Intro to PeriOperative Medicine

Intro to Intro to PeriOperative PeriOperative

MedicineMedicineCompiled by Compiled by

Tabitha Goring, MD Tabitha Goring, MD Hospitalist Attending/Assistant Professor of Hospitalist Attending/Assistant Professor of

MedicineMedicineJacobi Medical CenterJacobi Medical Center

Albert Einstein College of MedicineAlbert Einstein College of Medicine

Perioperative MedicinePerioperative Medicine

Cardiac Risk Assessment Cardiac Risk Assessment in non-cardiac surgeryin non-cardiac surgery

Goldman Cardiac Risk IndexGoldman Cardiac Risk Index PointsPoints

Age > 70 yoAge > 70 yo 55

MI < 6 months agoMI < 6 months ago 1010

JVD or S3 gallopJVD or S3 gallop 1111

Significant Aortic StenosisSignificant Aortic Stenosis 33

Non-sinus Rhythm, APCs or >5 PVC/minNon-sinus Rhythm, APCs or >5 PVC/min 77

PO2<60 or PCO2>50, K<3.0 or HCO3<20PO2<60 or PCO2>50, K<3.0 or HCO3<20

BUN >50 or Cr>3.0, abnormal AST,BUN >50 or Cr>3.0, abnormal AST,

Signs of chronic liver disease, or bedridden pt.Signs of chronic liver disease, or bedridden pt. 33

Intraperitoneal, intrathoracic or aortic procedureIntraperitoneal, intrathoracic or aortic procedure 33

Emergent OperationEmergent Operation 44


Goldman Risk AssessmentGoldman Risk Assessment

ClassClass Points Points Risk Risk(Complication/Death Risk)(Complication/Death Risk)

II 0-50-5 0.7%/ 0.2% 0.7%/ 0.2%

IIII 6-126-12 5% / 2% 5% / 2%

IIIIII 13-2513-25 11% / 2% 11% / 2%

IVIV >26>26 22% / 56% 22% / 56%

Perioperative MedicinePerioperative MedicineSeverity of Perioperative StressSeverity of Perioperative Stress

HIGH

LOWMODERATE

Aortic Cross ClampIntrathoracicInfrainguinal Vascular

OrthopedicHead & NeckCarotidAmputation

TURPSuperficialCataract


Perioperative Stress HormonePerioperative Stress Hormone Norepinephrine/EpinephrineNorepinephrine/Epinephrine Most anesthetics suppress many elements of the stress responseMost anesthetics suppress many elements of the stress response

therefore, most problems occur postoperativelytherefore, most problems occur postoperatively ComplicationsComplications

TachyarrythmiasTachyarrythmias HyperglycemiaHyperglycemia

HypertensionHypertension Protein MetabolismProtein Metabolism

Myocardial ischemiaMyocardial ischemia CHF (Na CHF (Na retention)retention)

Vasoconstriction (wound failure)Vasoconstriction (wound failure) HypoNa, K, MgHypoNa, K, Mg

HypercoaguabilityHypercoaguability SIRSSIRS


Non-invasive Pre-op Cardiac TestingNon-invasive Pre-op Cardiac Testing

Exercise TreadmillExercise Treadmill

Exercise ThalliumExercise Thallium

Dipyridamole ThalliumDipyridamole Thallium

Holter MonitorHolter Monitor

Dobutamine EchocardiogramDobutamine Echocardiogram

Peri-Operative MedicinePeri-Operative Medicine

Dobutamine Stress EchoDobutamine Stress Echo(Shaw et al 1996- Metaanalysis)(Shaw et al 1996- Metaanalysis)

Highest positive predictive value(45-Highest positive predictive value(45-65%)65%)

Well ToleratedWell Tolerated Predictive Value increases with Predictive Value increases with

number of walls imaged.number of walls imaged.


Post-op Pulmonary ComplicationsPost-op Pulmonary Complications

Diaphramatic dysfunctionDiaphramatic dysfunction

HypoxemiaHypoxemia

Pneumonia Pneumonia

BronchospasmBronchospasm

Respiratory FailureRespiratory Failure


PulmonaryPulmonary

No need for routine pre-op PFTsNo need for routine pre-op PFTs No data that routine pre-op CXR No data that routine pre-op CXR

improves outcomeimproves outcome

Perioperative Perioperative ManagementManagement

Asthma Rec’sAsthma Rec’s Consider Oral Streoids 24-48h in mod-Consider Oral Streoids 24-48h in mod-

severe asthmatics (better than inhaled severe asthmatics (better than inhaled steroids to prevent periop flares)steroids to prevent periop flares)studies show no increased wound infections, impaired wound healing or studies show no increased wound infections, impaired wound healing or hyperglycemia.hyperglycemia.

