Best Perioperative Care for AAA Patients NCEPOD Report Regents Park College Regents Park College, London Anthony J Cunningham Royal College of y g Surgeons in Ireland 10/2/2009
NCEPOD - Changing Medical Practice • NCEPOD 2001 - Changing the Way We Operate • NCEPOD 2002 - Functioning as a Team NCEPOD 2002 i i • NCEPOD 2003 - Who Operates When • NCEPOD 2004 - Scoping our Practice • NCEPOD 2005 • NCEPOD 2005 - An Acute Problem ( Medical An Acute Problem ( Medical Admissions into Intensive Care) 10/2/2009
NCEPOD 2005 - Abd Abdominal Aortic Aneurysm: A i l A ti A A Service in Need of Surgery Service in Need of Surgery • Vascular Society of Great Britain and I l Ireland (VSGBI) d (VSGBI) • Vascular Anaesthesia Society of Great y Britain and Ireland (VASGBI) • Royal College of Radiologists • Royal College of Radiologists 10/2/2009
Presentation • Conventional wisdom UK outcome studies Best practice • NCEPOD Anaesthesia findings • Limitations of study • Recommendations • Recommendations Personal reflections 10/2/2009
Outcome Following AAA Repair • Patient factors Age • Co-existing disease states Cardiac Respiratory Renal • Surgical factors Elective/Urgent/Rupture g p AOD vs. AAA Open vs. endovascular repair • Institution case load • Institution case load 10/2/2009
Global Haemodynamic Responses to Abdominal Aortic Cross Clamp Abdominal Aortic Cross Clamp Gelman S :Anesthesiology 1995; 82: 1026-60 • Afterload increased Arterial pressure SVR LVESWS • Preload Blood volume redistribution CVP/PCWP CVP/PCWP • Heart rate • Myocardial contractility M di l ili 10/2/2009
Factors Affecting Haemodynamic Changes • Pre-existing Blood volume Coronary blood flow LV function • Surgical Site Duration Metabolic Humeral • Anaesthetic technique 10/2/2009
Global Haemodynamic Responses to Global Haemodynamic Responses to Abdominal Aortic Unclamp • Reactive hyperaemia • Decreased arterial pressure p • Decreased systemic vascular resistance vascular resistance • Decreased left ventricular end ventricular end- diastolic pressure • Cardiac output C di t t 10/2/2009
Br J Surg 1998; 85: 645-7 A 21-year Experience of Abdominal Aortic Aneurysm Operations in Edinburgh Bradbury AW, Adam DJ, Makhoomi KR et al: • Infrarenal AAA 673 700 • Prospective 600 • 1976-96 492 500 • 1515 patients 400 • 492 elective asymptomatic 300 • 194 elective symptomatic 194 200 156 • 156 emerg non-ruptured 100 • 673 ruptured 0 Elective Elective Emerg Ruptured asymp asympt 10/2/2009
Br J Surg 1998; 85: 645-7 A 21-year Experience of Abdominal Aortic A Aneurysm Operations in Edinburgh O ti i Edi b h Bradbury AW, Adam DJ, Makhoomi KR et al: 30 day mortality 40 37 • Elective - 6.1% 35 • Elective asymp -5.8% 30 • Emerg asympt -14.1% E 14 1% 25 • Ruptured -37% 20 14.1 • Increased operative I d ti 15 15 mortality 10 6.1 5.8 • Increased patient age Increased patient age 5 5 • Increased coexisting 0 Elective Elective Emerg rupture disease asympt asymp 10/2/2009
Br J Surg 2000 ; 87: 742-9 J Su g 000 ; 87: 74 9 Risk Factors for Postoperative Death Following Elective Surgical Repair of Abdominal Aortic Aneurysm: Results from the UK Small Aneurysm Trial • MRC Clinical Trials Unit • Identification of preoperative risk factors Identification of preoperative risk factors • Elective infra-renal AAA • 820 patients p • 30 day mortality - 5.6 % • Mortality related to Age Renal impairment - increased s. creatinine Lung disease - reduced FEV-1 Lung disease reduced FEV 1 10/2/2009
NCEPOD 2005 - Abd Abdominal Aortic Aneurysm: A i l A ti A A Service in Need of Surgery g y • Population • Population Adults AAA repair AAA repair Elective/emergency Open/endovascular • Hospitals • Hospitals England Wales Northern Ireland Northern Ireland • Data Collection 2 months - February / March 2004 y 10/2/2009
Anaesthesia Anaesthesia • Preoperative Management Management Beta blockade Statins Investigations Investigations • Intraoperative Personnel Grade VASGBI Management Blood loss Blood loss Monitoring Vasopressors • Postoperative P t ti EAA 10/2/2009 Destination
NCEPOD AAA - Findings Total number of cases 884 Operative Palliative 805 (91%) 805 (91%) 79 (9%) 79 (9%) Endovascular Open 53 (7%) Proceudres 752 (93%) Emergenc Elective Unknown y 264 434 (58%) 54 (7%) (35%) (35%) 10/2/2009
