Objectives. Old School. Preoperative Evaluation and Postoperative Complications: Where are the opportunities for risk reduction?

Transcription

1 Preoperative Evaluation and Postoperative Complications: Where are the opportunities for risk reduction? Jeffrey Carter, MD RMHMS October 5, 2010 Objectives Understand the preoperative cardiac evaluation Understand preoperative pulmonary evaluation Understand the opportunities for cardiopulmonary risk reduction in the perioperative period Old School You are an internist who follows their patients in the hospital Your are seeing a 65 year old female you have know for years and recently diagnosed with colon cancer She is postop day 5 following a hemicolectomy. Postoperative course complicated by NSTEMI on POD#2 and LLL pneumonia on POD#4

2 Case Frustrated by these outcomes, you revisit your preoperative assessment and look for missed opportunities for risk reduction Case 65 year old female, colon CA 40 pack year smoking history Htn TIA 3 years ago Sedentary Wheezing on exam Notable labs Cr 2.1 Albumin 2.7 No meds Case Surgery scheduled 10 days after preop visit Knowing the limited opportunities for perioperative risk reduction and the urgency of the surgery, you sent her to surgery as is. Let us review that decision

3 Case- Preoperative Cardiac Evaluation Which of the following of strategies is most likely to have reduced her perioperative cardiac risk? A. Beta blocker started one week before surgery B. No further workup C. Stress test and CABG if positive D. Angiogram and PCI if positive E. Statin started one week before surgery Case Let s review the preoperative cardiac evaluation Preoperative Cardiac Evaluation Use the 2007 ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery

4 Copyright 2007 American Heart Association Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater Fleisher, L. A. et al. Circulation 2007;116:e418-e ACC/AHA Active Cardiac Conditions Unstable coronary syndromes Decompensated heart failure High-grade AV block Ventricular arrhythmias with underlying heart disease Supraventricular arrhythmias with uncontrolled ventricular rate Severe valvular disease (ie Critical AS) Low Risk Surgery Reported cardiac risk generally less than 1% Endoscopic procedures Superficial procedure Cataract surgery Breast surgery Extremity orthopedic surgery ie ankle fracture repair

5 Copyright 2007 American Heart Association Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater Fleisher, L. A. et al. Circulation 2007;116:e418-e499 Functional Capacity 1 MET:Basic ADL s 4 METs: Climb a flight of stairs or walk up a hill heavy housework golf dancing 10 METS: skiing, cycling, running Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater Fleisher, L. A. et al. Circulation 2007;116:e418-e499 Copyright 2007 American Heart Association

6 ACC/AHA Clinical Risk Factors history of ischemic heart disease history of compensated or prior HF history of cerebrovascular disease diabetes mellitus renal insufficiency (Cr >2) Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater Fleisher, L. A. et al. Circulation 2007;116:e418-e499 Copyright 2007 American Heart Association High Risk Surgery Reported cardiac risk often greater than 5% Emergent major operations, particularly in the elderly Aortic and other major vascular surgery Peripheral vascular surgery Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss.

7 Intermediate Risk Surgery Reported cardiac risk generally less than 5% Carotid endarterectomy Head and neck surgery Intraperitoneal and intrathoracic surgery Major Orthopedic surgery Prostate Surgery Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater Fleisher, L. A. et al. Circulation 2007;116:e418-e499 Copyright 2007 American Heart Association Case Great. Our patient has two clinical risk factors. And the algorithm gives vague, contingent recommendations How could a stress test change our management?

8 4 Outcomes of + Stress Prior to Surgery 1. Cancel surgery- too high risk 2. Proceed to surgery as is 3. Revascularization- PCI or CABG 4. Start a beta blocker Perioperative MI Type 1 PMI Plaque Rupture Unpredictable based on angiographic appearance Prothombotic milieu Increased sympathetic tone Type 2 PMI Mismatch of Oxygen Supply and demand Hyperdynamic state of surgery Increased myocardial oxygen demand Fixed coronary lesions Potential for prolonged ischemia Preoperative Revascularization CARP and DECREASE-V showed no benefit to revascularization of high risk patients prior to major vascular surgery Included PCI and CABG Subsequent meta-analysis suggests 30 day risk of death and MI increased with revascularization Does not appear to be beneficial in high risk patients undergoing major vascular surgery McFalls EO, et al. NEJM.2004;351:2795 Poldermans D et al. JACC. 2007;49: Biccard BM and Rodseth RN. Anaesthesia.2009;64:

9 Recent Stents and Noncardiac Surgery 13% cardiac death if surgery within recommended duration of dual antiplatelet therapy 0.6% mortality if beyond 5.5% vs. 0% cardiac death if dual antiplatelets held perioperatively Discontinuation of dual antiplatelets did not change frequency or amount of transfusion Schouten O et al. JACC 49(1);2007:122 Risk of MI and Death vs. time from stent From Schouten et al. Anesthesiology 106(5);2007:1067 BB Positive Studies- DECREASE I 173 patients with + DSE undergoing vascular surgery Bisoprolol started on average 37 days before surgery and continued during hospitalization Endpoint= cardiac death or non fatal MI 3.4% bisoprolol group 34% placebo group Poldermans NEJM 1999;341:

10 BB Positive Studies-DECREASE IV 1000 pts randomized to bisoprolol vs placebo Intermediate risk pts undergoing noncardiac, non vascular surgery Bisoprolol started 1 month prior to surgery, titrated to HR <70 Combined CV endpoint 2.1% bisoprolol 6% placebo No difference in stroke, hypotension, bradycardia Dunklegrun M et al. Ann Surg. 2009;249(6):921 BB Negative Studies- DIPOM 921 patients with DM undergoing NCS > 1 hour Randomized to 100 mg metoprolol or placebo Preop day 1 to postop day 4-8 Composite primary outcome Time to all cause mortality Acute MI Unstable angina CHF At 18 months Primary outcome 20% both groups All cause mortality in 16% both groups Juul AB et al. BMJ.2006;332:1482 BB Negative Studies- MAVS 496 pts undergoing major vascular surgery Randomized to metoprolol or placebo 2 hours before surgery to POD 5 >80% pts had RCRI < 2 Composite Primary outcome at 30 days Primary outcome: 12% placebo 10.2% metoprolol No change by RCRI Increased incidence hypotension and Yang bradycardia H et al. Am Heart in J. 2006; metoprolol 152: arm

11 Effect of Beta Blockers on Mortality Lindenauer PK et al. NEJM 2005;353(4):349 POISE 8300 pts Patients >45 undergoing non-cardiac surgery who had a history of CAD, PVD, CVA, CHF; or major vascular surgery Randomized to placebo or metoprolol 200 mg/day for 30 days. Primary endpoint was a 30 day composite of cardiovascular death, non-fatal myocardial infarction or non-fatal cardiac arrest. Deveraux PJ et al. Lancet. 2008;371: POISE Primary endpoint Non Fatal MI Total Mortality Metoprolol (n = 4174) Placebo (n = 4177) p value 5.8% 6.9% % 5.1% % 2.3%.03 Stroke 1.0% 0.5%.005

12 Data Review DECREASE I and IV suggest starting BB early associated with improved outcomes DIPOM, MAVS suggest starting immediately preoperatively not helpful POISE suggests empiric large doses reduce cardiac outcomes with serious collateral damage DECREASE IV establishes safety and efficacy of titrated beta blockade in intermediate risk patients Lindenauer s paper suggests harm in low risk patients BB Data Review Theme: In patients with 2 clinical risk factors, or proven CAD, beta blockers are most efficacious and safe when started a month preoperatively and titrated to a target HR Starting immediately preop increases risk of over- or under dosing OK fine, how about Statins? RCT: Fluvastatin reduced perioperative CV events in vascular surgery patients 10.8% vs 19% ischemia 4.8% vs 10.1% composite death and MI RCT: Fluvastatin vs placebo in intermediate risk, non cardiovascular surgery patients Non significant trend towards decreased CV events Large body of evidence on perioperative statins-> SAFE! Schouten O et al. NEJM. 2009;360:980-9 Dunkelgrun M et al. Ann Surg. 2009; 249:921-26

13 What could you have done differently? Revascularization would probably have INCREASED risk Beta blockade probably indicated with 2 risk factors Short time to surgery decrease likelihood of benefit, increase likelihood of harm Statin efficacy less clear in intermediate risk patients, but safe Case- Preoperative Cardiac Evaluation Which of the following of strategies is most likely to have reduced her perioperative cardiac risk? A. Beta blocker started one week before surgery B. No further workup C. Stress test and CABG if positive D. Angiogram and PCI if positive E. Statin started one week before surgery Case- Preoperative pulmonary Evaluation Which of the following strategies is most likely to have reduced her risk of postoperative pulmonary complications? A. Smoking cessation B. Albumin infusion during surgery C. Empiric nasogastric tube after surgery D. Course of steroids and bronchodilators before surgery

