pre-operative cardiac evaluation - cmcmac.in cme pdfs/18 dr. cijoy pre-operative medical... ·...

PRE-OPERATIVE MEDICAL EVALUATION IN THE SECONDARY CARE SETTING

OUTLINE

• Premise

• Purpose

• Principles

• Practice

PREMISE Indications and evidence for the Physician consultation

INDICATIONS

WHY WOULD A SURGEON REQUEST A PHYSICIAN CONSULT?

• Common practice – clinical and legal reasons

• Usually not specialty specific in secondary care

• Often implies comprehensive medical evaluation

• Rationale – high risk of medical complications post-operatively

FREQUENCY OF POSTOPERATIVE COMPLICATIONS

Complication Incidence (%)

Infection 14.3

Respiratory 9.5

Cardiac 4.5

Khuri SF, Daley J, Henderson W, Barbour G, Lowry P, Irvin G, et al. The National

Veterans Administration Surgical Risk Study: risk adjustment for the comparative

assessment of the quality of surgical care. J Am Coll Surg. 1995;180:519–31.



Infection 14.3

Wound 5.1

Pneumonia 3.6

Urinary tract 3.5

Systemic sepsis 2.1


Veterans Administration Surgical Risk Study: risk adjustment for the

comparative assessment of the quality of surgical care. J Am Coll Surg.

1995;180:519–31.



Respiratory 9.5

Pneumonia 3.6

Failure to wean from respirator in 48 hours

3.2

Unplanned intubation 2.4

Pulmonary embolus 0.3






Cardiac 4.5

Pulmonary edema 2.3

Cardiac arrest 1.5

Myocardial infarction 0.7




EVIDENCE

CONFLICTING REPORTS ON BENEFITS

Consultation

• Identify issues and recommend interventions

• Optimize medical conditions

• High clinician satisfaction

No Consultation

• Frequency of detection of new issues too less

• Cancel or delay in procedures

• May be over or under-utilized

Levinson W. Preoperative evaluations by an internist--are they worthwhile? West J Med 1984; 141:395. Macpherson DS, Lofgren RP. Outpatient internal medicine preoperative evaluation: a randomized clinical trial. Med Care 1994; 32:498 Devor M, Renvall M, Ramsdell J. Practice patterns and the adequacy of residency training in consultation medicine. J Gen Intern Med 1993; 8:554 Chen LM, Wilk AS, Thumma JR, et al. Use of medical consultants for hospitalized surgical patients: an observational cohort study. JAMA Intern Med 2014; 174:1470.

CONFLICTING REPORTS ON BENEFITS

Consultation • 3 cohort studies showed decreased

length of stay

• Slight reduction in overall costs

No Consultation

• 1 retrospective cohort showed no change; another increased

• Increased cost of consultation

Levinson W. Preoperative evaluations by an internist--are they worthwhile? West J Med 1984; 141:395. Macpherson DS, Lofgren RP. Outpatient internal medicine preoperative evaluation: a randomized clinical trial. Med Care 1994; 32:498 Devor M, Renvall M, Ramsdell J. Practice patterns and the adequacy of residency training in consultation medicine. J Gen Intern Med 1993; 8:554 Chen LM, Wilk AS, Thumma JR, et al. Use of medical consultants for hospitalized surgical patients: an observational cohort study. JAMA Intern Med 2014; 174:1470.

HIGHER MORTALITY?

• Slightly higher 30 day and 1 year mortality in those who had medical consultation pre-operatively

• Probably due to selection bias

Wijeysundera DN, Austin PC, Beattie WS, et al. Outcomes and processes of care related

to preoperative medical consultation. Arch Intern Med 2010; 170:1365.

EVIDENCE ON PRE-OPERATIVE PHYSICIAN EVALUATION

• Strong evidence is lacking

• Practice is widespread

• Legal implications abound

• Could improve outcomes

PURPOSE Goals of the Physician Consultation

GOALS OF PRE-OPERATIVE EVALUATION

Identify – Optimize – Manage

• Identifying unrecognized comorbid disease and risk factors for medical complications of surgery

• Optimizing the preoperative medical condition and medications

• Recognizing and treating potential complications

In all these, working effectively as a member of the pre and peri-operative team (including surgical and anesthesia colleagues)

PRINCIPLES Principles of the Physician Consultation

THE “TEN COMMANDMENTS”

1. Determine the question and respond to it.

2. Establish the urgency of the consultation and provide a timely response.

3. "Look for yourself"; confirm the history and physical examination and check test results.

4. Be as brief as appropriate; be definitive and limit the number of recommendations.

5. Be specific, including medication details.

Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med

1983; 143:1753.

THE “TEN COMMANDMENTS”

6. Provide contingency plans; anticipate potential problems and questions.

7. Honor thy turf; don't steal other clinician's patients.

8. Teach with tact; consult, don't insult.

9. Talk is cheap and effective; direct verbal communication is crucial.

10. Follow-up to ensure that recommendations are followed.

Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med

1983; 143:1753.

THE QUESTION

• Not clear often - try to determine

• 50% for ‘evaluation’ and 40% for ‘medical clearance’

• The myth of ‘clearance’ – ‘average risk’

• Concept of co-management

• If ‘clearance’ is asked for without a specific question, global pre-operative evaluation needed

Kleinman B, Czinn E, Shah K, et al. The value to the anesthesia-surgical care team of the

preoperative cardiac consultation. J Cardiothorac Anesth 1989; 3:682.

PRACTICE Approach for the Physician Consultation

APPROACH

APPROACH 1: Is the proposed procedure an emergency? If not, step 2.

