Exam 16 - Heart83,84 - Medical Evaluation Of The Surgical Patient

Front 1

Preoperative Evaluation Primary Assessment:

Begin with these three questions

What is the __________ of this surgery?
-Emergent nature of some surgeries supersedes consideration of risks.

What risks are specific to this ___________?

What risks are specific to this ___________?

Back 1

urgency
patient
surgery

Front 2

Patient-Specific Risk Factors:

Major predictors of perioperative cardiac risk
-Recent _____.
-Unstable or severe stable ______________.
-Heart failure (esp new onset, worsening, or class IV).
-Cardiac ______________ (esp high-grade AV block, v-tach or any ventricular arrhthmia, SVT with resting rate > 100, symptomatic bradycardia.
-Severe ____________ heart disease (esp AS, MS).

Back 2

MI
angina
arrhythmias
valvular

Front 3

Other predictors of perioperative cardiac risk:

-History of ... heart disease.
-History of ... disease. (TIA or stroke)
-History of compensated heart failure.
-Diabetes.
-Renal insufficiency.
-Hypertension.
-... disease – marker of coronary heart disease
-Abnormal EKG (non-sinus rhythm, LVH, BBB, ST-T wave changes).
-??? Obesity???

Back 3

ischemic
cerebrovascular
Peripheral vascular

Front 4

is carotid surgery considered a high risk surgery?

Back 4

no, it is an intermediate risk surgery

Front 5

Surgery-Specific Risk Factors:

High-Risk Surgical Procedures
-... major operations, especially among the elderly.
-... and other ... peripheral vascular surgery.
-Prolonged surgery (>... hrs) associated with large fluid shifts and/or blood loss.

Back 5

Emergent
Aortic
noncarotid
3

Front 6

Intermediate-Risk Surgery

-Intrathoracic surgery.
-... (abdominal) surgery.
-... endarterectomy.
-Head/neck surgery.
-Orthopedic surgery.
Prostate surgery.

Back 6

Intraperitoneal
Carotid

Front 7

Low-Risk Surgery

-Eye (cataract).
-Skin.
-... surgery (Breast surgery, abdominoplasty, liposuction).
-... surgery.
-Ambulatory.

Back 7

Superficial
Endoscopic

Front 8

... status / ... tolerance is also an important component of the history during the preoperative evaluation.

Back 8

Functional
exercise

Front 9

Exercise tolerance:

Q: What level of poor exercise tolerance is considered significant relative to predicting adverse perioperative events?

A: Inability to
-Walk _____ blocks at a normal pace.
-Climb _____ flights of stairs at a normal pace.
-Meet a metabolic equivalent (MET) of _____.

Back 9

4
2
4

Front 10

Metabolic Equivalents (METs):

-1 MET is defined as 3.5 mL O2 uptake/kg per min.
-1 MET is the resting oxygen uptake in a sitting position during performance of basic self-care tasks such as eating, dressing, using the toilet, etc.
-About _______ METs are required to walk up stairs or walk up a hill.
-_______ METs are required for heavy work around the house such as scrubbing floors, moving furniture, etc.
-_______ METs are required for strenuous sports such as swimming, singles tennis, football, basketball, skiing, etc.

Back 10

4
4-10
>10

Front 11

What is an absolute must to do in a preoperative physical exam?

Back 11

Auscultate the heart, lungs, abdomen, and carotids.

Front 12

Resting EKG:

_________________ or significant ST segment elevation or depression are associated with an increased risk of perioperative cardiac complications.

Right or left bundle branch block may increase risk of perioperative MI.

_______________________ may increase risk of perioperative mortality.

Back 12

Pathologic Q waves
LBBB

Front 13

A healthy patient with no risk factors for an adverse cardiac event undergoing an elective low-risk surgical procedure (does?/does not?) require any preoperative cardiac testing.

There are several algorithms published regarding the perioperative management of patients with risk factors – most use the RCRI scoring system.

Back 13

does NOT

Front 14

The revised Cardiac Risk Index (RCRI):

Patient is assigned one point for each of the following

1. High-risk ....
2. ... heart disease.
3. ... failure.
4. ... disease.
5. ....
6. ... dysfunction.

Back 14

surgery
Ischemic
Congestive heart
Cerebrovascular
Diabetes mellitus
Renal

Front 15

RCRI:

... (1 point)
-Vascular surgery (not carotid).
-Major intraperitoneal or intrathoracic procedures.

... (1 point)
-History of myocardial infarction.
-Current angina considered to be ischemic.
-Any angina requiring sublingual nitroglycerin.
-Positive exercise stress-test.
-Pathological Q-waves on ECG.
-History of PTCA and/or CABG with current angina considered to be ischemic.

