1. Hospital Medicine Grand Rounds The role of the peri-operative evaluation in safe patient outcomes: an initial patient dissatisfaction with a happy ending Moises Auron MD FAAP Feb 11, 2009

2. Objectives

Appraise the importance of the peri-operative assessment to detect unrecognized conditions that increase surgical risk.

Describe the evaluation and management of aortic regurgitation and its peri-operative implications

3. Objectives

Describe the evaluation and management of pleural effusion and its perioperative implication.

Describe the peri-operative implications of active tuberculosis.

Describe the initial peri-operative assessment of Rheumatoid arthritis.

4. Case presentation

55 y/o male

CC: Tracheostomy and subglotic stenosis

Referred for pre-operative evaluation for a laser dilatation of the subglottic stenosis

Surgery scheduled for the next day.

Patient travelled from Boston, MA.

5. PMH

HTN (10 years)

Tracheostomy

G-tube on enteral feeding

MVA 4 months ago with complicated ICU stay: prolonged intubation.

D/C to SNF, and recent D/C to home 1 week prior to preoperative visit.

6. PSH

Evacuation of subdural hematoma

Pleural tube placement for closed chest injury

Exploratory laparotomy with splenectomy and small bowel resection.

ORIF hip fracture

Tracheostomy

Gastrostomy

7. Medications

Esomeprazole 20 mg daily

Polyethilen-glycol 17 g daily

Indapamide 2.5 mg daily

Aliskiren 150 mg daily

Clonidine 0.2 mg bid

Gabapentin 600 mg tid

Aspirin 81 mg daily

Oxycodone 10 mg po q6h prn (pain)

8. Social

Smokes 1 ppd for 30 years (not smoking currently since accident 4 months ago).

No EtOH intake.

No Drugs.

Prosecution lawyer, married for 25 years, 2 children.

9. Pre-operative assessment

Able to walk indoors with a walker (2.5 mets) but is mostly in wheelchair

• Chest discomfort when straining (because I had a chest tube)

• Needs 4 pillows to sleep, orthopnea, no PND

• Edema managed with indapamide

Denied any complications with anesthesia.

10. Circulation.2007;116:1971-1996 11. Physical examination

BP 205/70HR 90RR 16

Gen: anxious, head tremors

Neck: Carotid pulsations appreciated. Trach.

Cor: S4, 3/6 diastolic murmur in Right 2 ndIC space with presence of diastolic murmur (rumble) in apical area

Chest: CTA BL

Abd: S, NT, ND, BS+, pulsatile liver, GT

Ext: brisk pulses, pulsating capillary nail bed

12.

What do you think?

13. Signs of aortic insufficiency

Austin Flint murmur

Corrigans pulse

de Musset's sign

Quinckes sign

Traube's sign

Duroziezs sign

Lighthouse sign

Landolfis sign

Beckers sign

Mllers sign

Mayens sign

Rosenbachs sign

Gerhardts sign

Hills sign

Lincolns sign

Shermans sign

Ashrafians sign

Babu AN, et al. Ann Intern Med.138(9): 73642.Ashrafian H. Int J Cardiol. 2006 Mar 8;107(3):421-3. 14. Signs of aortic insufficiency

Austin Flint murmur

Large-volume, 'collapsing' pulse

Bounding peripheral pulses (waterhammer)

Low diastolic BP and increased pulse pressure

Corrigans pulse (rapid upstroke and collapse of the carotid artery)

de Musset's sign (head nodding in time with the heart beat)

Quinckes sign (pulsation of the capillary bed in the nail)

Traube's sign (systolic and diastolic murmurs described as 'pistol shots' heard over the femoral artery when it is gradually compressed)

Duroziezs sign (double sound heard over the femoral artery when it is compressed distally)

Babu AN, et al. Ann Intern Med.138(9): 73642.Ashrafian H. Int J Cardiol. 2006 Mar 8;107(3):421-3. 15.

