Preoperative care

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Preoperative care is defined as "Care given during the period prior to undergoing surgery when psychological and physical preparations are made according to the special needs of the individual patient. This period spans the time between admission to the hospital to the time the surgery begins."[1]

Components of preoperative care

Cardiac risk reduction

Clinical practice guidelines

Clinical practice guidelines[2] by the American College of Cardiology (ACC) and American Heart Association (AHA) recommend (as summarized by Journal Watch:[3][4]

  • 'Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity (less than 4 metabolic equivalents METs) who require vascular surgery is reasonable if it will change management"[2]
  • "Patients scheduled for low-risk noncardiac surgery should proceed to surgery."[3]
  • "Patients with good functional capacity should proceed to surgery."[3]
  • "Patients with poor or unknown functional capacity who are scheduled for non-low-risk surgery should be stratified according to the Revised Cardiac Risk Index[3] (Journal Watch Sep 17 1999). Patients with no risk factors should proceed to surgery. For those with one or more risk factors, clinicians are given the option of proceeding with surgery or performing noninvasive stress testing; the decision should be influenced by the type of noncardiac surgery (vascular vs. other), and by whether the clinician believes that noninvasive testing "will change management."
  • "For patients with risk factors, clinicians should consider perioperative ß-blockade."[3]
  • "The algorithm does not apply to patients who require emergency noncardiac surgery, or to patients with active cardiac problems." Active cardiac conditions are:[5]
Emerging issues

"Noncardiac surgery should be delayed until at least 30 days (and perhaps even 90 days) after placement of bare-metal coronary stents and 1 year after placement of drug-eluting stents."[6][7]

Evidence for interventions

Perioperative ß-blockade
Comparison of the POISE, MSPI, and DECREASE trials of
beta-blockers for noncardiac surgery
POISE trial[8] MSPI study[9] DECREASE Study[10]
Total patients 8351 200 173
(all had positive results on dobutamine echocardiography stress test)
Proportion of patients
undergoing vascular surgery		 42% 41% 100%
Risk of bias according to the Cochrane Collaboration bias scale[11] as assigned by Bangalore et al.[12] high   low
Beta-blocker dose Intravenous oral metoprolol tartrate followed by metoprolol succinate 200 mg/day Atenolol 50 to 100 mg/day Bisoprolol 5 to 10 mg/day
Goal pulse rate 50 to 80
(allowed delayed dosing when pulse 45 to 49)		 55 to 65 50 to 60
(started Bisoprolol one week preoperatively)
Significant bradycardia
in beta-blocker group		 4.2%
(requiring treatment or stopping
of metoprolol)		 0%
(requiring stopping
of atenolol)		 Not reported
Short-term mortality
Beta-blocker group 3.1%
(death at two weeks)		 4%
(in hospital death)		 3.4%
(within 30 days)
Placebo group 2.3%
(death at two weeks)		 2%
(in hospital death)		 17%
(within 30 days)
Notes:
1. Metoprolol is the only one of these adrenergic beta-antagonists that is metabolized by cytochrome P-450 2D6 allele. 3-10% of anglos are poor metabolizers of drugs that use the CYP2D6 isoenzyme.[13] As a consequence, metoprolol has more variable effect than bisoprolol.[14]

A meta-analysis of randomized controlled trials found that beta-blockers may cause a decrease in myocardial ischemia (number needed to treat = 16) with a lesser increase in non-fatal strokes (number needed to harm [NNH] = 293).[12] This meta-analysis excluded the MSPI study for unclear reasons.

POISE trial

Among the trials in the meta-analysis was the POISE trial.[15][8] The patient population in the trial, as noted in an earlier methods paper by the authors:[15]

"The POISE trial has recruited >6300 patients in 182 centers in 21 countries. Currently, the patients' mean age is 69 years; 63% are males, 43% have a history of coronary artery disease, 43% have a history of peripheral arterial disease, and 30% have diabetes. Most participants have undergone vascular (42%), intraabdominal (23%), or orthopedic (19%) surgery."

