7/27/2017 Disclosures Updates in Preoperative Evaluation and - PDF document

7/27/2017 Disclosures Updates in Preoperative Evaluation and  Shareholder in Seattle Genetics Perioperative Care  No discussion of investigational or ‘off label’ use of medications or products Henry Crevensten, MD Associate Professor of Medicine Division of General Internal Medicine San Francisco Veterans Affairs Medical Center August 2017 *All images from UCSF brand photography, in the public domain from governmental sites, or personal collection Learning Objectives Outline and Scope  Scope: You will be able to… • Non-cardiac, elective procedures 1. Perform an appropriate preoperative evaluation for elective surgical procedures using  We will review: updated guidelines • Guidelines for testing 2. Manage anticoagulation in the perioperative period using updated guidelines • Updates over the last few years • Issues for selected populations (women, geriatrics) in perioperative care • Anticoagulants and Antiplatelet agents  Methodology: • Case based learning 1

7/27/2017 Consider these Patients… Goals of Perioperative Management 1. A 68 year old woman with atrial fibrillation (on anticoagulation) and heart failure about to undergo cataract surgery  Evaluate risk of procedure to allow patient, primary care physician, surgeon, and anesthesiologist to make informed decisions regarding surgical management 2. A 68 year old man with heart failure, diabetes, COPD, hypertension and CAD with left knee pain who is scheduled for left total knee replacement. His orthopaedist is  Optimize medical conditions wondering what workup and management needs to be done prior to surgery.  Minimize unnecessary testing 3. A 68 year old woman with atrial fibrillation (on anticoagulation) who would like to have a total knee arthroplasty. Her orthopaedist asks you to manage her anticoagulation in the  Minimize complications perioperative period Sources of Recommendations Prevalence, Cost, and Risk of Preoperative Testing  ~30 million people undergo surgery per year in the United States, most are ambulatory 1  American College of Physicians  ~18% of patients undergoing cataract surgery had a preoperative consultation 2  American College of Surgeons  ~ 50% of perioperative consultants recommended an unnecessary test 3  American Society of Anesthesiologists  Preoperative testing is estimated to cost $18 Billion annually in the U.S. 4 Some of these sources do not entirely agree  NEJM Review Article 2015  ACOG Guidelines  Risks : unnecessary delay in procedure, unnecessary testing and harm from investigating results, unnecessary cost to patient  AHA/ACC 2014  ACC Periprocedural Anticoagulation Consensus Pathway 2017  You can make a difference!  US Preventative Services Task Force  University of Washington Medicine Consult Service 1. Onuoha OC, Arkoosh VA, Fleishre LA. JAMA Int Med. 2014; 174(8):1391-1395 3. Kachalia A, Berg A, Fagerlin A, et al. Ann Intern Med. 2015; 162(2):100-108 2. Thilen S, Treggiari M, Lange J et al. JAMA Int Med. 2014; 173(3):380-388 4. Kumar A, Srivastava U. J Anaesthesiol Clin Pharmacol. 2011 Apr;27(2):174-9 2

7/27/2017 General Framework Case 1: Mrs. Haniger 1. Perform / Update H&P Mrs. Haniger is seeing you in clinic prior to left eye cataract surgery. Her ophthalmologist Note cardiac or 2. Address / Optimize has contacted you and has asked you to determine what testing and management is pulmonary issues Medical Issues needed prior to her procedure. (incl. nutrition, 3. Review Medications smoking, Mrs. Haniger is a 68 year old woman with a history of: sleep apnea) Anticoagulants Diabetes 4. Assess Functional Steroids • heart failure with reduced ejection fraction (EF 45%) (Rx: furosemide, metoprolol, Status lisinopril), 5. Evaluate Surgical Risk (patient + procedure) • diabetes (HgbA1c 7.5%) (Rx: metformin) 6. Consider Additional • mild COPD (FEV 1 /FVC 0.65, FEV 1 85% pred, current non smoker) (Rx: albuterol) Testing • and atrial fibrillation (Rx: metoprolol, warfarin) If Risk is Elevated Case 1: Mrs. Haniger, continued: Case 1: Mrs. Haniger, continued UPDATED Mrs. Haniger is a complicated patient, right?  What pre-operative evaluation should you perform? • History & Physical exam: BUT: ‒ No recent chest pain For cataract surgery preoperative testing has NOT been shown to affect outcomes. Rates of adverse events in patients were similar (~3%) whether or not they underwent testing ‒ No murmurs or wheezes on exam (American Academy of Ophthalmology Guideline 2014). ‒ No evidence for volume overload ‒ Normal creatinine 3 months ago • Functional Status ‒ She can walk up 3 flights of stairs without difficulty American Academy of Ophthalmology, http://www.aao.org/clinical-statement/routine-preoperative- laboratory-testing-patients-s, accessed May 2016 3