Lighthouse sign (blanching & flushing of forehead)

Landolfis sign (alternating constriction & dilatation of pupil)

Beckers sign (pulsations of retinal vessels)

Mllers sing (pulsations of uvula)

Mayens sign (diastolic drop of BP>15 mm Hg with arm raised)

Rosenbachs sign (pulsatile liver)

Gerhardts sign (enlarged spleen)

Hills sign- a 20 mmHg difference in popliteal and brachial systolic cuff pressures.

Lincolns sign (pulsatile popliteal)

Shermans sign (dorsalis pedis pulse is quickly located & unexpectedly prominent in age>75 yr)

Ashrafians sign (Pulsatile pseudo-proptosis)

Signs of aortic insufficiency 16. Pre-operative optimization

EKG: NSR, left axis deviation, LVH, PVCs

Labs: creatinine 1.5 (GFR 51 by MDRD)

IS HE OPTIMALLY PREPARED?

17. Circulation.2007;116:1971-1996 18. Circulation.2007;116:1971-1996 19. Circulation.2007;116:1971-1996 20. Clinical risk factors: RCRI Lee, et al. Circulation. 1999; 100: 1043 1049. 21. Despite patients anger and yelling

he was not cleared for surgery and was sent to the ER:

Aortic regurgitation with severe symptoms

• NYHA III-IV

• Orthopnea

• Hypertensive urgency with wide pulse pressure

• Unclear evolution surprising that was not diagnosed in recent hospitalization

22. Aortic regurgitation: Etiology

Idiopathic dilatation (annuloaortic ectasia)

Congenital (bicuspid valves)

Calcific degeneration (accompained by AS)

Rheumatic disease

Infective endocarditis

Systemic hypertension (cystic medial necrosis)

Myxomatous degeneration

Dissection of the ascending aorta

Marfan syndrome

Traumatic injuries

Ankylosing spondylitis

Syphilitic aortitis (tertiary)

Rheumatoid arthritis

Osteogenesis imperfecta

Giant cell aortitis

Ehlers-Danlos syndrome

Reiters syndrome

Whipple disease

Discrete subaortic stenosis

Ventricular septal defects with prolapse of an aortic cusp.

Anorectic drugs (Fenfluramine, dexfenfluramine)

Circulation2008;118;e523-e661 23. Natural history of AR Circulation2008;118;e523-e661 24. Natural history of chronic AR

Asymptomatic Patients With Normal EF

Variables associated with higher risk (likelihood of death, symptoms, and/or LV dysfunction):

• Age

• LV end-systolic dimension

• • > 50 mm had a dysfunction - 19% per year.

• • 40 to 50 mm - 6% per year,

• • < 40 mm 0%.

• LV end-diastolic dimension

• LV ejection fraction during exercise.

Circulation2008;118;e523-e661 25. TTE

Dilated LV size (300 cc end-diastolic volume) with moderate LVH. EF=50%.

• Left Ventricle ID(dia - cm):6.5

• Left Ventricle ID(sys - cm):3.6

Normal RV size and function

Bicuspid aortic valve. Severe (4+) AR with holodiastolic flow reversal in the descending arch.

Mildly dilated Aorta with effacement of the S-T junction. Aortic sinus(cm) - 4.3. Sino-tubular Junction(cm) - 3.5. Ascending Aorta(cm) - 3.8. Aortic Arch(cm) - 3.7.

Bi-atrial enlargement. LA index=28ml.

Trivial TR. RVSP=41mmHg c/w mild PHTN

26. LV Catheterization

LEFT MAIN: Normal.

LEFT ANTERIOR DESCENDING: 20-25% narrowing proximal mid and distal segment.

CIRCUMFLEX ARTERY: Minimal irregularities.

RIGHT CORONARY ARTERY: mild narrowing about 30% in the mid third.

LEFT VENTRICLE: Dilated. End diastolic size is increased. End systolic size is significantly increased. EF 35-40%. There are some PVC's and some mild mitral regurgitation.

AORTIC VALVE: Bicuspid. There is 4+aortic regurgitation. There is partial effacement of the sino-tubular junction on the right side. The ascending aorta is mildly dilated.

