Pre-op cardiac ev (2)

Views:
 
Category: Education
     
 

Presentation Description

No description available.

Comments

Presentation Transcript

Slide 1:

Guideline on Preoperative Cardiovascular Evaluation and Management of Patients Undergoing Non-cardiac Surgery DR SUNIL MALIK CONSULTANT ANAESTHETIST FORTIS MEMORIAL RESEARCH HOSPITAL GURGAON

Pre-op evaluation:

Pre-op evaluation

Pre-op evaluation:

Pre-op evaluation

Slide 9:

Calculation of Risk to Predict Perioperative Cardiac Morbidity

Multivariate Risk Indices :

Multivariate Risk Indices Recommendations COR LOE A validated risk-prediction tool can be useful in predicting the risk of perioperative MACE in patients undergoing noncardiac surgery. IIa B For patients with a low risk of perioperative MACE, further testing is not recommended before the planned operation . III: No Benefit B

Multivariate Risk Indices :

Multivariate Risk Indices Recommendations COR LOE A validated risk-prediction tool can be useful in predicting the risk of perioperative MACE in patients undergoing noncardiac surgery. IIa B For patients with a low risk of perioperative MACE, further testing is not recommended before the planned operation . III: No Benefit B

Five main predictors of periop MI and cardiac arrest:

Five main predictors of periop MI and cardiac arrest Type of surgery Functional status ASA class Elevated creatinine AGE Diabetes Patient factors are mort important then surgical factors

Type of Surgery-Surgery grades:

Type of Surgery-Surgery grades Surgical grades examples Low risk excising skin lesion draining breast abscess Intermediate primary repair of inguinal hernia excising varicose veins in the leg tonsillectomy or adenotonsillectomy knee arthroscopy High risk total abdominal hysterectomy endoscopic resection of prostate lumbar discectomy thyroidectomy total joint replacement lung operations colonic resection radical neck dissection

Type of Surgery-Surgery grades:

Type of Surgery-Surgery grades Surgical grades examples Low risk excising skin lesion draining breast abscess Intermediate primary repair of inguinal hernia excising varicose veins in the leg tonsillectomy or adenotonsillectomy knee arthroscopy High risk total abdominal hysterectomy endoscopic resection of prostate lumbar discectomy thyroidectomy total joint replacement lung operations colonic resection radical neck dissection

Functional Capacity:

Functional Capacity

Pre-op ECG:

Pre-op ECG

Pre-op ECG AHA:

Pre-op ECG AHA Recommendations COR LOE Preoperative resting 12-lead ECG is reasonable for patients with known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease, except for those undergoing low-risk. IIa B Preoperative resting 12-lead ECG may be considered for asymptomatic patients without known coronary heart disease, except for those undergoing low-risk surgery. IIb B Routine preoperative resting 12-lead ECG is not useful for asymptomatic patients undergoing low-risk surgical procedures. III: No Benefit B

Slide 31:

ECG in Patient with any risk factors Patient with no risk factors and age above 65 Patient with no risk factors undergoing low risk surgeries does not require ECG

Resting ECHO-as per ESA/ESC:

Resting ECHO-as per ESA/ESC

AHA-adds more detail :

AHA-adds more detail Recommendations COR LOE It is reasonable for patients with dyspnea of unknown origin to undergo preoperative evaluation of LV function. IIa C It is reasonable for patients with HF with worsening dyspnea or other change in clinical status to undergo preoperative evaluation of LV function. IIa C Reassessment of LV function in clinically stable patients with previously documented LV dysfunction may be considered if there has been no assessment within a year. IIb C Routine preoperative evaluation of LV function is not recommended. III: No Benefit B

Slide 34:

Any Dyspnoe of unknown origin Any change in clinical status from previous ECHO If stable patient but ECHO done year back showed LV dysfunction.

