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Perioperative Care: Preventing Complications

Perioperative Care: Preventing Complications. Salim D. Islam, MD Karen E. Hauer, MD 2006. Workshop learning objectives. Learn the indications for preoperative testing and preparation for a healthy patient having elective surgery

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Perioperative Care: Preventing Complications

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  1. Perioperative Care: Preventing Complications Salim D. Islam, MD Karen E. Hauer, MD 2006

  2. Workshop learning objectives • Learn the indications for preoperative testing and preparation for a healthy patient having elective surgery • Learn the indications for cardiac stress testing and beta blockade prior to noncardiac surgery • Understand new recommendations for preventing postoperative pulmonary complications

  3. Outline • Preoperative risk stratification • Perioperative cardiac risk reduction • Preventing postoperative pulmonary complications

  4. Case #1 74 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?

  5. Case #1 What do you recommend prior to cataract surgery? • CBC, lytes, creatinine, glucose, EKG • Stress test • A & B • Recommend against surgery • Proceed with surgery

  6. Routine Preoperative Testing before Cataract SurgeryN 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

  7. ASA Physical Status

  8. Routine Preoperative Testing before Cataract SurgeryN Engl J Med 2000;342;168 *Events = Cardiac, Hyper/hypotension, Stroke/TIA, respiratory distress requiring treatment, hypoglycemia, DKA

  9. 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

  10. What preoperative cardiac evaluation do you recommend? • None. Proceed with surgery • Add a beta-blocker • Exercise stress test • Exercise-thallium stress test

  11. Preventing Perioperative Cardiac Complications • What are we trying to prevent? • Perioperative MI (mortality up to 15%) • Mortality (all cause) • Other - CHF, ischemia, nonfatal arrhythmia

  12. 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

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

  14. Assessing Functional Capacity

  15. 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?

  16. Outline • Preoperative risk stratification • Perioperative cardiac risk reduction • Preventing postoperative pulmonary complications

  17. Case #4 68 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

  18. Case #4 What preoperative assessment do you recommend? • Proceed with surgery • Exercise treadmill test • Persantine-thallium test • Cardiac catheterization • Add atenolol

  19. Preoperative Stress TestingEagle 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

  20. Perioperative Beta Blockers In what clinical settings would you prescribe a perioperative beta-blocker? A. Hypertension B. Major vascular surgery C. History of CAD D. CAD risk factors E. All surgical patients

  21. Benefits of Perioperative Beta Blockers • Reduce perioperative myocardial ischemia • Decrease perioperative cardiac complications • Improve survival

  22. 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

  23. Perioperative Beta Blockers in Noncardiac Surgery Mangano, NEJM, 1996

  24. 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

  25. 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

  26. Outline • Preoperative risk stratification • Perioperative cardiac risk reduction • Preventing postoperative pulmonary complications

  27. Case # 5 A 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.

  28. Case #5 Which of the following is most likely to reduce the risk of perioperative pulmonary complications? • Preoperative CXR • Incentive spirometry • Laparoscopic technique • Smoking cessation

  29. 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

  30. Risk assessment and strategies to reduce perioperative pulmonary complications after noncardiothoracic surgery: A guideline from the ACP Ann Intern Med 2006;144:575

  31. Patient risk factors for postop pulmonary complications

  32. Surgery risk factors for postop pulmonary complications • Surgery type: abdominal, thoracic, neuro, head/neck, vascular, AAA • Surgery > 3 hours • Emergency surgery • General anesthesia

  33. 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

  34. 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

  35. 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

  36. Summary • Preoperative risk stratification • Perioperative cardiac risk reduction • Preventing postoperative pulmonary complications

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