surgical techniques of orthotopic liver transplanation · bja 2016 117(6): 6814.-what is...

Preoperative Evaluation

Elizabeth A. Valentine, MDDepartment of Anesthesia and Critical Care

July 5, 2018

Goals

• Review important contact information for the Department of Anesthesiology and Critical Care

• Provide a framework for understanding preoperative medical evaluation (and why it is important)

• Review major societal recommendations regarding preoperative evaluation and testing– 2012 ASA Advisory for Preoperative Evaluation– 2014 ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation

for Noncardiac Surgery– 2016 ACC/AHA Guideline Focused Update on Duration of Dual

Antiplatelet Therapy in Patients With Coronary Artery Disease

HOW DO I CONTACT THE DEPARTMENT OF ANESTHESIOLOGY AND CRITICAL CARE IF I HAVE QUESTIONS ABOUT A CASE?

Important Anesthesia Contact Information

• Anesthesia Scheduler: – Sandy Boyer ([email protected])

• Directors of Preoperative Medicine:– Marc Royo, MD MBA ([email protected])– Onyi Onuoha, MD MPH ([email protected])

• Anesthesia Consults:– Email Sandy and Directors of Preoperative Medicine– Call Preoperative Medicine Resident (7a-5p): 215-964-5752– On call resident (evening): 215-908-0400

• Anesthesia Coordinator: 215-771-3498

WHAT IS PREOPERATIVE EVALUATION (AND WHY IS IT IMPORTANT)?

• What is risk assessment/stratification?• What is medical optimization?• What is “clearance”?

Risk Assessment/Stratification

• The decision to undergo surgery requires a complex weighing risks, benefits, and non-surgical alternatives for treatment

• Many factors play into this decision:– Surgical risk– Medical risk– Urgency of the procedure

• Many vested stakeholders in the decision:– Surgical team– Medical team– Patient and family


• Risk assessment/stratification attempts to estimate a particular patient’s risk, based on surgical and medical factors, to predict likelihood of adverse events

• There is no such thing “clearance” of risk• There is no safe surgery – even a healthy patient

undergoing a minor procedure incurs risk!

How Can We Estimate Risk?

https://riskcalculator.facs.org/RiskCalculator/index.jsp


• Our goal is to make surgery safer – to minimize the modifiable risk– Lifestyle changes– Diagnostic tests– Optimization of

medical therapies– Procedural

interventionsRiggs KR, Segal JB. What is the rationale for preoperative medical evaluations? A closer look at surgical risk and common terminology. BJA 2016 117(6): 681-4.

What is Optimization?

• Clear outline of what is wrong, and how bad• Determination of whether the patient/condition is “the

best s/he is going to get”• If not optimized: what is the plan to

intervene/improve?• If optimized: what is the plan to try to mitigate risk or

manage predictable complications?

This is a Bad Preop “Clearance” Note

A Little Better…

If you really want to see an anesthesiologist’s head explode

Surgeon

WHAT SHOULD PREOPERATIVE EVALUATION ENTAIL?

Preoperative Evaluation

• Evaluation of pertinent medical records• Patient interview• Physical Examination• Additional laboratory studies, preoperative testing, and

preoperative consultation as dictated by the above• Thoughtful decision making about perioperative

medication management

Preoperative Testing

• Ideally:– Cheap– High positive and negative predictive values– Add to information obtained from clinical history

and physical exam– Change or modify perioperative decision making

to prevent perioperative complications


• Should be ordered for specific indication only• Results should clarify questions about preexisting

medical condition or establish a relevant new diagnosis in patients with significant risk factors for specific conditions

• The more tests ordered, the more chance of a false-positive result– Wasted time – Wasted money– Risk for complications


• In the medical population, 50% of clinical diagnoses and nearly 50% of management decisions based on history alone

• Routine studies contribute to less than 1% of all diagnoses

• In the surgical world, routine preop screening rarely discovers abnormalities not predicted by history alone, and when detected, results are rarely actionable

Sandler G. Costs of unnecessary tests. Br Med J 1979; 2:21-4.Delahunt B, Turnbull PRG. How cost effective are routine preoperative investigations. N Z Med J 1980; 92:431-2.Kaplan EB, Sheiner LB, Boeckmann AJ, Roizen MF, Beal SL, Cohen SN, et al. The usefulness of preoperative laboratory screening. JAMA 1985; 253:3576-81.Narr BJ, Warner ME, Schroeder DR, Warner MA. Outcomes of patients with no laboratory testing before anesthesia and a surgical procedure. Mayo ClinProc 1997; 72:505-9.

