GRG-Journal Club13 aprile 2007

La preparazione del paziente anziano alla chirurgia

addominaleIntissar Sleiman- Claudio Codignola

Preoperative risk management

Cardiac risk

Pulmonary risk

Venous thromboembolic disease and management ofanticoagulation

Cardiac risk

Pulmonary risk

Venous thromboembolic disease and management of anticoagulation

ACC/AHA guideline summary: clinical predictors of increased perioperative cardiovascular risk (MI, HF, death)

Major predictors

Acute miocardial infarction (within 7 days)

Recent myocardial infarction (within 8 to 30 days)

Instable angina

Severe angina, may include patients with stable angina who are usually sedentary

Decompensated heart failure

High grade atrioventricolar block

Symptomayic ventricolar arrhytmias in patients who have underlying heart disease

Supraventricolare arrhytmias with a poorly controlled ventricular rate

Severe heart valve disease

Intermediate predictors

Mild angina

Previous myocardial infarction

Compensated HF or a prior history of HF

Diabetes mellitus, particularly in patients who are insulin-dependent

Reduced renal function

Minor predictorsAdvanced age

Abnormal ECG

Rhythm other than sinus rhythm

Low functional capacity

History of stroke

Uncontrolled hypertensionJ Am Coll Cardiol 2002

J Am Coll Cardiol 2006

ACC/AHA guideline summary: cardiac risk stratification for

noncardiac surgical procedures

High risk (reported risk cardiac death or nonfatal MI > 5 %):

Emergent major operations, particulary in elderly patients

Aortic and other major surgery

peripheral arterial surgery

Anticipad prolonged surgical procedures associated with large fluid shifts and/or blood loss

Intermediate risk (reported risk cardiac death or nonfatal MI < 5 %):

Carotid endarectomy

Head and neck surgery

Intraperitoneal and intrathoracic surgery

Orthopedic surgery

Prostate surgery

Low risk* (reported risk cardiac death or nonfatal MI < 1 %):

Endoscopic procedures

Superficial procedure

Cataract surgery

Breast surgery

J Am Coll Cardiol 2002* Do not generally require further preoperativa cardiac testing

Goldman cardiac risk index

Variable Point scoreHistory Age > 70 years 5

Preoperative MI within six months 10

Physical examinationS3 gallop or increased JVP >12 cm H2O 11

Significant valvular aortic stenosis 3

ECGRhythm other than sinus, or atriale ectopy 7

VPBs > 5/min at any time 7

Gneral medical status-one or more of the following: 3PO2 < 60 or PCO2 > 50 mmHg

Serum K < 3.0 or HCO3 < 20 meq/L

BUN > 50 or creatinine < 3.0 mg/dl

Chronic liver disease or debilitation

OperationIntraperitoneal, intrathoracic, or aortic 3

Emergency 4

TOTAL POSSIBLE POINTS 53

Goldman L, et al, N Engl J Med 1977

RCRI (Revised Goldmen Cardiac Risk Index)

Six independent predictors of major cardiac complications *High-risk type of surgery (includes any intraperitoneal, intrathoracic,or suprainguinal vascular procedures)

History of ischemic heart disease

History of heart failure

History of cerebrovascular disease

Diabetes mellitus requiring treatment with insulin

Preoperative serum creatinine > 2.0 mg /dl

Rate of cardiac death, non fatal myocardial infarction, and non fatal cardiac arrest according to the number of predictors#

No risk factors: 0.4 % (95 % CI 0.1-0.8 %)

One risk factors: 1.0 % (95 % CI 0.5-1.4 %)

Two risk factors: 2.4 % (95 % CI 1.3-3.5 %)

Three or more risk factors: 5.4 % (95 % CI 2.8-7.9 %)

Rate of cardiac death and non fatal myocardial infarction, cardiac arrest or ventricular fibrillation, pulnumary edema, and complete heart block according to the number of predictors and the nonuse of beta blockers@

