clearance of the cardiac patient for non-cardiac surgery
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Clearance of the Cardiac Patient for Non-cardiac Surgery. Evaluation and Management. PRE-OP CLEARANCE. Not truly “Clearance” – but assurance that the pt.’s condition is optimal for the proposed surgery in the planned time frame. - PowerPoint PPT PresentationTRANSCRIPT
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Clearance of the Cardiac Patient for Non-cardiac Surgery
Evaluation and
Management
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PRE-OP CLEARANCE
• Not truly “Clearance” – but assurance that the pt.’s condition is optimal for the proposed surgery in the planned time frame.
• A focused assessment, addressing a particular issue specified by the parties: Cardiac risk? Atr. Fib? CHF? Pulmonary risk? General medical status? What is consultant’s role here?
• A calculation of the relative risk and estimation of the Risk/Benefit. Controversial issues best communicated verbally.
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PRE-OP CLEARNCE –II
THE NOTE• List of the medical/cardiac problems, severity, and
degree of control. • List of medications.
Allergies.• Steps to achieve optimal pre-op status-
Tests (minimal) and treatments, e.g., A/C Rx, CHF, BB’s.
• Peri-op precautions, e.g., prophylactic Abx, volume guidelines. Post-op monitoring steps.
• One page! Concise! LEGIBLE! Clearly signed, with Tel./Beeper No.
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COMPOSITE QUALITATIVE ESTIMATION OF OPERATIVE RISK
CLINICAL FUNCTIONAL PERIOP. INHERENT SURGICAL
PREDICTORS IMPAIRMENT RISK RISK
High risk Very limited ADLs HIGH High risk >5%
e.g.,unstable or ++++ EST e.g., AAA or
cor syndrome - emergent abd.op.
Intermediate risk - INTER- Intermediate 1-5%
e.g., prior MI - MEDIATE e.g. TURP or
Low risk Vigorous ADLs ORIF
e.g., stable abn’l or (-) EST at LOW Low risk <1%
EKG hight workload. e.g., cataract op.
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Energy Requirements –Can Patient Perform 4 Mets?
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CARDIAC
RISK
INDICES
(I)
The Goldman Index
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RISK OF MAJORCARDIAC COMPLICATIONS
Class I 0-5 pts.
Class II 6-12 pts.
Class III 13-25 pts.
Class IV =,> 26 pts.
Mangano, Goldman et al.
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(II)
ACC
AHAGuide-
lines
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Up-to-date
S
I
C
C
I
C
S
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S
I
C
C
I
C
(III)
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Indications for pre-op stress testing
• EXCLUSIONS: Pts. with likely CAD who will not consent to revascularization procedures. Pts. whose non-cardiac surgery cannot be deferred for 4-6 weeks.
• Pts. with recent ACS- MI, Unst.AP, ischemic APE- not revascularized, now asymptomatic, for intermediate or high risk surgery.
• Pts. for intermediate or high risk surgery with limited exertional capacity, plus additional clinical risk factors such as CHF, cerebrovascular disease, diabetes, CRI.
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Risk Reduction for the Cardiac Patient for Non-cardiac Surgery
Choice of procedureChoice of surgeon and hospital
Choice of pre-op interventions and meds.Optimization of status in time allotted(?)
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Expected post-revascularization delays
• CABS-1-3 months convalescence for physical and emotional rehab.
• DES- at least 3 months clopidigrel,to reduce instent-thrombosis risk.
• BMS- 4-6 weeks clopidigrel.
• POBA- one month, for hypercoagulable intima.
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8/56= 14% MACE- IF WITHIN 6 WEEKS OF PCI. Am. J. Cardiol. 2005; 95:755
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McFalls et al., Coronary-Artery Revascularization before Elective Major Vascular Surgery. NEJM 2004;351:2795-804.
510 pts randomized.
For expanding AAA or PVD of legs.
At incr. clinical risk or ischemia on EST.
All had coronary angios with stenosis>70% in one or more major cor. arts.
Exclusions:
Need for urgent or emergency surgery.
LMCAD > 50%
LVEF < 20%
Severe AS.
30-day mortality: Revasc-3.1% No Revasc- 3.4%Post-op MI(incr. Trop.)- 12% vs 14%
REVASCULARIZATION
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Myoc. O2 Demand during Anesthesia and Surgery
.
RPP
10,000
Hosp. O.R. Induction I hr.into Transfer 24 hrs
Adm. Arrival of Anesth. Surgery to PACU later
Consent
On BBs
Frishman and Oka
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.
Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Mangano et al, NEJM 1996; 335;1713-20
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NEJM 1999;341:1789-94
112 pts., + DSE
Bisoprolol 5-10mg po vs P.
Begun av. 37 d. pre-op, to 30 d. post-op.
Cardiacdeath
3.4%vs 17%
Nonfatal MI
0% vs 17%
Cardiac death
3.4%vs 17%
Nonfatal MI
0% vs 17%
53 pts. on BBs previously -
Mortality 4.5%
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B-Blockers and Reduction of Cardiac Events in Noncardiac Surgery. A.D.Auerbach, MD, MPH and Lee Goldman, MD
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Boersma et al, JAMA 2001:285;1865-1873
PREDICTORS OF CARDIAC EVENTS AFTER MAJOR VASCULAR SURGERY
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Case control study. 2816 pts.- vasc. Surgery- 160 died - each compared to 2 survivors matched by year and surgery.
