Updates in Preoperative Evaluation and No financial relationships - - PDF document

Updates in Preoperative Evaluation and Perioperative Care

Henry Crevensten, MD Associate Professor of Medicine Division of Hospital Medicine San Francisco Veterans Affairs Medical Center July 2016

Disclosures

• No financial relationships with

commercial interests within the past year

• No discussion of investigational or

‘off label’ use of medications or products *All images from UCSF brand photography or in the public domain from governmental sites

Outline and Scope

• Scope:
• Non-cardiac, elective procedures
• We will review:
• Guidelines for testing
• Updates over the last two years
• Issues for selected populations (women, geriatrics) in perioperative care
• Methodology:
• Case based learning
• We will take several pauses in order to help improve information retention

Take Home Points

1. Routine preoperative testing is usually NOT indicated 2. NO preoperative testing is indicated for cataract surgery 3. Surgical risk evaluation involves using RCRI/NSQIP and functional status 4. For patients on warfarin, bridging anticoagulation is indicated ONLY for patients with high risk of thromboembolic event 5. Probably safe to HOLD aspirin in the perioperative setting unless the patient has a recent coronary stent 6. Screen for Obstructive Sleep Apnea (OSA) and treat if indicated

Summary of Recommendations

• Evaluate Surgical Risk
• Evaluate Functional Status
• Review medications
• Continue Statin, Beta-Blocker
• Screen for Sleep Apnea

DO:

• Routinely obtain testing in low risk

patients

• Routinely obtain chest x-ray, ECG,

echocardiogram, or PFTs

• Bridge anticoagulation except in patients

with high risk of thromboembolic event

• Start beta-blocker unless medically

indicated DON’T:

Sources of Recommendations

• American College of Physicians
• American College of Surgeons
• American Society of Anesthesiologists
• NEJM Review Article 2015
• ACOG Guidelines
• AHA/ACC 2014
• US Preventative Services Task Force
• University of Washington Medicine Consult Service

Some of these sources do not entirely agree

Goals of Perioperative Management

• Evaluate risk of procedure to allow patient, primary care physician, surgeon, and

anesthesiologist to make informed decisions regarding surgical management

• Optimize medical conditions
• Minimize unnecessary testing
• Minimize complications

Prevalence, Cost, and Risk of Preoperative Testing

• ~30 million people undergo surgery per year in the United States, most are ambulatory1
• ~18% of patients undergoing cataract surgery had a preoperative consultation2
• ~ 50% of perioperative consultants recommended an unnecessary test3
• Preoperative testing is estimated to cost $18 Billion annually in the U.S.4
• Risks: unnecessary delay in procedure, unnecessary testing and harm from

investigating results, unnecessary cost to patient

General Principles

• Less > More
• Optimize what can be optimized
• Obtain testing ONLY if it would normally be

indicated (besides preparing for surgery) and/or ONLY if the results would change management

General Framework

• 1. Perform / Update H&P

• 2. Address / Optimize

Medical Issues

• 3. Review Medications

• 4. Assess Functional

Status

• 5. Evaluate Surgical Risk

(patient + procedure)

• 6. Consider Additional

Testing If Risk is Elevated

Case 1: Mrs. Marte

• Mrs. Marte is seeing you in clinic prior to left eye cataract surgery. Her ophthalmologist

has contacted you and has asked you to determine what testing and management is needed prior to her procedure.

• Mrs. Marte is a 68 year old woman with a history of:
• heart failure with reduced ejection fraction (EF 45%) (Rx: furosemide, metoprolol,

lisinopril),

• diabetes (HgbA1c 7.5%) (Rx: metformin)
• mild COPD (FEV1/FVC 0.65, FEV1 85% pred, current non smoker) (Rx: albuterol)
• and atrial fibrillation (Rx: metoprolol, apixaban)

Case 1: Mrs. Marte, continued

• What pre-operative evaluation should you perform?
• History & Physical exam:

‒ No recent chest pain ‒ No murmurs or wheezes on exam ‒ No evidence for volume overload ‒ Normal creatinine 3 months ago

• Functional Status

‒ She can walk up 3 flights of stairs without difficulty

Case 1: Mrs. Marte, continued

• Pre-operative evaluation:
• Chest xray?
• ECG?
• Labs?

