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Valut az rischio anest sia napoli dic 2008;italian + bibliografy

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Claudio Melloni

The document discusses the preoperative cardiac risk assessment for patients undergoing noncardiac surgery, emphasizing the importance of accurately predicting perioperative events and the need for appropriate risk stratification tools. It highlights various clinical factors affecting cardiac risk, such as age, specific medical conditions, and exercise tolerance, along with recommendations for evaluation and management before surgery. Additionally, it underscores that unnecessary interventions to merely reduce surgical risk should be avoided unless indicated by the patient's condition.

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La valutazione del rischio in anestesia Claudio Melloni Libero professionista Consulente di anestesia per Villa Torri,Villa Chiara,Poliambulatorio Gynepro Bologna
Rischio in anestesia
Limitazioni della lettura • Non si parla del rischio tecnico,legato alle attrezzature o alle diverse tecniche di anestesia • La lettura è piuttosto focalizzata alla valutazione preoperatoria,con excursus nella dinamica operatoria (presunta almeno….) • Ci si riferisce alla chir.noncardiaca
Critical Elements for Risk Stratification in Patients Undergoing Noncardiac Surgery • Risk-assessment tool must be accurate • Predicts perioperative events (positive likelihood ratio 10) • Predicts absence of perioperative events (negative likelihood ratio 0.2) • Risk-assessment tool must influence outcome • Identifies subgroups in which surgery should be cancelled or treatment changed • Identifies subgroups that do or do not benefit from proven therapy to reduce risk • Risk-assessment tool must have a favorable harms–benefit tradeoff
Cardiac Risk Index in Noncardiac Surgery Criteria Finding Age (yr) >70 5 Cardiac status MI within 6 mo 10 Ventricular gallop or jugular venous distention (signs of heart failure) 11 Significant aortic stenosis 3 Arrhythmia other than sinus or premature atrial contractions 7 ≥5 premature ventricular contractions/min 7 General medical condition Po2 < 60 mm Hg, Pco2 > 50 mm Hg, K < 3 mmol/L, HCO3 <20 mmol/L, BUN > 50 mg/dL, serum creatinine > 3 mg/dL, elevated AST, a chronic liver disorder, or bedbound 3 Type of surgery needed Emergency surgery 4 Intraperitoneal, intrathoracic, or aortic surgery 3 *Risk is based on the total number of points: Level I: 0–5 Level II: 6–12 Level III: 13–25 Level IV: >25 Adapted from Goldman L et al: Multifactorial index of cardiac risk in noncardiac surgical procedures. New England Journal of Medicine 297:845–850, 1977.
Revised cardiac risk index(RCRI) . Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L: Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major Noncardiac Surgery. Circulation 1999; 100: 1043-1049 • • High risk surgery • – intraperitoneal, intrathoracic or suprainguinal vascular procedures • • Ischemic heart disease • • H/O CHF • • H/O Cerebrovascular disease • • Insulin therapy for DM • • Preop Cr>2.0mg/dl
• Circulation. 1999 Sep 7;100(10):1043-9. Links • Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. • Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. • Department of Medicine, Brigham and Women's Hospital and Harvard Medical
• Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, Fleisher LA, Froehlich JB, Gusberg RJ, Leppo JA, Ryan T, Schlant RC, Winters WL, Jr., Gibbons RJ, Antman EM, Alpert JS,Faxon DP, Fuster V, Gregoratos G, Jacobs AK, Hiratzka LF, Russell RO, Smith SC, Jr.: ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery--- executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 2002;105: 1257-67
• Importance of Surgical Procedure • The surgical procedure influences the extent of the preoperative evaluation required by determining the potential range of changes in perioperative management. There is little hard data to define the surgery specific incidence of complications, and the rate may be very institution depedendent. Eagle et. al. published data on the incidence of perioperative myocardial infarction and mortality by procedure for patients enrolled in the coronary artery surgery study (CASS).6 Higher risk procedures for which coronary artery bypass grafting reduced the risk of noncardiac surgery compared to medical therapy include major vascular, abdominal, thoracic, and orthopedic surgery. Ambulatory procedures denote low risk. Vascular surgery represents a unique group of patients in whom there is extensive evidence regarding preoperative testing and perioperative interventions.
• Importance of exercise tolerance • Exercise tolerance is one of the most important determinants of perioperative risk and the need for invasive monitoring. If a patient can walk a mile without becoming short of breath, than the probability of extensive coronary artery disease is small. Alternatively, if patients become dyspneic associated with chest pain during minimal exertion, then the probability of extensive coronary artery disease is high. Reilly and colleagues demonstrated that the likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked or flights of stairs that could be climbed.7 Exercise tolerance can be assessed with formal treadmill testing or with a questionnaire that assesses activities of daily living.
• Reilly DF, McNeely MJ, Doerner D, Greenberg DL, Staiger TO, Geist MJ, Vedovatti PA, Coffey JE, Mora MW, Johnson TR, Guray ED, Van Norman GA, Fihn SD: Self-reported exercise tolerance and the risk of serious perioperative complications. Arch Intern Med 1999; 159: 2185-92
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jr., Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B: ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update 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, and Society for Vascular Medicine and Biology. Circulation 2006; 113: 2662-74.
• Yang H, Raymer K, Butler R, Parlow J, Roberts R: The effects of perioperative beta- blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J 2006; 152: 983-90 • Juul AB, Wetterslev J, Gluud C, Kofoed-Enevoldsen A, Jensen G, Callesen T, Norgaard P, Fruergaard K, Bestle M, Vedelsdal R, Miran A, Jacobsen J, Roed J, Mortensen MB, Jorgensen L, Jorgensen J, Rovsing ML, Petersen PL, Pott F, Haas M, Albret R, Nielsen LL, Johansson G, Stjernholm P, Molgaard Y, Foss NB, Elkjaer J, Dehlie B, Boysen K, Zaric D, Munksgaard A, Madsen JB, Oberg B, Khanykin B, Blemmer T, Yndgaard S, Perko G, Wang LP, Winkel P, Hilden J, Jensen P, Salas N: Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. Bmj 2006; 332: 1482 • Wallace AW, Galindez D, Salahieh A, Layug EL, Lazo EA, Haratonik KA, Boisvert DM, Kardatzke D: Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery. Anesthesiology 2004; 101: 284-93. • Hindler K, Shaw AD, Samuels J, Fulton S, Collard CD, Riedel B: Improved postoperative outcomes associated with preoperative statin therapy. Anesthesiology 2006; 105: 1260- 72. Durazzo AE, Machado FS, Ikeoka DT, De Bernoche C, Monachini MC, Puech-Leao P, Caramelli B: Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. J Vasc Surg 2004;39: 967-75
• (http://www.acc.org/qualityandscience/clinic al/topic/topic.htm).
Key words • perioperative risk • cardiac risk, • noncardiac surgery, • intraoperative risk, • postoperative risk, • risk stratification, • cardiac complication, • cardiac evaluation, • perioperative care, • preoperative evaluation, • preoperative assessment • intraoperative complications.
Scopi della valutazione cardiaca preop • 1)identificazione dei pazienti con rischio cardiaco troppo alto,non accettabile • 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop. • 3)identificazione dei pazienti che possono beneficiare di intervento di CABG
Come può la visita preop modificare il trattamento?
Fattori che determinano il rischio cardiaco periop • Marcatori clinici • Capacità funzionale • Intervento chirurgico
I marcatori clinici condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie: • 1)instabilità coronarica;per esempio un MI recente o una angina instabile o severa; • 2)Insufficienza cardiaca scompensata;NYHA Classe IV o una insufficienza in peggioramento o di nuova insorgenza; • 3)aritmie significative;blocco AV di alto grado(Mobitz 2,BAV 3,aritmie ventricolari sintomatiche,aritmie sopraventricolari con ritmo cardiaco non controllato,tachicardia sintomatica,tachicardia ventricolare di nuova scoperta. • 4)malattia valvolare severa,cioè stenosi aortica serrata o stenosi mitralica sintomatica.
