Intro to PeriOperative
Medicine
Compiled by
Tabitha Goring, MD
Hospitalist Attending/Assistant Professor of Medicine
Jacobi Medical Center
Albert Einstein College of Medicine
Perioperative Medicine
Cardiac Risk Assessment
in non-cardiac surgery
Goldman Cardiac Risk Index
Age > 70 yo
MI < 6 months ago
JVD or S3 gallop
Significant Aortic Stenosis
Non-sinus Rhythm, APCs or >5 PVC/min
PO2<60 or PCO2>50, K<3.0 or HCO3<20
BUN >50 or Cr>3.0, abnormal AST,
Signs of chronic liver disease, or bedridden pt.
Intraperitoneal, intrathoracic or aortic procedure
Emergent Operation
Points
5
10
11
3
7
3
3
4
Perioperative Medicine
Class
Goldman Risk Assessment
Points
Risk
(Complication/Death Risk)
I
0-5
0.7%/ 0.2%
II
6-12
5% / 2%
III
13-25
11% / 2%
IV
>26
22% / 56%
Perioperative Medicine
Severity of Perioperative Stress
HIGH
Aortic Cross Clamp
Intrathoracic
Infrainguinal Vascular
Orthopedic
Head & Neck
Carotid
Amputation
MODERATE
TURP
Superficial
Cataract
LOW
Perioperative Medicine
Perioperative Stress Hormone



Norepinephrine/Epinephrine
Most anesthetics suppress many elements of the stress response
therefore, most problems occur postoperatively
Complications
Tachyarrythmias
Hyperglycemia
Hypertension
Protein Metabolism
Myocardial ischemia
CHF (Na retention)
Vasoconstriction (wound failure)
HypoNa, K, Mg
Hypercoaguability
SIRS
Perioperative Medicine
Non-invasive Pre-op Cardiac Testing
Exercise Treadmill
Exercise Thallium
Dipyridamole Thallium
Holter Monitor
Dobutamine Echocardiogram
Peri-Operative Medicine
Dobutamine Stress Echo
(Shaw et al 1996- Metaanalysis)



Highest positive predictive value(45-65%)
Well Tolerated
Predictive Value increases with number of walls
imaged.
Perioperative Medicine
Post-op Pulmonary Complications
Diaphramatic dysfunction
Hypoxemia
Pneumonia
Bronchospasm
Respiratory Failure
Perioperative Medicine
Pulmonary
No need for routine pre-op PFTs
 No data that routine pre-op CXR improves
outcome

Perioperative Management
Asthma Rec’s

Consider Oral Streoids 24-48h in mod-severe
asthmatics (better than inhaled steroids to prevent
periop flares)
studies show no increased wound infections, impaired wound healing or hyperglycemia.
Kabalin, Arch Intern Med 1995; 155


Inhaled Albut/Atrov for wheezing
Smoking Cessation 8 wks prior to surgery
Perioperative Management
Asthma Rec’s cont’d
 Consider use of regional anesthesia
 Nebulizers intra-op for flares
 IV lidocaine + inhaled salbutamol have synergy
pretreat prior to airway irritation
 Propofol, ketamine useful in asthmatics
(bronchodilators).
PeriOperative Medicine
What does the anesthesiologist know?
Cancel a case….
Well versed in IV meds not PO meds
(HTN, DM, MI, CHF, BrSpasm, Oliguria, Pain)
Choice of anesthestic agent
Choice of invasive or non-invasive monitoring
PeriOperative Medicine
What doesn’t the anesthesiologist know?
Long term management of chronic problems…
-HTN
-CAD
-Renal Failure
-Malnutrition
-Hepatic Dysfunction
-Endocrinologic Conditions
PeriOperative Medicine
What does the anesthesiologist want to know?
Regarding Drug Regimens….
-1st line, 2nd line, initial dose, titration, expected SEs
-Further tests might be indicated preoperatively
-Management suggestions
-Help to optimize the underlying disease p/t the surgical insult
-Never “clear” for a certain type of anesthesia
(may need to convert to GA anyway)
-Stent info; Type; Location; When placed; Antiplatelet Agents
-Pacer/AICD (date last checked) - ?magnet
-Suggest Cardiology when needed
Perioperative Medicine
Internists primary goal is not simply to “clear” pts
for surgery, but to
1. establish and optimize the pts risk for cardiopulmonary
complications, based on the pts current medical status in
conjunction with the degree of perioperative stress caused by a
particular procedure.
2. provide management recommendations which pertain to
pts underlying medical problems
Perioperative Medicine
ACC/AHA 2007 Guidelines on Perioperative
Cardiovascular Evaluation and Care for Cardiac
Surgery (J Am Coll Cardiology 2007;50e159-241)
The bottom line……….
****Intervention is rarely necessary to simply lower
risk……unless it is indicated irrespective of the
planned procedure.
Perioperative Medicine
Components of the Pre-op Evaluation
~History (chronic illnesses, meds, social hx)
~Physical
~Prior hx of cardiac w/u (echo, stress test, holter, AICD, cardiac cath)
~Assessment of functional status (METS)
~PSH/Anesthetic complications
~DI
~EKG (in moderate to high risk pts)
Perioperative Medicine
Establish Patient risk
Establish Surgical risk
Perioperative Medicine
PATIENT RISK
Who is High Risk?
Acute MI (<7 days)
→
Stress Testing → delay 4-6 weeks
Recent MI (8-30 days) →
Stress Testing → delay 4-6 weeks
Unstable angina/severe angina
(+) stress test/echo with large ischemic burden
Decompensated CHF (+) S3
→
? Echocardiogram
Arrhythmia → high-degree HB →
Cardiology Consult
→ symptomatic arrhythmia c CAD
“
Severe valvular disease
Perioperative Medicine
Who is Intermediate Risk?

