How to Keep Your Surgeon Out of Trouble: Perioperative Medicine ...

How to Keep Your Surgeon Out of

Trouble: Perioperative Medicine:

Risk Stratification

Jalal K. Ghali, M.D., F.A.C.C.

Professor of Medicine

Associate Chair for Clinical Research

Chief, Division of Cardiology

Department of Medicine

Mercer University School of Medicine

Macon, GA

How to Make Your Surgeon

Happy

Dear Dr. GS,

Your patient Mr. MC has been “cleared” for

the planned surgery.

I would like to assure you that no medical

complications will arise from the planned

surgery and furthermore, should they arise, I

take full responsibility for managing them.

Our commitment extends for full 30 days post

op.

How to Keep Your Surgeon Out of

Trouble:

Impossible

Disclosures

Internists: Know everything

Surgeons: Know nothing

Psychiatrists: Have no clue

Pathologists: Know everything, one day late

do everything…

and do no procedures

and do everything

Definition of the

Medical Consultant

Magnitude of the problem

Is there a need for medical consultation?

Pathophysiology

Predictive models

Revised Cardiac Risk Index

Thoracic Revised Cardiac Risk Index

Vascular Study Group of New England

Surgical Mortality Probability Model

Risk Calculator for Prediction of Cardiac Risk

Perioperative Medicine

Clinical Recommendations

Special considerations

Biomarkers

Hypertension

PCI

Statins

Beta Blockers

Summary

Definition of the medical consultant

Perioperative Medicine

10 million major noncardiac surgery

4 million in patients ≥65 years

High risk account for 80% of death

250 million procedures worldwide

Common preventable complications after non-cardiac surgery

that may be prevented by enhanced perioperative care

Pneumonia

Superficial and deep wound infection

Myocardial infarction

Arrhythmias

Severe pain

Pulmonary embolism

Acute kidney injury

Stroke

Respiratory failure

Acute confusion or delirium

Cardiac arrest

Pearse RM, et al. BMJ 2011;343:d5759.

84,730 patients who had undergone inpatient

general and vascular surgery 2005 - 2007

Very low mortality Very high mortality

3.5% 6.9%

Ghaferi AA. N Engl J Med 2009;361:1368-75

Ghareri AA, et al. N Engl J Med 2009;361:1368-1375.

Rates of All Complications, Major Complications,

and Death after Major Complications

Khuri SF, et al. Ann Surg 2005;242(3):326-343.

Patients with no complications

Patients with 1 or more 30-day postop complications

Patients surviving beyond

30 days postop All Patients

Days

Su

rviv

al P

rob

ab

ilit

y

Hospital-specific rates of preoperative medical

consultation for major elective noncardiac surgery

Wijeysundera DN, et al. Anesthesiology 2012;116:25-34.

Associations Between Perioperative Consultation,

Quality of Care, and Subsequent Complications

Auerbach AD, et al. Arch Intern Med 2007;167:2338-2344.

Wijeysundera DN, et al. Arch Intern Med 2009;169(6):595-602.

217,082 39% (n = 104,716) underwent

anesthesia consultations

- Reduced mean hospital length of stay

8.17 vs 8.52 day

- No reduction of 30 day or 1 year mortality

n = 104695 (38.8%) underwent consultation

30 day mortality RR 1.16 (1.07 – 1.25)

Number needed to harm

516

1 year mortality RR 1.08 (1.04 – 1.12)

Number needed to harm

227

Wijeysundera DN, et al. Arch Intern Med 2010;170(15):1365-1374.

1994 – 2004 269,866

Pathophysiology

Emotional stress

Pain

Surgical trauma

Tissue injury

Hypothermia

Hypoxemia

Immobility

Bleeding and anemia

Fasting

Landesberg G et al. Circulation 2009;119:2936-2944.

Devereaux PJ, et al. CMAJ 2005;173(6):627-634.

