None. O u t l i n e. Conflict Of Interests. Reengineering in Surgical Paradigm. Patient Selection Influences Perioperative Outcome

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1 THE UNIVERSITY OF TEXAS Conflict Of Interests SOUTHWESTERN MEDICAL CENTER AT DALLAS ne Patient Selection For : Can Any Patient Be an Outpatient? Girish P Joshi, MB, BS, MD, FFARCSI Professor of Anesthesiology and Pain Management Director of Perioperative Medicine and Ambulatory Anesthesia O u t l i n e Describe the concerns of ambulatory surgery in challenging patients Understand the approach to determining patient selection for ambulatory surgery Justify appropriate selection of challenging adult patients scheduled for ambulatory surgery Sick, elderly, obese, OSA, diabetes mellitus, cardiac implantable electronic devices Reengineering in Surgical Paradigm In the US, ~ 70% surgical procedures performed on an outpatient basis Improvements in surgical and anesthetic techniques make more procedures possible in outpatient setting Complex surgical procedures are increasingly performed on complex patients Source: Intellimarker Ambulatory Surgical Centers Financial & Operational Benchmarking Study Fifth Edition VMG Health, July 2010 (67) Patient Selection Influences Perioperative Outcome Delayed discharge home In an ambulatory setting, patient selection influences perioperative outcome Reduced efficiency of the ASC Unplanned hospital admission Increased post-discharge complications Unplanned readmission Patient/family dissatisfaction

2 Suitability For : Complex and Dynamic Process Surgical procedure Cataract, peripheral, cavity Patient s preoperative health ASA Physical status Proposed anesthetic technique Local/regional anesthesia vs GA Suitability of surgical facility HOPD, ASC, Office-based Social considerations Appropriate caregiver availability Procedure Considerations Low risk of severe intra- or postop blood loss Tranexamic acid allowed TKA on outpatient basis Postoperative pain easily controlled need for intensive or prolonged postop care Duration of procedure?? Surgeon s expertize Birkmeyer et al: Surgical Skill and Complication Rates after Bariatric Surgery N Engl J Med 2013;369: Outpatient Total Knee Arthroplasty Outpatients were younger, had lower comorbidity burden TKA performed on an outpatient basis had lower risk of re-hospitalization Reasons for re-hospitalization Inadequate pain control Comorbidities, particularly HF Lovald S, et al: J Surg Ortho Adv 2014; 23:2 8 Laparoscopic Roux-En-Y Gastric Bypass Bariatric Outcomes Longitudinal Database (n=51,788) lap gastric bypass procedures Median age=45 years; BMI=463 kg/m 2 Patients discharged on an ambulatory basis had a 13-fold increased risk of 30-day mortality when compared with the LOS of 2 days Ambulatory discharge was associated with a trend toward increased serious complication Morton JM, et al: Ann Surg 2014; 259: : Predictors of Complications ACS-NSQIP database (n=244,397) Predictors of 72-h perioperative morbidity: High BMI COPD Previous PCI/cardiac surgery Hypertension H/o TIA/CVA Prolonged operative time Mathis M, et al: Anesthesiology 2013; 119: Unplanned Admission After Length of surgery more than one hour High ( 3) ASA physical status classification Advanced age (>80 years) High BMI Whippey A, et al Can J Anaesth 2013; 60:

3 Reliability of the ASA Physical Status Scale Inter-rater reliability assessed in a cohort of 10,864 patients ASA Physical Status Scale ASA 1=55%, ASA 2=42%, ASA 3=467%, ASA 4=58% ASA-PS scale had moderate ability to predict in-hospital mortality and cardiac complications Despite the inherent subjectivity, ASA-PS scale can be used as a measure of preoperative health Shankar A, et al: Br J Anaesth 2014; 113: Patient Considerations Patients with ASA physical status 4 NOT suitable for ambulatory surgery A patient with severe systemic disease that is a constant threat to life Patients with ASA physical status 3 consider other factors Age A patient with severe systemic disease Outpatient Laparoscopic Cholecystectomy in the Elderly Age alone should not be used to determine suitability for ambulatory surgery Analysis of the NSQIP database ( ) Elderly (>65 yr) undergoing elective lap chole on an outpatient basis (n=7499) compared with inpatients (n=7799) Predictors of inpatient admission and mortality ASA 4, CHF, bleeding disorder, CRF on dialysis Factors that did not influence admission Diabetes mellitus, BMI, smoking status Rao A, et al: Am Coll Surg 2013; 217:

4 Age and Age > 80 years is an indicator of increased perioperative risk Whippey A, et al: Can J Anesth 2013; 60: Fleischer LA, et al: Arch Surg 2004; 139: Consider post-discharge issues Increased need for supervision Obese Patients For Social issues such as elderly or debilitated partner in Obese Systematic Review: Results 106,119 patients (prospective cohort trials = 62,476 and retrospective trials = 43,643) Bariatric surgery population = 39,548, and systematic review patients n=2549 Obese had increased respiratory events O 2 desaturation, need for O 2 supplementation Stridor/laryngospasm, airway obstruction Joshi GP et al: Anesth Analg 2013; 117: Systematic Review: Results differences in unanticipated admission rate Obese and non-obese cohorts Studies of bariatric and non-bariatric surgery BMI in non-bariatric surgery studies around 30 BMI in bariatric surgery studies was around 40 Rigorous preoperative preparation Super obese (BMI>50) higher risk of complications Joshi GP et al: Anesth Analg 2013; 117: Selection of a Obese Patient For BMI<40 kg/m 2 Proceed With Preoperative Assessment & Identification of Comorbid Conditions [OSA, Hypoventilation, Cardiovascular, Difficult airway, DM] Comorbid Conditions Optimized BMI kg/m 2 BMI>50 kg/m 2 Known or Presumed OSA Follow SAMBA-OSA Recommendations * Comorbid Conditions NOT optimized t Suitable For Joshi GP, et al: Anesth Analg 2013; 117: * Joshi GP, et al: Anesth Analg 2012; 115:

5 OSA Patients For Scientific literature on safety and perioperative management of OSA patients is sparse and of limited quality Anesthesiology 2014; 120: ASA-Scoring System For OSA Patients A Severity of OSA (0-3 pts) B Invasiveness of surgery/anesthesia (0-3 pts) C Requirements for postoperative opioids (0-3 pts) Overall score (0-6): A + greater of B or C Score 4 increased risk from OSA Score 5 or 6 significantly increased risk from OSA t suitable for ambulatory surgery Intra-abdominal and upper airway surgery are not suitable for ambulatory surgery Anesthesiology 2014; 120: SAMBA-OSA Systematic Review difference in complications between OSA and non-osa patients undergoing ambulatory surgery Most studies used standardized, protocolized approach to patient care Emphasis on preoperative diagnosis Emphasis on use of non-opioid analgesics to minimize opioid use Emphasis on postoperative care particularly use of CPAP after discharge Joshi GP et al: Anesth Analg 2012; 115: Joshi GP et al: Anesth Analg 2012; 115: Selection of a OSA Patient For Patient With Known OSA Optimized Comorbid Conditions AND Able to use CPAP after discharge Proceed With Patient With Presumptive Diagnosis of OSA Patients With n-optimized Comorbid Conditions Optimized Co-morbid Conditions AND Postoperative opioids can be limited by using nonopioid analgesic techniques t Suitable For, may benefit from diagnosis and treatment Proceed With guidance can be provided for airway surgery Joshi GP et al: Anesth Analg 2012; 115:

6 Surgery For OSA in An Ambulatory Setting Systematic review of 18 studies (2160 patients) deaths or major catastrophic events Overall adverse event rate = 53% Respiratory complications = 15% Majority were O2 desaturations, and were not clinically significant Readmission rate 04% OSA surgery performed on an outpatient basis is generally safe Exceptions: tongue base surgery, high AHI, high postop opioid requirements Rotenberg B: Curr Anesthesiol Rep 2014; 4: 10-8 Laryngopharyngeal Surgery in OSA Analysis of the National Survey of Ambulatory Surgery increase in airway surgery over a decade Unplanned readmission rate <4% mortality or serious complications Minor complications: 9% Mahboubu H et al: JAMA Otolaryngol Head Neck Surg 2013; 139: Glycemic Control Guidelines Diabetic Patients For Is there a preoperative blood glucose level above which one should postpone elective surgery? evidence that any particular blood glucose level is harmful for outpatients First step in decision making: assess for significant complications of hyperglycemia such as severe dehydration, ketoacidosis, and hyperosmolar non-ketotic states Postpone surgery of these conditions are present Preoperative Blood Glucose Level Good long-term control: proceed with surgery Poor long-term control: consider comorbidities and risks of surgical complications (eg, delayed wound healing and wound infection) Decision to proceed made in conjunction with the surgeon

