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Challenging Cases in Perioperative Medicine

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Title: Challenging Cases in Perioperative Medicine


1
Challenging Cases in Perioperative Medicine
  • Margaret M. Beliveau MD
  • General Internal Medicine
  • Mayo Clinic,
  • Rochester, Mn

2
Disclosures
  • No relevant industry conflict of interest
  • I will not be discussing off-label use of drugs
  • I have 2 teenage drivers, which resulted in all
    my hair turning grey

3
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4
Objectives
  • Discuss the management of patients with cardiac
    stents in the perioperative setting
  • Discuss the perioperative management of the frail
    elderly patient with multiple co-morbidities
  • Discuss issues in hypertension management in the
    perioperative setting
  • Discuss the perioperative management of patients
    with hemophilia

5
Case 1
  • A 70 year old man falls while out walking his
    dog. For the next week, his family notices
    progressive gait instability. After a second
    fall, they take him to the emergency room, where
    he is discovered to have a large right subdural
    hematoma.

6
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7
Case 1
  • He had an ST elevation MI 4 months ago at an
    outside facility and a drug-eluting stent was
    placed (paclitaxel). No further information is
    available.
  • He also has a history of recurrent DVT and PE has
    been maintained on warfarin
  • Bipolar disorder

8
Case 1
  • Lexapro 20 mg by mouth daily
  • Aspirin 325 mg by mouth daily
  • Warfarin 4 mg by mouth daily
  • Plavix 75 mg by mouth daily
  • Atenolol 75 mg daily

9
Case 1
  • INR 2.9 on admission
  • Plan for Burr hole evacuation of subdural
    hematoma

10
Case 1
  • In addition to stopping the warfarin, what do you
    tell the surgeon with regard to his medications?

11
Case 1
  • The patient should undergo the surgical procedure
    on aspirin and clopidogrel
  • The aspirin should be stopped, but the
    clopidogrel should be continued
  • The aspirin and clopidogrel can be interrupted
    for the surgical procedure
  • The clopidogrel can be stopped, but the aspirin
    should be continued

12
Case 2
  • 72 yo man
  • Nov. 2006- gross hematuria
  • TURBT, muscle invasive bladder cancer
  • Cystectomy recommended, but preoperative cardiac
    evaluation abnormal
  • Radiation therapy, ended June 2007
  • Feb. 2008- recurrent hematuria

13
Case 2
  • Chemotherapy given
  • Ongoing hematuria, now transfusion dependent
  • Proposed curative cystectomy

14
Case 2
  • March 2007- abnormal EKG on preoperative
    evaluation
  • Coronary angiogram- CABG recommended, patient
    refused
  • 15 bare metal stents placed
  • July 2007- patient complains of fatigue
  • Angiogram- restenosis

15
Case 2
  • 14 more drug eluting stents placed
  • 5- LAD, 5- RCA, 4- circumflex
  • March 2008- adenosine sestamibi positive for
    ischemia (severe left main disease), small area
    of infero-septal infarct
  • Patient remains asymptomatic
  • Cardiology evaluation benefits of surgery
    outweigh risks

16
Case 2
  • What do you tell the surgeon with regard to his
    medications?

17
Case 2
  • The patient should undergo the surgical procedure
    on aspirin and clopidogrel
  • The aspirin should be stopped, but the
    clopidogrel should be continued
  • The aspirin and clopidogrel can be interrupted
    for the surgical procedure
  • The clopidogrel can be stopped, but the aspirin
    should be continued

18
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19
The Story of the Stent
  • Bare Metal Stent (BMS) first introduced in the US
    in 1994
  • Drug Eluting Stent (DES) became available in 2003
  • Over 4 million stents (BMS and DES) placed
    annually worldwide

20
The Story of the Stent
  • DES are being deployed in 80-90 of coronary
    interventions in the US (the majority of these
    for off label indications)
  • More than 6 million drug eluting stents have been
    placed since they became available in 2003

21
FDA Indications for Use
  • The CYPHER (Sirolimus-eluting Coronary Stent) is
    indicated for
  • improving coronary luminal diameter in patients
    with symptomatic ischemic disease due to discrete
    de novo lesions of length 30 mm in native
    coronary arteries with reference vessel diameter
    of 2.5 mm to 3.5 mm.
  • The TAXUS (Express Paclitaxel-Eluting Coronary
    Stent System) is indicated for
  • improving luminal diameter for the treatment of
    de novo lesions 28 mm in length in native
    coronary arteries 2.5 to 3.75 mm in diameter.

