Before surgery: Have you done enough to mitigate risk?

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Applied Evidence

Before surgery: Have you done enough to mitigate risk?

J Fam Pract. 2010 April;59(4):202-211

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References

1. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2007;50:e159-e241.

2. Tricoci P, Allen JM, Kramer JM, et al. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA. 2009;301:831-841.

3. Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371:1839-1847.

4. Fleisher LA, Beckman JA, Brown KA, et al. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2009;120:e169-e276.

5. Falcone RA, Nass C, Jermyn R, et al. The value of preoperative pharmacologic stress testing before vascular surgery using ACC/AHA guidelines: a prospective, randomized trial. J Cardiothorac Vasc Anesth. 2003;17:694-698.

6. McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351:2795-2804.

7. Qaseem A, Snow V, Fitterman N, et al. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med. 2006;144:575-580.

8. Gibbs J, Cull W, Henderson W, et al. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg. 1999;134:36-42.

9. Tait AR, Malviya S, Voepel-Lewis T, et al. Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections. Anesthesiology. 2001;95:299-306.

10. Parnis SJ, Barker DS, Van Der Walt JH. Clinical predictors of anaesthetic complications in children with respiratory tract infections. Paediatr Anaesth. 2001;11:29-40.

11. Tait AR, Malviya S. Anesthesia for the child with an upper respiratory tract infection: still a dilemma? Anesth Analg. 2005;100:59-65.

12. Tanguy M, Seguin P, Malledant Y. Bench-to-bedside review: Routine postoperative use of the nasogastric tube - utility or futility? Crit Care. 2007;11:201.-

13. Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg. 2005;92:673-680.

14. Gilbert PL, Stein R. Preoperative evaluation of the patient with chronic renal disease. Mt Sinai J Med. 1991;58:69-74.

15. Himmelfarb J, Ikizler TA. Acute kidney injury: changing lexicography, definitions, and epidemiology. Kidney Int. 2007;71:971-976.

16. Weldon BC, Monk TG. The patient at risk for acute renal failure. Recognition, prevention, and preoperative optimization. Anesthesiol Clin North Am. 2000;18:705-717.

17. Carmichael P, Carmichael AR. Acute renal failure in the surgical setting. ANZ J Surg. 2003;73:144-153.

18. Kellerman PS. Perioperative care of the renal patient. Arch Intern Med. 1994;154:1674-1688.

19. Jones DR, Lee HT. Perioperative renal protection. Best Pract Res Clin Anaesthesiol. 2008;22:193-208.

20. Thakar CV, Arrigain S, Worley S, et al. A clinical score to predict acute renal failure after cardiac surgery. J Am Soc Nephrol. 2005;16:162-168.

21. Deutsch E, Bernstein RC, Addonizio P, et al. Coronary artery bypass surgery in patients on chronic hemodialysis. A case-control study. Ann Intern Med. 1989;110:369-372.

22. Ebell MH. Predicting postoperative pulmonary complications. Am Fam Physician. 2007;75:1837-1838.

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24. Spear M. Risk factors for surgical site infections. Plast Surg Nurs. 2008;28:201-204.

25. Blondet JJ, Beilman GJ. Glycemic control and prevention of perioperative infection. Curr Opin Crit Care. 2007;13:421-427.

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30. Vamvakas EC, Carven JH. Transfusion of white-cell containing allogeneic blood components and postoperative wound infection: effect of confounding factors. Transfus Med. 1998;8:29-36.

31. Bierbaum BE, Callaghan JJ, Galante JO, et al. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am. 1999;81:2-10.

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Identify pulmonary risks with help from ACP
Postoperative pulmonary complications are as prevalent as cardiac complications, and contribute equally to morbidity, mortality, and length of stay. But pulmonary complications are better predictors of long-term mortality after surgery.⁷

FAST TRACK

The ACP does not recommend chest radiography or spirometry as part of a standard preop evaluation.

