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Preoperative Risk Evaluation

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									Preoperative Risk Evaluation:
   An Old School Approach
   With a Few New Tools


    • David Chamberlain MD
“Clear the Patient for Surgery”
  What Causes Perioperative Mortality?
   0.7 – 0.8% All cause (4,038 out of 485,850 pts)
   1:2680 Anesthesia
   1:420 Surgical error
   1:95    Underlying medical condition(s)

   67% Progression/complication of presenting disease
   44% Progression/complication of underlying disease
   30% Surgery contributed to mortality

   < 1/3 Cardiac
   > 1/3 Pulmonary
     1/3 Other medical conditions
Fleischer, L, J Am Soc Anesthesiology, May 2002,Vol 96, Issue 5, p.1039-1041
          Are Internists Really Worth It?
More likely to identify and intervene on medical conditions
  related to surgical outcomes.
  Devereaux, PJ, et al, Clin Invest Med 2000: 23:116

Decreased length of stay post thoracic and hip surgery.
  Phy, MP, et al, Arch Intern Med 2005; 165:796




No improvement of glucose control, perioperative Beta
  Blockers, DVT prophylaxis.
  Auerbach, AD, et al, Arch Intern Med 2007; 167:2338

Higher 30 day and 1 year mortality rate, but in multi-
  variable analysis consulted patients had a significantly
  higher disease burden. Rates similar when adjusted.
  Wijeysundera, DN, et al, Arch Intern Med 2010: 170:1365



No study has shown a decrease in perioperative mortality.
    Preoperative Risk Evaluation
      an Old School Approach
• Risk Assessment
  – Global Assessment of Risk
  – Cardiac Perioperative Risk
     • Goldman Risk Index, Functional capacity, Surgical risk
  – Pulmonary Perioperative Risk
     • Risk Factor Evaluation
  – DVT Risk
     • Risk Factor Evaluation
  – Endocarditis Risk
     • Sanford Guidelines
  – Risk from Medical Conditions
  – Risk from Medications
          Global Assessment of Risk
                     or
           “Looks good from door”
• American Society of Anesthesiologists
  Preoperative Patient Classification
   – Created in 1941
   – Purpose was to assess the degree of a
     patient’s “sickness”
   – NPV far exceeds PPV – better at defining
     healthy than incapacitated
   – Not originally intended to predict operative
     risk, but …… (millions of patients later)
        ASA Patient Classification
Class                                    48hr Mortality
1   Healthy                              0.07%
2   Mild Systemic Disease                0.24%
3   Severe Systemic Disease, limits      1.4%
    activity, but not incapacitating
4   Incapacitating systemic disease,     7.5%
    which is a constant threat to life
5   Moribund, not expected to survive    34%
    24 hours with or without surgery

Emergent Surgery                         Risk Doubles
         Who is Too Sick or
  the “Are You Nuts?” Assessment
Predictors of Risk for MI, Heart Failure, Death
  – Unstable Coronary Syndrome
     angina, acute or recent MI


  – Decompensated Heart Failure
     new onset, worsening HF, NYHA Class IV


  – Significant Arrhythmias
     high grade AV block, symptomatic or new ventricular arrhythmia,
     tachycardia with rate > 100, symptomatic bradycardia


  – Severe Valvular Disease
     severe aortic stenosis, symptomatic mitral stenosis
                      Predictors of Risk

• Any one has high positive predictive value for MI, Heart
  failure, Death

• Risk and severity of complications likely greater than
  benefit of surgery

• Recommend delay or cancel surgery unless emergent

• Those patients removed from subsequent cardiac risk
  assessments

      ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for non-cardiac surgery.
      J Am Coll Cardiol. 2007; OCT 23;50(17):e159-241
      Cardiac Perioperative Risk
      Updated Old School Tools

• Revised Goldman Cardiac Risk Index

• Functional Capacity

• Risk Specific to Type of Surgery
                Beyond the
         Goldman Cardiac Risk Index
• 2893 patients
• Elective non-cardiac surgery
• Monitored for cardiac complications
  –    MI
  –    Pulmonary Edema
  –    Ventricular Fibrillation
  –    Cardiac Arrest
  –    Complete Heart Block

  NOT all cause mortality
  Lee, TH, et al, Circulation 1999; 100:1043.
          Six Independent Predictors of
           Major Cardiac Complications
• High Risk Surgery
• History of Ischemic Heart Disease
           History MI, History positive stress test, angina, using NTG, Pathologic Q
           Not History CABG or PTCA or Stent

•   History of Heart Failure
•   History of Cerebrovascular Disease
•   DM treated with insulin
•   Serum Creatinine > 2.0
•   Lee, TH, Marcantonio, ER, Mangione, CM, et al, Circulation 1999; 100;1043
      Revised Goldman Cardiac Risk Index
                      vs.
    Rate of Cardiac Death, MI, Cardiac Arrest


