how to keep your surgeon out of trouble: … mortality probability model ... it is reasonable for...
TRANSCRIPT
![Page 1: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/1.jpg)
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
![Page 2: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/2.jpg)
How to Make Your Surgeon
Happy
![Page 3: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/3.jpg)
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.
![Page 4: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/4.jpg)
How to Keep Your Surgeon Out of
Trouble:
![Page 5: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/5.jpg)
Impossible
![Page 6: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/6.jpg)
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
![Page 7: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/7.jpg)
Definition of the
Medical Consultant
![Page 8: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/8.jpg)
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
![Page 9: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/9.jpg)
Clinical Recommendations
Special considerations
Biomarkers
Hypertension
PCI
Statins
Beta Blockers
Summary
Definition of the medical consultant
Perioperative Medicine
![Page 10: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/10.jpg)
10 million major noncardiac surgery
4 million in patients ≥65 years
High risk account for 80% of death
250 million procedures worldwide
![Page 11: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/11.jpg)
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.
![Page 12: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/12.jpg)
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
![Page 13: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/13.jpg)
Ghareri AA, et al. N Engl J Med 2009;361:1368-1375.
Rates of All Complications, Major Complications,
and Death after Major Complications
![Page 14: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/14.jpg)
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
![Page 15: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/15.jpg)
Hospital-specific rates of preoperative medical
consultation for major elective noncardiac surgery
Wijeysundera DN, et al. Anesthesiology 2012;116:25-34.
![Page 16: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/16.jpg)
Associations Between Perioperative Consultation,
Quality of Care, and Subsequent Complications
Auerbach AD, et al. Arch Intern Med 2007;167:2338-2344.
![Page 17: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/17.jpg)
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
![Page 18: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/18.jpg)
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
![Page 19: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/19.jpg)
Pathophysiology
![Page 20: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/20.jpg)
Emotional stress
Pain
Surgical trauma
Tissue injury
Hypothermia
Hypoxemia
Immobility
Bleeding and anemia
Fasting
![Page 21: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/21.jpg)
Landesberg G et al. Circulation 2009;119:2936-2944.
![Page 22: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/22.jpg)
Landesberg G et al. Circulation 2009;119:2936-2944.
![Page 23: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/23.jpg)
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
![Page 24: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/24.jpg)
Risk Prediction Models
![Page 25: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/25.jpg)
Revised Cardiac Risk Index
![Page 26: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/26.jpg)
Lee TH, et al. Circulation 1999;100:1043-1049.
![Page 27: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/27.jpg)
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
![Page 28: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/28.jpg)
Thoracic Revised Cardiac
Risk Index
![Page 29: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/29.jpg)
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.
![Page 30: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/30.jpg)
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)
![Page 31: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/31.jpg)
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
![Page 32: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/32.jpg)
Vascular Study Group of
New England(VSG-CRI)
![Page 33: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/33.jpg)
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
![Page 34: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/34.jpg)
Surgical Mortality Probability
Model
![Page 35: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/35.jpg)
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.
![Page 36: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/36.jpg)
S-MPM Scoring System for Estimating Risk of 30-Day
Mortality After Noncardiac Surgery
Glance LG, et al. Ann Surg 2012;255:696-702.
![Page 37: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/37.jpg)
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%
Glance LG, et al. Ann Surg 2012;255:696-702.
![Page 38: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/38.jpg)
Risk Calculator for Prediction
of Cardiac Risk After Surgery
![Page 39: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/39.jpg)
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.
![Page 40: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/40.jpg)
Clinical Recommendations
![Page 41: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/41.jpg)
CCS ACC/
AHA ESC HFSA
![Page 42: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/42.jpg)
CCS ACC/AHA ESC HFSA
![Page 43: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/43.jpg)
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
![Page 44: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/44.jpg)
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.
![Page 45: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/45.jpg)
Electrocardiogram
![Page 46: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/46.jpg)
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.
![Page 47: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/47.jpg)
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.
Fleisher LA, et al. Circulation 2009;120:e169-e276.
![Page 48: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/48.jpg)
Feely MA, et al. Am Fam Physician 2013;87(6):414-8.
Suggested algorithm for performing preoperative
electrocardiography
![Page 49: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/49.jpg)
Echocardiography
![Page 50: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/50.jpg)
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)
![Page 51: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/51.jpg)
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.
Fleisher LA, et al. Circulation 2009;120:e169-e276.
![Page 52: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/52.jpg)
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.
Fleisher LA, et al. Circulation 2009;120:e169-e276.
![Page 53: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/53.jpg)
Stress Testing
![Page 54: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/54.jpg)
Wijeysundera DN, et al. BMJ 2010;340:b5526.