Back 15

High-risk surgical procedures
Ischemic heart disease

Front 16

RCRI:

... (1 point)
-Left ventricular failure by physical examination.
-History of paroxysmal nocturnal dyspnea.
-History of pulmonary edema.
-S3 gallop on cardiac auscultation.
-Bilateral rales on pulmonary auscultation.
-Pulmonary edema on chest x-ray.

... (1 point)
-History of transient ischemic attack.
-History of cerebrovascular accident.

Back 16

Congestive heart failure
Cerebrovascular disease

Front 17

RCRI:

... (1 point)

... (1 point)
-Serum creatinine >2 mg/dL.

Back 17

Diabetes mellitus
Chronic renal insufficiency

Front 18

The RCRI can be used to predict the risk of a major cardiac event defined as

Myocardial ....
... edema.
... heart block.
... fibrillation.
... arrest.

Back 18

infarction
Pulmonary
Complete
Ventricular
Primary cardiac

Front 19

Stress testing has a high ... predictive value (90-100 %) but low ... predictive value in predicting adverse cardiac events.

If exercise stress test is ..., that patient is unlikely to have a cardiac event. This is a strong ... predictive value.
If the test is ..., it doesn’t mean that they are going to have a heart attack.

A ... test is reassuring.

Back 19

negative
positive
normal
negative
positive
negative

Front 20

________________is an important predictor of outcome that some studies suggest may be more important than the ECG response.

Inability to perform moderate exercise or to achieve greater than 85 percent of predicted maximal heart rate during exercise treadmill testing is associated with an increased risk for adverse perioperative cardiac events, even in the absence of diagnostic ischemic ECG changes.

Back 20

exercise tolerance

Front 21

Noninvasive Cardiac testing:

Indications for pharmacologic stress testing:
-Patients who cannot or should not exercise.
-Patients who have abnormalities on the baseline _________ that may interfere with interpretation of an exercise stress test.

The two most common pharmacologic tests are:
-dipyridamole-thallium radionuclide myocardial perfusion imaging (stress-thal).
-dobutamine echocardiography.

Back 21

EKG

Front 22

EKG changes that can mask ischemic changes are ... (especially ...). In the presence of a ..., you can not rule out an MI.

Back 22

BBBs
LBBB
LBBB

Front 23

Noninvasive Cardiac testing:

Exercise ECG testing can be performed with perfusion imaging or echocardiography.

Imaging can better identify features that would warrant referral for _______________.
-Reversible large anterior wall defect.
-Multiple reversible defects.
-Ischemia occurring at a low heart rate.
-Extensive stress-induced wall motion abnormalities.
-Transient ischemic dilatation.

Back 23

angiography

Front 24

A special consideration:

Since exercise increases systolic pressure it would be intuitive to consider avoidance of exercise stress testing in patients with aortic aneurysms.

However, exercise stress appears to be safe in patients with asymptomatic aortic aneurysms < _____cm.

Pharmacologic stress testing is recommended for patients with aortic aneurysms ≥ _____ cm in diameter or aneurysms that are symptomatic.

Back 24

6
6

Front 25

Perioperative Risk Modification:

Patients identified at intermediate-risk (RCRI ... or ...) or high-risk (RCRI >=...) may benefit from medical and/or surgical perioperative risk modification.

... therapy is aimed at reducing perioperative adrenergic stimulation, ischemia, and inflammation.

... therapy is aimed at coronary artery revascularization.

Back 25

1 or 2
3
Medical
Surgical

Front 26

Perioperative Risk Modification
(Medical Therapy):

...
-Should be given to high-risk patients.
-May be considered for intermediate-risk patients.

...
-Should be given to patients with established atherosclerosis.

...
-Should be discontinued at least 24 hours before surgery due to adverse circulatory effects after induction of anesthesia.

Back 26

Beta-adrenergic antagonists (Beta-blockers)
HMG-COA Reductase Inhibitors (Statins)
ACE Inhibitors

Front 27

Perioperative Risk Modification
(Medical Therapy):

Oral antiplatelet agents (aspirin, clopidogrel)
-Discontinuation for ... prior to surgery desirable to reduce risk of bleeding complications.
-However, thrombotic/embolic complications are increased in the absence of antiplatelet therapy.
-Patients with recent ... placement represent a particular management dilemma due to risk of ....
*Risk of MI and death is ... in patients who discontinue antiplatelet therapy after stent placement.

