drive post operatively Preventing ventricular arrhythmias Preventing rupture of atheromatous plaque Cruickshank, Eur Heart J, 2000; 21:

51 First Major Data Supporting Perioperative β- blockers Mangano et al. Effect of Atenolol on Mortality and Cardiovascular Morbidity After Noncardiac Surgery. NEJM 1996; 335: Randomized, double blind, placebo controlled study at SF VA Perioperative beta-blockade in 200 VA patients (2/3 > 65 years old) with known or suspected CAD having non-cardiac surgery

52 Effect of Perioperative Atenolol on Overall Survival $2500 per life-year saved Mangano, et al. NEJM, 1996

53 Pendulum Swings More small + RCTs Devereaux neutral meta-analysis in Neutral studies Lindenauer retrosp. cohort: harm in low risk Then.. Came POISE in 2008

54 POISE PeriOperative Ischemic Evaluation Randomized placebo controlled trial 8351 Patients, 190 hospitals, 23 countries Extended release metoprolol 2-4 hours preop, postop, to 30 days Primary endpoints CV death, non fatal MI, non-fatal cardiac arrest Lancet, May 2008

55 POISE PeriOperative Ischemic Evaluation 99.8% followup Metoprolol group Fewer reached primary endpoints Fewer MI More death* (3.1 vs 2.3), strokes (1.0 vs 0.5), hypotension (15 vs 9.7) and bradycardia (6.6 vs 2.4) *sepsis or infection Lancet, May 2008

56 POISE PeriOperative Ischemic Evaluation Should we give up on perioperative beta blockers? Main problem with the trial high dose, long acting metoprolol 100 mg pre, 100 mg post, then 200 mg per day if SBP> 100 mm Hg and HR >49 bpm Lancet, May 2008

57 CONCLUSIONS Perioperative beta blockade started within 1 day or less before noncardiac surgery prevents nonfatal MI but increases risks of stroke, death, hypotension, and bradycardia. Without the controversial DECREASE studies, there are insufficient data on beta blockade started 2 or more days prior to surgery. Multicenter RCTs are needed to address this knowledge gap.

58 Who should get perioperative beta blockers? Continue them (I) Reasonable in the setting of Intermediate or high risk preoperative tests (IIb) >2 RCRI factors (IIb) Start > 1 day prior to surgery (IIb) Don t use if contraindications (III) Fleisher et al, JACC 64(22) Dec 2014

59 When to start and stop BB Start as early as is possible Tolerance Titrate to goal HR of Keeping SBP>100 Continue indefinitely if indicated If not, continue to at least POD #7, up to 30 days

60 Stents and Anti-platelet Therapy aka: what to do with the Plavix and ASA??

61 Algorithm for antiplatelet management in patients with PCI and noncardiac surgery. Fleisher L A et al. Circulation. 2014;130:e278-e333 Copyright American Heart Association, Inc. All rights reserved.

62 Atrial fibrillation (AF) and Coumadin To bridge or not to bridge..? Weigh the risks of thrombosis vs. bleeding and cost Minimize time off anticoagulation using heparin bridge

63 AF Bridge based on CHADS2 CHADS2 1-2 LOW RISK (2-4%)* CHADS2 3-4 INTERMEDIATE RISK (6-9%) CHADS2 5-6 HIGH RISK (13-18%) Bridging should be offered to all patients at high risk Bridging is not recommended for patients at low risk Patients at moderate risk should have the bridging decision made based on an assessment of individual patient- and surgery-related factors *Stroke rate per 100 Patient-Years - Based on 2012 ACCP guidelines

64 Another approach to bridging in AF No Bridge: CHADS2 score of 1-3 Yes Bridge: prior CVA, cardiac thrombus, CHADS2 score of 4-6 Baron, et. al., NEJM 368(22): May 30, 2013 Mgt of AT Therapy in Pts Undergoing Invasive Procedures

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66 Conclusion For patients with AF who require temporary interruption of warfarin treatment for an elective operation or invasive procedure, a strategy of forgoing bridging anticoagulation was noninferior to perioperative bridging with LMWH (dalteparin in this study) for prevention of arterial thromboembolism Forgoing bridging treatment also decreased the risk of major bleeding compared to perioperative bridging with LMWH

67 Excluded patients Limitations Mechanical heart valve CVA/embolism/TIA within 12 weeks Major bleeding within 6 wks egfr < 30ml/min Plt<100k Cardiac, intracranial, intraspinal surgery

68 Mean 2.3 Distribution of CHADS2 Scores at Baseline

69 Bridging Protocol Stop warfarin POD -5 (93% of patients) Start enoxaparin 1mg/kg bid POD -3 Last dose in am of POD -1 Prescribe 5 doses (1mg/kg q12hrs) Post op bridge at discretion of surgeon when hemostasis is achieved.

70 Not everyone can use LMWH HIT Hypersensitivity to pork Renal impairment (excretion) Caution with CrCl < 30 ml/min Qd dosing rather than bid Not in dialysis patients or CrCl<15 ml/min Extremes of weight

71 What to do the TSOACs have in common? No reversal agent (other than dabigatran) Cleared via the kidneys, so renal function determines timing of perioperative cessation Bridging is not required given short half life

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73 Case Mr. Jones is a 72 yo M with h/o CAD, HTN, DM2, COPD, OSA and hyperlipidemia. He has poor functional capacity due to lumbar stenosis. He denies CP or SOB currently. You are asked to preop him. Does your evaluation differ if Mr. Jones is having cataract surgery vs. L3/4/5 laminectomy? YES

74 Mr. Jones MACE is < 1% with cataract surgery MACE is elevated with lumbar stenosis surgery With no symptoms, yet poor functional capacity, I might elect to perform NIST if there is no study within 2 years given elective and non-urgent nature of the surgery

75 Summary Preoperative Evaluation is a Unique Process and Knowledge Base Risk/Benefit Analysis Quantify risk and determine candidacy Optimize and Reduce Risks GDMT or revascularization, when indicated Perioperative Medication Management

76 Questions? Thank you