mild angina
remote MI >1 month

stable CHF

creatinine >2.0
diabetes, uncontrolled
Qwaves on EKG



METS
1 -ADLeat,dress,toilet,walk around house(↑)
2-3 -walks 1-2 blocks on level ground (↑ risk)
4 - light housework/climb 2 flights of stairs
5-9 – heavy housework,golf,bowling,dancing
10 - strenuous exercise swimming, tennis
football, basketball, skiing
METS
(Working metabolic rate relative to the resting metabolic rate)
4 METS
i.
ii.
iii.
Ability to perform a spectrum of common
tasks correlate well with maximum O2 uptake
by treadmill testing. (Mangano 1990)
Increased cardiac and long-term risks in pts
unable to meet the 4-met demand
Perioperative ischemia more common in those
with poor exercise tolerance.
Perioperative Medicine
Pts with low functional capacity <4 METS MAY
benefit from preoperative stress testing to
-identify preoperative ischemia
-identify inducible cardiac arrythmias
-to help estimate cardiac risk
-help identify at risk territory after recent MI
***there is only real evidence to support stress testing in pts with 3 or more risk factors
who have poor functional capacity AND require high risk surgery ONLY IF it will
change management!!!
Perioperative Medicine
Who is Low Risk?
 advanced age
 abnormal EKG/old LBBB/LVH
 low functional capacity
 hx of CVA
 uncontrolled HTN
 frequent PVCs/NSVT
**risk is not known to increase with accumulation of low risk
factors….
Perioperative Medicine
SURGICAL RISK
High Risk
Open Aortic Surgery
Peripheral vascular surgery
XS blood loss estimated
Large fluid shifts
Prolonged Surgery
Perioperative Medicine
SURGICAL RISK
Moderate Risk
Intraperitoneal/Intrathoracic Surgery
CEA/Endovascular AAA
Head and Neck Surgery
Orthopedic Procedures
Open Prostate Resection
Perioperative Medicine
SURGICAL RISK
Low Risk
Superficial Procedures
Endoscopic Procedures
Cataract Surgery
Breast Surgery
Ambulatory Procedures
Perioperative Medicine

