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236 SECTION III Pulmonary and Critical Care Medicine
TABLE 21.1 Specific Educational Goals by Age—cont’d
Milestones 6-9 Years Old 10-12 Years Old 13-15 Years Old 16-18 Years Old 18-25 Years Old
Exercise Participates in sports,
exercise, or other health
activities
Self-advocacy Can answer very basic
questions about CF from
family, friends, and
teachers
Support system Understands the
importance of a support
system of peers with CF
Maintains an exercise
routine/participates in
sports of other healthy
activities
Has a short statement to
answer basic questions
about CF
Understands the
importance of a support
system and starts to
develop a group of
peers with CF
Maintains an exercise
routine/participates in
sports or other healthy
activities
More comfortable inde-
pendently answering
common questions from
peers/others about CF
Understands the impor-
tance of and starts
to develop a support
system of peers with CF
Works with care team
to develop an exercise
routine
Able to answer questions
from peers/others
about CF
Understands the impor-
tance of and utilizes a
support system of peers
with CF
Able to answer questions
from peers/others
about CF
Understands the impor-
tance of and utilizes a
support system of peers
with CF
life and have a normal lifespan. The rate of lung function decline is
much slower than that with CF. Similar to CF, individuals with PCD
benefit from implementation of a preventative airway clearance regimen to mobilize retained pulmonary secretions. Retained pulmonary
secretions can be corrosive leading to chronic inflammation, recurrent
infections, and bronchiectasis.
Bronchiectasis is a structural abnormality characterized by abnormal dilatation and distortion of the bronchial tree with resultant
chronic obstructive lung disease. A range of pathophysiologic and
disease processes other than CF contribute to bronchiectasis, and
most include some combination of bronchial obstruction and infection. Bronchiectasis is frequently associated with atelectasis, emphysema, pulmonary fibrosis, and bronchial vasculature hypertrophy.
Improving airway clearance and preventing further airway damage
are the cornerstones of therapy. Prognosis and outcome in non-CF
related bronchiectasis depends primarily on the underlying etiology.
Prediction of outcomes is limited, but with early diagnosis and appropriate therapies, including a preventative airway clearance regimen,
lung function in children can stabilize or improve over time. Non-CF
related bronchiectasis typically progresses much more slowly than
CF-related bronchiectasis and often improves if an airway clearance
regimen is implemented to minimize retained pulmonary secretions.
Consensus guidelines for transitioning individuals with PCD or
non-CF related bronchiectasis from pediatric to adult providers have not
been established to date. Both benefit from continued implementation of a
preventative airway clearance regimen to mobilize pulmonary secretions.
ASTHMA AND BRONCHOPULMONARY DYSPLASIA
Asthma and bronchopulmonary dysplasia (BPD) are two of the most
common chronic lung diseases in pediatrics. While adult health care
providers will likely have experience and be comfortable managing
asthma, BPD is a disease that few will be familiar with. BPD results
from premature birth with an incidence of 10,000 to 15,000 new cases
annually in the United States.
In premature infants, the type II pneumocytes of the lung are
underdeveloped and produce insufficient quantities of surfactant, a
surface-active substance produced by specific alveolar epithelial cells
that helps to decrease surface tension and prevent alveolar collapse.
This disorder is called respiratory distress syndrome (RDS). The treatment of RDS is administration of exogenous surfactant and corticosteroids to enhance lung maturation. To sustain life while allowing
maturation, mechanical ventilation and oxygen supplementation are
required but contribute to the development of BPD.
BPD is defined as the need for 30% or greater oxygen and/or positive pressure at 36 weeks postgestational age (PGA) or discharge, in
infants born before 32 weeks gestational age. The neonatal and pediatric provider is likely to be more familiar with the immediate sequela
and morbidity associated with BPD than adult health care providers
who may inherit an individual years after symptoms have become
silent. Birth history is often overlooked by both pediatric and adult
health care providers but may provide health information relevant well
into adulthood. BPD is often clinically silent by age four, but there is
increasing evidence that abnormal spirometry can be detected in early
childhood and significantly contributes to adult diseases including
chronic obstructive pulmonary disease (COPD) and asthma.
Recent studies challenge the traditional teaching that lung function continuously improves from birth until the third decade of life.
Evidence suggests childhood illnesses such as BPD and asthma can
contribute to lower-than-expected lung function. Given this lower-than-expected lung function, pathology such as COPD is more
likely to occur earlier in life and potentially have a more severe course.
It is essential for pediatric providers to begin early with age-appropriate conversations on the management of asthma in preparation for
transfer and transition of health care in adolescence and young adulthood. A minority of patients with moderate to severe childhood asthma
will experience remission as they enter adulthood. The majority of individuals will have persistent symptoms. There is an association between
severe asthma in childhood with decreased peak lung function and
a more rapid decline of lung function compared to children without
asthma that ultimately leads to COPD later in life. Pediatric and adult
providers should be aware of these long-term outcomes, appropriately
monitor lung function, and manage symptoms accordingly to try and
prevent long-term lung remodeling leading to persistent disease.
DIFFUSE LUNG DISEASE (INTERSTITIAL LUNG
DISEASE)
Diffuse lung disease (DLD) consists of a diverse group of disorders that
impact the pulmonary parenchyma and interfere with gas exchange
reflecting a spectrum of underlying pathology. These disorders are associated with extensive alteration of alveolar and airway architecture in
addition to interstitial changes, therefore the term DLD is now preferred
to ILD. Childhood interstitial lung disease (chILD) is still a term utilized
when DLD is suspected based on clinical and radiologic features without
an established etiology. Some conditions that cause DLD are similar in
children and adults, they occur in different proportions, and certain diseases are unique to infants. All diseases are rare in childhood.
