Optimizing Patients for Ophthalmic Surgery with Minimal Work-Up - - PowerPoint PPT Presentation

Presented by Teresa Krosnick PA-C and Susan Wolf PA-C September 28, 2018 1

Optimizing Patients for Ophthalmic Surgery with Minimal Work-Up

Center for Peri-operative Optimization The Johns Hopkins Hospital Wilmer Eye Institute

• No Disclosures

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Objectives

• 1.

Review current practice, evidence based research and clinical practice guidelines (CPGs)

• 2. Identify high risk patients
• 3. Discuss perioperative optimization
• 4.

Review risk assessment tools

• 5. Patient presentations.
• 6. Summary

2000 Landmark Study

The New England Journal of Medicine 1-20-2000;342: 168-175 Oliver D. Schein, MD, MPH, Joanne Kath, Sc.D., Eric Bass, MD, MPH, et al

The Value of Routine Preoperative Medical Testing Before Cataract surgery

Prospective randomized clinical trial at 9 centers H&P only H&P + EKG, CBC, BMP

9408 patients 9411 patients

2000 Landmark Study

Combined intra-op and post-op events

31.3/1000 – the same for both groups

H&P H&P + EKG, CBC, BMP

Intra-op event 19.2/1000 19.7/1000 Post-op event 12.6/1000 12.1/1000

Adverse Event & Criteria Primarily Cardiovascular and Respiratory

Co-morbidities Associated with Adverse Events No significant Difference Routine testing Versus No Testing Intraoperative and Postoperative Events

Additional Studies Supporting No Routine Testing

• Dr Schein’s combined his original data

1025 patients in Brazil and 1276 in Italy cataract surgery

• Benarroch-Gampel

46,977 patients ambulatory surgery (hernia)

• Pershing

1,223,733 patients cataract surgery

Clinical Practice Guidelines (CPGs) No Mandates for Routine Pre-op Testing

The Joint Commission on Accreditation of Healthcare Organizations Institute for Clinical Systems Improvement The National Institute for Clinical Excellence Guidelines Centers for Medicare and Medicaid American College of Cardiology/ American Heart Association

Clinical Practice Guidelines (CPGs)

ACC/AHA (2014 guidelines) CPGs for cardiac testing for non-cardiac surgery Low Risk Surgery MACE < 1%

~95% of ophthalmic surgeries are low risk procedures

No Routine ECGs required for low risk surgery

2014 ACC/AHA

High Risk Surgery Major Adverse Cardiac Event (Mace) Periop of >1%

Medical Conditions associated with MACE >1%

Cardiovascular and Pulmonary Predictors CAD, STEMI or non-STEMI within 6 weeks or unstable angina Decompensated CHF VAD High grade Arrhythmias causing hemodynamic instability Cardiomyopathy and congenital heat disease Severe valve disease AV or MV stenosis with valve area < 1cm 2 Severe COPD/pulmonary disease PAH

Other Co-morbidities

Diabetes Renal Failure Anemia

2014 ACC/AHA CPGs

All Cardiac testing for low risk surgery is based

• n Medical not Surgical decisions

ECGs

Significant change since last evaluation

• History
• Hospitalizations
• ROS
• Physical Exam
• Decreased Functional capacity < 4 METs

Routine preoperative ECG is not useful for asymptomatic patients with known CAD or other significant structural heart disease undergoing low risk surgery

2014 ACC/AHA CPGs

Echocardiogram

Worsening DOE Valve Disease PAH

Routine echo is not recommended for low - moderate risk surgery in patients with stable cardiac disease

2014 ACC/AHA CPGs

Stress test Cardiac Catheterization Pacemaker/AICD interrogation

What Do Low Risk Patients Require For Optimization

H&P

ANACHRONISTIC EKG CBC BMP/CMP PT/PTT PFT UA CXR ECHO/STRESS

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Risk of Ophthalmic Surgery

• Group Risk is low
• Individual Risk can be high
• Identify High Risk Patients
• Use Risk Assessment tools to evaluate
• Communicate findings and target specific pathways

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Identify High Risk Patients

Choose Wisely

ECG and Labs

H&P Driven

Communicate Optimize Pathway driven

Perioperative Optimization

• Emerging Specialty
• Advancements of Anesthesia over the past 30 years

Specialization - Ophthalmic and Cardiac

• Advancement of surgical technique
• Hospital Specialists

– CHF – PAH – DM

• Perioperative pathways

– medical management; e.g. Remodulin pump for PAH

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Perioperative Optimization of Ophthalmic Patient

