Optimizing the surgical patientDana Doll D.O.

Chair of AnesthesiaSt Michaels Hospital

Stevens Point, WI

40 million anesthetics are administered each year in this country. Anesthesiologists provide or participate in more than 90 percent of these anesthetics

10 percent of the United States population undergoes non-cardiac surgery annually.

Over 8 million have known CAD or cardiac risk factors.

Over 50,000 will suffer a perioperative myocardial infarction. (0.2%)

Surgery statistics

What are You Really Being Asked to Do?

Assess risks of anesthesia Assess the risks of the procedure Manage “complicated” medical problems Predict the future

Review the AHA/ACC guidelines for the cardiac evaluation for a non-cardiac surgery

Discuss OSA and anesthesia Discuss NPO status Medications to have and to hold Expectations for surgical procedures Anesthesia planning

objectives

ASA Physical Status Classification System

For emergent operations, you have to add the letter ‘E’ after the classification.

Surgical risk

“The purpose of preoperative evaluation is not to give medical clearance, but rather to perform an evaluation of the patient’s current medical status; make recommendations concerning the evaluation, management, and risk of cardiac problems over the entire perioperative period; and provide a clinical risk profile that the patient, primary physician, anesthesiologist, and surgeon can use in making treatment decisions…”

Kim A. Eagle, FACC, Chair, ACC/AHA Task Force on Practice Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular

Evaluation and Care for Noncardiac Surgery

The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context.

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular

Evaluation and Care for Noncardiac Surgery

Optimizing the patient is optimizing the oxygen supply and demand. HR and BP control

Slower less O2 demand Lower BP less work for heart less o2 demand

Respiratory optimization Less O2 dissolved less to deliver Pulmonary HTN to CHF

Renal optimization Acidosis Fluid overload

Hematologic optimization O2 carrying capacity

Neurologic optimization Cushing reflex

Cardiac optimization

Cardiac evaluation and care algorithm for noncardiac surgery

Cardiac evaluation and care algorithm for noncardiac surgery

Unstable coronary syndromes Recent MI Decompensated HF Significant arrhythmiasSevere valvular disease

Cardiac evaluation and care algorithm for noncardiac surgery

Endoscopic proceduresSuperficial procedureCataract surgeryBreast surgeryAmbulatory surgery

Cardiac evaluation and care algorithm for noncardiac surgery

Cardiac evaluation and care algorithm for noncardiac surgery

History Of Ischemic Heart DiseaseHistory Of Compensated Or Prior HFHistory Of Cerebrovascular DiseaseDiabetes MellitusRenal Insufficiency

Pre operative testing

Assessment of LV Function Recommendations for Preoperative Noninvasive

Evaluation of LV Function Class IIa

Dyspnea of unknown origin ( Level of Evidence: C ) Current or prior HF with worsening dyspnea if not

performed within 12 months. ( Level of Evidence: C ) Class IIb

Stable patients with previously documented cardiomyopathy ( Level of Evidence: C )

Class III Routine perioperative evaluation ( Level of Evidence: B )

Echocardiography

Resting 12-Lead ECG Class I

1 clinical risk factor undergoing vascular procedures. (Level of Evidence: B)

known CAD, peripheral arterial disease, or cerebrovascular disease undergoing intermediate-risk procedures. ( Level of Evidence: C )

Class IIa no clinical risk factors undergoing vascular surgical

procedures. (Level of Evidence: B ) Class IIb

1 clinical risk factor and undergoing intermediate-risk procedures. (Level of Evidence: B )

Class III asymptomatic persons undergoing low-risk procedures. (Level

of Evidence: B )

EKG

Noninvasive Stress Testing Class I

Active cardiac conditions in whom surgery is planned should be evaluated and treated per ACC/AHA guidelines before surgery. (Level of Evidence: B)

Class IIa 3 or more clinical risk factors and poor functional capacity (less than 4

METs) undergoing vascular surgery if it will change management. (Level of Evidence: B)

Class IIb 1 to 2 clinical risk factors and poor functional capacity (less than 4 METs)

undergoing intermediate-risk or vascular surgery if it will change management. (Level of Evidence: B)

Class III No clinical risk factors undergoing intermediate-risk surgery. ( Level of

Evidence: C ) Low-risk surgery. ( Level of Evidence: C )

Noninvasive Stress Testing

Beta-Blocker Medical Therapy Class I

Receiving beta blockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA class I guideline indications. ( Level of Evidence: C )

Vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing. ( Level of Evidence: B )

Class IIa Vascular surgery in whom preoperative assessment identifies CAD.

