Epidemiology of Noncardiac Surgery Dr. Mohammed Naser.
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Transcript of Epidemiology of Noncardiac Surgery Dr. Mohammed Naser.
![Page 1: Epidemiology of Noncardiac Surgery Dr. Mohammed Naser.](https://reader035.fdocuments.in/reader035/viewer/2022062321/56649da95503460f94a969e5/html5/thumbnails/1.jpg)
Epidemiology of Noncardiac Surgery
Dr. Mohammed Naser
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![Page 3: Epidemiology of Noncardiac Surgery Dr. Mohammed Naser.](https://reader035.fdocuments.in/reader035/viewer/2022062321/56649da95503460f94a969e5/html5/thumbnails/3.jpg)
Overview
• Important Decision points:– Urgent vs Elective Surgery– High risk surgery vs intermediate vs low
-Active Cardiac Condition vs non-active
Functional capacity on basis of pt ablility
To perform certain activities
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The Search For High Risk
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Methods for Assessing Risk Pre-Operatively
Is the surgery emergency
PROCEED and manage post operatively
according to AHA& ACC guidelines
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If the surgery emergency..??
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Active/Major Cardiac Conditions
• Unstable Coronary Conditions
• Decompensated CHF
• Significant arrhythmias (i.e. 3 HB, new ⁰Vtach)
• Severe Valvular Disease (aortic stenosis >40 mm hg gradient or valve area <1.0cm₂)???????
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Non-Active Cardiac Factors
• Intermediate Risk • Hx of CHD• History of prior
CHF• Hx of stroke• Diabetes • Renal insufficiency
• Minor Risk*• Age > 70• Abnormal ECG• Nonsinus rhythm• Uncontrolled
systolic BP
* Not associated with cardiac risk
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Six Independent predictors of cardiac risk
1) ischemic heart disease
2) congestive heart failure
3) cerebrovascular disease
4) high risk surgery (AAA, orthopedic sx)
5) pre-operative insulin tx for diabetes
6) preoperative creatinine for creat > 2 mg/dL
Lee et al
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Functional capacity
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Functional Capacity
• Functional status has shown to be a reliable periop and long-term predictor of cardiac events
• MET: metabolic equivalent resting oxygen consumption of 70 kg, 40 yr old man at rest
• Periop risk is increased if person cannot > 4 METS
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1 MET 4 MET 10 MET
Eat, d
ress
DO li
ght h
ouse
wor
k i.e.
Was
hing d
ishes
Climb a
fligh
t of s
tairs
Run a sh
ort d
istan
ces
Mod
erat
e rec
reat
iona
l gol
f, da
ncin
g, b
aseb
all
Stre
nuou
s spo
rts s
wimm
ing,
bas
ketb
all
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The Trump Card: Functional Capacity
• Perioperative cardiac risk is increased in patients unable to exercise 4 METs
• Functional capacity can be estimated in the office
– Energy expenditure for eating, dressing, walking around house, dishwashing ranges from 1-4 METs
– Climbing a flight of stairs, running a short distance, scrubbing floors, and golf ranges from 4-10 METs
– Swimming and singles tennis exceeds 10 METs
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Surgery Risk Type
Type Cardiac risk examples
High > 5% Aortic, peripheral vasc sx
Intermediate risk 1-5% IntraperitonealIntrathoracicCarotid EndHead and neckOrthopedic SxProstate Sx
Low <1% Endoscopic proceduresSuperficialCataract SxBreast SxAmbulatory Sx
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Surgery-Specific Risk: High Risk*
• Major emergency surgery
• Vascular surgery including: aortic surgery, infra-inguinal bypass
• Prolonged surgery with large fluid shifts or blood loss
* Reported risk of cardiac death or nonfatal MI >5%
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Stepwise Approach
• Step 1: Determine urgency of surgery
• Step 2: Active cardiac condition?-→test
• Step 3: Undergoing low-risk surgery? < 1%*
• Step 4: Good functional capacity?
* Combined morbidity and mortality < 1% even in high risk
patients
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The Catheterization Questions to Ask Yourself
• Does this patient have symptomatic coronary disease that will have a mortality benefit from revascularization now?
• Am I willing to send the patient to CABG?
• Am I doing this just to know the anatomy?
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Is pre-op coronary revasc advantageous?
• If high risk surgery and patient has active cardiac issue
• Functional test and perfusion Imaging and if
• L main 50% or 3 VD, 2VD + LAD Prox, LVEF < 20%, aortic stenosis – consider revasc pre-op
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STENTS
If upcoming Sx is known then PTCA alone or BMS with 4-6 wks dual antiplatelet tx after
If received DES....– 1) postpone sx until > 12 months,– 2) do sx on both asa+clop – 3) do sx on single ap tx
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Use of a DES for coronary revascularization before imminent or planned non cardiac sx that will necessitate d/c of antiplatelet agents is not recommended
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Medical tx
1) beta blockers-if on keep them if not....
2) Statins continue, ? Start -need randomized trials
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Other Issues
• DVT/PE prophylaxis
• Anesthetic technique-volatile agent with general anesthetic - ↓ troponin ↑ LV function >> propofol, midazolam, balanced anesthesia (Grade B)
• No evidence that epidural anesthesia >>general anesthesia for cardiac outcomes
• Routine troponin monitoring not recommended
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Surveillance for Perioperative Myocardial Infarction
• ECGs–All intermediate and high-risk patients
should get a post-op ECG.–As need for signs or symptoms of
ischemia
• Troponin / CK – In patients with signs or symptoms of
ischemia–Do not do screening biomarkers
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High Risk Features
• Severe obstructive or restrictive pulmonary disease
• Diabetes
• Renal impairment
• Anemia, polycythemia, thrombocytosis
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PCI pre-op
• ST-elevation MI
• Unstable angina
• Non ST elevation MI
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2007 ACC/AHA Perioperative Guidelines
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Take Home Messages
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Take Home Messages• Unstable syndromes require management prior to surgery. Look
for
– Unstable angina
– Signs of heart failure
– Stenotic valve lesions
– Ventricular arrhythmias
• Functional tolerance is the best single predictor of outcome
• Be very specific in your history (one step at at time, regular or slow pace, etc)
• If patient on beta blockers & statins continue them, more trials to mandate them
• PCI/CABG only if patient needs it independent of surgery. Think twice because of stent data and delays.
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