Documente Academic
Documente Profesional
Documente Cultură
10/2/2015
7:30 AM– 9:30 AM
by
Dr. Raj Gutta
Dr. Daniel Meara
“Comprehensive Preop Clearance”
• Medical Clearance: *********
*
• Patient is “cleared” for surgery
–Does the physician share the risk?
–Is the surgeon immune from a
complication?
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• “The purpose of preoperative evaluation is not
• What is risk? to give medical clearance, but rather to perform
an evaluation of the patient’s current medical
status; make recommendations concerning the
• What makes a procedure low risk? evaluation, management, and risk of cardiac
problems over the entire perioperative period;
– Less stress on the myocardium and provide a clinical risk profile that the
patient, primary physician, anesthesiologist, and
surgeon can use in making treatment
– No major fluid shifts decisions…”
Kim A. Eagle, Chair, ACC/AHA Task Force on Practice
Guidelines for Perioperative Cardiovascular Evaluation for
Noncardiac Surgery
Patient risk factors: Major clinical predictors
– Unstable Coronary syndromes
– Decompensated CHF
– Significant arrhythmias
– Severe valvular disease
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Patient risk factors: Intermediate clinical predictors Patient risk factors: Minor clinical predictors
– Mild Angina Pectoris
– Advanced age
– Prior MI
– Abnormal ECG
– Compensated or prior CHF
– Rhythm other than NSR
– IDDM
– Low functional capacity
– Renal Failure
– History of CVA
– Uncontrolled HTN
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ACS risk factors
Cardiac Testing: Resting ECG
http://www.riskcalculator.facs.org
Class IIa (probably warranted)
• Age • Metastatic Cancer Preoperative resting 12‐lead electrocardiogram (ECG) is
reasonable for patients with known coronary heart disease,
• Renal failure • Chronic Steroid use significant arrhythmia, peripheral arterial disease, cerebrovascular
• IDDM • HTN disease, or other significant structural heart disease, except for
those undergoing low‐risk surgery
• Functional status • h/o MI
• Type of surgery • Sex Class IIb
• ASA – PS Preoperative resting 12‐lead ECG may be considered for
• Dyspnea asymptomatic patients without known coronary heart disease,
• Wound class • Smoker except for those undergoing low‐risk surgery.
• Ascites • COPD
Class III: No Benefit
• Sepsis • BMI Routine preoperative resting 12‐lead ECG is not useful for
• Vent dependent • Emergency procedure
asymptomatic patients undergoing low‐risk surgical procedures.
Echocardiography Cardiac Stress Test
• Class IIa (probably indicated)
– Suspected severe moderate or severe valvular stenosis or
regurgitation Class III: No Benefit
– Dyspnea of unknown etiology
– Worsening symptoms of LV function
Routine screening with noninvasive stress testing is
• Class IIb (probably warranted) not useful for patients at low risk for non‐cardiac
– Prior CHF and no recent (1 yr) evaluation
surgery
• Class III (not indicated)
– Routine testing of ventricular function in asymptomatic patients
without a prior history of CHF
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Risk of cardiac complication = patients risk + cardiac stress
ACC/AHA guidelines on pre‐op testing related to surgery
Major risk factors Intermediate risks Low risks
• Not indicated in low‐risk procedures with minor risk factors
MI < 6 weeks MI >6weeks and < 3 months h/o Coronary artery disease
Post infarction (>3 months),
CABG or PTCA < 6 weeks Ventricular arrhythmia
• Stress test is not useful for patients undergoing low‐risk asymptomatic without treatment
Duke Activity Status Index
How does this relate to Surgery?