7/27/2017 Case 1: Mrs. Haniger, continued Case 1: Mrs. Haniger, Take Home Points  Medication Management:  Routine preoperative testing is not indicated in cataract surgery • Continue warfarin: for procedures with low risk of bleeding (i.e. cataract, pacemaker, dental extraction), interruption of anticoagulation is usually NOT necessary. However,  Perform your usual history, physical, and review of systems and address any consulting with surgeon and anticoagulation clinic and adhering to your local practice abnormalities is always advisable • Continue lisinopril, furosemide, metoprolol  May continue anticoagulation (warfarin) for procedures with very low risk of bleeding • Hold metformin (NPO) How do you discuss this with the Ophthalmologist? Case 2: Mr. Cano Determining Surgical Risk Mr. Cano is seeing you in clinic prior to left knee arthroplasty surgery. His orthopaedic surgeon has contacted you and has asked you to determine what testing and Goal is to divide patients into two categories: management is needed prior to his procedure.  LOW RISK: Mr. Cano is a 68 year old man with a history of: • Combined patient and surgical procedure characteristics result in a • heart failure with reduced ejection fraction (EF 45%) (Rx: furosemide, metoprolol, predicted risk of < 1% of a Major Adverse Cardiac Event lisinopril), ( MACE = death or myocardial infarction) • diabetes (HgbA1c 7.5%) (Rx: insulin glargine PM) • mild COPD (FEV 1 /FVC 0.65, FEV 1 85% pred, current non smoker) (Rx: albuterol, one  ELEVATED RISK: 5 day steroid burst in last year) • MACE ≥ 1% • CAD (DES to RCA 5 years ago) (Rx: ASA, atorvastatin, metoprolol) • and hypertension (Rx: metoprolol) 4

7/27/2017 Why Determine Surgical Risk? ACC / AHA Flowchart (2014) UPDATED UPDATED Low Risk  LOW RISK patients (MACE < 1%) do NOT need preoperative testing except as Proceed to Surgery Evaluate Risk (MACE < 1%, RCRI 0 or 1) indicated by H&P (as you would normally practice) Elevated Risk (MACE ≥ 1%, RCRI 2+)  ELEVATED RISK patients (MACE ≥ 1%) MAY need preoperative testing depending on functional status. Surgical procedure may need to be modified Evaluate Functional ≥ 4 METs Capacity Pharmacologic Yes Normal Stress Test < 4 METs OR cannot be assessed Abnormal AND Optimize Medical Management testing will influence No Consider Alternative Approach to ? Revascularization management Surgery ACC/AHA Guideline 2014 Fleisher LA, Fleischmann KE, Auerbach AD, et al. J Am Coll Cardiol 2014;64:e77–137 Tools for Determining Surgical Risk Revised Cardiac Risk Index (RCRI) UPDATED  Clinical Predictors (1 point each)  Revised Cardiac Risk Index (RCRI) Predictors Complications MACE • ‘High Risk’ surgery 0 0.5% 0.4% (intrathoracic, intraperitoneal,  American College of Surgeons NSQIP Surgical Risk Calculator 1 1.3% 1% suprainguinal vascular) 2 4% 2.4% • Ischemic Heart Disease 3 + 9% 5.4% • Heart Failure Pros: • Diabetes Requiring Insulin - Simple • Creatinine > 2.0 - Validated outside original cohort • CVA or TIA Cons: - Older - Smaller sample - Other tools with greater predictive ability 5

7/27/2017 American College of Surgeons NSQIP Surgical Risk Functional Status, defined Calculator  MET = Metabolic Equivalent of Task  http://www.riskcalculator.facs.org/RiskCalculator/  1 MET = basal oxygen consumption of a 40 year old, 70 kg male  Pros: • Provides other outcomes METs Activity • Probably best predictor Simple activities of daily living, < 4 (poor)  Cons: walk < 2 blocks Walk 2 flights of stairs, • Only validated within cohort 4 - 6 (moderate) heavy housework/yardwork • Need specific surgery 7 - 10 (good) Jogging, bicycling (light effort) • Need ASA class > 10 (excellent) 10-minute mile • MI defined as STEMI Note: capability of less than 4 METs of activity associated with higher cardiac risk Cardiac Testing and Intervention Case 2: Mr. Cano, continued  What pre-operative evaluation should you perform?  Even in patients with known, stable coronary disease revascularization does NOT • History & Physical exam: improve long-term survival ‒ No recent chest pain  CARP trial: 510 patients with 1+ coronary artery with 70% occlusion. Randomized to revascularization vs. not prior to major vascular surgery. ‒ No murmurs or wheezes on exam • No difference in death or MI ‒ No evidence for volume overload • Excluded: unstable angina, left main stenosis > 50%, severe aortic stenosis, and ‒ Normal creatinine 3 months ago LVEF < 20% ‒ BMI 24 • Functional Status ‒ He can walk up 3 flights of stairs without dyspnea or chest pain. Has some pain in his left knee McFalls EO, Ward HB, Moritz TE, et al. N Engl J Med. 2004; 351: 2795–280 6