Risk Factors                                      Rate           95% CI
No Risk Factors                                   0.4%           0.1 – 0.8%
One Risk Factor                                   1.0%           0.5 – 1.4%
Two Risk Factors                                  2.4%           1.3 – 3.5%
Three Risk Factors                                5.4%           2.8 – 7.9%
Devereaux, PJ, Goldman, L, Cook, DJ, et al. CMAJ 2005; 173:627
           Revised Goldman Cardiac Risk Index
                           vs.
          Cardiac Death, MI, Cardiac Arrest, Vfib,
         Pulmonary Edema, Complete Heart Block


Risk Factors                          Rate            Rate with Beta Blockers
None                                  0.4 – 1.0%      < 1%
One to Two                            2.2 – 6.6%      0.8 – 1.6%
Three or More                         > 9%            > 3%

Auerbach, A, Goldman, L. Circulation 2006; 113:1361
        Revised Cardiac Risk Index
        Most Studied and Validated
• Validated in Cohort of 1422 patients
• Predictive value for cardiac complications and mortality
    significant in All types of non-cardiac surgery except AAA
•   Does Not Capture all-cause Mortality
        Ford, MK et al, Ann Intern Med 2010; 152:26



• Better Predictive Value than original Goldman Criteria or
    Detsky Modified Risk Index
        Lee, TH, et al, Circulation 1999: 100:1043



• Retrospective study; 663,665 pts; major non-cardiac Sx;
    329 hospitals, 2000 – 2001
    RCRI likely underestimates risk of cardiac complications
    Increased mortality without Beta Blockers
        Devereaux, PJ, Goldman,L, et al, CMAJ 2005; 173:627
                   Functional Capacity
                            or
                 “What’s the METs thing?”
• 1 MET = 3.5 mL O2 uptake/KG per min
• O2 uptake of a 40 y/o, 70 kg male sitting upright

• Peak exercise capacity an independent predictor of all
  mortality in normals and subjects with cardiovascular dz
  <    5 METs : Poor Survival Prognosis (<50%)
      10 METs : Medical therapy = CABG (>75%)
   >= 13 METs : Good Survival Prognosis (>90%)
     (either category, data points at 10 year, linear separation as early as 1 year)



   For each 1 MET there is a 12% improvement in survival
     Myers, J, et al, N Engl J Med 2002; 346;793
        Specific Activity Scale
METs         Can Complete Activity Without Stopping
 1     Sit upright
 2     Eat, dress, use toilet, make bed
 3     Walk around house, shower
 4     1 flight stairs, walk up hill, 2 block @ 2mph
       Light house work, dust, wash dishes, golf, bowl
 5     2 flights of stairs, walk on flat @ 4mph,
       Sex
  6    Scrubbing floors, weight lifting, moving furniture
  7    Broke the bed/neighbors called the cops sex
  8    Shovel snow
  9    Doubles tennis, swing dancing
 10    Recreational Sports: Singles tennis, soccer,
          basketball, skiing, jogging
12+    Competitive sports
  How does this relate to Surgery?


• < 4 METs Significantly Increases Risk MI, HF,
  Arrhythmia regardless of Surgical Risk

• Functional Capacity                                         Complication Rate
  < 4 METs                                                    > 5%
  4 – 10 METs                                                 1 – 5%
  > 10 Mets                                                   < 1%
     Eagle, KA, et al, J Am Coll Cardiol, 2002; 39, 542-553
  What about Surgery Specific Risk?

Risk                              Cardiac death or nonfatal MI
High                                   >5%
Intermediate                           1–5%
Low Risk                               <1%

Emergency                         2 – 5 times the surgical risk

Fleischer, LA, Beckman, JA, Brown, KA, et al, ACC/AHA 2007 Guidelines on perioperative
     cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiology 2007; 50:e159.
Surgery Specific Risk for Cardiac Death or
               Nonfatal MI

 High Risk ( > 5% )
   Aortic, Major vascular, Cardiothoracic, Emergent,
   long with large blood loss/fluid shifts

 Intermediate Risk ( 1 – 5% )
   CEA, Head, Neck, Intraperitoneal, Intrathoracic,
   Orthopedic, Prostate

 Low Risk ( < 1% )
   Ambulatory surgery, Endoscopy, Superficial
   Procedure, Cataract surgery, Breast surgery
      The New School Uses:
 2007 ACC/AHA Cardiac Evaluation
       and Care Algorithm
• Step 1              Emergency Surgery
• Step 2              Global Assessment of Risk
                              Too Sick for Surgery
• Step 3              Global Assessment of Risk
                              Low Risk and Low risk Surgery
• Step 4              Assess Functional Capacity
• Step 5              Calculate RCRI and Surgical Risk