The study drug was controlled-release metoprolol:[15]

"Administration of the study drug at each dosing time, except during the first 6 hours after surgery, requires a patient to have a heart rate ≥50 beats/min and a systolic blood pressure (SBP) ≥100 mm Hg."
"Two to 4 hours before surgery, patients will take 100 mg (ie, half a tablet) of the study drug orally. If the patient heart rate is >80 beats/min and their SBP is ≥100 mm Hg during the first 6 hours after surgery, they will take 100 mg of the study drug orally. Patients who do not receive a dose of the study drug during the first 6 hours after surgery will take 100 mg of the study drug orally at 6 hours after surgery. Starting 12 hours after patients receive their first postoperative study drug dose and daily thereafter for 30 days, they will take 200 mg of the study drug orally. If the patients' heart rate is consistently <45 beats/min or their SBP is <100 mm Hg, caregivers will hold the study drug until the patients' heart rate or SBP recovers and will then administer 100 mg of the study drug orally. If the patients' heart rate is consistently between 45 and 49 beats/min and their SBP is >100 mm Hg, they will delay taking the study drug for 12 hours."
"Patients who are unable to take medications orally will receive the study drug by slow or rapid intravenous infusion every 6 hours until they are able to receive the study drug orally. The slow intravenous infusion consists of 15 mg of the study drug in 25 mL of normal saline infused over a 60-minute period, and patients will have their heart rate and blood pressure checked 10, 30, and 60 minutes after starting the infusion. If the patients' heart rate is <50 beats/min or their SBP is <100 mm Hg, the infusion is stopped and subsequent infusions will consist of 10 mg of the study drug in 25 mL of normal saline infused over a 60-minute period."
"The rapid intravenous infusion will consist of 5 mg of the study drug infused over 2 minutes. Patients will receive the rapid intravenous infusion every 5 minutes, for a total of 15 mg, as long as their vital signs fulfill the standard heart rate and SBP requirements before each dosing."

The results were:[8] Metoprolol reduced risk of the primary composite endpoint of cardiovascular death, nonfatal MI, and nonfatal cardiac arrest at 30 days (hazard ratio: 0.83, P=0.04):

  • Metoprolol 5.8%
  • Placebo 6.9%

Total mortality at 30 days was increased among patients taking metoprolol (HR: 1.33, P=0.03):

  • Metoprolol 3.1%
  • Placebo 2.3%

These results suggest that the benefits on the primary outcome were outweighed by adverse effects; however, the POISE trial was unique in using metoprolol in an anglo population although 3-10% of anglos are poor metabolizers of drugs such as metopolol that use the CYP2D6 isoenzyme.[13] This affects many antidepressants, metoprolol and other drugs that use this isoenzyme. More information is available at Entrez Gene.[16]

MSPI trial

In the The Multicenter Study of Perioperative Ischemia Research Group (MSPI)[9], the patients were similar to the POISE study in that about 40% had vascular surgery. The intervention was 50-100 mg of atenolol per day starting on the first postoperative day and continuing for up to 7 days. However, at 6 months there was a trend for more atenolol patients to still be taking beta-blockers (13.8% versus 8.8%).

The MSPI study focused its results on mortality at 6 months to two years. In order to compare to the POISE trial, the hospital death rate in the MSPI study was:

  • Atenolol 4% (4/99)
  • Placebo 2% (2/101)
DECREASE trial

The DECREASE study found benefit by starting bisoprolol 5-10 mg per day at least one week prior to vascular surgery.[10]

Myocardial revascularization

A randomized controlled trial found that myocardial revascularization was associated with a statistically insignificant 2% absolute reduction in perioperative myocardial infarction among patients undergoing major vascular surgery.[17] The benefit, while still statistically insignificant, was greater for high risk patients.