( Level of Evidence: B ) vascular and 1 clinical risk factor. (Level of Evidence: B) CAD or 1 clinical risk factor, who are undergoing intermediate-risk or

vascular surgery. (Level of Evidence: B) Class IIb

Intermediate-risk procedures or vascular surgery, in whom preoperative assessment identifies a single clinical risk factor. (Level of Evidence: C)

Vascular surgery with no clinical risk factors who are not currently taking beta blockers. ( Level of Evidence: B )

Class III Absolute contraindications to beta blockade. ( Level of Evidence: C )

Who gets Beta Blockers?

Recommendations for Statin Therapy Class I

currently taking statins and scheduled for noncardiac surgery ( Level of Evidence: B )

Class IIa vascular surgery (Level of Evidence: B )

Class IIb 1 clinical risk factor undergoing intermediate-

risk procedure (Level of Evidence: C )

Who gets statins?

CABG or Percutaneous Coronary Intervention Class I

Any person who meets criteria according to ACC/AHA guidelines for revascularization ( Level of Evidence: A )

Class IIa Revascularization with PCI for mitigation of cardiac symptoms and elective noncardiac

surgery in the subsequent 12 months, balloon angioplasty or bare-metal stent placement followed by 4 to 6 weeks of dual-antiplatelet therapy. ( Level of Evidence: B )

drug-eluting coronary stents and who must undergo urgent surgical procedures that mandate the discontinuation of thienopyridine therapy, it is reasonable to continue aspirin if at all possible and restart the thienopyridine as soon as possible. ( Level of Evidence: C )

Class IIb High-risk ischemic patients (e.g., abnormal dobutamine stress echocardiograph with at

least 5 segments of wall-motion abnormalities). ( Level of Evidence: C ) low-risk ischemic patients with an abnormal dobutamine stress echocardiograph

(segments 1 to 4). ( Level of Evidence: B ) Class III

Prophylactic coronary revascularization in patients with stable CAD before noncardiac surgery. ( Level of Evidence: B )

Elective noncardiac surgery within 4 to 6 weeks of bare-metal coronary stent implantation or within 12 months of drug-eluting coronary stent implantation in patients in whom thienopyridine therapy, or aspirin and thienopyridine therapy, will need to be discontinued perioperatively. (Level of Evidence: B )

Elective noncardiac surgery is not recommended within 4 weeks of coronary revascularization with balloon angioplasty. ( Level of Evidence: B )

Who gets coronary revascularization?

A.T. Still

Labs

Formal spirometry rarely indicated Subjective response to bronchodilators Detailed H&P

Smoking cessation 24 hours will decrease carboxyhemoglobin levels 2-3 days will increase ciliary function but increase secretions 1-2 weeks will decrease secretions 4-8 weeks will decrease postop pulmonary complications relative risk of pulmonary complications among smokers as

compared with nonsmokers ranges from 1.4 to 4.3

Pulmonary

Prevalence of sleep disordered breathing is 9% in women and 24% in men

Overt OSA has been estimated to be 2% in women and 4% in men

OSA is an independent risk factor for perioperative pulmonary complications

Case report demonstrates hemodynamic changes associated with apneic episodes

Pulse increase of up to40 bpm coinciding with hypoxia Similar increases in SBP with levels above 180 mmHg coinciding with

arousal Hemodynamic instability did not respond to supplemental oxygen

but resolved with CPAP Postoperative nocturnal hypoxia precipitated myocardial

ischemia in patients undergoing major vascular surgery

OSA

Length of Stay 7.2 days in patients with Obstructive Sleep Apnea not

using CPAP 6.0 days if patients on CPAP 5.1 days for patients in the control group