  Looks like the old school and the new school are the same school
        Evaluating Cardiac Risk
       2007 ACC/AHA Algorithm
Step 1              Yes
Need Emergent Sx?   Proceed to OR
                    Post Op risk stratification
                    Risk Factor Management

Step 2              Yes
Active Cardiac      Evaluate and Treat
  Condition?        Consider OR when stable
        Evaluating Cardiac Risk
       2007 ACC/AHA Algorithm
Step 3              Yes
Low Risk Surgery?   Proceed to OR

Step 4              Yes
Good Functional     Proceed to OR
  Capacity?

Step 5              Yes
Poor or Unknown     Compute RCRI
        Evaluating Cardiac Risk
       2007 ACC/AHA Algorithm
Step 5 continued         Yes
Zero Risk Factors        Proceed to Surgery

1 – 2 Risk Factors       Yes
      or                 Proceed to OR
3 or more Risk Factors   Rate Control with Beta
      and                   Blocker
Intermediate Risk        Consider Non-Invasive
  Surgery
                           Cardiac Testing if will
                           change management
        Evaluating Cardiac Risk
       2007 ACC/AHA Algorithm
Step 5 continued         Yes
3 or more Risk Factors   Consider Non-Invasive
      And                  or Invasive testing
High Risk Surgery          if will change
                           management
                         Rate control with Beta
                           Blockers
       Evaluating Pulmonary Risk
      It’s No Longer Just a Guess
Pulmonary Complications
  MORE COMMON than Cardiac Complications
  Cause Significantly LONGER Hospital Stays
      Lawrence, VA, Hilsenbeck, SG, et al. J Gen Intern Med 1995; 10:671


  MOST COSTLY Complications
      Dimick, JB, Chen, SL, et al. J Am Coll Surg 2004; 199:531



Pulmonary Complications 6.8% across all types Sx
  Atelectasis, Pulmonary Infection,
  Prolonged Mechanical Ventilation, Respiratory Failure,
  Chronic Lung Disease Exacerbation, Bronchospasm
      Smetana, GW, Lawrence, GA, et al, Ann Intern Med 2006; 144:581
  Predictors of Pulmonary Complications

• Patient Related                                • Odds Ratio of Complications
Age > 50, 60, 70, 80                             1.5, 2.28, 3.9, 5.63
Chronic Lung Disease                             2.36
Asthma                                           Uncontrolled 3, Controlled 1
Smoking                                          Current 5.5, 2 mo Cessation 1.26
Heart Failure                                    2.93
Albumin                                          2.53
BUN                                              2.29
Functional Dependence                            Total 2.51    Partial 1.65
ASA Class >= 2                                   4.87
Qasam, A, et al, Ann Intern Med, 2006; 144:575
Predictors of Pulmonary Complications

• Procedure Related                                • Odds Ratio
Surgical Site                                      Upper Abdominal 2.8
Duration > 3 – 4 hr                                2.14
Type of Anesthesia                                 General 1.83 vs. Spinal
Emergency                                          2.21

  Qasam, A, et al, Ann Intern Med, 2006, 144:575
 Other Conditions That May Require
         Special Attention
• Obesity                                   Inconsistent data
• OSA                                       Probable
• Pulmonary HTN                             Probable,
                                            Limited data
• URI                                       Data limited,
                                            usually defer Sx
Smetana, G, Ann Intern Med, 2006; 144:581
          Recommendations for
      Assessment of Pulmonary Risk
• History and Physical Exam

• Identify Pulmonary Risk Factors

• American Society of Anesthesiologists -
           Global Assessment of Pulmonary Risk

• Arozulla Multifactorial Risk Index for
  Postoperative Respiratory Failure
  Smetana, G, et al, Ann Intern Med, 2006; 144:581
      ASA Postoperative Pulmonary
             Complications
Class                                          Pulmonary Complications
1 Healthy                                                      1.2%
2 Mild Systemic Disease                                        5.4%
3 Severe Systemic Disease, limits                              11.4%
  activity, but not incapacitating
4 Incapacitating systemic disease,                             10.9%
  which is a constant threat to life
5 Moribund, not expected to survive                            NA
  24 hrs with or without surgery