Potential triggers of states associated with perioperative

elevations in troponin levels, arterial thrombosis and fatal

myocardial infarction

Risk Prediction Models

Revised Cardiac Risk Index

Lee TH, et al. Circulation 1999;100:1043-1049.

Risk of Cardiac Death and Nonfatal Myocardial

Infarction for Noncardiac Surgical Procedures

Risk of

procedure

High (> 5%) Aortic and major vascular surgery, peripheral

vascular surgery

Intermediate

(1 to 5%)

Intraperitoneal or intrathoracic surgery, carotid

endarterectomy, head and neck injury,

orthopedic surgery, prostate surgery

Low (< 1%) Ambulatory surgery, breast surgery,

endoscopic procedures, superficial

procedures, cataract surgery

Thoracic Revised Cardiac

Risk Index

Thoracic Revised Cardiac Risk Index

Ischemic Heart Disease 1.5

CVA or TIA 1.5

Pneumonectomy 1.5

Creatinin >2 mg/DL 1.0

Brunelli A, et al. Ann Thorac Surg 2011;92:445-8.

Brunelli A, et al. Ann Thorac Surg 2011;92:445-8.

.

ThRCRI

Score

Risk Class

No. of Cases

Major Cardiac

Complications

0 A 1,909 18 (0.9%)

1-1.5 B 616 26 (4.2%)

2-2.5 C 25 2 (8%)

>2.5 D 71 13 (18%)

p < 0.0001

Distribution of Patients in Each Class of the Recalibrated

Revised Cardiac Risk Index (ThRCRI)

Brunelli A , et al. Ann Thorac Surg 2011;92:445-8.

.

Rates of cardiac complication according to the Thoracic

Revised Cardiac Risk Index classes A, B, C, D

Vascular Study Group of

New England(VSG-CRI)

Bertges, et al. J Vasc Surg 2010;52(3):674-83.

Vascular Surgery Group Cardiac Risk Index (VSG-CRI) scoring

system and predicated risk of adverse cardiac events

Surgical Mortality Probability

Model

ASA PS Classification

ASA PS Definition

I A normal healthy patient

II A patient with mild systemic disease

III A patient with severe systemic disease

IV A patient with severe systemic disease that

is a constant threat to life

V A moribund patient who is not expected to

survive without the operation

Glance LG, et al. Ann Surg 2012;255:696-702.

S-MPM Scoring System for Estimating Risk of 30-Day

Mortality After Noncardiac Surgery


S-MPM Class Levels and Associated Risk of Mortality

Class Point Total Mortality

I 0-4 <0.50%

II 5-6 1.5%-4.0%

III 7-9 >10%


Risk Calculator for Prediction

of Cardiac Risk After Surgery

Calculator to Predict the risk of

myocardial infarction or cardiac arrest

(MICA)

Type of surgery

Functional status

Abnormal creatinine

American Society of Anesthesiologists class

Increasing age

The MICA risk calculator is available at www.surgicalriskcalculator.com

Gupta PK, et al. Circulation 2011;124:381-387.

Clinical Recommendations

CCS ACC/

AHA ESC HFSA

CCS ACC/AHA ESC HFSA

Definition

Something that provides direction or

advice as to a decision or course of

action;

A detailed plan or explanation to guide

you in setting standards or determining a

course of action

Collins English Dictionary http://www.thefreedictionary.com/guideline

Definition

Systematically developed statements to assist

practitioner and patient decisions about

appropriate health care for specific clinical

circumstances1

To assist health care providers in clinical

decision making by describing a range of

generally acceptable approaches2

1. Institute of Medicine. Washington, DC: National Academy PR; 1992

2. Hunt S, et al. Circulation 2005;112:1825-52.

Electrocardiogram

Recommendations for Preoperative Resting

12-Lead ECG

Class I

1. Patients with at least 1 clinical risk factor who are

undergoing vascular surgical procedures.

2. patients with known CHD, peripheral arterial disease,

or cerebrovascular disease who are undergoing

intermediate-risk surgical procedures.