No risk factors: 0.4 to 1.0 % versus < 1 % with beta blockers

One to two risk factors: 2.2 to 6.6 % versus 0.8-1.6 % with beta blockers

Three or more risk factors : > 9 % versus > 3 % with beta blockers

*Lee TH et al, Circulation 1999# Devereaux PJ, et al, CMAJ 2005@ Auerbach A, et al, Circulation 2006

Cardiac risk

Pulmonary risk

Venous thromboembolic disease and management of anticoagulation

Reported frequency of postoperative

pulmonary complications in the literature varies

from 2 to 70 %. This wide range is due in part to

patient selection and procedure-related risk

factors, although differing definitions for

postoperative complications account for much

of the variability and make comparison of

reported incidences across different studies

difficult.

Wightman JA et al Br J Surg, 1968

Gracey et al, Chest 1979

Age

Chronic lung disease

Asthma

Smoking

General health status

Obesity

Obstructive sleep apnea

Metabolic factors

Patient – related risk factors

Age

50 to 59 OR 1.50 (95 % CI 1.31-1.71)

60 to 69 OR 2.28 (95 % CI 1.86-2.80)

70 to 79 OR 3.90 (95 % CI 2.70-5.65)

>80 OR 5.65 (95 % CI 4.63-6.85)

COPD

OR 2.36 CI (95 % 1.90-2.93)

Smoking

OR 1.40 (95 % CI 1.17-1.68)

Obesity

Not a significant risk factorSmentana, GW, et al Ann Intern Med, 2006

ASTHMA

Warner DO, Warner MA, Barnes RD et al, Perioperative respiratory complications in patients with asthma. Anesthesiology 1996; 85:460

Obstructive sleep apnea

The impact of obstructive sleep apnea on postoperative risk has not been well studied

General health status

ASA class >2 OR 4.87 (95 % 3.34-10)

Procedure – related risk factors

Surgical site: inversely related to the distance of the surgical incision from the diaphragm

Duration of surgery: more than 3-4 hours are associated with a higher risk

Type of anesthesia: general anesthesia leads to a higher risk than to epidural or spinal anesthesia. Regional nerve block is associated with lower risk

Type of neuromuscolar blockade: pancuronium

Recommendations

PFTs:

Patients with COPD or asthma

Patients with dispnea or exercise intollerance that remains unexplained after clinical evaluation

Arterial blood gas analasysis:

All patients undergoing lung resection

Coronary bypass surgery or upper abdominal surgery with a history of tobacco use or dispnea

Chest radiographs:

Age > 50

Patients with known cardiopulmonary disease

Exercise testing:

Preparation for lung surgery

Age > 50 years

COPD

Congestive heart failure

Poor general health status as defined by ASA > 2

Functional dependence

Serum albumin < 3.5 mg/L

Upper abdominal,thoracic, aortic, head and neck, neurosurgery, and abdominal aortic aneurysm surgery

Surgery lasting greater than three hours

Emergency surgery

Use of pancuronium

Definite risk factors:

Obstructive sleep apnea

General anesthesia, spinal or epidural

Pa CO2 > 45 mmHg

Abnormal chest radiograh

Cigarette use within the previous 8 weeks

Current upper respiratory tract infection

Probable risk factors:

Cardiac risk

Pulmonary risk

Prevention of venous thromboembolic disease and management of anticoagulation

Categories of risk for venous thromboembolism in surgical patients

Low risk:

Minor surgery in patients < 40 years of age with no additional risk factors present *

Moderate risk:

Minor surgery in patients with additional risk factor present * or

Surgery in patient aged 40 – 60 with no additional risk factor

High risk:

Surgery in patients > 60 or

Surgery in patients aged 40-60 with additional risk factor

Highest risk:

Surgery in patient > 40 with multiple risk factors* or Hip Or

Knee arthroplasty, hip fracture surgery, or

major trauma, spinal cord injury

* Additional risk factors include one or more of the following: advanced age, cancer,prior venous thromboembolism, obesity, heart failure, paralysis, or presence of amolecular hypercoagulable state (eg, protein C deficiency, factor V Leiden).

