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Perioperative and Consultative Medicine
Pamela J. Pride MD, FHM
Medical University of South Carolina
2/7/2012
Overview Role of consultant Cardiac risk assesment Perioperative beta blockade Preop pulmonary assesment and postop
risk reduction
Objectives Describe the risk factors for perioperative
complication. Explain ACC risk stratification for surgery. Describe the evidence supporting prophylactic
perioperative Beta Blockers. Use algorithms, when available, to assess and risk
stratify patients. Reassess patients for postoperative complications and
make medical recommendations when needed.
Key Messages
Limited role for routine preoperative coronary revascularization
Perioperative beta blockers for high risk pts, need to be titrated
Preoperative PFTs have limited role
Role of the Consultant Evaluate and optimize patient’s medical status Treat modifiable risk factors Estimate and manage cardiac risk Recommend measures to attenuate all
perioperative complications
What Not to Do
Recommend for or against surgery Tell anesthesiologists how to do their job Recommend the obvious “Clear” the patient Say nothing
Pre-operative Cardiac Risk Assessment
To Stress or Not to Stress
ACC/AHA guidelines
ACC Guidelines-Getting Started Define “Active Cardiac Syndromes”
ACS HF (Class 4 or newly found)
Significant arrhythmias (VT, symptomatic bradyarhythmias, rhythms requiring pacing, uncontrolled svts)
Severe Valvular disorders (severe AS, symptomatic MS)
ACC Guidelines-Getting Started Define “Clinical risk factors”
Prior MI CKD Hx of CHF DM CVA
ACC Risk Stratification for Surgery
High: (cardiac risk >5%)-Emergency surgeries, aortic and major vascular, prolonged surgeries with large fluid shifts or blood loss
Intermediate: (cardiac risk <5%)-CEA, ENT, intra peritoneal and intra thoracic, orthopedic, urologic
Low: (cardiac risk <1%)-endoscopic, superficial, breast, cataract
Metabolic Equivalents What is 4 mets?
Walking 3 miles/hour, yoga, water aerobics Scrubbing floors, yardwork Carrying groceries in from car Competitive table tennis Dancing
Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply.
American College of Cardiology Foundation, et al. J Am Coll Cardiol 2009;54:e13-e118
ACC Algorithm for Non-Cardiac Surgery
Estimating Cardiac RiskRevised Cardiac Risk Index
Circulation 1999;100:1043-1049
1. High risk surgery
2. History of CAD
3. CHF
4. CVA
5. DM
6. CKD
# risk factors % complication
0…………………..0.4-0.5%
1…………………..0.9-1.3%
2……………………..4-7%
≥3……………………9-11%
Perioperative Beta BlockersThe Controversy
Multiple early RCTs showed benefit The bandwagon rolls out
AHRQ list ACC recommends ACP recommends
More recent studies equivocal
Perioperative Beta BlockadeNEJM July 28,2005
Perioperative Beta BlockersThe POISE Trial
Lancet May 31, 2008
High risk pts undergoing non cardiac surgery Randomized to perioperative beta blockade vs.
placebo Drug started hours before surgery and
continued for 30 days post op Primary endpoints included cardiac death, non-
fatal mi and non-fatal cardiac arrest
The POISE Trial Results
Poise Trial Results
0
1
2
3
4
5
6
30d nonfatal mi all cause mort cva
Placebometoprolol
Peri-operative Beta BlockersWhat should we do?
Continue beta blockers for all pts on them chronically
Start and titrate beta blockers preop for pts with Known CAD + ischemia on stress test High cardiac risk profile
Unclear utility in pts with low cardiac risk profiles Do not use in absence of titration (goal hr 60-80)
What about statins?
Several observational studies suggest benefit from peri-operative statins.
Randomised trials less clear Bottom line-prescribe only if statin is
indicated regardless of surgery
Preoperative Pulmonary Assessment andPostoperative Risk Reduction
Patient Factors Advanced Age Poor functional status COPD CHF Tobacco abuse OSA Low albumin
Surgical Factors Aortic, thoracic, upper
abdominal Prolonged surgery General anesthesia Emergency surgery Routine NG tube placement
Preoperative Pulmonary Function Testing
Indicated for all lung resection patients Fail to consistently predict pulmonary complications
Abnormal exam, CXR, and Goldman risk index more predictive
Low rate of complications in patients with severe obstruction Use the “if they walked into my office” principle
Evaluate unexplained dyspnea Establish baseline for patients with known lung disease
Reducing Postoperative Pulmonary Complications
Incentive Spirometry Selective NG decompression after general surgery Cigarette cessation* Medically optimize COPD Avoid sedating meds Neuraxial anesthesia
Reference List Derivation and Prospective Validation of a Simple Index for Prediction of
Cardiac Risk of Major Noncardiac Surgery . Circulation 1999;100:1043-1049 September 7, 1999
Perioperative Beta-Blocker Therapy and Mortality after Major Noncardiac Surgery. N ENGL J MED 2005; 353:349-361 July 28, 2005
Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet, 5/31/2008, Vol. 371 Issue 9627, p1839-1847
Risk of Pulmonary Complications After Elective Abdominal Surgery Chest September 1996 110:3 p744-750
2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation
and Care for Noncardiac Surgery, J Am Coll Cardiol, 2009; 54:13-118