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Perioperative Risk Assessment - Can You Get It Right?
From the Publishers of Perioperative Risk Assessment - Can You Get It Right? COPYRIGHT © 2013, ALL RIGHTS RESERVED
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Need Advice – How Low is Low?
Dear Consult Sages; I need your help and guidance to provide better service to my referring surgeons and their patients. I’ve attended your Consult Guys presentation at the annual meeting of the ACP for years. You have helped me abandon the use of the term “Cleared for Surgery” and to instead really hone in on the patient’s perioperative risk as well as approaches to reduce that risk. I recently saw a patient who I assessed to be at low cardiac risk. The surgeon wanted me to be more precise in risk determination. Here is the case and I’d appreciate your sage advice.
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Case: The patient is a 60 year old man for resection of a pulmonary nodule. Hx: hypertension, hypercholesterolemia Smokes 2ppd many years. Does not exercise but climbs 1 flight stairs daily without difficulty Bp 120/70 HR 60 Exam unremarkable. ECG: Normal sinus rhythm. Within normal limits “By current guidelines his risk is low but help me be more precise.”
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ACC / AHA Guideline 2002 Philosophy
“… the concept of “medical clearance” for surgery is short sighted. Goals of the preoperative consult: Evaluate current medical status Advise on disease management in the periop period. At times recommend preventive measures for future. Define your role in care (Co-manager?, subspecialty consultant?, etc.)
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“Clearance 2007” ACC / AHA Guideline: Circulation 2007;116:e418-e500
Free at:
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Anesthesia for the Consultant: Summary
ACC / AHA Guideline: Circulation 2007;116:e418-e500 Free at:
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October 23, 2007 400 new articles reviewed since 2002 guideline
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Key Elements of Risk Stratification
Emergency surgery Active cardiac conditions Low risk surgery Functional capacity Clinical risk factors Will testing – preop intervention change management ?
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Step 1 Step 1 Perioperative surveillance and Need for emergency
postoperative risk stratification Need for emergency noncardiac surgery? YES Operating room NO Step 2
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Step 2 Active Cardiac Conditions Unstable coronary syndromes
Evaluate and treat per ACC/AHA guidelines Active cardiac conditions Consider operating room YES NO Active Cardiac Conditions Unstable coronary syndromes Unstable or severe angina Recent MI Decompensated HF Significant arrhythmias Severe valvular disease Step 3 Acute or Recent MI—Acute MI (within 7 days); Recent M (7-30 days). WITH evidence of important ongoing ischemic risk as evidenced by continued clinical symptoms or by non-invasive study Heart Failure—ischemic or non-ischemic Significant Arrhythmias: High grade A-V block Symptomatic ventricular arrhythmias in presence of underlying heart disease Supraventricular arrhythmias with uncontrolled ventricular rate Severe valvular disease: Mostly talking about AS
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Step 3 Low Risk Surgery Endoscopic procedures Superficial procedures
Proceed with planned surgery YES NO Low Risk Surgery Endoscopic procedures Superficial procedures Cataract surgery Breast surgery Step 4 Low risk surgery with combined incidence of cardiac death and nonfatal MI of < 1%
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Good functional capacity
Step 4 Step 4 Good functional capacity (METS > 4) without symptoms Proceed with planned surgery YES No or Unknown Step 5
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Step 5 History of ischemic heart disease
Clinical Risk Factors History of ischemic heart disease History of compensated or prior HF History of cerebrovascular disease Diabetes Renal insufficiency
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Step 5 Step 5 Clinical Risk Factors 3 or more 1 or 2 None Vascular
(Isch HD, CHF hx, Cereb vasc dx, DM, Cr >2 3 or more 1 or 2 None Vascular surgery Intermediate Risk surgery Proceed with planned surgery Vascular or intermediate risk surgery Consider testing if it will change management Proceed with planned surgery with HR control or consider Noninvasive testing if it will change management
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Revised Cardiac Risk Index Lee, Circulation 1999
4315 patients, > 50 years old Major elective noncardiac surgery Six independent risk factors High risk surgery AAA, vascular,thoracic, abdominal, ortho History ischemic heart disease History CHF History cerebrovascular disease Preoperative insulin use Preoperative serum Cr > 2.0 mg/dl
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= patients
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= patients
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National Surgical Quality Improvement Database
>250 hospitals >200,000 pts/year Predictors of perioperative (up to 30 day) MI, Arrest ASA Class Functional status Age Serum Cr Type of surgery Article (Free) Circulation. 2011;124: = patients
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Problems - Limitations
MI (one or more of the following) STEMI; new LBBB, new Q waves Tn > 3 times top normal
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Gupta vs ACC/AHA
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= patients
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= patients
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State Farm Arena, Hidalgo Texas
Seating 5,500
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Yankee Stadium, Bronx NY
Seating 50,082
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State Farm Arena, Hidalgo Texas
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Problems - Limitations
Outcomes dominated by 30 day death NSQIP does not record all cardiac complications Pulmonary edema Preop stress test Echo Arrhythmia history / occurrence Aortic valve disease Beta blocker use Remote history of CAD (except prior PTCA or CABG) Most perioperative MI’s NSTEMI Revised Cardiac Risk Index still helpful in predicting cardiac complications
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Consults Guys’ Replies
Gupta cardiac risk assessment 30 day MI, Cardiac arrest MI: STEMI, Tn 3X elevation Not all cardiac arrests due to periop MI NSQIP database does not include Pulmonary edema NSTEMI Robust data base Data on procedure not previously known Bedside calculation
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