Back 27

one week
stent
stent thrombosis
increased

Front 28

Perioperative Risk Modification
(Surgical Therapy):

Patients with ... or ... disease AND poor ... function may benefit from prophylactic coronary revascularization.
-Percutaneous coronary intervention (PCI).
-Coronary artery bypass grafting (CABG).
-PCI carries less inherent procedural risk than CABG but then presents the bleeding/clotting risk dilemma when surgery is eventually performed.

Back 28

left main
three-vessel coronary artery
left ventricular systolic

Front 29

look at slide 42

Back 29

ok

Front 30

Perioperative Pulmonary Risk Assessment/Modification:

Preoperatively
-Screen for tobacco use and recommend cessation of smoking for at least ... wks prior to surgery.
-Training in proper breathing (incentive spirometry).
-... and/or steroid therapy for patients with asthma or COPD.
-Control of infection and secretion if indicated.
-Weight reduction if indicated.

Back 30

8
Bronchodilator

Front 31

Perioperative Pulmonary Risk Assessment/Modification:

Intraoperatively
-Attempt to limit duration of surgery/anesthesia.
-Select shorter acting neuromuscular blocking drugs when appropriate.
-... prevention.
-Maintenance of optimal bronchodilation.

Back 31

Aspiration

Front 32

Perioperative Pulmonary Risk Assessment/Modification:

Postoperatively – continue preoperative measures
-... capacity maneuvers.
-Mobilization of secretions.
-Early ....
-Encourage ....
-Selective use of a nasogastric tube.
-Adequate pain control without excessive ..., which will decrease respiratory drive and bowel motility.

Back 32

Inspiratory
ambulation
coughing
narcotics

Front 33

Infective endocarditis (IE) – the theory regarding suspected etiology:

-Small __________ forms on an abnormal endothelial surface.
-This __________ becomes secondarily infected when seeded with bacteria that are transiently circulating in the bloodstream.
-Bacterial proliferation results in the formation of _______________ on the endothelial surface.

Back 33

thrombus
nidus
vegetations

Front 34

In contrast to prior guidelines, the 2007 AHA guidelines for the prevention of infective endocarditis (IE) eliminated the recommendation for antimicrobial prophylaxis for several conditions and several procedures.

Prophylactic antibiotics are now only recommended for ...-risk conditions and ...-risk procedures.

Back 34

highest
highest

Front 35

IE Highest-risk conditions:

1. ... heart valves, including ... and ... valves.
2. A prior history of ....
3. ... cyanotic congenital heart disease, including palliative shunts and conduits.
4. Completely repaired congenital heart defects with ... material or device, whether placed by surgery or by catheter intervention, during the first ... months after the procedure.
5. Repaired congenital heart disease with residual defects at the site or adjacent to the site of the ... device.
6. Cardiac "valvulopathy" in a ... heart. Valvulopathy is defined as documentation of substantial leaflet pathology and regurgitation.

Back 35

Prosthetic
bioprosthetic and homograft
IE
Unrepaired
prosthetic
six
prosthetic
transplanted

Front 36

IE Prophylaxis is No Longer Indicated For:

... aortic valve.

Acquired ... or ... valve disease.
-This includes ... valve prolapse with regurgitation and those who have undergone prior valve repair.

... cardiomyopathy with latent or resting obstruction.

Back 36

Bicuspid
aortic or mitral
mitral
Hypertrophic

Front 37

IE prophylaxis no longer indicated for:

The 2007 AHA guidelines no longer consider any ...(including colonoscopy or EGD) or ... procedures high risk and therefore do not recommend routine use of IE prophylaxis even in patients with the highest risk cardiac conditions.

However, if there is known ... at the time of surgery then prophylaxis may be appropriate for highest-risk patients.

Back 37

GI
GU
GI or GU infection

Front 38

Summary of IE prophylaxis:

Administer prophylactic antibiotics only for patients with highest-risk conditions who are undergoing highest-risk procedures.

______________ – 2g po about 30-60 minutes before the procedure is appropriate for most situations.

Alternatives appropriate for some patients and some conditions include: ampicillin, azithromycin, clarithromycin, clindamycin, cephalexin, cefazolin, ceftriaxone, vancomycin.

Back 38

Amoxicillin

Front 39

Final remark regarding IE:

Maintenance of optimal ________ health and hygiene may reduce the incidence of bacteremia from daily activities and is therefore more important than prophylactic antibiotics to reduce the risk of IE.

Back 39

oral

Front 40

Remember diabetic patients are at risk for “...” due to autonomic dysfunction.

Back 40

silent ischemia

Front 41

Anesthesia considerations:

Neuroaxial (spinal/epidural) anesthesia is generally safer than general (inhaled).
-Decreased venous thrombosis, pulmonary embolism, pneumonia, respiratory depression => decreased mortality.
-No significant difference in _______ events.

Back 41

cardiac