Challenges in Pre-Operative I have no disclosures Evaluation Geoff - - PDF document

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

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

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

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

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

Risks of Unnecessary PreOp Testing

Worse Patient and System Outcomes

Harm Cost Delay

Case 1 10 Minutes

Question 1

Clearance Risk Stratification

General Approach

Update H&P Cardiac Risk Assessment Pulmonary Risk Assessment Medication History Substance Abuse and EtOH Screen Optimize Medical Co- Morbidities

Source of Guiding Principles

ACC/AHA Flowchart

ACC/AHA Flowchart

Risk Calculators

• Revised Cardiac Risk Index (RCRI)
• American College of Surgeons (ACS) National

Surgical Quality Improvement Program (NSQIP)

RCRI

• Revised Cardiac Risk Index (RCRI)
• 6 Predictors of MACE (MI, V.fib, Cardiac Arrest,

Complete Heart Block, Pulm Edema)

• 0-1 predictors = low risk
• 2+ predictors = high risk
• One center; thoracic, vascular, ortho over-

represented

• Retrospectively validated numerous times

RCRI

Revised Cardiac Risk Index (RCRI)

• 1. CAD (MI, + stress, use NTG, CP c/w

angina, Q-waves)

• 2. CHF
• 3. CVA/TIA
• 4. DM (requiring insulin)
• 5. CKD (Cr > 2.0 mg/dL)
• 6. High Risk Surgery (suprainguinal vascular,

intraperitoneal, intrathoracic) Score % of MACE 0.4% 1 0.9% 2 6.6% 3+ 11%

ACS NSQIP

• 21 predictors, created in 2011
• 525 US hospitals, > 1 million operations
• Calculates risk of: MACE, death, PNA, VTE, AKI,

return to OR, unplanned intubation, discharge to rehab/nursing home, surgical infection, UTI

• Limitations: Not validated outside NSQIP, unclear

what to do with all the predictive information

ACS NSQIP – Inputs

Did anyone use a calculator? Which one? How did our patient do?

RCRI

Revised Cardiac Risk Index (RCRI)

• 1. CAD (MI, + stress, use NTG, CP c/w

angina, Q-waves)

• 2. CHF
• 3. CVA/TIA
• 4. DM (requiring insulin)
• 5. CKD (Cr > 2.0 mg/dL)
• 6. High Risk Surgery (suprainguinal vascular,

intraperitoneal, intrathoracic) Score % of MACE 0.4% 1 0.9% 2 6.6% 3+ 11%

ACS NSQIP – Results

ACC/AHA Flowchart

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

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

ACC/AHA Flowchart

Now, what about those meds?

Medications

• Diabetes Medications
• Betablockers
• ACEI/ARB
• Statins
• Anticoagulation
• Aspirin

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

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+)

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

Statins

• Continue statins if patient already taking one
• Consider starting statin if patient to undergo

vascular procedure

Anticoagulation

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

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

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

• 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

Quick Note About Labs

• Laboratory testing should be dictated by H&P
• Normal results within 4 months should be

sufficient

Case 2 10 Minutes

Postoperative Pulmonary Complications (PPCs)

• Incidence 2.0-5.6%
• PPCs associated with poor outcomes:
• ↑LOS, rehospitalization, and mortality rates
• Under-appreciation for PPCs and their

consequences

Postoperative Pulmonary Complications (PPCs)

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

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

Qaseem et al Ann Int Med 2006; 144; 575-580. Gupta et al Chest 2011; 140: 1207-1215 Johnson 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

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

Qaseem et al Ann Int Med 2006; 144; 575-580. Gupta et al Chest 2011; 140: 1207-1215 Johnson 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

ARISCAT Risk Index

Assess 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 surgery Upper abdominal 15 Thoracic 24 Duration of surgery 2-3 hours 16 >3 hours 23 Emergency surgery 8 Preop hemoglobin ≤ 10 g/dL 11

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

infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, aspiration

What to do with this data?

• KEY – Recognize Elevated Risk for PPC
• Identify strategies to mitigate individual modifiable

risk factors

• Communicate risk to anesthesia, surgery, hospital

medicine, and patient

Husband’s Collateral

• What diagnosis are we considering?
• Do we care?
• What are our next steps?