22
Off-Label Indications for Drug Eluting Stents
  • 50-60 of DES are placed for off-label use

23
Iakovou et al JAMA 2005Prospective observational
cohort of 2229 consecutive patients who had DES
placed
9 month followup
Subacute lt 30 Days
Late gt 30 Days
Cumulative incidence of stent thrombosis 1.3
24
Iakovou et alJAMA 2005
  • In this study, 29 of the patients who
    prematurely discontinued dual antiplatelet
    therapy developed stent thrombosis
  • Case fatality rate for patients who developed
    stent thrombosis was 45
  • These were all patients who had stent placement,
    not just patients undergoing non-cardiac surgery

25
What Do You Recommend if a Patient with a Recent
Stent Needs Surgery?
  • Approximately 5 of patients who undergo coronary
    stenting require noncardiac surgery within 1 year
    of stenting
  • Fear of excessive bleeding leads to the generally
    accepted policy of discontinuing these agents
    7-10 days before elective surgery

26
The Perfect Storm
Trouble
27
Abrupt discontinuation of clopidogrel
Abrupt discontinuation of aspirin
  • Rebound effect
  • Significantly increased inflammatory
    prothrombotic state
  • Significantly increased platelet adhesion and
    aggregation
  • Excessive thromboxane A2 activity
  • Surgical intervention with increased
    prothrombotic and inflammatory state
  • increased cytokines, neuroendocrine inflammatory
    mediator release
  • increased platelet adhesiveness and persistently
    high platelet counts
  • increased release of procoagulant factors
  • decreased or impaired fibrinolysis

Prothrombotic state with incompletely
endothelialized stent(s)
Stent thrombosis, MI, Death
Newsome LT Anesth Analg 2008 107570-90
28
Anti-platelet Drugs
  • Widely used for primary and secondary prevention
    of cardiovascular disease
  • Plaque stabilization
  • Used after placement of intracoronary stents to
    prevent thrombosis

29
Anti-platelet Drugs
  • Continuationgt increased risk of perioperative
    bleeding
  • Interruptiongtrisk of stent thrombosis

30
Anti-platelet Drugs
  • Aspirin
  • Thienopyridines (clopidogrel)
  • GP IIb/IIIa receptor antagonists

31
Anti-platelet Drugs
  • Bleeding risks
  • No large prospective randomized trials
  • Aspirin risk of bleeding increased by a factor
    of 1.5, without increased morbidity or mortality
  • Risk highest in specific procedures CABG,
    prostatectomy and intra-cranial neurosurgery

Chassot PG BJA 99316-28, 2007
32
Anti-platelet Drugs
  • Dual therapy ASA plus clopidogrel
  • Moderate increase in surgical blood loss, but not
    in morbidity, mortality or surgical outcome
  • Exception intracranial neurosurgery

33
Anti-platelet Drugs
  • Risks of maintaining
  • Increased surgical blood loss
  • Increased transfusion rate
  • Withdrawal risks
  • Rebound increased platelet adhesiveness
  • Doubled infarction and death rate in acute
    coronary syndrome
  • Increased risk of stent thrombosis with high
    mortality

34
Risk of Stent Thrombosis
  • High risk stents long, proximal, multiple,
    overlapping, small vessels, bifurcation
  • High risk patients Low EF, diabetes
  • High risk timing lt 6 weeks after bare metal
    stent lt 12 months after drug-eluting stent

35
Risk of Stent Thrombosis
  • If stent not completely endothelialized, risk of
    acute stent thrombosis increased
  • Prothrombotic state induced by surgery

36
Risk of Stent Thrombosis
  • The most powerful predictor of acute stent
    thrombosis with BMS is time delay of lt 14 days
    between implantation and interruption of
    anti-platelet therapy

37
Risk of Stent Thrombosis
  • Drug-eluting stents adverse clinical events (MI,
    death) noted when patients stopped anti-platelet
    therapy prematurely

38
The Perioperative Dilemma
  • Discontinue antiplatelet drugs perioperatively
  • Stent thrombosis
  • MI
  • Cardiac death
  • Continue perioperative antiplatelet drugs
  • Surgical bleeding

