Update in Perioperative Medicine
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1 Update in Perioperative Medicine Linda Venner MD FACP March 2018
2 Agenda Optimized not Cleared Identify red flags for cardiac and pulmonary complications Optimize management Prevent delirium Don t cause unnecessary delays
3 Perioperative Myocardial Ischemia 300 million patients annually undergo noncardiac surgery worldwide Leading cause of death -> 2 million deaths/year is MACE (major adverse cardiac events) -Myocardial injury/infarction -CHF -Cardiogenic Shock -Cardiac arrest -Stroke/TIA -Death Devereaux PJ. NEJM 2015: Dec 28. doi Smilowitz NR. JAMA Cardiol 2016
4 Question: Which of the following describes trends in preoperative MACE during the past 10 years? A. Decreased B. Increased C. Not sure
5 Nauder Faraday MD; Perioperative Management Johns Hopkins
6 Perioperative MI Nauder Faraday MD; Perioperative Management Johns Hopkins
7 Question: The majority of perioperative myocardial ischemic events are caused by? A. Physiologic O2 imbalance; ie hypertension, hypotension, tachycardia, etc B. Anatomic O2 imbalance; ie plaque rupture/thrombosis C. Both D. Neither
8 Physiologic stress of surgery
9 Natural History of Postop MACE review 9:00 WHERE IS THE WINDOW OF OPPORTUNITY FOR DIAGNOSIS AND TREATMENT? Intraoperative- few POD1- many Majority of events are SILENT?concurrent surgical pain?analgesic therapy Management is conventional medical therapy: ASA or Plavix BBlocker Statin Death occurs (well after) myocardial injury happens Pathophysiology is similar to nonoperative ACS
10 Preoperative Cardiac Risk Assessment 1.WHAT CLINICAL FEATURES PLACE AN INDIVIDUAL AT INCREASED RISK OF MACE? 2.DOES EXISTING DATA SUPPORT ROUTINE USE OF NON- INVASIVE TESTING? 3.WHAT ARE THE 2014 AHA/ACC GUIDELINES FOR RISK ASSESSMENT?
11 Monitoring and diagnosis of post-op MI ACC/AHA GUIDELINE RECOMMENDATIONS 2014 EKG if symptoms YES Class I EKG if high risk: surveillance Maybe Class IIb PA cath if high risk Maybe Class IIb Echo if symptoms or hemodynamic instability Yes Class I Troponin if symptoms Yes Class I if high risk: surveillance Maybe Class IIb
12 Question: 65yo man scheduled for prostatectomy. He is aysmptomatic, does normal daily activities comfortably, can mow his lawn, take long walks and climb 2 flights of steps. PMHx: H/o CAD with LAD stent 5 years earlier, IDDM, HTN Normal exam, normal EKG, Creatinine 1.2 Which statement is most accurate? 1. /A He is low risk and does not need a stress test 2. /B He is at elevated risk but has good functional capacity, and therefore he can proceed to surgery without a stress test 3. /C He is at elevated risk and should have an exercise treadmill test 4. /D His is at elevated risk and should have a stress test, but it should be a nuclear study or dobutamine echo to increase sensitivity
13 How do we assess Perioperative risk of MACE? Type of Surgery Type of patient Functional Capacity Clinical risk factors
14 Perioperative risk by type of surgery
15 Question: CLINICAL RISK FACTORS ALONE ARE INSUFFICIENT IN PREDICTING PERIOPERATIVE MACE 1/A. TRUE 2/B. FALSE
16 Major risk factors = "Hard stops" UNSTABLE CORONARY SYNDROMES ACUTE DECOMPENSATED CHF SIGNIFICANT ARRHYTHMIA (HIGH DEGREE AVB, SYMPTOMATIC BRADYCARDIA, VT) SEVERE VALVULAR DISEASE (SEVERE AS OR SYMPTOMATIC MS) SEVERE VALVULAR DISEASE (I.E. SEVERE AS, SYMPTOMATIC MS)
17 Suggested Risk Models/Calculators in Updated ACC/AHA Guidelines NSQIP
18 Revised Cardiac Risk Index 1 point for each: Hx CAD Hx stroke/tia Hx CHF DM on insulin Renal insufficiency Creat >2.0 High Risk Surgery (chest, abd, vascular) Risk increases in proximity to cardiac event MI <6 months PCI <2 years CHF <2 years Hawn MT, JAMA 2013; 310:
19 Functional capacity Can they do >4 METs activity?* FLIGHT OF STAIRS OR A HILL RUN A SHORT DISTANCE WALK 4 MILES/HR ON LEVEL GROUND DO HEAVY HOUSEWORK MODERATE RECREATIONAL ACTIVITIES:GOLF, BOWLING, DANCING)
20 Question: Noninvasive tests are good at identifying patients most likely to have MACE (major adverse cardiac events) 1/A. TRUE 2/B. FALSE
21 Predictive value of noninvasive tests
22 Question: REVASCULARIZATION WILL DECREASE THE RISK OF PERI- OPERATIVE MACE AND IMPROVE OUTCOMES 1.TRUE 2. FALSE
23 Outcomes with revascularization
24
25 Medications