Pulmonary risk reduction

Clinical practice guidelines by the American College of Physicians state:[18]

  1. "All patients undergoing noncardiothoracic surgery should be evaluated for the presence of the following significant risk factors for postoperative pulmonary complications in order to receive pre- and postoperative interventions to reduce pulmonary risk: chronic obstructive pulmonary disease, age older than 60 years, American Society of Anesthesiologists (ASA) class of II or greater, functionally dependent, and congestive heart failure."
  2. "Patients undergoing the following procedures are at higher risk for postoperative pulmonary complications and should be evaluated for other concomitant risk factors and receive pre- and postoperative interventions to reduce pulmonary complications: prolonged surgery (>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 (<35 g/L) is a powerful marker of increased risk for postoperative pulmonary complications and should be measured in all patients who are clinically suspected of having hypoalbuminemia; measurement should be considered in patients with 1 or more risk factors for perioperative pulmonary complications."
  4. "All patients who after preoperative evaluation are found to be at higher risk for postoperative pulmonary complications should receive the following postoperative procedures in order to reduce postoperative pulmonary complications: 1) deep breathing exercises or incentive spirometry and 2) selective use of a nasogastric tube (as needed for postoperative nausea or vomiting, inability to tolerate oral intake, or symptomatic abdominal distention)."
  5. "Preoperative spirometry and chest radiography should not be used routinely for predicting risk for postoperative pulmonary complications."
  6. "The following procedures should not be used solely for reducing postoperative pulmonary complication risk: 1) right-heart catheterization and 2) total parenteral nutrition or total enteral nutrition (for patients who are malnourished or have low serum albumin levels)."

For patients with asthma, more aggressive clinical practice guidelines by the U.S. National Asthma Education and Prevention Program recommend:[19]

  • "Patients who have asthma should have an evaluation before surgery that includes a review of symptoms, medication use (particularly the use of oral systemic corticosteroids for longer than 2 weeks in the past 6 months), and measurement of pulmonary function".
  • "If possible, attempts should be made to improve lung function preoperatively (FEV1 or peak expiratory flow rate [PEFR]) to either their predicted values or their personal best level. A short course of oral systemic corticosteroids may be necessary to optimize lung function".

Smoking cessation may reduce pulmonary complications according to the results of a randomized controlled trial.[20]

Incentive spirometry does not clearly help reduce pulmonary complications during the perioperative care after coronary artery bypass grafting according to a meta-analysis of randomized controlled trials by the Cochrane Collaboration. [21]

Hepatic risk reduction

The MELD Score can help predict complications of surgery among patients with cirrhosis.[22] The MELD Score may [23] or may not[24] perform better than the Child-Turcotte-Pugh class.


Management of chronic anticoagulation

A systematic review found warfarin does not need interruption during minor procedures.[25] This was confirmed in a cohort study that found that interruption for 5 days or less was generally safe.[26]

For patients needing a low molecular weight heparin bridge, a protocol is available.[27]

Benefits of preoperative medical consultation

The benefits of internal medicine consultation are not clear in an observational study[28]; whereas a pseudorandomized trial found benefit from a hospitalist consultation[29] and a non-randomized trial using historical controls found benefit from geriatrics consultation[30].

Unnecessary delays in surgery is associated with increased operative risk.[31]

Preoperative methods for surgical risk reduction

A wide range of methods for avoiding surgical errors, either in the operating room or shortly before surgery, are increasingly in use. One method, long used by the choice of individual surgeons, is becoming more of a standard: when, for example, a procedure could be prepared on either the left or right extremity, the surgeon, or even the patient, may write, with an indelible pen, "cut here" on the appropriate site and "do not cut here" on the contralateral extremity, signing both.

Drawing from aviation methods of risk reduction, there are specific points, such as the induction of anesthesia or the entry into a body cavity, when the team stops and goes through a specific checklist of physiological parameters, equipment readiness, etc. In the discipline of crew resource management, one team member is specifically tasked to ask each structured question, and another member to check the matter and give the answer.