Kabalin, Arch Intern Med Kabalin, Arch Intern Med 1995; 1551995; 155

Inhaled Albut/Atrov for wheezingInhaled Albut/Atrov for wheezing Smoking Cessation 8 wks prior to surgerySmoking Cessation 8 wks prior to surgery

Perioperative Perioperative ManagementManagementAsthma Rec’s cont’dAsthma Rec’s cont’d

Consider use of regional anesthesiaConsider use of regional anesthesia Nebulizers intra-op for flaresNebulizers intra-op for flares IV lidocaine + inhaled salbutamol have IV lidocaine + inhaled salbutamol have

synergysynergy

pretreat prior to airway irritationpretreat prior to airway irritation Propofol, ketamine useful in asthmaticsPropofol, ketamine useful in asthmatics

(bronchodilators).(bronchodilators).

PeriOperative MedicinePeriOperative Medicine

What does the anesthesiologist What does the anesthesiologist know?know?

Cancel a case….Cancel a case….

Well versed in IV meds Well versed in IV meds notnot PO meds PO meds((HTN, DM, MI, CHF, BrSpasm, Oliguria, Pain)HTN, DM, MI, CHF, BrSpasm, Oliguria, Pain)

Choice of anesthestic agentChoice of anesthestic agent

Choice of invasive or non-invasive Choice of invasive or non-invasive monitoringmonitoring


What doesn’t the anesthesiologist What doesn’t the anesthesiologist know?know?

Long term management of chronic Long term management of chronic problems…problems…

-HTN-HTN-CAD-CAD-Renal Failure-Renal Failure-Malnutrition-Malnutrition-Hepatic Dysfunction-Hepatic Dysfunction-Endocrinologic Conditions -Endocrinologic Conditions


What does the anesthesiologist want to What does the anesthesiologist want to know?know?

Regarding Drug Regimens….Regarding Drug Regimens….

-1-1stst line, 2 line, 2ndnd line, initial dose, titration, expected SEs line, initial dose, titration, expected SEs

-Further tests might be indicated preoperatively-Further tests might be indicated preoperatively

-Management -Management suggestionssuggestions

-Help to optimize the underlying disease p/t the surgical insult-Help to optimize the underlying disease p/t the surgical insult

-Never “clear” for a certain type of anesthesia -Never “clear” for a certain type of anesthesia

(may need to convert to GA anyway) (may need to convert to GA anyway)

-Stent info; Type; Location; When placed; Antiplatelet Agents-Stent info; Type; Location; When placed; Antiplatelet Agents

-Pacer/AICD (date last checked) - ?magnet-Pacer/AICD (date last checked) - ?magnet

-Suggest Cardiology when needed-Suggest Cardiology when needed


Internists primary goal is not simply to Internists primary goal is not simply to “clear”“clear” pts for surgery, but to pts for surgery, but to

1. establish and optimize the pts risk for 1. establish and optimize the pts risk for cardiopulmonary complications, based on the pts cardiopulmonary complications, based on the pts current medical status in conjunction with the current medical status in conjunction with the degree of perioperative stress caused by a degree of perioperative stress caused by a particular procedure.particular procedure.

2. provide management recommendations 2. provide management recommendations which pertain to pts underlying medical problemswhich pertain to pts underlying medical problems


ACC/AHA 2007 Guidelines on ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation Perioperative Cardiovascular Evaluation and Care for Cardiac Surgery and Care for Cardiac Surgery ((J Am Coll J Am Coll Cardiology 2007;50e159-241)Cardiology 2007;50e159-241)

The bottom line……….The bottom line……….

****Intervention is rarely necessary to simply ****Intervention is rarely necessary to simply lower risk……unless it is indicated lower risk……unless it is indicated irrespective of the planned procedure. irrespective of the planned procedure.


