Challenges in Pre-Operative Evaluation Geoff Stetson, MD Assistant Professor of Medicine, UCSF Hospitalist, San Francisco VA Medical Center I have no disclosures Special Thanks Heather Nye, MD, PhD • Professor of Medicine UCSF • Director of Co-Management Service and Veterans Integrated Preoperative Clinic at San Francisco VA Medical Center Henry Crevensten, MD • Associate Professor of Medicine UCSF • Director of Quality Improvement at San Francisco VA Medical Center Challenges in Pre-Operative Evaluation 3 Roadmap Overview of pre-op evaluation Case 1 – 10 Minutes • Cardiac risk-stratification in pre-operative evaluation • High-risk medications Case 2 – 10 Minutes • Pulmonary risk-stratification in pre-operative evaluation • OSA considerations Case 3 – 5 Minutes • An approach to geriatric pre-operative evaluation 4 Challenges in Pre-Operative Evaluation
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Challenges in Pre-Operative Evaluation
Geoff Stetson, MDAssistant Professor of Medicine, UCSFHospitalist, San Francisco VA Medical Center
I have no disclosures
Special Thanks
Heather Nye, MD, PhD• Professor of Medicine UCSF
• Director of Co-Management Service and Veterans Integrated Preoperative Clinic at San Francisco VA Medical Center
Henry Crevensten, MD• Associate Professor of Medicine UCSF
• Director of Quality Improvement at San Francisco VA Medical Center
Challenges in Pre-Operative Evaluation3
Roadmap
Overview of pre-op evaluation
Case 1 – 10 Minutes
• Cardiac risk-stratification in pre-operative evaluation
• High-risk medications
Case 2 – 10 Minutes
• Pulmonary risk-stratification in pre-operative evaluation
• OSA considerations
Case 3 – 5 Minutes
• An approach to geriatric pre-operative evaluation
4 Challenges in Pre-Operative Evaluation
Learning Objectives
Understand the risks and benefits of pre-operative evaluation
Appropriately risk-stratify a patient from a cardiac standpoint
Explain how to modify use of certain high-risk medications in the perioperative period
Describe PPCs and their role in perioperative care
Appropriately risk-stratify a patient from a pulmonary standpoint
Understand the role of OSA in the perioperative period
Develop a holistic framework for approaching the pre-operative evaluation of a geriatric patient
5 Challenges in Pre-Operative Evaluation
Goals of Pre-Op Evaluation
Evaluate risk of a procedure to a particular patient
• Allows for informed decision-making
Optimize medical conditions
Minimize unnecessary testing
Minimize complications
6 Challenges in Pre-Operative Evaluation
Prevalence and Costs
~30 million people/yr undergo surgery in US, most ambulatory1
~18% of cataract surgery patients had preoperative consultation2
~ 50% of preoperative consultants recommended an unnecessary test3
Preoperative testing costs ~$18 Billion annually in the U.S.4
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1. Onuoha OC, Arkoosh VA, Fleishre LA. JAMA Int Med. 2014; 174(8):1391-13952. Thilen S, Treggiari M, Lange J et al. JAMA Int Med. 2014; 173(3):380-3883. Kachalia A, Berg A, Fagerlin A, et al. Ann Intern Med. 2015; 162(2):100-1084. Kumar A, Srivastava U. J Anaesthesiol Clin Pharmacol. 2011 Apr;27(2):174-9
• One center; thoracic, vascular, ortho over-represented
• Retrospectively validated numerous times
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Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999;100:1043-9.
6. High Risk Surgery (suprainguinal vascular, intraperitoneal, intrathoracic)
Score % of MACE
0 0.4%
1 0.9%
2 6.6%
3+ 11%
Challenges in Pre-Operative Evaluation
ACS NSQIP – Results
22 Challenges in Pre-Operative Evaluation
ACC/AHA Flowchart
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METs = Metabolic Equivalents; CPG = Clinical Practice Guidelines; GDMT = Guideline-Directed Medical Therapy
Challenges in Pre-Operative Evaluation
Functional Capacity
1 MET (metabolic equivalent) = basal O2 consumption of a 70 kg 40-year-old man
>10 METs Excellent
7-10 METs Good
4-6 METs Moderate• Climbing 2 flights of stairs, walking up a hill, walking on level ground
at 4 mph, heavy work around the house
<4 METs Poor• Golfing with golf cart, playing a musical instrument, slow ballroom
dancing, walking at 2-3 miles per hour
24 Challenges in Pre-Operative Evaluation
Functional Capacity
Making Beds – 3-5
Ironing – 2
Archery – 4.3
Doubles Badminton – 3-4
Bocce – 2-3
Broomball – 6.3
Cricket – 6.1
Equestrianism (not horseback riding) – 7
Ringette – 12.6
Tobogganing – 7
25 Challenges in Pre-Operative Evaluation
ACC/AHA Flowchart
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METs = Metabolic Equivalents; CPG = Clinical Practice Guidelines; GDMT = Guideline-Directed Medical Therapy
Challenges in Pre-Operative Evaluation
Now, what about those meds?
