1. Cardio-Pulmonary Pre Operative Risk Assessment Andy Shakespeare MD PGY2 Baylor Scott and White IM ashakespeare@sw.org

2. Outline General measures Cardiac Risk Models Who needs further testing Pulmonary Risk Assessment Who needs further testing When to delay surgery

3. Basic Assessment Surgical Urgency Surgical Risk Patient Risk factors Medical Optimization Pre-operative testing if results would change management or are expected to be abnormal

4. Cardiac Risk Assessment

5. Surgical Risk of Cardiac Death or Non-fatal MI *** Emergent Surgery 2- 5 x the risk of above

7. Fleischer-Eagle Algorithm 6 factors including 5 of those in RSCI Ischemic Heart Disease HF High Risk Surgery Diabetes Renal Insufficiency Poor Functional Status

8. Figure 1. Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions (high-risk indicators), known cardiovascular disease, or cardiac risk factors for patients aged ≥50 years. Gregoratos G Circulation. 2008;117:3134-3144 Copyright © American Heart Association, Inc. All rights reserved.

9. Stress Testing High Negative Predictive Value Recommended for – High Risk Patients (RSCI ≥ 3) – High Risk Surgeries (Vascular) – Low Functional Status (< 4 METS or 1 flight of stairs) Exercise Stress ECG preferred if patients are able Dipiramidole – Thalium if arrythmia Dobutamine Echo if bronchospastic lung disease Resting Echocardiography if new murmur, poorly controlled HF, unclear dyspnea or if Pulmonary HTN suspected. There are very few candidates that need pre-op revascularization

10. Pulmonary Risk Assessment Begins with clinical assessment Patient Factors – Age > 50, Chronic Lung Disease, Asthma, Obstructive Sleep Apnea, Pulmonary Hypertension, Heart Failure, Upper Respiratory Infection Surgical Risk ABGs play no role in identifying high risk patients or delaying surgery

11. Patient Risk Factors Age > 50 yrs is an independent risk factor for pulmonary complications Chronic Lung Disease, Asthma Smoking > 20 pack years most at risk – Even 2 days of no smoking improves outcome – Each week of non-smoking increases magnitude of benefit by 19 % Obesity, OSA

12. General Health Status American Society of Anesthesiology ASA 1A normal healthy patient ASA 2A patient with mild systemic disease ASA 3A patient with severe systemic disease ASA 4A patient with severe systemic disease that is a constant threat to life ASA 5 A moribund patient who is not expected to survive without the operation ASA 6 A declared brain-dead patient whose organs are being removed for donor purposes ASA > 2 = 4.87 fold increased risk of pulmonary complications

13. Surgical Risk Factors Risk FactorComments Surgical SiteHigher risk for thoracic and upper abdominal surgery Surgical DurationMore than 3 hours increases risk Type of anestheticGeneral anesthesia higher risk than epidural or spinal anesthesia Neuromuscular Blockade Type Longer acting agents with increased risk

14. When to obtain PFTs All candidates for lung resection Uncharacterized dyspnea or exercise intolerance COPD or Asthma if airflow obstruction is not clinically optimized Notes*** – Most of the time PFTs only confirm clinical suspicion of disease and do not add to risk assessment profile – Should not be used as the primary factor to deny surgery – Should not be ordered routinely prior to abdominal surgery or other high risk surgeries

15. References https://www.acponline.org/mobile/clinicalguidelines/guidelines/perioperative_pulmonary_risk_0406.html http://www.uptodate.com/contents/perioperative-medication- management?source=search_result&search=preoperative+antiplatelet+use&selectedTitle=1%7E150 http://www.uptodate.com/contents/perioperative-medication- management?source=search_result&search=preoperative+antiplatelet+use&selectedTitle=1%7E150 http://circ.ahajournals.org/content/117/24/3134.full