Perioperative Surgical Home. Jessica Hoge, M.D. Co-Director Bozeman Health POSH; Hospitalist

Transcription

1 Perioperative Surgical Home Jessica Hoge, M.D. Co-Director Bozeman Health POSH; Hospitalist

2 Disclosures Prior Medical Director of the Bozeman Health Research Group

3 What is a Perioperative Surgical Home? Patient-centered Reduced length of stay Coordinated care Reduced readmissions Standardization Reduced complications Empowered patients Reduced costs Preoperative Intraoperative Postoperative Post Discharge A patient-centered and physician-led multidisciplinary team-based system of coordinated care that guides the patient throughout the entire surgical experience. - Marc Warner, MD Mayo Clinic College of Medicine

4 What is a Perioperative Surgical Home? Hospitalists / Anesthesiologists Discharge planning Orthopedic surgeons Physical Therapy Pharmacy Nutritionists Educators Respiratory Therapy Preoperative Intraoperative Postoperative Post Discharge A patient-centered and physician-led multidisciplinary team-based system of coordinated care that guides the patient throughout the entire surgical experience. - Marc Warner, MD Mayo Clinic College of Medicine

5 Preoperative standardization Labs/ diagnostics SNF risk identification Cardiac risk stratification Patient education OSA screening Medications Frailty assessment Identify opiate track Preoperative Postoperative

6 Risk assessment & prediction tool RAPT score Predicts discharge disposition after total joint replacement 90% <6 & >9

7 Intraoperative standardization Normothermia Total joints: TXA Goal-directed IVF Total joints: Avoid foley Total joints: Neuraxial Multimodal analgesia GA: 80% FIO2 Intensive BG control Preoperative Intraoperative

8 Multimodal Pain for Total Knee Pre: Tylenol, Celebrex, Gabapentin, oxycodone Bupivacaine spinal Versed Propofol Fentanyl Ketamine Adductor canal catheter Preoperative Intraoperative

9 Postoperative standardization PONV treatment DVT prophylaxis Bowel regimen Early ambulation Opiate track Avoid post-operative IVF Total knee: Adductor block Colorectal: eat regular diet POD #0 Preoperative Intraoperative Postoperative

10 Post-Discharge standardization Discharge plan already identified preoperatively Patient has realistic expectations for recovery time Patient has realistic expectations for pain Patient access for post-operative issues Communication with PCP, ER Preoperative Intraoperative Postoperative Post Discharge

11 Q&A #1 75-yo male NSTEMI 3 months ago 1 DES RCA. Preserved EF Discharged on aspirin, clopidogrel, atorvastatin, and metoprolol. Referred to you prior to a total knee arthroplasty for severe OA Which of the following preoperative recommendations would you make to this patient? No recurrent angina sx

12 Q&A #1 1. Defer surgery for 1 year post-pci 2. Stop aspirin 7 days prior to surgery 3. Stop clopidogrel 7 days prior to surgery 4. Stop both aspirin and clopidogrel 7 days prior to surgery

13 Q&A #1 1. Defer surgery for 1 year post-pci 2. Stop aspirin 7 days prior to surgery 3. Stop clopidogrel 7 days prior to surgery 4. Stop both aspirin and clopidogrel 7 days prior to surgery

14 Q&A #1 This is elective surgery! Defer for 1 year. For patients who cannot wait one year, defer for minimum of 6 months for DES Cessation of DAPT prematurely is the strongest predictor of stent thrombosis PCI to surgery had increased MACE if within 1 year (OR 2.59, 95% CI ). Case control N=24313 NCS with 1120 stented Mahmoud KD, et al. J Am Coll Cardiol 2016;67(9):

15 Cardiac disease Screen for active angina. N= 1568 NSQIP Previous MI & NCS. Primary outcome MI/cardiac arrest (5.8%). Angina is an independent predictor for postop MI. OR 2.49 [CI ]. Pandey A et al. Am J Cardiol (8):

16 Cardiac disease Risk stratify using RCRI or NSQIP; Gupta If high risk (>1%), only perform cardiac stress testing for elective surgery if cardiac symptoms or METS< ACC/AHA Guidelines

17 Cardiac disease If 30-day post-op mortality was a disease, it would be the 3 rd leading cause of death. Daniel Sessler, Cleveland Clinic Threshold for injury is intraoperative MAP < 65 mmhg. Injury worse with the longer and deeper hypotension. Masha, et al. Anesthesiology; 2015;123:79-91.