Fleisher LA, et al. Circulation 2009;120:e169-e276.

Recommendations for Preoperative Resting

12-Lead ECG

Class III

1. Preoperative and postoperative resting 12-lead

ECGs are not indicated in asymptomatic persons

undergoing low-risk surgical procedures.


Feely MA, et al. Am Fam Physician 2013;87(6):414-8.

Suggested algorithm for performing preoperative

electrocardiography

Echocardiography

Wijeysundera DN, et al. BMJ 2011;342:d3695.

264, 823 patients undergoing elective intermediate to

high risk noncardiac surgery 1998 - 2008

Echocardiography 40,084 (15.1%)

70,996

30 day mortality 1 year mortality

1.14 (1.02-1.27) 1.07 (1.01-1.12)

Recommendations for Preoperative Noninvasive

Evaluation of LV Function

Class IIa

1. It is reasonable for patients with dyspnea of unknown

origin.

2. It is reasonable for patients with current or prior HF

with worsening dyspnea or other change in clinical

status if not performed within 12 months.


Recommendations for Preoperative Noninvasive

Evaluation of LV Function

Class IIb

1. Reassessment of LV function in clinically stable

patients with previously documented cardiomyopathy is

not well established.

Class III

1. Routine perioperative evaluation of LV function in

patients is not recommended.


Stress Testing

Wijeysundera DN, et al. BMJ 2010;340:b5526.

Association of preoperative stress testing with one year

survival in the subgroup analyses

Active Cardiac Conditions for Which the Patient

Should Undergo Evaluation and Treatment Before

Noncardiac Surgery


Unstable coronary symptoms

Decompensated HF (NYHA functional

class IV: worsening or new-onset HF)

Significant arrythmias

Severe valvular disease

Recommendations for Noninvasive Stress Testing

Before Noncardiac Surgery

Class I

1. Patients with active cardiac conditions.

Class IIa

1. 3 or more clinical risk factors and poor functional

capacity (less than 4 METs) who require vascular

surgery is reasonable if it will change management.


Recommendations for Noninvasive Stress Testing

Before Noncardiac Surgery

Class IIb

1. may be considered for patients with at lease 1 to 2 clinical

risk factors and poor functional capacity (less than 4

METs) who require intermediate risk or vascular surgery if

it will change management.

Class III

1. Noninvasive testing is not useful for patients with no

clinical risk factors undergoing low or intermediate-risk

noncardiac surgery.


McFalls EO, et al. NEJM 2004;351:2795-2804.

Long-Term Survival among Patients Assigned to Undergo

Coronary-Artery Revascularization or No Coronary-Artery

Revascularization before Elective Major Vascular Surgery

American College of Cardiology (ACC)/ American

Heart Association (AHA) 2007 Guidelines

Open Vascular Surgery Required

Emergent Proceed with planned procedure Yes

No

Active Cardiac Condition Class I: Non-Invasive Stress Testing

Class I: Coronary Revascularization indications

same as in patients not undergoing surgery

Known Functional Capacity

< 3 Clinical Risk Factors Class I: No Further Testing

Class I: Continue β-blocker if currently prescribed

Class IIa: Consider Non-Invasive Stress Testing

Yes

No

No Yes

No

Biomarkers

Postoperative NT-proBNP Thresholds and the Incidence of

Mortality or Nonfatal MI at 30 Days after Surgery

Rodseth et al. Anesthesiology 2013;119:270-83.

Postoperative BNP Thresholds and the Incidence of Mortality

or Nonfatal MI at 30 Days after Surgery

Rodseth et al. Anesthesiology 2013;119:270-83.

Risk of death for patients with estimated glomerular filtration

rate <60 ml-min-1.73 m-2 compared with ≥60 mil-min-1.73 m-2

at both short-term and long-term follow up

Mooney et al. Anesthesiology 2013;118:809-24.