CHAPTER 21 Transitions in Care From Pediatric to Adult Providers for Individuals With Pulmonary Disease
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237
For many forms of DLD, treatment options are limited and often
include medications with unproven efficacy and substantial side effects.
Lung transplantation is an option for children with severe and progressive disease without a response to therapy. Consensus guidelines for
transitioning individuals with DLD from pediatric to adult providers
have not been established to date. Given the spectrum of underlying
pathology and possible post–lung transplant status, individuals with
DLD benefit from a focused transition of care.
INDIVIDUALS WITH TECHNOLOGY DEPENDENCE
OR OTHER SPECIAL HEALTH CARE NEEDS
Children and youth with special health care needs (CYSHN) is
defined as those who have one or more chronic physical, developmental, behavioral, or emotional condition requiring additional
health and related services beyond that of children generally.
Approximately 750,000 CYSHN transition into adulthood annually.
While these individuals make up a small fraction of the pediatric
patient population, they utilize the largest fraction of health care
resources. Individuals with technology dependence include those
who have tracheostomy dependence requiring part- or full-time
mechanical ventilatory support.
Home oxygen therapy is often required in children with chronic
respiratory conditions including CF, BPD, sleep-disordered breathing,
sickle cell disease, pulmonary hypertension with and without congenital heart disease, and DLD. Despite a lack of empirical evidence regarding implementation, monitoring, and discontinuation of supplemental
oxygen therapy, an expert panel through the American Thoracic
Society published clinical practice guidelines in 2018. Optimal implementation includes age-appropriate oxygen equipment to maintain
acceptable oxygen saturations according to age and respiratory condition and pulse oximetry.
Important steps to optimal transfer and transition include updating insurance status to reflect the coordination of special services with
durable medical equipment companies and qualifying patients for certain state or national services. Adult providers frequently have a more
patient-centered than family-centered approach to care than pediatric counterparts. Adolescence and young adulthood is often a time
of educational transition with variation in access and medical support provided for children and youth with special health care needs.
Lack of disease-specific education and few evidence-based guidelines
may contribute to adult pulmonologists’ limited expertise caring for
an individual with technology dependence. General pediatric recommendations for improving transition include the preparation of
a transition plan written in early adolescence starting at age 14. This
plan includes individual patient and family perspectives, anticipated
health care services the individual will need, and a financial plan.
It should include preventative as well as disease-specific therapies
and insurance coverage strategies for the transition period to decrease
gaps of care.
IMPORTANCE OF A SUCCESSFUL TRANSITION
Data from 10 years ago suggested that more than 500,000 adolescents
with special health care needs in the United States reach adulthood
annually. As life expectancy for individuals with chronic lung disease,
technology dependence or other special health care needs has increased,
so has the need for a guided, structured transfer and transition of care
and transition from pediatric to adult-focused care. The transition of
individuals from pediatric to adult care should begin years before the
actual transfer. The transition process should include individual- and
family-specific education, patient understanding of disease including
TABLE 21.2 Multilevel Suggestions for
Transition of Health Care
Patient level Begin discussions of transition early in life
Develop a road map in preparation for transition
readiness, disease knowledge, and skills
assessment to share with patients and families
Create a personalized medical summary to ensure
seamless continuity of care, especially where an
electronic medical record is not shared by
pediatric and adult programs
CF team level Create an open and transparent dialogue between
the pediatric and adult CF programs
Develop a working transitional care policy at all
levels of the multidisciplinary team (include input
from patients and parents)
Create a registry of eligible patients and a plan to
discuss them periodically
Identify outcome measures to monitor progress and
success, including establishment of best practices
and communication among pediatric and adult
care teams
Institutional level Seek institutional leadership buy-in
Collaborate with other hospital programs focused
on transition
Invest in EMR systems with patient access to personal
health records and built-in transition tools
rationale for therapies and overall prognosis, as well as a patient readiness assessment indicating if the patient can independently manage
therapies and navigate the health care system.
The goals of a planned transition are to improve quality of life, maximize independence, and minimize interruption in care as a patient
transfers from pediatric to adult primary and subspecialty care. A designated transition coordinator or champion allows for streamlined
communication between health care providers and helps to ensure
individual access to medications, interventions, and medical devices
through to establishment of care with the adult provider. Although no
single process for transition will work in all health care systems, it is
essential that an approach that best meets the needs of patient populations and fits within the health care system constraints be established
(Table 21.2).
Transition of health care is a complex process involving multiple
factors for which a multidisciplinary care team will provide the best
chance for success for the individual patient and family (Table 21.3).
Effective transition of care can prevent the deterioration of chronic
health conditions while engaging the adolescent to become involved
and take over their own care. Poor transition of care has been associated with missed health care visits, loss to follow-up, poor compliance with medications, and increased morbidities. All of these lead to
increased emergency care utilization and worse outcomes. Research
has identified obstacles that can make transition challenging, including
the limited number of capable providers for adults, lack of individual
readiness, cognitive disability, instability of mental health (anxiety/
depression), and communication issues between pediatric and adult
providers.
