Perioperative Care: Preventing

ComplicationsSalim D. Islam, MDKaren E. Hauer, MD

2006

Workshop learning objectives

1. Learn the indications for preoperative testing and preparation for a healthy patient having elective surgery

2. Learn the indications for cardiac stress testing and beta blockade prior to noncardiac surgery

3. Understand new recommendations for preventing postoperative pulmonary complications

Outline

• Preoperative risk stratification

• Perioperative cardiac risk reduction

• Preventing postoperative pulmonary complications

Case #174 y.o. woman with CAD s/p stent in 1998, hypertension, osteoporosis, GERD, scheduled for cataract surgery. Able to walk 2 blocks, no chest pain or dyspnea. Meds: enalapril, lovastatin, ranitidine, aspirin.

PE: BP 128/70 HR 80

Surgeon asks you to perform routine preoperative tests and clear for surgery. What do you recommend?

Case #1What do you recommend prior to

cataract surgery?

A. CBC, lytes, creatinine, glucose, EKGB. Stress testC. A & BD. Recommend against surgeryE. Proceed with surgery

Routine Preoperative Testing before Cataract Surgery

N Engl J Med 2000;342;168

19,557 cataract surgeries• Randomized to preop testing

or no testing• Average age 74• 89% ASA class II or III• Outcome = perioperative

events

ASA Physical StatusI Healthy DJD, Glaucoma

II Asymptomatic systemic disease

Hypertension,diabetes

III Symptomatic systemic disease

Stable angina, chronic renal insufficiency

IV Systemic disease - constant threat to life

COPD on home 02, Class III CHF

V Will die within 24 hours without surgery

Ruptured AAA

VI Brain dead organ donor

Routine Preoperative Testing before Cataract Surgery

N Engl J Med 2000;342;168

No testing

Routine testing

Relative risk (95%

CI)

Intraop events* 1.9% 2% 0.97

(0.8-1.2)

Postop events* 1.3% 1.2% 1.04

(0.8-1.3)*Events = Cardiac, Hyper/hypotension, Stroke/TIA, respiratory distress requiring treatment, hypoglycemia, DKA

Case #2: Preop Risk Stratification

55 y.o. woman scheduled for hysterectomy

PMH: hypertension, on hydrochlorothiazide

PE: BP 135/90 HR 85 Normal exam

EKG: Normal sinus rhythm, left ventricular hypertrophy

What preoperative cardiac evaluation do

you recommend?A. None. Proceed with surgeryB. Add a beta-blockerC. Exercise stress testD. Exercise-thallium stress

test

Preventing Perioperative Cardiac

Complications•What are we trying to prevent?•Perioperative MI (mortality up to 15%)

•Mortality (all cause)•Other - CHF, ischemia, nonfatal arrhythmia

Risk of Cardiac Complications Based on Type

of Surgery• High (>5%)• Major aortic, peripheral vascular

surgery• Emergent major surgery• Long case - large fluid shifts, blood

loss

• Intermediate (<5%)• Carotid, head, neck• Abdominal, thoracic, pelvic• Orthopedic

• Low (<1%)• Endoscopic, skin, breast

Clinical Predictors of Perioperative Cardiac ComplicationsEagle, JACC 2002;39:542

Major MI within 1 month, unstable anginaDecompensated CHF, severe valve diseaseSignificant arrhythmia

Intermediate

Prior MIMild anginaCHFDiabetesCreatinine > 2.0 mg/dl

Minor Advanced ageAbnormal ECG or rhythm not sinusPrior strokeUncontrolled hypertensionFunctional capacity < 4 METs

Assessing Functional Capacity

1-4 METs EatDressWalk in house

4-10 METs Climb flight of stairsScrub floorsGolfShort run

10+ METs SwimmingSingles tennis

Case #3: Preop Hypertension Management

55 y.o. woman arrives for hysterectomy PMH: hypertension, on hydrochlorothiazide

PE: BP 185/100 HR 85 Normal exam

EKG: Normal sinus rhythm, left ventricular hypertrophy

How does your management change?

Outline

• Preoperative risk stratification

• Perioperative cardiac risk reduction

• Preventing postoperative pulmonary complications

Case #468 y.o. woman with type 2 diabetes, osteoarthritis of the knees, and hypothyroidism, scheduled for right hemicolectomy. Meds: glyburide, metformin, levothyroxine, acetaminophen. Non-smoker.

PE: BP 130/70 HR 88 98% RA 02 Sat

Case #4

What preoperative assessment do you recommend?