Timing of Preoperative Testing

• Test results should be within 6 months of surgery, provided the patient’s medical history has not changed substantially in the interim

• More recent test results may be desirable when the medical history has changed or when a test results may play a role in the selection of a specific anesthetic technique (e.g. , regional anesthesia in the setting of anticoagulation therapy).

The American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice Advisory for Preanesthesia Evaluation. Anesthesiology 2012; 116:2-17.

Complete Blood Count• Clinically asymptomatic anemia has been shown to be

present in about 1% of patients but surgically significant anemia in unselected patients is even more rare

• Should be considered if:– Highly invasive procedure/high risk of blood loss– Extremes of age– History of liver disease– History of anemia– History of bleeding diatheses

Kaplan EB, Sheiner LB, Boeckmann AJ, Roizen MF. Beal SL. Cohen SN, et al. The usefulness of preoperative laboratory screening. JAMA 1985; 253:3576-81.The American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice Advisory for Preanesthesia Evaluation. Anesthesiology 2012; 116:2-17.

Coagulation Studies

• An unexpected coagulation defect leading to excessive surgical bleeding is extremely unlikely, provided a thorough history (both personal and family) and physical exam is performed

• Reasonable for patients with:– Bleeding diatheses (inherited or iatrogenic)– Renal dysfunction– Liver dysfunction– Undergoing highly invasive procedures

Chee YL, Crawford JC, Watson HG, Greaves M. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British J Haematol 2008; 140:496-504.The American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice Advisory for Preanesthesia Evaluation. Anesthesiology 2012; 116:2-17.

Regional/Neuraxial Anesthesia and Antithrombotic/Antiplatelet Therapy

Serum Chemistries• Significant electrolyte abnormalities noted on routine

screening are extremely rare• Increased glucose in patients having noncardiac,

nonvascular surgery are associated with increased perioperative cardiovascular mortality compared to normoglycemic patients

• Consider if:– Known endocrine abnormalities– Renal dysfunction– Liver dysfunction– Use of certain medicine/therapies (diuretics, dialysis..)

The American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice Advisory for Preanesthesia Evaluation. Anesthesiology 2012; 116:2-17.Wattsman TA, Davies RS. The utility of preoperative laboratory testing in general surgery patients for outpatient procedures. Am Surg 1997; 63:81-90.Nordic PG, Vergsma E. Schreiner F, Keratin MD, Fringe HH, Dunkelgrun J, et al. Increased preoperative glucose levels are associated with perioperative mortality in patients undergoing noncardiac, nonvascular surgery. Eur J Endocrinol 2007; 156:137-42.Frisch A, Chandra P, Smiley D, Pen L, Rizzo M, Gatcliffe C, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiacsurgery. Diabetes Care 2010; 33:1783-8.

Chest Radiograph• Abnormalities on chest radiograph are incredibly

common but rarely change perioperative outcome or management

• Exception is to evaluate possible acute processes (pneumonia, decompensated CHF)

Joo HS, Wong J, Naik VB, Savodelli GL. The value of screening preoperative chest x-rays: a systematic review. Can J Anesthes 2005; 52:568-74.

Chest Radiograph• ASA says consider for:

– Smoking– Recent upper respiratory infection– COPD– Cardiac disease

• ACP suggests CXR may be helpful in patients >50yo who are undergoing AAA repair, upper abdominal, or thoracic surgery

• AHA adds BMI > 40 kg/m2

The American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice Advisory for Preanesthesia Evaluation. Anesthesiology 2012; 116:2-17.Smetana GW, Lawrence VA, Cornell JE, American College of Physicians. Preoperative pulmonary risk stratification for noncardiothoracic surgery: a systematic review for the American College of Physicians. Ann Intern Med 2006; 144:581.Poirer P, Alpert MA, Fleisher LA, Thompson PD, Sugerman HJ, Burke LE, et al. Cardiovascular evaluation and management of severely obese patients undergoing surgery: a science advisory from the American Heart Association. Circulation 2009; 120:86-95.