• The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context. • The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patient’s current medical status; make recommendations concerning the evaluation, management, and risk of cardiac problems over the entire perioperative period; and provide a clinical risk profile that the patient, primary physician, and nonphysician caregivers, anesthesiologist, and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes. • No test should be performed unless it is likely to influence patient treatment. • The goal of the consultation is the optimal care of the patient
Condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie • Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop • Scarsa capacità funzionale(<4 MET) • Chirurgia ad alto rischio (rischio cardiovascolare periop > 5%)
Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I, Level of Evidence: B):major clinical predictors
Estimated Energy Requirements for Various Activities
MET: equivalenti energetici indice delle possibilità energetiche per varie attività • scaletta dei MET :risposta a domande semplici,quali: • sei in grado di avere cura di te stesso?mangiare,bere,usare la toilette(MET 1)?; • puoi camminare in casa (MET 2) ; • puoi camminare 100-200m in piano alla velocità di 3-4.5 Km/h?(Met 3); • puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti?(MET 4); • puoi salire una rampa di scale o in salita?o camminare in piano a 6,5 Km/h o correre per una breve distanza?(Met 5). • Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere mobilio pesante(Met 6-7)? • Puoi partecipare a attività ricreative leggere come giocare a golf,a bocce,ballare,giocare a tennis in doppio,o lanciare la palla a baseball o calcio(MET 8-9)? • Puoi partecipare a sport pesanti come il nuoto,tennis in singolo,calcio,pallacanestro o sci?(Met 10).
Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater. *
• See Table 2 for active clinical conditions. • †See Table 3 for estimated MET level equivalent. ‡Clinical risk factors include ischemic heart disease, compensated or prior HF, diabetes mellitus, renal insufficiency, and cerebrovascular disease. §Consider perioperative beta blockade (see Table 11) for populations in which this has been shown to reduce cardiac morbidity/mortality. ACC/AHA indicates American College of Cardiology/American Heart Association; HR, heart rate; LOE, level of evidence; and MET, metabolic equivalent
La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco • rischio di MI o morte cardiaca superiore al 5%: – chirurgia vascolare maggiore(aortica) e quella periferica; • a rischio intermedio ,compreso fra 1 e 5%: la chirurgia intraperitoneale ed intratoracica endoarterectomia carotidea chirurgia della testa e del collo chirurgia ortopedica maggiore chir prostatica. • rischio minore,inferiore all’1% : – procedure endoscopiche, – superficie corporea – chirurgia per cataratta – Chir mammaria.
Cardiac Risk* Stratification for Noncardiac Surgical Procedures
Scopi dei test aggiuntivi cardiovascolari • Fornire una misura obbiettiva di capacità funzionale • Identificare una ischemia preop miocardica importante • Diagnosticare aritmie cardiache rilevanti • Stimare il rischio cardiaco periop e definire una prognosi
Valut az rischio anest sia napoli dic 2008;italian + bibliografy
Dipiridamolo tallio • the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events. In order to increase the predictive value of the test, several strategies have been suggested. Lung uptake, left ventricular cavity dilation, and redistribution defect size have all been shown to be predictive of subsequent morbidity.10
Dobutamine stress test • Dobutamine stress echocardiography has been suggested as the best preoperative test in several recent meta-analyses.11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test. The advantage of this test is that it is a dynamic assessment of ventricular function. Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values. Poldermans et al. demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates.12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial.13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics.11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death
Noninvasive Stress Testing Recommendations for Noninvasive Stress Testing Before Noncardiac Surgery • CLASS I • 1. Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be evaluated and treated per ACC/AHA guidelines† before noncardiac surgery. (Level of Evidence: B) • CLASS IIa • 1. Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity (less than 4 METs) who require vascular surgery‡ is reasonable if it will change management. (Level of Evidence: B) • CLASS IIb • 1. Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management. (Level of Evidence: B) • 2. Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery. (Level of Evidence: B) • CLASS III • 1. Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk noncardiac surgery. (Level of Evidence: C) • 2. Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery. (Level of Evidence: C)
Razionale dei test non invasivi preop nella valutazione del rischio Test non invasivi Paz con valori del test anormali Valori predittivi per morte o MI periop Positivo : negativo Monitoraggio ECG ambulat 9-39% 4-15 1-16 Esercizio con monitoraggio ECG 16-70% 5-25 90-100 Dipiridamolo-tallio Chir vasc 22-69 4-20 95-100 Chir non vasc 23-47 8-27 98-100 Eco cardio grafia stress dobutamina 23-50 7-23 93-100
EF preop e outcome cardiaco postop. (Franco et al,J Vasc Surg 10;656:1989) EF>55% N=50 EF 35-55% N=20 EF 20-35% N=15 MI 19% 15% 20% Morte 0 0 13%
Chir vasc dopo precedente rivascolarizzazio ne Chir vascolare senza prec edente rivascolarizzazio ne Complicazioni % Mortalità % Complicazioni % Mortalità % angiografia 0.2-0.5 0.1-0.5 - - PTCA/CABG 3-13 1-5.5 - - Chir vasc 0.3-2 0.3-0.4 0.6-11.7 0.6-10 Rischio globale 3.5-10.5 1.4-12.4 0.6-11.7 0.8-10 Ma…….. Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate Diminuiscono il rischio cardiovascolare a lungo termine Aumentano il rischio cardiaco a lungo termine Rischio globale a ?? ??
Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et al,Circulation 1997 96 1892-7 N=395 N=582 N=964
Cardiac outcome in low risk surgery:n=1297
Incidenza di mortalità periop in pazienti con CAD(n=1632) Eagle et al High risk surgery >=4% Low risk surgery<=4% Abdominal 4% Urologic 1.8 Vascolare 11.3 Orthopedic 1.2 Thoracic 7.7 Skin 0 Head neck 7.3 Miscellaneous 3
Cardiac outcome in noncardiac surgery following CABG
Class I indications for preop coronary angiography in non cardiac surgery • High risk results during non invasive testing • Amgina pectoris unresponsive to adequate medical therapy • Most patients with unstable angina pectoris • Nondiagnostic or equivocal noninvasive test result in a high risk patient undergoing a high risk noncardiac surgical procedure
Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac surgery, based on expert opinion
BETA BLOCCANTI E CHIRURGIA NON CARDIACA
Perioperative Beta-Blocker Therapy Recommendations for Beta-Blocker Medical Therapy • CLASS I • 1. Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA class I guideline indications. (Level of Evidence: C) • 2. Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing. (Level of Evidence: B) • CLASS IIa • 1. Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative assessment identifies CHD. (Level of Evidence: B) • 2. Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery identifies high cardiac risk, as defined by the presence of more than 1 clinical risk factor.* (Level of Evidence: B) • 3. Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high cardiac risk, as defined by the presence of more than 1 clinical risk factor,* who are undergoing intermediate-risk or vascular surgery. (Level of Evidence: B) • CLASS IIb • 1. The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or vascular surgery, in whom preoperative assessment identifies a single clinical risk factor.* (Level of Evidence: C) • 2. The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers. (Level of Evidence: B) • CLASS III • 1. Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta blockade. (Level of Evidence: C)
Indicazioni ai beta bloccanti • i betabloccanti devono essere continuati nel periop per coloro che li assumono per indicazione di angina,aritmie sitomatiche,ipertensione o altre indicazioni delle linee guida ACC/AHA di classe I. • i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B). • I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia e/o un elevato rischio cardiaco ,definito come la presenza di più di 1 fattore di rischio clinico ,anche se vanno incontro a chirurgia classificata come rischio intermedio . • l’utilità dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B). • Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego. • In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco
Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 1999;341;1789-94 Bisoprolol n=59 Standard care n=53 Cardiac death 2(3,4%) 9(17%) * Non fatal MI 0 9(17%) ** Total 2(3.4%) 18(34%) ** *=p<0.02 **=p<0.01
• N Engl J Med. 1999 Dec 9;341(24):1789-94. Links • Comment in: N Engl J Med. 1999 Dec 9;341(24):1838-40. N Engl J Med. 2000 Apr 6;342(14):1051-2; author r N Engl J Med. 2000 Apr 6;342(14):1052; author rep Rev Cardiovasc Med. 2001 Winter;2(1):25-6. The effect of bisoprolol on perioperative mortality and myocardial infarction in high- risk patients undergoing vascular surgery.
Weksler N, Klein M, Szendro G, Rozentsveig V, Schily M, Brill S, Tarnopolski A, Ovadia L, Gurman GM: The dilemma of immediate preoperative hypertension: to treat and operate, or to postpone surgery? J Clin Anesth 2003; 15: 179-83 • There is a great deal of debate regarding a trigger to delay or cancel a surgical procedure in a patient with poorly or untreated hypertension • In the absence of end-organ changes, such as renal insufficiency or left ventricular hypertrophy with strain, it would seem appropriate to proceed with surgery. • A randomized trial of treated hypertensive patients without known CAD who presented the morning of surgery with an elevated diastolic blood pressure was unable to demonstrate any difference in outcome between those who were actively treated versus those in whom surgery was delayed. • In contrast, a patient with a markedly elevated blood pressure and the new onset of a headache should have surgery delayed for further evaluation and potential treatment..