CF is an example of a chronic pulmonary disease in which much
effort has been placed into implementing models to optimize the
process of transition. The CF Foundation supported the training of additional providers and developed Adult Care Consensus
Guidelines to provide goals and help standardize care. Research and
238 SECTION III Pulmonary and Critical Care Medicine
TABLE 21.3 Multidisciplinary Care Team
for Transition of Health Care
Multidisciplinary Care
Team
Physician/nurse practitioner Supervising overall transfer and
Registered nurse/care coordinator Supporting communication of trans-
Registered dietician Nutrition and supplementation
Clinic facilitator Scheduling transfer; meet-and-greet
Pharmacist Medication knowledge
Behavioral psychologist Mental/emotional strengths and any
Clinical social worker Psychosocial strengths and any
Respiratory therapist Airway clearance knowledge
Physical therapist Physical activity knowledge as
Child life specialist Age-appropriate disease educa-
Focus for Transition
Assessment
transition process
fer and transition process
knowledge, food insecurity risk
adult team; supplying documents
barriers to transition
barriers to transition
relates to airway clearance
tion and tools for medication
adherence
quality improvement projects have identified areas that can make
transition a success:
• Maketransitiontoadultcareagradualprocess.
• Rememberthatparentsandcaregiversalsoaregoingthrougha
transition.
• Pediatricandadultcareteamsshouldworktogethertoimprove
transition.
Developing a transition program is critically important and does
not develop without committed individuals and institutions. Finally,
there needs to be pediatric and young adult focused research to better establish guidelines for care that are applicable to this special
population.
SUGGESTED READINGS
American Academy of Pediatrics Transition ECHO: https://www.aap.org/en-us/
professional-resources/practice-transformation/echo/Pages/Transition.
aspx.
CF R.I.S.E. Program materials: https://www.cfrise.com/.
A Consensus Statement on Health Care Transitions for Young Adults With
Special Health Care Needs, Pediatrics 110(Suppl 3), 2002.
https://www.aap.org/en-us/Documents/practicesupport_preparing_
adolescents_independent_living_webinar.pdf.
The Transition Readiness Assessment Questionnaire (TRAQ):
www.rheumatology.org/Portals/0/Files/Transition-Readiness-Assessment-
Questionnaire.pdf.
Preoperative and
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Postoperative Care
22 Preoperative and Postoperative Care, 240
SECTION IV
239
239
22
Preoperative and Postoperative Care
Kim A. Eagle, Kwame Dapaah-Afriyie, Arkadiy Finn
INTRODUCTION
More than 40 million people undergo noncardiac surgical procedures in the United States annually. A general medical and focused
cardiovascular preoperative risk assessment involves evaluation
of pertinent medical problems with an emphasis on those conditions that may become exacerbated in the perioperative period.
Emerging evidence-based practices dictate that the physician
should thoughtfully perform an individualized evaluation of the
surgical patient to provide an accurate preoperative risk assessment, risk stratification, and modification of risk parameters that
can then provide the framework for optimal perioperative risk
reduction strategies.
The perioperative period is associated with hemodynamic changes
due to surge in sympathetic activity, fluid shifts and their associated
effect on the renin-angiotensin system (RAS), and effect of exposure
to anesthetic agents.
Assessment of patients’ functional status, exercise tolerance, and
other preexisting comorbidities are core components of perioperative management. Patients younger than 50 years of age and having
no significant medical comorbidities are at very low risk for developing perioperative complications. The increasing prevalence of
medical conditions in the surgical patient warrants review of the
perioperative approach to those conditions that may pose significant
risk. This chapter reviews preoperative and postoperative cardiovascular and medical risk assessment that targets intermediate- to highrisk patients to strategically guide perioperative preventive therapies
for optimal outcome.
CARDIAC DISEASE
Preoperative and Postoperative Cardiac Care
It is estimated that the incidence of cardiac complications after
noncardiac surgical procedures is between 0.5% and 1%. In other
words, 200,000 to 400,000 people will experience perioperative cardiac complications annually. Moreover, more than 25% of these
patients will die. Patients who survive a postoperative myocardial
infarction (MI) are twice as likely to die in the following 2 years
as are patients with uneventful surgical procedures. Emerging evidence-based practices dictate that the physician should thoughtfully perform an individualized evaluation of the surgical patient
to provide an accurate preoperative risk assessment, risk stratification, and modification of risk parameters that can then provide
the framework for optimal perioperative risk reduction strategies.
This section reviews preoperative and postoperative cardiovascular
risk assessment that targets intermediate- to high-risk patients to
strategically guide perioperative preventive therapies for optimal
outcome.
IDENTIFICATION OF PATIENTS WITH ELEVATED
RISK
The preoperative evaluation includes an assessment of the risk associated with the planned surgery or procedure. Low-risk procedures (e.g.,
colonoscopy, cataract surgery) are associated with a less than 1% risk
of major adverse cardiovascular events (MACE) of death or MI. Those
procedures with a MACE risk of 1% or greater are classified as conferring higher risk. Simple standardized preoperative screening questionnaires have been developed for the purpose of identifying patients at
intermediate to high risk who may benefit from a more detailed clinical
evaluation (Table 22.1).
TABLE 22.1 Standardized Preoperative
Questionnaire
1. Age, weight, and height
2. Are you
a. Female and 55 years of age or older or male and 45 years of age or older?
b. If yes, are you also 70 years of age or older?