26 Beta blockers ACC/AHA GUIDELINES (2014) Class III- Harm Beta blocker therapy should not be started on the day of surgery Class IIb-Benefit >Harm In patients with RCRI >3, it may be reasonable to begin BBlockers before surgery (Level of Evidence B) In patients with intermediate or high risk myocardial ischemia in preoperative risk stratification tests, it may be reasonable to begin perioperative beta blockers. (Level of Evidence: C) In patients in whom beta-blockers are started, it may be reasonable to begin them far enough in advance to assess safety and tolerability, preferably more than 1 day before surgery (Level of Evidence:B)
27
28 Statins CONTINUE IF ON ONE OBSERVATIONAL STUDY SUGGESTS DECREASED MORTALITY IF STARTED 1-2 DAYS PRE- OP START IF VASCULAR SURGERY START PERIOPERATIVE IF CLINICAL INDICATIONS 29
29 ACE-I /ARB
30 Management of Anticoagulants Assess bleeding risk: Procedure and Patient risk factors Assess thrombotic risk: Indications for anticoagulation
31 Assess bleeding risk: PROCEDURE Very high risk-closed space CNS Intraocular procedures High risk-high blood loss Aortic, cardiac, hepatic Some abdominal, urologic, Pulmonary,ENT, GYN, plastic/reconstructive Moderate risk- low to mod blood loss Most peripheral limb orthopedic, peripheral vascular Most abdominal, pulmonary, ENT, GYN, plastic/reconstructive Low risk- min blood loss or easy local control Minor surgery- skin, dental, cataract Baron TH. NEJM 2013; 368: Doherty JU. JACC 2017; S (16)
32 Assess Thrombotic risk INDICATIONS FOR ANTICOAGULANT TX Chronic Atrial Fibrillation:CHADS2/CHADSVASc score CHF = 1 point HTN = 1 point Age >75 = 1 point Diabetes = 1 point Stroke/TIA = 2 points (Vascular dz = 1, Age 65-74=1, Sc = female = 1) Prosthetic cardiac valve Mechanical vs. bioprosthetic Mitral vs Aortic Presence/absence of AF or atrial dilation PE/DVT Time of diagnosis of VTE Presence/absence of hypercoaguable state
33 When to stop Anticoagulants? D/C anticoagulant 3-5 t1/2 before surgery Warfarin: t 1/2 = h If INR 2-3->D/C 5 days before surgery; may adjust according to baseline INR Check INR 24 h before surgery: target <1.5 LMWH: t1/2 = h D/C 24h before surgery; adjust according to renal clearance Unfractionated heparin: t1/2 = h D/C 6 h before surgery Direct oral anticoagulants (DOAC) Dabigatran: t1/2 = h D/C 3-5 days before surgery; adjust according to renal clearance Rivaroxaban, apixaban, edoxaban: t1/2=7-17 h D/C 2-3 days before surgery
34 When Click to bridge? to add Title Bridge High Risk patients and? Mod-High risk Multidisciplinary decision Patient input and acceptance
35 Post-op Pulmonary Complications PPC
36 Post-operative Pulmonary Complications (PPCs) LACK OF A STANDARDIZED DEFINITION ~3-10% of patients undergoing major surgery will experience PPC: Pneumonia Bronchospasm Respiratory failure Atelectasis Significant Pleural effusion Aspiration Failed extubation Early Reintubation
37 Risk factors for Perioperative Pulmonary Complications PPC
38 Incidence of PPC
39 Post-Operative induced respiratory depression (POIRD) PREVENTABLE WITH BETTER ASSESSMENT OF SEDATION LEVEL, MONITORING OF OXYGENATION AND VENTILATION, AND EARLY RESPONSE AND INTERVENTION 90 % of POIRD occurs within 24 hours of surgery 97% preventable with better monitoring and response Risk factors: multiple prescribers, use of sedating meds, inadequate nursing assessment and response Lee Anesthesiology 2015; 122:
40 Postoperative Hypoxemia COMMON, UNDERESTIMATED, AND SUSTAINED
41 PPC prevention Wear CPAP/BIPAP in sleep apnea Optimize bronchodilators and steroids Optimize nutrition stop smoking consider spirometry post op Alert anesthesia to high risk Asthma patients -Systemic steroids within 6 months -long term high dose ICS
42 Delirium AVOIDING DELIRIUM IS MORE SUCCESSFUL THAN TREATING IT
43 Click to add Title CLICK TO ADD SUBTITLE
44 AVOIDING DELIRIUM IS MORE SUCCESSFUL THAN TREATING IT * *Patients with delirium need a MEDICAL EVALUATION
45 AVOIDING DELIRIUM IS MORE SUCCESSFUL THAN TREATING IT Avoid meds that cause delirium
46 AVOIDING DELIRIUM IS MORE SUCCESSFUL THAN TREATING IT Pain control decreases delirium
47 AVOIDING DELIRIUM IS MORE SUCCESSFUL THAN TREATING IT MCI decreases delirium
48 AVOIDING DELIRIUM IS MORE SUCCESSFUL THAN TREATING IT CLICK TO ADD SUBTITLE MCI decreases delirium
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