39
The Perioperative Dilemma
  • Based on currently available data, the risk of
    withdrawing anti-platelet drugs is greater than
    continuing them
  • Withdrawal imposes perioperative cardiac death
    rate that is increased 5-10 times

40
Chassot PG BJA 99316-28, 2007
41
Society for Cardiovascular Angiography Clinical
Alert, Jan 2007
42
Joint Advisory Recommendations and Noncardiac
Surgery
  • Consider bare metal stent if patient requires PCI
    and is likely to require invasive or surgical
    procedure within next 12 months.
  • Educate patient prior to discharge re risk of
    premature antiplatelet discontinuation.
  • Instruct patient to contact treating cardiologist
    before antiplatelet discontinuation

43
Joint Advisory Recommendations and Noncardiac
Surgery
  • Healthcare providers who perform surgical or
    invasive procedures must be made aware of
    catastrophic risks of premature antiplatelet
    discontinuation and should contact the treating
    cardiologist to discuss optimal management
    strategy

44
Joint Advisory Recommendations and Noncardiac
Surgery
  • Defer elective procedures for which there is
    bleeding risk until completion of antiplatelet
    course
  • 1 month bare metal stent
  • 12 months drug eluting stent
  • For patient with drug eluting stents who are to
    undergo procedures that mandate discontinuation
    of thienopyridine (e.g., clopidogrel), continue
    aspirin if at all possible and restart
    thienopyridine as soon as possible

45
Joint Advisory Recommendations and Noncardiac
Surgery
  • No evidence for bridging therapy with
    antithrombins, warfarin, or glycoprotein
    IIIB/IIIA agents

46
Proposed Approach for Management of Dual
Antiplatelet Therapy with Previous PCI who
Require Surgery
Balloon Angioplasty
Bare-metal Stent
Drug-eluting Stent
lt365 Days
lt 30-45 Days
lt 14 Days
gt 14 Days
gt365 Days
gt 30-45 Days
Delay Elective or Non-urgent Surgery
Delay Elective or Non-urgent Surgery
Proceed to Operating Room with Aspirin
Proceed to Operating Room with Aspirin
Based on Expert Opinion, from the ACC/ AHA
guidelines, 2007
47
Back to the patients
  • Patient 1 Drug-eluting stent, DVT/PE, on
    warfarin, aspirin and clopidogrel, sub dural
    hematoma
  • My recommendations Stop antiplatelet agents,
    restart aspirin 5 days after surgery if stable,
    restart clopidogrel as soon as possible after
    surgery (10 days-2 weeks per neurosurgeon)
  • ? Loading dose (300 mg) of clopidogrel

48
Case 1
  • The patient should undergo the surgical procedure
    on aspirin and clopidogrel
  • The aspirin should be stopped, but the
    clopidogrel should be continued
  • The aspirin and clopidogrel can be interrupted
    for the surgical procedure
  • The clopidogrel can be stopped, but the aspirin
    should be continued

49
Back to the patients
  • Patient 2 29 stents, locally invasive bladder
    cancer
  • Underwent radical cystoprostatectomy, limited
    pelvic lymphadenectomy, and ileal conduit
    formation
  • Aspirin and clopidogrel held prior to surgery
    (despite our recommendations)
  • POD1

50
Case 2
  • The patient should undergo the surgical procedure
    on aspirin and clopidogrel
  • The aspirin should be stopped, but the
    clopidogrel should be continued
  • The aspirin and clopidogrel can be interrupted
    for the surgical procedure
  • The clopidogrel can be stopped, but the aspirin
    should be continued

51
Case 2
  • However, the surgeon was not comfortable
    operating with aspirin and clopidogrel on board,
    and these were held prior to surgery
  • Surveillance ECG was done on POD1

52
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53
Back to the Patients
  • ST elevation MI
  • Preserved ejection fraction
  • Treated medically, dismissed from the hospital
    POD 15
  • Died 5 months later from complications of bladder
    cancer

54
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55
  • Older patients are at increased risk for a host
    of complications and it is probably easier to
    precipitate these complications than to prevent
    them. This precarious state is a function of
    decreased functional reserve, variable response
    to stress, and the number of comorbidities.
  • DJ Cook and GA Rooke, 2003, Anesth Analg.

56
Case 1
  • A 92 yo woman, in a nursing home because of
    advancing dementia, falls and fractures her hip
    while making her bed!
  • Past history includes dementia, hypertension,
    atrial fibrillation, moderate to severe aortic
    and mitral insufficiency, pulmonary hypertension
    and congestive heart failure (LVEF40).