Lee et al -(Circulation 1999;100:1043-1049)
“simple index for prediction of cardiac risk”
1.
2.
3.
4.
5.
6.
Ischemic heart disease (MI, +stress test, NTG, active CP, abnormal
Qwaves)
CHF (hx of HF, APE, PND, LE edema, rales, S3, PVC)
CVA (hx if TIA or stroke)
High risk surgery (AAA, vascular, thoracic sx)
Insulin-requiring DM
Creatinine >2.0
Perioperative Medicine
Who gets an EKG?
Evidence supports:
Anyone who is undergoing intermediate or high
risk procedures who have at least one clinical
risk factor…CAD, PAD, CVA, CRI, DM, CHF
**low risk pts do not need EKGs (although we do them
anyway)
Perioperative Medicine
Who gets PCI (preoperatively)?
Balloon angioplasty- Plavix x 2 weeks +ASA
Bare-Metal Stent – Plavix x 4 weeks + ASA
Drug-eluting Stent – Plavix x 1 year (at least) + ASA
**(expert-opinion only…no real evidence to support)
**evidence reveals that PCI has no valve in prevention of cardiac
events with except in those who PCI is indicated for ACS
***CABG for left main disease
Perioperative Medicine
Perioperative Beta-Blockers
Who should be started?
•
•
•
•
Angina/Arrythmias/HTN – continue!
High Risk pt undergoing high risk procedures (evidence
supports)
CHD + high risk procedure
High risk pt undergoing intermediate risk procedure
**always use caution in pts in whom BBs are contraindicated (dCHF, severe
valvular dx, IHSS, mod-pers asthma etc………
Perioperative Medicine
Perioperative B-blockers
The Verdict is still out on….
•
Intermediate Risk pts undergoing moderate risk procedures
(although it is generally accepted that these pts are begun on BBs)
•
Low Risk pts undergoing high risk procedures
•
Low risk pts do not appear to benefit from and may be harmed
by initiation of BBs. (Lindenauer et al (retrospective)NEJM
2005.)
PeriOperative Medicine
POISE Study
(PeriOperative ISchemic Evaluation)
Inclusion Criteria
o
o
o
o
o
Undergoing non-cardiac surgery
> 45 yo
LOS 24 hours
CAD/PVD/hx of CHF/major vascular surgery or
Any 3 of the 7 thoracic/abdominal surgery/CHF/TIA/DM/CRF/>70yo/urgent surgery
PeriOperative Medicine
POISE Study
(PeriOperative ISchemic Evaluation)
Exclusion Criteria
o
o
o
o
o
o
o
Bradycardia <50bpm
2nd or 3rd degree HB
Asthma
Adverse rxn to a BB
CABG w/i 5 yrs
Low risk procedure
On Verapamil
PeriOperative Medicine
(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)
406
3548
2005
1506
191 sites
23 countries
886
PeriOperative Medicine
POISE Study
(PeriOperative ISchemic Evaluation)
o
o
o
o
o
8,351 patients included in the analysis, 99.8% of pts completed 30day f/u
Metoprolol 200 mg (starting 2-4 hours prior to surgery)
Continued qD x 30 days
Held for HR below 45bpm or hypotension (drug restarted @ lower dose)
EKG post-op, first day, second day and 30 days after surgery
(biomarkers if MI is suspected)
PeriOperative Medicine
POISE Study
(PeriOperative ISchemic Evaluation)
Primary Outcome
1. Cardiovascular death
2. Non-fatal MI
3. Non-fatal cardiac arrest 30 days after randomization
(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)
0.08
H R(95%CI)=0.70(0.56-0.86), p=0.0007
0.04
0.02
0.06
0.04
0.02
Risk
Non-fatal MI
H R(95%CI)=0.83(0.70-0.99), p=0.035
0.06
0.08
Primary Outcome
Metoprolol
# at Risk0
P 4177
M 4174
0.0
0.0
Placebo
10
20
30
3915
3959
3873
3909
3853
3879
0
P 4177
M 4174
10
20
30 Days
3923
3976
3882
3922
3859
3889
PeriOperative Medicine
Stroke
0.020
(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)
Metoprolol
0.010
Placebo
0.0
0.005
Risk
0.015
H R (95%C I)=2.17(1.26-3.73), p=0.005
0
No. at Risk
4177
P
4174
M
10
20
30 Days
4102
4085
4076
4038
4055
4011
PeriOperative Medicine
All Deaths
(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)
0.02
0.01
Risk
0.03
H R (95%C I)=1.33(1.02-1.74), p=0.032
Metoprolol
0.0
Placebo
0
No. at Risk
4177
P
4174
M
10
20
30 Days
4116
4113
4091
4066
4069
4038
PeriOperative Medicine
(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)
For every 1,000 treated patients, metoprolol would
prevent
15 MIs
 7 cases of new AF
 3 post-op CABGs

And there would be
8 excess deaths
 5 excess strokes
 53 patients with significant hypotension

PeriOperative Medicine
(Adapted from Kate Leslie, MD, PP presentation; Royal Melbourne Hospital)