Obstructive Sleep Apnea

• Incidence Estimates:
• ~90% of patients with mod-severe OSA unaware
• f dx
• Few controlled, prospective studies
• Based on 2 meta-analyses, increased risk for:
• MI, Cardiac Arrest, Arrhythmias, ICU stay,

reintubation

Age 30-49 Age 50-70 Women 9% 27% Men 26% 43%

Kaw et al. Brit J Anesthes. 2012;109:897-106 Hai et al. J Clin Anesthes. 2014;26:591-600

Assess Risk – STOP-BANG

• Snoring: Do you snore loudly?
• Tiredness: Do you often feel tired,

fatigued, or sleepy during daytime?

• Observed apnea: Has anyone observed

you stop breathing during your sleep?

• Pressure: Do you have or are you being

treated for high BP?

• BMI > 35 kg/m2
• Age > 50
• Neck circumference ≥ 17” M, ≥ 16” F
• Gender (biologic sex) = male

• Increased risk of OSA:
• Score ≥ 3
• Increased risk of

moderate-severe OSA:

• Score ≥ 5
• High sensitivity, poor

specificity (~30%)

• STOP-BANG ≥ 3 + serum

HCO3 ≥ 28 increases specificity to ~80%

Chung F et al. Anesthesiology. 2008;108(5):812-21. Chung F et al. Br J Anaesth. 2012;108(5):768–75. Chung F et al. Chest. 2013;143(5):1284-93.

OSA Risk Management

• Use a reliable screen in the pre-operative period
• The earlier the better
• Insufficient evidence to delay surgery for full sleep

study unless:

• Poorly controlled systemic disease (e.g. HTN,

pulm HTN)

• Evidence of impaired gas exchange (↑pCO2,

↑HCO3)

Chung F et al. Anesthesia & Analgesia. 2016;123(2):452-73. ASA OSA Task Force. Anesthesiology. 2014;120(2):268-86.

Diagnostic Studies

Chest X-Ray

• Large meta-analysis: 10%

abnormal 87% were expected findings, 0.1% changed management

• More recent study, found 20% CXRs

with abnormalities, but only 3% changed management

• Poor correlation of CXR

abnormalities with risk/outcomes

• Obtain only if active cardio-

pulmonary (CP) symptoms, unstable CP disease, or CT surgery

C Archer et al, Can J Anaesth 1993; 40:1022 Qaseem et al, Ann Int Med 2006; 144:575-580

PFTs

• Rarely indicated in non-CT surgery
• No FEV1 cutoff that would absolutely cancel non-

CT surgery

• Consider in patients with otherwise unexplained

dyspnea

SMOKING CESSATION!!!

• Preop Smoking cessation shown to:
• Decrease overall post-op complications
• Decrease PPC
• Fewer wound healing complications
• No change in mortality
• Risk eliminated with >1y cessation
• Timeline controversial, >6-8 weeks

Mills et al Am J Med 2011; 124(2): 144-54 Wong Et al Can J Anesth 2012;59(3): 268-279 Thompson et al Cochrane Database Mar 27 2014

🚭

Case 3 5 Minutes

Expert Panel in Geriatric Surgery

• 2010 Med-Surg

Partnership

• 28 member

multidisciplinary panel

• Reviewed ~20 years of

literature

• Provide consensus

recommendations based on best evidence

2012 2016

PreOp Eval  What’s Different?

BODY BRAIN BIG PICTURE

PreOp Eval  What’s Different?

• STANDARD
• Update H&P
• Cardiac Risk Assessment
• Pulmonary Risk Assessment
• Medication History
• Substance Abuse and EtOH

Screen

• Optimize Medical Co-

Morbidities

• GERIATRICS PATIENTS
• Cognitive Baseline & Delirium

Risk

• Functional Capacity
• Polypharmacy Screen
• Frailty Assessment
• Nutritional Assessment
• Advanced Directives, Goals, &

Shared Decisions

• Education, Expectation Setting

PreOp Eval  What’s Different?

• STANDARD
• Update H&P
• Cardiac Risk Assessment
• Pulmonary Risk Assessment
• Medication History
• Substance Abuse and EtOH

Screen

• Optimize Medical Co-

Morbidities

• GERIATRICS PATIENTS
• Cognitive Baseline &

Delirium Risk

• Functional Capacity
• Polypharmacy Screen
• Frailty Assessment
• Nutritional Assessment
• Advanced Directives, Goals,

& Shared Decisions

• Education, Expectation

Setting

How about our patient (BODY)?

• RCRI = 2 (CAD, CKD)
• TTE – grade 1 diastolic

dysfunction, rest normal

• Myocardial perfusion normal
• PM interrogation normal
• ARISCAT = 3!
• No absolute contraindications
• Surgery time!!!! Right?