57
Case 1
  • Can walk a short distance, but does complain of
    dyspnea
  • Meds Toprol XL, Lisinopril, Donepezil

58
Case 1
  • Exam
  • Awake and alert, not oriented to time or place
  • Hard of hearing
  • Pulse 80, irregularly irregular
  • Holosystolic murmur at the apex, early diastolic
    murmur, lungs with basilar crackles
  • No edema

59
Case 1
  • Data
  • EKG A. fib with controlled ventricular response
  • Sodium 128, creatinine 1.6, BUN 52
  • UA gt100 WBCs with bacteria present

60
  • You are the medical consultant. What would you
    do?
  • Tell the patient and her family that the risk of
    surgery is too high, and recommend hospice
  • Send the patient to the ICU for invasive
    monitoring, and allow her to go to surgery
  • Get a cardiology consult and let them decide
  • Treat the UTI, start to correct the sodium, then
    send the patient to the OR when the Nagt 135

61
Weighing the risks and benefits
  • Benefits
  • The mortality of an unrepaired hip fracture is
    extremely high- as much as 90 in the first 3
    months
  • Surgical repair will relieve pain and improve her
    overall functional status

62
Weighing the risks and benefits
  • Risks
  • Known heart disease, with at least moderate
    valvular disease, CHF, and pulmonary hypertension
    implies little cardiac reserve to tolerate the
    stress of surgery
  • Her dementia makes obtaining informed consent
    from the patient difficult or impossible

63
Weighing the risks and benefits
  • Her dementia puts her at increased risk of
    postoperative delirium
  • The presence of hyponatremia puts her at
    increased risk of postoperative delirium
  • Elevated creatinine means that her renal reserve
    is limited and is also an additional risk factor
    for perioperative cardiac complications
  • She already has a urinary tract infection

64
Risks and Benefits
  • Known heart disease
  • Dementia
  • Hyponatremia
  • Elevated creatinine
  • Urinary tract infection
  • The mortality of an unrepaired hip fracture is
    extremely high- as much as 90 in the first 3
    months
  • Surgical repair will relieve pain and improve her
    overall functional status

65
Case 2
  • An 89 yo woman who is being evaluated for total
    hip arthroplasty
  • Hip fracture 9 months ago, ongoing severe hip
    pain, which has limited her ability to function
  • Had NSTEMI after her hip fracture
  • LVEF40 with RWMAs

66
Case 2
  • Postoperatively
  • Acute on chronic renal insufficiency
  • Delirium, which gradually cleared
  • Now
  • Lives alone with support from her family
  • Does most of her own ADLs, but not iADLs
  • Mild cognitive dysfunction
  • Urinary incontinence

67
Case 2
  • Exam
  • Heart rate 90, some PVCs
  • Lungs clear
  • Heart S3 gallop, no murmurs
  • No edema
  • Mild cognitive dysfunction

68
Case 2
  • Data
  • Hgb 13.6, MCV 100.1
  • K 5.0, creatinine 2.1
  • NT-proBNP 2926 (nllt263)
  • Dobutamine Stress Echo positive for myocardial
    ischemia, which occurred at a heart rate of 110

69
  • You are the medical consultant. What do you
    recommend?
  • Start beta blockers and titrate to heart rate
    55-65 before surgery
  • This is an elective procedure and should not be
    done because of the cardiac risk
  • Refer the patient for coronary angiography before
    surgery
  • Defer the decision until the patient has been
    seen by cardiology, nephrology and neurology

70
Weighing the risks and benefits
  • Benefits
  • Relieve pain
  • Improve function, which has been compromised due
    to pain
  • Maintain independence
  • Improve quality of life

71
Weighing the risks and benefits
  • Risks
  • Coronary artery disease with abnormal DSE
  • Renal insufficiency increases the risk of
    perioperative cardiac event
  • Renal insufficiency, with creatinine clearance of
    about 14 ml/min increases the risk of drug
    toxicity

72
Weighing the risks and benefits
  • Previous postoperative delirium and mild
    cognitive decline increase the risk of
    postoperative delirium
  • MCV of 100.1 raises the question of malnutrition,
    which is associated with increased perioperative
    mortality

73
Risks and Benefits
  • Benefits
  • Relieve pain
  • Improve function, which has been compromised due
    to pain
  • Maintain independence
  • Improve quality of life
  • Risks
  • Known CAD
  • Renal insufficiency
  • Cognitive dysfunction and delirium risk
  • Malnutrition
  • CHF?