DIAGNOSIS:1. Severe aortic regurgitation secondary to bicuspid aortic valve. 2. Moderately severe left ventricular dysfunction. 3. Mild coronary artery disease. 4. Mild dilatation of the ascending aorta.

27. http://www.med.yale.edu/intmed/cardio/echo_atlas/entities/aortic_regurgitation.html 28. Circulation2008;118;e523-e661 29. Immediate Postoperative TEE

LV systolic function is normal.

RV systolic function is normal.

Bioprosthetic valve (Carpentier-Edwards #27). There is no aortic regurgitation.

30. 31. Case presentation

56 y/o eastern european male (living in USA for the past 5 years).

CC: Sigmoid adenocarcinoma

Referred for preoperative evaluation for sigmoidectomy and probable primary anastomosis

Surgery scheduled for the next day.

32. HPI

2 months with several episodes of hematochezia - colonoscopy showed a villotubular adenomatous polyp with focal areas of adenocarcinoma in-situ.

33. ROS

nocturnal diaphoresis

pleuritic chest pain

dry cough

34. Under further questioning:

5 months of nocturnal fever (100F) and diaphoresis,

• generalized arthralgias and bilateral ankle edema.

• A non-erosive arthritis was diagnosed and treated empirically with prednisone (PDN), but no definite diagnosis was made.

35. HPI.

2 months prior to visit was hospitalized for presumed pneumonia receiving i.v. antibiotics; PDN was stopped.

A chest CT scan revealed intra-thoracic lymphadenopathy and interstitial lung infiltrates.

36. HPI

PPD and IFN test for TB were positive

BAL: Negative AFB stain and mycobacterial cultures

Patient has history of BCG administration.

An axillary lymph node biopsy showed benign hyperplasia.

37. PMH, FH and PSH

PMH

• Well controlled HTN for 5 years

• No surgeries

Social H

• Smoker 16 ppy.

• No EtOH or drugs.

• Literature teacher

• Wife is an internist physician trained in Poland and works as Physician assistant in US.

FH

• Colon CA.

38. Medications

HCTZ 12.5 mg daily

Atenolol 50 mg daily

Centrum 1 tablet daily

Fish oil 1 tablet daily

Acetaminophen 1 g po qid prn

Sildenafil 50 mg prn

39. Preoperative assessment

Able to climb a flight of stairs (> 4 mets)

No previous anesthetic complications

No active cardiac symptoms

40. Physical exam

BP 140/85HR 67RR 22SpO2 94% (RA)

HEENT: PERRL, EOMI, MMM

Neck: supple, anterior cervical LAD mobile, increased in consistency, no goiter

Cor: RRR, normal S1, S2, no MRG

Chest: Decreased left breath sounds, no egophony or fremitus, minimal dullness on percussion on L

Abdomen: S, NT, ND, BS+, no masses

Extremities: Limitation of ROM of elbows, with discrete swelling and erythema of ankles bilaterally, no palpable synovitis.

41. Pre-operative assessment

EKG: NSR, HR 65

Labs: WNL

Is he optimally prepared?

42. 43. Despite angry complaints.

Surgery was delayed

Active symptoms suggestive of systemic inflammatory process warrant further assessment

A CXR was required

An urgent ID evaluation was requested

• High risk for TB

44.

WHAT TESTS WOULD YOU ORDER?

45. Further evaluation 46. Perioperative implications of pleural effusion

Restrictive ventilatory defect

VC

FRC

TLC

V/Q mismatchHypoxemia

• Atelectasis

• ventricular diastolic collapse (tamponade)

• C.O.

Gilmartin, et al. Thorax 1985; 40:6065. Agusti, et al. Am J Respir Crit Care Med 1997; 156:12051209. 47. Pleural effusion and mechanical ventilation Graf J. Current Opinion in Critical Care 2009; 15:1017. 48.

ID requested evaluation by Thoracic surgery

Unsuccessful US-guided thoracentesis

Thoracoscopy with pleural fluid drainage and pleural biopsy were done

http://www.thoracicmedicine.org 49. Perioperative air safety

Each cough = 600,000 droplets

Subsequently evaporate to form much smaller invisible droplet nuclei of up to 5 microns in size

Particles < 10 microns can reach the alveoli

Most concerning microorganism is Mycobacterium tuberculosis

Hickle R. Acta Anaesthesiol Scand Suppl. 1997;111:241-7. 50.