• Challenges in Pre-Operative Evaluation

Need think about the

• ~20% of adults >70 have cognitive impairment
• Associated with increased:
• Postop LOS, delirium, functional decline,

mortality

• Difficult to assess postop cognitive status without

baseline

How to evaluate the ?

• Mini-COG
• 3 item recall (🐹 🌉 ) – 1 point each
• 3 minute Clock draw (hands at 11:10) – 2 vs. 0

points

• If < 3, likely impairment  do full MMSE
• Assess decision making capacity

Functional Screen

• Functional dependence – one of strongest

predictors of:

• postoperative mortality, delirium, surgical site infections,

discharge to SNF

• ADLs/IADLs (any “NO” may warrant discharge

planning)

• Can you get out of bed or chair yourself?
• Can you dress and bathe yourself?
• Can you make your own meals?
• Can you do your own shopping?

Endicott et al J Vasc Surg 2017 Scarborough et al Ann Surg 2015

Functional Screen

• Falls?
• Timed Up and Go Test (TUGT) > 15 sec
• Rise from chair without armrests (no pushing off)
• Walk 10 feet
• Turn around
• Return to chair
• Sit down

Endicott et al J Vasc Surg 2017 Scarborough et al Ann Surg 2015

Back to the – Delirium

• Postop incidence: 10-51%
• 30-40% attributable to modifiable risk factors (i.e.

PREVENTABLE)

• Highest in hip fracture, vascular, and cardiac
• Associated with:
• Increased mortality, increased LOS, higher costs,

discharge to SNF, worse surgical outcomes, functional and cognitive decline

Ganai, Arch Surg 2007 Inouye, Lancet 2014

How about our patient ( )?

• Known MCI
• MOCA score 18/30
• Recites surgical indications &

possible complications

• Independent in ADLs, help for

some IADLs (meds, $$$)

• Has hearing aid & glasses
• TUGT (with cane) = 30 secs

• Challenges in Pre-Operative Evaluation

Delirium Prevention

• Preop
• Eliminate, cut down EtOH
• Minimize offending meds, opiates (Beers)
• EDUCATE FAMILY
• Communicate with anesthesia and surgery
• Intraop and Postop
• So many things, beyond scope, happy to

discuss

Medication Review

• Standard Med Review +
• Screen for deliriogenic

meds (Beers)

• Screen for polypharmacy
• >50% of patients >60 y/o on

5+ meds

• Associated with: delirium,

ADEs, drug-drug interactions, non-adherence, functional decline

• Dr. Seuss, “You’re Only Old Once” 1986

Back to our patient

• On total of 17 meds, including

apixaban

• Off NSAIDs 2/2 recent UGIB
• Recent severe delirium / MS

changes in setting of Percocet

• Chart lists codeine and

hydrocodone as causing hives

• Challenges in Pre-Operative Evaluation

PreOp Eval  What’s Different?

BODY BRAIN BIG PICTURE

PreOp Eval  What’s Different?

• STANDARD
• Update H&P
• Cardiac Risk Assessment
• Pulmonary Risk Assessment
• Medication History
• Substance Abuse and EtOH

Screen

• Optimize Medical Co-

Morbidities

• GERIATRICS PATIENTS
• Cognitive Baseline & Delirium

Risk

• Functional Capacity
• Polypharmacy Screen
• Frailty Assessment
• Nutritional Assessment
• Advanced Directives, Goals,

& Shared Decisions

• Education, Expectation

Setting

Establish Goals and Preferences

• Understand patient goals for surgery…consistent

with likely outcome?

• Review potential scenarios / set expectations
• Functional limitations, loss of independence, prolonged

recovery, need for nursing facility, ICU stay, postoperative cognitive decline

• BEST case & WORST case
• Advanced Directives / Health Care Proxy

Case Conclusion

• Major concerns!!! (Very very high risk)
• Extended conversations with patient and wife
• Discussed with geriatrics, anesthesia, ortho, social

work

• Decision was made to proceed

Case Conclusion

• Successful THA with epidural only
• POD 1-2 clear MS, but suboptimal pain control

with APAP + epidural

• Gabapentin was added…
• 12 hours later, “saw bugs crawling on his skin.”
• Later that evening, code blue  hypoxia to 70s,

hypotension

• To ICU, intubated, on pressors

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

Thank you!