9/6/ % 25% 25% 25%

Transcription

1 Objectives Risky (Factor) Business: Preoperative Evaluation for the Primary Care Physician David M Schneider, MD Faculty Physician, Santa Rosa Family Medicine Residency 9/6/12 By the end of this conference, attendees will be able to: 1. Identify minimum functional level for perioperative safety. 2. State which lab tests should be done preoperatively on a routine basis. 3. State at least one step in preop cardiac evaluation. 4. Identify at least 1 low risk surgery. 5. State which pts should definitely get preop β- blockers. 6. Remember at least 1 fact about the movie Risky Business. Case 1 You are called at 0200 by a surgeon to see a pt with abdominal pain. The surgeon tells you the pt is an 86 yo white male with CHF with RLQ abdominal pain, tenderness at McBurney s point, and a fever to CBC shows WBC of Case 1 - continued Surgeon: Please clear this pt for surgery. I think I should wait until the morning and have cardiology do an echo. What do you do? 33% 86 yo M w/h/o CHF & Appy sx/sx echo? 33% 1. Yes echo echo only 33% 2. Yes echo echo + Cardio eval 3. No Clearance for Surgery Does clear for surgery mean there are no risks? Your task is to find the risks. Risks vary based on many factors. Your other key tasks: Optimize medical condition of the surgical pt. Propose strategies to reduce risk & complications. 1

2 Clearance for Surgery 2 As a medical consultant, generally avoid the phrase clear for surgery. Cardiologists & surgeons felt it was important to clear pt for surgery, anesthesiologists did not. It is the anesthesiologist s duty to recommend type of anesthesia not yours. Anesthesiologists felt it was unimportant for consultant to recommend type of anesthesia, cardiologists & surgeons disagreed. What Should You Consider in Preop Evaluation? My approach = the 4 C s: Conditioning (general condition of pt) Cardiac Chest (lungs) Clots (VTE prophylaxis) AnesthAnalg 1998;87:830-6 What Should You Consider in Preop Evaluation? My approach = the 4 C s: Conditioning (general condition of pt) Cardiac Conditioning 1 MET = metabolic demand at rest. Increased perioperative risk in pts unable to perform at 4 METs. Walk up 2 flights of stairs. Run a short distance. Walk up a hill 1 2 blocks. Carry 2 bags of groceries up 1 flight of stairs. Walk 2 4 blocks (flat). Simple questions on history. AmJCardiol 1989;64:651-4; 4; Circulation 2009;120:e169-e276; e276; ArchIM 1999;159: ; 92; Chest 2001;120: Risky Business Trivia Bob Seger s 1 st Billboard- Charted Song 1. Old Time Rock & Roll 2. Ramblin Gamblin Man 3. Get Out of Denver 4. Katmandu 25% 25% 25% 25%

3 Does Age Matter? Maybe. Older studies found risk w/ age. Recent studies found mortality & pulmonary morbidity w/advancing age. Other studies have not found mortality. After adjusting for other morbidities, impact of age is relatively small. Avoid ageism: age alone is not a reason to withhold surgery. Speaking of General Condition What about labs? NEJM 1977;297:845-50; 50; AnnSurg 1982;195:90-6; EffClinPract 2001;4:172-7; 7; AnnIM 2006;144:581-95; JAMA 1989;261: ; 15; AnnIM 2001;134:637-43; 43; MedClinNorthAm 1993;77: Which Should Be Ordered as Routine Preop Lab? 1. CBC 2. Coag Studies 3. Basic Chem Panel 4. EKG 5. Other Routine Preop Testing BC Electrolytes, glc, Cr EKG XR PT/PTT Preop Testing vs None Ambulatory surgery pts: no difference in perioperative adverse events. ataract surgery: no difference. holecystectomy (teaching hospital): 2.1% of tests abnormal & potentially significant, 0.66% resulted in action, 0.16% benefitted from preop management changes. AnesthAnalg 2009;108:467-75; 75; Cochrane Database Syst Rev. 2012;3:CD007293; ArchIM 1987;147: Preop Testing vs None 2 Elective surgery: 60% of tests not needed; 0.22% w/abnormality possibly affecting periop management, none of these were acted on & no adverse consequences. Elective surgery, asymptomatic pts: 4.2% of tests abnormal (18.8% predictable by H&P), 29.4% of these (1.2% of all pts) prompted more eval 0.26% of all pts required treatment, no surgeries delayed, no association between lab abnormality and adverse outcome. JAMA 1985;253: ; 81; MayoClinProc 1991;66:

4 Preop Testing vs None 3 Review of studies of preop testing: Normal test does not reduce chance of postop complications for nearly all tests evaluated. Exceptions: + LR 3 4 (small increase in likelihood of disease if test is +) only for electrolytes, Hgb, renal function. Clinical evaluation predicts most abnormalities. Preop management changed by test result in only 0 3% of cases. MedClinNorthAm 2003;87:7-40; What About Coags? Unexpected & clinically significant bleeding disorders are unusual. Most bleeding disorders are evident on history. Most common reasons for PTT are mild factor XII deficiency & lupus anticoagulant neither is assoc d w/bleeding or postop complications. JAMA 1985;253: ; 81; BrJAnaesth 2011;106:1-3; ClinApplThrombHemost 2004;10: ; 204; ArchIM 1995;155: ; 15; JThrombHaemost 2006;4:766 73; 73; JAMA 1986;256:750-3; CanJAnaesth. 2006;53(6 Suppl):S12-20; 20; MedClinNorthAm 2003;87:7-40 What About Coags? 2 History or questionnaire is at least as accurate as lab tests to predict clinically significant bleeding. Routine Preop Testing Routine preoperative testing in asymptomatic patients is not indicated (even PT/PTT). Selective preop testing based on likelihood of underlying condition that might affect perioperative management. HOWEVER: know your local surgeons patterns and practices. You are not likely to change them, so make sure your pts get the care they need. Assessment of Cardiac Risk ardiovascular complications are the most common & serious perioperative complications. Pts > 40 yo (unselected): 1.4% periop MI. Pts w/some CV risk factors: 3.2% periop MI. Pts w/pad: RR 3.1 for all-cause mortality, 5.9 for CV mortality, 6.6 for death d/t CAD. 1/3 of periop deaths are due to cardiac causes. Chest 2006;130: ; 596; NEJM 2001;345: ; AnnIM 2011;154:523-8; Anesthesiology 1998; 88: ; 578; AmJSurg 1997;174:755-8; MedClinNorAm 2001;85: ; N EJM 1995;333:1750-6; ; N EJM 1992;326:381-6; 6; surgery?source=search_result&search=preop+eval&selectedtitle=1~150#h21 Assessment of Cardiac Risk 2 30 million surgeries/yr in US. >8 million w/cv risk factors or CAD. 50,000 periop MI s. Most (74%) occur within 48 hrs of surgery. Most pts (65%) did not have ischemic sx. Difficult to diagnose % mortality. Prevention is important. Chest 2006;130: ; 596; NEJM 2001;345: ; AnnIM 2011;154:523-8; Anesthesiology 1998; 88: ; 578; AmJSurg 1997;174:755-8; MedClinNorAm 2001;85: ; N EJM 1995;333:1750-6; ; N EJM 1992;326:381-6; 4

5 Revised Cardiac Risk Index (RCRI) 20 years after the original Goldman risk index, a simplified method for determining cardiac risk in noncardiac surgery. Derived & validated in original study (1999). Validated at another institution (2010). Limitations: Less accurate for vascular noncardiac surgery, esp AAA. Predicts cardiac, but not all-cause, mortality (it s a cardiac index duh!). RCRI 2 Easy to use. ACC/AHA finally incorporated RCRI into its algorithm for preop eval. Easy to remember. Circulation 1999;100:1043-9; 9; AnnIM 2010;152:26-35; ; CMAJ 2005;173: D R RCRI Mnemonic Which is NOT Part of the RCRI (DR C 4 )? 1. Diabetes 2. Dysrhythmia 3. CAD 4. Cerebrovascular Dz 25% 25% 25% 25% David M Schneider, MD D R RCRI Mnemonic David M Schneider, MD RCRI Mnemonic Diabetes requiring insulin Risky surgery (intrathoracic, vascular) (intrathoracic, intraperitoneal, AD (including + test, EKG, etc) HF erebrovascular dz hx r > 2.0 David M. Schneider, MD Circulation 1999;100:

6 RCRI Interpretation ount the risk factors to estimate cardiac mortality! 0 0.4% [<1%] 1 1.0% [1%] % [5%] 3 or more % [10%] Some later studies had higher death rates, but similar predictive value of increasing RCRI score. Circulation 1999;100: ; CMAJ 2005;173: RCRI Predicts CV Morbidity, Too VFib/Cardiac arrest omplete heart block MI Pulmonary edema Circulation 1999;100: Risky Business Trivia 2 Curtis Armstrong Played Joel s Friend Miles in Risky Business. His Next Role? 1. Goov (Clan of Cave Bear) 2. Herbert Quentin Burt Viola (Moonlighting) 3. Booger (Revenge of Nerds) 4. Ronnie (Coneheads) 25% 25% 25% 25% Steps to Eval of CV Risk in Surgical Pts ACC/AHA updated guideline, A bit cumbersome, but mostly manageable. E A R L I Mnemonic for Steps in ACC Algorithm (i.e., early eval for CV dz) David M Schneider, MD 6

7 Mnemonic for Steps in ACC Algorithm Emergency? Active cardiac conditions? Risk of surgical procedure Limitation (functional capacity) Index (RCRI) In Other Words 5 steps: 1. Is surgery an emergency? 2. Does pt have active cardiac conditions? 3. Is it a low risk surgery? 4. Does pt have good functional capacity? 5. What clinical or surgery-related related risk factors does pt have by the RCRI? David M Schneider, MD Step 1 Does the surgery need to be done emergently? Yes go to OR! Perioperative surveillance. Postop risk stratification & management. No go to step 2. 25% 25% Which Active Cardiac Condition is NOT a Contraindication to Surgery? 25% 1. Unstable angina 25% 2. Decompensated CHF 3. Symptomatic Aortic Stenosis 4. 2 AV Blk Type I (Wenkebach) Step 2 Are there active cardiac conditions? Acute/unstable coronary syndromes Blocks/arrhythmias CHF Severe stenoses Yes evaluate & treat per ACC guideline. No go to step 3. Active Cardiac Conditions Acute/unstable coronary syndromes Unstable or severe angina (NYHA/CCS III or IV). Acute or recent MI (within 30 days). May include stable angina in patients who are unusually sedentary. 7

8 Grading Angina Active Cardiac Conditions 2 anadian CV Society 1. Sx only w/strenuous activity 2. Sl limitation sx w/vigorous activity 3. Mod limitation sx w/everyday living activities 4. Severe limitation sx w/any activity rest NYHA 1. No limitation of activity no sx w/ ordinary activity 2. Sl limitation sx w/ordinary activity 3. Mod limitation sx w/less-than-ordinary activity 4. Severe limitation sx w/any activity rest Blocks/significant arrhythmias: High-grade grade AV block. Mobitz II AV block. Third-degree degree AV heart block. Symptomatic ventricular arrhythmias. Supraventricular arrhythmias (including atrial fib) w/uncontrolled ventricular rate (HR > rest). Newly recognized ventricular tachycardia. Symptomatic bradycardia. Active Cardiac Conditions 3 Decompensated Congestive heart failure NYHA class IV Worsening or new onset HF Severity of CHF NYHA Class I - symptoms of HF only at activity levels that would limit normal individuals. Class II - symptoms of HF with ordinary exertion. Class III - symptoms of HF with less than ordinary exertion. Class IV - symptoms of HF at rest. Same scale as NYHA angina grading (or CCS). Active Cardiac Conditions 4 Severe valvular disease Severe aortic stenosis Symptomatic mitral stenosis (progressive DOE, exertional presyncope, HF) Step 3 Risk of surgery Low risk surgery proceed to OR. Not low risk go to step 4. 8