3. Do you take anticoagulant medications (“blood thinners”)?
4. Do you have or have you had any of the following heart-related condi-
tions?
a. Heart disease
b. Heart attack within the last 6 months
c. Angina (chest pain)
d. Irregular heartbeat
e. Heart failure
5. Do you have or have you ever had any of the following?
a. Rheumatoid arthritis
b. Kidney disease
c. Liver disease
d. Diabetes
6. Do you get short of breath when you lie flat?
7. Are you currently on oxygen treatment?
8. Do you have a chronic cough that produces any discharge or fluid?
9. Do you have lung problems or diseases?
10. Have you or any blood member of your family ever had a problem with
any anesthesia other than nausea?
a. If yes, describe
11. If female, is it possible that you could be pregnant?
a. Perform pregnancy test
b. Please list date of last menstrual period
a
University of Michigan Health System patient information report.
Patients who answer yes to any of questions 2 through 9 should receive
a more detailed clinical evaluation.
From Tremper KK, Benedict P: Paper “preoperative computer,” Anesthesiology 92:1212-1213, 2000.
a
240
CHAPTER 22 Preoperative and Postoperative Care
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241
Evaluation of such surgical patients should always begin with a
thorough history and physical examination including a 12-lead resting
electrocardiogram (ECG) in accordance with the American College
of Cardiology/American Heart American (ACC/AHA) guidelines.
A determination of the urgency of the surgery should be included
in the history because truly emergent procedures are associated with
unavoidably higher rates of morbidity and mortality.
Perioperative risk assessment begins with an assessment of the
urgency of the noncardiac surgery; emergency surgery should not be
delayed but may not allow for in-depth risk stratification. Preoperative
testing should be done only for specific clinical conditions based on
the history. Healthy patients of any age who are undergoing elective
surgical procedures and have no coexisting medical conditions should
not need any testing unless the degree of surgical stress could result in
unusual changes from the baseline state. The history should focus on
symptoms of occult cardiac disease.
PREOPERATIVE CARDIAC RISK ASSESSMENT
During the perioperative risk assessment of patients undergoing
noncardiac surgery, there are active cardiac conditions that should be
evaluated and treated in accordance with the ACC/AHA guidelines.
These conditions include unstable coronary artery disease (CAD),
decompensated heart failure, severe arrhythmia, and severe valvular disease (notably severe aortic stenosis and symptomatic mitral
stenosis).
Assessment of exercise tolerance in preoperative risk stratification
and precise prediction of in-hospital perioperative risk is most applicable in patients who self-report worsening exercise-induced cardiopulmonary symptoms, patients who may benefit from noninvasive or
invasive cardiac testing regardless of the scheduled surgical procedure,
and patients with known CAD or with multiple risk factors and the
ability to exercise. For the prediction of perioperative events, “poor”
exercise tolerance has been defined as inability to walk four blocks and
climb two flights of stairs or as inability to meet a metabolic equivalent
(MET) level of 4 (Table 22.2). Highly functional symptomatic patients
(i.e., those who are able to achieve a functional capacity ≥4 METS
TABLE 22.2 Functional Status
Excellent (Activities Requiring >7 METS)
Carry 24 lb up eight steps
Carry objects that weigh 80 lb
Outdoor work (shovel snow, spade soil)
Recreation (ski, basketball, squash, handball, jog or walk 5 mph)
Moderate (Activities Requiring >4 but <7 METS)
Have sexual intercourse without stopping
Walk at 4 mph on level ground
Outdoor work (garden, rake, weed)
Recreation (roller-skate, dance, foxtrot)
Poor (Activities Requiring <4 METS)
Shower/dress without stopping, strip and make bed, dust, wash dishes
Walk at 2.5 mph on level ground
Outdoor work (clean windows)
Recreation (golf, bowl)
MET, Metabolic equivalent.
Modified from Hlatky MA, Boineau RE, Higginbotham MB, et al: A
brief self-administered questionnaire to determine functional capacity
(the Duke Activity Status Index), Am J Cardiol 64:651-654, 1989.
without symptoms, as when climbing a flight of stairs or running a
short distance) rarely require noninvasive testing or intervention to
lower the risk of noncardiac surgery.
If the patient has poor functional capacity or is symptomatic,
physicians often use risk indices derived from empirical multivariable predictive models based on clinical assessment of risk factors
to identify patients with elevated perioperative cardiac risk. Based
on prospective comparison studies, the Revised Cardiac Risk
Index (RCRI) is favored by many given its accuracy and simplicity
(Table 22.3). A newer predictive model is the National Surgical
Quality Improvement Program (NSQIP) risk calculator, which
is based on multiple clinical predictors. The RCRI relies on the
presence or absence of six identifiable predictive factors: high-risk
surgery (suprainguinal vascular, intrathoracic, or intraperitoneal
surgery), ischemic heart disease, congestive heart failure (CHF),
cerebrovascular disease, diabetes mellitus (requiring insulin therapy), and renal failure (with a serum creatinine concentration >2.0
mg/dL). Each of the RCRI clinical predictors, if present, is assigned
1 point. The risk for cardiac events (i.e., MI, pulmonary edema, ventricular fibrillation or primary cardiac arrest, and complete heart
block) can then be predicted. A patient with an RCRI score of 0
has an estimated risk of 0.4% to 0.5% for major cardiac complications; the risk is 0.9% to 1.3% for someone with a score of 1, 4% to
6.6% with a score of 2, and 9% to 11% with a score of 3 (Fig. 22.1).
