Perioperative evaluation of difficult clinical scenarios which prompted to delay of surgery: - Undiagnosed aortic regurgitation - Pleural effusion with suspected TB
- 1. Hospital Medicine Grand Rounds The role of the
peri-operative evaluation in safe patient outcomes: an initial
patient dissatisfaction with a happy ending Moises Auron MD FAAP
Feb 11, 2009
2. Objectives
- Appraise the importance of the peri-operative assessment to
detect unrecognized conditions that increase surgical risk.
- Describe the evaluation and management of aortic regurgitation
and its peri-operative implications
3. Objectives
- Describe the evaluation and management of pleural effusion and
its perioperative implication.
- Describe the peri-operative implications of active
tuberculosis.
- Describe the initial peri-operative assessment of Rheumatoid
arthritis.
4. Case presentation
- CC: Tracheostomy and subglotic stenosis
- Referred for pre-operative evaluation for a laser dilatation of
the subglottic stenosis
- Surgery scheduled for the next day.
- Patient travelled from Boston, MA.
5. PMH
- G-tube on enteral feeding
- MVA 4 months ago with complicated ICU stay: prolonged
intubation.
- D/C to SNF, and recent D/C to home 1 week prior to preoperative
visit.
6. PSH
- Evacuation of subdural hematoma
- Pleural tube placement for closed chest injury
- Exploratory laparotomy with splenectomy and small bowel
resection.
7. Medications
- Polyethilen-glycol 17 g daily
- Oxycodone 10 mg po q6h prn (pain)
8. Social
- Smokes 1 ppd for 30 years (not smoking currently since accident
4 months ago).
- Prosecution lawyer, married for 25 years, 2 children.
9. Pre-operative assessment
- Able to walk indoors with a walker (2.5 mets) but is mostly in
wheelchair
-
- Chest discomfort when straining (because I had a chest
tube)
-
- Needs 4 pillows to sleep, orthopnea, no PND
-
- Edema managed with indapamide
- Denied any complications with anesthesia.
10. Circulation.2007;116:1971-1996 11. Physical examination
- Gen: anxious, head tremors
- Neck: Carotid pulsations appreciated. Trach.
- Cor: S4, 3/6 diastolic murmur in Right 2 ndIC space with
presence of diastolic murmur (rumble) in apical area
- Abd: S, NT, ND, BS+, pulsatile liver, GT
- Ext: brisk pulses, pulsating capillary nail bed
12.
13. Signs of aortic insufficiency
Babu AN, et al. Ann Intern Med.138(9): 73642.Ashrafian H. Int J
Cardiol. 2006 Mar 8;107(3):421-3. 14. Signs of aortic
insufficiency
- Large-volume, 'collapsing' pulse
- Bounding peripheral pulses (waterhammer)
- Low diastolic BP and increased pulse pressure
- Corrigans pulse (rapid upstroke and collapse of the carotid
artery)
- de Musset's sign (head nodding in time with the heart
beat)
- Quinckes sign (pulsation of the capillary bed in the nail)
- Traube's sign (systolic and diastolic murmurs described as
'pistol shots' heard over the femoral artery when it is gradually
compressed)
- Duroziezs sign (double sound heard over the femoral artery when
it is compressed distally)
Babu AN, et al. Ann Intern Med.138(9): 73642.Ashrafian H. Int J
Cardiol. 2006 Mar 8;107(3):421-3. 15.
- Lighthouse sign (blanching & flushing of forehead)
- Landolfis sign (alternating constriction & dilatation of
pupil)
- Beckers sign (pulsations of retinal vessels)
- Mllers sing (pulsations of uvula)
- Mayens sign (diastolic drop of BP>15 mm Hg with arm
raised)
- Rosenbachs sign (pulsatile liver)
- Gerhardts sign (enlarged spleen)
- Hills sign- a 20 mmHg difference in popliteal and brachial
systolic cuff pressures.
- Lincolns sign (pulsatile popliteal)
- Shermans sign (dorsalis pedis pulse is quickly located &
unexpectedly prominent in age>75 yr)
- Ashrafians sign (Pulsatile pseudo-proptosis)
Signs of aortic insufficiency 16. Pre-operative optimization
- EKG: NSR, left axis deviation, LVH, PVCs
- Labs: creatinine 1.5 (GFR 51 by MDRD)
- IS HE OPTIMALLY PREPARED?
17. Circulation.2007;116:1971-1996 18.
Circulation.2007;116:1971-1996 19. Circulation.2007;116:1971-1996
20. Clinical risk factors: RCRI Lee, et al. Circulation. 1999; 100:
1043 1049. 21. Despite patients anger and yelling
- he was not cleared for surgery and was sent to the ER:
- Aortic regurgitation with severe symptoms
-
- Hypertensive urgency with wide pulse pressure
-
- Unclear evolution surprising that was not diagnosed in recent
hospitalization
22. Aortic regurgitation: Etiology
- Idiopathic dilatation (annuloaortic ectasia)
- Congenital (bicuspid valves)
- Calcific degeneration (accompained by AS)
- Systemic hypertension (cystic medial necrosis)
- Dissection of the ascending aorta
- Syphilitic aortitis (tertiary)
- Discrete subaortic stenosis
- Ventricular septal defects with prolapse of an aortic
cusp.
