Optimizing the surgical patient

1. Optimizing the surgical patient Dana Doll D.O. Chair of Anesthesia St Michaels Hospital Stevens Point, WI

2. Surgery statistics 40 million anesthetics are administered each year in this country. Anesthesiologists provide or participate in more than 90 percent of these anesthetics 10 percent of the United States population undergoes non-cardiac surgery annually. Over 8 million have known CAD or cardiac risk factors. Over 50,000 will suffer a perioperative myocardial infarction. (0.2%)

3. What are You Really Being Asked to Do? • Assess risks of anesthesia • Assess the risks of the procedure • Manage “complicated” medical problems • Predict the future

4. objectives Review the AHA/ACC guidelines for the cardiac evaluation for a non-cardiac surgery Discuss OSA and anesthesia Discuss NPO status Medications to have and to hold Expectations for surgical procedures Anesthesia planning

5. ASA Physical Status Classification System For emergent operations, you have to add the letter ‘E’ after the classification.

6. Surgical risk

7. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery “The purpose of preoperative evaluation is notto give medical clearance, but rather to perform an evaluationof the patient’s current medical status; make recommendations concerning the evaluation, management, and risk of cardiac problems over the entire perioperative period; and provide a clinical risk profile that the patient, primary physician, anesthesiologist, and surgeon can use in making treatment decisions…” Kim A. Eagle, FACC, Chair, ACC/AHA Task Force on Practice Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery

8. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for NoncardiacSurgery The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context.

9. Cardiac optimization • Optimizing the patient is optimizing the oxygen supply and demand. • HR and BP control • Slower less O2 demand • Lower BP less work for heart less o2 demand • Respiratory optimization • Less O2 dissolved less to deliver • Pulmonary HTN to CHF • Renal optimization • Acidosis • Fluid overload • Hematologic optimization • O2 carrying capacity • Neurologic optimization • Cushing reflex

10. Cardiac evaluation and care algorithm for noncardiac surgery

11. Cardiac evaluation and care algorithm for noncardiac surgery Unstable coronary syndromes Recent MI Decompensated HF Significant arrhythmias Severe valvular disease

12. Cardiac evaluation and care algorithm for noncardiac surgery Endoscopic procedures Superficial procedure Cataract surgery Breast surgery Ambulatory surgery

13. Cardiac evaluation and care algorithm for noncardiac surgery

14. Cardiac evaluation and care algorithm for noncardiac surgery History Of Ischemic Heart Disease History Of Compensated Or Prior HF History Of Cerebrovascular Disease Diabetes Mellitus Renal Insufficiency

15. Pre operative testing

16. Echocardiography • Assessment of LV Function • Recommendations for Preoperative Noninvasive Evaluation of LV Function • Class IIa • Dyspnea of unknown origin (Level of Evidence: C) • Current or prior HF with worsening dyspnea if not performed within 12 months. (Level of Evidence: C) • Class IIb • Stable patients with previously documented cardiomyopathy (Level of Evidence: C) • Class III • Routine perioperative evaluation (Level of Evidence: B)

17. EKG • Resting 12-Lead ECG • Class I • 1 clinical risk factorundergoing vascular procedures. (Level of Evidence: B) • known CAD, peripheral arterial disease, or cerebrovascular disease undergoing intermediate-risk procedures. (Level of Evidence: C) • Class IIa • no clinical risk factors undergoing vascular surgical procedures. (Level of Evidence: B) • Class IIb • 1 clinical risk factor and undergoing intermediate-risk procedures. (Level of Evidence: B) • Class III • asymptomatic persons undergoing low-risk procedures. (Level of Evidence: B)

18. NoninvasiveStress Testing • Noninvasive Stress Testing • Class I • Active cardiac conditions in whom surgery is planned should be evaluated and treated per ACC/AHA guidelinesbefore surgery. (Level of Evidence: B) • Class IIa • 3 or more clinical risk factors and poor functional capacity (less than 4 METs) undergoing vascular surgeryif it will change management. (Level of Evidence: B) • Class IIb • 1 to 2 clinical risk factors and poor functional capacity (less than 4 METs) undergoing intermediate-risk or vascular surgery if it will change management. (Level of Evidence: B) • Class III • No clinical risk factors undergoing intermediate-risk surgery. (Level of Evidence: C) • Low-risk surgery. (Level of Evidence: C)