Cough inducing procedures

• Extubation

• Suctioning

• Average cough in PACU = 32 times during first 40 minutes of recovery

Cost analysis study estimated the expense associated with an episode of unprotected exposure to TB in the PACU:

• $57,000to$74,000

Perioperative air safety Hickle R. Acta Anaesthesiol Scand Suppl. 1997;111:241-7. 51. Perioperative air safety

N95 respirator prevents passage of 95% of particles>0.3 microns

Minimize personnel exposed

Isolation with negative pressure

Direct transfer to OR

Bacterial filter in ETT

Careful cleansing of OR and leaving room closed until air is completely changed

Neil J. AORN J. DEC 2008; 88 (6): 942-958 52. Perioperative air safety

Schedule aerosol-generating procedure at the end of the day

Attempt to do the procedure in the patients room

Use disposable anesthesia equipment

Neil J. AORN J. DEC 2008; 88 (6): 942-958 53. Patient with active pulmonary TB

Higher risk for temperature disregulation, hypoxemia and hypoventilation.

• Fever metabolic rate and cardiac output

Hypoxemia and hypoventilation occur due to anatomical lesions and necrotic lung parenchyma; atelectasis; pleural effusion

Malnutrition and weakness secretions clearance and ineffective cough

inspiratory and expiratory efforthypoventilation.

Neil J. AORN J. DEC 2008; 88 (6): 942-958 54. Pleural biopsy

• Fibrinous pleuritis with mesothelial hyperplasia.

• AFB stain was negative as well as mycobacterial cultures. Fungal serologies were negative.

• Pleural fluid is an exudate

55. Light RW. NEJM. 2002; 346 (25): 1971-1977 56. Yataco JC, Dweik R. CCJM. 2005; 72(10): 854-872. 57. Ancillary testing

ESR 99

CRP 11

Positive Rheumatoid factor

Positive anti-CCP antibodies

ANA, ANCA and hepatitis serology: negative

Complement was normal.

Pleural fluid Rheumatoid factor positive

58. Pleural rheumatoid factor

Can be elevated in:

Rheumatoid arthritis

SLE

Malignancy

Pneumonia

Tuberculosis

Yataco JC, Dweik R. CCJM. 2005; 72(10): 854-872. 59. Rheumatology consult

Considered that patient could undergo surgery.

Treatment would be started after surgery.

C-spine flexion and extension X-Rays were normal.

60. Preoperative lateral flexion-extension C-spine X-Rays

Progression of peripheral joint erosion parallels cervical spine disease

RF seropositivity associated with higher incidence of cervical spine involvement

C-spine involvement affects 15-86% of patients with RA

Patients with erosive RA 30-40% have C-spine disease

Macarthur A, et al. Can J Anaesth. 1993; 40: 154-9. Crosby ET. Can J Anaesth. 1990; 37: 77-93. 61.

Patient underwent sigmoidectomy with primary colorectal anastomosis. No further chemotherapy was advised.

http://nyp.org/masc/colorectal.htm 62. Post-operative

Prednisone and methotrexate were started with progressive improvement of articular and pulmonary symptoms.

Subsequently hydrocloroquine was added and prednisone dose was decreased.

ESR and CRP normalized after 3 months and symptoms improved dramatically.

63. Clinical conundrum

Pleuritis and interstitial lung disease are the most frequent pleuropulmonary manifestations of rheumatoid arthritis.

Co-existence of constitutional symptoms in a smoker patient with presumed TB as well as with a recent diagnosis of sigmoid cancer.

64. Take home message

Make precise diagnoses

Evaluate the extent of organ disease

Optimize medical diagnoses

Assess and describe physiologic limitations

Ensure adequate post-operative follow-up

Regardless of the patient's desire to "proceed with surgery" - we have an obligation to do what is in the patient's best interest and to provide the surgical team with the service that they expect....

65.