18 Q&A #2 60-yo female h/o atrial fibrillation and embolic stroke with no residual deficits She takes apixaban bid and metoprolol daily. Orthopedics recommends right hip She is referred to you from his orthopedic surgeon for preoperative assessment prior to elective right hip arthroplasty. Which of the following preoperative recommendations would you make to this patient? replacement for her severe OA Anesthesiology plans on performing neuraxial anesthesia for the surgery.

19 Q&A #2 1. Stop apixaban 3 days prior to surgery and continue metoprolol. Restart apixaban postop if hemostasis is achieved. 2. Stop apixaban 3 days prior to surgery and continue metoprolol. Restart apixaban the day of surgery if hemostasis is achieved. 3. Stop apixaban 3 days prior to surgery and continue metoprolol. Start enoaxparin bridge before and after surgery. Restart apixaban the day of surgery if hemostasis is achieved. 4. Stop apixaban 3 days prior to surgery and continue metoprolol. Start enoaxparin bridge before and after surgery. Restart apixaban post-op if hemostasis is achieved.

20 Q&A #2 1. Stop apixaban 3 days prior to surgery and continue metoprolol. Restart apixaban postop if hemostasis is achieved. 2. Stop apixaban 3 days prior to surgery and continue metoprolol. Restart apixaban the day of surgery if hemostasis is achieved. 3. Stop apixaban 3 days prior to surgery and continue metoprolol. Start enoaxparin bridge before and after surgery. Restart apixaban the day of surgery if hemostasis is achieved. 4. Stop apixaban 3 days prior to surgery and continue metoprolol. Start enoaxparin bridge before and after surgery. Restart apixaban post-op if hemostasis is achieved.

21 Q&A #2 Avoid bridging except for HIGH thrombotic risk which outweighs bleeding risk. This patient s CHA2DS2-VASc = 3. (High thrombotic risk is 7) When to stop NOAC: AHA and SHM recommend discontinuation based on CrCl. For apixaban, 48 hr if intermed/high bleed risk, but ASRA has stricter guidelines (3 days). When in doubt, call the anesthesiologist. When to restart NOAC: h after major surgery if hemostasis achieved. When in doubt, check with surgery. ASRA allows resuming within 6 hr. Doherty JU, et al ACC consensus periprocedural anticoagulation nonvalvular Afib. Horlocker TT, et al. ASRA guidelines. Reg Anesth Pain Med. 2010;35(1):64. with 2016 update Johnson SA, Labrin J. Periprocedural Bridging Anticoagulation. JHM; Published online January 24, Raval, et al. AHA Scientific Statement: NOAC in the acute care and periprocedural setting. Circulation: 2017;

22 Johnson SA, Labrin J. Periprocedural Bridging Anticoagulation. JHM; Published online January 24, 2018.

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24 Obstructive Sleep Apnea OSA & sedation / anesthesia associated with higher complications (respiratory complications, postoperative cardiac events and transfer to the ICU) 17% fewer major complications if neuraxial anesthesia used instead of general anesthesia in OSA pts for total joint replacement Kaw et al, Br J Anaesth 2012;109(6): Memtosoudis et al. Anesth Pain Med 2013;38(4): Nagappa et al. PloS 2015

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26 Q&A #3 1. High muscle / High fat Which of the following body phenotypes 2. Low muscle / Low fat have the highest 1-year mortality rate following elective surgery? 3. Low muscle / High fat 4. High muscle / Low fat

27 1. High Muscle / High Fat 2. Low Muscle / Low Fat 3. Low Muscle / High Fat 4. High Muscle / Low Fat

28 ~14% 1-year post-op mortality 1. High Muscle / High Fat 2. Low Muscle / Low Fat 3. Low Muscle / High Fat 4. High Muscle / Low Fat

29 Frailty N=202,911 (6289; 3.1% were frail) Retrospective cohort for elective NCS Increased risk for death in frail patients existed between different surgery types, but was strongest after total joint arthroplasty. (HR, 3.79; 95% CI, for hip replacement; HR, 2.68; 95% CI, for knee replacement) McIsaac DI, Bryson GL, van Walraven C. JAMA Surg. 2016;15(6):

30 Frailty Measuring frailty Nutrition Medication management Discharge planning Opiate naïve track Prehabilitation? Delirium risk

31 Frailty Timed Up and Go test (TUG) Easy and quantifiable Cutoff of 10 would identify 93% frail, but specificity only 62% Afilalo J, et al. JACC. 2014;63(8): Savva GM et al. 2012;68(4):441-6.

