Challenges in Pre-Operative I have no disclosures Evaluation Geoff - PDF document

Challenges in Pre-Operative I have no disclosures Evaluation Geoff Stetson, MD Assistant Professor of Medicine, UCSF Hospitalist, San Francisco VA Medical Center Special Thanks Roadmap  Heather Nye, MD, PhD  Overview of pre-op evaluation  Case 1 – 10 Minutes • Professor of Medicine UCSF • Cardiac risk-stratification in pre-operative evaluation • Director of Co-Management Service and Veterans Integrated Preoperative Clinic at San Francisco VA Medical Center • High-risk medications  Henry Crevensten, MD  Case 2 – 10 Minutes • Associate Professor of Medicine UCSF • Pulmonary risk-stratification in pre-operative evaluation • Director of Quality Improvement at San Francisco VA Medical • OSA considerations Center  Case 3 – 5 Minutes • An approach to geriatric pre-operative evaluation 3 Challenges in Pre-Operative Evaluation 4 Challenges in Pre-Operative Evaluation

Learning Objectives Goals of Pre-Op Evaluation  Evaluate risk of a procedure to a particular patient  Understand the risks and benefits of pre-operative evaluation  Appropriately risk-stratify a patient from a cardiac standpoint • Allows for informed decision-making  Explain how to modify use of certain high-risk medications in the  Optimize medical conditions perioperative period  Describe PPCs and their role in perioperative care  Minimize unnecessary testing  Appropriately risk-stratify a patient from a pulmonary standpoint  Minimize complications  Understand the role of OSA in the perioperative period  Develop a holistic framework for approaching the pre-operative evaluation of a geriatric patient 5 Challenges in Pre-Operative Evaluation 6 Challenges in Pre-Operative Evaluation Prevalence and Costs Risks of Unnecessary PreOp Testing  ~30 million people/yr undergo surgery in US, most ambulatory 1 Delay Cost  ~18% of cataract surgery patients had preoperative consultation 2 Harm  ~ 50% of preoperative consultants recommended an unnecessary test 3 Worse Patient and System Outcomes  Preoperative testing costs ~$18 Billion annually in the U.S. 4 1. Onuoha OC, Arkoosh VA, Fleishre LA. JAMA Int Med. 2014; 174(8):1391-1395 2. Thilen S, Treggiari M, Lange J et al. JAMA Int Med. 2014; 173(3):380-388 3. Kachalia A, Berg A, Fagerlin A, et al. Ann Intern Med. 2015; 162(2):100-108 4. Kumar A, Srivastava U. J Anaesthesiol Clin Pharmacol. 2011 Apr;27(2):174-9 7 Challenges in Pre-Operative Evaluation 8 Challenges in Pre-Operative Evaluation

Question 1 Case 1 10 Minutes Risk Clearance Stratification 9 Challenges in Pre-Operative Evaluation 10 Challenges in Pre-Operative Evaluation General Approach Source of Guiding Principles Pulmonary Cardiac Risk Update H&P Risk Assessment Assessment Optimize Substance Medication Medical Co- Abuse and History Morbidities EtOH Screen 11 Challenges in Pre-Operative Evaluation 12 Challenges in Pre-Operative Evaluation

ACC/AHA Flowchart ACC/AHA Flowchart CAD = Coronary Artery Disease, ACS = Acute Coronary Syndrome, GDMT = Guideline-Directed Medical Therapy, MACE = Major Adverse Cardiac Events 13 Challenges in Pre-Operative Evaluation 14 Challenges in Pre-Operative Evaluation Risk Calculators RCRI  Revised Cardiac Risk Index (RCRI)  Revised Cardiac Risk Index (RCRI)  American College of Surgeons (ACS) National • 6 Predictors of MACE (MI, V.fib, Cardiac Arrest, Surgical Quality Improvement Program (NSQIP) Complete Heart Block, Pulm Edema) • 0-1 predictors = low risk • 2+ predictors = high risk • One center; thoracic, vascular, ortho over- represented • Retrospectively validated numerous times Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999;100:1043-9. 15 Challenges in Pre-Operative Evaluation 16 Challenges in Pre-Operative Evaluation

RCRI ACS NSQIP Revised Cardiac Risk Index (RCRI)  21 predictors, created in 2011 1. CAD (MI, + stress, use NTG, CP c/w angina, Q-waves)  525 US hospitals, > 1 million operations Score % of MACE 2. CHF  Calculates risk of: MACE, death, PNA, VTE, AKI, 0 0.4% return to OR, unplanned intubation, discharge to 3. CVA/TIA 1 0.9% rehab/nursing home, surgical infection, UTI 2 6.6% 4. DM (requiring insulin) 3+ 11% 5. CKD (Cr > 2.0 mg/dL)  Limitations: Not validated outside NSQIP, unclear 6. High Risk Surgery (suprainguinal vascular, what to do with all the predictive information intraperitoneal, intrathoracic) 17 Challenges in Pre-Operative Evaluation 18 Challenges in Pre-Operative Evaluation ACS NSQIP – Inputs Did anyone use a calculator? Which one? How did our patient do? 19 Challenges in Pre-Operative Evaluation 20 Challenges in Pre-Operative Evaluation

