perioperative medicine

Perioperative Perioperative MedicineMedicine

Thomas W. Barrett, MDThomas W. Barrett, MD

Portland VA Medical CenterPortland VA Medical Center

Assistant Professor of MedicineAssistant Professor of Medicine

Oregon Health and Science Oregon Health and Science UniversityUniversity

Oregon ACP Scientific Oregon ACP Scientific MeetingMeeting

November 5, 2004November 5, 2004

Goals & AudienceGoals & Audience

Define Perioperative MedicineDefine Perioperative Medicine Review best predictor of outcomesReview best predictor of outcomes Review options for decreasing risk after Review options for decreasing risk after

surgerysurgery Practice Paradigms for Perioperative Practice Paradigms for Perioperative

MedicineMedicine Current State of Perioperative MedicineCurrent State of Perioperative Medicine ChallengesChallenges FutureFuture

DefinitionDefinition The use of medicines, techniques, or The use of medicines, techniques, or

devices to improve outcomes after devices to improve outcomes after surgery.surgery.

Less heart attack, stroke, renal failure, Less heart attack, stroke, renal failure, pneumonia, ileus, delirium, VTE Dz, pneumonia, ileus, delirium, VTE Dz, disability, and death.disability, and death.

Multidisciplinary: Surgery, Multidisciplinary: Surgery, Anesthesiology, Internal Medicine, Anesthesiology, Internal Medicine, Nursing, Pharmacy, Physical Therapy, Nursing, Pharmacy, Physical Therapy, Occupational Therapy, Speech Therapy, Occupational Therapy, Speech Therapy, Nutrition, Social WorkNutrition, Social Work

SignificanceSignificance 100,000 patients undergo surgery daily in 100,000 patients undergo surgery daily in

the US, 33 million annually, 10% of the US, 33 million annually, 10% of populationpopulation

Cost $ 450 Billion annually, average $ Cost $ 450 Billion annually, average $ 13,000 per treatment, 40% of the 13,000 per treatment, 40% of the healthcare budgethealthcare budget

1 million patients have adverse events per 1 million patients have adverse events per year, costing $ 45 Billion annuallyyear, costing $ 45 Billion annually

Within next 2 decades, surgical patients will Within next 2 decades, surgical patients will increase by 25%, cost by 50%, in-hospital increase by 25%, cost by 50%, in-hospital complications by 100%, as population agescomplications by 100%, as population ages

Mangano, J Cardiothorac Vasc Anesth. 2004 Feb;18(1):1-6.

Population PressorPopulation Pressor

At present, 10,000 “baby boomers” At present, 10,000 “baby boomers” are turning 58 each dayare turning 58 each day

The present surgical burden may The present surgical burden may become a surgical crisisbecome a surgical crisis

Biggest impact on above would be to Biggest impact on above would be to address the best predictor of address the best predictor of outcomesoutcomes

Best Predictor of Best Predictor of Outcomes?Outcomes?

3 fold increase in odds of adverse 3 fold increase in odds of adverse cardiac outcome (CHF,VT),and 9 cardiac outcome (CHF,VT),and 9 fold increase in odds of clinical fold increase in odds of clinical ischemia event (USA, non fatal MI, ischemia event (USA, non fatal MI, Cardiac death), up to 2 years after Cardiac death), up to 2 years after surgerysurgery

70% of adverse outcomes (CHF, VT, 70% of adverse outcomes (CHF, VT, MI, USA, Cardiac death) associated MI, USA, Cardiac death) associated with itwith it

Best Predictor?Best Predictor?