Howell SJ, Sear YM, Yeates D, Goldacre M, Sear JW, Foëx P. Hypertension, admission blood pressure and perioperative cardiovascular risk. Anaesthesia 1996;51:1000-1004. • A retrospective case-controlled study which found that a history of hypertension was an important predictor for perioperative cardiac death but not admission blood pressure. • The study implies that end-organ damage resulting from hypertension is the likely villain in this group of patients.
• In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications
• Adrenergic Receptor Genotype but Not Perioperative • Bisoprolol Therapy May Determine Cardiovascular Outcome • in At-risk Patients Undergoing Surgery with Spinal Block • The Swiss Beta Blocker in Spinal Anesthesia (BBSA) Study: A Double-blinded, • Placebo-controlled, Multicenter Trial with 1-Year Follow-up • Michael Zaugg, M.D.,* Lukas Bestmann, Ph.D.,†
Periop statin therapy • Recommendations for Statin Therapy • CLASS I • 1. For patients currently taking statins and scheduled for noncardiac surgery, statins should be continued. (Level of Evidence: B) • CLASS IIa • 1. For patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable. (Level of Evidence: B) • CLASS IIb • 1. For patients with at least 1 clinical risk factor who are undergoing intermediate-risk procedures, statins may be considered. (Level of Evidence: C)
terapia preoperatoria con statine • La terapia preoperatoria con statine deve essere continuata per coloro che le assumono già (livello di evidenza B); • la loro somministrazione è ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B): • Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)
• usinSchouten, Olaf MD a; Poldermans, Don MD, PhD b; Visser, Loes MD b; Kertai, Miklos D. MD c; Klein, Jan MD, PhD b; van Urk, Hero MD, PhD a; Simoons, Maarten L. MD, PhD c; van de Ven, Louis L. MD, PhD c; Vermeulen, Maarten MSc c; Bax, Jeroen J. MD, PhD d; Lameris, Thomas W. MD, PhD c; Boersma, Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery: Rationale and design of the DECREASE-IV study. American Heart Journal. 148(6):1047-1052, December 2004
Eur J Vasc Endovasc Surg. 2004 Oct;28(4):343-52. Links A combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery. Kertai MD, Boersma E, Westerhout CM, Klein J, Van Urk H, Bax JJ, Roelandt JR, Poldermans D . • Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands. • OBJECTIVE: To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA). BACKGROUND: Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers. METHODS: We studied 570 patients (mean age 69+/-9 years, 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC. Patients were evaluated for clinical risk factors (age>70 years, histories of MI, angina, diabetes mellitus, stroke, renal failure, heart failure and pulmonary disease), DSE, statin and beta-blocker use. The main outcome was a composite of perioperative mortality and MI within 30 days of surgery. RESULTS: Perioperative mortality or MI occurred in 51 (8.9%) patients. The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence interval (CI): 0.13-0.74; p=0.01). After correcting for other covariates, the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR: 0.24, 95% CI: 0.10-0.70; p=0.01). Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR: 0.24, 95% CI: 0.11-0.54). Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata; particularly patients with 3 or more risk factors experienced significantly lower perioperative events. CONCLUSIONS: A combination of statin and beta-blocker use in patients with AAA- surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk.
Eur J Vasc Endovasc Surg. 2004 Oct;28(4):343-52. Links A combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery. Kertai MD, Boersma E, Westerhout CM, Klein J, Van Urk H, Bax JJ, Roelandt JR, Poldermans D. • 570 pazienti sottoposti a chirurgic dell’aorta addominale • Perioperative mortality or MI occurred in 51 (8.9%) patients. • Perioperative mortality or MI significantly lower in statin users compared to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence interval (CI): 0.13-0.74; p=0.01). • Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR: 0.24, 95% CI: 0.11-0.54). • Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata; particularly patients with 3 or more risk factors experienced significantly lower perioperative events. CONCLUSIONS: A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk. •
• Attenzione però che è necessario che il beta bloccante sia effettivamente efficace nel controllare la FC;infatti solo se la FC rimane < 100 bpm se ne dimostra l’efficacia………….
Anesth Analg 2008;106:1039 –48, Beattie WS, Wijeysundera DN, Karkouti K, McCluskey S, Tait G.) • Metanalisi:molti degli studi sull’argomento sono estremamente eterogenei e solo quando la massima frequenza cardiaca misurata era inferiore a 100 bpm, si aveva un significativo effetto protettivo (OR 0.23; 95% CI 0.08–0.65; P=0.005), mentre quando questo target non era raggiunto non vi era alcuna efficacia dimostrabile (OR 1.17; 95% CI 0.79–1.80; P=0.43) • Inoltre, con l’utilizzo di una meta-regressione si dimostra un’associazione lineare tra l`effetto del Bbloccante sulla frequenza cardiaca (media, massima, e sulla sua variazione) e l`incidenza di IM (r2=0.63; P=0.001), dove una maggiore efficacia del Bbloccante era associato ad una riduzione di incidenza di IM postoperatorio
Anesthesiology. 2004 Aug;101(2):284-93.Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery. Wallace AW, Galindez D, Salahieh A, Layug EL, Lazo EA, Haratonik KA, Boisvert DM, Kardatzke D. • Department of Anesthesia and Perioperative Care, University of California, USA. awallace@cardiacengineering.com • BACKGROUND: Perioperative myocardial ischemia occurs in 20-40% of patients at risk for cardiac morbidity and is associated with a ninefold increase in risk of cardiac morbidity. METHODS: In a prospective, double-blinded, clinical trial, we studied 190 patients with or at risk for coronary artery disease in two study groups with a 2:1 ratio (clonidine, n = 125 vs. placebo, n = 65) to test the hypothesis that prophylactic clonidine reduces the incidence of perioperative myocardial ischemia and postoperative death in patients undergoing noncardiac surgery. Clonidine (0.2 mg orally as well as a patch) or placebo (tablet and patch) was administered the night before surgery, and clonidine (0.2 mg orally) or placebo (tablet) was administered on the morning of surgery. The patch or placebo remained on the patient for 4 days and was then removed. RESULTS: The incidence of perioperative myocardial ischemia was significantly reduced with clonidine (intraoperative and postoperative, 18 of 125, 14% vs. placebo, 20 of 65, 31%; P = 0.01). Prophylactic clonidine administration had minimal hemodynamic effects. Clonidine reduced the incidence of postoperative mortality for up to 2 yr (clonidine, 19 of 125 [15%] vs. placebo, 19 of 65 [29%]; relative risk = 0.43 [confidence interval, 0.21-0.89]; P = 0.035). CONCLUSIONS: Perioperative administration of clonidine for 4 days to patients at risk for coronary artery disease significantly reduces the incidence of perioperative myocardial ischemia and postoperative death.
Wallace AW, Galindez D, Salahieh A, Layug EL, Lazo EA, Haratonik KA, Boisvert DM, Kardatzke D .Effect of clonidine on cardiovascular morbidity andmortality after noncardiac surgery.Anesthesiology. 2004 Aug;101(2):284-93.
Long term protection offered by 4 days of perioperative clonidine in patients at risk of CAD
• Am J Med. 2009 Jan 28. [Epub ahead of print] Links • Perioperative Beta-blockers for Major Noncardiac Surgery: Primum Non Nocere. • Chopra V, Plaisance B, Cavusoglu E, Flanders SA, Eagle KA. • Division of General Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor.
• Lancet. 2008 Dec 6;372(9654):1962-76. Epub 2008 Nov 13. Links • Comment in: Lancet. 2008 Dec 6;372(9654):1930-2. Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis. • Bangalore S, Wetterslev J, Pranesh S, Sawhney S, Gluud C, Messerli FH. • Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA.