Statin use - in Deaths: 8%. - in Survivors: 25%
OR for periop. mortality among statin users vs. nonusers:0.22 (0.10-0.47)
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Grayburn, P.A. and Hillis, L.D., Annals Int. Med. 2003; 138:506-511
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IN CONCLUSION…..
• Who need B-Blockers? Pts. for intermediate or high risk surgery, with confirmed or likely CAD, or coronary risk factors (without asthma or bradys.)
• Who need stress testing?* Pts. with (probable) CAD, for elective intermediate or high risk surgery, with limited exertional capacity, plus additional clinical risk factors such as CHF, CVA/TIA, diabetes, CRI.
• Who need coronary angios?* Pts. with recent ACS for intermediate or high risk op. Pts. with extensive ischemia on EST. Pts. with hair-trigger angina despite Rx. * if urgency of surgery permits.
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1. 76 M. for TURP. Had IWMI 5 yrs. ago, with occasional exertional angina since. Is on Imdur.
• Inherent surgical risk – 1-3%.
• Pt.’s clinical risk - Intermediate.
• Exercise tolerance – very good. Condition is stable.
• Overall peri-op risk – 2-3 % for peri-op Mortality, M.I., CHF.
• Steps to reduce risk:Add B-blocker pre-op.
?Add statins - proper run-in time?Maintain HCT > 30%
Add ASA soon post-op.
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Qualitative assessment of operative riskCLINICAL FUNCTIONAL PERIOP. INHERENT SURGICAL
PREDICTORS IMPAIRMENT RISK RISK
High risk Very limited ADLs HIGH High risk >5%
e.g.,unstable or ++++ EST e.g., AAA or
cor syndrome - emergent abd.op.
Intermediate risk - INTER- Intermediate 1-5%
e.g., prior MI - MEDIATE e.g. TURP or
Low risk Vigorous ADLs ORIF
e.g., stable abn’l or (-) EST at LOW Low risk <1%
EKG hight workload. e.g., cataract op.
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2. 72 yo W. –acute NSTEMI 2 wks. ago. Has 2 cm. left breast nodule.
• Clinical risk intermediate or high, depending on ease of precipitating ischemia.
• Surgical risk- low for biopsy - intermediate for mastectomy.
• Moderate time pressures for intervention-chiefly emotional:
PCI and Plavix x 6 weeks to 3-6 months?CABS and rehab x two months?
EST and BB’s in one-two weeks?
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3. 73 yo M. has ischemic rest pain.Also HTN, LVH and angina on Rx.
Fem-pop bypass proposed.
• Surgical risk- intermediate –to - high.• Clinical risk- Intermediate.• Exercise tolerance – limited by claudication. • Time factor - < 30 days- no gangrene yet. • Options? - BB’s
-EST stratification - PCI
- CABS• If 2-block claudication w/o rest pain?
Med. management or possibly iliac stent.Future CAD risk stratifiction.
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4. 54 yo W. needs hysterectomy, has anemia.Has HTN and NSSTTC.
• Surgical risk is intermediate; low if laparoscopic.
• Clinical risk low (hypertension) - or -intermediate ( if NSSTTC are significant and
new.)
• Exercise tolerance very good.
• Time factor – not urgent.
• Steps: Obtain old EKGs. Start HTN Rx- BB’s, diuretics, ACE-
inhibs. Consider EST if duration of STTC is unknown.
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5. 80 yo W., left hip IT fracture x5wks, history of HTN, and atrial fibrillation.
• Heart rate control- BB’s, CCB’s, digoxin.
• Heart disease assessment – Px, 2DE. Stress testing and revascularization are
precluded by the fracture.
• Anticoagulation Rx- indicated but not urgent.Long term use will depend on reliability
and communication issues.
• Orthopedic time frame – elective at this point.
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6. 28 yo W., with click and MVP, requires dental work.
• Dx- Mitral valve prolapse, with (perhaps) MR.No arrhythmias or chest pain.
• Meds- e.g., Fiorinal PRN, OCPs. Not on A/C Rx.
• Allergies- NKDA• Recs: Premedicate with Amoxicillin 2 gms po.
Use “EPI” if preferable.
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7. 72 yo M. for TKR, with NIDDM and asymptomatic left carotid stenosis.
• Time frame is elective.• Estimate surgical risk as low intermediate.• Exercise tolerance is unknown and CAD likely, but
he has no CHF, prior MI,CVA/TIA, insulin use or CRI. DSE or Persantine MIBI are probably not indicated.
• Plan for CEA, in view of ACAS data if institutional surgical risk is <5%.
• With DM and carotid vasc. disease, consider coronary risk equivalent to that of prior MI with respect to statin, BB, and ASA use
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8. 55. yo W. has mechanical MVR, Atr. Fib, on A/C RX, and needs dental extractions.
• Hold Warfarin for 3 nights, check INR and proceed, then immediately resume RX.
• Or- Hold A/C RX for 4 nights. Check INR on 3rd day, and cover with LMWH pre-op and
immediately post-op, while resuming warfarin.
• Remember SBE prophylaxis- Amox orErythro. or Clinda.
• “Epi” is permitted.