Updates in Preoperative Evaluation and No financial relationships - PDF document

Disclosures Updates in Preoperative Evaluation and  No financial relationships with commercial interests within the past year Perioperative Care  No discussion of investigational or ‘off label’ use of medications or products Henry Crevensten, MD Associate Professor of Medicine Division of Hospital Medicine San Francisco Veterans Affairs Medical Center July 2016 *All images from UCSF brand photography or in the public domain from governmental sites Outline and Scope Take Home Points  Scope: 1. Routine preoperative testing is usually NOT indicated • Non-cardiac, elective procedures 2. NO preoperative testing is indicated for cataract surgery  We will review: • Guidelines for testing 3. Surgical risk evaluation involves using RCRI/NSQIP and functional status • Updates over the last two years 4. For patients on warfarin, bridging anticoagulation is indicated ONLY for patients with high • Issues for selected populations (women, geriatrics) in perioperative care risk of thromboembolic event  Methodology: • Case based learning 5. Probably safe to HOLD aspirin in the perioperative setting unless the patient has a recent coronary stent • We will take several pauses in order to help improve information retention 6. Screen for Obstructive Sleep Apnea (OSA) and treat if indicated

Summary of Recommendations Sources of Recommendations  American College of Physicians DO: DON’T:  American College of Surgeons  Evaluate Surgical Risk  Routinely obtain testing in low risk  American Society of Anesthesiologists patients  Evaluate Functional Status Some of these sources do not entirely agree  NEJM Review Article 2015  Routinely obtain chest x-ray, ECG,  Review medications echocardiogram, or PFTs  ACOG Guidelines  Continue Statin, Beta-Blocker  Bridge anticoagulation except in patients  AHA/ACC 2014 with high risk of thromboembolic event  Screen for Sleep Apnea  US Preventative Services Task Force  Start beta-blocker unless medically indicated  University of Washington Medicine Consult Service Goals of Perioperative Management Prevalence, Cost, and Risk of Preoperative Testing  Evaluate risk of procedure to allow patient, primary care physician, surgeon, and  ~30 million people undergo surgery per year in the United States, most are ambulatory 1 anesthesiologist to make informed decisions regarding surgical management  ~18% of patients undergoing cataract surgery had a preoperative consultation 2  Optimize medical conditions  ~ 50% of perioperative consultants recommended an unnecessary test 3  Minimize unnecessary testing  Preoperative testing is estimated to cost $18 Billion annually in the U.S. 4  Minimize complications  Risks : unnecessary delay in procedure, unnecessary testing and harm from investigating results, unnecessary cost to patient 1. Onuoha OC, Arkoosh VA, Fleishre LA. Choosing Wisely in Anesthesiology: the Gap Between Evidence and Practice. JAMA Int Med. 2014; 174(8):1391-1395 2. Thilen S, Treggiari M, Lange J et al. Preoperative Consultation for Medicare Patients Undergoing Cataract Surgery. JAMA Int Med. 2014; 173(3):380-388 3. Kachalia A, Berg A, Fagerlin A, et al. Oversuse of testing in preoperative evaluation and syncope: a survey of hospitalists. Ann Intern Med. 2015; 162(2):100-108 4. Kumar A, Srivastava U. Role of routine laboratory investigations in preoperative evaluation. J Anaesthesiol Clin Pharmacol. 2011 Apr;27(2):174-9

General Principles General Framework 1. Perform / Update H&P 2. Address / Optimize Note cardiac or  Less > More pulmonary issues Medical Issues (incl. nutrition, 3. Review Medications smoking,  Optimize what can be optimized sleep apnea) Anticoagulants Diabetes 4. Assess Functional Steroids Status  Obtain testing ONLY if it would normally be 5. Evaluate Surgical Risk indicated (besides preparing for surgery) and/or (patient + procedure) ONLY if the results would change management 6. Consider Additional Testing If Risk is Elevated Case 1: Mrs. Marte Case 1: Mrs. Marte, continued Mrs. Marte is seeing you in clinic prior to left eye cataract surgery. Her ophthalmologist has contacted you and has asked you to determine what testing and management is  What pre-operative evaluation should you perform? needed prior to her procedure. • History & Physical exam: Mrs. Marte is a 68 year old woman with a history of: ‒ No recent chest pain • heart failure with reduced ejection fraction (EF 45%) (Rx: furosemide, metoprolol, lisinopril), ‒ No murmurs or wheezes on exam ‒ No evidence for volume overload • diabetes (HgbA1c 7.5%) (Rx: metformin) • mild COPD (FEV 1 /FVC 0.65, FEV 1 85% pred, current non smoker) (Rx: albuterol) ‒ Normal creatinine 3 months ago • and atrial fibrillation (Rx: metoprolol, apixaban) • Functional Status ‒ She can walk up 3 flights of stairs without difficulty

Case 1: Mrs. Marte, continued Case 1: Mrs. Marte, continued UPDATED  Pre-operative evaluation:  Medication Management: • Chest xray? • Continue apixaban: for procedures with low risk of bleeding (i.e. cataract), interruption of anticoagulation is usually NOT necessary. However, consulting with surgeon and • ECG? anticoagulation clinic and adhering to your local practice is always advisable • Labs? • Continue lisinopril, furosemide, metoprolol • Hold metformin (NPO) NO additional testing is indicated Case 1: Take Home: Determining Surgical Risk UPDATED For cataract surgery preoperative testing has NOT been shown to affect outcomes. Rates Goal is to divide patients into two categories: of adverse events in patients were similar (~3%) whether or not they underwent testing (American Academy of Ophthalmology Guideline 2014).  LOW RISK: • Combined patient and surgical procedure characteristics result in a predicted risk of < 1% of a Major Adverse Cardiac Event ( MACE = death or myocardial infarction)  ELEVATED RISK: • MACE ≥ 1% American Academy of Ophthalmology, http://www.aao.org/clinical-statement/routine-preoperative- laboratory-testing-patients-s, accessed May 2016

Why Determine Surgical Risk? ACC / AHA Flowchart (2014) UPDATED UPDATED  LOW RISK patients (MACE < 1%) do NOT need preoperative testing except as Low Risk 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 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

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: Mrs. Cano  Even in patients with known, stable coronary disease revascularization does NOT Mrs. Cano is seeing you in clinic prior to left knee arthroplasty surgery. Her orthopaedic improve long-term survival surgeon has contacted you and has asked you to determine what testing and management is needed prior to her procedure.  CARP trial: 510 patients with 1+ coronary artery with 70% occlusion. Randomized to revascularization vs. not prior to major vascular surgery. Mrs. Cano is a 68 year old woman with a history of: • No difference in death or MI • heart failure with reduced ejection fraction (EF 45%) (Rx: furosemide, metoprolol, lisinopril), • Excluded: unstable angina, left main stenosis > 50%, severe aortic stenosis, and LVEF < 20% • 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 5 day steroid burst in last year) • CAD (DES to RCA 5 years ago) (Rx: ASA, atorvastatin, metoprolol) • and hypertension (Rx: metoprolol) McFalls EO, Ward HB, Moritz TE, et al. N Engl J Med. 2004; 351: 2795–280