Components of the Pre-op EvaluationComponents of the Pre-op Evaluation~History ~History (chronic illnesses, meds, social hx)(chronic illnesses, meds, social hx)

~Physical~Physical~Prior hx of cardiac w/u ~Prior hx of cardiac w/u (echo, stress test, holter, AICD, (echo, stress test, holter, AICD,

cardiac cath)cardiac cath)

~Assessment of functional status (METS) ~Assessment of functional status (METS)

~PSH/Anesthetic complications~PSH/Anesthetic complications

~DI~DI

~EKG (in moderate to high risk pts)~EKG (in moderate to high risk pts)


Establish Patient riskEstablish Patient risk

Establish Surgical riskEstablish Surgical risk

Perioperative MedicinePerioperative MedicinePATIENT RISKPATIENT RISK

Who is High Risk?Who is High Risk?

Acute MI (<7 days) → Stress Testing → delay 4-Acute MI (<7 days) → Stress Testing → delay 4-6 weeks6 weeks

Recent MI (8-30 days) → Stress Testing → delay 4-Recent MI (8-30 days) → Stress Testing → delay 4-6 weeks6 weeks

Unstable angina/severe anginaUnstable angina/severe angina (+) stress test/echo with large ischemic burden(+) stress test/echo with large ischemic burden Decompensated CHF (+) S3 → ? Decompensated CHF (+) S3 → ?

EchocardiogramEchocardiogram Arrhythmia → high-degree HB → Cardiology Arrhythmia → high-degree HB → Cardiology

ConsultConsult → → symptomatic arrhythmia c CAD “symptomatic arrhythmia c CAD “ Severe valvular diseaseSevere valvular disease


Who is Intermediate Risk?Who is Intermediate Risk?

mild anginamild angina 1 -ADLeat,dress,toilet,walk 1 -ADLeat,dress,toilet,walk around house(↑) around house(↑)

remote MI >1 monthremote MI >1 month 2-3 -walks 1-2 blocks on level 2-3 -walks 1-2 blocks on level ground (ground (↑ risk)↑ risk)

stable CHFstable CHF METS METS 4 - light housework/climb 2 - light housework/climb 2 flights of stairsflights of stairs

creatinine >2.0creatinine >2.0 5-9 – heavy 5-9 – heavy housework,golf,bowling,dancinghousework,golf,bowling,dancing

diabetes, uncontrolled diabetes, uncontrolled 10 - strenuous exercise 10 - strenuous exercise swimming, tennisswimming, tennis

Qwaves on EKGQwaves on EKG football, basketball, skiing football, basketball, skiing

METSMETS(Working metabolic rate relative to the resting (Working metabolic rate relative to the resting

metabolic rate)metabolic rate)

44 METSMETS

i.i. Ability to perform a spectrum of Ability to perform a spectrum of common tasks correlate well with common tasks correlate well with maximum O2 uptake by treadmill maximum O2 uptake by treadmill testing. (Mangano 1990)testing. (Mangano 1990)

ii.ii. Increased cardiac and long-term risks Increased cardiac and long-term risks in pts unable to meet the 4-met demandin pts unable to meet the 4-met demand

iii.iii. Perioperative ischemia more common Perioperative ischemia more common in those with poor exercise tolerance. in those with poor exercise tolerance.


Pts with low functional capacity <4 METS Pts with low functional capacity <4 METS MAY benefit from MAY benefit from preoperative stress preoperative stress testingtesting to to

-identify preoperative ischemia-identify preoperative ischemia

-identify inducible cardiac arrythmias-identify inducible cardiac arrythmias

-to help estimate cardiac risk-to help estimate cardiac risk

-help identify at risk territory after recent -help identify at risk territory after recent MIMI

***there is only real evidence to support stress testing in pts with 3 or more ***there is only real evidence to support stress testing in pts with 3 or more risk factors who have poor functional capacity AND require high risk risk factors who have poor functional capacity AND require high risk surgery ONLY IF it will change management!!! surgery ONLY IF it will change management!!!


Who is Low Risk?Who is Low Risk? advanced ageadvanced age abnormal EKG/old LBBB/LVHabnormal EKG/old LBBB/LVH low functional capacitylow functional capacity hx of CVAhx of CVA uncontrolled HTNuncontrolled HTN frequent PVCs/NSVTfrequent PVCs/NSVT**risk is not known to increase with accumulation **risk is not known to increase with accumulation

of low risk factors….of low risk factors….


