Perioperative medicine - Internal Medicine Board Review Conference

Preoperative

ConsultationInternal Medicine Board Review Conference

Robert Robinson, MD, FACP

Assistant Professor of Clinical Medicine

Educational Objectives

Understand reasons for consultation

Understand role of IM consultant

Understand cardiovascular risk assessment

Understand pulmonary risk assessment

“Preop Clearance?”

Reasons for Preoperative Consultation

Risk assessment

Risk reduction

Liability reduction?

Role of the IM Consultant

Assess and manage risk

Manage chronic medical problems

Monitor for postoperative complications

Other factors to consider…

Customer service

Patient

Surgeon

Local standard of care

Preop testing?

Preop for cataract surgery?

Practice revenue

Cardiovascular Risk Assessment

Importance of assessing Cardiovascular Risk

Cardiac Death and Nonfatal MI Occur in 0.2% all general anesthesia cases and surgery

~500,000 deaths annually

Cardiac death40% perioperative mortality

Myocardial Infarction (MI) Most often occurs within 4 days of surgery

15-25% mortality rate

Nonfatal perioperative MI increases 6 month riskCardiovascular events

Death

Robert Robinson, MD 11Current Diagnosis & Treatment Cardiology 3rd Edition

Cardiac Complications

General anesthesia risks

Myocardial depression

Transient hypotension

Tachycardia

Few deaths occur intraoperatively

Risk of cardiac complications peaks 2-5 days

postoperativelyPneumonitis and atelectasis produce V/Q mismatch

Sedation or analgesia can produce respiratory depression

Thrombosis is favored due to tissue damage

Sympathetic activation increases myocardial oxygen consumption

Robert Robinson, MD 12

Surgery Specific Risks

Low Risk

(<1%)

• Endoscopy

• Superficial Biopsy

• Cataract

• Hysterectomy

• Vasectomy

Moderate Risk

(1-5%)

• Endarterectomy

• Abdominal

• Orthopedic

• Head/Neck

• Nephrectomy

• Prostate

High Risk

(>5%)

• Major vascular

• Prolonged

• Emergency


ACC/AHA Guidelines, 2007

Revised Cardiac Risk Index

Risk FactorsHigh risk surgery

Ischemic heart disease

History of heart failure

History of cerebrovascular

disease

Diabetes requiring insulin

Preoperative creatinine >2.0

mg/dL

Risk ClassClass I zero risk factors 0.4%

Class II one risk factor 0.9%

Class III two risk factors 6.6%

Class IV three or more risk

factors 11%

Class III or IV riskRequire additional cardiac testing

for risk stratification AND more

aggressive perioperative medical

management


ACC/AHA Guidelines, 2007

Figure 1. Cardiac evaluation and care algorithm for noncardiac surgery

Fleisher L A et al. Circulation 2007;116:e418-e500

Copyright © American Heart Association

When to Order Preop Testing


Risk

Intermediate

or

High

Non Invasive Cardiac Testing

No Testing if

<5 Years from Revascularization

or

<2 years from

Non Invasive Testing

Low No Further Testing

New directions in cardiovascular risk

assessment

Development and Validation of a Risk Calculator for Prediction of Cardiac Risk After SurgeryClinical

Perspective

by Prateek K. Gupta, Himani Gupta, Abhishek Sundaram, Manu Kaushik, Xiang Fang, Weldon J. Miller, Dennis J. Esterbrooks, Claire B. Hunter, Iraklis I. Pipinos, Jason M. Johanning, Thomas G. Lynch, R. Armour Forse, Syed M. Mohiuddin, and Aryan N.

Mooss

CirculationVolume 124(4):381-387

July 26, 2011


Gupta Perioperative Cardiac Risk Calculator

• Free medical calculator

• Smartphones

• Tablets

Cardiovascular Risk Reduction


Indications for Revascularization

• Left Main Stenosis

• Triple Vessel Disease

• Severe Ventricular Dysfunction

Revascularize

• Use of bare metal stents decreases risk of coronary thrombosis

Delay SurgeryAt least 6 weeks post

stent


Date of download:

11/16/2012

Copyright © The American College of Cardiology.

All rights reserved.

From: A Clinical Randomized Trial to Evaluate the Safety of a Noninvasive Approach in High-Risk Patients

Undergoing Major Vascular Surgery: The DECREASE-V Pilot Study

J Am Coll Cardiol. 2007;49(17):1763-1769. doi:10.1016/j.jacc.2006.11.052

Incidence of All-Cause Death or Myocardial Infarction During 1-Year Follow-Up According to the Allocated Strategy in Patients With

3 or More Cardiac Risk Factors With Extensive Stress-Induced Ischemia

Light line = best medical treatment only; dark line = best medical treatment and prophylactic revascularization.

Figure Legend:

Date of download:

11/16/2012



From: Pre-Operative Risk Assessment and Risk Reduction Before Surgery


Prophylactic Coronary Revascularization

Results of the CARP (Coronary Artery Revascularization Prophylaxis) study: long-term survival among patients assigned to

undergo coronary artery revascularization or no revascularization. Reprinted with permission from McFalls et al. (31).

Figure Legend:

Anti-platelet Drug

Management

Figure 3. Proposed treatment for patients requiring percutaneous coronary intervention (PCI)

who need subsequent surgery.