Preoperative Preoperative DemographicsDemographics

Results of risk Results of risk indicesindices

Stress test resultsStress test results Intraoperative Intraoperative

eventsevents Perioperative Perioperative

ischemiaischemia

Perioperative IschemiaPerioperative Ischemia

More predictive of adverse outcomes More predictive of adverse outcomes than preoperative demographics, stress than preoperative demographics, stress test results, or intraoperative eventstest results, or intraoperative events

Post op day 0-2: if no ischemia then rare Post op day 0-2: if no ischemia then rare adverse outcome (CHF, VT, MI, USA, adverse outcome (CHF, VT, MI, USA, Cardiac death) 6 v 17% over 2 yrs., if Cardiac death) 6 v 17% over 2 yrs., if positive ischemia, 2.2 fold increase positive ischemia, 2.2 fold increase odds, if infarction, 20 fold increaseodds, if infarction, 20 fold increase

Mangano et al., 1990s

Perioperative IschemiaPerioperative Ischemia Perioperative ischemia defined by three Perioperative ischemia defined by three

lead Holter monitor, lasting at least one lead Holter monitor, lasting at least one minute, >0.1 mV ST depression, or>0.2 minute, >0.1 mV ST depression, or>0.2 mV ST elevationmV ST elevation

Known CAD and pts with 2 CAD RFs Known CAD and pts with 2 CAD RFs (age>65, HTN, DM, Hyperlipidemia, (age>65, HTN, DM, Hyperlipidemia, tobacco) are equally likely to have tobacco) are equally likely to have ischemia, p=0.60; incidence 27% and ischemia, p=0.60; incidence 27% and 27% 27%

Ischemia most common post op day 0-3Ischemia most common post op day 0-3 Persists up to 7 days after surgeryPersists up to 7 days after surgery


Perioperative IschemiaPerioperative Ischemia Silent 84-97%Silent 84-97% Anesthesia and surgery are not associated Anesthesia and surgery are not associated

with an increase in ischemiawith an increase in ischemia Mean ST change pre/intra/post op, 1.5/ 2/ Mean ST change pre/intra/post op, 1.5/ 2/

2.62.6 Duration of ischemia 69/ 45/ 207 minutesDuration of ischemia 69/ 45/ 207 minutes Area under the curve: 88/ 74/ 383 mm.minArea under the curve: 88/ 74/ 383 mm.min Postoperative ischemia is related to HR, Postoperative ischemia is related to HR,

Mean HR; 76/ 71/ 92; with 57% ischemia in Mean HR; 76/ 71/ 92; with 57% ischemia in HR>100, some studies had a threshold of HR>100, some studies had a threshold of 80.80.


Pathophysiology of the Pathophysiology of the Perioperative StatePerioperative State

Hyperadrenergic state with excitotoxic, Hyperadrenergic state with excitotoxic, inflammatory, thermic, thrombogenic inflammatory, thermic, thrombogenic stressorsstressors

Tachycardia, increased myocardial Tachycardia, increased myocardial contractility, increased myocardial Ocontractility, increased myocardial O22 demand, changes in endothelium, demand, changes in endothelium, clotting factors, and plaque stabilityclotting factors, and plaque stability

Critical fixed obstructive coronary lesionsCritical fixed obstructive coronary lesions Coronary vulnerable plaque disruptionCoronary vulnerable plaque disruption May not manifest for weeks or monthsMay not manifest for weeks or months

Interventions to Interventions to Decrease RiskDecrease Risk

Perioperative Perioperative --blockersblockers

2-agonists2-agonists StatinsStatins ASAASA

Perioperative Perioperative -Blockers-Blockers

Retrospective Retrospective observational observational cohortcohort

Case controlCase control Randomized Randomized

Clinical TrialsClinical Trials Meta-analysisMeta-analysis Systematic reviewSystematic review AHRQ Quality AHRQ Quality

markermarker

Perioperative Perioperative -Blockers -Blockers DecreaseDecrease

Perioperative ischemiaPerioperative ischemia Postoperative myocardial infarctionPostoperative myocardial infarction Postoperative mortality, especially in Postoperative mortality, especially in

vascular surgery, but also other vascular surgery, but also other noncardiac surgerynoncardiac surgery

Not studied in CABG as it is Not studied in CABG as it is standard carestandard care

GuidelinesGuidelines

ACC/AHA 2002 update: Perioperative ACC/AHA 2002 update: Perioperative beta-blockers are Class I for symptomatic beta-blockers are Class I for symptomatic angina, arrhythmia, hypertension,or angina, arrhythmia, hypertension,or positive ischemia on stress test and positive ischemia on stress test and undergoing vascular surgery.undergoing vascular surgery.