NO additional testing is indicated UPDATED

Case 1: Mrs. Marte, continued

• Medication Management:
• Continue apixaban: for procedures with low risk of bleeding (i.e. cataract), interruption
• f anticoagulation is usually NOT necessary. However, consulting with surgeon and

anticoagulation clinic and adhering to your local practice is always advisable

• Continue lisinopril, furosemide, metoprolol
• Hold metformin (NPO)

Case 1: Take Home:

For cataract surgery preoperative testing has NOT been shown to affect outcomes. Rates

• f adverse events in patients were similar (~3%) whether or not they underwent testing

(American Academy of Ophthalmology Guideline 2014).

American Academy of Ophthalmology, http://www.aao.org/clinical-statement/routine-preoperative- laboratory-testing-patients-s, accessed May 2016

UPDATED

Determining Surgical Risk

Goal is to divide patients into two categories:

• LOW RISK:
• Combined patient and surgical procedure characteristics result in a

predicted risk of < 1% of a Major Adverse Cardiac Event (MACE = death or myocardial infarction)

• ELEVATED RISK:
• MACE ≥ 1%

Why Determine Surgical Risk?

• LOW RISK patients (MACE < 1%) do NOT need preoperative testing except as

indicated by H&P (as you would normally practice)

• ELEVATED RISK patients (MACE ≥ 1%) MAY need preoperative testing

depending on functional status. Surgical procedure may need to be modified UPDATED

ACC / AHA Flowchart (2014)

Evaluate Risk Proceed to Surgery Elevated Risk (MACE ≥ 1%, RCRI 2+) Evaluate Functional Capacity ≥ 4 METs < 4 METs OR cannot be assessed AND testing will influence management Pharmacologic Stress Test Optimize Medical Management Consider Alternative Approach to Surgery

UPDATED

Low Risk (MACE < 1%, RCRI 0 or 1) No Yes Normal ? Revascularization Abnormal

Tools for Determining Surgical Risk

• Revised Cardiac Risk Index (RCRI)
• American College of Surgeons NSQIP Surgical Risk Calculator

UPDATED

Revised Cardiac Risk Index (RCRI)

• Clinical Predictors (1 point each)
• ‘High Risk’ surgery

(intrathoracic, intraperitoneal, suprainguinal vascular)

• Ischemic Heart Disease
• Heart Failure
• Diabetes Requiring Insulin
• Creatinine > 2.0
• CVA or TIA

Predictors Complications MACE 0.5% 0.4% 1 1.3% 1% 2 4% 2.4% 3 + 9% 5.4%

Pros:

• Simple
• Validated outside original cohort

Cons:

• Older
• Smaller sample
• Other tools with greater predictive ability

American College of Surgeons NSQIP Surgical Risk Calculator

• http://www.riskcalculator.facs.org/RiskCalculator/
• Pros:
• Provides other outcomes
• Probably best predictor
• Cons:
• Only validated within cohort
• Need specific surgery
• Need ASA class
• MI defined as STEMI

Functional Status, defined

• MET = Metabolic Equivalent of Task
• 1 MET = basal oxygen consumption of a 40 year old, 70 kg male

METs Activity < 4 (poor) Simple activities of daily living, walk < 2 blocks 4 - 6 (moderate) Walk 2 flights of stairs, heavy housework/yardwork 7 - 10 (good) Jogging, bicycling (light effort) > 10 (excellent) 10-minute mile Note: capability of less than 4 METs of activity associated with higher cardiac risk

Cardiac Testing and Intervention

• Even in patients with known, stable coronary disease revascularization does NOT

improve long-term survival

• CARP trial: 510 patients with 1+ coronary artery with 70% occlusion. Randomized to

revascularization vs. not prior to major vascular surgery.

• No difference in death or MI
• Excluded: unstable angina, left main stenosis > 50%, severe aortic stenosis, and

LVEF < 20%

McFalls EO, Ward HB, Moritz TE, et al. N Engl J Med. 2004; 351: 2795–280

Case 2: Mrs. Cano

• Mrs. Cano is seeing you in clinic prior to left knee arthroplasty surgery. Her orthopaedic

surgeon has contacted you and has asked you to determine what testing and management is needed prior to her procedure.

