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Perioperative Management of Surgical Patients

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Perioperative Risk Assessment

1) Stabilize acutely active cardiac disease prior to non-emergent non-cardiac surgery * General * Increase risk, require further evaluation before non-emergent non-cardiac surgery * Unstable Angina or recent MI * Decompensated HF * Significant Arrhythmia (Symptomatic bradycardia, high grade AV block, SVT, New or recent onset VT) * Severe Valvular Disease (Severe AS, Symptomatic MS) 2) Assess Procedural Risk * Pts undergoing low risk surgeries have <1% risk of MACE * No further cardiac workup is needed regardless of underlying comorbidities * 1) Cardiac Risk of Non-cardiac Surgical Procedures * Risk of cardiac death, nonfatal cardiac arrest, nonfatal MI * Low-Risk * Breast (lumpectomy, mastectomy) * Skin Surgery * Simple Dental Work * Endoscopic Procedure * Cataract Extraction * Intermediate-Risk * Head and Neck (Thyroidectomy) * Orthopedic (Knee Arthroplasty) * Prostate * High-Risk * Aortic or other major vascular * Intrathoracic * Open Intraperitoneal * 2) Cardiac Risk Stratification * Revised Cardiac Risk Index (RCRI) * Predictors of major cardiac complications with noncardiac surgery * 6 Risk Predictors * High-risk surgery (vascular) * History of IHD * History of CHF * History of Stroke or TIA * T2DM w/Insulin * Pre-op Creatinine >2 * Rate of Cardiac Death, nonfatal cardiac arrest, or nonfatal MI * No RF: 0.4% (low risk) * 1 RF: 1.0% (low risk) * 2 RF: 2.4% (moderate risk) * ≥3 RF: 5.4% (high risk) * RCRI ≤1% (low risk) can proceed directly to surgery * Otherwise assess functional status * 3) Assess Functional Status * If able to achieve ≥4 METS, generally do not require additional evaluation * MET = volume of O2 consumed at rest (3.5mL O2 uptake/kg/min) * <4 METs: * Eat, dress, use toilet * Walk indoors in the house * Do light work (Vacuuming) * ≥4 METs * Climb a flight of stairs * Run a short Distance * Do yardwork (Raking leaves) * Participate in golf, tennis, or dancing * Otherwise needs cardiac eval w/TTE or Preop Stress Testing * Usefulness of transthoracic echocardiography as a tool for risk stratification of patients undergoing major noncardiac surgery

Pre-Op Complication Prevention Strategies

  • Quit smoking >8 weeks prior
  • Treat respiratory infections
  • Aspiration Pneumonia
    • Bed elevation
  • Patient education
    • Chest PT, coughing, deep breathing, incentive spirometry
  • DECREASE-IV: Preoperative statins ASAP (Bisoprolol and Fluvastatin reduce perioperative mortality in intermediate-risk patients)
  • Consider A1c in T2DM patients
  • Preoperative glucocorticoids for uncontrolled COPD
  • Give IV cefazolin as antimicrobial prophylaxis within 60mins of procedure
  • Perioperative Management of Anemia

Perioperative Management of Anticoagulation

  • Perioperative Management of Antithrombotic therapy
  • Management of antithrombotic agents for endoscopic procedures
  • Assess Elective vs. Emergent/Urgent
    • <24hrs: IV VitK 2.5-5mg and PCC 30 IU/kg if needed

    • 24hrs: IV VitK 2.5-5mg

  • Assess Cardiac Risk of Noncardiac Surgical Procedures
  • Assess Perioperative Bleeding Risk
    • https://pubmed.ncbi.nlm.nih.gov/22315257/
    • https://pubmed.ncbi.nlm.nih.gov/19926021/
    • High-Risk (2-day risk: 2-4%)
      • Cardiac, vascular, neurosurgical
      • Intraabdominal, urologic (TURP)
      • Joint replacement, laminectomy
      • Renal biopsy, endoscopy with FNA
      • Spinal surgery
      • Major cancer surgery
      • Notes
        • Temporary interruption for high bleeding risk patients
        • Bridge very high thrombotic risk patients (CHA2D2-Vasc ≥6) using LMWH or UFH
    • Low-Risk (2-day risk: ≤2%)
      • Arthrocentesis
      • Coronary Angiography
      • Cataracts, outpatient tooth extraction
      • CVC removal, Pacemaker/ICD placement
      • LN biopsy, endoscopy without needle biopsy
      • Carpal Tunnel repair
      • Skin biopsy, Bronchoscopy, Colonoscopy w/o biopsy
      • Notes
        • Typically do not need warfarin interruption regardless of thrombotic risk
  • Assess Drug Type
    • Warfarin
      • Low-Risk surgery: No need to stop/adjust warfarin regardless of thrombotic risk
        • Continue through perioperative period
      • High-Risk surgery:
        • Very High VTE Risk: Bridge
        • High VTE Risk: No Bridge, stop 5 days
        • Low VTE Risk: Don’t Stop?
    • DOACs
      • Eliquis/Xarelto
      • Dabigatran
        • Hold for 48 hours prior to surgery
          • No need for thrombin time unless unknown time of last dose (dementia/urgent sx)
        • If Thrombin time is normal: proceed with surgery
        • Elevated Thrombin: Idarucizumab if life-threatening bleeding or urgent/emergent surgery
  • Assess Perioperative Thrombotic Risk (VTE Risk)
    • Very High Risk (>10% annually)
      • Valve
        • Mechanical Mitral Valve
        • Cage-ball or tilting disc mechanical aortic valve
      • VTE
        • Within 3 months
        • Severe thrombophilia (eg. Protein C deficiency)
      • AF
        • AF with CHA2D2-VASc score ≥6
        • AF with TIA/Stroke within 3 months
        • AF with rheumatic valve disease
    • High Risk (5-10%)
      • Valve
        • Patients with bileaflet mechanical aortic valve & ≥1 other risk factor for stroke (HTN, DM)
      • VTE
        • VTE within 1 year but >3 months
        • Active malignancy within 6 months
        • Non-severe thrombophilia (Heterozygous Factor V Leiden or prothrombin gene mutation)
      • AF
        • AF with CHA2Ds2-VASc score 4-5
    • Moderate Risk
      • Valve
        • Patients with bileaflet mechanical aortic valve w/o other risk factor for stroke (HTN, DM)
    • Low Risk (<5% annually)
      • VTE >12 months ago and no risk factors
    • Assess Kidney function
    • High Bleed Risk Surgery
      • Very High VTE Risk
        • Perioperative Bridging w/LMWH or UFH
          • Hold warfarin for 5 days, start heparin once INR <2.0
          • Stop heparin the day of procedure
          • Restart 24-48 hours after with warfarin
      • Moderate-High VTE Risk
        • BRIDGE Trial – bridging didn’t help unless Very High VTE Risk
        • Hold DOAC for 4 half-lives (2-3 days) – 6.25% of Xarelto left
          • Hold Dabigatran 48 hours
      • Hold Warfarin for 5 days until the INR falls <1.5 then perform procedure
        • Resume warfarin the evening following the procedure
    • Low Bleed Risk Surgery
      • Very High VTE Risk
        • Warfarin
          • Continue anticoagulation2
      • Low/Moderate VTE Risk
        • Continue DOAC until day of surgery
        • Stop warfarin 5 days prior; INR <1.5
          • No bridging needed