27 Challenges in Pre-Operative Evaluation
Medications
Diabetes Medications
Betablockers
ACEI/ARB
Statins
Anticoagulation
Aspirin
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Diabetes Meds
Assuming patient is NPO at MN…
Stop oral meds (including metformin*)
Dose reduce long-acting insulin ~25%
Stop prandial insulin
Start sliding-scale insulin
29 Challenges in Pre-Operative Evaluation
β Blockers
In NON-CARDIAC surgery, β blockers:
• Reduce cardiac events perioperatively
• Higher risk of death and stroke
CONTINUE β blockers for other indications
DO NOT start β blocker solely for surgery (consider RCRI 3+)
30 Challenges in Pre-Operative Evaluation
ACEI/ARB
Continuation associated with hypotension, not worse CV outcomes
Many hold ACEI/ARB 2/2 concern for perioperative AKI
ACC/AHA: “Continuation of ACEIs or ARBs perioperatively is reasonable.”
Recommend: if patient on ACEI/ARB for CHF or difficult to control HTN, continue
31 Challenges in Pre-Operative Evaluation
Statins
Continue statins if patient already taking one
Consider starting statin if patient to undergo vascular procedure
32 Challenges in Pre-Operative Evaluation
Anticoagulation
33 Challenges in Pre-Operative Evaluation
Aspirin
Aspirin for primary/secondary prevention (excluding prior PCI):
• No decrease in death or non-fatal MI
• Increased Hemorrhage
Stop ASA 5-10 days before procedure, restart 7-10 days later
In patients with previous PCI and intervention, should continue ASA if possible
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Devereaux PJ et al for the POISE-2 Investigators. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014 Mar 31; [e-pub ahead of print].Graham MM et al. Aspirin in patients with previous percutaneous coronary intervention undergoing noncardiac surgery. Ann Intern Med 2017 Nov 14; [e-pub].
Challenges in Pre-Operative Evaluation
Medications
Diabetes Medications – Reduce Glargine by 25% + SSI
Betablockers – Continue
ACEI/ARB – Controversial…+/-
Statins – Continue
Anticoagulation – Hold, restart when surgeons deem safe, usually POD 1-3
Aspirin – Hold
35 Challenges in Pre-Operative Evaluation
How about that ?
Patient Characteristics
Procedure Characteristics
Perform EKG?
Low Risk Low Risk NO
Low Risk Int. or High Risk NO
High Risk Low Risk NO
High Risk Int. or High Risk YES
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• Low risk patients – asymptomatic, <10% 10-year risk of CAD• High risk patients – coronary artery, peripheral artery, or cerebrovascular
disease, structural heart disease, or arrhythmia• Optimal timing of EKG is unknown, consensus 1-3 months
Challenges in Pre-Operative Evaluation
Quick Note About Labs
Laboratory testing should be dictated by H&P
Normal results within 4 months should be sufficient
Under-appreciation for PPCs and their consequences
39 Challenges in Pre-Operative Evaluation
Postoperative Pulmonary Complications (PPCs)
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More Morbid/Serious Less Morbid/Serious
Respiratory Failure* Pneumothorax
Prolonged Mechanical Ventilation Pleural Effusion
Infection Atelectasis
Exacerbation of Underlying Lung Disease Bronchospasm
Prolonged Cough*Respiratory Failure has various definitions, most: PPV, NiPPV
Challenges in Pre-Operative Evaluation
PPC Risk Factors
Risk Factor Odds Ratio
Functional Dependence in ADLs Partial 1.93-2.16 Total 4.07-4.22
Age 60-69y 2.09 70-79y 3.04
CHF, NYHA class II 2.20
OSA 1.86-2.46
COPD 1.79
Smoking 1.26
Recent URI/LRI -
Patient Specific
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Qaseem et al Ann Int Med 2006; 144; 575-580.Gupta et al Chest 2011; 140: 1207-1215Johnson et al J Am Coll Surg 2007; 204: 1188-1198.Canet et al Anesthesiology 2010; 113:1338-1350.Smetana et al Ann Int Med 2006;144:582-595
*Obesity and mild-moderate asthma are not consistently associated with increased PPC risk
Challenges in Pre-Operative Evaluation
PPC Risk Factors
Risk Factor Odds Ratio
Emergency surgery 2.21
Surgery > 3-4 hours 2.14
General anesthesia 1.83
Aortic 2.94
Foregut/hepatobilliary 2.64
Brain 2.08
Other abdominal 1.27-1.78
ENT 1.11
Procedure Specific
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Qaseem et al Ann Int Med 2006; 144; 575-580.Gupta et al Chest 2011; 140: 1207-1215Johnson et al J Am Coll Surg 2007; 204: 1188-1198.Canet et al Anesthesiology 2010; 113:1338-1350.Smetana et al Ann Int Med 2006;144:582-595
Challenges in Pre-Operative Evaluation
ARISCAT Risk IndexAssess Respirator Risk in Surgical Patients in Catalonia
Risk Factor Risk Score
Age (years)51-80 3
>80 16
PreOp SpO2 (%)91-95 8
<91 24
Respiratory infection in past month 17
Location of surgeryUpper abdominal 15
Thoracic 24
Duration of surgery2-3 hours 16
>3 hours 23
Emergency surgery 8
Preop hemoglobin ≤ 10 g/dL 11
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Risk Class Risk Score PPCs (%)
Low <26 1.6-3.4
Intermediate 26-44 13-13.3
High >44 38-42.1
Derived in 2010, Validated in 2014
Wide variety of surgeries Southern European population Defined PPCs: respiratory