10/30/2017 1 Perioperative Medicine 2017 November 3, 2017 Scott Marsal, MD MSc FACP Chief, Medicine Division Medical Director, Quality & Patient Safety Providence St. Vincent Medical Center Disclosures • No conflicts of interest • Employer: Providence Health & Services
47
Embed
Perioperative Medicine 2017 - Internal Medicine · Cardiac Complication Risk Estimate of < 1% 2. Revised Cardiac Risk Index (RCRI) • Six independent predictors of cardiovascular
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
10/30/2017
1
Perioperative Medicine 2017November 3, 2017
Scott Marsal, MD MSc FACP
Chief, Medicine Division
Medical Director, Quality & Patient Safety
Providence St. Vincent Medical Center
Disclosures
• No conflicts of interest
• Employer: Providence Health & Services
10/30/2017
2
Objectives
• Highlight current understanding of perioperative risks
• Foster understanding of current guideline recommendations for perioperative assessment and management
• Review key points on medication management in perioperative period
Outline
• Background
• Risk Factors
• Evaluation
• Medication Management
10/30/2017
3
Background
48,000,0002009 US Inpatient Surgical Volume
National Center for Health Statistics
10/30/2017
4
Background- Key Data
• Overall perioperative complication rate low
< 0.1% for “healthy patients”
• Increase in non-cardiac surgery anticipated
• Migration of “healthy patients” to
Ambulatory Surgery Centers (ASC’s)
• Deaths (2001-2006) in ‘approved’ ASC’s
23/ 1,141,418 (0.002%)
Amer. Assoc. for Accreditation of Ambulatory Surgery Facilities
Ann Int Med. 2016;165(11):ITC81
Inpatient
• Hospital inpatient population
higher/increasing risk (ASC growth)
• Non-standardized perioperative medicine
approach � risk not fully mitigated at times
10/30/2017
5
Risk Factors
Determinants of Perioperative Risk
•Type
•Urgency
•Duration
•Medical Conditions
� CAD Risk
•Functional Capacity
Procedure Risk Patient Risk
10/30/2017
6
Perioperative Risk Classification
Low (<1%)
• Superficial
• Breast
• Dental
• Cataract
• Endoscopic
• Thyroid
• TURP
• Minor GYN, ortho
Ann Int Med. 2016;165(11):ITC81
Perioperative Risk Classification
Low (<1%)
• Superficial
• Breast
• Dental
• Cataract
• Endoscopic
• Thyroid
• TURP
• Minor GYN, ortho
Intermediate (1% - 5%)
• Intrathoracic; non-major
• Intraperitoneal
(splenectomy,
cholecystectomy)
• Carotid
• Endovascular aneurysm
• Head & neck
• Neuro, ortho, GYN, Uro
major
• Renal Transplant
10/30/2017
7
Perioperative Risk Classification
High (>5%)
• Aortic, major vascular
• Major abdominal (esp.
with large fluid shifts or
blood loss)
• Esophagectomy
• Pneumonectomy
• Lung, liver, pancreas
transplant
• adrenalectomy
Ann Int Med. 2016;165(11):ITC81
Procedure Risk
• Aortic, peripheral vascular
• Big Cases (� blood loss, fluid shifts)
• Emergent major (elderly)
• Endoscopic
• Superficial procedures & minor ortho
• Cataract
• Breast surgery & minor GYN
• Most other procedures
> 5%
≤≤≤≤1%
1-5%
10/30/2017
8
Patient Specific Risk
• Chronic conditions
Chronic Conditions and
Perioperative Risk
More comorbid conditions
Higher risk for perioperative complications
10/30/2017
9
American Society of Anesthesiology
ASA Classification of Physical Status
Grade Classification Perioperative Mortality
I Healthy
II Mild systemic disease-
no functional limitation
III Severe systemic disease-
definite functional
limitation
IV Severe systemic disease-
constant threat to life
V Moribund (not expected
to survive despite
surgery)
American Society of Anesthesiology
ASA Classification of Physical Status
Grade Classification Perioperative Mortality
I Healthy
< 0.4%II Mild systemic disease-
no functional limitation
III Severe systemic disease-
definite functional
limitation
0.9%
IV Severe systemic disease-
constant threat to life
V Moribund (not expected
to survive despite
surgery)
10/30/2017
10
Another Tool- Perioperative Risk
http://riskcalculator.facs.org
10/30/2017
11
Broad Array of Complications
Estimated (not solely CV)
Broad Array of Complications
Estimated (not solely CV)
Outcomes
Death
Outcomes:
Serious Complications
Any Complication
Pneumonia
Cardiac Complication
Surgical Site Infection
Urinary Tract Infection
Venous Thromboembolism
Renal Failure
Return to OR
Death
10/30/2017
12
Patient Specific Risk
• Chronic conditions
• Lifestyle factors
Patient Specific Risk
• Chronic conditions
• Lifestyle factors
– Exercise capacity: 4 METS (4 blocks or 2 flights of
stairs) a threshold effect
– Smoking
Arch Int Med 1999;159:2185
10/30/2017
13
Patient Specific Risk
• Chronic conditions
• Lifestyle factors
– Exercise capacity: 4 METS (4 blocks or 2 flights of
stairs) a threshold effect
– Smoking
• Functional status
Arch Int Med 1999;159:2185
Evaluation
10/30/2017
14
Our Patient
• 65 y/o woman with
isolated left colon
cancer
• Hemicolectomy
planned
• PMH:
– Hypertension
– Borderline lipids
Pre-operative Consultation
Continued…
• Meds:
– ASA, lisinopril,
hydrochlorothiazide
• Walks 3 miles/day
• No CHF/angina
• Exam:
– HR 74, BP 138/80
– Cardiopulmonary
unremarkable
• ECG: NSR, LVH
• CBC, lytes, Creat Nl
10/30/2017
15
“Usually not helpful for low-risk patients without