Figure 2. Proposed approach to the management of patients with previous percutaneous

coronary intervention (PCI) who require noncardiac surgery, based on expert opinion.



….New Data…

Date of download: 12/11/2013Copyright © 2012 American Medical

Association. All rights reserved.

From: Risk of Major Adverse Cardiac Events Following Noncardiac Surgery in Patients With Coronary Stents

JAMA. 2013;310(14):1462-1472. doi:10.1001/jama.2013.278787

Association With Perioperative Antiplatelet Management and 30-Day Postoperative Major Adverse Cardiac Event in Matched Case-

Control Cohort

Figure Legend:

….may change management

Reducing Risk with Medications

Beta blockersMeta analysis of 33 trials showed no clear benefit

Lancet 2008;372(9654):1962-1976

Reduced morbidity and mortality in some trials

Higher risk patient = higher benefit

Metoprolol in patients not on beta blocker therapy

5-10 mg IV every 4-6 hours

Titrate to pulse of 60 bpm

StatinsIntermediate and high risk patients

Clonidine?


Date of download:

11/16/2012





Perioperative Beta-Blocker Therapy

Comparison of patients treated with perioperative beta-blocker therapy versus no drug or placebo.

CI = confidence interval; MI = myocardial infarction; OR = odds ratio; Rx = treatment. Reprinted, with permission, from Schouten et

al. (44).

Figure Legend:

Date of download:

11/16/2012





Perioperative Statin Therapy

Results of the effect of perioperative statin therapy in different studies. CI = confidence interval; OR = odds ratio.

Figure Legend:

Pulmonary Risk Assessment


Perioperative Pulmonary Complications

Pneumonia

Mucous plugs

Atelectasis

Respiratory failure

Respiratory depression

V/Q Mismatch

As common as

cardiovascular

complications

Similar impact on

morbidity and

mortality


Surgical Impact on Pulmonary Function

Vital Capacity reduced 1 week post operatively

Functional Residual Capacity reduced by up to 30%

Worsening of OSA (due to medications)


Date of download:

11/16/2012

Copyright © The American College of Physicians.


From: Risk Assessment for and Strategies To Reduce Perioperative Pulmonary Complications for Patients

Undergoing Noncardiothoracic Surgery: A Guideline from the American College of Physicians

Ann Intern Med. 2006;144(8):575-580. doi:10.7326/0003-4819-144-8-200604180-00008

American Society of Anesthesiologists Classification

Figure Legend:

Risk Factors for Pulmonary Complications

Robert Robinson, MD 38Cleveland Clinic Journal of Medicine November 2009 vol. 76 Suppl 4 S60-S65

Procedure Related Risk Factors

Risk Factor # Studies Pooled Estimate OR

Surgical Site

Aortic 2 6.9

Thoracic 3 4.24

Any abdominal 6 3.09

Neurosurgery 2 2.53

Head and Neck 2 2.21

Emergency 6 2.52

Prolonged surgery 5 2.26

General anesthesia 6 2.35

Transfusion (>4 units) 2 1.47


Annals Int Med 2006;144:581-595

Assessing the Risk of Pulmonary Complications

Careful and Thorough History and Physical

Exam

COPD or Asthma

Unsure if at Baseline

Smoking Hx

High Risk Surgery

Unexplained Dyspnea or

Exercise Intolerance

ASA > 1

Negative

Low Risk

Proceed to Surgery

CXR or PFT

Consider surgical

alternatives

Optimize perioperative

therapy


Screening for Obstructive Sleep Apnea


Date of download: 12/11/2013

Copyright © American College of Chest Physicians. All rights reserved.

From: Development and Validation of a Risk Calculator Predicting Postoperative Respiratory FailureRisk

Calculator Predicting Respiratory Failure

Chest. 2011;140(5):1207-1215. doi:10.1378/chest.11-0466

Calibration of predictions of PRF in the training set (final model). ♦Denotes deciles of patients. See Figure 1 legend for expansion of

abbreviation.

Figure Legend:

Gupta Perioperative Pulmonary Risk Calculator

• Free medical calculator

• Smartphones

• Tablets

Spirometry

Helps identify patients with COPD

Not superior to clinical evaluation at predicting risk

Obtain for PFTs for

COPD or Asthma if unable to assess if patient is at

baseline

Unexplained dyspnea or exercise intolerance


Pulmonary Risk Reduction


Robert Robinson, MD 46Cleveland Clinic Journal of Medicine November 2009 vol. 76 Suppl 4 S60-S65

Postoperative Delirium


Rates of Postoperative Delirium

35% after major vascular surgery

60% after hip fracture repair


Risk factors for Postop Delirium

Preop Factors

Age

Cognitive impairment

Cerebrovascular disease

Neurodegenerative

disease

History of delirium

ETOH abuse

BZD or Narcotic use

Postop factors

Low HgB

Low O2 Saturation

Abnormal sodium

Abnormal potassium

Abnormal glucose

Poor pain control


Treatment of Delirium

Identify and treat underlying cause

Limit drugs that can cause delirium

Reorient patient

Evaluate for withdrawal

Alcohol

Benzodiazepines

Antipsychotic agents if needed


Perioperative medicine - Internal Medicine Board Review Conference

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