9 Which is a Low Risk Surgery? Risks of Surgery 1. Mastectomy 2. Tonsillectomy 3. Total Knee Replacement 4. Appendectomy 25% 25% 25% 25% High risk (>5% CV events): Aortic and other major vascular surgery Peripheral vascular surgery Intermediate risk (1-5%): Intraperitoneal and intrathoracic surgery Carotid endarterectomy Head and neck surgery Orthopedic surgery Prostate surgery AmJMed 2005;118, ; 1141; Circulation 2009;120:e169-e276; e276; EurHeartJ 2009;30: Risks of Surgery 2 Low risk surgery (<1% CV events) generally no additional CV testing required: Ambulatory surgery Breast surgery Cataract surgery Derm/Superficial procedure Endoscopic procedures Step 4 Functional Limitation: Functional capacity 4 METs w/o sx go to OR. Functional capacity < 4 METs w/o sx go to step 5. Walk up 2 flights of stairs. Walk 2 4 blocks (flat). Step 5 Here is where the RCRI comes in. Score 0 go to OR. Score 1 2 either: Surgery w/possible β-blocker if it will change mgmt. Consider noninvasive testing. Score 3: Vascular surgery consider further testing (if it will change management) & β-blocker. Intermediate risk surgery surgery w/possible β- blocker OR consider noninvasive testing. RCRI Mnemonic Diabetes requiring insulin Risky surgery (intrathoracic, vascular) (intrathoracic, intraperitoneal, AD (including + test, EKG, etc) HF erebrovascular dz hx r > 2.0 David M. Schneider, MD Circulation 1999;100:

10 25% Who Should Get β-blocker? 25% yo F carotid endarterectomy 25% yo M colonoscopy yo F already on β-blocker 25% Mastectomy yo M liver transplant (no GIB) Surgery w/β-blocker vs More Testing Insufficient data. 1-2 risk factors: 2 studies in vasc surg pts showed no difference in outcomes. 3 risk factors: Degree of cardiac stress (change in HR, BP, vascular volume, pain, bleeding, clotting tendencies, oxygenation, neurohumoral activation, other) may help determine risk of periop cardiac events & need for testing. JCardiothoracVas Anesth 2003;17:694-8; JACC 2006;48:964-9 Perioperativeβ-Blockers onflicting early data: 1996: Periop atenolol mortality & CV complications for 2 yrs in pts w/cad or CAD risk. Above study of? validity small # s, risk factors & meds not identical. DECREASE, 1999: preop bisoprolol MI & CV events by 90%.? Validity small # s, unblinded, stopped early. β -blocker evidence considered unreliable. Perioperativeβ-Blockers : No benefit in DM pts. Periop β-blockers in-hosp mortality only in high risk pts. NEJM 1996;335: ; N EJM 1996;335:1761-3; 3; AmJMed 2005;118:1413; NEJM 1999;341: ; 94; EurHeartJ 2001;22:1353-8; JAMA 2005;294:2203-9; 9; BMJ 2005;331: BMJ 2006;332:1482; NEJM 2005;353: POISE Study Large RCT, 8351 pts w/atherosclerosis or risk. High dose metoprolol succinate vs placebo. Hold for HR < 50 or SBP < 100. Combined endpoint CV death, nonfatal MI, or nonfatal cardiac arrest. 16% in 1 endpoint, ARR = 1.1% NNT = 91. MI by 27%, ARR = 1.5% NNT = 67. Total mortality 33%, NNH = 125. CVA 117%, NNH = 200. Hypotension 55%, NNH = 19. Lancet 2008;371: More on β-blockers Only 2% in POISE had RCRI 3.?? benefit. Meta-analysis analysis 2008: No all-cause mortality, CV mortality, HF. 35% nonfatal MI (NNT=63). Doubling in nonfatal strokes (OR=2.01, NNH=293). Other risks: Periop bradycardia: NNH = 22. Periop hypotension: NNH = 17. No increased risk of bronchospasm. Lancet 2008;372:

11 ACC/AHA Recs on β-blockers lass I (benefit >> risk), intervention should be done: Continueβ-Blockers in pts already taking (LOE C = consensus opinion, limited studies). ACC/AHA Recs on β-blockers 2 lass IIa (benefit > risk, more studies needed, reasonable to do intervention), LOE B (limited info, 1 RCT or some unrandomized): Beta blockers titrated to HR & BP probably recommended for pts undergoing vascular surgery who are at high cardiac risk d/t CAD or cardiac ischemia on preoperative testing. Circulation 2009;120:e169-e276; e276; JAMA 2001;285: ; 1873; NEJM 1999;341: ; Ann Surg 2009;249:921 6 ACC/AHA Recs on β-blockers 3 lass IIa (benefit > risk, more studies needed, reasonable to do intervention), LOE B (limited info, 1 RCT or some unrandomized): Beta blockers titrated to HR & BP are reasonable for patients undergoing intermediate-risk risk surgery in whom preoperative assessment identifies CAD or RCRI > 1. ACC/AHA Recs on β-blockers 4 lass IIa (benefit > risk, more studies needed, reasonable to do intervention), LOE C (consensus opinion, limited studies): Beta blockers titrated to HR & BP are reasonable for pts in whom preoperative assessment for vascular surgery identifies high cardiac risk, as defined by RCRI > 1. Circulation 2009;120:e169-e276; e276; JAMA 2001;285: ; 1873; NEJM 1999;341: ; Ann Surg 2009;249:921 6 ACC/AHA Recs on β-blockers 4 lass IIb The usefulness of beta blockers is uncertain for pts who are undergoing either intermediate-risk risk procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor in the absence of coronary artery disease. (LOE C) The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers. (LOE B) Summary on β-blockers ontinue β-blockers in pts already taking them. Probably: Pts w/cad on preop testing (or known hx) undergoing vascular surgery. onsider: Pts w/known CAD or RCRI > 1 undergoing intermed risk surgery. RCRI >1 in undergoing vascular surgery. 11

12 How to Use β-blockers β-1 1 selective preferred. Atenolol may be superior to metoprolol. 1 study did not differentiate between metoprolol tartrate (regular) & succinate (sustained release). Other study included pts on both metoprolol forms. POISE used metoprolol succinate. Bisoprolol more selective, no comparative data. When to Give β-blockers Begin poβ-blockers at least 7 30 days before surgery, if possible, to enhance efficacy. IV β-blockers (atenolol > metoprolol) may be given shortly before surgery. BMJ 2005;331:932-8; Anesthesiology 2011;114:824-36; NEJM 1999;341: ; 94; JACC2010;56:1922-9; 9; Am HeartJ 2006;152:983-90; 90; Lancet 2008;371: Who Should Get Preop EKG? Who Should Get Preop EKG? 1. Nobody 2. Everybody yo M smoker + low risk surg 4. Known CAD + intermed risk surg 25% 25% 25% 25% lass I Recommended for pts RCRI 1 who are undergoing vascular surgical procedures LOE B). Recommended for pts w/known CHD, PAD, or cerebrovascular disease who are undergoing intermediate-riskrisk surgical procedures (LOE C). lass IIa Reasonable in persons with no clinical risk factors who are undergoing vascular surgical procedures. (LOE B). Maybe Preop EKG? lass IIb Preoperative resting 12-lead ECG may be reasonable in patients with RCRI 1 who are undergoing intermediate-riskrisk operative procedures (LOE B). lass III Preoperative and postoperative resting 12- lead ECGs are not indicated in asymptomatic persons undergoing low-risk surgical procedures (LOE B). Controversy: Another View 2009 retrospective study reviewed EKG s, 5 predictors of significantly abnormal EKG : Risk Factor Sensitivity 87.6%, specificity 59.5%. OR CHF Angina 7.49 MI 6.16 Severe valvular dz 4.80 Age > High cholesterol 2.26 Anesthesiology 2009;110:

13 What s Wrong With This Data? 1. It s Disease-Oriented Evidence 2. Retrospective Study 3. Not Pt-Oriented Evidence that Matters 4. Predict EKG findings, not pt outcomes 5. All the above Noninvasive Stress Testing lass I Pts w/active cardiac conditions in whom noncardiac surgery is planned eval eval & Tx per ACC/AHA guidelines (LOE B). lass IIa Pts w/3 or more clinical risk factors (RCRI) and poor functional capacity (less than 4 METs) who require vascular surgery reasonable if it will change management (LOE B). Noninvasive Stress Testing 2 lass IIb Noninvasive stress testing may be considered for patients with at least 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. (Level of Evidence: B) Noninvasive Stress Testing 3 NOTE: stress testing has high NPV (90+%), low PPV (6 67%, 18% in one review). Useful in predicting low risk if neg. Not as useful identifying high risk if +. Circulation 2009;120:e169-e276; e276; NEJM 1995;333:1750-6; Circulation 2006;113: Echocardiography Reasonable (Class IIa, LOE C): Dyspnea of unknown etiology. Current or prior CHF w/worsening dyspnea or other change in clinical status if LV function has not been assessed within last 12 months. Summary Higher risk more preop testing and more treatment (β-blockers). Pt risk factors Risk of surgery Cards consult: Acute cardiac condition. High risk surg + intermed risk pt, or vice versa. If you are not sure or comfortable. 13

14 ACC says: Class I Perioperative Statins Continue statins in pts currently on statin and scheduled for noncardiac surgery (LOE B). Class IIa For pts undergoing vascular surgery with or without clinical risk factors, statin use is reasonable (LOE B). Class IIb For pts w/at least 1 clinical risk factor who are undergoing intermediate-risk risk procedures, statins may be considered (LOE C). Perioperative Statins Evidence says: Statins may prevent A Fib in pts undergoing cardiovascular & non-cardiac surgery. 40% reduction in A Fib, even in pts already on β-blockers. Statins reduce periop mortality, MI, ischemia. Some conflicting evidence. These are high risk pts consistent w/acc rec. Tune in again next time. NEJM 2009;361:980-9; JVascSurg 2004;39:967-75; 75; JAMA 2004;291:2092-9; 9; Circulation 2003;107: ; JACC 2005;45:336-42; 42; AmJCardiol 2007;100:316-20; 20; JThorCardiovasc Surg 2008;135: ; 411; AnnThorCardiovascSurg 2011;17:376-82; ArchSurg 2012;147: CV Risk Assessment: Not Quite Ready For Prime Time NSQIP (Nat l Surgical Qual Improvement Prog) Large retrospective study, internally validated. Type of surgery Dependent functional status Abnormal creatinine American Society of Anesthesiologists' class Age Performed better than RCRI. Online calculator: diacarrest Circulation.2011;124:381-7; CV Risk Assessment: Not Quite Ready For Prime Time 2 Erasmus index Same as RCRI, adds age Retrospective, not yet validated. Ankle-Brachial Index (ABI) High risk population (19% DM, 14% CAD). ABI performed similarly to RCRI. Abnormal ABI OR of for cardiac complication. AmJMed 2005;118: ; 1141; AnesthAnalg 2008;107: Case 1 You are called at 0200 by a surgeon to see a pt with abdominal pain. The surgeon tells you the pt is an 86 yo white male with CHF with RLQ abdominal pain, tenderness at McBurney s point, and a fever to CBC shows WBC of Surgeon: Please clear this pt for surgery. I think I should wait until the morning and have cardiology do an echo. 33% 86 yo M w/h/o CHF & Appy sx/sx echo? 33% 1. Yes echo echo only 33% 2. Yes echo echo + Cardio eval 3. No 14

15 Let s Make it Crystal Clear CT shows inflamed appendix In Other Words 5 steps: 1. Is surgery an emergency? 2. Does pt have active cardiac conditions? 3. Is it a low risk surgery? 4. Does pt have good functional capacity? 5. What clinical or surgery-related related risk factors does pt have by the RCRI? In Other Words 5 steps: 1. Is surgery an emergency? YES go to OR! What Have We Learned? 1. Functional limitations (4 METs) 2. Ageism 3. Preop labs 4. Preop CV risk assessment 1. RCRI 2. ACC guidelines ( EARLI ) 3. Active cardiac conditions 4. Risks of surgeries 5. Preop EKG s What Have We Learned? 2 5. Periop management 1. Β-blockers 2. Statins 3. Preop cardiac testing What Should You Sometimes Say, per Miles? 1. The question isn't "what are we going to do," the question is "what aren't we going to do? 2. College women can smell ignorance 3. Sometimes you gotta say, What 33% 33% 33%