Stress testing:

Stress testing

Stress testing AHA:

Stress testing AHA Recommendations COR LOE For patients with elevated risk and excellent (>10 METs) functional capacity, it is reasonable to forgo further exercise testing with cardiac imaging and proceed to surgery. IIa B For patients with elevated risk and unknown functional capacity, it may be reasonable to perform exercise testing to assess for functional capacity if it will change management. IIb B For patients with elevated risk and moderate to good (≥4 METs to 10 METs) functional capacity, it may be reasonable to forgo further exercise testing with cardiac imaging and proceed to surgery. IIb B For patients with elevated risk and poor (<4 METs) or unknown functional capacity, it may be reasonable to perform exercise testing with cardiac imaging to assess for myocardial ischemia if it will change management. IIb C Routine screening with noninvasive stress testing is not useful for patients at low risk for noncardiac surgery. III: No Benefit B

Stress testing:

Stress testing Not recommended for low risk surgeries as routine. Elevated risk surgeries- functional capacity is very important deciding factor. ? Functional capacity evaluation- based on daily activity and calculating METs. Idea just from patient history (?reliable) Concealed information

Assessment of functional capacity:

Assessment of functional capacity Assessment of Functional capacity reflects-ability to perform daily activities that require sustained aerobic metabolism. Integrated efforts and health of Pulm , CVS and skeletal muscle systems dictate individuals functional capacity. Treadmill, Cycle ergometer , 6min walk test Measuring various parameters-Vo2, VT, spo2, EtCO2, peak heart rate, B.P, C.I

Cardiopulmonary Exercise Testing:

Cardiopulmonary Exercise Testing Recommendation COR LOE Cardiopulmonary exercise testing may be considered for patients undergoing elevated risk procedures in whom functional capacity is unknown. IIb B

Cardiopulmonary Exercise Testing:

Cardiopulmonary Exercise Testing Recommendation COR LOE Cardiopulmonary exercise testing may be considered for patients undergoing elevated risk procedures in whom functional capacity is unknown. IIb B

Stepwise Approach to Perioperative Cardiac Assessment:

Stepwise Approach to Perioperative Cardiac Assessment

Perioperative Therapy :

Perioperative Therapy

Pre-op angiography:

Pre-op angiography

Timing of Elective Noncardiac Surgery in Patients With Previous PCI :

Timing of Elective Noncardiac Surgery in Patients With Previous PCI Recommendations COR LOE Elective non cardiac surgery should be delayed 14 days after balloon angioplasty… I C …and 30 days after BMS implantation I B Elective noncardiac surgery should optimally be delayed 365 days after DES implantation. I B In patients in whom noncardiac surgery is required, a consensus decision among treating clinicians as to the relative risks of surgery and discontinuation or continuation of antiplatelet therapy can be useful. IIa C

Slide 47:

Recommendations COR LOE Elective noncardiac surgery after DES implantation may be considered after 180 days if the risk of further delay is greater than the expected risks of ischemia and stent thrombosis. IIb* B Elective noncardiac surgery should not be performed within 30 days after BMS implantation or within 12 months after DES implantation in patients in whom DAPT will need to be discontinued perioperatively. III: Harm B Elective noncardiac surgery should not be performed within 14 days of balloon angioplasty in patients in whom aspirin will need to be discontinued perioperatively. III: Harm C

Non cardiac surgery after revascularisation:

Non cardiac surgery after revascularisation

Slide 49:

Except high risk, asymp . Pat. undergone CABG in past 6 yrs sent for surgery without angiography. Elective surgery After Balloon angioplasty- 2 weeks After BMS- 4weeks min to 3 months After DES- 12 months (6 months with risk)

Proposed Algorithm for Antiplatelet Management in Patients with PCI and Noncardiac Surgery :

Proposed Algorithm for Antiplatelet Management in Patients with PCI and Noncardiac Surgery

Pre-op medications:

Pre-op medications Beta blockers Alpha 2 agonists Statins ACEi,ARBs antiplatelets

Slide 54:

Beta blockers should not be started on the day of surgery. Atleast 24-48 hrs before surgery.

Alpha 2 agonists:

Alpha 2 agonists Recommendation COR LOE Alpha-2 agonists for prevention of cardiac events are not recommended in patients who are undergoing noncardiac surgery. III: No Benefit B

NICE GUIDELINES:

NICE GUIDELINES

Slide 64:

Thank you

authorStream Live Help