Class IIA for untreated HTN, known CAD, Class IIA for untreated HTN, known CAD, or major RF for CADor major RF for CAD

ACP 1997 Author’s addendum: For all ACP 1997 Author’s addendum: For all patients, determine eligibility for Beta patients, determine eligibility for Beta blocker use.blocker use.

Perioperative Perioperative -Blockers: -Blockers: Mechanism of ActionMechanism of Action

Decreases tachycardia, inotropy, Decreases tachycardia, inotropy, arrhythmias, and ventricular wall stressarrhythmias, and ventricular wall stress

Redistributes coronary blood flowRedistributes coronary blood flow Potentiates minimum alveolar concentration Potentiates minimum alveolar concentration

for volatile anestheticsfor volatile anesthetics, which are , which are cardioprotectivecardioprotective

Decreases central nociception, so patients Decreases central nociception, so patients have less pain, and therefore less have less pain, and therefore less adrenergic stim.adrenergic stim.

Decreases inflammatory cytokinesDecreases inflammatory cytokines

Perioperative Perioperative -Blockers: -Blockers: QualityQuality

Perioperative Perioperative -Blockers are utilized -Blockers are utilized about 40% of the time, which is c/w about 40% of the time, which is c/w ambulatory use of ambulatory use of -Blockers for patients -Blockers for patients c CADc CAD

Very rare to have patients not already Very rare to have patients not already taking taking -Blocker, started on it for -Blocker, started on it for surgerysurgery

Noncardiac surgery one institution, PBB Noncardiac surgery one institution, PBB incidence 37%, full use of PBB would incidence 37%, full use of PBB would have prevented 62-89 deaths and saved have prevented 62-89 deaths and saved $ 318,000 to $ 463,000 annually$ 318,000 to $ 463,000 annually

Perioperative Perioperative -Blockers: -Blockers: QualityQuality

Canadian anesthesiologists self reported Canadian anesthesiologists self reported 57% usage of PBB, but 97% agreed it was 57% usage of PBB, but 97% agreed it was usefuluseful

VA survey: 71% self report, 87% agreed VA survey: 71% self report, 87% agreed helpful in known CAD, 72% for RFs, only helpful in known CAD, 72% for RFs, only 30% PBB efficacious for nonvascular, 30% PBB efficacious for nonvascular, noncardiac surgerynoncardiac surgery

A systems improvement involving FP, A systems improvement involving FP, internists, and anesthesiologists in Canada internists, and anesthesiologists in Canada resulted in a 69% incidence of PBB.resulted in a 69% incidence of PBB.

Perioperative Perioperative -Blockers: -Blockers: Subjective SuggestionsSubjective Suggestions

Start 7 days before surgery, Start 7 days before surgery, continue for 7 days after surgery.continue for 7 days after surgery.

If known vascular disease do not If known vascular disease do not stopstop

Titrate to goal HR of 65 postopTitrate to goal HR of 65 postop If HR>65 and SBP>100 double doseIf HR>65 and SBP>100 double dose If HR<55 or SBP<100 hold doseIf HR<55 or SBP<100 hold dose

Perioperative Perioperative -Blockers-Blockers

Controversial?Controversial? Large RCT of perioperative Large RCT of perioperative --

Blockers in a multi-center, Blockers in a multi-center, international design is ongoing, international design is ongoing, POISE (Perioperative Ischemic POISE (Perioperative Ischemic Evaluation) in Canada will enroll Evaluation) in Canada will enroll 10,000 patients.10,000 patients.