Perioperative Management of Beta-Blockers

  • Continue BBs through surgery
  • Pre-operative initiation if RCRI ≥3 w/o CI
    • Start 1 week prior
      • Beta-blocker therapy in patients with a history of stable angina, previous MI, systolic HF

Perioperative Management of DAPT

  • Elective Surgery: Defer Surgery until after minimum DAPT duration
    • 4 weeks for select BMS, 6 months for DES
  • Urgent Surgery: Continue P2Y12 receptor blacker or hold for shortest duration possible
  • Continue aspirin unless high risk of severe surgical bleeding
    • Reduces rate of early graft occlusion and overall CV morbidity and mortality in CABG
  • Hold P2Y12 inhibitors for 5-7 days prior to CABG
    • Increased risk of significant bleeding with increased requirements for blood transfusion and possible re-op

Perioperative Management of Glucocorticoids

  • Perioperative management of patients treated with glucocorticoids
  • Management of adrenal insufficiency during the stress of medical illness and surgery
  • Adrenal insufficiency in high-risk surgical ICU patients
  • Normal HPA Axis may not recover for up to 6-12 months after discontinuation of steroids
  • No Risk (No perioperative Stress-Dose Steroids Required)
    • Daily Morning dose of prednisone <5mg for any period
    • Any dose of any glucocorticoid for <3 weeks
    • Prednisone 10mg (or its equivalent) every other day
  • Intermediate or Unknown Risk for AI (Preoperative Eval of HPA Axis)
    • Daily Morning dose of prednisone 5-20mg for >3 weeks
    • Daily Evening dose of prednisone <5mg (may disrupt diurnal variation)
    • Prior longer duration or higher doses of glucocorticoids in the past year
    • Inhaled glucocorticoids for >3 weeks, or ≥3 intra-articular or spinal glucocorticoid injections within past 3 months
    • Co-syntropin Stimulation Test
  • High Risk (Stress-dose Glucocorticoids Perioperatively)
    • Daily Prednisone ≥20mg (or its equivalent) for >3 weeks
    • Any patient taking glucocorticoids who has Cushingoid features
    • Stress dose when intermediate to high-risk surgery (continue and increase dose on day of surgery)
      • Hydrocortisone 100mg IV during surgery
        • 50mg every 8 hours for 24 hours with rapid taper (1-2 days)
  • Only doses >15mg/d are associated with increased risk for post-arthropathy infection

Other

  • Rheum
    • DMARDS (methotrexate, sulfasalazine, hydroxychloroquine, leflunomide)
      • May be continued, no need to stop
    • Biologic Agents
      • Withheld one dosing cycle prior to hip and knee surgery
    • Restart after evidence of wound healing (14 days)
  • Antihypertensives
    • Continue CCBs
    • Continue ACEI if HF, hold night before if no HF
    • Hold Diuretics the morning of surgery
    • Continue Statins
    • Continue Clonidine
  • Meds to stop before Surgery
    • 1-2 weeks before – Aspirin, Vitamin E
      • Platelets need 7-10 days to regenerate (Non-CABG/High-Risk)
    • 5 days – Warfarin, drop INR to <1.5 (can use vitamin K)
    • 3-4 days – SGLT-2s (Euglycemic diabetic ketoacidosis)
    • 2 days – NSAIDS
      • Reversible unlike aspirin so platelets don’t need to regenerate
    • 1-2 days – Metformin, lactic acidosis (>4)
    • Morning of – ½ dose of Insulin, give 5% dextrose intra/post-op
  • Labs/Testing
    • U/A in UTI and urologic procedures
    • EKG in men ≥40 y/o and women ≥50 y/o, CVD, HTN, DM, Thoracic, Intraperitoneal, EM
    • CKD before Surgery
      • Dialyze 24 hours prior

  1. https://pubmed.ncbi.nlm.nih.gov/26927735/{:target="_blank"} ↩

  2. https://pubmed.ncbi.nlm.nih.gov/20131614/{:target="_blank"} ↩