RCRI ACS NSQIP – Results Revised Cardiac Risk Index (RCRI) 1. CAD (MI, + stress, use NTG, CP c/w angina, Q-waves) Score % of MACE 2. CHF 0 0.4% 3. CVA/TIA 1 0.9% 2 6.6% 4. DM (requiring insulin) 3+ 11% 5. CKD (Cr > 2.0 mg/dL) 6. High Risk Surgery (suprainguinal vascular, intraperitoneal, intrathoracic) 21 Challenges in Pre-Operative Evaluation 22 Challenges in Pre-Operative Evaluation ACC/AHA Flowchart Functional Capacity  1 MET (metabolic equivalent) = basal O2 consumption of a 70 kg 40-year-old man  >10 METs  Excellent  7-10 METs  Good  4-6 METs  Moderate • Climbing 2 flights of stairs, walking up a hill, walking on level ground at 4 mph, heavy work around the house  <4 METs  Poor • Golfing with golf cart, playing a musical instrument, slow ballroom dancing, walking at 2-3 miles per hour METs = Metabolic Equivalents; CPG = Clinical Practice Guidelines; GDMT = Guideline-Directed Medical Therapy 23 Challenges in Pre-Operative Evaluation 24 Challenges in Pre-Operative Evaluation

Functional Capacity ACC/AHA Flowchart  Making Beds – 3-5  Broomball – 6.3  Ironing – 2  Cricket – 6.1  Archery – 4.3  Equestrianism (not horseback riding) – 7  Doubles Badminton – 3-4  Ringette – 12.6  Bocce – 2-3  Tobogganing – 7 METs = Metabolic Equivalents; CPG = Clinical Practice Guidelines; GDMT = Guideline-Directed Medical Therapy 25 Challenges in Pre-Operative Evaluation 26 Challenges in Pre-Operative Evaluation Medications  Diabetes Medications  Betablockers  ACEI/ARB Now, what about those meds?  Statins  Anticoagulation  Aspirin 27 Challenges in Pre-Operative Evaluation 28 Challenges in Pre-Operative Evaluation

Diabetes Meds β Blockers  Assuming patient is NPO at MN…  In NON-CARDIAC surgery, β blockers:  Stop oral meds (including metformin*) • Reduce cardiac events perioperatively  Dose reduce long-acting insulin ~25% • Higher risk of death and stroke  Stop prandial insulin  CONTINUE β blockers for other indications  Start sliding-scale insulin  DO NOT start β blocker solely for surgery (consider RCRI 3+) 29 Challenges in Pre-Operative Evaluation 30 Challenges in Pre-Operative Evaluation ACEI/ARB Statins  Continuation associated with hypotension, not  Continue statins if patient already taking one worse CV outcomes  Consider starting statin if patient to undergo  Many hold ACEI/ARB 2/2 concern for vascular procedure perioperative AKI  ACC/AHA: “Continuation of ACEIs or ARBs perioperatively is reasonable.”  Recommend: if patient on ACEI/ARB for CHF or difficult to control HTN, continue 31 Challenges in Pre-Operative Evaluation 32 Challenges in Pre-Operative Evaluation

Anticoagulation Aspirin  Aspirin for primary/secondary prevention (excluding prior PCI): • No decrease in death or non-fatal MI • Increased Hemorrhage  Stop ASA 5-10 days before procedure, restart 7- 10 days later  In patients with previous PCI and intervention, should continue ASA if possible Devereaux PJ et al for the POISE-2 Investigators. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014 Mar 31; [e-pub ahead of print]. Graham MM et al. Aspirin in patients with previous percutaneous coronary intervention undergoing noncardiac surgery. Ann Intern Med 2017 Nov 14; [e-pub]. 33 Challenges in Pre-Operative Evaluation 34 Challenges in Pre-Operative Evaluation Medications How about that ?  Diabetes Medications – Reduce Glargine by 25% Patient Procedure Characteristics Perform EKG? + SSI Characteristics  Betablockers – Continue Low Risk Low Risk NO  ACEI/ARB – Controversial…+/- Low Risk Int. or High Risk NO High Risk Low Risk NO  Statins – Continue High Risk Int. or High Risk YES  Anticoagulation – Hold, restart when surgeons deem safe, usually POD 1-3 • Low risk patients – asymptomatic, <10% 10-year risk of CAD  Aspirin – Hold • High risk patients – coronary artery, peripheral artery, or cerebrovascular disease, structural heart disease, or arrhythmia • Optimal timing of EKG is unknown, consensus 1-3 months 35 Challenges in Pre-Operative Evaluation 36 Challenges in Pre-Operative Evaluation