• Anesth Analg. 2007 Jan;104(1):27-41. Links • Comment in: Anesth Analg. 2007 Jan;104(1):1-3. Perioperative beta-blockers for preventing surgery-related mortality and morbidity: a systematic review and meta-analysis. • Wiesbauer F, Schlager O, Domanovits H, Wildner B, Maurer G, Muellner M, Blessberger H, Schillinger M. • Department of Cardiology, Vienna General
• Diabetics share the same risks as patients with cardiac ischemia,renal insufficiency or cerebrovascular atherosclerotic disease***(42 Haffner
• Risks of the diabtiecs;autonomic dysfunction • Difficult intubation………..see lavoro Nova pub
• Anesth Analg. 2008 Dec;107(6):1919-23. Links • The extended Mallampati score and a diagnosis of diabetes mellitus are predictors of difficult laryngoscopy in the morbidly obese. • Mashour GA, Kheterpal S, Vanaharam V, Shanks A, Wang LY, Sandberg WS, Tremper KK. • Department of Anesthesiology, University of Michigan Medical School, Ann Arbor,
• J Postgrad Med. 2000 Apr-Jun;46(2):75-9. Links • The palm print as a sensitive predictor of difficult laryngoscopy in diabetics: a comparison with other airway evaluation indices. • Vani V, Kamath SK, Naik LD. • Department of Anaesthesiology, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India.
• : Anesth Analg. 1998 Mar;86(3):516-9. Links • Diabetes mellitus and difficult laryngoscopy in renal and pancreatic transplant patients. • Warner ME, Contreras MG, Warner MA, Schroeder DR, Munn SR, Maxson PM. • Department of Anesthesiology, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA. • Limited mobility of the cervical spine or
• (44) while : Anesth Analg. 1998 Mar;86(3):516-9. Links • Diabetes mellitus and difficult laryngoscopy in renal and pancreatic transplant patients. • Warner ME, Contreras MG, Warner MA, Schroeder DR, Munn SR, Maxson PM. • Department of Anesthesiology, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA. • Limited mobility of the cervical spine or temperomandibular joint may contribute to increased difficulty of laryngoscopy in patients who have severe diabetes mellitus. The frequency of difficult laryngoscopy in diabetics undergoing renal and/or pancreatic transplants has been reported to be as high as 32%. We retrospectively reviewed the anesthetic records of all adult patients who underwent renal and/or pancreatic transplant and endotracheal intubation from January 1, 1985 to October 31, 1995. Characteristics specifically reviewed included the presence of diabetes mellitus, type of organ donor, age, gender, body mass index, previous difficult laryngoscopy, known characteristics potentially related to difficult laryngoscopy, and degree of difficulty with laryngoscopy. Laryngoscopy was graded as easy, minimally to moderately difficult, and moderately to extremely difficult to perform. Factors associated with any degree of difficult intubation were univariately assessed by using Fisher's exact test. Of 725 patients, 15 (2.1%) were identified as having difficult laryngoscopies, although all underwent successful endotracheal intubations. Factors associated with difficult laryngoscopy were diabetes mellitus (P = 0.002) and characteristics known to be related to difficult laryngoscopy (P = 0.02). These findings confirm an increase in the frequency of difficult laryngoscopy in diabetic patients undergoing renal and/or pancreatic transplant, although no laryngoscopies were rated as moderately to extremely difficult. We conclude that the frequency of difficult laryngoscopy in these diabetic patients is much lower than previous reports have suggested. IMPLICATIONS: Previous studies have suggested that airway management of many diabetic patients may be difficult. Our medical record review of patients with severe diabetes undergoing organ transplants showed that extraordinary techniques were not required to successfully manage their airways. • Difficult Laryngoscopy and • Diabetes Mellitus • Key Words: INTUBATION, TRACHEAL-diabetes • and COMPLICATIONS, DIABETES MELLITUS. • METABOLISM, DIABETES MELLITUS. • To the Editor: • Like the authors, we too were surprised by the extremely • high incidence (32!%) of difficult laryngoscopy in diabetic • renal transplant patients reported by Hogan et al. (1). They • suggested that "stiff joint syndrome," a condition occasionally • seen in type I insulin-dependent diabetics, may have • been a major cause of this finding. Because their results • were so striking, we investigated the incidence of difficult • laryngoscopy and intubation in similar patients at our • institution.
Heart failure as a risk factor
Hammill BG,Curtis,LH,Bennett-Guerrior E,O’Connor,CM,Jollis JC,Schulman KA,Hernandez AF.Impact of heart failure on patients undergoing major noncardiac surgery.Anesthesiology 2008;108:559- 67 • Medicare 5% standard analytic files • Inpatients fee for service claims 2000-20004 • Patients >65 for major noncardiac surgery: – Carotid endarterectomy – Lower extr bypass – Open AAA – Hip replacement – Knee replacement – Spinal fusion – Above and below knee amputation – Open and laparoscopic cholecystectomy – Cancer resection abdominal,lung,colon
Hammill et al.Impact of heart failure on patients undergoing major noncardiac surgery.Anesthesiology • Main outcome : – Operative mortality – 30 days readmission
Hammill et al. Impact of heart failure on patients undergoing major noncardiac surgery.Anesthesiology 2008;108(4): 559-567 • I pazienti di età ≥65 anni • inseriti nel programma assicurativo statunitense Medicare • sottoposti, tra il 2000 e il 2004, ad uno tra tredici tipi di chirurgia maggiore non- cardiaca. • esclusi dall’analisi i pazienti con insufficienza renale terminale e quelli che non avessero soddisfatto, da almeno un anno, i criteri Medicare® per la sottoscrizione di una polizza. • 159.327 interventi,: 18% eseguiti in pazienti con insufficienza cardiaca e il 34% in pazienti con cardiopatia ischemica. • I rischi relativi corretti di mortalità e riammissione per i pazienti con insufficienza cardiaca, rispetto a quelli che non presentavano né insufficienza cardiaca né cardiopatia ischemica, erano 1.63 (intervallo confidenza 95%: 1.52-1.74) e 1.51 (intervallo confidenza 95%: 1.45-1.58), rispettivamente. • I rischi relativi corretti di mortalità e riammissione per i pazienti con cardiopatia ischemica, rispetto a quelli che non presentavano né insufficienza cardiaca né cardiopatia ischemica, erano 1.08 (intervallo confidenza 95%: 1.01-1.16) e 1.16 (intervallo confidenza 95%: 1.12-1.20), rispettivamente.
Characteristics of the study population by disease group heart faliure Cad normal età 79,4 75,3 75,6 Masch i% 42 48,8 34,4 nerii% 8,5 5,2 5,6 teaching hospitali% 16,9 19,7 16,3 admitted form a skilled nursing facilityi% 1,5 0,4 0,4 urgent admissioni% 19,2 13,8 14,5 emergent admissionji% 30 19 16,7 COPDi% 45,1 31,1 22,2 CADi% 81 100 0 dementiai% 9,1 5,1 4,1 diabetesi% 43,4 30,5 19,6 histrory of strokei% 26,9 21,5 11,4 hypertensioni% 86,4 82,4 66,8 periph vasc.diseasei% 46,3 36,3 17,9 renal diseasei% 15,2 5,2 2,7
Operative mortality HF CAD normal total 8 3,1 2,4 > Knee amput 25.8 18 16 <knee amput 12.8 10.4 7.2 Carotid endarterec tomy 2,5 1,2 0,9 Colon cancer resection 11.9 6.3 5.4 Hip replacement 8.4 3.9 2.8 Knee replacement 0.9 0.4 0.3 Laparoscopic cholecystectomy 5.6 2.1 1.8 Lower extremity bypass 8.1 3.7 4.1 Open AAA repair 10.3 5.8 4.8 Other abdominal cancer resections 11.8 4.3 4.9 Pulmonary cancer resection 10.2 6.0 4.1
30 day readmission HF CAD normal total 17.1 10.8 8.1 > Knee amput 25.2 21.6 18.9 <knee amput 24.1ns 23.4ns 19.9 ns Carotid endarterectomy 15.2 10.8 8.7 Colon cancer resection 18 13.2 10.5 Hip replacement 16.6 10.3 8.8 Knee replacement 9.9 6.2 4.7 Laparoscopic cholecystectomy 16.4 10.1 8.4 Lower extremity bypass 27.2 18.2 16.2 Open AAA repair 14.8 10.3 11.4 Other abdominal cancer resections 17.3 12.6 11.8 Pulmonary cancer resection 17.4 15.5 11.3 Spinal fusion
Effect of heart failure and CAD on mortality per procedure
Operative mortality and readmission rate for HF patients with or without CAD
Conclusion from the study of Hammil et al • Heart Failure patients : –mortality risk 63% –Readmission risk 51%
Hernandez AF, Whellan DJ, Stroud S, Sun JL, O’Connor CM, Jollis JG. Outcomes in heart failure patients after major noncardiac surgery. J Am Coll Cardiol. 2004;44(7):1446-1453 • OBJECTIVES: The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery. BACKGROUND: There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients. METHODS: Using the 1997 to 1998 Standard Analytic File 5% Sample of Medicare beneficiaries, we identified patients with HF who underwent major noncardiac surgery. A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery. Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups. RESULTS: Of 23,340 HF patients and 28,710 CAD patients, 1,532 (6.56%) HF patients and 1,757 (6.12%) CAD patients underwent major noncardiac surgery. There were 44,512 patients in the Control group with major noncardiac surgery. After accounting for demographic characteristics, type of surgery, and comorbid conditions, the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 11.7%, CAD 6.6%, and Control
PHILLIPS, FRANKLIN A. MICHOTA,W. H. WILSON TANG, CHRISTOPHER M. WHINNEY, ASHOK PANNEERSELVAM, ERIC D. HIXSON,MARIO GARCIA, GARY S. FRANCIS, AMIR K. JAFFER. Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac Surgery.Mayo Clin Proc. 2008;83(3):280- 288 • il rischio operatorio viene minimizzato dalla ottimizzazione preoperatoria effettuata dal servizio di medicina interna ,con abbattimento notevole della mortalità e morbilità :solo la sopravvivenza ad un anno è ridotta rispetto ai pazienti di controllo,come è logico attendersi in ogni caso in pazienti portatori di malattia cronica seria.