Cardiac risk particularly increases with the presence of two or more
predictors and is greatest with three or more. The clinical utility of
the RCRI is that it identifies patients who are at higher risk for cardiac complications and helps determine whether they may benefit
from further risk stratification with noninvasive cardiac testing or
from initiation of preoperative preventive medical management.
TABLE 22.3 Revised Cardiac Risk Index:
Clinical Markers
1. High-risk surgical procedures
2. Ischemic heart disease
a. History of myocardial infarction
b. Current angina considered to be ischemic
c. Requirement for sublingual nitroglycerin
d. Positive exercise test
e. Pathologic Q waves on ECG
f. History of PTCA and/or CABG with current angina considered to be ischemic
3. Congestive heart failure
a. Left ventricular failure by physical examination
b. History of paroxysmal nocturnal dyspnea
c. History of pulmonary edema
d. S3 gallop on cardiac auscultation
e. Bilateral rales on pulmonary auscultation
f. Pulmonary edema on chest radiography
4. Cerebrovascular disease
a. History of transient ischemic attack
b. History of cerebrovascular accident
5. Diabetes mellitus
a. Treatment with insulin
6. Chronic renal insufficiency
a. Serum creatinine concentration >2 mg/dL
CABG, Coronary artery bypass grafting; ECG, electrocardiogram; PTCA,
percutaneous transluminal coronary angioplasty.
Modified from Lee TH, Marcantonio ER, Mangione CM, et al: Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery, Circulation 100:1043-1049, 1999.
242 SECTION IV Preoperative and Postoperative Care
Risk stratification
15%
10%
Cardiac risk
5%
0%
4–6.6
0.4–0.5
012 ≥3
Low risk
0.9–1.3
Intermediate risk
9–11
High risk
risk for adverse outcomes based on the presence of unstable angina,
angina refractory to medical treatment, high-risk results on noninvasive testing, or a nondiagnostic test in a high-risk patient undergoing
high-risk noncardiac surgery. It should be considered on an individual
basis for those with extensive ischemia revealed during noninvasive
testing, for those at intermediate risk undergoing high-risk surgery
for whom test results are nondiagnostic, for those convalescing from
MI who require urgent noncardiac surgery, and for those with perioperative MI. In patients who have a high clinical risk (RCRI >3) and
high-risk features on noninvasive cardiac testing, diagnostic cardiac
catheterization should be considered (see Fig. 22.1).
Fig. 22.1 Bar graph shows the predicted risk for cardiac events during
surgery according to a patient’s Revised Cardiac Risk Index score.
Preoperative Noninvasive Cardiac Testing for Risk
Stratification
Evidence discourages widespread application of preoperative noninvasive cardiac testing for all patients. Rather, a selective approach based
on clinical risk categorization appears to be both effective and cost-effective. No testing is recommended if it might delay surgical intervention for urgent or emergent conditions.
On a rare occasion, coronary revascularization offers the potential
benefit of improving outcomes in high-risk patients—that is, patients
with acute coronary syndromes, those with left main CAD, those with
two-vessel coronary disease who have significant proximal left anterior descending artery stenosis (and either ischemia on noninvasive
testing or reduced left ventricular ejection fraction), and those with
three-vessel coronary vessel disease and an ejection fraction of less than
50%. Routine prophylactic coronary revascularization should not be
performed in patients with stable CAD before noncardiac surgery. An
RCRI score of 3 or higher in a patient with severe myocardial ischemia
suggestive of left main or three-vessel disease should lead to consideration of coronary revascularization before noncardiac surgery in
appropriate patients.
Noninvasive cardiac testing is most appropriate if it is anticipated
that the patient will meet guidelines for initiation of additional medical therapy or coronary angiography and coronary revascularization in
the event of a positive test. Noninvasive stress testing of patients with
three or more clinical risk factors and poor functional capacity (<4
METS) who require vascular surgery is reasonable, provided that the
result might change future management. When feasible, exercise stress
testing is the modality of choice and offers the benefit of an objective
assessment of functional capacity. Pharmacologic stress tests may
be performed instead of exercise tests; they are typically reserved for
patients with functional limitations.
Dobutamine echocardiography and nuclear perfusion testing for
purposes of identifying patients at risk for perioperative MI or death
have excellent negative predictive values (near 100%) but poor positive
predictive values (<20%). Therefore, a negative study is reassuring, but
a positive study is still only a weak predictor of a “hard” perioperative cardiac event. Which higher-risk patients are most likely to benefit
from preoperative noninvasive cardiac testing and treatment strategies
to improve outcomes is not well defined.
Preoperative Invasive Cardiac Testing for Risk
Stratification
Recommendations for perioperative coronary angiography are similar to those for patients with suspected or known CAD in general and
should conform to the ACC/AHA guidelines for coronary angiography. This procedure should be considered for patients who are at high
PREOPERATIVE RISK MODIFICATION TO REDUCE
PERIOPERATIVE CARDIAC RISK
Coronary Revascularization
Retrospective analyses of the Coronary Artery Surgery Study (CASS)
registry and the Bypass Angioplasty Revascularization Investigation
(BARI), along with prospective study of patients enrolled in the
Coronary Artery Revascularization Prophylaxis (CARP) trial, have
shown that prophylactic coronary revascularization with either coronary
artery bypass grafting (CABG) or percutaneous coronary intervention
(PCI) provides no short-term or mid-term benefit for patients without
left main disease or multivessel CAD in the presence of poor left ventricular systolic function. Evidence is lacking to support elective coronary
revascularization as a primary strategy for perioperative risk reduction in
intermediate-risk patients undergoing major noncardiac surgery.