• Mrs. Cano is a 68 year old woman with a history of:
• heart failure with reduced ejection fraction (EF 45%) (Rx: furosemide, metoprolol,

lisinopril),

• diabetes (HgbA1c 7.5%) (Rx: insulin glargine PM)
• mild COPD (FEV1/FVC 0.65, FEV1 85% pred, current non smoker) (Rx: albuterol, one

5 day steroid burst in last year)

• CAD (DES to RCA 5 years ago) (Rx: ASA, atorvastatin, metoprolol)
• and hypertension (Rx: metoprolol)

Case 2: Mrs. Cano, continued

• What pre-operative evaluation should you perform?
• History & Physical exam:

‒ No recent chest pain ‒ No murmurs or wheezes on exam ‒ No evidence for volume overload ‒ Normal creatinine 3 months ago ‒ BMI 24

• Functional Status

‒ She can walk up 3 flights of stairs without difficulty

ACC / AHA Flowchart (2014)

Evaluate Risk Proceed to Surgery Elevated Risk (MACE ≥ 1%, RCRI 2+) Evaluate Functional Capacity ≥ 4 METs < 4 METs OR cannot be assessed AND testing will influence management Pharmacologic Stress Test Optimize Medical Management Consider Alternative Approach to Surgery

UPDATED

Low Risk (MACE < 1%, RCRI 0 or 1) No Yes Normal ? Revascularization Abnormal

Case 2: Take Home

• Cardiac Testing?
• RCRI: 3 (ischemia, insulin, HF);

NSQIP MACE: 0.2%

• Higher risk by RCRI, but good functional status, so NO cardiac testing

Bottom line: if a patient has low risk of MACE, or higher risk but good functional status, then proceed with surgery. If higher risk of MACE and functional status cannot be assessed then may consider further cardiac testing.

Case 2: Mrs. Cano, continued

• NSQIP:

Pause Procedure

• Please take 1-2 minutes to pair share about:
• 1 or 2 things you have learned so far about pre-
• perative cardiac testing
• How what you have learned may change your

clinical practice

Case 2: Mrs. Cano, continued

• What preoperative labs and studies SHOULD we obtain? And when?
• CBC and Chemistry panel?
• LFTs?
• INR?
• ECG?
• Echocardiogram?
• PFTs?
• Chest x-ray?

Optimal Time Interval for Laboratory Testing?

• Unknown exactly
• IF laboratory testing is indicated, a normal result within 4 months should be sufficient
• Abnormal results are usually predicted clinically and usually do not effect management
• In a study of 1109 patients undergoing elective surgery only 0.4% had a change in test

results from normal (median 2 months prior to surgery, 70% within 4 months)

Macpherson DS, Snow R, Lofgren RP. Preoperative Screening: Value of Previous Tests. Ann Intern Med. 1990;113:969-973.

Electrocardiography (ECG)

• NOT INDICATED:
• Asymptomatic, low risk patients (< 10% 10-year risk of coronary disease)1
• Patients with coronary, peripheral arterial, cerebrovascular disease, structural heart

disease, or known arrhythmia undergoing low-risk surgery (<1% major adverse cardiac event) [ACC/AHA, 2014]2

• ‘REASONABLY’ INDICATED:
• Patients with coronary, peripheral arterial, cerebrovascular disease, structural heart

disease, or known arrhythmia undergoing an intermediate or high risk surgery2

• Optimal time interval unknown, general consensus is within 1-3 months prior to

surgery MAY BE INDICATED IN SELECT PATIENTS

1. Coronary Heart Disease: Screening with Electrocardiography. USPSTF. October 2014

• 2. Fleisher LA, Fleischmann KE, Auerbach AD, et al. J Am Coll Cardiol 2014;64:e77–137

Echocardiography

• Routine evaluation for asymptomatic patients is not indicated [ACC/AHA 2014]
• Consider if:
• New onset of dyspnea or symptoms of heart failure
• Clinically stable patient with known LV dysfunction or valvular disease has not had an

echocardiogram in the past year USUALLY NOT INDICATED

Chest Radiograph (x-ray)