Improved Long-term Survival • Preoperative assessment Preoperative assessment - optimization of medical therapy • Modification of anaesthetic technique Modification of anaesthetic technique q - EAA - - monitoring into postoperative period • Prophylactic therapy Prophylactic therapy - sympatholytic effects - alpha 2 agonists - vasodilators - nitrates / calcium channel entry blockers dil i / l i h l bl k - Control of heart rate - beta blockers • Lipid lowering - statins 10/2/2009
Abdominal Aortic Aneurysm: A NCEPOD 2005 - Service in Need of Surgery d f S Beta Blockers • Preoperative Drug Therapy i N i S 10/2/2009
A Anesthesiology 1998; 88: 2-5 th i l 1998 88 2 5 PROPHYLACTIC ATENOLOL REDUCES POSTOPERATIVE MYOCARDIAL ISCHEMIA. McSPI Research Group Arthur Wallace, Beth Layug, Ida Tateo, Juliet Li, Milton y g Hollenberg, Warren Browner, Denis Mangano Multicenter Study of Preioperative Ischemia Research Group 10/2/2009
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Anesthesiology 1998; 88: 2 5 Anesthesiology 1998; 88: 2-5 PROPHYLACTIC ATENOLOL REDUCES POSTOPERATIVE MYOCARDIAL ISCHEMIA MYOCARDIAL ISCHEMIA. • Patients only followed after discharge • 4 deaths in hospital group • 8 patients in placebo group on beta blockers - discontinued 8 patients in placebo group on beta blockers - discontinued • Placebo group - more severe cardiac disease • 40% did not tolerate dose 10/2/2009
NEJM 1999; 341: 1789-94 The Effect of Bisoprolol on p Perioperative Mortality and M ocardial Infarction in High Risk Myocardial Infarction in High -Risk Patients Undergoing Vascular g g Surgery Don Poldermans, Eric Boersma, Ian R Thompson et al and the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study 10/2/2009
Study Design • Prospective 1996-9 • Randomized standard perioperative care • 7 centres • Standard perioperative p p • Elective abdominal Elective abdominal care + bisoprolol 5 mg aortic or infrainguinal oral -1 week arterial reconstruction arterial reconstruction • Heart rate > 60 bpm • Clinical risk evaluation evaluation • Postoperative 30 days • Postoperative 30 days • Dobutamine • 12 lead ECG and CK- echocardiography h di h MB MB 10/2/2009
Mean Heart Rate Day 7 St + bisoprolol St + bisoprolol Day 3 Standard Standard Day 1 Before 90 80 70 60 60 50 40 30 30 20 10 0 10/2/2009
Cardiac Deaths/ Non Fatal MI 10/2/2009
NEJM 1999; 341: 1789-94 The Effect of Bisoprolol on Perioperative Mortality and Myocardial Infarction in High -Risk Patients Undergoing Vascular Surgery • Non blinded • Highly selected patient population • T i l t Trial terminated early i t d l • High complication rate in placebo • 80-90% treatment effect - unrealistic? 80 90% treatment effect unrealistic? 10/2/2009
Preoperative Drug Therapy • Beta blockade Yes - 35% Yes 35% Yes - 26% No - 65% 74% No - 74% Emergency Emergency Elective N 10/2/2009
Abdominal Aortic Aneurysm: A NCEPOD 2005 - A Service in Need of Surgery y g ti A • Preoperative Drug Therapy l A Statins i Abd 10/2/2009
Reduction in Cardiovascular Events after Vascular Surgery with Atorvastatin: A Randomized Trial Anai E Durazzo Fabio Machado Dimas T Ikeoka Anai E Durazzo, Fabio Machado, Dimas T Ikeoka J Vasc Surg 2004; 39: 967-76 Lipid - lowering Therapy and In - Hospital Mortality following Major Noncardiac Surgery j g y Peter K Lindenauer, Penelope Pekow, Kaijun Wang JAMA 2004; 291: 2092-2099 10/2/2009
Perioperative Drug Therapy Yes - 53% Yes - 31% No - 47% 69% No - 69% Emergency Emergency No • Statins Elective 10/2/2009
Investigations • Standard History Physical examination Chest X ray ECG • Transthoracic echocardiography echocardiography 60% • Cardiology review • Cardiology review 22% 10/2/2009
20% preoperative autologous blood Intraoperative Factors Intraoperative donation salvage p • Cell Saver 55% • Blood 10/2/2009
• Fractionated heparin < Epidural Anaesthesia • Elective AAA - 92% • ASA therapy - 38% ASA therapy 38% • Emergency - 73% 14% 12 hours - 14% 12 hours 10/2/2009
Anaesthetists • Consultant at start elective open AAA - 93% AAA 93% • Emergency - 85% • Audit - 49% no IT or logbook • < 5 / year - 22% elective < 5 / 22% l ti • < 5/ year - 61% emergency emergency 10/2/2009
Postoperative Destination • Level 3 - ICU - 56% • Level 2 HDU - 33% Level 2 HDU 33% • Recovery - 9% Ventilated • Elective - 42% • Emergency - 78% Emergency 78% 10/2/2009
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