perioperative medical evaluation for gynecological surgery cullen archer, md obstetrics and...

Perioperative Medical Evaluation for Gynecological Surgery

Cullen Archer, MDObstetrics and Gynecology

June 2006

6 Key Elements to Medicine Preop

• Cardiac Risk• Pulmonary Risk• DVT Risk and Prevention• Endocarditis Prophylaxis• Perioperative Delirium• Steroids

Topics

• Preoperative Cardiovascular Evaluation• Antibiotic Prophylaxis• Endocarditis Prophylaxis• DVT Prophylaxis

Preoperative Cardiac Evaluation

• Evaluation tailored to circumstances• H+P and ECG should identify potentially

serious cardiac disorders• Define disease severity, stability, and prior

treatment

Clinical Predictors of Increased Perioperative Cardiovascular Risk (Myocardial Infarction, Heart Failure, Death)

• Major– Unstable coronary syndromes

• Acute or recent myocardial infarction* with evidence of important ischemic risk by clinical symptoms or noninvasive study• Unstable or severe† angina (Canadian class III or IV)‡

– Decompensated heart failure– Significant arrhythmias

• High-grade atrioventricular block• Symptomatic ventricular arrhythmias in the presence of

underlying heart disease• Supraventricular arrhythmias with uncontrolled ventricular rate

– Severe valvular disease

*The American College of Cardiology National Database Library defines recent MI as greater than 7 days but less than or equal to 1 month (30 days); acute MI is within 7 days.

†May include “stable” angina in patients who are unusually sedentary.‡Campeau L. Grading of angina pectoris. Circulation. 1976;54:522–523.


• Intermediate– Mild angina pectoris (Canadian class I or II)– Previous myocardial infarction by history or

pathological Q waves– Compensated or prior heart failure– Diabetes mellitus (particularly insulin-

dependent)– Renal insufficiency


• Minor– Advanced age– Abnormal ECG (left ventricular hypertrophy, left

bundle-branch block, ST-T abnormalities)– Rhythm other than sinus (e.g., atrial fibrillation)– Low functional capacity (e.g., inability to climb

one flight of stairs with a bag of groceries)– History of stroke– Uncontrolled systemic hypertension

Functional Capacity

1 MET Can you take care of yourself?Eat, dress, or use the toilet?Walk indoors around the house?Walk a block or two on level ground at 2-3 mph (4.8kph)

4 MET Do light work around the house like dusting or washingdishes?

Climb a flight of stairs or walk up a hill?Run a short distance?Do heavy work around the house like scrubbing floors or

lifting or moving heavy furnitureParticipate in moderate recreational activities like golf,

bowling, dancing, doubles tennis, or throwing a baseball or football?

>10 Participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing?

Cardiac Risk* Stratification for Noncardiac Surgical Procedures

• High (Reported cardiac risk often greater than 5%)• Emergent major operations, particularly in the elderly• Aortic and other major vascular surgery• Peripheral vascular surgery• Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss

• Intermediate (Reported cardiac risk generally less than 5%)• Carotid endarterectomy• Head and neck surgery• Intraperitoneal and intrathoracic surgery• Orthopedic surgery• Prostate surgery

• Low† (Reported cardiac risk generally less than 1%)• Endoscopic procedures• Superficial procedure• Cataract surgery• Breast surgery

*Combined incidence of cardiac death and nonfatal myocardial infarction.†Do not generally require further preoperative cardiac testing.

ACC/AHA PRACTICE GUIDELINES:ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery—Executive Summary. J Am Coll Card. 2002; 39: 542-553.

Specific Preoperative Conditions

Hypertension– ≥ 180/110 should be controlled preoperatively– Perioperative antagonists

Valvular Heart Disease

Myocardial Disease

Arrhythmias

Specific Preoperative Conditions

• Implantable Pacemakers and Interventricular Conduction Devices– unipolar or bipolar pacemaker leads– Electrocautery: bipolar or unipolar ?

• ICD devices should be programmed off immediately before surgery and then on again postoperatively

Surgical Site ProphylaxisAntimicrobial Prophylactic Regimens by ProcedureProcedure Antibiotic Dose

Vaginal/abdominal cefazolin 1 or 2 g single dose IVhysterectomy* Cefoxitin 2 g single dose IV

Cefotetan 1 or 2 g single dose IVMetronidazole 500 mg single dose IV

Laparoscopy NoneLaparotomy NoneHysteroscopy NoneHysterosalpingogram Doxycycline† 100 mg po BID x 5 daysIUD insertion NoneEndometrial biopsy NoneInduced abortion/D&C Doxycycline 100 mg orally 1 hour

before and 200 mg orallyafter the procedure

Metronidazole 500 mg po BID for 5 daysUrodynamics None*A convenient time to administer antibiotic prophylaxis is just before induction of anesthesia†If hysterosalpingogram demonstrates dilated tubes. No prophylaxis is indicated for a normal study.