• Unlikely to change management or outcome
• Meta-analysis (1993)1 – 14,390 patients with preoperative chest x-rays
• 10% (1,439) ‘abnormal’ result but only 1.3% (187) were unexpected from H&P
• Only 0.1% (14) led to a change in management
• Note: chest radiograph abnormalities increase with age
• ACP Guidelines (2006)2 – some limited evidence for:
• patients with ‘cardiopulmonary disease’
• older than 50 years undergoing upper abdominal/thoracic or abdominal aortic

aneurysm surgery USUALLY NOT INDICATED

• 1. Archer, C, Levy AR, McGregor M. Can J Anaesth 1993; 40:1022
• 2. Qaseem A, Snow V, Fitterman N, et al. Ann Intern Med. 2006;144:575-580.

Spirometry (PFTs)

• ACP Guidelines (2006): “…spirometry should be reserved for patients who are thought

to have undiagnosed chronic obstructive pulmonary disease”

• H&P usually sufficient to determine degree of airflow obstruction that may lead to

complications

Qaseem A, Snow V, Fitterman N, et al; Ann Intern Med 2006; 144(8) 575-580

NOT INDICATED

Obstructive Sleep Apnea (OSA)

• OSA is associated with increased post-operative cardiac and pulmonary complications

(1.5 to 3x risk)

• Undiagnosed OSA patients have a higher risk of cardiovascular complications

compared to diagnosed OSA patients treated with CPAP and controls. This risk increases with OSA severity.

• Risk of pulmonary complications appears to be high whether or not the OSA is

diagnosed

• It is not clear if CPAP treatment actually decreases pulmonary risk in surgical patients.

However, it is reasonable to continue CPAP treatment while hospitalized. Also patients with OSA may benefit from closer cardiopulmonary monitoring.

Mutter TC, Chateau D, Moffatt M, et al, Anesthesiology. 2014; 121: 707-718

INDICATED, UPDATED

Case 2: Mrs. Cano, continued

• Testing:
• CBC: +/- due to possible blood loss
• Chemistry panel: NO, done within 3 months
• INR: NO
• LFTs, albumin: NO
• ECG: reasonable if not done within 3 months (atrial fibrillation, CAD)
• CXR: NO
• PFTs: NO
• Echocardiogram: NO
• Sleep Apnea screening: NO (no symptoms, BMI low)

Pause Procedure

• Please take 1-2 minutes to pair share about:
• 1 or 2 things you have learned so far about pre-
• perative testing
• How what you have learned may change your

clinical practice

Case 2: Mrs. Cano, continued

• How should we manage her medications?
• Aspirin:
• Metoprolol:
• Lisinopril:
• Atorvastatin:
• Insulin glargine:
• Furosemide:
• ‘Stress-dose’ steroid?
• Clonidine?

Antiplatelet Medications

• Aspirin for primary / secondary prevention (excluding recent stents):
• Aspirin in the perioperative period did not decrease death or non-fatal MI but

increased major hemorrhage (HR 1.23 95% CI 1.01 to 1.49). ‒ Caveats: low rate of PCI, low rate of vascular surgery ‒ These may not be your patients: mod- to high risk patients received 200mg ASA just before surgery and 100mg for 30 days afterward

• For procedures with higher risk of hemorrhage and patient without recent stents it is

probably safe to stop aspirin 5-10 days prior to procedure. Restart 8-10 days afterward UPDATED

Devereaux PJ, Mrkobrada M, Sessler DI, et al; POISE-2 Investigators. N Engl J Med. 2014;370:1494-503.

Antiplatelet Medications, continued

• Aspirin in patients with stents:
• Highest thrombosis risk is within 4-6 weeks after stent placement.
• Optimally, delay elective procedure at least 14 days after balloon angioplasty, 30 days

after bare metal stent and 1 year after drug-eluting stent.

• Continue dual antiplatelet medications perioperatively if possible.
• If surgery needs to be performed and risk of hemorrhage deems dual antiplatelet

therapy unacceptable: Continue aspirin, discontinue P2Y12 inhibitor (i.e. clopidogrel – 5 days) and resume as soon as possible. UPDATED

Beta-Blockers

• In NON-cardiac surgery, beta-blockers reduce cardiac events perioperatively but NOT
• death. They are associated with higher risk of death and stroke

[Cochrane Review 2014].