1 MET: the oxygen consumption (VO2) of a 70 kg, 40 y.o.
man at rest…3.5 cc/kg/min
• < 4 METs Significantly Increases Risk MI, HF, Arrhythmia
regardless of Surgical Risk
< 4 METS: > 4 METS:
Baking Ice skating • Unable to climb 2 flights of stairs
Slow dancing Moderate cycling
– 89% PPV for cardiopulmonary complications
Golfing with a cart Walking 4 mph
Playing a musical instrument Heavy housework
• Functional Capacity Complication Rate
Walking 2 – 3 mph Skiing
< 4 METs > 5%
4 – 10 METs 1 – 5%
> 10 Mets < 1%
Eagle, KA, et al, J Am Coll Cardiol, 2002; 39, 542‐553
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ACC / AHA recommendations Ischemic heart disease
– Greater risk for cardiac M&M
• Class I
1. It is recommended that patients with clinically – Low risk
suspected moderate or greater degrees of valvular • Stable angina
stenosis or regurgitation undergo preoperative • Previous CABG / stents
echocardiography if there has been either • Stable arrhythmias
1) no prior echocardiography within 1 year or
– Resting ECG is not useful
2) a significant change in clinical status or
physical examination since last evaluation.
– Per ACC/AHA guideline, No workup if asymptomatic in 2
2. For adults who meet standard indications for valvular years since last evaluation
replacement and repair, intervention before elective non • No tests if there is no change in perioperative
management
cardiac surgery is effective in reducing perioperative risk.
Myocardial Infarction Myocardial Ischemia
– Studies from 1980’s recommended waiting 6 months
– Wait for 30 days after revascularization
– Recent studies focused more on functional aspects of the
myocardium than the age of the infarct
– Proceed if asymptomatic & functionally
– 6 weeks after infarct is ok to proceed active
• Time needed for healing
• 6 weeks to 3 months intermediate risk period
– Don’t withhold oral anticoagulants for 1 yr
– For Oral surgery no benefit of delaying procedure after drug eluting stents
beyond the guidelines
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Perioperative cardiac drugs Rarely Indicated for Routine Screening
Drug Preoperative Long NPO period • Glucose
Beta-blockers Continue including day of Substitute IV form
surgery (DOS) • Electrolytes
Clonidine Continue including DOS Substitute transdermal form
• LFT’s
Calcium channel blockers Continue including DOS Substitute IV form for
arrhythmia.
• Platelets, Coags
ACEI HTN (-) CRI: Continue on Substitute Hydralazine /
DOS. CHF or CRI: Hold on NTP
DOS • Urinalysis
Diuretics Hold on DOS Use IV diuretic prn
Oral contraceptives and HRT Hold 4-6 weeks preop for Hold 4-6 weeks preop for • Pulmonary Function Testing
surgery with high risk of surgery with high risk of
thrombosis. thrombosis.
• Chest Radiography?
Smetana, Med Clin NA 2003: 87: 35
Pulmonary
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Evaluating Pulmonary Risk Predictors of Pulmonary Complications
Recommendations for
Assessment of Pulmonary Risk Pulmonary assessment.
• History and Physical Exam Evaluation should include:
• Identify Pulmonary Risk Factors Hx of smoking
Smetana, G, et al, Ann Intern Med, 2006; 144:581 Present of GE reflux.
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ASA Postoperative Pulmonary Complications Arozullah Respiratory Failure Risk Index
• Type of Surgery • Point Value
– AAA 27
Class Pulmonary Complications – Thoracic
21
– Neurosurgery, Upper Abdominal
1 Healthy 1.2% Peripheral Vascular, Neck 14
5 Moribund, not expected to survive NA • History of COPD 6
24 hrs with or without surgery
• Age > 70
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Qasim, A, et al. Ann Intern Med, 2006; 144:575‐580
• Age 60 ‐ 69
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Smetana, G, et al, Ann Intern Med, 2006; 144:581
Arozullah, AM, Daley, J, et al, Ann Surg 2000; 232:242
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Preoperative Pulmonary Evaluation
CXR? Only if needed for baseline
ABG? Rarely useful
PFT’s? Only if unexplained symptoms
There is no substitute for a good H&P!