Factors to consider

• Type of anesthesia
• Patient Co-Morbidities such as PAH and CHF
• Cardiac anesthesiologist
• Operating room setting

Free standing clinic or tertiary center

Commonly Used Risk Assessment Tools

American Society of Anesthesiologists ASA Physical Status Classification

ASA I Healthy Patient ASA II Mild Disease ASA III Severe Disease ASA IV Severe Disease that is a constant threat to life ASA V Moribund patient unlikely to survive 24 hours with

• r without operation

RCRI

PAH classification Pulmonary Arterial Hypertension

• Group 1:

Pulmonary arterial hypertension

• Group 2:

Due to left heart disease

• Group 3: Due to chronic lung disease hypoxia
• Group 4:

Chronic thromboembolic disease

• Group 5: Unclear or multifactorial

Functional Capacity

1-4 Mets Light activity 5-9 Mets Moderate activity >= 10 Mets Strenuous activity

NYHA

CHAD2DS2Vasc Score for risk of Stroke

The Cost of Routine Testing is Enormous.

2000 $150,000,000.00 2016 2020 3.3 million Medicare patients cataract surgery 2030 4.4 million 2018 3 million cataract surgeries $500,000,000.00 Cost of $175.00 H&P/routine testing

Cost Projection

4.4 million in 2030 assuming no increase in cost 4,400,000 x $175 = $770,000,000 Does not include further testing Referral to specialist Echos, PFTs

Paradoxical Increase in Referral by Anesthesiologists and Surgeons for Comprehensive H&P Since 1997

Preoperative Consultations for Medicare Patients Undergoing Cataract Surgery 2014 Thilen, Treggiari, Lange JAMA Referrals Comprehensive Physical Exams

• 1998 11.3%
• 2008 18.4%

1997 Balanced Budget Act

Patient 1

• 40 year old male presenting preoperative evaluation for

cataract surgery with MAC

Severe non-obstructive cardiomyopathy Uncontrolled HTN CHF - EF 20% Echo 2 months ago Multiple CHF exacerbations Moderate PAH - RVSP of 45-50 mm Hg BMI 39, IDDM A1C 7.5, noncompliance, ESRD creatinine 5.1 Activity Level: Wheelchair, walks short distances <1 FOS without significant SOB and stopping between steps. Unable to lie flat

Patient 1

Multiple Assessments – Compensated Labs and EKGs CHF and Pulm HTN clinic Diuresis prior to surgery Surgery 2-7 days decompensated Medications: Insulin, metformin, Lasix, Lisinopril, aspirin, amlodipine

Assessment of Patient 1 Using Risk Assessment Tools

• ASA IV

Severe systemic disease constant threat to life, symptomatic labile CHF EF 20% ESRD not undergoing regularly scheduled dialysis

• RCRI III

1- CHF, 1-preoperative insulin, 1- preoperative creatinine >2

• FC <4 METs

Can walk short distanced around house,

• PAH

class II

• NYHA III

Symptomatic , Class C Objective evidence of moderately severe CV disease , EF 20%, RVSP 50 mm Hg, marked limitation in activities, comfortable at rest. Which of the following strategies will most likely optimize this patient for surgery?

• 1. Labs and EKG, repeat echo or Dobutamine stress
• 2. Notify Specialist, high risk OR, diuresis and stat electrolytes the day before, early surgery,

Focal exam on am of surgery, perioperative pathways for CHF and pulmonary Hypertension.

Patient 2

• 64 yr old thin female presenting for preoperative

evaluation for cataract surgery with MAC

Hyperlipidemia – borderline H&P 1 yr ago - WNL Patient walked 13 blocks to the hospital ROS negative Medication – None Activity Level: Walk 1-2 miles moderate pace, 2- 3 FOS and can lie supine no SOB BP R 128/78, L 132/80 HR 28 RR 18 O2 100% T 37.2 Stat EKG - 3rd degree heart block. Labs - Expedite ER Cardiology consult - HR did not increase adequately with stress Pacemaker - several hours. DC to home – 24 hours

Assessment of Patient 2 Using Risk Assessment Tools

ASA II 3rd degree heart block asymptomatic with no functional limitations, ASA status changed to ASA III after placement of pacemaker RCRI 0 No risk factors FC>4 METs Walked 13 blocks NYHA Class I No Limitation on physical exertion. No overt symptoms If this patient presented as above HR of 64 Would pre-op labs and EKG be necessary? Yes/No