19. Who gets Beta Blockers? • Beta-Blocker Medical Therapy • Class I • Receiving beta blockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA class I guideline indications.(Level of Evidence: C) • Vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing. (Level of Evidence: B) • Class IIa • Vascular surgery in whom preoperative assessment identifies CAD. (Level of Evidence: B) • vascular and 1 clinical risk factor.(Level of Evidence: B) • CAD or 1 clinical risk factor, who are undergoing intermediate-risk or vascular surgery. (Level of Evidence: B) • Class IIb • Intermediate-risk procedures or vascular surgery, in whom preoperative assessment identifies a single clinical risk factor.(Level of Evidence: C) • Vascular surgery with no clinical risk factors who are not currently taking beta blockers. (Level of Evidence: B) • Class III • Absolute contraindications to beta blockade. (Level of Evidence: C)

20. Who gets statins? • Recommendations for Statin Therapy • Class I • currently taking statins and scheduled for noncardiacsurgery (Level of Evidence: B) • Class IIa • vascular surgery (Level of Evidence: B) • Class IIb • 1 clinical risk factor undergoing intermediate-risk procedure (Level of Evidence: C)

21. Who gets coronary revascularization? • CABG or Percutaneous Coronary Intervention • Class I • Any person who meets criteria according to ACC/AHA guidelines for revascularization (Level of Evidence: A) • Class IIa • Revascularization with PCI for mitigation of cardiac symptoms and elective noncardiac surgery in the subsequent 12 months, balloon angioplasty or bare-metal stent placement followed by 4 to 6 weeks of dual-antiplatelet therapy. (Level of Evidence: B) • drug-eluting coronary stents and who must undergo urgent surgical procedures that mandate the discontinuation of thienopyridine therapy, it is reasonable to continue aspirin if at all possible and restart the thienopyridine as soon as possible. (Level of Evidence: C) • Class IIb • High-risk ischemic patients (e.g., abnormal dobutamine stress echocardiograph with at least 5 segments of wall-motion abnormalities). (Level of Evidence: C) • low-risk ischemic patients with an abnormal dobutamine stress echocardiograph (segments 1 to 4). (Level of Evidence: B) • Class III • Prophylactic coronary revascularization in patients with stable CAD before noncardiac surgery. (Level of Evidence: B) • Elective noncardiac surgery within 4 to 6 weeks of bare-metal coronary stent implantation or within 12 months of drug-eluting coronary stent implantation in patients in whom thienopyridine therapy, or aspirin and thienopyridine therapy, will need to be discontinued perioperatively. (Level of Evidence: B) • Elective noncardiac surgery is not recommended within 4 weeks of coronary revascularization with balloon angioplasty. (Level of Evidence: B)

22. A.T. Still

23. Labs

24. Pulmonary • Formal spirometry rarely indicated • Subjective response to bronchodilators • Detailed H&P • Smoking cessation • 24 hours will decrease carboxyhemoglobin levels • 2-3 days will increase ciliary function but increase secretions • 1-2 weeks will decrease secretions • 4-8 weeks will decrease postop pulmonary complications • relative risk of pulmonary complications among smokers as compared with nonsmokers ranges from 1.4 to 4.3

25. OSA • Prevalence of sleep disordered breathing is 9% in women and 24% in men • Overt OSA has been estimated to be 2% in women and 4% in men • OSA is an independent risk factor for perioperative pulmonary complications • Case report demonstrates hemodynamic changes associated with apneic episodes • Pulse increase of up to40 bpm coinciding with hypoxia • Similar increases in SBP with levels above 180 mmHg coinciding with arousal • Hemodynamic instability did not respond to supplemental oxygen but resolved with CPAP • Postoperative nocturnal hypoxia precipitated myocardial ischemia in patients undergoing major vascular surgery