• CONTINUE beta blockers perioperatively if a patient is already on one. DO NOT

withdraw beta-blockers abruptly if at all possible.

• DO NOT initiate a beta blocker solely for surgery (note: ACC/AHA guidelines say

consider if RCRI 3+)

• IF you are starting a beta blocker perioperatively try to start it 2 – 7 days prior to the

procedure UPDATED

Blessberger H, Kammler J, Domanovits H, et al. Cochrane Database Syst Rev. 2014;9:CD004476

Angiotensin-Converting Enzyme Inhibitors (ACEI) and Angiotensin Receptor Blockers (ARB)

• Continuing ACEI/ARB associated with intraoperative hypotension but not with poorer

cardiovascular outcomes. Possible decrease in perioperative hypertension

• Anesthesia practice has been to hold ACEI / ARBs on day of surgery
• AHA/ACC Guidelines: “Continuation of angiotensin-converting enzyme (ACE) inhibitors
• r angiotensin-receptor blockers (ARBs) perioperatively is reasonable”
• Recent study: withholding ACEI/ARB safe in ambulatory surgery1
• Recommend: if patient on ACEI/ARB for heart failure or difficult to control hypertension

would probably continue. UPDATED

Twersky RS, Goel V, Narayan P, et al. Anesth Analg. 2014;118:938-44

Statins

• Continue statins if patient already taking one
• Reasonable to initiate a statin if patient is to undergo vascular surgery
• Reasonable to initiate a statin as indicated by current guidelines for higher risk surgeries

Anticoagulants

• Recent Updates:
• It is becoming more common to perform procedures while continuing anticoagulation
• There are fewer indications for bridging anticoagulation
• Use of Direct Oral Anticoagulants (DOACs) is becoming more common
• General Framework:
• Evaluate procedural bleeding risk
• Evaluate perioperative thromboembolic risk
• Consult with your surgeon and anticoagulation clinic and adhere to local practice

guidelines UPDATED

Steroids

Objective: determine IF the patient’s Hypothalamic-Pituitary-Adrenal (HPA) axis is suppressed or not. Goal: Avoid adrenal crisis and perioperative hypotension

HPA Axis Glucocorticoid Exposure Management NOT suppressed

• < 3 weeks / year
• Every Other Day use
• < 5 mg AM prednisone equivalent

Continue taking usual glucocorticoid Possibly Suppressed

• 5 – 20 mg daily prednisone equivalent or other

‘significant’ use

• Use of inhaled steroid
• Topical glucocorticoid use (Class I)
• > 3 steroid injections / 3 months

Check 8am cortisol, if suppressed give supplemental steroids vs. ACTH stimulation test vs. empiric supplementation Suppressed

• > 20 mg daily prednisone equivalent for > 3 weeks
• Cushingoid appearance

Steroid supplementation Adapted From: Molly Jackson, Somnath Mookherjee, and Nason Hamlin (eds.), The Perioperative Medicine Consult Handbook, Springer 2015.

Alpha-2 Agonists (clonidine)

• NOT RECOMMENDED perioperatively for cardiac prophylaxis
• Prior studies showed reduced mortality and ischemia
• However, POISE-2 (2014) was a larger trial (~10,000 patients):
• No decrease in perioperative death or MI
• Increase in non-fatal cardiac arrest (PEA) and clinically significant hypotension

UPDATED

Devereaux PJ, Sessler DI, Leslie K, et al. N Engl J Med 2014;370:1504-1513

Case 2: Mrs. Cano, continued

• How should we manage her medications?
• Aspirin: +/- continue (DES 5 yrs ago, intermediate risk of hemorrhage, ACC/AHA

recommends continuation, increased risk of hemorrhage with questionable benefit)

• Insulin: decrease basal insulin by ~20%, stop prandial.
• Furosemide: reasonable to discontinue
• Lisinopril: controversial, would prefer to continue
• Atorvastatin: continue
• Metoprolol: continue
• ‘Stress-dose’ steroid: NO

Case 3: What about anticoagulation? Mrs. Lee

• Mrs. Lee is seeing you in clinic prior to left knee arthroplasty surgery. Her orthopaedic

surgeon has contacted you and has asked you to determine what testing and management is needed prior to her procedure.