Significant decrease in the risk of non-fatal MI


Significant increase in the risk of perioperative
stroke


Pooled OR = 0.68 (0.53-0.87)
Pooled OR = 2.16 (1.04-4.50)
No effect on total mortality
Perioperative Medicine
Beta-Blockers
Evidence suggests:
•
•
Longer-Acting (Atenolol) appears to be superior to shorter
acting (Metoprolol).
The dose should be started at least 7 days prior to surgery and
titrated up to target HR 60-65 (which is often not feasible inhouse)
Perioperative Medicine
Post-op R/O MIs
The evidence does not support serial Troponin
measurements in pts who are clinically
stable and hv undergone intermediate or
high risk surgery!!!!!!!!
It is only recommended in pts with EKG changes or CP!!!
WOW!!!!!
Perioperative Medicine
Rather…..
Charlston et al (1988)…Obtain EKG
*Immediately post-op
*Day 1 post-op
*Day 2 post-op
If changes, (ST-T wave changes) or symptoms
then obtain Cardiac enzymes
(What do we do with all these slightly positive troponins? Do they
affect outcomes? What is the role of revascularization?)
Pt Risk vs. Surgical Risk
Low Risk Surgery
Moderate Risk Surgery
High Risk Surgery
Low Risk pt.
Intermediate
Risk pt.
High Risk pt.
Proceed with Surgery
Proceed with Surgery
Proceed with caution
Proceed with Surgery
Assess METS
Assess # of risk factors
??BB
Possible BB
Post-op EKG/?Trop
Possible BB
Post-op EKG/?Trop
Definite BB
?Intervention - PCI
Post-Op EKG/?Trop
Proceed with Caution
Perioperative Medicine
Why Give Stress Dose steroids???
Chronic Steroid use suppresses the
hypothalamic-pituitary-adrenal axis…
What constitutes chronic use?
Perioperative Medicine
Normal Daily Corticol Production
10 mg Hydrocortisone PO
Endogenous Cortisol levels rise to
50 mg – Minor Surgery
75-150 mg – Major Surgery
(at induction of anesthesia, with return to baseline within 24-48 h)
Perioperative Medicine
Time to recovery of HPA axis
- as short as 2-5 days or as long as 9-12 months
Therefore, recommendations have been to
administer steroids to any pt who has received
more than 10 mg of prednisone for more than 7
days consecutive within the last year. (or 3
months depending on the author)
Perioperative Medicine






Asthmatics
Chronic Rheumatologic/Autoimmune Diseases
Certain Neurologic Diseases
HIV (PCP)
Dematologic Diseases (include high potency topicals)
GI (UC)
Perioperative Medicine
Traditional dose
100 mg of hydrocortisone q8h
(With a quick taper over 1-3 days if uncomplicated.)
Technically, dose should be administered based on the
surgical risk
Minor - 25 mg Hydrocortisone at induction x 1
Moderate - 25 mg Hydrocortisone q8h x 24 h
Major - 50 mg Hydrocortisone q6h x 48-72h
PeriOperative Medicine
A Question…….
A 68 yo man recently diagnosed with AdenoCa of the cecum undergoes
preoperative evaluation before surgical resection. His PMH includes
inoperable CAD, heart failure with LVSF 35%, HTN, hyperlipidemia. Angina
is stable, occurring approx monthly, and he has no orthpnea or PND.
Medications include lisinopril, carvedilol, lasix, zocor and daily ASA. He
plays golf weekly and carries groceries up a flt of stairs to his apt.
On physical, P 64, 120/64, JVD 6 Lungs CTA S1S2 no S3. No LE edema
CBC, Chem are WNL
EKG – NSR, Qwaves in II, III, AVF (old)
PeriOperative Medicine
Which of the following is the most appropriate
next step in the preop eval of this pt?
a.
b.
c.
d.
e.
Order plasma BNP
Echo
Exercise stress test
Nuclear imaging for LVEF
No further evaluation
What is his risk category??????
PeriOperative Evaluation
Question #2
A 68 yo male with a PMH of CAD, HTN, chol, presents for a perioperative
evaluation before AAA repair (open). His meds include lisinopril, HCTZ,
Zocor, ASA. He has not had angina since undergoing a 3V CABG 4 yrs ago.
He plays gold weekly, walking and carrying his clubs on a hilly course, walks
two miles in 35-40 minutes 3w weekly and vacuums the house.
PE – P 78 BP 140/87. The remainder of the exam is unremarkable. Results of
the electrocardiography are c/w his most recent electrocardiogram, with
evidence of an old inferior infarction. CBC, Chem are WNL.
Perioperative Medicine
Which of the following is the most appropriate
perioperative management in this pt?
a. Atenolol
b. Exercise stress testing
c. Echocardiography
d. Intraoperative Rt heart Cath (Swan)
Perioperative Medicine
Diabetes
Anticoagulation
DVT Prophylaxis
Delirium
HTN in Pregnancy