- Anorectic drugs (Fenfluramine, dexfenfluramine)
Circulation2008;118;e523-e661 23. Natural history of AR
Circulation2008;118;e523-e661 24. Natural history of chronic AR
- Asymptomatic Patients With Normal EF
- Variables associated with higher risk (likelihood of death,
symptoms, and/or LV dysfunction):
-
- LV end-systolic dimension
-
-
- > 50 mm had a dysfunction - 19% per year.
-
-
- 40 to 50 mm - 6% per year,
-
- LV end-diastolic dimension
-
- LV ejection fraction during exercise.
Circulation2008;118;e523-e661 25. TTE
- Dilated LV size (300 cc end-diastolic volume) with moderate
LVH. EF=50%.
-
- Left Ventricle ID(dia - cm):6.5
-
- Left Ventricle ID(sys - cm):3.6
- Normal RV size and function
- Bicuspid aortic valve. Severe (4+) AR with holodiastolic flow
reversal in the descending arch.
- Mildly dilated Aorta with effacement of the S-T junction.
Aortic sinus(cm) - 4.3. Sino-tubular Junction(cm) - 3.5. Ascending
Aorta(cm) - 3.8. Aortic Arch(cm) - 3.7.
- Bi-atrial enlargement. LA index=28ml.
- Trivial TR. RVSP=41mmHg c/w mild PHTN
26. LV Catheterization
- LEFT ANTERIOR DESCENDING: 20-25% narrowing proximal mid and
distal segment.
- CIRCUMFLEX ARTERY: Minimal irregularities.
- RIGHT CORONARY ARTERY: mild narrowing about 30% in the mid
third.
- LEFT VENTRICLE: Dilated. End diastolic size is increased. End
systolic size is significantly increased. EF 35-40%. There are some
PVC's and some mild mitral regurgitation.
- AORTIC VALVE: Bicuspid. There is 4+aortic regurgitation. There
is partial effacement of the sino-tubular junction on the right
side. The ascending aorta is mildly dilated.
- DIAGNOSIS:1. Severe aortic regurgitation secondary to bicuspid
aortic valve. 2. Moderately severe left ventricular dysfunction. 3.
Mild coronary artery disease. 4. Mild dilatation of the ascending
aorta.
27.
http://www.med.yale.edu/intmed/cardio/echo_atlas/entities/aortic_regurgitation.html
28. Circulation2008;118;e523-e661 29. Immediate Postoperative
TEE
- LV systolic function is normal.
- RV systolic function is normal.
- Bioprosthetic valve (Carpentier-Edwards #27). There is no
aortic regurgitation.
30. 31. Case presentation
- 56 y/o eastern european male (living in USA for the past 5
years).
- CC: Sigmoid adenocarcinoma
- Referred for preoperative evaluation for sigmoidectomy and
probable primary anastomosis
- Surgery scheduled for the next day.
32. HPI
- 2 months with several episodes of hematochezia - colonoscopy
showed a villotubular adenomatous polyp with focal areas of
adenocarcinoma in-situ.
33. ROS
34. Under further questioning:
- 5 months of nocturnal fever (100F) and diaphoresis,
-
- generalized arthralgias and bilateral ankle edema.
-
- A non-erosive arthritis was diagnosed and treated empirically
with prednisone (PDN), but no definite diagnosis was made.
35. HPI.
- 2 months prior to visit was hospitalized for presumed pneumonia
receiving i.v. antibiotics; PDN was stopped.
- A chest CT scan revealed intra-thoracic lymphadenopathy and
interstitial lung infiltrates.
36. HPI
- PPD and IFN test for TB were positive
- BAL: Negative AFB stain and mycobacterial cultures
- Patient has history of BCG administration.
- An axillary lymph node biopsy showed benign hyperplasia.
37. PMH, FH and PSH
-
- Well controlled HTN for 5 years
-
- Wife is an internist physician trained in Poland and works as
Physician assistant in US.
38. Medications
- Acetaminophen 1 g po qid prn
39. Preoperative assessment
- Able to climb a flight of stairs (> 4 mets)
- No previous anesthetic complications
- No active cardiac symptoms
40. Physical exam
- BP 140/85HR 67RR 22SpO2 94% (RA)
- Neck: supple, anterior cervical LAD mobile, increased in
consistency, no goiter
- Cor: RRR, normal S1, S2, no MRG
- Chest: Decreased left breath sounds, no egophony or fremitus,
minimal dullness on percussion on L
- Abdomen: S, NT, ND, BS+, no masses
- Extremities: Limitation of ROM of elbows, with discrete
swelling and erythema of ankles bilaterally, no palpable
synovitis.