SURGICAL RISKSURGICAL RISK

High RiskHigh Risk

Open Aortic SurgeryOpen Aortic Surgery

Peripheral vascular surgeryPeripheral vascular surgery

XS blood loss estimatedXS blood loss estimated

Large fluid shiftsLarge fluid shifts

Prolonged SurgeryProlonged Surgery



Moderate RiskModerate Risk

Intraperitoneal/Intrathoracic SurgeryIntraperitoneal/Intrathoracic Surgery

CEA/Endovascular AAACEA/Endovascular AAA

Head and Neck SurgeryHead and Neck Surgery

Orthopedic ProceduresOrthopedic Procedures

Open Prostate ResectionOpen Prostate Resection



Low RiskLow Risk

Superficial ProceduresSuperficial Procedures

Endoscopic ProceduresEndoscopic Procedures

Cataract SurgeryCataract Surgery

Breast SurgeryBreast Surgery

Ambulatory ProceduresAmbulatory Procedures


Lee et al -(Circulation Lee et al -(Circulation 1999;100:1043-1049) 1999;100:1043-1049)

““simple index for prediction of cardiac risk”simple index for prediction of cardiac risk”

1.1. Ischemic heart disease (MI, +stress test, NTG, active CP, Ischemic heart disease (MI, +stress test, NTG, active CP, abnormal Qwaves)abnormal Qwaves)

2.2. CHF (hx of HF, APE, PND, LE edema, rales, S3, PVC)CHF (hx of HF, APE, PND, LE edema, rales, S3, PVC)

3.3. CVA (hx if TIA or stroke)CVA (hx if TIA or stroke)

4.4. High risk surgery (AAA, vascular, thoracic sx)High risk surgery (AAA, vascular, thoracic sx)

5.5. Insulin-requiring DMInsulin-requiring DM

6.6. Creatinine >2.0Creatinine >2.0


Who gets an EKGWho gets an EKG??

Evidence supports: Evidence supports:

Anyone who is undergoing intermediate Anyone who is undergoing intermediate oror high risk procedures who have at high risk procedures who have at least one clinical risk factor…CAD, least one clinical risk factor…CAD, PAD, CVA, CRI, DM, CHFPAD, CVA, CRI, DM, CHF

**low risk pts do not need EKGs **low risk pts do not need EKGs (although (although we do them anyway)we do them anyway)


Who gets PCIWho gets PCI (preoperatively)? (preoperatively)?

Balloon angioplasty- Plavix x 2 weeks +ASABalloon angioplasty- Plavix x 2 weeks +ASA

Bare-Metal Stent – Plavix x 4 weeks + ASABare-Metal Stent – Plavix x 4 weeks + ASA

Drug-eluting Stent – Plavix x 1 year (at Drug-eluting Stent – Plavix x 1 year (at least) + ASAleast) + ASA

**(expert-opinion only…no real evidence to support)**(expert-opinion only…no real evidence to support)

**evidence reveals that PCI has **evidence reveals that PCI has nono valve in prevention valve in prevention of cardiac events with except in those who PCI is of cardiac events with except in those who PCI is indicated for ACS indicated for ACS

***CABG for left main disease***CABG for left main disease


Perioperative Beta-BlockersPerioperative Beta-Blockers

Who should be started?Who should be started?• Angina/Arrythmias/HTN – continue!Angina/Arrythmias/HTN – continue!• High Risk pt undergoing high risk procedures High Risk pt undergoing high risk procedures

(evidence supports)(evidence supports)• CHD + high risk procedureCHD + high risk procedure• High risk pt undergoing intermediate risk High risk pt undergoing intermediate risk

procedureprocedure

**always use caution in pts in whom BBs are contraindicated **always use caution in pts in whom BBs are contraindicated (dCHF, severe valvular dx, IHSS, mod-pers asthma etc………(dCHF, severe valvular dx, IHSS, mod-pers asthma etc………


Perioperative B-blockersPerioperative B-blockers

The Verdict is still out on….The Verdict is still out on….• Intermediate Risk pts undergoing moderate risk Intermediate Risk pts undergoing moderate risk

proceduresprocedures (although it is generally accepted that these pts are begun on BBs)(although it is generally accepted that these pts are begun on BBs)

• Low Risk pts undergoing high risk proceduresLow Risk pts undergoing high risk procedures

• Low risk pts do not appear to benefit from and Low risk pts do not appear to benefit from and may be harmed by initiation of BBs. (Lindenauer may be harmed by initiation of BBs. (Lindenauer et al (retrospective)NEJM 2005.)et al (retrospective)NEJM 2005.)