74
Case 3
  • A 98 year old woman falls in her nursing home
    while ambulating with her walker.
  • Right humerus and right hip fracture

75
Case 3
  • Past history
  • CHF with 2/4 diastolic dysfunction
  • Severe aortic stenosis (not felt to be a surgical
    candidate)
  • Moderate dementia
  • Chronic renal insufficiency
  • Anemia (refused workup)
  • Atrial fibrillation, heart rate drops to 20-30
    with beta blocker

76
Case 3
  • Medications
  • Lisinopril
  • Lasix
  • Albuterol inhaler (no documented COPD)
  • Celexa

77
Case 3
  • ROS (per family)
  • No dyspnea
  • Ambulates with walker
  • No syncope

78
Case 3
  • Exam
  • P 61 irregular, BP 130/80
  • 3/6 late peaking systolic murmur
  • Lungs clear
  • No edema

79
Case 3
  • Labs
  • Hgb 9.2 gm/dL, MCV 106.7, WBC 11.6, Plt 213, INR
    1.0
  • Na 138, K 4.2, Cl 102, HCO3 28, BUN 35, Cr 1.7,
    Glucose 148
  • EKG Sinus rhythm, prolonged QT, LAFB, ST-T
    abnormalities

80
  • You are the medical consultant. What do you
    recommend?
  • The surgery is too high risk and the patient
    should be referred to hospice
  • She should be started on beta blockers prior to
    surgery
  • Her anemia should be corrected and she should be
    monitored in the ICU postoperatively
  • She should be evaluated by cardiology to see if
    her valve can be repaired prior to surgery

81
Weighing the Risks and Benefits
  • Benefits
  • She is having considerable pain and surgery would
    relieve that pain
  • She does not want to be non-ambulatory for a
    prolonged period of time
  • High mortality if hip fracture not repaired

82
Weighing the Risks and Benefits
  • Risks
  • Critical aortic stenosis, will not tolerate
    hypotension or atrial fibrillation
  • Cannot be given beta blockers
  • High risk of postoperative delirium
  • Surgery will carry a high mortality

83
Risks and benefits
  • Benefits
  • Pain relief
  • Ambulation
  • Mortality from un-repaired hip fracture
  • Risks
  • Critical aortic stenosis
  • Dementia- delirium risk
  • High surgical mortality

84
Principles of perioperative geriatric care
  • Functional assessment
  • Prevention of predictable disasters
  • Management of complexity
  • Seeking cumulative small gains in function
  • Aggressive rehabilitation

85
Principles of preoperative geriatric care
  • Interdisciplinary team care
  • Attention to social support status
  • Guarding autonomy in end-of-life decision making
  • Understanding the effects of dementia in the
    clinical setting

86
Decision-making
  • Pitfalls
  • Underestimate of predicted remaining lifespan
  • Failure to fully consider consequences of not
    doing the surgery

87
Decision-making
  • Goals of surgical therapy
  • Maintain quality of life
  • Improve or maintain functional status and
    independence
  • Relieve pain

88
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89
Some other issues
  • Elective vs emergency surgery
  • Emergency operations are a significant source of
    morbidity and mortality in older patients
  • Older patients require emergency operations more
    frequently than younger patients

90
Some other issues
  • Morbidity rates 30- 68 for emergency operations
    in older patients
  • General surgical procedures in patients over 90
    all deaths after emergency surgery

91
Some other issues
  • Many elderly patients present for emergency
    surgery for known conditions which could have
    been treated with elective surgery

92
In the end
  • Elderly patients often benefit from surgical
    therapy
  • Benefits include
  • Enhanced patient function and independence
  • Improved quality of life
  • Relief of pain and suffering

93
In the end
  • Elderly patients are at increased risk from
    surgical procedures
  • Age associated decline in organ system function
  • Alterations in pharmacokinetics
  • Decreased tolerance of stress
  • Increasing presence of comorbidities

94
In the end
  • Medical team caring for these patients is
    responsible for
  • Thorough preoperative assessment
  • Identification of risk factors
  • Optimization of medical conditions whenever
    possible

95
In the end
  • Postoperatively, the medical team must
  • Correct metabolic problems quickly
  • Monitor drugs to prevent adverse effects