41. Pre-operative assessment
- Is he optimally prepared?
42. 43. Despite angry complaints.
- Active symptoms suggestive of systemic inflammatory process
warrant further assessment
- An urgent ID evaluation was requested
44.
- WHAT TESTS WOULD YOU ORDER?
45. Further evaluation 46. Perioperative implications of pleural
effusion
- Restrictive ventilatory defect
-
- ventricular diastolic collapse (tamponade)
Gilmartin, et al. Thorax 1985; 40:6065. Agusti, et al. Am J
Respir Crit Care Med 1997; 156:12051209. 47. Pleural effusion and
mechanical ventilation Graf J. Current Opinion in Critical Care
2009; 15:1017. 48.
- ID requested evaluation by Thoracic surgery
- Unsuccessful US-guided thoracentesis
- Thoracoscopy with pleural fluid drainage and pleural biopsy
were done
http://www.thoracicmedicine.org 49. Perioperative air safety
- Each cough = 600,000 droplets
- Subsequently evaporate to form much smaller invisible droplet
nuclei of up to 5 microns in size
- Particles < 10 microns can reach the alveoli
- Most concerning microorganism is Mycobacterium
tuberculosis
Hickle R. Acta Anaesthesiol Scand Suppl. 1997;111:241-7. 50.
- Cough inducing procedures
-
- Average cough in PACU = 32 times during first 40 minutes of
recovery
- Cost analysis study estimated the expense associated with an
episode of unprotected exposure to TB in the PACU:
Perioperative air safety Hickle R. Acta Anaesthesiol Scand
Suppl. 1997;111:241-7. 51. Perioperative air safety
- N95 respirator prevents passage of 95% of particles>0.3
microns
- Minimize personnel exposed
- Isolation with negative pressure
- Careful cleansing of OR and leaving room closed until air is
completely changed
Neil J. AORN J. DEC 2008; 88 (6): 942-958 52. Perioperative air
safety
- Schedule aerosol-generating procedure at the end of the
day
- Attempt to do the procedure in the patients room
- Use disposable anesthesia equipment
Neil J. AORN J. DEC 2008; 88 (6): 942-958 53. Patient with
active pulmonary TB
- Higher risk for temperature disregulation, hypoxemia and
hypoventilation.
-
- Fever metabolic rate and cardiac output
- Hypoxemia and hypoventilation occur due to anatomical lesions
and necrotic lung parenchyma; atelectasis; pleural effusion
- Malnutrition and weakness secretions clearance and ineffective
cough
- inspiratory and expiratory efforthypoventilation.
Neil J. AORN J. DEC 2008; 88 (6): 942-958 54. Pleural biopsy
-
- Fibrinous pleuritis with mesothelial hyperplasia.
-
- AFB stain was negative as well as mycobacterial cultures.
Fungal serologies were negative.
-
- Pleural fluid is an exudate
55. Light RW. NEJM. 2002; 346 (25): 1971-1977 56. Yataco JC,
Dweik R. CCJM. 2005; 72(10): 854-872. 57. Ancillary testing
- Positive Rheumatoid factor
- Positive anti-CCP antibodies
- ANA, ANCA and hepatitis serology: negative
- Pleural fluid Rheumatoid factor positive
58. Pleural rheumatoid factor
Yataco JC, Dweik R. CCJM. 2005; 72(10): 854-872. 59.
Rheumatology consult
- Considered that patient could undergo surgery.
- Treatment would be started after surgery.
- C-spine flexion and extension X-Rays were normal.
60. Preoperative lateral flexion-extension C-spine X-Rays
- Progression of peripheral joint erosion parallels cervical
spine disease
- RF seropositivity associated with higher incidence of cervical
spine involvement
- C-spine involvement affects 15-86% of patients with RA
- Patients with erosive RA 30-40% have C-spine disease
Macarthur A, et al. Can J Anaesth. 1993; 40: 154-9. Crosby ET.
Can J Anaesth. 1990; 37: 77-93. 61.
- Patient underwent sigmoidectomy with primary colorectal
anastomosis. No further chemotherapy was advised.
http://nyp.org/masc/colorectal.htm 62. Post-operative
- Prednisone and methotrexate were started with progressive
improvement of articular and pulmonary symptoms.
- Subsequently hydrocloroquine was added and prednisone dose was
decreased.
- ESR and CRP normalized after 3 months and symptoms improved
dramatically.
63. Clinical conundrum
- Pleuritis and interstitial lung disease are the most frequent
pleuropulmonary manifestations of rheumatoid arthritis.
- Co-existence of constitutional symptoms in a smoker patient
with presumed TB as well as with a recent diagnosis of sigmoid
cancer.
64. Take home message
- Evaluate the extent of organ disease
- Optimize medical diagnoses
- Assess and describe physiologic limitations
- Ensure adequate post-operative follow-up
- Regardless of the patient's desire to "proceed with surgery" -
we have an obligation to do what is in the patient's best interest
and to provide the surgical team with the service that they
expect....
65.