Association of preoperative stress testing with one year
survival in the subgroup analyses
![Page 55: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/55.jpg)
Active Cardiac Conditions for Which the Patient
Should Undergo Evaluation and Treatment Before
Noncardiac Surgery
Fleisher LA, et al. Circulation 2009;120:e169-e276.
Unstable coronary symptoms
Decompensated HF (NYHA functional
class IV: worsening or new-onset HF)
Significant arrythmias
Severe valvular disease
![Page 56: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/56.jpg)
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.
Fleisher LA, et al. Circulation 2009;120:e169-e276.
![Page 57: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/57.jpg)
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.
Fleisher LA, et al. Circulation 2009;120:e169-e276.
![Page 58: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/58.jpg)
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
![Page 59: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/59.jpg)
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
![Page 60: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/60.jpg)
Biomarkers
![Page 61: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/61.jpg)
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.
![Page 62: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/62.jpg)
Postoperative BNP Thresholds and the Incidence of Mortality
or Nonfatal MI at 30 Days after Surgery
Rodseth et al. Anesthesiology 2013;119:270-83.
![Page 63: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/63.jpg)
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.
![Page 64: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/64.jpg)
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)
![Page 65: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/65.jpg)
Le Manach, et al. Anesthesiology 2005;102:885-891.
![Page 66: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/66.jpg)
Le Manach, et al. Anesthesiology 2005;102:885-891.
![Page 67: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/67.jpg)
Kikura M, et al. J Thromb Haemost 2008;6:742-748.
![Page 68: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/68.jpg)
Kikura M, et al. J Thromb Haemost 2008;6:742-748.
![Page 69: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/69.jpg)
Statins
![Page 70: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/70.jpg)
Effect of perioperative statins on myocardial
infarction, atrial fibrillation, and death.
Chopra V, et al. Arch Surg 2012;147(3):181-9.
![Page 71: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/71.jpg)
Effect of perioperative statins on hospital and intensive
care unit length of stay.
Chopra V, et al. Arch Surg 2012;147(3):181-9.
![Page 72: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/72.jpg)
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.
![Page 73: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/73.jpg)
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.
![Page 74: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/74.jpg)
PCI
![Page 75: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/75.jpg)
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.
![Page 76: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/76.jpg)
Fleisher LA, et al. Circulation 2009;120:e169-e276.
Proposed approach to the management of patients
with previous PCI requiring noncardiac surgery
![Page 77: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/77.jpg)
Fleisher LA, et al. Circulation 2009;120:e169-e276.
Proposed treatment for patients requiring
percutaneous coronary intervention (PCI) who need
subsequent surgery
![Page 78: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/78.jpg)
Perioperative Hypertension
![Page 79: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/79.jpg)
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)
![Page 80: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/80.jpg)
Consider lowering the dose of ACE
inhibitors or AR antagonist 24 hours ( at
least 10 hours) before surgery
![Page 81: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/81.jpg)
Perioperative Beta Blockers
![Page 82: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/82.jpg)
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.
![Page 83: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/83.jpg)
Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:1839-47.
Kaplan-Meier estimates of the primary outcome (A),
myocardial infarction (B), stroke (C) and death (D)
![Page 84: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/84.jpg)
Metoprolol
(n = 4179)
Placebo
(n = 4177)
Death 129 79 32
Strokes 41 19 32
Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:1839-47.
![Page 85: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/85.jpg)
Perioperative Ischemic Evaluation Study (POISE) Group. Lancet 2008;371:1839-47.
.
Meta-analysis of β-blocker trials in patients undergoing non-
cardiac surgery
![Page 86: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/86.jpg)
Comparison of effect of perioperative β-blockade on non-
fatal strokes in secure and non-secure trials.
Bouri S et al. Heart 2013.
![Page 87: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/87.jpg)
Meta-analysis of nine secure randomised controlled trials
showing a significant increase in mortality with
perioperative β-blockade.
Bouri S et al. Heart 2013.
![Page 88: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/88.jpg)
Prevalence of hypotension in β-blocker and control
groups.
Bouri S et al. Heart 2013.
![Page 89: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/89.jpg)
Thirty-Day Mortality Propensity Model
London MJ, et al. JAMA 2013;309(16):1704-13.
![Page 90: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/90.jpg)
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.
![Page 91: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/91.jpg)
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
![Page 92: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/92.jpg)
Fleisher LA. Cleve Clin J Med 2009;76:S9-15.
![Page 93: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/93.jpg)
Fleisher LA. Cleve Clin J Med 2009;76:S9-15.
![Page 94: How to Keep Your Surgeon Out of Trouble: … Mortality Probability Model ... It is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical](https://reader031.vdocuments.mx/reader031/viewer/2022030511/5abbf2c97f8b9a321b8d7685/html5/thumbnails/94.jpg)
Medical Consultant
Provide informed clinical judgment based on
knowledge, experience and the individual
patient’s data to optimize short and long term
outcomes.