References

  1. ↑ National Library of Medicine. Preoperative care. Retrieved on 2007-11-21.
  2. ↑ 2.0 2.1 Fleisher LA, Beckman JA, Brown KA, et al (2007). "ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A 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". Circulation 116 (17): 1971–1996. DOI:10.1161/CIRCULATIONAHA.107.185700. PMID 17901356. Research Blogging.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Brett AS (2007-11-20). Guidelines for Perioperative Cardiovascular Evaluation for Patients Considering Noncardiac Surgery. Retrieved on 2007-11-21.
  4. ↑ {{Cite web | title = Current Guidelines for Preoperative Management Leave Me Wanting More |author=Winawer N | accessdate = 2007-11-21 | date = 2008-08-25 | url = http://hospital-medicine.jwatch.org/cgi/content/full/2008/825/1 }
  5. ↑ Fleisher LA, Beckman JA, Brown KA, et al (2007). "ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A 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". Circulation 116 (17): 1971–1996. PMID 17901356.
  6. ↑ Brett AS (2008). Noncardiac Surgery in Patients with Recently Implanted Coronary Stents - Journal Watch (General). Journal Watch (General).
  7. ↑ Nuttall GA, Brown MJ, Stombaugh JW, et al (October 2008). "Time and cardiac risk of surgery after bare-metal stent percutaneous coronary intervention". Anesthesiology 109 (4): 588–95. DOI:10.1097/ALN.0b013e318186ddf8. PMID 18813036. Research Blogging.
  8. ↑ 8.0 8.1 8.2 (May 2008) "Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial". Lancet. DOI:10.1016/S0140-6736(08)60601-7. PMID 18479744. Research Blogging.
  9. ↑ 9.0 9.1 Mangano DT, Layug EL, Wallace A, Tateo I (1996). "Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group". N. Engl. J. Med. 335 (23): 1713-20. PMID 8929262. [e]
  10. ↑ 10.0 10.1 Poldermans D, Boersma E, Bax JJ, et al (1999). "The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group". N. Engl. J. Med. 341 (24): 1789-94. PMID 10588963. [e] Cite error: Invalid <ref> tag; name "pmid10588963" defined multiple times with different content
  11. ↑ Higgins JPT, Green S (editors). Table 8.5.a: The Cochrane Collaboration's Tool for assessing risk of bias. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1 [updated September 2008]. The Cochrane Collaboration, 2008. Available from www.cochrane-handbook.org.
  12. ↑ 12.0 12.1 Bangalore S, Wetterslev J, Pranesh S, Sawhney S, Gluud C, Messerli FH (December 2008). "Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis". Lancet 372 (9654): 1962–76. DOI:10.1016/S0140-6736(08)61560-3. PMID 19012955. Research Blogging.
  13. ↑ 13.0 13.1 Phillips KA, Veenstra DL, Oren E, Lee JK, Sadee W (November 2001). "Potential role of pharmacogenomics in reducing adverse drug reactions: a systematic review". JAMA 286 (18): 2270–9. PMID 11710893. [e]
  14. ↑ Nozawa T, Taguchi M, Tahara K, et al (November 2005). "Influence of CYP2D6 genotype on metoprolol plasma concentration and beta-adrenergic inhibition during long-term treatment: a comparison with bisoprolol". J. Cardiovasc. Pharmacol. 46 (5): 713–20. PMID 16220080. [e]
  15. ↑ 15.0 15.1 15.2 Devereaux PJ, Yang H, Guyatt GH, et al (2006). "Rationale, design, and organization of the PeriOperative ISchemic Evaluation (POISE) trial: a randomized controlled trial of metoprolol versus placebo in patients undergoing noncardiac surgery". Am. Heart J. 152 (2): 223-30. DOI:10.1016/j.ahj.2006.05.019. PMID 16875901. Research Blogging.
  16. ↑ Anonymous. Entrez Gene: CYP2D6 cytochrome P450, family 2, subfamily D, polypeptide 6 [ Homo sapiens ]. National Library of Medicine. Retrieved on 2009-01-03.