Dyspnea
Mucous production
Adventitious breath sounds
Prolonged expiratory phase
Risk Factors for Perioperative Pulmonary Complications
Risk Reduction: Smoking
Patient related Surgical
• Need to Quit > 2 mos. before surgery
Age Thoracic
• Abstinence < 2 mos. INCREASES risk of PPC’s
Hypoalbuminemia Upper Abdominal (AAA)
post CABG: 57% vs 14% in abstainers > 2 mos
Dependent Status Lengthy procedures
Weight Loss / Obesity Post‐op narcotics • Highest risk with 2‐4 weeks of abstinence.
Lung Disease / Symptoms
Impaired Cognitive Function • After 6 months, risk approximates non‐smokers.
History of Malignancy
Recent Smoking Warner, MA, Mayo Clinic Proc 1989: 64: 609‐16
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COPD & Asthma Pulmonary Function Tests
Not routinely recommended for healthy patients
• Pre‐operative optimization is critical
ACP recs:
• Nebulizers, antibiotics, inhaled steroids Lung resection surgery
CABG
• Systemic steroids if peak flow < 80% of
personal best despite optimal care. (No Upper abdominal surgery w/tobacco history
difference in infection rate)
Head & Neck Surgery
Renal Insufficiency & Anesthetics Preoperative Evaluation
• Optimal perioperative management is dependent on
• Most drugs employed during anesthesia preoperative dialysis
– Hemodialysis vs peritoneal dialysis
partly dependent on renal excretion
– On the day of surgery or previous day
• Causes: • ECG: signs of hyperkalemia, ischemia, conduction blocks,
– decreased protein binding ventricular hypertrophy
– greater brain penetration due to breach of BBB
– synergistic effect with toxins retained in renal failure • Cardiac echo: assess cardiac function
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Propofol & Etomidate Barbiturates
• Renal disease decreased protein
• Not significantly affected by impaired renal
function
binding ↑free circulating barbiturates
↑sensi vity
• Hypoalbuminemia decreased protein binding
of Etomidate may enhance its effects • Acidosis ↑nonionized fraction more
rapid entry into the brain
• Benzodiazepines: most are highly protein • Atropine: can be used safely in renal impairment,
bound, hypoalbuminemia ↑sensi vity but accumulation exists following repeated
doses
• Diazepam: accumulation of active
metabolites
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Volatile Agents Muscle Relaxants
• Not dependent on kidneys for elimination • Succinylcholine: safely used in renal failure when serum
K < 5 mEq/L
• Chronic renal failure with severe anemia (Hb < 5)
↓blood:gas partition coefficient accelerated • Cisatracurium: degraded in plasma by ester hydrolysis
induction and Hofmann elimination
Reversal Agents
• Neostigmine: renal excretion is the principle
route of elimination
• Renal impairment half‐lives prolonged
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Summary Preoperative Testing
• What is the patients risk for complications? • Resting ECG
– Cardiac indicators – Not indicated in low risk procedure
• Acute
• Chronic – Definitely indicated in recent ischemic symptoms
• Major & Minor risk factors
• Would risk stratification alter the treatment?
– Any changes in anesthesia? • ECHO
– Alter the surgical technique? • Not indicated in low risk procedure
• Can you reduce the risk by altering the risk • Indicated in :
factors? – poorly controlled CHF
– symptomatic valvular disease
– Dyspnea of unknown origin
• Cardiac Stress Test Indication • Pre‐op functional capacity
– Most important predictor of outcomes
• Severe valvular disease
• ACS
• Decompensated heart failure • Low exercise tolerance = poor outcome
• Significant arrhythmias
• Stress test detects flow‐limiting lesions
• Pulmonary Function Tests – No use in non‐flow limiting plaques
– Not indicated for low risk procedures – Major source of MI
• Routine Labs • Resting ECG, ECHO, & Cardiac Stress tests
‐ Very low positive predictive value for cardiac events
– Not indicated
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• Renal Failure
– Surgery after Dialysis • Oral Anticoagulants
– Don’t Hold
– Baseline renal panel
• K+ levels – INR <3.5
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