Optimizing Patients for Ophthalmic Surgery with Minimal Work-Up Center for Peri-operative Optimization The Johns Hopkins Hospital Wilmer Eye Institute Presented by Teresa Krosnick PA-C and Susan Wolf PA-C September 28, 2018 1
• No Disclosures 9/29/2018 2
Objectives • 1. Review current practice, evidence based research and clinical practice guidelines (CPGs) • 2. Identify high risk patients • 3. Discuss perioperative optimization • 4. Review risk assessment tools • 5. Patient presentations. • 6. Summary
2000 Landmark Study The New England Journal of Medicine 1-20-2000;342: 168-175 Oliver D. Schein, MD, MPH, Joanne Kath, Sc.D., Eric Bass, MD, MPH, et al The Value of Routine Preoperative Medical Testing Before Cataract surgery Prospective randomized clinical trial at 9 centers H&P only H&P + EKG, CBC, BMP 9408 patients 9411 patients
2000 Landmark Study Combined intra-op and post-op events 31.3/1000 – the same for both groups H&P H&P + EKG, CBC, BMP Intra-op event 19.2/1000 19.7/1000 Post-op event 12.6/1000 12.1/1000
Adverse Event & Criteria Primarily Cardiovascular and Respiratory
Co-morbidities Associated with Adverse Events No significant Difference Routine testing Versus No Testing Intraoperative and Postoperative Events
Additional Studies Supporting No Routine Testing • Dr Schein’s combined his original data 1025 patients in Brazil and 1276 in Italy cataract surgery • Benarroch-Gampel 46,977 patients ambulatory surgery (hernia) • Pershing 1,223,733 patients cataract surgery
Clinical Practice Guidelines (CPGs) No Mandates for Routine Pre-op Testing The Joint Commission on Accreditation of Healthcare Organizations Institute for Clinical Systems Improvement The National Institute for Clinical Excellence Guidelines Centers for Medicare and Medicaid American College of Cardiology/ American Heart Association
Clinical Practice Guidelines (CPGs) ACC/AHA (2014 guidelines) CPGs for cardiac testing for non-cardiac surgery Low Risk Surgery MACE < 1% ~ 95% of ophthalmic surgeries are low risk procedures No Routine ECGs required for low risk surgery
2014 ACC/AHA High Risk Surgery Major Adverse Cardiac Event (Mace) Periop of >1% Medical Conditions associated with MACE >1% Cardiovascular and Pulmonary Predictors CAD, STEMI or non-STEMI within 6 weeks or unstable angina Decompensated CHF VAD High grade Arrhythmias causing hemodynamic instability Cardiomyopathy and congenital heat disease Severe valve disease AV or MV stenosis with valve area < 1cm 2 Severe COPD/pulmonary disease PAH Other Co-morbidities Diabetes Renal Failure Anemia
2014 ACC/AHA CPGs All Cardiac testing for low risk surgery is based on Medical not Surgical decisions ECGs Significant change since last evaluation • History • Hospitalizations • ROS • Physical Exam • Decreased Functional capacity < 4 METs Routine preoperative ECG is not useful for asymptomatic patients with known CAD or other significant structural heart disease undergoing low risk surgery
2014 ACC/AHA CPGs Echocardiogram Worsening DOE Valve Disease PAH Routine echo is not recommended for low - moderate risk surgery in patients with stable cardiac disease
2014 ACC/AHA CPGs Stress test Cardiac Catheterization Pacemaker/AICD interrogation
What Do Low Risk Patients Require For Optimization ANACHRONISTIC EKG H&P CBC BMP/CMP PT/PTT PFT UA CXR ECHO/STRESS 9/29/2018 15
Risk of Ophthalmic Surgery • Group Risk is low • Individual Risk can be high • Identify High Risk Patients • Use Risk Assessment tools to evaluate • Communicate findings and target specific pathways 9/29/2018 16
Identify High Risk Patients Choose Wisely ECG and Labs H&P Driven Communicate Optimize Pathway driven
Perioperative Optimization • Emerging Specialty • Advancements of Anesthesia over the past 30 years Specialization - Ophthalmic and Cardiac • Advancement of surgical technique • Hospital Specialists – CHF – PAH – DM • Perioperative pathways – medical management; e.g. Remodulin pump for PAH 9/29/2018 18
Perioperative Optimization of Ophthalmic Patient Factors to consider • Type of anesthesia • Patient Co-Morbidities such as PAH and CHF • Cardiac anesthesiologist • Operating room setting Free standing clinic or tertiary center
Commonly Used Risk Assessment Tools American Society of Anesthesiologists ASA Physical Status Classification ASA I Healthy Patient ASA II Mild Disease ASA III Severe Disease ASA IV Severe Disease that is a constant threat to life ASA V Moribund patient unlikely to survive 24 hours with or without operation