There are several well-validated risk factors for increased perioperative pulmonary morbidity and mortality—HF, chronic obstructive pulmonary disease (COPD), advanced age, and the need for assistance with activities of daily living among them. In addition to identifying patient-specific risk factors, knowledge of the type of surgery planned will provide insight into procedure-specific risk factors (TABLE 1). The approach to the surgical pulmonary patient is addressed in an American College of Physicians (ACP) guideline published in 2006 and available at http://www.annals.org/content/144/8/575.full.pdf+html.⁷

What tests to consider? The ACP guideline is notable not only for its recommendations, but for the things that are not recommended but may nevertheless be considered the standard of care in some locales. Chest radiography and spirometry are 2 such examples. Although these tests may be appropriate on an individual basis for patients with a previous diagnosis of COPD or asthma, their routine use is of little value—and the ACP does not recommend them as part of a standard preop evaluation.⁷ Some laboratory tests may aid in risk stratification, however.

FAST TRACK

Check patients with 1 or more pulmonary risk factors for hypoalbuminemia; a serum albumin level <35 g/L is strongly associated with postop pulmonary complications.

A serum albumin level <35 g/L is strongly associated with postop pulmonary complications.⁸ Checking levels in all patients suspected of hypoalbuminemia, including any patient with 1 or more pulmonary risk factors, is reasonable for a physician performing a preoperative evaluation. Consider checking blood urea nitrogen (BUN) levels, as well. Uremia (BUN >21 mg/dL) is also associated with increased pulmonary complications, although not as strongly as hypoalbuminemia.

Postpone or proceed? Acute conditions are another key consideration. An upper respiratory infection (URI) increases the risk of postoperative pulmonary complications, especially in children.^9,10 A simple algorithm offers guidance in deciding when to postpone surgery in pediatric patients with a URI:⁹

Recommend that it be delayed if the procedure involves general anesthesia and 1 or more of the following risk factors is present: asthma, a history of prematurity, copious secretions, a parent who smokes, planned use of an endotracheal tube, or a procedure involving the airway.

Surgery can proceed if symptoms of the infection are mild, general anesthesia is not required, or a risk/benefit analysis supports it. Considerations include the urgency of the procedure, whether the surgery has previously been postponed, the comfort level of the clinicians involved, and the distance the family must travel for the procedure.¹¹

If you recommend that surgery proceed as planned, suggest perioperative interventions to mitigate risk. Recommend that a laryngeal mask airway be used, if needed, in place of an endotracheal tube; that pulse oximetry monitoring occur; that good hydration and humidification of air be provided; and that the patient receive anticholinergic agents for secretions.

FAST TRACK

Document the presence and type of coronary stents or implanted cardiac devices in the preoperative consultation note.

Other measures that have been shown to be effective in reducing perioperative pulmonary complications include deep breathing exercises (incentive spirometry) and the use of a nasogastric tube for those with postoperative emesis, intolerance of oral intake, or symptomatic abdominal distension.⁷ If your patient has risk factors for pulmonary complications, include a recommendation for a postop nasogastric tube in your preop consultation note. However, newer data indicating that patients had fewer pulmonary complications, a more rapid return of normal bowel function, no increased discomfort, and no increase in anastomotic leaks without a nasogastric tube^12,13 may lead to guideline revision.

A scoring system helps evaluate renal risk
Patients with CRF face increased risk of perioperative morbidity and mortality. But as long as the glomerular filtration rate (GFR) is >25 mL/min—which is only 25% of normal—surgery is generally well tolerated. As GFR drops to 10 to 15 mL/min, the rate of surgical complications rises rapidly, reaching 55% to 60%. For such patients, preoperative dialysis is worth considering.¹⁴

FAST TRACK

Preoperative dialysis for patients with chronic renal failure and a GFR of 10 to 15 mL/min can decrease the risk of postop complications.

Postoperative acute kidney injury (AKI), as acute renal failure is now known,¹⁵ is associated with a 58% mortality rate.¹⁶ Fortunately, this complication develops in only about 1% of surgical patients.¹⁷ Both patient-specific risk factors (CRF, with creatinine >2.1 mg/dL; HF; diabetes, particularly being insulin dependent; age >60 years; jaundice) and procedure-specific risks (aortic, cardiovascular, or liver transplant surgery) help predict which surgical candidates face the highest risk.^16,18,19 Thakar et al have developed a scoring system to identify those at greatest risk for AKI.²⁰ (See “Cardiovascular surgery and acute kidney injury: Scoring the risk” at www.jfponline.com by clicking on “Before surgery: Have you done enough to mitigate risk?” and scrolling to the end.)