  17. ↑ McFalls EO, Ward HB, Moritz TE, et al (December 2004). "Coronary-artery revascularization before elective major vascular surgery". N. Engl. J. Med. 351 (27): 2795–804. DOI:10.1056/NEJMoa041905. PMID 15625331. Research Blogging.
  18. ↑ Qaseem A, Snow V, Fitterman N, et al (2006). "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. 144 (8): 575–80. PMID 16618955. [e]
  19. ↑ NHLBI, Diagnosis and Management of Asthma. National Heart, Lung, Blood Institute. Retrieved on 2008-01-24.
  20. ↑ Møller AM, Villebro N, Pedersen T, Tønnesen H (2002). "Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial". Lancet 359 (9301): 114–7. PMID 11809253. [e]
  21. ↑ Freitas ER, Soares BG, Cardoso JR, Atallah AN (2007). "Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft". Cochrane Database Syst Rev (3): CD004466. DOI:10.1002/14651858.CD004466.pub2. PMID 17636760. Research Blogging.
  22. ↑ Teh SH, Nagorney DM, Stevens SR, et al (April 2007). "Risk factors for mortality after surgery in patients with cirrhosis". Gastroenterology 132 (4): 1261–9. DOI:10.1053/j.gastro.2007.01.040. PMID 17408652. Research Blogging.
  23. ↑ Farnsworth N, Fagan SP, Berger DH, Awad SS (November 2004). "Child-Turcotte-Pugh versus MELD score as a predictor of outcome after elective and emergent surgery in cirrhotic patients". Am. J. Surg. 188 (5): 580–3. DOI:10.1016/j.amjsurg.2004.07.034. PMID 15546574. Research Blogging.
  24. ↑ Suman A, Barnes DS, Zein NN, Levinthal GN, Connor JT, Carey WD (August 2004). "Predicting outcome after cardiac surgery in patients with cirrhosis: a comparison of Child-Pugh and MELD scores". Clin. Gastroenterol. Hepatol. 2 (8): 719–23. PMID 15290666. [e]
  25. ↑ Dunn AS, Turpie AG (April 2003). "Perioperative management of patients receiving oral anticoagulants: a systematic review". Arch. Intern. Med. 163 (8): 901–8. DOI:10.1001/archinte.163.8.901. PMID 12719198. Research Blogging.
  26. ↑ Garcia DA, Regan S, Henault LE, et al (January 2008). "Risk of thromboembolism with short-term interruption of warfarin therapy". Arch. Intern. Med. 168 (1): 63–9. DOI:10.1001/archinternmed.2007.23. PMID 18195197. Research Blogging.
  27. ↑ Douketis JD, Johnson JA, Turpie AG (June 2004). "Low-molecular-weight heparin as bridging anticoagulation during interruption of warfarin: assessment of a standardized periprocedural anticoagulation regimen". Arch. Intern. Med. 164 (12): 1319–26. DOI:10.1001/archinte.164.12.1319. PMID 15226166. Research Blogging.
  28. ↑ Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli J (2007). "Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery". Arch. Intern. Med. 167 (21): 2338–44. DOI:10.1001/archinte.167.21.2338. PMID 18039993. Research Blogging.
  29. ↑ Roy A, Heckman MG, Roy V (2006). "Associations between the hospitalist model of care and quality-of-care-related outcomes in patients undergoing hip fracture surgery". Mayo Clin. Proc. 81 (1): 28-31. PMID 16438475. [e]
  30. ↑ Fisher AA, Davis MW, Rubenach SE, Sivakumaran S, Smith PN, Budge MM (2006). "Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare". J Orthop Trauma 20 (3): 172-8; discussion 179-80. DOI:10.1097/01.bot.0000202220.88855.16. PMID 16648698. Research Blogging.
  31. ↑ Shiga T, Wajima Z, Ohe Y (2008). "Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression: [Le delai operatoire est-il associe a une mortalite accrue chez les patients atteints d'une fracture de la hanche ? Synthese systematique, meta-analyse et meta-regression]". Can J Anaesth 55 (3): 146-54. PMID 18310624. [e]

See also

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