Kaplan-Meier estimates of 30-Day mortality based on peak

Troponin T values

The Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION)

Study Investigators. JAMA 2013;307:2295-2304.

15,133 noncardiac surgery (2007 – 2011)

Le Manach, et al. Anesthesiology 2005;102:885-891.

Kikura M, et al. J Thromb Haemost 2008;6:742-748.

Statins

Effect of perioperative statins on myocardial

infarction, atrial fibrillation, and death.

Chopra V, et al. Arch Surg 2012;147(3):181-9.

Effect of perioperative statins on hospital and intensive

care unit length of stay.

Chopra V, et al. Arch Surg 2012;147(3):181-9.

Forest plot of comparison: I Statin versus

placebo/no treatment, outcome: 1.2 All-Cause

mortality

Sanders RD, et al. Cochrane Database Syst Rev 2013;7.

Forest plot of comparison: I Statin versus

placebo/no treatment, outcome: 1.4 Myocardial

Infarction (non-fatal)

Sanders RD, et al. Cochrane Database Syst Rev 2013;7.

Singla S, et al. JACC 2012;60:2005-2016.

The highest-risk period for ST after PCI with

either BMS or DES following NCS is the first 4

weeks. Therefore, it seems reasonable to

withhold NCS, if possible, for at least 4 weeks

after PCI.


Proposed approach to the management of patients

with previous PCI requiring noncardiac surgery


Proposed treatment for patients requiring

percutaneous coronary intervention (PCI) who need

subsequent surgery

Perioperative Hypertension

No link between perioperative complications with

either preexistant hypertension or an elevated

blood pressure

Types of surgery: CABG, AA, CEA, PVS,

intraperitoneal or intrathoracic

Perioperative cardiac complications are

associated with hemodynamic lability (>20%

change in mean BP)

Consider lowering the dose of ACE

inhibitors or AR antagonist 24 hours ( at

least 10 hours) before surgery

Perioperative Beta Blockers

Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:1839-47.

8,351 patients with, or at risk of, atherosclerotic

disease received extended-release metoprolol

succinate (n=4174) or placebo (n=4177)

started 2-4 h before surgery and continued

for 30 days.


Kaplan-Meier estimates of the primary outcome (A),

myocardial infarction (B), stroke (C) and death (D)

Metoprolol

(n = 4179)

Placebo

(n = 4177)

Death 129 79 32

Strokes 41 19 32



.

Meta-analysis of β-blocker trials in patients undergoing non-

cardiac surgery

Comparison of effect of perioperative β-blockade on non-

fatal strokes in secure and non-secure trials.

Bouri S et al. Heart 2013.

Meta-analysis of nine secure randomised controlled trials

showing a significant increase in mortality with

perioperative β-blockade.


Prevalence of hypotension in β-blocker and control

groups.


Thirty-Day Mortality Propensity Model

London MJ, et al. JAMA 2013;309(16):1704-13.

Beta Blockers

28,263 adults with IHD who underwent noncardiac

surgery 2004 - 2009

MACE Mortality

Heart Failure 22% 18%

MI within 2 years 46% 20%

MI 2 – 5 years 29% 26%

MI > 5 years 35% 33%

No MI or HF 44% 30%

Anderson C et al. Annual Congress of the European Society of Cardiology. September 18, 2013.

Summary of ACC/AHA Guideline Recommendations

Beta-Blocker Medical Therapy

Class I Beta-blockers should be continued in patients

undergoing surgery who are receiving beta-

blockers to treat angina, symptomatic

arrhythmias, hypertension, or other ACC/AHA

class I guideline indications

Class III Routine administration of high-dose beta-

blockers in the absence of dose titration is not

useful and may be harmful to patients not

currently taking beta-blockers who are

undergoing noncardiac surgery

Fleisher LA. Cleve Clin J Med 2009;76:S9-15.

Medical Consultant

Provide informed clinical judgment based on

knowledge, experience and the individual

patient’s data to optimize short and long term

outcomes.

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