• Mrs. Cano is a 68 year old woman with a history of:
• heart failure with reduced ejection fraction (EF 45%) (Rx: furosemide, metoprolol,

lisinopril),

• diabetes (HgbA1c 7.5%) (Rx: insulin glargine PM)
• CAD (DES to RCA 5 years ago) (Rx: atorvastatin, metoprolol, no ASA – on warfarin**)
• hypertension (Rx: metoprolol)
• And atrial fibrillation [CHA2DS2- VASc = 4 (age, HF, HTN, female)] (Rx: warfarin,

metoprolol)

Anticoagulants: warfarin

UPDATED

Procedural Bleeding Risk Perioperative Thromboembolic Risk (per year) Low (< 2%) Moderate (2-10%) High (> 10%)

Very Low

• Cataract, ICD/pacemaker

Probably do not need to interrupt anticoagulation Low Some procedures may be performed on warfarin IF interrupting anticoagulation:

• Stop warfarin 5 days prior to procedure
• No bridging
• Check INR day of surgery
• Restart warfarin POD #0 or when deemed

IF bridging:

• Stop warfarin 5 days prior to procedure
• Initiate enoxaparin 36 hrs after last warfarin dose
• Stop enoxaparin 24 hrs prior to procedure
• Restart warfarin POD #0, enoxaparin POD #1

High Vascular, CABG, knee/hip replacement, kidney biopsy, neurosurgical, Stop warfarin 5 days prior to procedure No bridging Check INR day of surgery IF bridging:

• Stop warfarin 5 days prior to procedure
• Initiate enoxaparin 36 hrs after last warfarin dose
• Stop enoxaparin 24 hrs prior to procedure
• Restart warfarin when safe, enoxaparin @ 48-72 hrs

Adapted From: UCSF, SFVA, and ZSFGH Reference for Perioperative Management of Patients on Warfarin. Approved Feb 2016

Anticoagulants: DOACs

UPDATED

Procedural Bleeding Risk Perioperative Thromboembolic Risk (per year) Low (< 2%) Moderate (2-10%) High (> 10%)

Very Low Cataract, ICD/pacemaker, skin biopsy, endoscopic w/o biopsy Do not need to interrupt anticoagulation Low-Med-High Vascular, CABG, knee/hip replacement, kidney biopsy, neurosurgical, procedures with biopsy

Very High Neurosurgical, cardiothoracic, spine. Interrupt anticoagulation depending on pharmacokinetics of agent and renal

• function. Generally 72 – 120 hours prior to

procedure Resume at 5-7 days post-procedure Interrupt anticoagulation depending on pharmacokinetics of agent and renal function. Generally 72 – 120 hours prior to procedure Resume no sooner than 48-72 hrs post-procedure Adapted From: UCSF, SFVA, and ZSFGH Guidelines for the Peri-Procedural Management of Adults Taking Target-Specific Anticoagulants. Approved 2015

Case 3: Mrs. Lee – managing anticoagulation

• Warfarin – with moderate perioperative thromboembolic risk (CHA2DS2- VASc = 4)

bridging anticoagulation is NO LONGER recommended. Procedure bleeding risk is ‘high’ so warfarin should be HELD. Plan: hold warfarin 5 days prior to procedure. No bridging. Resume warfarin POD#0 or when deemed safe. For orthopaedic procedures administer prophylactic enoxaparin until INR therapeutic.

• Apixaban – bridging anticoagulation generally not recommended. Procedure bleeding

risk is ‘high’ so apixaban should be HELD. Plan: hold apixaban 48 hours prior to procedure. No bridging. Resume apixaban no sooner than 5 – 7 days post-procedure. For orthopaedic procedures administer prophylactic enoxaparin (or prophylactic dose apixaban) post-operatively.

Case 3: Mrs. Lee – Anticoagulation Learning Points

• Bridging anticoagulation is NO LONGER recommended for patients on warfarin and low-

moderate perioperative thromboembolic risk. Consult your anticoagulation service/pharmacist for patients at high risk for thromboembolism.

• Pharmacokinetics of DOACs are variable, depending on agent and renal function.

Consult your anticoagulation service or pharmacist regarding specific hold times prior to procedures.