7 Proceed After BGL Correction or Correct BGL in the Operating Room Rapid correction of BGL not necessary Timing of BGL correction based upon Patients With Cardiac Disease available time in the preop period duration of surgery For Perioperative Myocardial Infarction or Cardiac Arrest Risk Calculator Perioperative Cardiac Assessment Stepwise approach to perioperative cardiac assessment for CADColors correspond to the Classes of Recommendations in Table 1 Perioperative*Myocardial*Infarction*or*Cardiac*Arrest*Risk*Calculator Age 65 Enter actualageinyears EstimatedriskprobabilityforperioperativeMICA: Enter 1F5forAmericanSocietyofAnesthesiologists'Class * 028% ASAClass 3 ASAClassification: 1Anormalhealthypatient 2Apatientwithmildsystemicdisease 3Apatientwithseveresystemicdisease 4Apatientwithseveresystemicdiseasethatisaconstantthreattolife 5Amoribundpatientwhoisnotexpectedtosurvivewithouttheoperation Creatinine (preoperative) FunctionalStatus (preoperative) Procedure: 0 Enter 2formissingvalue 1for>=15mg/dL 0for<15mg/dL 0 Enter 2forpatientswithtotallydependentfunctionalstatus 1forpatientswhohavepartiallydependentfunctionalstatus 0forthosewhoaretotallyindependent 10 Enter 1forAnorectal 2forAortic 3forBariatric 4forBrain 5forBreast 6forCardiac 7forENT(exceptthyroid/parathyroid) 8forForegut/Hepatopancreatobiliary 9forGallbladder,appendix,adrenalandspleen 10forHernia(ventral,inguinal,femoral) 11forIntestinal Percentile 25thpercentile 50thpercentile 75thpercentile 90thpercentile 95thpercentile 99thpercentile 12forNeck(ThyoidandParathyroid) 13forObstetric/Gynecologic 14forOrthopedicandnonFvascularExtremity 15forOtherabdominal 16forPeripheralVascular 17forSkin 18forSpine 19fornonFesophagealThoracic 20forVein 21forUrology Authors: PrateekKGupta,MD Circulation2011Jul26;124(4):381F7Epub2011Jul5 Gupta PK, et al: CirculationMethodologyin: 2011; 124: 381-7; HimaniGupta,MD Fleisher L A et al Circulation 2014;130: AbhishekSundaram,MD ManuKaushik,MBBS XiangFang,PhD WeldonJMiller,MS DennisJEsterbrooks,MD ClaireBHunter,MD IraklisIPipinos,MD JasonMJohanning,MD ThomasGLynch,MD RArmourForse,MDPhD SyedMMohiuddin,MD AryanNMooss,MD From: 1/4/15 6:54 PM DepartmentofSurgery,CreightonUniversity,Omaha,NE68131 prateekgupta@creightonedu DepartmentofMedicine,CreightonUniversity,Omaha,NE68131 himanigupta@creightonedu ACS NSQIP: Surgical Risk Calculator Patient Information - ACS Risk Calculator DepartmentofSurgery,CreightonUniversity,Omaha,NE68131 abhisheksundaram@creightonedu DepartmentofMedicine,CreightonUniversity,Omaha,NE68131 manukaushik@creightonedu - ACS Risk Calculator Biostatisticalcore,CreightonUniversity,Omaha,NE68131 xiangfang@creightonedu 1/4/15 6:54 PM SchoolofMedicine,UniversityofPittsburg,Pittsburg,PA15261 millerweldon@medstudentpittedu Risk Calculator Homepage About FAQ Website ACS Website Procedure Risk Calculator Homepage Repair inguinal hernia, sliding, any age Clear Begin by entering the procedure name or CPT code One or more procedures will appear below the procedure box You will need to click on the desired procedure to properly select it You may also search using two words (or two partial words) by placing a + in between, for example: cholecystectomy+cholangiography Other Surgical Options Other noperative options Age Group Sex Emergency case ASA class Wound class Steroid use for chronic condition Ascites within 30 days prior to surgery Systemic sepsis within 48 hours prior to surgery Diabetes years Male Independent Yes Previous cardiac event Risk Factors Age: 65-74, Male, ASA III, Diabetes (oral), HTN, Obese (Class3) ACS NSQIP Website Clean Dyspnea Estimated Risk 2% 4% Pneumonia Cardiac Complication Surgical Site Infection 1% Urinary Tract Infection Venous Thromboembolism Renal Failure 1% Return to OR Current smoker within 1 year History of severe COPD Dialysis Acute Renal Failure ne Death BMI Calculation: Height (in) 66 Disseminated cancer Weight (lbs) 270 Discharge to Nursing or Rehab Facility 1% 0% (Better) 100% (Worse) Predicted Length of Hospital Stay: 05 days Surgeon Adjustment of Risks This will need to be used infrequently, but surgeons may adjust the estimated risks if they feel the calculated risks are underestimated This should only be done if the reason for the increased risks was NOT already entered into the risk calculator 1 - adjustment necessary Step 3 of 4 Page 1 of 2 DepartmentofSurgery,UniversityofNebraskaMedicalCenter,Omaha,NE68154 ipipinos@unmcedu Chance of Outcome Any Complication ne DepartmentofCardiology,CreightonUniversity,Omaha,NE68131 clairehunter@cardiaccreightonedu Change Patient Risk Factors III - Severe systemic disease Ventilator dependent ACS Website ne Oral Hypertension requiring medication Congestive heart failure in 30 days prior to surgery FAQ Repair inguinal hernia, sliding, any age Outcomes Please enter as much of the following information as you can to receive the best risk estimates A rough estimate will still be generated if you cannot provide all of the information below Functional status About Procedure Serious Complication Reset All Selections Are there other potential appropriate treatment options? DepartmentofCardiology,CreightonUniversity,Omaha,NE68131 DennisEsterbrooks@cardiaccreightonedu ACS NSQIP Enter Patient and Surgical Information PercentRisk 005% 014% 061% 147% 260% 769% Page 1 of 2 Patients With CIED DepartmentofSurgery,UniversityofNebraskaMedicalCenter,Omaha,NE68154 jjohanning@unmcedu DepartmentofSurgery,UniversityofNebraskaMedicalCenter,Omaha,NE68154 tlynch@unmcedu DepartmentofSurgery,CreightonUniversity,Omaha,NE68131 rarmourforse@creightonedu For DepartmentofCardiology,CreightonUniversity,Omaha,NE68131 syedmohiuddin@cardiaccreightonedu DepartmentofCardiology,CreightonUniversity,Omaha,NE68131 aryanmooss@cardiaccreightonedu Acknowledgement: ChristopherFranck,MS DepartmentofStatistics,VirginiaTech,VA24060 chfranck@vtedu

8 Management of Pacemaker Patients Rendering PM asynchronous, even in PMdependent patients, not always required Render asynchronous, by programming or by a magnet, only if significant inhibition is observed Caution: pacemakers with special algorithms (eg, rate responsive devices, MV sensors, Crossley GH et al: Heart Rhythm 2011; 8: search hysteresis/ capture, battery extenders) Crossley GH et al: Heart Rhythm 2011; 8: Preoperative Considerations in Patients With Implantable Cardioverter Defibrillator Is EMI likely Yes Is the Procedure below umbilicus Proceed With Surgery Yes Proceed Is the patient pacemaker dependent? Future! Reprogram ICD Why is the patient in the hospital? Will hospitalization improve outcome? Use a Magnet Based on Crossley GH et al: Heart Rhythm 2011; 8: S u m m a r y Complex ambulatory surgical procedures will increasingly be performed on complex patients Patient selection is complex and dynamic process First step in determining appropriate patient selection includes preoperative assessment and identification of any comorbid conditions, which should be optimized to minimize risks Developing and implementing clinical pathways should improve the process of patient selection Thank You Questions The Art of Anesthesia