Recommendations for PCI are similar to those for patients with
suspected or known CAD and should conform to the ACC/AHA guidelines. Recommendations by the AHA/ACC Society for Cardiovascular
Angiography and Intervention, the American College of Surgeons, and
the American Dental Association Science Advisory Committee are for
a 30- to 45-day delay of surgery in patients taking thienopyridine dual
antiplatelet therapy after bare-metal coronary stent placement and
a 365-day wait after placement of a drug-eluting stent. Some studies
indicate that the duration of dual antiplatelet therapy may be shortened to less than 1 year in selected patients receiving newer-generation
stents (such as everolimus- or zotarolimus-eluting stents).
Currently, studies suggest that optimal medical therapy is the preferred strategy for intermediate- to high-risk patients with RCRI scores
of 2 or higher who are without documented severe myocardial ischemia. As stated previously, the CARP trial demonstrated that preoperative coronary revascularization strategies to reduce perioperative
cardiovascular risk did not offer significant benefit compared with
excellent medical treatment in intermediate- to high-risk patients
undergoing vascular surgery. However, high-risk patients with left
main coronary stenosis, severe aortic stenosis, left ventricular ejection
fraction of 20% or less, or unstable coronary symptoms were excluded
from that trial. In many of these patients, coronary or valve surgery
may be indicated on its own merit, without factoring in the noncardiac
surgery. Therefore, coronary revascularization may be appropriate if
diagnostic catheterization reveals left main disease or multivessel disease and depressed ejection fraction.
Using the information obtained from the composite algorithm
(Fig. 22.2), a key decision is whether the risk for perioperative cardiac
events is sufficiently low to proceed with surgery. For patients identified to be at high cardiac risk who are not candidates for coronary
revascularization, the physician may decide to perform an operation
that is thought to be less stressful such as a less extensive major plastic reconstruction, laparoscopic versus open procedures or alternative
palliative procedures, or attempt to modify cardiac risk by additional
intraoperative and perioperative therapies.
CHAPTER 22 Preoperative and Postoperative Care
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243
1
2
3
4
5
NEED FOR SURGERY
Urgent Elective
CORONARY
REVASCULARIZATION
WITHIN 5 YEARS
If no, or recurrent
symptoms
RECENT CORONARY
EVALUATION
No
CLINICAL ASSESSMENT
• Age >70, <4 METs
• Signs of CHF, AS
• ECG changes —
ischemic or infarct
Yes
REVISED CARDIAC RISK
INDEX STRATIFICATION
Emergent
If yes, and no
recurrent
symptoms
Favorable findings
Yes
• Adequate test
• Adequately
reviewed
Only continue treatment
No
in patients requiring long-
term preventive medical
therapy
SURGERY
SURGERY
SURGERY
SURGERY
RCRI = 0
ONLY CONTINUE TREATMENT
6
IN PATIENTS REQUIRING
LONG-TERM PREVENTIVE
MEDICAL THERAPY
SURGERY
Fig. 22.2 Stepwise clinical evaluation algorithm for diagnostic cardiac catheterization. (1) Emergency sur-
gery; (2) prior coronary revascularization; (3) prior coronary evaluation; (4) clinical assessment; (5) Revised
Cardiac Risk Index; (6) risk modification strategies. Preventive medical therapy includes β-blocker and statin
therapy. ACC, American College of Cardiology; AHA, American Heart Association; AS, aortic stenosis; CHF,
congestive heart failure; ECG, electrocardiogram; MET, metabolic equivalent; RCRI, Revised Cardiac Risk
Index.
RCRI = 1–2 RCRI ≥3
IDENTIFY AND INITIATE
OR CONTINUE
TREATMENT IN PATIENTS
REQUIRING PREVENTIVE
TERM MEDICAL
PREVENTIVE THERAPY
Poor functional
capacity, history
of angina
SURGERY
β-Adrenergic Antagonists
There is uncertainty about the effectiveness and safety of perioperative
β-blockade in patients undergoing noncardiac surgery. The ACC/AHA
guidelines focusing on recommendations for perioperative β-blocker
therapy limit class I recommendations to patients undergoing surgery
who are already receiving β-blockers to treat angina, symptomatic
arrhythmias, or hypertension. Class IIb recommendations are given
for the initiation of β-blocker therapy prior to surgery in those with
LONG-
No
NONINVASIVE
CARDIAC TEST
Negative
Yes
stress test
Initiate and/or continue
optimal preventive medical
therapy
SURGERY
Positive
stress test
Coronary
revascularization
ACC/AHA
guidelines
SURGERY
intermediate- or high-risk myocardial ischemia noted on preoperative
noninvasive stress testing (level of evidence C) and patients with three
or more RCRI risk factors (level of evidence B).
The Perioperative Ischemic Evaluation (POISE) trial addressed the
benefit versus risk of perioperative β-blockade. The POISE trial randomized 8351 intermediate- to high-risk patients older than 45 years
of age to receive either a long-acting oral metoprolol succinate (metoprolol
CR) or placebo in the perioperative period. The results showed that the
244 SECTION IV Preoperative and Postoperative Care
incidence of cardiac death, nonfatal MI, or cardiac arrest was reduced
in the metoprolol group compared with placebo. However, there
was an increased incidence of mortality and stroke in the metoprolol
group compared with the placebo group. Stroke was associated with
perioperative hypotension, bleeding, atrial fibrillation, and a history of
stroke or transient ischemic attack. The POISE trialists highlighted the
importance of a clear risk and benefit assessment for the initiation of
preoperative β-blockers (see Fig. 22.2).
