Perioperative and
Consultative Medicine
Pamela J. Pride MD, FHM
Medical University of South Carolina
2/7/2012
Overview
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Role of consultant
Cardiac risk assesment
Perioperative beta blockade
Preop pulmonary assesment and postop
risk reduction
Objectives
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Describe the risk factors for perioperative
complication.
Explain ACC risk stratification for surgery.
Describe the evidence supporting prophylactic
perioperative Beta Blockers.
Use algorithms, when available, to assess and risk
stratify patients.
Reassess patients for postoperative complications
and make medical recommendations when needed.
Key Messages
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Limited role for routine preoperative coronary
revascularization
Perioperative beta blockers for high risk pts,
need to be titrated
Preoperative PFTs have limited role
Role of the Consultant
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Evaluate and optimize patient’s medical status
Treat modifiable risk factors
Estimate and manage cardiac risk
Recommend measures to attenuate all
perioperative complications
What Not to Do
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Recommend for or against surgery
Tell anesthesiologists how to do their job
Recommend the obvious
“Clear” the patient
Say nothing
Pre-operative Cardiac Risk
Assessment
To Stress or Not to Stress
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ACC/AHA guidelines
ACC Guidelines-Getting Started
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Define “Active Cardiac Syndromes”
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ACS
HF (Class 4 or newly found)
Significant arrhythmias (VT, symptomatic
bradyarhythmias, rhythms requiring pacing, uncontrolled svts)
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Severe Valvular disorders (severe AS, symptomatic
MS)
ACC Guidelines-Getting Started
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Define “Clinical risk factors”
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Prior MI
CKD
Hx of CHF
DM
CVA
ACC Risk Stratification for Surgery
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High: (cardiac risk >5%)-Emergency surgeries,
aortic and major vascular, prolonged surgeries with
large fluid shifts or blood loss
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Intermediate: (cardiac risk <5%)-CEA, ENT,
intra peritoneal and intra thoracic, orthopedic,
urologic
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Low: (cardiac risk <1%)-endoscopic, superficial,
breast, cataract
Metabolic Equivalents
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What is 4 mets?
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Walking 3 miles/hour, yoga, water aerobics
Scrubbing floors, yardwork
Carrying groceries in from car
Competitive table tennis
Dancing
ACC Algorithm for Non-Cardiac Surgery
American College of Cardiology Foundation, et al. J Am Coll Cardiol 2009;54:e13-e118
Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply.
Estimating Cardiac Risk
Revised Cardiac Risk Index
Circulation 1999;100:1043-1049
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High risk surgery
History of CAD
CHF
CVA
DM
CKD
# risk factors
% complication
0…………………..0.4-0.5%
1…………………..0.9-1.3%
2……………………..4-7%
≥3……………………9-11%
Perioperative Beta Blockers
The Controversy
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Multiple early RCTs showed benefit
The bandwagon rolls out
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AHRQ list
ACC recommends
ACP recommends
More recent studies equivocal
Perioperative Beta Blockade
NEJM July 28,2005
Perioperative Beta Blockers
The POISE Trial
Lancet May 31, 2008
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High risk pts undergoing non cardiac surgery
Randomized to perioperative beta blockade vs.
placebo
Drug started hours before surgery and
continued for 30 days post op
Primary endpoints included cardiac death, nonfatal mi and non-fatal cardiac arrest
The POISE Trial
Results
Poise Trial Results
6
5
4
Placebo
metoprolol
3
2
1
0
30d nonfatal mi
all cause mort
cva
Peri-operative Beta Blockers
What should we do?
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Continue beta blockers for all pts on them
chronically
Start and titrate beta blockers preop for pts with
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Known CAD
+ ischemia on stress test
High cardiac risk profile
Unclear utility in pts with low cardiac risk profiles
Do not use in absence of titration (goal hr 60-80)
What about statins?
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Several observational studies suggest
benefit from peri-operative statins.
Randomised trials less clear
Bottom line-prescribe only if statin is
indicated regardless of surgery
Preoperative Pulmonary Assessment and
Postoperative Risk Reduction
Patient Factors
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Advanced Age
Poor functional status
COPD
CHF
Tobacco abuse
OSA
Low albumin
Surgical Factors
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Aortic, thoracic, upper
abdominal
Prolonged surgery
General anesthesia
Emergency surgery
Routine NG tube placement
Preoperative Pulmonary Function Testing
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Indicated for all lung resection patients
Fail to consistently predict pulmonary complications
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Abnormal exam, CXR, and Goldman risk index more
predictive
Low rate of complications in patients with severe obstruction
Use the “if they walked into my office” principle
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Evaluate unexplained dyspnea
Establish baseline for patients with known lung disease
Reducing Postoperative Pulmonary
Complications
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Incentive Spirometry
Selective NG decompression after general surgery
Cigarette cessation*
Medically optimize COPD
Avoid sedating meds
Neuraxial anesthesia
Reference List
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Derivation and Prospective Validation of a Simple Index for Prediction of
Cardiac Risk of Major Noncardiac Surgery . Circulation 1999;100:1043-1049
September 7, 1999
Perioperative Beta-Blocker Therapy and Mortality after Major Noncardiac
Surgery. N ENGL J MED 2005; 353:349-361 July 28, 2005
Effects of extended-release metoprolol succinate in patients undergoing noncardiac surgery (POISE trial): a randomised controlled trial. Lancet, 5/31/2008,
Vol. 371 Issue 9627, p1839-1847
Risk of Pulmonary Complications After Elective Abdominal Surgery Chest
September 1996 110:3 p744-750
2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated
Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation
and Care for Noncardiac Surgery, J Am Coll Cardiol, 2009; 54:13-118