2: Risk assessment

What are the risks involved? – investigate appropriately

3: Reversal of the correctable

Are any of these reversible? – make a time-bound plan

4: Reduction of complications

How can the expected complications be minimized? – appropriate interventions

5: Re-organize medications

What are the precautions regarding medications?

– instructions on starting, stopping, re-starting, reducing, increasing medications

‘RELATIVE RISK’

Step 1

EMERGENCY OR NOT?

• Which is a higher risk to life?

• Clinical risk stratification for documentation

• Proceed

RISK ASSESSMENT

Step 2

OVERALL RISK WHAT IS WRONG AND HOW BAD IS IT?

History – Known risk factors

• Effort tolerance - METS

• Past, personal and treatment

Examination – Known and unknown risk factors

• Assess status of known

• Unknown – eg: stenotic valvular lesion

Investigation - Known and unknown risk factors

• Identify unknown risk factors

• Assess status of known

HISTORY AND EXAMINATION

EFFORT TOLERANCE

• METS – metabolic equivalents

• One MET equals the oxygen consumption of a 70-kg, 40-year-old man in a resting state

• > 4 METS considered good

• Cycling, climbing 1 flight of stairs, walking 4 mph, yard work, sweeping floor/yard etc.

Fletcher GF, Balady G, Froelicher VF, Hartley LH, Haskell WL, Pollock ML.

Exercise standards. A statement for healthcare professionals from the American Heart

Association.

Circulation 1995;91:580-615.

HIGH RISK FACTORS AND THEIR IMPLICATIONS

System Risk factors Implications

Cardiovascular Unstable angina

Recent MI

Decompensated CHF

Significant arrhythmias

Severe valvular

disease

Perioperative cardiac

events

REVISED GOLDMAN CARDIAC RISK INDEX(RCRI)

6 independent risk factors Points

Cerebrovascular disease 1

Congestive heart failure 1

Creatinine level > 2.0 mg per dL (176.80 μmol per L) 1

Diabetes mellitus requiring insulin 1

Ischemic cardiac disease 1

Suprainguinal vascular surgery, intrathoracic surgery, or

intra-abdominal surgery

1

Total Score

Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a

simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999;

100:1043.

REVISED GOLDMAN CARDIAC RISK INDEX(RCRI)

Risk factors Rate of complications

No risk factors 0.4 percent (95% CI: 0.1-0.8)

One risk factor 1.0 percent (95% CI: 0.5-1.4)

Two risk factors 2.4 percent (95% CI: 1.3-3.5)

Three or more risk factors 5.4 percent (95% CI: 2.8-7.9)

Devereaux PJ, Goldman L, Cook DJ, et al. Perioperative cardiac events in patients

undergoing noncardiac surgery: A review of the magnitude of the problem, the

pathophysiology of the events, and methods to estimate and communicate risk. CMAJ 2005;

173:627.



Respiratory Chronic Lung diseases

Smoking

Obesity

Abnormal ABG

Tolerance for

anesthesia

Post-Op extubation

and weaning

Intra-op

bronchospasm



Liver Hypoalbuminimia

Coagulopathy

Hemostasis

Wound healing

Nervous Neuro-muscular weakness

Previous CVA

Post-op extubation

and weaning

Perioperative vascular

events

Rheumatologic Active disease

On DMARDs

Medications –

interactions and

complications



Diabetes Requiring insulin

High HbA1C

Recent change in drugs

Complicated

Peri-operative

glycemic status

Peri-op vascular

events

Wound healing and

infections

Other endocrine Addison’s Disease

Uncontrolled hyperthyroidism

Hormone-related

crises

INVESTIGATIONS

PRE-OPERATIVE INVESTIGATIONS

Investigation Indication

ECG Signs or symptoms of CV disease

High risk surgery

Intermediate risk surgery with

cardiac risk factors

CXR Cardiopulmonary signs or

symptoms

Feely MA, Collins CS, Daniels PR, Kebede EB, Jatoi A, Mauck KF.

Preoperative testing before noncardiac surgery: guidelines and recommendations.

Am Fam Physician. 2013 Mar 15;87(6):414-8.



Urinalysis Invasive urologic procedures

Implantation of foreign material

Creatinine and electrolytes Chronic diseases or medications

which could alter these

Blood sugar Diabetics

High risk of occult diabetes –

history, exam, drugs






Complete Blood Count or

Hemoglobin

High risk of anemia

Anticipating procedural blood

loss

Coagulation studies Predisposing medical condition

History of abnormal bleeding

Drugs causing bleeding




REVERSE RISK

Step 3

REVERSE RISK

• In reversible conditions

• Tailor drugs – eg. MDIs according to PFR, Beta blockade

• Delay (or abandon) procedure

• Plan interventions for risk mitigation – treatment of an ARI, CAG and revascularization, stop smoking

REDUCE COMPLICATIONS

Step 4

ANTICIPATE AND PREVENT

• Product support for CLD, hematological conditions, those on anti-platelets

• Avoiding tachycardia in those with angina, mitral stenosis

• Perioperative euglycemia

RE-ORGANIZE MEDICATIONS

Step 5

RE-ORGANIZE MEDICATIONS

• Which is to be stopped and when

• Which to be continued

• What precautions to be taken with regard to medications

APPROACH

THANK YOU

Copyright of this educational material rests with the author and

Christian Medical College, Vellore. Duplication, revision and

redistribution are not permitted. For any further clarification please

contact the concerned author

© reserved to author and Christian Medical College, Vellore

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