POISE StudyPOISE Study(P(PeriOperative ISchemic Evaluation)eriOperative ISchemic Evaluation)

Inclusion CriteriaInclusion Criteriao Undergoing non-cardiac surgeryUndergoing non-cardiac surgeryo > 45 yo> 45 yoo LOS 24 hoursLOS 24 hourso CAD/PVD/hx of CHF/major vascular surgery CAD/PVD/hx of CHF/major vascular surgery ororo Any 3 of the 7 thoracic/abdominal Any 3 of the 7 thoracic/abdominal

surgery/CHF/TIA/DM/CRF/>70yo/urgent surgerysurgery/CHF/TIA/DM/CRF/>70yo/urgent surgery

PeriOperative MedicinePeriOperative MedicinePOISE StudyPOISE Study

(P(PeriOperative ISchemic Evaluation)eriOperative ISchemic Evaluation)

Exclusion CriteriaExclusion Criteriao Bradycardia <50bpmBradycardia <50bpmo 22ndnd or 3 or 3rdrd degree HB degree HBo AsthmaAsthmao Adverse rxn to a BBAdverse rxn to a BBo CABG w/i 5 yrsCABG w/i 5 yrso Low risk procedureLow risk procedureo On VerapamilOn Verapamil

PeriOperative MedicinePeriOperative Medicine(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)

3548

1506

406

886191 sites23 countries

2005



o 8,351 patients included in the analysis, 99.8% of pts completed 8,351 patients included in the analysis, 99.8% of pts completed 30day f/u30day f/u

o Metoprolol 200 mg (starting 2-4 hours prior to surgery)Metoprolol 200 mg (starting 2-4 hours prior to surgery)o Continued qD x 30 daysContinued qD x 30 dayso Held for HR below 45bpm or hypotension (drug restarted @ Held for HR below 45bpm or hypotension (drug restarted @

lower dose)lower dose)o EKG post-op, first day, second day and 30 days after EKG post-op, first day, second day and 30 days after

surgerysurgery

(biomarkers if MI is suspected)(biomarkers if MI is suspected)

PeriOperative Medicine PeriOperative Medicine


Primary Outcome Primary Outcome 1. Cardiovascular death1. Cardiovascular death

2. Non-fatal MI2. Non-fatal MI

3. Non-fatal cardiac arrest 30 days after randomization3. Non-fatal cardiac arrest 30 days after randomization

(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)

Primary Outcome Non-Primary Outcome Non-fatal MIfatal MI

Ris

k

0.0

0.02

0.04

0.06

0.08

0 10 20 30

HR(95%CI)=0.83(0.70-0.99), p=0.035

4177 3915 3873 38534174 3959 3909 3879

# at Risk

MP

0.0

0.02

0.04

0.06

0.08

0 10 20 30 Days

Metoprolol

Placebo

HR(95%CI)=0.70(0.56-0.86), p=0.0007

4177 3923 3882 38594174 3976 3922 3889M

P

PeriOperative MedicinePeriOperative MedicineStrokeStroke


Ris

k

0.0

0.0

05

0.0

10

0.0

15

0.0

20

0 10 20 30 Days

Metoprolol

Placebo

HR(95%CI)=2.17(1.26-3.73), p=0.005

4177 4102 4076 40554174 4085 4038 4011

No. at Risk

MP

PeriOperative MedicinePeriOperative MedicineAll DeathsAll Deaths


Ris

k

0.0

0.0

10.0

20.0

3

0 10 20 30 Days

Metoprolol

Placebo

HR(95%CI)=1.33(1.02-1.74), p=0.032

4177 4116 4091 40694174 4113 4066 4038

No. at Risk

MP

PeriOperative MedicinePeriOperative Medicine (Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)

For every 1,000 treated patients, For every 1,000 treated patients, metoprolol would preventmetoprolol would prevent 15 MIs15 MIs 7 cases of new AF7 cases of new AF 3 post-op CABGs3 post-op CABGs

And there would beAnd there would be 8 excess deaths8 excess deaths 5 excess strokes5 excess strokes 53 patients with significant hypotension53 patients with significant hypotension

PeriOperative MedicinePeriOperative Medicine (Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)

Significant decrease in the risk of Significant decrease in the risk of non-fatal MInon-fatal MI Pooled OR = 0.68 (0.53-0.87) Pooled OR = 0.68 (0.53-0.87)