YE OLIVIA XU-CAI, DANIEL J. BROTMAN, CHRISTOPHER O. PHILLIPS, FRANKLIN A. MICHOTA,W. H. WILSON TANG, CHRISTOPHER M. WHINNEY, ASHOK PANNEERSELVAM, ERIC D. HIXSON,MARIO GARCIA, GARY S. FRANCIS, AMIR K. JAFFER. Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac Surgery.Mayo Clin Proc. 2008;83(3):280-288
Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI, DANIEL J. BROTMAN, CHRISTOPHER O. PHILLIPS, FRANKLIN A. MICHOTA,W. H. WILSON TANG, CHRISTOPHER M. WHINNEY, ASHOK PANNEERSELVAM, ERIC D. HIXSON,MARIO GARCIA, GARY S. FRANCIS, AMIR K. JAFFER. Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac Surgery.Mayo Clin Proc. 2008;83(3):280-288
Valut az rischio anest sia napoli dic 2008;italian + bibliografy
YE OLIVIA XU-CAI, DANIEL J. BROTMAN, CHRISTOPHER O. PHILLIPS, FRANKLIN A. MICHOTA,W. H. WILSON TANG, CHRISTOPHER M. WHINNEY, ASHOK PANNEERSELVAM, ERIC D. HIXSON,MARIO GARCIA, GARY S. FRANCIS, AMIR K. JAFFER. Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac Surgery.Mayo Clin Proc. 2008;83(3):280-288 • Our data suggest that perioperative mortality is surprisingly low (<2%) in patients with clinically stable HF— regardless of EF— undergoing elective noncardiac surgery. • At 1 year, crude mortality rates for patients with HF with reduced EF (13.5%) or with preserved EF (6.3%) were significantly higher than for controls (3.1%). However, we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months. This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF, particularly those with low EF, represents the background mortality expected in patients with chronic illnesses. • Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF
Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery Preoperative evaluation at the Internal Medicine Preoperative Assessment Consultation and T reatment (IMPACT) Center at the Cleveland Clinic
Unrecognized MI and silent myocardial ischemia • Unrecognized MI:, determined by rest wall motion abnormalities in the absence of a history of MI. • Silent myocardial ischemia ;stress-induced wall motion abnormalities in the absence of angina pectoris • 23 and 28% respectiverly in pts undergoing major vascular surgery! – Feringa HH, Karagiannis SE, Vidakovic R, Elhendy A, ten Cate FJ, Noordzij PG, van Domburg RT, Bax JJ, Poldermans D. The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery. Coron Artery Dis. 2007 Nov;18(7):571-6.
.N-TERMINAL PRO-BRAIN NATRIURETIC PEPTIDE .ENDOGENOUS NITRIC OXIDE SYNTHASE INHIBITOR ASYMMETRIC DIMETHYLARGININE . POLYMORPHISMS IN PLATELET GLYCOPROTEIN (GP) IIIA AND GPIB[ALPHA] Laboratory markers for cardiac risk after noncardiac surgery
Laboratory markers for cardiac risk after noncardiac surgery • Elevated NT-proBNP levels are independently associated with an increase in the risk of perioperative cardiovascular KO – Yun KH, Jeong MH, Oh SK, Choi JH, Rhee SJ, Park EM, Yoo NJ, Kim NH, Ahn YK, Jeong JW.Preoperative plasma N-terminal pro-brain natriuretic peptide concentration and perioperative cardiovascular risk in elderly patients.Circ J.2008 Feb;72(2):195-9. – Leibowitz D, Planer D, Rott D, Elitzur Y, Chajek-Shaul T, Weiss ATBrain natriuretic peptide levels predict perioperative events in cardiac patients undergoing noncardiac surgery: a prospective study. Cardiology. 2008;110(4):266-70. Epub 2007 Dec 12. • per 0.1-micromol/L increment in plasma ADMA concentration, the odds ratio to experience the primary end point increased by 1.26 – Maas R, Dentz L, Schwedhelm E, Thoms W, Kuss O, Hiltmeyer N, Haddad M, Klöss T, Standl T, Böger RH.Elevated plasma concentrations of the endogenous nitric oxide synthase inhibitor asymmetric dimethylarginine predict adverse events in patients undergoing noncardiac surgery. Crit Care Med. 2007 Aug;35(8):1876-81 • Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha]. Pro33 and Met145 genotypes were independent predictors of composite ischemic outcome – Faraday, Nauder , Martinez, Elizabeth A. Scharpf, Robert B. Kasch-Semenza, Laura ; Dorman, Todd ; Pronovost, Peter J. Perler, Bruce ; Gerstenblith, Gary Bray, Paul F. Fleisher, Lee A. Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients. Anesthesiology. 101(6):1291-1297, December 2004.
Ma…..gli eventi avversi emodinamici intraoperatori come vengono raccolti e definiti? • Esame delle cartelle di anestesia scritte a mano……………………………………….. • raccolta automatica dei dati – Anesth Analg. 2004 Mar;98(3):569-77,The incidence and prediction of automatically detected intraoperative cardiovascular events in noncardiac surgery.Röhrig R, Junger A, Hartmann B, Klasen J, Quinzio L, Jost A, Benson M, Hempelmann G – gli eventi cardiovascolari avversi si accompagnavano ad una aumentata mortalità (2.1% versus 1.0%). – Però questi eventi non erano previsti nè dalla classificazione ASA né dall’ indice di rischio cardiaco riveduto e corretto Revised Cardiac Risk Index (RCRI)
Levels of Thromboembolism Risk in Surgical Patients Without Prophylaxis
Livelli di rischio tromboembolico in pazienti senza profilassi (Goertz et al 114 AHA/ACC DVT PE Livello di rischio polpac cio prossimale Evento clinico fatale Strategia di prevenzione con successo Basso: Chir minore in paz <40 anni senza fattori di rischio 2 0.4 0.2 <0.01 No profilassi,deambulazione precoce,aggressiva Moderata: Chir minore in paz con fattori di rischio aggiuntivi; Chir in paz 40-60 anni senza fattori di rischio aggiuntivi 10-20 2-4 1-2 0.2- 0.4 Hep(ogni 12 h),LMWH <3400,GCS,IPC Alta: chir in paz>60 a tra 40-60 con fatt.di rischio(VTE,cancro,ipercoagulabilità molecolare) 20-40 4-8 2-4 0.4-1 HEP ogni 8 h,LMWH>3400,Ipc Altissima: Chir in paz con fattori di rischio multipli Artroprotesi anca ,ginocchio Frattura anca Trauma maggiore Trauma midollare spinale 40-80 10-20 4-10 0.2-5 LMWH>3400,fondaparinux, Vit K antag p os(INR 2-3),IPC o GCS+LMWH o Hep IPC;cpmpressione penumatica intermittente, Hep;eparina non frazionata
• J Am Coll Surg. 2007 Jun;204(6):1211-21. Links • Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery: results from the patient safety in surgery study. • Rogers SO Jr, Kilaru RK, Hosokawa P, Henderson WG, Zinner MJ, Khuri SF. • Department of Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA 02115, USA.
