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Perioperative Medicine[1]

Perioperative Medicine[1]

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Published by rmesquitajr
An excellent text talking about the newest perspectives in perioperative medicine for pacients undergoing non-cardiovascular surgeries.
An excellent text talking about the newest perspectives in perioperative medicine for pacients undergoing non-cardiovascular surgeries.

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Published by: rmesquitajr on Feb 28, 2010
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05/21/2012

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Perioperative Medicinefor the Hospitalized Patient
Paul J. Grant, MD*, David H. Wesorick, MD
University of Michigan Medical School, Division of General Medicine,Department of Internal Medicine, 3119 Taubman Center, Box 5376, 1500East Medical Center Drive, Ann Arbor, MI 48109-5376, USA
In many medical centers, hospitalists have become an important resourcefor providing inpatient preoperative evaluations. Given the increasing com-plexity of hospitalized patients and the increasing specialization among sur-geons, there is greater reliance on hospitalists for preoperative assessment.Several institutions have developed surgery/medicine comanagement teamsthat jointly care for patients in the perioperative setting. Despite a growingbody of evidence, it is important to recognize there are many gaps in theperioperative literature. This has led to considerable dependence on consen-sus statements and expert opinion when evaluating patients perioperatively.This review focuses on the preoperative cardiovascular and pulmonaryevaluation of the hospitalized patient: the two systems responsible for thegreatest morbidity and mortality. Prevention of postoperative venousthromboembolism and management of perioperative hyperglycemia willalso be discussed.
Clinical vignette
A 70-year-old female presents to the emergency department with a hipfracture after a fall. She has a history of chronic obstructive pulmonary dis-ease (COPD), hypertension, type 2 diabetes treated with insulin, and chronickidney disease with a baseline creatinine of 2.2 mg/dL. Her medicationsinclude aspirin, ramipril, hydrochlorothiazide, 70/30 insulin twice daily,and inhaled ipratropium. She has no complaints except those related toher hip, and denies all cardiopulmonary symptoms on a complete review
* Corresponding author.
E-mail address:
paulgran@umich.edu(P.J. Grant).0025-7125/08/$ - see front matter
Ó
2008 Elsevier Inc. All rights reserved.doi:10.1016/j.mcna.2007.10.003
Med Clin N Am 92 (2008) 325–348
 
of symptoms. Her functional capacity has been limited to ambulating withinher home but avoiding stairs. Her blood pressure is 134/86 and heart rate is82. The remainder of her physical exam is normal. Should the medicalconsultant recommend stress testing before surgery for this patient? Arethere any interventions that could be employed to reduce the patient’sperioperative cardiac or pulmonary risk?
Cardiovascular evaluation
In 2004, there were approximately 35 million noncardiac inpatient surgi-cal procedures performed in the United States[1]. To determine the risk of major perioperative cardiac events for noncardiac surgery, Devereaux andcolleagues[2]pooled results from prospective studies that assessed patientswho either had or were at risk for cardiac disease. They found that 3.9% of patients experienced a major cardiac event defined as cardiac death, nonfa-tal myocardial infarction, and nonfatal cardiac arrest. There are many rea-sons why the perioperative period poses an increased risk for cardiovascularcomplications. Operative stresses such as anesthesia, intubation/extubation,pain, fasting, stress steroid surges (eg, catecholamines and cortisol), bloodloss, thrombophilia, and hypothermia may all increase the risk for a perio-perative cardiovascular event[2].We recommend a step-wise approach to preoperative cardiac assessmentand risk reduction (Fig. 1). Although there are many areas of uncertaintywithin this approach, we feel that it represents a clinically useful synthesisof the available knowledge related to the subject.
Step 1. Determine if the patient has recently undergone a cardiacevaluation or revascularization procedure
Although limited to retrospective data, studies indicate that a previousrevascularization procedure such as coronary artery bypass grafting(CABG) or percutaneous transluminal coronary angioplasty (PTCA) offersa protective benefit with respect to future surgical risk[3–7]. This is bestdemonstrated in a retrospective analysis of 1600 patients in the CoronaryArtery Surgery Study (CASS) registry[3]. The operative mortality for pa-tients without significant coronary artery disease (CAD) undergoingnoncardiac surgery (0.5%) was not significantly different from those withCAD having had CABG before surgery (0.9%). However, in patients withconsiderable CAD without prior CABG, the operative mortality was signif-icantly higher (2.4%). Extrapolating from these data, the American Collegeof Cardiology/American Heart Association (ACC/AHA) guidelines onperioperative cardiovascular evaluation for noncardiac surgery suggestthat coronary revascularization within 5 years, and a stable clinical statuswithout signs or symptoms of ischemia, precludes the need for any further
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GRANT & WESORICK
 
cardiac testing[8]. These guidelines also state that patients who have under-gone a coronary evaluation with favorable results within the past 2 years(such as a cardiac stress test or diagnostic cardiac catheterization) do not
Step 3. Determine the patient’s functional capacity.
Anassessment of functional capacity provides a context in which to viewany reported symptoms.Extremes of functional capacity (eg. very good or very poor) may influencedecision-making.
Step 2. Assess for any signs or symptoms of active cardiac disease.
Undiagnosed or unstable cardiac signs or symptoms require additionalevaluation and/or risk stratification before surgery.
Step 4. Estimate cardiac risk using an objective measure.
The Revised Cardiac Risk Index provides an objective measure of perioperative cardiovascular risk that can aid in decision-making (seetables 1and 2).
Step 5. Determine the urgency of the surgery.
Emergent surgery should not be delayed to allow for preoperativeassessment.In urgent surgery, the main objective is to identify unstable cardiacconditions which may require urgent treatment. Noninvasive testing israrely indicated prior to urgent surgery.
Step 6. Determine if additional testing is needed.
We usually reserve preoperative noninvasive stress testing for thefollowing situations:patients with signs or symptoms of undiagnosed or unstable cardiacdisease, orpatients with 3 or more of the RCRI undergoing intermediate- orhigh-risk surgery (see table 2).
Step 7. Incorporate appropriate risk reduction strategies.
Coronary revascularization is only rarely indicated in the preoperativesettingWe recommend prophylactic perioperative beta-blockers for patients whoare undergoing intermediate- or high-risk surgery with 2 or more of theRCRI predictors (see tables 1 and 2).
Step 1. Determine if the patient has recently undergone a cardiacevaluation or revascularization procedure.
Revascularization in the last 5 years usually precludes stress testing unlessthe patient presents with new signs or symptoms.Favorable results of non-invasive testing in the last 2 years usually makeadditional testing unnecessary.
Fig. 1. A stepwise approach to perioperative cardiovascular assessment and risk reduction.327
PERIOPERATIVE MEDICINE

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