• More procedures with low risk of hemorrhage are being performed while on

anticoagulation (i.e. cataract, dental, endoscopic procedures without biopsy). Discuss with person performing procedure, your anticoagulation service, and adhere to local guidelines.

Pause Procedure

• Please take 1-2 minutes to pair share about:
• 1 or 2 things you have learned so far about pre-
• perative medication management
• How what you have learned may change your

clinical practice

Additional Optimization

• Smoking Cessation
• Stop smoking as far out from surgery as possible
• Earlier data that showed worse outcomes with smoking cessation < 4 weeks not

borne out by later meta-analysis

• Nutrition
• Low albumin is predictor of poor pulmonary outcomes
• Patients with severe malnutrition may benefit from enteral nutritional supplementation
• Pulmonary
• Preoperative inspiratory muscle training decreases pulmonary complications,

especially in cardiothoracic and abdominal surgery

Select Populations…

Women

• Pregnancy Testing - rate of incidental pregnancies found pre-operatively: 0.3 to 2.4%
• American Society of Anesthesiologists: “…the literature is inadequate to inform

patients or physicians on whether anesthesia causes harmful effects on early

• pregnancy. Pregnancy testing may be offered to female patients of childbearing age

and for whom the result would alter the patient’s management”

• However, general practice is to obtain urine pregnancy testing in women of

childbearing age (time of initial reported menses and one year after last reported menses, without exclusion criteria i.e. hysterectomy)

• Genital tract infection – routine screening NOT indicated. Evaluate based on

symptoms.

Practice advisory for preanesthesia evaluation: ANESTHESIOLOGY 2012; 116:1-17

Women, continued

• Oral Contraceptives / Hormone Therapy – increased risk of thromboembolic events
• Low-risk procedures / early ambulation: CONTINUE
• Moderate- to High-Risk procedures / relative immobility: DISCONTINUE 4-6 weeks

prior to procedure after DISCUSSION with patient. ‒ Risk of unintended pregnancy (use backup method) ‒ Post-operative prophylaxis: defer to surgeon

Johnson B, Porter J, Obstetrics & Gynecology, 2008; 111:1183-1194

Older Patients

• Risk of mortality in elective surgery increases slightly with age but probably due to co-

morbidities rather than age alone

• ‘No Care Without Goals of Care’
• Discuss risks and benefits of procedure given life expectancy, expected outcome
• Advance Directive / Code Status
• Surrogate Decision-Maker

Older Patients, Pre-Operative Evaluation

• Evaluate Cognitive Status and decision-making capacity. Cognitive impairment

increases risk of perioperative delirium and mortality. Advise patient to bring assistive devices (hearing aids, glasses) to hospital

• Evaluate Functional Status – older patients are at risk for loss of functional status simply

due to hospitalization. Decreased functional status is a risk for increased morbidity.

• Evaluate Nutrition – poor nutrition may be risk for mortality (studies variable)
• Consider pre-operative rehabilitation program to improve functional status and nutrition

and ensure post-operative rehabilitation plan is in place.

Oresanya LB, Lyons WL, Finlayson E, JAMA. 2014; 311 (20): 2110-2120

Postoperative Care

• Postoperative troponin elevation is associated with increased 30-day mortality
• However, unclear how to manage this risk – many were asymptomatic and mechanism

is likely supply/demand mismatch

• ACC/AHA recommends against routine post-operative troponin screening
• Bottom line: more studies needed. If your patient is found to have an elevated troponin

post operatively it would be prudent to further evaluate and manage her cardiac risk. UPDATED

Summary of Recent Updates

• NO testing is required prior to cataract surgery
• Determining need for cardiac testing has been simplified:
• determine risk of MACE: if < 1%, proceed with surgery, if ≥ 1% and good functional

status, proceed with surgery

• if not, consider cardiac testing if management would change.
• Screening and treating for OSA can decrease cardiovascular events
• Okay to HOLD Aspirin in the perioperative period unless patient has recent coronary

stent

• DO NOT use bridging anticoagulation in patients on warfarin and low-moderate

thromboembolic risk

• BE AWARE that post-op troponin elevation leads to increased mortality

Questions? Thank you!