• J Oral Maxillofac Surg. 2007 Jun;65(6):1149- 54. Links • Oral surgery in patients on anticoagulant treatment without therapy interruption. • Ferrieri GB, Castiglioni S, Carmagnola D, Cargnel M, Strohmenger L, Abati S. • Department of Medicine, Università degli Studi di Milano, Milano, Italy. giovanni.ferrieri@unimi.it
Valut az rischio anest sia napoli dic 2008;italian + bibliografy
Valut az rischio anest sia napoli dic 2008;italian + bibliografy
Valut az rischio anest sia napoli dic 2008;italian + bibliografy
Choice of Anesthetic Technique and Agent • Recommendations for Use of Volatile Anesthetic Agents • CLASS Iia 1. It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia. (Level of Evidence: B)
Valut az rischio anest sia napoli dic 2008;italian + bibliografy

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Valut az rischio anest sia napoli dic 2008;italian + bibliografy

  • 1. La valutazione del rischio in anestesia Claudio Melloni Libero professionista Consulente di anestesia per Villa Torri,Villa Chiara,Poliambulatorio Gynepro Bologna
  • 3. Limitazioni della lettura • Non si parla del rischio tecnico,legato alle attrezzature o alle diverse tecniche di anestesia • La lettura è piuttosto focalizzata alla valutazione preoperatoria,con excursus nella dinamica operatoria (presunta almeno….) • Ci si riferisce alla chir.noncardiaca
  • 4. Critical Elements for Risk Stratification in Patients Undergoing Noncardiac Surgery • Risk-assessment tool must be accurate • Predicts perioperative events (positive likelihood ratio 10) • Predicts absence of perioperative events (negative likelihood ratio 0.2) • Risk-assessment tool must influence outcome • Identifies subgroups in which surgery should be cancelled or treatment changed • Identifies subgroups that do or do not benefit from proven therapy to reduce risk • Risk-assessment tool must have a favorable harms–benefit tradeoff
  • 5. Cardiac Risk Index in Noncardiac Surgery Criteria Finding Age (yr) >70 5 Cardiac status MI within 6 mo 10 Ventricular gallop or jugular venous distention (signs of heart failure) 11 Significant aortic stenosis 3 Arrhythmia other than sinus or premature atrial contractions 7 ≥5 premature ventricular contractions/min 7 General medical condition Po2 < 60 mm Hg, Pco2 > 50 mm Hg, K < 3 mmol/L, HCO3 <20 mmol/L, BUN > 50 mg/dL, serum creatinine > 3 mg/dL, elevated AST, a chronic liver disorder, or bedbound 3 Type of surgery needed Emergency surgery 4 Intraperitoneal, intrathoracic, or aortic surgery 3 *Risk is based on the total number of points: Level I: 0–5 Level II: 6–12 Level III: 13–25 Level IV: >25 Adapted from Goldman L et al: Multifactorial index of cardiac risk in noncardiac surgical procedures. New England Journal of Medicine 297:845–850, 1977.
  • 6. Revised cardiac risk index(RCRI) . Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L: Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major Noncardiac Surgery. Circulation 1999; 100: 1043-1049 • • High risk surgery • – intraperitoneal, intrathoracic or suprainguinal vascular procedures • • Ischemic heart disease • • H/O CHF • • H/O Cerebrovascular disease • • Insulin therapy for DM • • Preop Cr>2.0mg/dl
  • 7. • Circulation. 1999 Sep 7;100(10):1043-9. Links • Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. • Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. • Department of Medicine, Brigham and Women's Hospital and Harvard Medical
  • 8. • Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, Fleisher LA, Froehlich JB, Gusberg RJ, Leppo JA, Ryan T, Schlant RC, Winters WL, Jr., Gibbons RJ, Antman EM, Alpert JS,Faxon DP, Fuster V, Gregoratos G, Jacobs AK, Hiratzka LF, Russell RO, Smith SC, Jr.: ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery--- executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 2002;105: 1257-67
  • 9. • Importance of Surgical Procedure • The surgical procedure influences the extent of the preoperative evaluation required by determining the potential range of changes in perioperative management. There is little hard data to define the surgery specific incidence of complications, and the rate may be very institution depedendent. Eagle et. al. published data on the incidence of perioperative myocardial infarction and mortality by procedure for patients enrolled in the coronary artery surgery study (CASS).6 Higher risk procedures for which coronary artery bypass grafting reduced the risk of noncardiac surgery compared to medical therapy include major vascular, abdominal, thoracic, and orthopedic surgery. Ambulatory procedures denote low risk. Vascular surgery represents a unique group of patients in whom there is extensive evidence regarding preoperative testing and perioperative interventions.
  • 10. • Importance of exercise tolerance • Exercise tolerance is one of the most important determinants of perioperative risk and the need for invasive monitoring. If a patient can walk a mile without becoming short of breath, than the probability of extensive coronary artery disease is small. Alternatively, if patients become dyspneic associated with chest pain during minimal exertion, then the probability of extensive coronary artery disease is high. Reilly and colleagues demonstrated that the likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked or flights of stairs that could be climbed.7 Exercise tolerance can be assessed with formal treadmill testing or with a questionnaire that assesses activities of daily living.
  • 11. • Reilly DF, McNeely MJ, Doerner D, Greenberg DL, Staiger TO, Geist MJ, Vedovatti PA, Coffey JE, Mora MW, Johnson TR, Guray ED, Van Norman GA, Fihn SD: Self-reported exercise tolerance and the risk of serious perioperative complications. Arch Intern Med 1999; 159: 2185-92
  • 12. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jr., Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B: ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update 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, and Society for Vascular Medicine and Biology. Circulation 2006; 113: 2662-74.
  • 13. • Yang H, Raymer K, Butler R, Parlow J, Roberts R: The effects of perioperative beta- blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J 2006; 152: 983-90 • Juul AB, Wetterslev J, Gluud C, Kofoed-Enevoldsen A, Jensen G, Callesen T, Norgaard P, Fruergaard K, Bestle M, Vedelsdal R, Miran A, Jacobsen J, Roed J, Mortensen MB, Jorgensen L, Jorgensen J, Rovsing ML, Petersen PL, Pott F, Haas M, Albret R, Nielsen LL, Johansson G, Stjernholm P, Molgaard Y, Foss NB, Elkjaer J, Dehlie B, Boysen K, Zaric D, Munksgaard A, Madsen JB, Oberg B, Khanykin B, Blemmer T, Yndgaard S, Perko G, Wang LP, Winkel P, Hilden J, Jensen P, Salas N: Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. Bmj 2006; 332: 1482 • Wallace AW, Galindez D, Salahieh A, Layug EL, Lazo EA, Haratonik KA, Boisvert DM, Kardatzke D: Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery. Anesthesiology 2004; 101: 284-93. • Hindler K, Shaw AD, Samuels J, Fulton S, Collard CD, Riedel B: Improved postoperative outcomes associated with preoperative statin therapy. Anesthesiology 2006; 105: 1260- 72. Durazzo AE, Machado FS, Ikeoka DT, De Bernoche C, Monachini MC, Puech-Leao P, Caramelli B: Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. J Vasc Surg 2004;39: 967-75
  • 15. Key words • perioperative risk • cardiac risk, • noncardiac surgery, • intraoperative risk, • postoperative risk, • risk stratification, • cardiac complication, • cardiac evaluation, • perioperative care, • preoperative evaluation, • preoperative assessment • intraoperative complications.
  • 16. Scopi della valutazione cardiaca preop • 1)identificazione dei pazienti con rischio cardiaco troppo alto,non accettabile • 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop. • 3)identificazione dei pazienti che possono beneficiare di intervento di CABG
  • 17. Come può la visita preop modificare il trattamento?
  • 18. Fattori che determinano il rischio cardiaco periop • Marcatori clinici • Capacità funzionale • Intervento chirurgico
  • 19. I marcatori clinici condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie: • 1)instabilità coronarica;per esempio un MI recente o una angina instabile o severa; • 2)Insufficienza cardiaca scompensata;NYHA Classe IV o una insufficienza in peggioramento o di nuova insorgenza; • 3)aritmie significative;blocco AV di alto grado(Mobitz 2,BAV 3,aritmie ventricolari sintomatiche,aritmie sopraventricolari con ritmo cardiaco non controllato,tachicardia sintomatica,tachicardia ventricolare di nuova scoperta. • 4)malattia valvolare severa,cioè stenosi aortica serrata o stenosi mitralica sintomatica.