96
In the end
  • Provide for adequate nutrition
  • Be aware of signs of infection
  • Encourage mobility and ambulation
  • Provide adequate psychosocial support for
    patients and families

97
In the end
  • Comprehensive, multidisciplinary approach is
    improving surgical outcomes and improving
    morbidity and mortality in elderly patients

98
Follow-up Case 1
  • 92 yo woman with dementia, heart disease, hip
    fracture
  • Well Ăź-blocked, no obvious heart failure
  • Seen by cardiology
  • Son (POA) gave informed consent, understood risks
    and benefits
  • Went to ICU postoperatively x 24 hours
  • No postoperative delirium
  • Returned to NH POD 6

99
Case 1
  • You are the medical consultant. What would you
    do?
  • Tell the patient and her family that the risk of
    surgery is too high, and recommend hospice
  • Send the patient to the ICU for invasive
    monitoring, and allow her to go to surgery
  • Get a cardiology consult and let them decide
  • Treat the UTI, start to correct the sodium, then
    send the patient to the OR when the Nagt 135

100
Follow-up Case 2
  • 89 yo woman with CAD, positive DSE
  • Low risk positive stress test
  • ?-blockers started, heart rate controlled in 60s
  • Underwent total hip replacement without problems,
    dismissed POD 5

101
Case 2
  • You are the medical consultant. What do you
    recommend?
  • Start beta blockers and titrate to heart rate
    55-65 before surgery
  • This is an elective procedure and should not be
    done because of the cardiac risk
  • Refer the patient for coronary angiography before
    surgery
  • Defer the decision until the patient has been
    seen by cardiology, nephrology and neurology

102
Follow-up Case 3
  • 98 year old woman, hip fracture, aortic stenosis,
    renal insufficiency, dementia
  • Seen by cardiology, no beta blocker, recommended
    keeping intravascular volume high
  • Patient, family agree to proceed despite risks
  • Surgery tolerated well, to ICU postoperatively
    for 24 hours

103
Case 3
  • You are the medical consultant. What do you
    recommend?
  • The surgery is too high risk and the patient
    should be seen by hospice
  • She should be started on beta blockers prior to
    surgery
  • Her anemia should be corrected and she should be
    monitored in the ICU postoperatively
  • She should be evaluated by cardiology to see if
    her valve can be repaired prior to surgery

104
  • We must be very careful not to protect our
    patients from perceived surgical risk and deny
    them the benefits of a carefully planned surgical
    procedure

105
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106
Case
  • 68 year old female scheduled for an elective open
    cholecystectomy tomorrow, AM surgery
  • Past history HTN, depression
  • Meds Lisinopril 40 mg po AM, Sertraline 50mg po
    q HS.

107
Case
  • Labs Creatinine 1.4, Na and K normal
  • ECG normal
  • Exam unremarkable, although she is very anxious
  • Vitals BP 165/98, P 72

108
  • You are the medical consultant. What do you
    recommend?
  • Cancel the surgery until her blood pressure is lt
    140/85
  • Start HCTZ, send to surgery tomorrow
  • Continue her current medication, send to surgery
    tomorrow
  • Start beta blockers, send to surgery tomorrow

109
Chronic hypertension
  • Is chronic hypertension really a risk factor for
    perioperative complication?
  • Is elevated BP prior to surgery a risk?
  • What evidence supports delaying elective surgery
    in the patient with poorly controlled
    hypertension?
  • How much BP control is needed and for how long
    preop?

110
Prys-Roberts et al. Studies of anaesthesia in
relation to hypertension. Br J Anaesth 1971
  • 34 patients elective anesthesia surgery
  • 15 normotensive
  • 19 hypertensive (treated and untreated)
  • Mean BP similar in both groups
  • Untreated had greater decrease in BP at induction
  • Untreated had more myocardial ischemia
  • No adverse events in either group
  • Implication Defer surgery to treat hypertension

