PERIOPERATIVE MEDICINE & THE BARIATRIC PATIENT Angela T. Corea, MD, FHM Medical Director, St. Vincent Carmel Surgical Evaluation Center 10/18/2012

Objectives  

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Discuss benefits of a Surgical Evaluation Center Discuss what a preoperative assessment of a bariatric patient involves Discuss optimization strategies for patients with significant risk

Surgical Evaluation Center (SEC)  

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Team approach to the surgical patient Anesthesiologists-Hospitalists-Surgeons-Primary Care Physicians-Specialists Transition from outpt  OR  inpt  outpt Fewer same-day cancellations Less pressure on anesthesiologists and/or surgeons to proceed with a patient‟s surgery who may have medical concerns – patients are safer

SEC – Preoperative Logistics 

Surgeon-initiated consultation 

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after surgery decided, insurance approved, psych screen

Nursing education / practitioner visit H&P and labs/studies reviewed/airway assessed Patient follow up testing addressed within the SEC Medically optimized  surgeon decision to proceed Medical chart forwarded to the Surgery Department to stay with the patient – accessible by all Any OR instructions communicated to OR scheduler

SEC – Preoperative Assessment 

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Not your ordinary History and Physical – Perioperative Plan There is no doubt that weight loss is beneficial for patients‟ overall health, however the patient is choosing surgery  We

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are specifically going over the surgical risks

Long-term benefits >>>short-term surgical risks??? The very medical comorbidities that patients are attempting to improve are also the very concerns that put them at risk for surgery - OPTIMIZATION strategies - Patients CAN do it!

Preoperative Risk Assessment - Approach  

Detailed history of comorbidities DEVELOP A PLAN Medication Reconciliation – instructions given at visit   

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SurgHx: Detailed history of any surgical complications 

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Recent changes Supplements Steroids VTE, MI, respiratory, transfusions, diff intubation, infection, etc

Activity Level – ACC/AHA, ASA guidelines Physical Exam Airway assessment OSA Screening Discussion of Medical risks (Cardiac, DVT, Pulm, SSI, etc)

Preoperative Assessment – The Literature on Obesity and Surgery

Preoperative Assessment – The Literature on Obesity and Surgery Obesity-Related Comorbidities That Are Most Likely to Influence the Preoperative Cardiac Assessment and Management of Severely Obese Patients 1    

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Atherosclerotic cardiovascular disease Heart failure Systemic hypertension Pulmonary hypertension related to sleep apnea and obesity hypoventilation Cardiac arrhythmias Deep vein thrombosis History of pulmonary embolism Poor exercise capacity

Preoperative Assessment – The Literature on Obesity and Surgery1,5 OS-MRS5

Assign 1 point to each of 5 preoperative variables: -BMI >= 50 kg/m2, -male gender, -hypertension, -known risk factors for pulmonary embolism (previous thromboembolism, preoperative vena cava filter, hypoventilation, pulmonary hypertension, findings of venous stasis with skin changes/ulceration, etc), -age 45 years or more. 0 to 1: „A‟ lowest mortality risk group = 0.2%, 2 to 3: „B‟ intermediate mortality risk group = 1.1%, 4 to 5: „C‟ high mortality risk group = 2.4%.

Cardiac

Cardiac Risk

3 Assessment

Cardiac Risk Assessment

Cardiac Risks – ACC/AHA Guidelines Bariatric surgery is ELECTIVE – not emergent  Intraperitoneal – upper abdominal (?high risk)  Non-invasive testing would change mgmt  Deconditioning vs Cardiopulmonary Condition 

From: ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Title and subTitle BreakA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery

Cardiac Risk Assessment 

Discuss any known cardiac history in depth  Any

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prior cardiac testing

Assess for any active cardiac conditions  Acute

coronary disease  Decompensated heart failure  Valvular disease  Arrhythmias

Cardiac Risk Assessment 

Assess activity level and any symptoms  Deconditioning

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Determine risk predictors  IDDM,

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vs cardiopulmonary concern

CHF, cardiac ischemia, CKD, CVA

Can surgery be delayed if further workup needed? (yes)

Cardiac Risks – Revised Cardiac Risk Index3,6 High Risk Surgery H/O Ischemic Heart Disease H/O CHF H/O CVA / TIA Insulin-requiring Diabetes Renal Disease (Cr >2) POINTS