Henry Crevensten, MD Contact: Henry.Crevensten@ucsf.edu

References – Good Places to Start

• ACC/AHA Guideline 2014

Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64:e77–137

• University of Washington Medicine Consult Service

Molly Jackson, Somnath Mookherjee, and Nason Hamlin (eds.), The Perioperative Medicine Consult Handbook, Second Edition, DOI 10.1007/978-3-319-09366-6, Springer 2015

• American College of Obstetrics and Gynecology

Johnson B, Porter J, Preoperative Evaluation of the Gynecologic Patient, Obstetrics & Gynecology, 2008; 111:1183-1194 (note: an older reference)

• Cataract Surgery Guidelines

American Academy of Ophthalmology, Routine Preoperative Laboratory Testing for Patients Scheduled for Cataract Surgery - 2014, http://www.aao.org/clinical-statement/routine-preoperative-laboratory- testing-patients-s, accessed May 2016

References – Additional Reading

General

• Macpherson DS, Snow R, Lofgren RP. Preoperative Screening: Value of Previous Tests.

Ann Intern Med. 1990;113:969-973.

• Thilen S, Treggiari M, Lange J et al. Preoperative Consultation for Medicare Patients Undergoing

Cataract Surgery. JAMA Int Med. 2014; 173(3):380-388

• Kumar A, Srivastava U. Role of routine laboratory investigations in preoperative evaluation. J

Anaesthesiol Clin Pharmacol. 2011 Apr;27(2):174-9

• Onuoha OC, Arkoosh VA, Fleishre LA. Choosing Wisely in Anesthesiology: the Gap Between Evidence

and Practice. JAMA Int Med. 2014; 174(8):1391-1395

• Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a

survey of hospitalists. Ann Intern Med. 2015; 162(2):100-108

• American Society of Anesthesiologists Task Force on Preanesthesia : Practice advisory for

preanesthesia evaluation: An Updated Report by the American Society of Anesthesiologists Task Force

• n Preanesthesia. ANESTHESIOLOGY 2012; 116:1-17

References – Additional Reading

Cardiac

• McFalls EO, Ward HB, Moritz TE, Goldman S, Krupski WC, Littooy F, Pierpont G, Santilli S, Rapp J,

Hattler B, Shunk K, Jaenicke C, Thottapurathu L, Ellis N, Reda DJ, Henderson WG. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med. 2004; 351: 2795–280

• Clinical Summary: Coronary Heart Disease: Screening with Electrocardiography. U.S. Preventive

Services Task Force. October 2014

• Blessberger H, Kammler J, Domanovits H, et al. Perioperative beta-blockers for preventing surgery-

related mortality and morbidity. Cochrane Database Syst Rev. 2014;9:CD004476

• Devereaux PJ, Mrkobrada M, Sessler DI, et al; POISE-2 Investigators. Aspirin in patients undergoing

noncardiac surgery. N Engl J Med. 2014;370:1494-503.

• Devereaux PJ, Sessler DI, Leslie K, et al. Clonidine in patients undergoing noncardiac surgery. N Engl

J Med 2014;370:1504-1513

• Twersky RS, Goel V, Narayan P, et al. The risk of hypertension after preoperative discontinuation of

angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists in ambulatory and same- day admission patients. Anesth Analg. 2014;118:938-44

References – Additional Reading

Pulmonary

• Archer, C, Levy AR, McGregor M. Value of routine preoperative chest x-rays: a meta-analysis. Can J

Anaesth 1993; 40:1022

• Qaseem A, Snow V, Fitterman N, Hornbake ER, Lawrence VA, Smetana GW, et al. Risk Assessment

for and Strategies To Reduce Perioperative Pulmonary Complications for Patients Undergoing Noncardiothoracic Surgery: A Guideline from the American College of Physicians. Ann Intern Med. 2006;144:575-580.

• Mutter TC, Chateau D, Moffatt M, et al, A Matched Cohort Study of Postoperative Outcomes in

Obstructive Sleep Apnea: Could Preoperative Diagnosis and Treatment Prevent Complications?

• Anesthesiology. 2014; 121: 707-718

Geriatrics

• Oresanya LB, Lyons WL, Finlayson E, Preoperative Assessment of the Older Patient: A Narrative

Review, JAMA. 2014; 311 (20): 2110-2120