  • 20. • The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context. • The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patient’s current medical status; make recommendations concerning the evaluation, management, and risk of cardiac problems over the entire perioperative period; and provide a clinical risk profile that the patient, primary physician, and nonphysician caregivers, anesthesiologist, and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes. • No test should be performed unless it is likely to influence patient treatment. • The goal of the consultation is the optimal care of the patient
  • 21. Condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie • Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop • Scarsa capacità funzionale(<4 MET) • Chirurgia ad alto rischio (rischio cardiovascolare periop > 5%)
  • 22. Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I, Level of Evidence: B):major clinical predictors
  • 23. Estimated Energy Requirements for Various Activities
  • 24. MET: equivalenti energetici indice delle possibilità energetiche per varie attività • scaletta dei MET :risposta a domande semplici,quali: • sei in grado di avere cura di te stesso?mangiare,bere,usare la toilette(MET 1)?; • puoi camminare in casa (MET 2) ; • puoi camminare 100-200m in piano alla velocità di 3-4.5 Km/h?(Met 3); • puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti?(MET 4); • puoi salire una rampa di scale o in salita?o camminare in piano a 6,5 Km/h o correre per una breve distanza?(Met 5). • Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere mobilio pesante(Met 6-7)? • Puoi partecipare a attività ricreative leggere come giocare a golf,a bocce,ballare,giocare a tennis in doppio,o lanciare la palla a baseball o calcio(MET 8-9)? • Puoi partecipare a sport pesanti come il nuoto,tennis in singolo,calcio,pallacanestro o sci?(Met 10).
  • 25. Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater. *
  • 26. • See Table 2 for active clinical conditions. • †See Table 3 for estimated MET level equivalent. ‡Clinical risk factors include ischemic heart disease, compensated or prior HF, diabetes mellitus, renal insufficiency, and cerebrovascular disease. §Consider perioperative beta blockade (see Table 11) for populations in which this has been shown to reduce cardiac morbidity/mortality. ACC/AHA indicates American College of Cardiology/American Heart Association; HR, heart rate; LOE, level of evidence; and MET, metabolic equivalent
  • 27. La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco • rischio di MI o morte cardiaca superiore al 5%: – chirurgia vascolare maggiore(aortica) e quella periferica; • a rischio intermedio ,compreso fra 1 e 5%: la chirurgia intraperitoneale ed intratoracica endoarterectomia carotidea chirurgia della testa e del collo chirurgia ortopedica maggiore chir prostatica. • rischio minore,inferiore all’1% : – procedure endoscopiche, – superficie corporea – chirurgia per cataratta – Chir mammaria.
  • 28. Cardiac Risk* Stratification for Noncardiac Surgical Procedures
  • 29. Scopi dei test aggiuntivi cardiovascolari • Fornire una misura obbiettiva di capacità funzionale • Identificare una ischemia preop miocardica importante • Diagnosticare aritmie cardiache rilevanti • Stimare il rischio cardiaco periop e definire una prognosi
  • 31. Dipiridamolo tallio • the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events. In order to increase the predictive value of the test, several strategies have been suggested. Lung uptake, left ventricular cavity dilation, and redistribution defect size have all been shown to be predictive of subsequent morbidity.10
  • 32. Dobutamine stress test • Dobutamine stress echocardiography has been suggested as the best preoperative test in several recent meta-analyses.11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test. The advantage of this test is that it is a dynamic assessment of ventricular function. Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values. Poldermans et al. demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates.12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial.13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics.11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death
  • 33. Noninvasive Stress Testing Recommendations for Noninvasive Stress Testing Before Noncardiac Surgery • CLASS I • 1. Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be evaluated and treated per ACC/AHA guidelines† before noncardiac surgery. (Level of Evidence: B) • CLASS IIa • 1. Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity (less than 4 METs) who require vascular surgery‡ is reasonable if it will change management. (Level of Evidence: B) • CLASS IIb • 1. Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management. (Level of Evidence: B) • 2. Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery. (Level of Evidence: B) • CLASS III • 1. Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk noncardiac surgery. (Level of Evidence: C) • 2. Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery. (Level of Evidence: C)
  • 34. Razionale dei test non invasivi preop nella valutazione del rischio Test non invasivi Paz con valori del test anormali Valori predittivi per morte o MI periop Positivo : negativo Monitoraggio ECG ambulat 9-39% 4-15 1-16 Esercizio con monitoraggio ECG 16-70% 5-25 90-100 Dipiridamolo-tallio Chir vasc 22-69 4-20 95-100 Chir non vasc 23-47 8-27 98-100 Eco cardio grafia stress dobutamina 23-50 7-23 93-100
  • 35. EF preop e outcome cardiaco postop. (Franco et al,J Vasc Surg 10;656:1989) EF>55% N=50 EF 35-55% N=20 EF 20-35% N=15 MI 19% 15% 20% Morte 0 0 13%
  • 36. Chir vasc dopo precedente rivascolarizzazio ne Chir vascolare senza prec edente rivascolarizzazio ne Complicazioni % Mortalità % Complicazioni % Mortalità % angiografia 0.2-0.5 0.1-0.5 - - PTCA/CABG 3-13 1-5.5 - - Chir vasc 0.3-2 0.3-0.4 0.6-11.7 0.6-10 Rischio globale 3.5-10.5 1.4-12.4 0.6-11.7 0.8-10 Ma…….. Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate Diminuiscono il rischio cardiovascolare a lungo termine Aumentano il rischio cardiaco a lungo termine Rischio globale a ?? ??
  • 37. Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et al,Circulation 1997 96 1892-7 N=395 N=582 N=964
  • 38. Cardiac outcome in low risk surgery:n=1297
  • 39. Incidenza di mortalità periop in pazienti con CAD(n=1632) Eagle et al High risk surgery >=4% Low risk surgery<=4% Abdominal 4% Urologic 1.8 Vascolare 11.3 Orthopedic 1.2 Thoracic 7.7 Skin 0 Head neck 7.3 Miscellaneous 3
  • 40. Cardiac outcome in noncardiac surgery following CABG
  • 41. Class I indications for preop coronary angiography in non cardiac surgery • High risk results during non invasive testing • Amgina pectoris unresponsive to adequate medical therapy • Most patients with unstable angina pectoris • Nondiagnostic or equivocal noninvasive test result in a high risk patient undergoing a high risk noncardiac surgical procedure
  • 42. Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac surgery, based on expert opinion
  • 43. BETA BLOCCANTI E CHIRURGIA NON CARDIACA
  • 44. Perioperative Beta-Blocker Therapy Recommendations for Beta-Blocker Medical Therapy • CLASS I • 1. Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA class I guideline indications. (Level of Evidence: C) • 2. Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing. (Level of Evidence: B) • CLASS IIa • 1. Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative assessment identifies CHD. (Level of Evidence: B) • 2. Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery identifies high cardiac risk, as defined by the presence of more than 1 clinical risk factor.* (Level of Evidence: B) • 3. Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high cardiac risk, as defined by the presence of more than 1 clinical risk factor,* who are undergoing intermediate-risk or vascular surgery. (Level of Evidence: B) • CLASS IIb • 1. The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or vascular surgery, in whom preoperative assessment identifies a single clinical risk factor.* (Level of Evidence: C) • 2. The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers. (Level of Evidence: B) • CLASS III • 1. Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta blockade. (Level of Evidence: C)
  • 45. Indicazioni ai beta bloccanti • i betabloccanti devono essere continuati nel periop per coloro che li assumono per indicazione di angina,aritmie sitomatiche,ipertensione o altre indicazioni delle linee guida ACC/AHA di classe I. • i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B). • I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia e/o un elevato rischio cardiaco ,definito come la presenza di più di 1 fattore di rischio clinico ,anche se vanno incontro a chirurgia classificata come rischio intermedio . • l’utilità dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B). • Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego. • In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco
  • 46. Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 1999;341;1789-94 Bisoprolol n=59 Standard care n=53 Cardiac death 2(3,4%) 9(17%) * Non fatal MI 0 9(17%) ** Total 2(3.4%) 18(34%) ** *=p<0.02 **=p<0.01
  • 47. • N Engl J Med. 1999 Dec 9;341(24):1789-94. Links • Comment in: N Engl J Med. 1999 Dec 9;341(24):1838-40. N Engl J Med. 2000 Apr 6;342(14):1051-2; author r N Engl J Med. 2000 Apr 6;342(14):1052; author rep Rev Cardiovasc Med. 2001 Winter;2(1):25-6. The effect of bisoprolol on perioperative mortality and myocardial infarction in high- risk patients undergoing vascular surgery.