Unplanned transfer to the ICU 33.3% in patients with undiagnosed Obstructive Sleep

Apnea 12.3% in patients with known Obstructive Sleep Apnea 6% in controls

OSA

Screening STOP BANG

Testing Polysomnography Home pulse oximitry

Treatment and recommendations CPAP Oral appliance Prolonged postoperative monitoring

OSASnoring

Tired

Observed Obstruction

Pressure (HTN)

BMI

Age (greater than 50)

Neck circumference

Gender

Take day of surgery CV meds

Beta blockers Antiarrythmics Clonidine Statins

Anti-reflux Seizure/ Parkinson Psych– inform anesthesiologist Bronchodilators OCP– unless stopped for DVT prevention Steroids – will likely get stress dose Thyroid replacement Pain meds– inform anesthesiologist

Medications to take or not to take

Do not take day of surgery Diuretics ACE/ ARB Potassium Diabetes oral medications

Metformin-- lactic acidosis Basal insulin ½ dose Hold bolus doses while NPO

NSAIDs/ ASA * Herbal supplements – one week

Medications to take or not to take

NSAIDs Diclofenac, IBU, indomethacin, keto – 1 day hold Naproxen and sulindac –3 day hold Meloxicam, nabumetone, piroxicam – 10 day hold

COX2 inhibitors –2 days (nephrotoxicity) Antiplatelet

Clopidigrel and Brillanta – 5 day hold Effient – 7 day hold ASA – 5 days Do not stop antiplatelet agents without carefully

reviewing indications and minimum duration from stenting and discussing with anesthesia, surgeon, and cardiologist

Warfarin – 5 days with bridging

Meds associated with bleeding

Dabigatran (pradaxa) Creatinine clearance > 50 then stop 2 days Creatinine clearance < 50 then stop 5 days Consider doubling days of cessation prior to

surgeries with high risk of bleeding Rivaroxaban (Xarelto)

Stop at least 1-2 days before procedure longer if chronic kidney disease or very high risk of

bleeding Ticlopidine (Ticlid)– stop 5 days before surgery

Newer anticoagulants

Rule: 2, 4, 6, 8 rule applies to all ages No clear liquids within 2 hours of surgery Clear liquid definition

Water, Fruit juice without pulp (e.g. apple juice), Gatorade, Pedialyte, Carbonated beverage, Clear tea, Black coffee

Not allowed as clear liquid: Milk, milk products or Alcohol No breast milk within 4 hours of surgery No solid foods within 6 hours of surgery

Includes orange juice with pulp, light meals (toast or crackers), infant formula and milk

No fried foods, fatty foods or meats within 8 hours of surgery These foods are associated with delayed gastric emptying

Fasting guidelines

Cough cold fever chills – is patient ever optimized? Fever never good If surgery will fix problem then usually reasonable

ASA 3 should go to pediatric center Oral sedation available

Prolongs wake up times and discharge times Mask induction until age 8-12 depending on

maturity level PIV needed otherwise

Pediatric pearls

Regional and anticoagulation Talk with anesthesia providers Give patients preview of what to expect Talk about NPO Tell them about general anesthesia, spinals,

nerve blocks, sedation Pain expectations

Planning for anesthetic technique

Reviewed the AHA/ACC guidelines for the cardiac evaluation/ preparation for a non-cardiac surgery

Discussed respiratory optimization Talked about day of surgery planning Examined the benefit of really understanding

the surgical process to better inform our patients

Summary

conclusion

ASA website patient information fast facts

J Am Coll Cardiol 2007; 50 p e159-e241 Anesthesiology 2012; 116 p 522-38 Anesthesia & Analgesia 2011; 112 p

113-121 Anesthesiology 2011; 114 p 495-511 Lancet 2008; 372: 139–44

References

Questions

A. T. Still