Preexisting β-blockade should be continued because withdrawal
might increase perioperative mortality. If β-blockers are newly initiated in appropriately selected higher-risk patients undergoing noncardiac surgery, they should be carefully titrated and not abruptly initiated
on a high-dose regimen in order to avoid hypotension or bradycardia.
HMG-CoA Reductase Inhibitors (Statins)
Prospective and retrospective evidence supports the perioperative
prophylactic use of 3-hydroxy-3-methylglutaryl–coenzyme A (HMGCoA) reductase inhibitors (statins) for reduction of perioperative cardiac complications in patients with established atherosclerosis. Statins
should be continued in patients who are already on statin therapy and
undergoing noncardiac surgery. A class IIa indication is assigned to the
use of statins for patients undergoing vascular surgery with or without
clinical risk factors.
Angiotensin-Converting Enzyme Inhibitors
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin
II–receptor blockers (ARBs) are frequently prescribed for the management of hypertension, CHF, chronic renal failure, and ischemic heart
disease. Evidence supports the discontinuation of these agents for 24
hours before noncardiac surgery because of adverse circulatory effects
after induction of anesthesia in patients on these medications (hypotension) that may result in the need for vasopressin agonists for management of the ensuing refractory hypotension.
Oral Antithrombotic Agents
Evidence-based recommendations regarding perioperative use of
aspirin, clopidogrel, other antiplatelet agents, or combination therapy
to reduce cardiac risk currently lack clarity. A substantial increase in
perioperative bleeding and transfusion requirement in patients receiving dual antiplatelet therapy has been observed. The discontinuation of
clopidogrel for 5 days and aspirin for 5 to 7 days before major surgery
to minimize the risk of perioperative bleeding and transfusion must be
balanced with the potentially increased risk for an acute coronary syndrome, especially in high-risk patients including those with recent coronary stent implantation. If clinicians elect to withhold aspirin before
surgery, it should be restarted as soon as possible postoperatively,
especially after vascular graft procedures. (See further information on
anticoagulants and surgery later in chapter.)
POSTOPERATIVE CARDIAC RISK ASSESSMENT
Monitoring for Myocardial Infarction
Although there are no standard criteria for their diagnosis, most
perioperative MIs occur within the first 3 days after noncardiac surgery. Although an ECG is recommended in the setting of signs or
symptoms suggestive of myocardial ischemia, MI, or arrhythmia in the
postoperative period, the usefulness of postoperative screening with
ECGs is uncertain. Measurement of serum cardiac biomarkers should
be reserved for patients at high risk and for those who demonstrate
ECG changes, symptoms of myocardial ischemia, new arrhythmias,
unexplained shortness of breath, or hemodynamic evidence of cardiovascular dysfunction.
NONCARDIAC SURGERY IN PATIENTS WITH
SPECIFIC CARDIOVASCULAR CONDITIONS
Valvular Heart Disease
All patients undergoing noncardiac surgery should be assessed especially for aortic stenosis by physical examination and by two-dimensional echocardiography for any suspicious murmur. Symptomatic
severe stenosis represents an active cardiovascular condition that
should be evaluated and managed before elective surgery is undertaken. Appropriately selected patients can be managed with valve
replacement or valvuloplasty as a bridge to noncardiac surgery.
Less is known about the perioperative risks associated with mitral
stenosis and mitral regurgitation in patients undergoing noncardiac
surgery. Usually, a preoperative history and physical examination,
chest radiograph, or ECG provides clues to the diagnosis, which can
be confirmed by echocardiography. Accurate diagnosis may help optimize intraoperative anesthetic strategies, choice of pharmacologic
interventions and invasive monitoring, and postoperative medical
management. Patients with severe mitral stenosis are likely to benefit
from balloon mitral valvuloplasty or surgical intervention before highrisk surgery.
Patients with aortic or mitral valvular regurgitation benefit from
volume control and afterload reduction. In aortic insufficiency, it
is thought that faster heart rates are better tolerated than slow ones
because slow heart rates lead to increased diastolic filling and can exacerbate left ventricular volume overload.
Arrhythmias and Conduction Defects
Ventricular and atrial arrhythmias historically are recognized as predictors of perioperative cardiac complications. Therefore, identification of a preoperative arrhythmia warrants a careful evaluation for
the presence and severity of underlying ischemic heart disease, cardiomyopathy, or other conditions that may contribute to perioperative
complications. In general, asymptomatic arrhythmias or conduction
defects warrant only observation and maintenance of an optimal metabolic state.
Congestive Heart Failure and Left Ventricular
Dysfunction
CHF has been identified as a significant marker of cardiac risk in noncardiac surgery. Every effort should be made to identify the etiology
of CHF and optimally control it preoperatively because it is a known
risk factor for postoperative cardiac complications. Close monitoring
of volume status is needed to avoid perioperative decompensation.
Intravenous inotropic agents, vasodilators, or both may be useful for
a short duration in the perioperative period to prevent or treat CHF,
depending on the situation.
RENAL DISEASE
Renal dysfunction affects critical excretory and synthetic functions
required for homeostasis. The major ensuing clinical effects include
hypertension, volume overload, and electrolyte derangements.