CLASS

RISK of EVENT (95%CI)

0

I

0.4% (0.1–0.8)

1

II

1.0% (0.5–1.4)

2

III

2.4% (1.3–3.5)

3+

IV

5.4% (2.8–7.9)

From: ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Title and subTitle BreakA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery

From: ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Title and subTitle BreakA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery

Cardiac Risk Assessment - PCI

From: ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Title and subTitle BreakA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery

Cardiac Risk Assessment - Meds 

Cardiac Medication Reconciliation   

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Assess control, any recent changes, and time of surgery BB – continue; consider adding in those at risk (POISE) ACE/ARB: consider holding morning of surgery Diuretics: Hold Statins18  

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Avoid abrupt cessation – adverse outcomes (ACS, stroke) Attenuation of vascular inflammatory response – consider starting in those at risk

ASA – verify dose; consider continuing 81mg in those at risk Coumadin/anticoagulation: bridge indicated? Plavix/antiplatelet Tx: assess risk of coming off Other anti-hypertensives: consider holding morning of surgery if controlled BP, early, etc. Hypotension factor

ASA Physical Status Classification System2,7  

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ASA Physical Status 1 - A normal healthy patient ASA Physical Status 2 - A patient with mild systemic disease ASA Physical Status 3 - A patient with severe systemic disease ASA Physical Status 4 - A patient with severe systemic disease that is a constant threat to life ASA Physical Status 5 - A moribund patient who is not expected to survive without the operation ASA Physical Status 6 - A declared brain-dead patient whose organs are being removed for donor purposes

ASA Classification and Mortality17 ASA class 1

Physical status Healthy, no disease outside surgical process

Risk

Risk status Little or no risk

3 hours), abdominal surgery, thoracic surgery, neurosurgery, head and neck surgery, vascular surgery, aortic aneurysm repair, emergency surgery, and general anesthesia. 3. A low serum albumin level (50, witnessed apnea, obvious daytime somnolence, chronic sedatives/narcotics) Ideally treated and use device nightly at least one week prior to surgery to decrease airway edema Avoid Opiate infusions, supine position, etc Bring device to hospital. Use prophy upon extubation? Balance pain control and opiate sedative effect

Pulmonary Risk- Assessment    

Identify and optimize any pulmonary disease History of prior postoperative respiratory issues Physical Exam Review/order data: 

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Screen for Obstructive Sleep Apnea 

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CBC, BMP, CXR, PFTs, O2 Saturation OSA has been associated with an increased rate of 30-day mortality, venous thromboembolism, need for reintervention and a longer length of hospital stay.13

Anesthesiologist assessment of airway Smoking cessation Consider preoperative tracheostomy/pulmonary consultation

DVT

DVT Risk Assessment     

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Surgery

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Inflammatory bowel disease Nephrotic syndrome Myeloproliferative disorders Paroxysmal nocturnal hemoglobinuria

 Trauma (major or lower extremity)  Immobility, paresis  Malignancy  Obesity Cancer therapy (hormonal, chemotherapy, or radiotherapy)  Smoking Previous VTE  Varicose veins Increasing age  Central venous catheterization Pregnancy and the postpartum period  Inherited or acquired thrombophilia Estrogen-containing oral contraception or hormone replacement therapy

Selective estrogen receptor modulators

Acute medical illness Heart or respiratory failure

William H. Geerts, et al. CHEST 2004; 126:338S–400S

DVT Risk 

Pre-op: minimize risks…        

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increase exercise, weight loss (as much as possible), leg elevation – avoid sitting or standing for prolonged periods, compression stockings, diuretics (only preop), limit sodium intake, tobacco cessation, discussion around HRT/BCPs

Post-op:   

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Early ambulation protocols, ted hose/SCDs, avoid IVs, catheters and other tethering items, BID dosing of LMWH in bariatric patients, Home with lovenox, education

Infection/Wound Risks

Infection and Wound Risk 

MRSA Screening – swab preop 

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History of SSI, poor wound healing 

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Discuss Risks vs Benefits w patient, Rheumatology MTX and biologic meds

Diabetes  

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Discuss Risks vs Benefits

RA and other inflammatory states 

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Insulin pump site

Recent steroid use/Immunosuppressive agents 

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Mupirocin/Bactroban, Hibiclens/Dynahex

Diagnose IFG or new diabetics To be discussed. A1C at least