26. OSA • Length of Stay • 7.2 days in patients with Obstructive Sleep Apnea not using CPAP • 6.0 days if patients on CPAP • 5.1 days for patients in the control group • Unplanned transfer to the ICU • 33.3% in patients with undiagnosed Obstructive Sleep Apnea • 12.3% in patients with known Obstructive Sleep Apnea • 6% in controls

27. OSA Snoring Tired Observed Obstruction Pressure (HTN) BMI Age (greater than 50) Neck circumference Gender • Screening • STOP BANG • Testing • Polysomnography • Home pulse oximitry • Treatment and recommendations • CPAP • Oral appliance • Prolonged postoperative monitoring

28. Medications to take or not to take • Take day of surgery • CV meds • Beta blockers • Antiarrythmics • Clonidine • Statins • Anti-reflux • Seizure/ Parkinson • Psych– inform anesthesiologist • Bronchodilators • OCP– unless stopped for DVT prevention • Steroids – will likely get stress dose • Thyroid replacement • Pain meds– inform anesthesiologist

29. Medications to take or not to take • Do not take day of surgery • Diuretics • ACE/ ARB • Potassium • Diabetes oral medications • Metformin-- lactic acidosis • Basal insulin ½ dose • Hold bolus doses while NPO • NSAIDs/ ASA * • Herbal supplements – one week

30. Meds associated with bleeding • NSAIDs • Diclofenac, IBU, indomethacin, keto – 1 day hold • Naproxen and sulindac –3 day hold • Meloxicam, nabumetone, piroxicam – 10 day hold • COX2 inhibitors –2 days (nephrotoxicity) • Antiplatelet • Clopidigrel and Brillanta – 5 day hold • Effient – 7 day hold • ASA – 5 days • Do not stop antiplatelet agents without carefully reviewing indications and minimum duration from stenting and discussing with anesthesia, surgeon, and cardiologist • Warfarin – 5 days with bridging

31. Newer anticoagulants • Dabigatran (pradaxa) • Creatinine clearance > 50 then stop 2 days • Creatinine clearance <50 then stop 5 days • Consider doubling days of cessation prior to surgeries with high risk of bleeding • Rivaroxaban (Xarelto) • Stop at least 1-2 days before procedure • longer if chronic kidney disease or very high risk of bleeding • Ticlopidine (Ticlid)– stop 5 days before surgery

32. Fasting guidelines • Rule: 2, 4, 6, 8 rule applies to all ages • No clear liquids within 2 hours of surgery • Clear liquid definition • Water, Fruit juice without pulp (e.g. apple juice), Gatorade, Pedialyte, Carbonated beverage, Clear tea, Black coffee • Not allowed as clear liquid: Milk, milk products or Alcohol • No breast milk within 4 hours of surgery • No solid foods within 6 hours of surgery • Includes orange juice with pulp, light meals (toast or crackers), infant formula and milk • No fried foods, fatty foods or meats within 8 hours of surgery • These foods are associated with delayed gastric emptying

33. Pediatric pearls • Cough cold fever chills – is patient ever optimized? • Fever never good • If surgery will fix problem then usually reasonable • ASA 3 should go to pediatric center • Oral sedation available • Prolongs wake up times and discharge times • Mask induction until age 8-12 depending on maturity level • PIV needed otherwise

34. Planning for anesthetic technique Regional and anticoagulation Talk with anesthesia providers Give patients preview of what to expect Talk about NPO Tell them about general anesthesia, spinals, nerve blocks, sedation Pain expectations

35. Summary • Reviewed the AHA/ACC guidelines for the cardiac evaluation/ preparation for a non-cardiac surgery • Discussed respiratory optimization • Talked about day of surgery planning • Examined the benefit of really understanding the surgical process to better inform our patients

36. conclusion

37. References • ASA website patient information fast facts • J Am CollCardiol 2007; 50 p e159-e241 • Anesthesiology 2012; 116 p 522-38 • Anesthesia & Analgesia 2011; 112 p 113-121 • Anesthesiology 2011; 114 p 495-511 • Lancet 2008; 372: 139–44

38. Questions

40. A. T. Still