Medico-legal implicationsMedico-legal implications

2-agonists2-agonists

Retrospective Retrospective observational observational cohortcohort

Case controlCase control Randomized Randomized

Clinical TrialsClinical Trials Meta-analysisMeta-analysis Systematic reviewSystematic review Centrally acting Centrally acting

sympatholyticsympatholytic

2-agonists2-agonists

Decrease perioperative ischemia, Decrease perioperative ischemia, myocardial infarction, and mortality after myocardial infarction, and mortality after vascular surgery vascular surgery

Decrease perioperative ischemia and Decrease perioperative ischemia and mortality for up to 2 years after noncardiac mortality for up to 2 years after noncardiac surgery, study design questionssurgery, study design questions

Decrease perioperative ischemia after CABGDecrease perioperative ischemia after CABG Still controversial, and considered second Still controversial, and considered second

line to line to -Blockers. Not everyone can -Blockers. Not everyone can tolerate tolerate BB

StatinsStatins

1 Case control1 Case control 2 Observational 2 Observational

cohortcohort 1 RCT1 RCT Pleotrophic Pleotrophic

effectseffects

StatinsStatins

Case control vascular surgery, reduced Case control vascular surgery, reduced in-hospital mortality by a factor of 4.5in-hospital mortality by a factor of 4.5

Observational cohort: 780,000 Observational cohort: 780,000 patients. Reduced in-hospital mortality patients. Reduced in-hospital mortality after noncardiac surgery by 38%, but after noncardiac surgery by 38%, but mortality 2.13% v 3.05%mortality 2.13% v 3.05%

Observational cohort CABG, 323 Observational cohort CABG, 323 patients, decreased death, MI, USA, patients, decreased death, MI, USA, arrhythmiaarrhythmia

StatinsStatins

Vascular surgery RCT: 100 patients, Vascular surgery RCT: 100 patients, atorvastatin 20 mg, 30 days before atorvastatin 20 mg, 30 days before surgery, f/u 6 monthssurgery, f/u 6 months

Composite of death, nonfatal MI, USA, Composite of death, nonfatal MI, USA, strokestroke

Incidence 8% v 26%, p=0.031Incidence 8% v 26%, p=0.031 Event free survival at 6 months 91% v Event free survival at 6 months 91% v

74%, p=0.01874%, p=0.018 More studies neededMore studies needed

ASA in CABGASA in CABG

Prospective observational cohort of Prospective observational cohort of 5,022 patients surviving 2 days post 5,022 patients surviving 2 days post CABGCABG

Compared patients receiving ASA Compared patients receiving ASA within 48 hrs of CABG to those notwithin 48 hrs of CABG to those not

30 day mortality 1.3 v 4%, p<0.00130 day mortality 1.3 v 4%, p<0.001 48% reduction in MI48% reduction in MI 50% reduction in stroke50% reduction in stroke

Mangano, NEJM 2002;347(17):1309-17

ASA in CABGASA in CABG

74% reduction in renal failure74% reduction in renal failure 62% reduction in bowel infarction62% reduction in bowel infarction Risk of bleeding, gastritis, impaired Risk of bleeding, gastritis, impaired

wound healing, and infection was wound healing, and infection was not increasednot increased

No other drug explained benefitNo other drug explained benefit Kind of study that changes Kind of study that changes

managementmanagementMangano, NEJM 2002;347(17):1309-17

Current State of Current State of Perioperative Medicine: Perioperative Medicine:

TraditionalTraditional Local system of care defines patient Local system of care defines patient

responsibilitiesresponsibilities Traditional: PCP sees patient before Traditional: PCP sees patient before

surgery and assesses risk and need surgery and assesses risk and need for risk stratification or for risk stratification or intervention?intervention?

Anesthesiologist meets patient for Anesthesiologist meets patient for the first time minutes before the first time minutes before surgery, up to discharge from PACUsurgery, up to discharge from PACU


TraditionalTraditional Surgeon schedules surgery, then Surgeon schedules surgery, then

addresses all postoperative issues until addresses all postoperative issues until discharge. If there is a problem, then discharge. If there is a problem, then gets subspecialty consultationgets subspecialty consultation

Surgeons can take 1-2 days longer to Surgeons can take 1-2 days longer to realize there is a medical problem realize there is a medical problem (Anecdotal)(Anecdotal)

If wait until there is a problem, then it is If wait until there is a problem, then it is too late. We want to prevent problems.too late. We want to prevent problems.