Significant increase in the risk of Significant increase in the risk of perioperative strokeperioperative stroke Pooled OR = 2.16 (1.04-4.50)Pooled OR = 2.16 (1.04-4.50)

No effect on total mortalityNo effect on total mortality


Beta-BlockersBeta-Blockers

Evidence Evidence suggestssuggests::• Longer-Acting (Atenolol) appears to be superior Longer-Acting (Atenolol) appears to be superior

to shorter acting (Metoprolol).to shorter acting (Metoprolol).• The dose should be started at least 7 days prior The dose should be started at least 7 days prior

to surgery and titrated up to target HR 60-65 to surgery and titrated up to target HR 60-65 (which is often not feasible in-house)(which is often not feasible in-house)


Post-op R/O MIsPost-op R/O MIs

The evidence The evidence does not supportdoes not support serial Troponin measurements in serial Troponin measurements in pts who are clinically stable and pts who are clinically stable and hv undergone intermediate or hv undergone intermediate or high risk surgery!!!!!!!! high risk surgery!!!!!!!!

It is only recommended in pts with EKG It is only recommended in pts with EKG changes or CP!!!changes or CP!!!

WOW!!!!!WOW!!!!!


Rather…..Rather…..Charlston et al (1988)…Obtain EKGCharlston et al (1988)…Obtain EKG*Immediately post-op*Immediately post-op*Day 1 post-op*Day 1 post-op*Day 2 post-op*Day 2 post-opIf changes, (ST-T wave changes) or If changes, (ST-T wave changes) or

symptoms then obtain Cardiac enzymessymptoms then obtain Cardiac enzymes(What do we do with all these slightly positive (What do we do with all these slightly positive

troponins? Do they affect outcomes? What is the role troponins? Do they affect outcomes? What is the role of revascularization?)of revascularization?)

Pt Risk vs. Surgical RiskPt Risk vs. Surgical Risk

Low Risk Low Risk pt.pt.

IntermediaIntermediate Risk pt.te Risk pt.

High Risk High Risk pt.pt.

Low Risk Low Risk SurgerySurgery

Proceed with Proceed with SurgerySurgery Proceed with Proceed with

SurgerySurgeryProceed with Proceed with cautioncaution

Moderate Risk Moderate Risk SurgerySurgery

Proceed with Proceed with SurgerySurgery

Assess METSAssess METS

Assess # of risk Assess # of risk factorsfactors

??BB??BB

Possible BBPossible BB

Post-op EKG/?Post-op EKG/?TropTrop

High Risk SurgeryHigh Risk Surgery Proceed with Proceed with CautionCaution

Possible BBPossible BB

Post-op EKG/?Post-op EKG/?TropTrop

Definite BBDefinite BB

?Intervention - PCI?Intervention - PCI

Post-Op EKG/?TropPost-Op EKG/?Trop


Why Give Stress Dose steroids???Why Give Stress Dose steroids???

Chronic Steroid use suppresses Chronic Steroid use suppresses the hypothalamic-pituitary-the hypothalamic-pituitary-adrenal axis…adrenal axis…

What constitutes chronic use?What constitutes chronic use?


Normal Daily Corticol ProductionNormal Daily Corticol Production

10 mg Hydrocortisone PO10 mg Hydrocortisone PO

Endogenous Cortisol levels rise toEndogenous Cortisol levels rise to

50 mg – Minor Surgery50 mg – Minor Surgery

75-150 mg – Major Surgery75-150 mg – Major Surgery (at induction of anesthesia, with return to (at induction of anesthesia, with return to

baseline within 24-48 h)baseline within 24-48 h)


Time to recovery of HPA axisTime to recovery of HPA axis

- as short as 2-5 days or as long as 9-12 - as short as 2-5 days or as long as 9-12 monthsmonths

Therefore, Therefore, recommendations have been to recommendations have been to administer steroids toadminister steroids to any pt who has any pt who has received more than 10 mg of prednisone received more than 10 mg of prednisone for more than 7 days consecutive within for more than 7 days consecutive within the last year. (or 3 months depending on the last year. (or 3 months depending on the author)the author)


AsthmaticsAsthmatics Chronic Rheumatologic/Autoimmune Chronic Rheumatologic/Autoimmune

DiseasesDiseases Certain Neurologic DiseasesCertain Neurologic Diseases HIV (PCP)HIV (PCP) Dematologic Diseases Dematologic Diseases (include high potency (include high potency

topicals)topicals)