14 Postoperative Pulmonary Complications Typically defined as: Respiratory failure Pneumonia Atelectasis Bronchospasm Complicate 6.8% of surgeries 1 Most costly of postoperative complications 2 1. Ann Intern Med Apr 18;144(8): J Am Coll Surg Oct;199(4): Preoperative Pulmonary Evaluation No published algorithm Some opportunity for risk reduction Patient Related Risk Factors Age >60 ASA class > 2

15 Patient Related Risk Factors Chronic Lung disease- COPD OR for postop complications Other lung diseases not well studied Active symptoms increase risk Expert recommendations are to delay surgery Supported by ancient literature 1. Ann Intern Med Apr 18;144(8): Patient Related Risk Factors OSA- emerging risk factor Historically associated with critical respiratory events following extubation 1 Emergent reintubation Hypoxemia Increased ICU transfer, LOS, all complications 2. 8% vs. 1% postop pulmonary complications 3 1. Anesthesiology 2006; 104: Mayo Clin Proc Sep;76(9): Chest May;133(5): Patient Related Risk Factors Pulmonary Hypertension Severe PH (PA >70 mmhg) associated w adverse postoperative outcomes 1 Delayed extubation: 21% vs 3% CHF 9.7% vs 0% In hospital death 9.7% vs 0% All etiologies of PH evaluated Risk of mild PH not clear 1. Br J Anaesth Aug;99(2):184-90

16 Patient Related Risk Factors Tobacco Use Current smokers OR 2.3 for PPC 1 >40 pack years- OR 1.9 for PPC 2 Cessation for < 2 months associated with paradoxic increase in risk of PPC % versus 14.5% in CABG pts NOT a reason to recommend against cessation Cessation > 6 months yields risk similar to nonsmokers (~12%) 1. Chest 1997 Mar;111(3): Am J Respir Crit Care Med 2003 Mar 1;167(5): Mayo Clin Proc 1989 Jun;64(6): Patient Related Risk Factors Obesity Causes restrictive lung disease Associated with OSA and PH 272 patients- non thoracic surgery 1 BMI >30 OR 4.1 for PPC in univariate Not independent predictor in multivariate Obesity NOT independent RF Risk from associated comorbidities 1. Am J Respir Crit Care Med 2003 Mar 1;167(5):741-4 Surgery Specific Risk Factors Surgical site most important Closer to diaphragm = higher risk AAA repair highest risk Length of surgery 1 8 % if < 2 hours 40% if > 4 hours Upper Abdominal Lower abdominal 19.7% 7.7% Esophagectomy 18.8% Ann Intern Med Apr 18;144(8): Acta Anaesthesiol Scand 2001 Mar;45(3):345-8

17 Role of PFT s Spirometry less predictive of PPC than physical exam 1 OR 1.0 for spirometry vs. 5.8 for abormal exam In patients w FEV1 <50% predicted, spirometry not predictive of PPC 2 Length of surgery ASA class Type of surgery No minimum FEV1 for surgery Not a reason to deny surgery Limited role in preop eval Uncharacterized dyspnea 1. CHEST. 1996;110: CHEST 1997;111: Preoperative Risk Reduction 2 weeks preop IMT decreases risk of pneumonia, PPC and LOS in CABG patients 1 OR.52 for PPC Preoperative opitmization of COPD 2 23% PPC in optimized 35% PPC in untreated 1. Hulzebos EJ et al. JAMA. 2006; 296(15): Surgery 1973; 74:720.

18 Postoperative Risk Reduction Empiric nasogastric tubes increase risk 1 compared with as needed decompression OR 1.7 for pna OR 1.9 for atelectasis Postoperative incentive spirometry 2 48% PPC in control 22% PPC in IS or supervised deep breathing 1. Ann Surg 1995 May;221(5): Am Rev Respir Dis 1984 Jul;130(1):12-5 Back to Case Our patient s risk factors Smoking Age Low albumin Wheezing What could you have done differently? Most patient and procedure specific RF s not able to be modified COPD not optimized prior to surgery Steroids and bronchodilators improve outcomes Consider preop IMT Extrapolation of data from CABG patients, SAFE Postoperative IS Safe, cheap, effective Smoking cessation- wait until postop? NG tube only if needed

19 Case- Preoperative pulmonary Evaluation Which of the following strategies is most likely to reduce her risk of postoperative pulmonary complications? A. Smoking cessation B. Albumin infusion during surgery C. Empiric nasogastric tube after surgery D. Course of steroids and bronchodilators before surgery Summary Preoperative cardiac and pulmonary evaluations more about understanding risk than reducing it Evaluate risk/reward ratio of an intervention with strength of evidence