Pulmonary Function Testing

• Range from noninvasive passive or provocative screening tests (e.g., PFTs or spirometry) to invasive assessment of pulmonary function (e.g., ABG, split lung function, right heart catheterization)

• Incidence of pulmonary complications is higher in patients with preexisting lung disease

• Preoperative PFTs have not proven to be better predictors than clinical findings in predicting significant postoperative pulmonary complications after surgical procedures not involving lung resection

Kroenke K, Lawrence VA, Theroux JF, Tuley MR, Hilsenbeck SG. Postoperative complications after thoracic and major abdominal surgery I patients with and without obstructive lung disease. Chest 1993; 104:1445-51.Smetana GW, Lawrence VA, Cornell JE. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006; 144:581-95.Ivanov A, Yossef J, tailon J, et al. Do pulmonary function tests improve risk stratification before cardiothoracic surgery? J Thor Cardiovasc Surg 2016; 151(4):1183-9.

Risk Factors for Postoperative Pulmonary Complications

Patient factors:• Advanced age• ASA PS 2 or higher• Functional dependence• COPD• Smoking• CHF• OSA• PHTN

Surgical Factors:• Surgery close to the

diaphragm (thoracic and upper abdominal)

• Emergency surgery• Prolonged duration• Neurosurgery• Head and neck surgery• Vascular surgery• General anesthesia

Smetana GW, Lawrence VA, Cornell JE. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006; 144:581-95.Hwang D, Shakir N, Limann B, Sison C, Kalra S, Shulman L, et al. Association of sleep-disordered breathing with postoperative complications. Chest 2008; 133:1128-34.Ramakrishna G, Sprung J, Ravi BS, Chandrasekaran K, McGoon MD. Impact of pulmonary hypertension on the outcomes of noncardiacsurgery: predictors of perioperative morbidity and mortality. J Am Coll Cardiol 2005; 45:1691-9.

UPHS PreOp Testing GuidelinesUPHS Recommendation

No Testing NO testing in ASA 1 or 2 regardless of age having a low risk procedure.

Duration of acceptability of tests

SIX MONTHS before surgery if the patient’s medical history has not changed.

Basic Metabolic Panel In patients having major surgery, taking diuretics, digoxin, potassium supplements, with a history of CKD, or if IV contrast dye will be injected

CBC Having major surgery, anemia history, or cirrhosis

CXR Not Required

EKG In patients with known Diabetes, CAD, CVD, arrhythmias, structural heart disease, or peripheral arterial disease having elevated risk surgery. No age or BMI inclusion.

Finger Stick (Glucose) All Diabetics the day of surgery

Pregnancy Urine HCG for all females with potential of pregnancy

PT/PTT/INR Any patient on anticoagulants, with a bleeding history, or cirrhosis

T & S If indicated

WHAT ABOUT PREOPERATIVE CARDIAC EVALUATION AND TESTING?

Preoperative Cardiac Testing

• Range from noninvasive (e.g., electrocardiogram or echocardiogram) to invasive (e.g., cardiac catheterization) assessment of cardiac structure, function, and vascularity

• May be passive or provocative (e.g., stress testing)

• Clinical characteristics to consider include:– cardiovascular risk factors– type and invasiveness of surgery

The American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice Advisory for Preanesthesia Evaluation. Anesthesiology 2012; 116:2-17.

Preop ECG

Preop Echo: Assessment of LV function

Valvular heart disease• Preoperative echo is recommended for patients with clinically

suspected moderate or greater degree of valvularregurgitation or stenosis if: (1) no prior echo w/in 1y; or (2) significant change in clinical status since last exam. (Class I, LOE C)

• Valve replacement or repair before noncardiac surgery for patients who meet standard criteria for valve replacement/repair is effective in reducing perioperative risk (Class I, LOE C)

• Elevated-risk noncardiac surgery w/appropriate monitoring is reasonable in patients with: (1) asymptomatic severe AS; (2) asymptomatic severe MR; (3) asymptomatic severe AI with normal LVEF (Class IIa/b, LOE B/C)

2014 ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery


Risk Factors:AgeSexHTNCVDCKDIDDMObesity….