   Qasim, A, et al. Ann Intern Med, 2006; 144:575-580
Arozullah Respiratory Failure Risk Index
• Type of Surgery             • Point Value
     – AAA                      27
     – Thoracic                 21
     – Neurosurgery, Upper      14
       Abdominal Peripheral
       Vascular, Neck
•   Emergency Surgery           11
•   Albumin < 3.0 g/dL           9
•   BUN      > 30 mg/dL          8
•   Partial/Full Dependence      7
•   History of COPD              6
•   Age > 70                     6
•   Age 60 - 69                  5
       Arozullah Respiratory Failure Index
                    Scoring
Class                     Point Total                    % Respiratory Failure
One                       <= 10                          0.5
Two                       11 – 19                        1.8
Three                     20 – 27                        4.2
Four                      28 – 40                        10.1
Five                      > 40                           26.6

Arozullah, AM, Daley, J, et al, Ann Surg 2000; 232:242
                     Put It All Together
Step 1                ASA 1 and                      To OR
Low Risk              Arozulla 1

Step 2                ASA 2 or                       Consider Further Testing
                      Arozulla 2 - 3                 CXR, PFT if will change
                                                     management.

Step 3                ASA >= 3 or                    Reconsider Surgery
High Risk             Arozulla >= 4                  Shorter Procedure
                                                     Spinal or Epidural

For all: Deep Breathing Exercises/Incentive Inspirometry
         Treat Identified Risk Factors & “Special” Conditions
  Smetana, G, et al, Ann Intern Med, 2006; 144:581
 Strategies to Reduce Postoperative
      Pulmonary Complications
• What Works                                • What Doesn’t
Pre-op Asthma Evaluation                    Smoking Cessation
Aggressive Tx. For COPD                     Pre-op Antibiotics
Inspiratory Muscle Training                 Tube Feed or TPN
Pre-op Patient Education
Selective Post-op NG
  decompression
Median Length of Stay 1 day shorter
Complication rate vs controls 18% vs.35%
Hulzebos, EH, et al, JAMA, 2006; 296:1851
                        DVT Risk
• Low Risk ( < 2% )
  Age < 40 and Duration < 60 min and No Risk Factors
      Calf DVT 2%              Proximal DVT 0.4%
      Significant PE 0.2%      Fatal PE < 0.01%
  Tx: Ted Hose, early ambulation

• Moderate Risk ( 10 – 40% )
  Age 40 – 60 or Duration > 60 min or Risk Factor
      Calf DVT 10 – 20%         Proximal DVT 2 – 4%
      Significant PE 1 – 2%     Fatal PE 0.1 – 0.4%
  Tx: LMWH, SCD

Additional Risk Factors: Advanced Age, Cancer, Prior Venous
  Thromboembolism, Obesity, HF, Paralysis, Hypercoagulable State
                                            DVT Risk
• High Risk ( 40 % )
  Age > 60
  Age 40 – 60 With Additional Risk Factor
      Calf DVT 20 – 40%          Proximal DVT 4 – 8%
      Significant PE 1 – 2%      Fatal PE 0.4 – 1.0%
  Tx: LMWH, SCD, Consider Prolonged Anticoagulation

• Highest Risk ( 40 – 80% )
  Age > 40 with Multiple Additional Risk Factors or
  THR, TKR, Hip Fracture, Major Trauma, Spinal Cord
      Calf DVT 40 – 80%          Proximal DVT 10 – 20%
      Significant PE 4 – 10%     Fatal PE 0.2 – 5%
  Tx: Long Term LMWH/Anticoagulation,
      Vena Caval Interruption
  Geerts, WH, et al, Chest 2004; 126:3385
                  Endocarditis Prophylaxis
                        One from
                    Column A and Column B

• Column A: Procedure • Column B: Abnormality
Dental                        Prosthetic Cardiac Valve
Skin and Soft Tissue          History of Endocarditis
  Infection                   Congenital Heart Disease
Respiratory                     Unrepaired Cyanotic
                                Repaired <= 6 months
                              Cardiac Transplant
                                Valvulopathy
AHA, April 2007
              Endocarditis Prophylaxis
• None for GI
• None for GU
• None for MVP
• None for ASD
AHA, April 2007




• None for bad hair day
            Medication Considerations
            Aspirin and Clopidogrel
• When possible delay non-cardiac surgery
 in patients with recent coronary stenting
  – 4 to 6 weeks for bare metal stent
  – At least 12 months for drug-eluting stent

• Optimize antiplatelet therapy with aspirin
 and clopidogrel by continuing it or
 reinstating it ASAP after procedure
 Fleischer, L, et al, Circulation, 2007, 118:418
 MKSAP Item 95,
 ACP IM Board Review Course October, 2010
 I’m not saying this was on the IM Boards, but it sure does come up a lot lately. You didn’t hear nothing from me.
     Medication Considerations
                and
     Specific Medical Conditions
Expertise comes from residency and years
 of clinical experience.

We are the experts in these areas.

Consider assuming care. This is where an
 Internist is really worth it.

								
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