Geerts, WH et al Chest 2001

Management of anticoagulation before and after elective surgery

•Elective surgery should be avoided in the first month after an acute episode of venous thromboembolism

•If avoidence of elective surgery is not possible, warfarin should be withheld of threeto four days and intravenous heparin or low molecular weight heparin should be given before and after the procedure while the INR is below 2.0

•The heparin should be continued until six hours before surgery, and PTT should be monitored

•Heparin or LMWH should not be restarted postoperatively until at least 12 hours after major surgery and delayed longer if there is any evidence of bleeding

•If the patient has been receiving warfarin for more than one month but less than three months, preoperative intravenous heparin is probably not needed. Postoperative intravenous heparin is recommended until warfarin therapy is resumed and the INR is above 2.0

•If it has been three months or more since the last episode of acute venous thromboembolism and the patient has been taking warfarin, preoperative heparin is not necessary, but postoperative prophilaxis with subcutaneous heparin or LMWH is recommended until oral anticoagulation is reestablished

Kearon et al NEJM 1997

Torn M et al Br J Haematol 2003

Larson BJ et al chest 2005

PERCHE’ E’ UTILE TUTTO QUESTO

LAVORO ?

Anziani sempre sottotrattati

1. Sensazione di non poter sottoporre i pazienti anziani a trattamenti convenzionali

2. Problema delle comorbilità

3. Riluttanza nel reclutare anziani nei trials o nella sperimentazione di nuovi farmaci

Rapporto chirurgia - età

Surgery-related mortality

Surgical risk factors, morbidityand mortality in elderly patientsJ Am Coll Surg 2006, 203: 865-877

• 7696 pazienti (18-103 anni)• Chirurgia di vario tipo• Morbilità e mortalità perioperatoria (30

giorni)

Come è possibile evidenziare il rischio

chirurgico preoperatoriamente ?

Risk scores• ASA• APACHE• PACE• POSSUM, pPOSSUM• altri

Ulteriore problema

• In chirurgia addominale diventa molto importante il fattore nutrizionale (ANASTOMOSI)

• Relativa scarsa attenzione alla valutazione nutrizionale

• Scores complessi e poco “comodi”

……COME FARE ?

Geriatric Nutritional Risk Index• 4 parametri:

– KH (altezza piede-ginocchio in cm)– Età– Peso attuale– Albuminemia plasmatica

4 CATEGORIE DI RISCHIO

• GNRI < 82: Rischio maggiore

• GNRI 82-92: Rischio moderato

• GNRI 92-98: Rischio lieve

• GNRI > 98: Nessun rischio

Geriatric Nutritional Risk Index

Paz 1 Paz 2 Paz 3 Paz 4 Paz 5 Paz 6 Paz 7KH 44 49 54 48,5 55 48 45W 90 57 95 47,5 100 75 58Età 90 69 61 87 76 76 85

Albumina 34,9 23,1 40,4 37,7 19,2 38,1 35,4Sex F F M F M M F

H 143,8 157,99 170,83 152,755 172,25 158,11 146,83

Wlo 41,32 54,794 65,6225 51,653 66,6875 56,0825 48,098

W/Wlo 1 1 1 0,919598 1 1 1

GNRI 93,67 76,10 101,86 94,48 70,29 98,43 94,41

Paz 1 Paz 2 Paz 3 Paz 4 Paz 5 Paz 6 Paz 7KH 44 49 54 48,5 55 48 45W 90 57 95 47,5 100 75 58Età 90 69 61 87 76 76 85

Albumina 34,9 23,1 40,4 37,7 19,2 38,1 35,4Sex F F M F M M F

H 143,8 157,99 170,83 152,755 172,25 158,11 146,83

Wlo 41,32 54,794 65,6225 51,653 66,6875 56,0825 48,098

W/Wlo 1 1 1 0,919598 1 1 1

GNRI 93,67 76,10 101,86 94,48 70,29 98,43 94,41

Considerazioni finali

• Anziano non è da discriminare

• Anziano da valutare

• Tecnica chirurgica molto “leggera” e rapida

• L’età è fattore da considerare comunque

Evidence do notmake decision.

People do.