Current State of Current State of Perioperative Medicine: Co-Perioperative Medicine: Co-

ManagementManagement New practice paradigmNew practice paradigm An Internist (Hospitalist) sees patient An Internist (Hospitalist) sees patient

several weeks before surgery for a several weeks before surgery for a preoperative consultation. Systems carepreoperative consultation. Systems care

Risk assessment is done for all organ Risk assessment is done for all organ systems: CNS, Lung, Heart, GI, VTE Dz, systems: CNS, Lung, Heart, GI, VTE Dz, HemeHeme

Risk stratification performedRisk stratification performed New risk reduction drugs initiatedNew risk reduction drugs initiated Patient is seen every day in the hospital Patient is seen every day in the hospital

until d/cuntil d/c

Current State of Current State of Perioperative Medicine: Co-Perioperative Medicine: Co-

ManagementManagement Regions of country that having been doing Regions of country that having been doing

this for > 20 yearsthis for > 20 years Hospitalist academic community started Hospitalist academic community started

this ~5 years ago, and are amassing datathis ~5 years ago, and are amassing data Private practice model, resident resistancePrivate practice model, resident resistance Sound business modelSound business model One study published to date: HOT 526 One study published to date: HOT 526

patients undergoing total hip or knee patients undergoing total hip or knee replacementreplacement

Hospitalist Orthopedic Hospitalist Orthopedic TrialTrial

Decreased minor complications such as: Decreased minor complications such as: electrolyte abnormalities, fever, UTI, 30 electrolyte abnormalities, fever, UTI, 30 v 44%v 44%

Unadjusted LOS sameUnadjusted LOS same Adjusted for care facility taking patient: Adjusted for care facility taking patient:

0.5 day less 0.5 day less Costs the sameCosts the same Nurses, Orthopedic faculty and residents Nurses, Orthopedic faculty and residents

preferred the co-management modelpreferred the co-management model More studies are neededMore studies are needed

Huddleston et al., Ann Intern Med 2004 Jul 6;141(1):28-38


ResearchResearch NIH NHLBI Working Group Statement NIH NHLBI Working Group Statement

Feb. 2004Feb. 2004 Drs. Claude Lenfant and Dennis Drs. Claude Lenfant and Dennis

Mangano organized, 18 months, 45 Mangano organized, 18 months, 45 experts from surgery, anesthesiology, experts from surgery, anesthesiology, general medicine, subspecialties, critical general medicine, subspecialties, critical care, government and health economicscare, government and health economics

Topics included risk profiling, Topics included risk profiling, preventable and treatable preventable and treatable complications, and multispecialty complications, and multispecialty guidelinesguidelines


NHLBI Working Group NHLBI Working Group RecommendationsRecommendations

There is an impending surgical crisisThere is an impending surgical crisis Total numbers of surgeries will Total numbers of surgeries will

increase, adverse events will increase, adverse events will increase, in-hospital and discharge increase, in-hospital and discharge plans will become more challengingplans will become more challenging

Risk profiling, multispecialty Risk profiling, multispecialty paradigms, patient education before paradigms, patient education before surgery, and discharge risk profiling surgery, and discharge risk profiling needed more attentionneeded more attention



Non vascular, noncardiac surgery and Non vascular, noncardiac surgery and elderly populations need more attentionelderly populations need more attention

Assessment and reporting of Assessment and reporting of complications varies across specialtiescomplications varies across specialties

No consistent approach to informed No consistent approach to informed consent is standardconsent is standard

A comprehensive, national database A comprehensive, national database with multispecialty, multi-center, and with multispecialty, multi-center, and agreed upon components would best agreed upon components would best address this variability.address this variability.