GI (UC)GI (UC)


Traditional doseTraditional dose 100 mg of hydrocortisone q8h100 mg of hydrocortisone q8h

(With a quick taper over 1-3 days if uncomplicated.)(With a quick taper over 1-3 days if uncomplicated.)Technically, dose should be administered based on Technically, dose should be administered based on

the surgical riskthe surgical risk

MinorMinor - 25 mg Hydrocortisone at induction - 25 mg Hydrocortisone at induction x 1x 1

ModerateModerate - 25 mg Hydrocortisone q8h x 24 - 25 mg Hydrocortisone q8h x 24 hh

MajorMajor - 50 mg Hydrocortisone q6h x 48-72h - 50 mg Hydrocortisone q6h x 48-72h

PeriOperative Medicine PeriOperative Medicine

A Question…….A Question…….

A 68 yo man recently diagnosed with AdenoCa of the cecum A 68 yo man recently diagnosed with AdenoCa of the cecum undergoes preoperative evaluation before surgical resection. undergoes preoperative evaluation before surgical resection. His PMH includes inoperable CAD, heart failure with LVSF His PMH includes inoperable CAD, heart failure with LVSF 35%, HTN, hyperlipidemia. Angina is stable, occurring 35%, HTN, hyperlipidemia. Angina is stable, occurring approx monthly, and he has no orthpnea or PND. approx monthly, and he has no orthpnea or PND. Medications include lisinopril, carvedilol, lasix, zocor and Medications include lisinopril, carvedilol, lasix, zocor and daily ASA. He plays golf weekly and carries groceries up a daily ASA. He plays golf weekly and carries groceries up a flt of stairs to his apt.flt of stairs to his apt.

On physical, P 64, 120/64, JVD 6 Lungs CTA S1S2 no S3. No LE edemaOn physical, P 64, 120/64, JVD 6 Lungs CTA S1S2 no S3. No LE edemaCBC, Chem are WNLCBC, Chem are WNLEKG – NSR, Qwaves in II, III, AVF (old)EKG – NSR, Qwaves in II, III, AVF (old)


Which of the following is the most Which of the following is the most appropriate next step in the preop appropriate next step in the preop eval of this pt?eval of this pt?

a. Order plasma BNPa. Order plasma BNPb. Echob. Echoc. Exercise stress testc. Exercise stress testd. Nuclear imaging for LVEFd. Nuclear imaging for LVEFe. No further evaluatione. No further evaluation

What is his risk category??????What is his risk category??????

PeriOperative EvaluationPeriOperative Evaluation

Question #2Question #2A 68 yo male with a PMH of CAD, HTN, chol, presents for a A 68 yo male with a PMH of CAD, HTN, chol, presents for a

perioperative evaluation before AAA repair (open). His perioperative evaluation before AAA repair (open). His meds include lisinopril, HCTZ, Zocor, ASA. He has not had meds include lisinopril, HCTZ, Zocor, ASA. He has not had angina since undergoing a 3V CABG 4 yrs ago. He plays angina since undergoing a 3V CABG 4 yrs ago. He plays gold weekly, walking and carrying his clubs on a hilly gold weekly, walking and carrying his clubs on a hilly course, walks two miles in 35-40 minutes 3w weekly and course, walks two miles in 35-40 minutes 3w weekly and vacuums the house. vacuums the house.

PE – P 78 BP 140/87. The remainder of the exam is PE – P 78 BP 140/87. The remainder of the exam is unremarkable. Results of the electrocardiography are c/w unremarkable. Results of the electrocardiography are c/w his most recent electrocardiogram, with evidence of an old his most recent electrocardiogram, with evidence of an old inferior infarction. CBC, Chem are WNL.inferior infarction. CBC, Chem are WNL.


Which of the following is the most Which of the following is the most appropriate perioperative appropriate perioperative management in this pt?management in this pt?

a. Atenolola. Atenolol

b. Exercise stress testingb. Exercise stress testing

c. Echocardiographyc. Echocardiography

d. Intraoperative Rt heart Cath d. Intraoperative Rt heart Cath (Swan)(Swan)


DiabetesDiabetes

AnticoagulationAnticoagulation

DVT ProphylaxisDVT Prophylaxis

DeliriumDelirium

HTN in PregnancyHTN in Pregnancy

Documents

Intro to PeriOperative Medicine