RCRI
PAH classification Pulmonary Arterial Hypertension • Group 1: Pulmonary arterial hypertension • Group 2: Due to left heart disease • Group 3: Due to chronic lung disease hypoxia • Group 4: Chronic thromboembolic disease • Group 5: Unclear or multifactorial
Functional Capacity 1-4 Mets Light activity 5-9 Mets Moderate activity >= 10 Mets Strenuous activity
NYHA
CHAD2DS2Vasc Score for risk of Stroke
The Cost of Routine Testing is Enormous. 2000 $150,000,000.00 2016 2020 3.3 million Medicare patients cataract surgery 2030 4.4 million 2018 3 million cataract surgeries $500,000,000.00 Cost of $175.00 H&P/routine testing
Cost Projection 4.4 million in 2030 assuming no increase in cost 4,400,000 x $175 = $770,000,000 Does not include further testing Referral to specialist Echos, PFTs
Paradoxical Increase in Referral by Anesthesiologists and Surgeons for Comprehensive H&P Since 1997 Preoperative Consultations for Medicare Patients Undergoing Cataract Surgery 2014 Thilen, Treggiari, Lange JAMA Referrals Comprehensive Physical Exams • 1998 11.3% • 2008 18.4% 1997 Balanced Budget Act
Patient 1 • 40 year old male presenting preoperative evaluation for cataract surgery with MAC Severe non-obstructive cardiomyopathy Uncontrolled HTN CHF - EF 20% Echo 2 months ago Multiple CHF exacerbations Moderate PAH - RVSP of 45-50 mm Hg BMI 39, IDDM A1C 7.5, noncompliance, ESRD creatinine 5.1 Activity Level: Wheelchair, walks short distances <1 FOS without significant SOB and stopping between steps. Unable to lie flat
Patient 1 Multiple Assessments – Compensated Labs and EKGs CHF and Pulm HTN clinic Diuresis prior to surgery Surgery 2-7 days decompensated Medications: Insulin, metformin, Lasix, Lisinopril, aspirin, amlodipine
Assessment of Patient 1 Using Risk Assessment Tools • ASA IV Severe systemic disease constant threat to life, symptomatic labile CHF EF 20% ESRD not undergoing regularly scheduled dialysis • RCRI III 1- CHF, 1-preoperative insulin, 1- preoperative creatinine >2 • FC <4 METs Can walk short distanced around house, • PAH class II • NYHA III Symptomatic , Class C Objective evidence of moderately severe CV disease , EF 20%, RVSP 50 mm Hg, marked limitation in activities, comfortable at rest. Which of the following strategies will most likely optimize this patient for surgery? 1. Labs and EKG, repeat echo or Dobutamine stress 2. Notify Specialist, high risk OR, diuresis and stat electrolytes the day before, early surgery, Focal exam on am of surgery, perioperative pathways for CHF and pulmonary Hypertension.
Patient 2 • 64 yr old thin female presenting for preoperative evaluation for cataract surgery with MAC Hyperlipidemia – borderline H&P 1 yr ago - WNL Patient walked 13 blocks to the hospital ROS negative Medication – None Activity Level: Walk 1-2 miles moderate pace, 2- 3 FOS and can lie supine no SOB BP R 128/78, L 132/80 HR 28 RR 18 O2 100% T 37.2 Stat EKG - 3 rd degree heart block. Labs - Expedite ER Cardiology consult - HR did not increase adequately with stress Pacemaker - several hours. DC to home – 24 hours
Assessment of Patient 2 Using Risk Assessment Tools 3 rd degree heart block asymptomatic with no functional limitations, ASA II ASA status changed to ASA III after placement of pacemaker RCRI 0 No risk factors FC>4 METs Walked 13 blocks NYHA Class I No Limitation on physical exertion. No overt symptoms If this patient presented as above HR of 64 Would pre-op labs and EKG be necessary? Yes/No
Patient 3 • 22 y old female presenting for preoperative evaluation for retinal surgery under GA Marfan disease S/P aortic root replacement and MVR 4 years ago F/U with cardiologist 3 years ago Retinal surgery under GA Decrease in Activity Pale complexion noted ROS Recent Fatigue > walking 2+ blocks at a slow to moderate pace, SOB with 2 consecutive FOS Medications Atenolol and Lisinopril Activity level: Walks 1-3 blocks 2-4 times a day Physical Exam Pallor, III/VI holosystolic murmur at the apex without radiation.
Assessment of Patient 3 Using Risk Assessment Tools ASA III Severe systemic disease Marfan disease S/P aortic root replacement and MV Repair RCRI 1 Can not rule out ischemic heart disease FC>4 METs 1 FOS NYHA II Does this patient need an echo? Yes Medical recommendation every 2 years Does she need a referral to cardiology? Yes Routine F/U is every 2 years Labs Yes (pallor) EKG Yes (fatigue with exertion) 9/29/2018 35
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