National Perioperative Initiative (Funding)National Perioperative Initiative (Funding) Perioperative Medicine Advisory Board at Perioperative Medicine Advisory Board at

NHLBINHLBI Involvement of specialty societies are Involvement of specialty societies are

crucial crucial Current guidelines of preoperative Current guidelines of preoperative

assessment have much in common, but assessment have much in common, but without widespread recognition and without widespread recognition and implementation of a general paradigm by implementation of a general paradigm by the multiple specialties, a unified approach the multiple specialties, a unified approach will not be realizedwill not be realized


Other ChallengesOther Challenges Common adverse events involving the Common adverse events involving the

CNS, renal, pulmonary, GI, heme are CNS, renal, pulmonary, GI, heme are not addressed by the current guidelinesnot addressed by the current guidelines

Interventions to decrease perioperative Interventions to decrease perioperative risk are few, and when existent not used risk are few, and when existent not used in over 50% of high risk patients in over 50% of high risk patients (Perioperative (Perioperative -Blockers)-Blockers)

Drug and technology development that Drug and technology development that is tailored to the unique perioperative is tailored to the unique perioperative physiologic state is non existent at physiologic state is non existent at presentpresent

Other ChallengesOther Challenges

Long term outcome data are few. A couple Long term outcome data are few. A couple 1-2 year studies with a few hundred patients 1-2 year studies with a few hundred patients

Customary window to follow is 30 daysCustomary window to follow is 30 days If we had robust long term data, then we If we had robust long term data, then we

may be able to identify high risk population may be able to identify high risk population that would benefit from other interventions, that would benefit from other interventions, e.g. drugs.e.g. drugs.

Effectiveness of Risk Indices and Effectiveness of Risk Indices and Guidelines? Ease of use v. efficient systems Guidelines? Ease of use v. efficient systems care. Audience?care. Audience?

Proposed Actions for Proposed Actions for CliniciansClinicians

Look at your system of care and assess Look at your system of care and assess interest in establishing a Perioperative interest in establishing a Perioperative Medicine program.: Internists Medicine program.: Internists (Hospitalists), surgeons, (Hospitalists), surgeons, anesthesiologists.anesthesiologists.

Benefits: Financial, variety, patient Benefits: Financial, variety, patient satisfactionsatisfaction

Consider a Perioperative Consider a Perioperative -Blocker -Blocker protocol, which will require active protocol, which will require active involvement if it is to work.involvement if it is to work.

Proposed Actions for Proposed Actions for ResearchersResearchers

Establish fruitful multispecialty Establish fruitful multispecialty collaborative relationshipscollaborative relationships

Assist government to prioritize Assist government to prioritize Perioperative Medicine with the help of Perioperative Medicine with the help of societiessocieties

Hospitalists need to enter the Hospitalists need to enter the Perioperative Medicine debate (Youth)Perioperative Medicine debate (Youth)

Multidisciplinary skills may be helpfulMultidisciplinary skills may be helpful

Future Future

Systems of care that have highly Systems of care that have highly evolved multispecialty co-evolved multispecialty co-management programs do not want management programs do not want to go backto go back

Quality of life for PCP, surgeon, Quality of life for PCP, surgeon, anesthesiologistanesthesiologist

Data will cement the co-Data will cement the co-management model, which will management model, which will become standard of care everywherebecome standard of care everywhere

Future Future

Multispecialty Multispecialty research will advance research will advance drug and technology drug and technology development to give development to give our patients our patients undergoing surgery undergoing surgery the safest, most the safest, most robust system of care robust system of care available, thus available, thus averting the averting the impending surgical impending surgical crisis.crisis.

Thank youThank you

Please email me if you wish to have a Please email me if you wish to have a copy of this presentation or a list of copy of this presentation or a list of references.references.

Look for the SHM Supplement on Look for the SHM Supplement on Perioperative MedicinePerioperative Medicine

[email protected]@ohsu.eduu

perioperative medicine

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