Emergency procedure = life or limb is threatened if not in the operating room with no or very limited time for preoperative clinical evaluation, typically within <6 hours. Urgent procedure = life or limb is threatened but there may be time for a limitedclinical evaluation, typically between 6 and 24hours. Time-sensitive procedure = a delay of >1 to 6 weeks to allow for an evaluation and significant changes in management will negatively affect outcome.Elective procedure = the procedure couldbe delayed for up to 1 year.


Acute Coronary Syndrome Equivalents:• Unstable (active or

crescendo angina) coronary syndromes or recent MI

• Decompensated HF (NYHA Class IV, new onset, worsening)

• Suspected new or significant worsening of valvular heart disease

• Unstable arrhythmias (Symptomatic or new ventricular arrhythmias, supraventricular arrhythmias with uncontrolled ventricular rate, High grade AV block, symptomatic bradycardia


Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the AmericanCollege of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 63:e57–185.

Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force onPractice Guidelines. J Am Coll Cardiol. 2013;62:e147–239.

O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American HeartAssociation Task Force on Practice Guidelines. J AmColl Cardiol. 2013;61:e78–140.

Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/ AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American Collegeof Cardiology Foundation/ American Heart AssociationTask Force on Practice Guidelines, and theAmerican College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiographyand Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2012;60:e44–164.

Fihn SD, Blankenship SC, Alexander KP, et al. 2014ACC/AHA/AATS/PCNA/SCAI/STS focused update of theguideline for the diagnosis and management of patientswith stable ischemic heart disease: a report ofthe American College of Cardiology/American HeartAssociation Task Force on Practice Guidelines, and theAmerican Association for Thoracic Surgery, PreventiveCardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Societyof Thoracic Surgeons. J Am Coll Cardiol. 2014;64: 1929–49.

Jneid H, Anderson JL, Wright RS, et al. 2012 ACCF/AHA focused update of the guideline for themanagement of patients with unstable angina/non-ST-elevation myocardial infarction (updating the2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association TaskForce on Practice Guidelines. J Am Coll Cardiol. 2012;60:645–81.


American College of Surgeons NSQIP risk calculator

www.surgicalriskcalculator.com


Low risk = can proceed to surgery without any further testing


If elevated risk, it’s all about symptomatology and functional capacity

Functional capacity > 4 METS


Elevated risk but moderate/good to excellent functional status = can go to surgery


Elevated risk and poor to unknown functional status = pharmacologic stress IF IT WILL IMPACT CARE

Provocative/invasive cardiac testing

Should we revascularize everyone preoperatively?

Should we revascularize everyone preoperatively?

• Based largely on the CARP trial, ACC/AHA guidelines do not recommend revascularization for the general population

• Follow the recommendations found in routine clinical practice guidelines for revascularization (CABG/PCI)

• There are subsets of populations who benefit from preoprevascularization – probably worth having cardiology and anesthesia weigh in on perioperative management

What if the patient already had a recent cardiac revascularization?

Treatment Algorithm for the Timing of Elective Noncardiac Surgery in Patients With Coronary Stents

Patients Treated With PCI Undergoing Elective Noncardiac Surgery

BMS treated with DAPT

DES treated with DAPT

Class I:Proceed with

surgery

Class III: HarmDelay surgery

Class IIb:Proceeding with surgery may be

considered

Class I:Proceed with

surgery

Class III: HarmDelay surgery

3-6 mo since DES implantation,

discontinue DAPT; delayed surgery risk is

great than stent thrombosis risk

≥6 mo since DES

implantation, discontinue

DAPT

<30 d since BMS

implantation

<3 mo since DES implantation

≥30 d since BMS

implantation

0 d

30 d

3 mo

6 mo

Perioperative Management:Timing of Elective Noncardiac Surgery in Patients Treated

With PCI and DAPT

Levine GN, et al. 2016 ACC/AHA Guideline Focused Update on Duration of DAPT in Patients with CAD. JACC 2016 & Circulation 2016

Conclusions

• A good history and physical exam will get you far• Most extensive workups are unnecessary unless a

change in clinical status• Determining functional status answers a lot of

questions• Early multidisciplinary involvement in complex patients

can help ensure appropriate optimization • We are happy to help answer any questions!

surgical techniques of orthotopic liver transplanation · bja 2016 117(6): 6814.-what is...

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