111
Meta analysis of 30 studies No evidence that
preoperative hypertension directly affects
perioperative outcome
112
No perioperative risk Stage I BP (140-159 /
90-99) Stage II BP (160-179 / 100-109) Control
BP Preop Stage III BP (gt180 / gt110)
113
No perioperative risk Stage I BP (140-159 /
90-99 Stage II BP (160-179 / 100-109) Control
BP Preop Stage III BP (gt180 / gt110)
NO Supportive evidence
114
No discussion of perioperative hypertension
JNC VI 1997
115
JNC VII December 2003
116
JNC VII
117
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118
ACC / AHA 2007 Preoperative Evaluation Guideline
ACC / AHA 2007 Guideline
119
ACC / AHA 2007 Preoperative Evaluation Guideline
(ACC / AHA 2007 Guideline)
ACC / AHA 2007 Guideline
ACC / AHA 2007 Guideline
120
BP 165/98
  • You are the medical consultant. What do you
    recommend?
  • Cancel the surgery until her blood pressure is lt
    140/85
  • Start HCTZ, send to surgery tomorrow
  • Continue her current medication, send to surgery
    tomorrow
  • Start beta blockers, send to surgery tomorrow

121
Major issues of chronic hypertension
  • Too aggressive control of BP a problem
  • Increased perioperative hemodynamic lability
  • More comorbidities
  • CAD
  • CHF
  • CRF
  • Medication management
  • perioperative continuation of medications

122
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123
Case
  • A 65 year old man with known moderate hemophilia
    A presents with an infected right total knee
    arthroplasty
  • The surgical plan is for initial removal of the
    infected prosthesis, with placement of an
    antibiotic impregnated spacer, IV antibiotics,
    and ultimately placement of a new prosthesis

124
Case
  • The patient has required bilateral total knee
    arthroplasties, due to damage from multiple
    hemarthroses
  • He also has a history of type 2 DM, CAD and
    hypertension

125
Case
  • You are the medical consultant. The surgeon asks
    about perioperative management of his bleeding
    problems. What do you recommend?

126
  • Treatment should be based on his clinical course
  • He should receive Factor 8 concentrate to
    maintain his level at 100 perioperatively
  • He should receive both Factor 8 concentrate and
    LMWH perioperatively
  • He should receive Factor 8 concentrate to
    maintain his level at 75 and no DVT prophylaxis

127
Classification of Hemophilia
128
Antithrombotic Prophylaxis In Persons With
Hemophilia Undergoing Orthopedic Surgery
129
Prophylaxis Schedule For Indications Other Than
Cardiovascular Diseases In Elderly Persons With
Severe Hemophilia
Major surgery, especially orthopedic
Mancucci PM, Blood 2009
130
  • Treatment should be based on his clinical course
  • He should receive Factor 8 concentrate to
    maintain his level at 100 perioperatively
  • He should receive both Factor 8 concentrate
    (Level 100) and LMWH perioperatively
  • He should receive Factor 8 concentrate to
    maintain his level at 75 and no DVT prophylaxis

131
References- Stents
  • Shilling AM, Duriex ME. Pharmacologic Modulation
    of operative Risk in Patients Who Have Cardiac
    Disease. Anesthesiology Clin N Am 2006
    24365-379.
  • Newsome LT, Weller RS et al. Coronary Artery
    Stents II. Perioperative Considerations and
    Management. Anesth Analg 2008 107570-90.

132
References- Stents
  • Chassot PG, Delabays A, Spahn DR. Perioperative
    antiplatelet therapy the case for continuing
    therapy in patients at risk of myocardial
    infarction. Br J Anesth 200799 316-28.
  • Iakovou I et al. Incidence, predictors and
    outcomes after successful implantation of
    drug-eluting stents. JAMA 2005 293(17)2126-30.

133
References- Elderly Patients
  • Beliveau M, Multach M. Perioperative Care of the
    Elderly Patient. Med Clin No Am 2003 87 273-89.
  • Pofahl W, Pories W. Current Status and Future
    Directions of Geriatric General Surgery. J Am
    Geriatr Soc 2003 51 S351-S354.

134
References-Elderly Patients
  • Solomon D, Burton J, et al. The New Frontier
    Increasing Geriatrics Expertise in Surgical and
    Medical Specialities. J Am Geriatri Soc 2000 48
    702-704.
  • Cook DJ, Rooke GA. Priorities in Perioperative
    Geriatrics. Anesth Analg 2003 96 1823-36.

135
References- Hypertension
  • Comfere T, et al. Angiotensin System Inhibitors
    in a General Surgical Population. Anesth Analg
    2005 100636-44.

136
References- Hemophilia
  • Mannucci P, et al. How I treat age-related
    morbidities in elderly persons with hemophilia.
    Blood 2009 114(26) 5256-63.
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