A. Proceed with surgeryB. Exercise treadmill testC. Persantine-thallium test D. Cardiac catheterizationE. Add atenolol

Preoperative Stress Testing

Eagle ACC/AHA 2002•Indications: 2 or more of the following–Intermediate clinical predictor (Eagle 2002)

• Stable cardiac disease, DM, Cr > 2–High risk surgery–Poor functional status (< 4 METs)

•Which test?–Ambulatory, normal ECG exercise treadmill–Ambulatory, abnormal ECG exercise + imaging

–Can’t exercise P-Thal or Dobutamine echo

•Better for ruling out than ruling in cardiac disease

Perioperative Beta Blockers

In what clinical settings would you prescribe a perioperative beta-blocker?

A. HypertensionB. Major vascular surgeryC. History of CADD. CAD risk factorsE. All surgical patients

Benefits of Perioperative Beta Blockers

• Reduce perioperative myocardial ischemia

• Decrease perioperative cardiac complications

• Improve survival

Perioperative Beta Blockers in Noncardiac

Surgery• Patients: 200 Veterans w/ CAD or 2 CAD risk factors

• Atenolol one hour prior to surgery until hospital discharge, unless HR < 55, vs. placebo

• Operations: major vascular, abdominal, ortho, neurosurg

• Outcomes: mortality, cardiac complications over 2 years

Mangano, NEJM, 1996

Perioperative Beta Blockers in Noncardiac

Surgery

Mangano, NEJM, 1996

0

5

10

15

20

25

6 month mortality 2 year mortality

AtenololPlaceob

Which Beta Blocker?• Cardioselective (atenolol, metoprolol)

– Effective– Fewest side effects

• Non-cardioselective (propranolol, nadolol)– Equally effective– More side effects - pulmonary, hypotension– Use only if patient already taking

• Avoid beta blockers with intrinsic sympathomimetic activity

• Consider clonidine if beta blockers contraindicated

Dosing Perioperative Beta Blockers

• Already taking a Beta Blocker:– Adjust previous dose to a target HR of 60

• New prescriptions:– Begin treatment with atenolol 25-50 mg q day within one month of surgery

– Consider a follow-up appt for HR check and dose adjustment 1-7 days before surgery

Outline

• Preoperative risk stratification

• Perioperative cardiac risk reduction

• Preventing postoperative pulmonary complications

Case # 5A 70 year old man with diabetes, hypertension, CAD, and COPD is admitted with right upper quadrant pain. He smokes 1 pack/day. Ultrasound reveals acute cholecystitis, and cholecystectomy is recommended. In addition to preoperative cardiac risk stratification, you consider the risk of pulmonary complications.

Case #5Which of the following is most likely to reduce the risk of perioperative pulmonary complications?

A.Preoperative CXRB.Incentive spirometryC.Laparoscopic techniqueD.Smoking cessation

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Perioperative Pulmonary

Complications• As common as postop cardiac complications; similar morbidity and mortality– Pulmonary complications may better predict long term mortality

• Most important and morbid:– Atelectasis– Pneumonia– Respiratory failure– Exacerbation of chronic lung disease

Risk assessment and strategies to reduce

perioperative pulmonary complications after

noncardiothoracic surgery: A guideline from the ACP

Ann Intern Med 2006;144:575

Patient risk factors for postop pulmonary

complicationsRisk factor Odds ratio

Age > 60 2.09 - 3.04

COPD 1.79

Current smoking 1.26

CHF 2.93

ASA class > I 4.87

Functional dependence

2.51 (total); 1.65 (partial)

Surgery risk factors for postop pulmonary

complications• Surgery type: abdominal, thoracic, neuro, head/neck, vascular, AAA

• Surgery > 3 hours• Emergency surgery• General anesthesia

QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.

Interventions to reduce postop

pulmonary complications: Preop

• Identify and target high risk patients– Patient and surgery risk risk factors

• Preop - consider:– Spirometry - only with COPD– CXR - for age > 50, high risk surgery, known cardiopulmonary disease

Interventions to reduce postop

pulmonary complications:

Post op• Lung expansion–Deep breathing exercises or –Incentive spirometry or–CPAP

• Selective use of NG tube after abdominal surgery–for nausea/emesis, inability to take p.o., abdominal distention

QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.

Interventions that might reduce postop

pulmonary complications:

• Laparoscopic instead of open surgery–Improves pain, spirometry, oxygenation

–Unclear benefit on clinically important pulmonary complications

• Epidural anesthesia/analgesia - unclear benefit

• Smoking cessation: > 2 months preop

Summary

• Preoperative risk stratification

• Perioperative cardiac risk reduction

• Preventing postoperative pulmonary complications