32 Prehabilitation Enhancement of the preoperative condition of the patient Aims to improve the functional capacity of the patient before surgery with the intent to minimize morbidity and improve surgical recovery.

33 Q&A #4 43-yo female Rheumatoid arthritis Which of the following preoperative recommendations would you make to this patient? Infliximab IV Q4 weeks for a year. She is a marathon runner and has no other medical problems. No active infections or RA flares. She was offered elective right total knee replacement for severe right knee pain.

34 Q&A #4 1. Continue infliximab and schedule surgery after monthly dose 2. Continue infliximab and schedule surgery the week prior to monthly dose 3. Stop infliximab and schedule surgery on week 5 relative to last dose 4. Stop infliximab and schedule surgery on week 9 relative to last dose

35 Q&A #4 1. Continue infliximab and schedule surgery after monthly dose 2. Continue infliximab and schedule surgery the week prior to monthly dose 3. Stop infliximab and schedule surgery on week 5 relative to last dose 4. Stop infliximab and schedule surgery on week 9 relative to last dose

36 Q&A #4 New guidelines 2017 developed by American College of Rheumatology and the American Association of Hip & Knee Surgeons for rheumatic disease patients undergoing total knee or hip surgeries. In general, continue DMARDs, hold biologics Different recommendations on immunosuppressants depending on the severity of systemic lupus erythematous Avoid stress dose steroids, taper <20 mg/day when possible Different from gastroenterologist recommendations regarding inflammatory bowel disease patients and infliximab for colorectal surgeries. Goodman, et al Arthritis Care & Research. 2017;DOI /acr.23274

37 Surgical Site Infection Prevention Total knee replacement CMS: $31K I&D for SSI: $93K non-reimbursable 2-stage exchange SSI: $187K non-reimbursable

38 Surgical Site Infection Prevention Shower within 24 hours & no shaving Chlorhexidine scrub prior (mupirocin X 5 days in addition if +MRSA) Appropriate antibiotics Blood glucose control Avoid hypothermia intraop Goal directed fluids Smoking cessation Limit steroid /biologic use* Allegranzi B, et al. WHO recommendations, Lancet 2016 *Goodman, et al Arthritis Care & Research. 2017;DOI /acr.23274

39 Surgical Site Infection Prevention HbA1C >7% increased SSI 35.3% compared to 0.0% for thoracic and lumbar spinal instrumentation surgery. Peri-operative hyperglycemia (>200 mg/dl) even without a diagnosis of diabetes is an independent risk factor for SSI at 30 days (OR 3.2, 95% CI: ). Post-operative morning hyperglycemia associated with a 3-fold increased risk of peri-prosthetic infection in lower total joints Hikata T, et al.. J Orhop Sci. 2014;19(2): Mraovic B, et al. J Diabetes Sci Technol. 2011;5(2): Richards JE, et al. J Bone Joint Surg. 2012;94(13):

40 Enhanced Recovery After Surgery ERAS Pathway for colorectal No fasting Minimally invasive surgery Avoid drains & NG tubes Early removal drains Opiate-sparing pre-op Early mobilization Goal directed IVF PO POD#0 Carmichael JC, et al. Dis Colon Rectum 2017;60: Ljungquvist O, Scott M, Fearon KC. ERAS. JAMA Surgery 2017;152(3):292-8

41 ERAS Surgical Site Prevention ERAS Pathway for colorectal Chlorhexidine shower Blood glucose control Mechanical bowel prep with oral antibiotics and IV antibiotics 1 hour prior Avoid hypothermia intraop Goal directed fluids Dedicated wound closure tray Smoking cessation Carmichael JC, et al. Dis Colon Rectum 2017;60: Ljungquvist O, Scott M, Fearon KC. ERAS. JAMA Surgery 2017;152(3):292-8

42 ERAS Pulm Complication Prevention ERAS Pathway for colorectal Ariscat pulmonary risk stratification tool (N=5099. C-stat 0.8) Inspiratory muscle training preoperatively associated with a reduction of postop atelectasis and pneumonia compared to usual care Dutta, S, et al. JHM.2016;11(3): Mazo V, et al. Anesthesiology. 2014;121: Katsura M et al Cochrane Review 2015

43 Jessica Hoge