ACOG Practice Bulletin 23, January 2001

Endocarditis Prophylaxis

Endocarditis prophylaxis recommended Respiratory tract Tonsillectomy and/or adenoidectomy Surgical operations that involve respiratory mucosa Bronchoscopy with a rigid bronchoscope Gastrointestinal tract1

Sclerotherapy for esophageal varices Esophageal stricture dilation Endoscopic retrograde cholangiography with biliary

obstruction Biliary tract surgery Surgical operations that involve intestinal mucosa Genitourinary tract Prostatic surgery Cystoscopy Urethral dilation

1Prophylaxis is recommended for high-risk patients; it is optimal for medium-risk patients.

Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association. Circulation. 1997;96:358-366.

Endocarditis ProphylaxisEndocarditis prophylaxis not recommended Respiratory tract Endotracheal intubation Bronchoscopy with a flexible bronchoscope, with or without biopsy2

Tympanostomy tube insertion Gastrointestinal tract Transesophageal echocardiography2

Endoscopy with or without gastrointestinal biopsy2

Genitourinary tract Vaginal hysterectomy2

Vaginal delivery2

Cesarean section In uninfected tissue: Urethral catheterization Uterine dilatation and curettage Therapeutic abortion Sterilization procedures Insertion or removal of intrauterine devices Other Cardiac catheterization, including balloon angioplasty Implanted cardiac pacemakers, implanted defibrillators, and coronary stents Incision or biopsy of surgically scrubbed skin Circumcision

2Prophylaxis is optional for high-risk patients


Endocarditis Prophylaxis

ACC/AHA Recommendations for Antibiotic Prophylaxis to Prevent Bacterial EndocarditisACOG Practice Bulletin No. 47, October 2003

Prophylactic regimens for GI/GU Procedures

Situation Agents Regimen

High-risk patients Ampicillin plus Adults: ampicillin 2.0 g IM or IV plus gentamicin 1.5 Gentamicin mg/kg (not to exceed 120 mg) within 30 min of starting

procedure; 6 hr later, ampicillin 1 g IM/IV or amoxicillin 1 g orallyChildren: ampicillin 50 mg/kg IM or IV (not to exceed 2.0 g) plus gentamicin 1.5 mg/kg within 30 min of starting the procedure; 6 h later, ampicillin 25 mg/kg IM/IV or amoxicillin 25 mg/kg orally

High-risk patients allergic Vancomycin Adults: vancomycin 1.0 g IV over 1-2 h plus gentamicinto ampicillin/amoxicillin plus gentamicin 1.5 mg/kg IV/IM (not to exceed 120 mg); complete

injection/infusion within 30 min of starting procedureChildren: vancomycin 20 mg/kg IV over 1-2 h plus gentamicin 1.5 mg/kg IV/IM; complete injection/infusion within 30 min of starting procedure

Moderate-risk patientsAmoxicillin or Adults: amoxicillin 2.0 g orally 1 h before procedure, orampicillin ampicillin 2.0 g IM/IV within 30 min of starting procedure

Children: amoxicillin 50 mg/kg orally 1 h before procedure, or ampicillin 50 mg/kg IM/IV within 30 min of starting procedure

Moderate-risk patients Vancomycin Adults: vancomycin 1.0 g IV over 1-2 h allergic to ampicillin/ complete infusion within 30 min of starting procedureamoxicillin Children: vancomycin 20 mg/kg IV over 1-2 h; complete

infusion within 30 min of starting procedure

IM indicates intramuscularly, and IV, intravenously.1Total children’s dose should not exceed adult dose.2No second dose of vancomycin or gentamicin is recommended.


Infective EndocarditisDefinition of Infective Endocarditis According to the Modified Duke CriteriaDefinite infective endocarditis• Pathological criteria: microorganisms demonstrated by culture or histological examination of a

vegetation, a vegetation that has embolized, or an intracardiac abscess specimen; or• Pathological lesions: vegetation or intracardiac abscess confirmed by histological examination showing

active endocarditisClinical criteria• 2 major criteria; or• 1 major criterion and 3 minor criteria; or• 5 minor criteriaPossible IE• 1 major criterion and 1 minor criterion; or• 3 minor criteriaRejected• Firm alternative diagnosis explaining evidence of IE; or• Resolution of IE syndrome with antibiotic therapy for < 4 days; or• No pathological evidence of IE at surgery or autopsy, with antibiotic• therapy for < 4 days; or• Does not meet criteria for possible IE as above

Modifications shown in boldface.

Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications. A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association. Circulation. 2005; 111:e394-e433.

Modified Duke CriteriaMajor criteria• Blood culture positive for IE

– Typical microorganisms consistent with IE from 2 separate blood cultures: Viridans streptococci, Streptococcus bovis, HACEK group, Staphylococcus aureus; or community-acquired enterococci in the absence of a primary focus; or

– Microorganisms consistent with IE from persistently positive blood cultures defined as follows: At least 2 positive cultures of blood samples drawn > 12 h apart; or all of 3 or a majority of ≥ 4 separate cultures of blood (with first and last sample drawn at least 1 h apart)

– Single positive blood culture for Coxiella burnetii or anti–phase 1 IgG antibody titer >1:800

• Evidence of endocardial involvement– Echocardiogram positive for IE (TEE recommended for patients with prosthetic valves, rated at least “possible IE” by clinical

criteria, or complicated IE paravalvular abscess; TTE as first test in other patients) defined as follows: oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation; or abscess; or new partial dehiscence of prosthetic valve; new valvular regurgitation (worsening or changing or preexisting murmur not sufficient)

Minor criteria• Predisposition, predisposing heart condition, or IDU• Fever, temperature > 38°C• Vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm,

intracranial hemorrhage, conjunctival hemorrhages, and Janeway’s lesions• Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, and

rheumatoid factor• Microbiological evidence: positive blood culture but does not meet a major criterion as

noted above* or serological evidence of active infection with organism consistent with IE

Echocardiographic minor criteria eliminated

Modifications shown in boldface.*Excludes single positive cultures for coagulase-negative staphylococci and organisms that do not cause endocarditis.

Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications. A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association. Circulation. 2005; 111:e394-e433.

DVT Prophylaxis

Absolute Risk for DVT in Hospitalized Patients

Patient Group DVT Prevalence, %

Medical patients 10–20General surgery 15–40Major gynecologic surgery 15–40Major urologic surgery 15–40Neurosurgery 15–40Stroke 20–50Hip or knee arthroplasty, hip fracture surgery 40–60Major trauma 40–80Spinal cord injury 60–80Critical care patients 10–80

*Rates based on objective diagnostic testing for DVT in patients not receiving thromboprophylaxis.

DVT Prophylaxis

Risk Factors for VTE• Surgery• Trauma (major or lower extremity)• Immobility, paresis• Malignancy• Cancer therapy (hormonal, chemotherapy, or radiotherapy)• Previous VTE• Increasing age• Pregnancy and the postpartum period• Estrogen-containing oral contraception or hormone replacement therapy• Selective estrogen receptor modulators• Acute medical illness• Heart or respiratory failure• Inflammatory bowel disease• Nephrotic syndrome• Myeloproliferative disorders• Paroxysmal nocturnal hemoglobinuria• Obesity• Smoking• Varicose veins• Central venous catheterization• Inherited or acquired thrombophilia

ACCP Grading Recommendations

Applying the Grades of Recommendation for Antithrombotic and Thrombolytic Therapy The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. CHEST 2004; 126:179S–187S)

DVT Prophylaxis - Recommendations

Minor Surgery• < 30 minutes for benign disease• Recommend against use if specific

prophylaxis other than early and persistent mobilization (Grade 1C).

Laparoscopy• If VTE risk factors are present, we

recommend the use of thromboprophylaxis with one or more of the following: LDUH, LMWH, IPC, or GCS (all Grade 1C)


Major Surgery• Benign with no additional R.F.

– LDUH, 5,000 U bid (Grade 1A)– once-daily prophylaxis with LMWH ≤ 3,400 U/d (Grade

1C+), or– IPC started just before surgery and used continuously

while the patient is not ambulating (Grade 1B)

• Malignant, or with additional R.F.– DUH, 5,000 U tid (Grade 1A), or – higher doses of LMWH (i.e., > 3,400 U/d) [Grade 1A]– Alternative considerations include IPC alone continued until

hospital discharge (Grade 1A), or– combination of LDUH or LMWH plus mechanical

prophylaxis with GCS or IPC (all Grade 1C)


Duration of Prophylaxis• until discharge from the hospital (Grade 1C)• if particularly high risk, including those who have

undergone cancer surgery and are > 60 years of age or have previously experienced VTE, prophylaxis for 2 to 4 weeks after hospital discharge (Grade 2C)

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