Patient 3

• 22 y old female presenting for preoperative evaluation for retinal

surgery under GA

Marfan disease S/P aortic root replacement and MVR 4 years ago F/U with cardiologist 3 years ago Retinal surgery under GA Decrease in Activity Pale complexion noted ROS Recent Fatigue > walking 2+ blocks at a slow to moderate pace, SOB with 2 consecutive FOS Medications Atenolol and Lisinopril Activity level: Walks 1-3 blocks 2-4 times a day Physical Exam Pallor, III/VI holosystolic murmur at the apex without radiation.

Assessment of Patient 3 Using Risk Assessment Tools

ASA III Severe systemic disease Marfan disease S/P aortic root replacement and MV Repair RCRI 1 Can not rule out ischemic heart disease FC>4 METs 1 FOS NYHA II Does this patient need an echo? Yes Medical recommendation every 2 years Does she need a referral to cardiology? Yes Routine F/U is every 2 years Labs Yes (pallor) EKG Yes (fatigue with exertion)

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Assessment of Patient 3 Using Risk Assessment Tools

ASA III Severe systemic disease Marfan disease S/P aortic root replacement and MV Repair RCRI 1 Can not rule out ischemic heart disease FC>4 METs 1 FOS NYHA II Does this patient need an echo? Yes Medical recommendation every 2 years Does she need a referral to cardiology? Yes Routine F/U is every 2 years Labs Yes (pallor) EKG Yes (fatigue with exertion)

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Patient 4

55 y o male presenting for preop evaluation for cataract surgery with MAC.

Hypertension CAD - MI 18 m ago S/P CABG 2 days > MI, COPD -FEV1 of 1.4 L. Sleep apnea, daily CPAP CKD stage 2 creatinine baseline 1.6-1.9, Anemia HGB- baseline 9.1-10.2 Lower extremity neuropathy IDDM, hypothyroidism, BMI of 29, GERD, Cardiology 7 months ago. Stable on medical management Echo 1 m > CABG. EF - 45-50% . Pulmonology consult 1 year ago - stable Activity Level: Walks 2-3 blocks, climbs 2 FOS, lie flat for 1 hour

Patient 4

ROS, no recent SOB or chest pain, orthopnea, edema, recent illnesses. No admissions since MI. Medications: Coreg, Lisinopril, Insulin, Metformin, Synthroid, Prilosec ASA III History of MI RCRI I Mild ischemic heart disease, FC>4METs Cardiac rehab 2 times a week and states 2 FOS slow – mod pace no sig SOB Can lie flat 1+ hour with 1-2 pillows – Uses daily CPAP NYHA II Slight limitations on physical activity Does this patient need Preoperative EKG and labs? Yes or No?

Optimization Team Effort

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Multiple Models for Evaluation

• f Patients

RNs Hospitalist or Internist CPO/PEC

(Center for Perioperative Optimization)/ (Preoperative Evaluation Center)

Anesthesiologists Physician Assistants Nurse Practitioners

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Effectiveness of Perioperative Risk Assessment Clinic

Measure Effectiveness Cost Cancellations and delays Perioperative Events Ophthalmic Surgery Cancellations on DOS $3000 + per hour

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Effective Optimization Model

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Physician Anesthesiologist

Evidence Based Research Clinical Practice Guidelines Documentation Identify High Risk Patients Comprehensive H&P Optimize Specialist Pathway Driven Choose Wisely Low Risk Patient Minimal Work-Up Safe and Sufficient

Choosing Wisely and Going Forward

Focused Anesthesia assessments DOS

For low risk patients Heart Lung Airway Electronic data base and patient surveys Pilot program at Wilmer Eye Institute 1 in 5 patient - comprehensive H&P

Summary

Anachronistic practice

Tradition Medico legal Geographic Anesthesia

Moving forward

Abandon tradition Document decisions based on CPGs Risk Assessment tools Optimize

One Last Thought

4.4 million in 2030 H&P/routine tests of $175.00 4,400,000 x $175 = $770,000,000 Identify 1 in 5 patients - Comprehensive H&P 800,000 x $175 = $154,000,000 $770,000,000 - $154, 000,000 = $616,000,000 Savings

Fun Fact

Oldest documented cataract surgery 5th dynasty Egypt 2457-2467 BC

• We have come a long way

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