Hypertension
A well-controlled blood pressure is desirable to reduce perioperative cardiovascular complications. The goal is to have blood pressure
within an acceptable range based on current guidelines. Non-urgent
procedures should be delayed for adequate BP control to be attained.
The stress response in the perioperative period does increase the
incidence of so-called “white coat hypertension.” These patients do
not require aggressive lowering of blood pressure that can result in
CHAPTER 22 Preoperative and Postoperative Care
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245
reduced perfusion to the brain and kidneys, resulting in cerebrovascular accidents and acute kidney injury, respectively.
Antihypertensives (Medications)
• ACEIs,ARBs,andreninantagonists’effectontheRAShavebeen
associated with intraoperative hypotension and should be held
on the day of surgery. These can be resumed within 48 hours
based on patients’ blood pressure, volume status, and renal
function
• Diureticsshouldideallybeheldintheperioperativeperiodexcept
in patients with evidence of volume overload. The need for patients
to be NPO and associated volume losses during surgery usually
result in hypovolemia. Diuretics often need to be adjusted perioperatively to reduce risk of acute kidney injury.
• α-Blockers and β-blockers should not be stopped abruptly except
in patients who are hypotensive. These medications are associated
with rebound hypertension when stopped abruptly. Doses should
rather be reduced and holding parameters instituted in cases of
hypotension in order to prevent hypertensive crisis associated with
rebound hypertension.
• Calcium-channelblockersandvasodilatorscanbestoppedabruptly
if not required for optimization of blood pressure.
Acute Kidney Injury
Refer to the Kidney Disease: Improving Global Outcomes (KDIGO)
classification of acute kidney injury (AKI).
Kidney injury can be due to prerenal, intrarenal or postrenal etiologies. Perioperative AKI occurs in about 1% of patients, but risk is
much higher in patients having vascular and/or cardiac procedures
and in patients with chronic kidney disease, cirrhosis, and heart failure. AKI in the perioperative period is often due to fluid losses, fluid
shifts to other body compartments, and/or activation of the RAS. It
is essential for the etiology of preoperative AKI to be elucidated and
addressed before proceeding with elective surgery. It is critical to maintain euvolemia, while aiming to keep electrolytes—especially serum
potassium, magnesium, and sodium—within normal limits.
Management
Prerenal AKI patients typically respond to IVF and measures to ensure
adequate renal perfusion by preventing hypotension.
Intrarenal AKI patients require consultation from nephrology colleagues to ensure adequate and timely management to prevent progression of the underlying AKI condition and for initiation of renal
replacement therapy if needed.
Postrenal insufficiency is due to obstructive uropathy typically due to
BPH, urethral stenosis or calculi. Renal ultrasound or CT of the abdomen and pelvis provides information about the nature and severity of
the obstruction. Consultation from urology colleagues is often required.
In all patients with AKI, maintaining adequate renal perfusion by
keeping spontaneous bacterial peritonitis (SBP) greater than 110 mm
Hg is critical, and avoidance of potential nephrotoxins is essential.
Chronic Kidney Disease (CKD)
Refer to the KDIGO classification for staging.
The majority of the perioperative complications are of cardiac
etiology. As much as possible, euvolemic status needs to be attained
before surgical procedures are performed. Patients on dialysis need to
be dialyzed at least 24 hours before the planned procedure. Patients
on peritoneal dialysis who require laparotomy often need temporary
conversion to hemodialysis to maintain required volume status and
address electrolyte abnormalities.
For non–dialysis dependent patients, adequate renal perfusion
needs to be maintained and potential nephrotoxins avoided to prevent
worsening of CKD.
Nephrotic Syndrome
Maintenance of adequate volume status and renal perfusion is
important. Diuretic doses may need to be adjusted. For patients on
corticosteroids (prednisone >5 mg daily) for the management of this
condition, it should be assumed that their hypothalamic-pituitaryadrenal (HPA) axis is at least partially compromised. Stress dose corticosteroids given as hydrocortisone 100 mg IV every 8 hours, with
a transition to an oral regimen in 24 to 48 hours, and then continuing with the usual dose during the perioperative period is usually an
appropriate plan.
Renal Transplant Medicine
Immunosuppressive medications should be continued perioperatively.
For patients who are unable to take oral medications such as cyclosporine, IV cyclosporine should be given; the dose required is a third of
the oral dose.
Monitoring of drug serum levels is essential in view of potential
drug-drug interactions.
HEPATIC DISEASE
Acute and chronic liver diseases (Fig. 22.3) can lead to hepatic dysfunction that may worsen perioperatively because of anesthetic
agents and hemodynamic effects of a surgical procedure. The major
Patient with liver disease
requiring surgery
Acute hepatic dysfunction:
E.g., hepatitis, acute
hepatic injury
Postpone elective surgery
until levels improved
Fig. 22.3 Approach to preoperative risk stratification and interventions in patients with liver disease.
Coagulopathy:
- Treat with vitamin K, ±
FFP, cryoprecipitate
Chronic liver disease:
Intermediate risk: Child class
A-B, MELD<20
Encephalopathy:
- Lactulose, rifaximin
- Prevent precipitants, e.g., GI
bleeding, azotemia, opiate
pain medications
Ascites:
- Diuretics
- Fluid restriction
- Paracentesis
Chronic liver disease:
High risk: Child class C,
MELD>20
Postpone surgery until
condition improves,
consider transplantation
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