  • 48. Weksler N, Klein M, Szendro G, Rozentsveig V, Schily M, Brill S, Tarnopolski A, Ovadia L, Gurman GM: The dilemma of immediate preoperative hypertension: to treat and operate, or to postpone surgery? J Clin Anesth 2003; 15: 179-83 • There is a great deal of debate regarding a trigger to delay or cancel a surgical procedure in a patient with poorly or untreated hypertension • In the absence of end-organ changes, such as renal insufficiency or left ventricular hypertrophy with strain, it would seem appropriate to proceed with surgery. • A randomized trial of treated hypertensive patients without known CAD who presented the morning of surgery with an elevated diastolic blood pressure was unable to demonstrate any difference in outcome between those who were actively treated versus those in whom surgery was delayed. • In contrast, a patient with a markedly elevated blood pressure and the new onset of a headache should have surgery delayed for further evaluation and potential treatment..
  • 49. Howell SJ, Sear YM, Yeates D, Goldacre M, Sear JW, Foëx P. Hypertension, admission blood pressure and perioperative cardiovascular risk. Anaesthesia 1996;51:1000-1004. • A retrospective case-controlled study which found that a history of hypertension was an important predictor for perioperative cardiac death but not admission blood pressure. • The study implies that end-organ damage resulting from hypertension is the likely villain in this group of patients.
  • 50. • In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications
  • 51. • Adrenergic Receptor Genotype but Not Perioperative • Bisoprolol Therapy May Determine Cardiovascular Outcome • in At-risk Patients Undergoing Surgery with Spinal Block • The Swiss Beta Blocker in Spinal Anesthesia (BBSA) Study: A Double-blinded, • Placebo-controlled, Multicenter Trial with 1-Year Follow-up • Michael Zaugg, M.D.,* Lukas Bestmann, Ph.D.,†
  • 52. Periop statin therapy • Recommendations for Statin Therapy • CLASS I • 1. For patients currently taking statins and scheduled for noncardiac surgery, statins should be continued. (Level of Evidence: B) • CLASS IIa • 1. For patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable. (Level of Evidence: B) • CLASS IIb • 1. For patients with at least 1 clinical risk factor who are undergoing intermediate-risk procedures, statins may be considered. (Level of Evidence: C)
  • 53. terapia preoperatoria con statine • La terapia preoperatoria con statine deve essere continuata per coloro che le assumono già (livello di evidenza B); • la loro somministrazione è ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B): • Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)
  • 54. • usinSchouten, Olaf MD a; Poldermans, Don MD, PhD b; Visser, Loes MD b; Kertai, Miklos D. MD c; Klein, Jan MD, PhD b; van Urk, Hero MD, PhD a; Simoons, Maarten L. MD, PhD c; van de Ven, Louis L. MD, PhD c; Vermeulen, Maarten MSc c; Bax, Jeroen J. MD, PhD d; Lameris, Thomas W. MD, PhD c; Boersma, Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery: Rationale and design of the DECREASE-IV study. American Heart Journal. 148(6):1047-1052, December 2004
  • 55. Eur J Vasc Endovasc Surg. 2004 Oct;28(4):343-52. Links A combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery. Kertai MD, Boersma E, Westerhout CM, Klein J, Van Urk H, Bax JJ, Roelandt JR, Poldermans D . • Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands. • OBJECTIVE: To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA). BACKGROUND: Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers. METHODS: We studied 570 patients (mean age 69+/-9 years, 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC. Patients were evaluated for clinical risk factors (age>70 years, histories of MI, angina, diabetes mellitus, stroke, renal failure, heart failure and pulmonary disease), DSE, statin and beta-blocker use. The main outcome was a composite of perioperative mortality and MI within 30 days of surgery. RESULTS: Perioperative mortality or MI occurred in 51 (8.9%) patients. The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence interval (CI): 0.13-0.74; p=0.01). After correcting for other covariates, the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR: 0.24, 95% CI: 0.10-0.70; p=0.01). Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR: 0.24, 95% CI: 0.11-0.54). Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata; particularly patients with 3 or more risk factors experienced significantly lower perioperative events. CONCLUSIONS: A combination of statin and beta-blocker use in patients with AAA- surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk.
  • 56. Eur J Vasc Endovasc Surg. 2004 Oct;28(4):343-52. Links A combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery. Kertai MD, Boersma E, Westerhout CM, Klein J, Van Urk H, Bax JJ, Roelandt JR, Poldermans D. • 570 pazienti sottoposti a chirurgic dell’aorta addominale • Perioperative mortality or MI occurred in 51 (8.9%) patients. • Perioperative mortality or MI significantly lower in statin users compared to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence interval (CI): 0.13-0.74; p=0.01). • Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR: 0.24, 95% CI: 0.11-0.54). • Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata; particularly patients with 3 or more risk factors experienced significantly lower perioperative events. CONCLUSIONS: A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk. •
  • 57. • Attenzione però che è necessario che il beta bloccante sia effettivamente efficace nel controllare la FC;infatti solo se la FC rimane < 100 bpm se ne dimostra l’efficacia………….
  • 58. Anesth Analg 2008;106:1039 –48, Beattie WS, Wijeysundera DN, Karkouti K, McCluskey S, Tait G.) • Metanalisi:molti degli studi sull’argomento sono estremamente eterogenei e solo quando la massima frequenza cardiaca misurata era inferiore a 100 bpm, si aveva un significativo effetto protettivo (OR 0.23; 95% CI 0.08–0.65; P=0.005), mentre quando questo target non era raggiunto non vi era alcuna efficacia dimostrabile (OR 1.17; 95% CI 0.79–1.80; P=0.43) • Inoltre, con l’utilizzo di una meta-regressione si dimostra un’associazione lineare tra l`effetto del Bbloccante sulla frequenza cardiaca (media, massima, e sulla sua variazione) e l`incidenza di IM (r2=0.63; P=0.001), dove una maggiore efficacia del Bbloccante era associato ad una riduzione di incidenza di IM postoperatorio
  • 59. Anesthesiology. 2004 Aug;101(2):284-93.Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery. Wallace AW, Galindez D, Salahieh A, Layug EL, Lazo EA, Haratonik KA, Boisvert DM, Kardatzke D. • Department of Anesthesia and Perioperative Care, University of California, USA. [email protected] • BACKGROUND: Perioperative myocardial ischemia occurs in 20-40% of patients at risk for cardiac morbidity and is associated with a ninefold increase in risk of cardiac morbidity. METHODS: In a prospective, double-blinded, clinical trial, we studied 190 patients with or at risk for coronary artery disease in two study groups with a 2:1 ratio (clonidine, n = 125 vs. placebo, n = 65) to test the hypothesis that prophylactic clonidine reduces the incidence of perioperative myocardial ischemia and postoperative death in patients undergoing noncardiac surgery. Clonidine (0.2 mg orally as well as a patch) or placebo (tablet and patch) was administered the night before surgery, and clonidine (0.2 mg orally) or placebo (tablet) was administered on the morning of surgery. The patch or placebo remained on the patient for 4 days and was then removed. RESULTS: The incidence of perioperative myocardial ischemia was significantly reduced with clonidine (intraoperative and postoperative, 18 of 125, 14% vs. placebo, 20 of 65, 31%; P = 0.01). Prophylactic clonidine administration had minimal hemodynamic effects. Clonidine reduced the incidence of postoperative mortality for up to 2 yr (clonidine, 19 of 125 [15%] vs. placebo, 19 of 65 [29%]; relative risk = 0.43 [confidence interval, 0.21-0.89]; P = 0.035). CONCLUSIONS: Perioperative administration of clonidine for 4 days to patients at risk for coronary artery disease significantly reduces the incidence of perioperative myocardial ischemia and postoperative death.
  • 60. Wallace AW, Galindez D, Salahieh A, Layug EL, Lazo EA, Haratonik KA, Boisvert DM, Kardatzke D .Effect of clonidine on cardiovascular morbidity andmortality after noncardiac surgery.Anesthesiology. 2004 Aug;101(2):284-93.
  • 61. Long term protection offered by 4 days of perioperative clonidine in patients at risk of CAD
  • 62. • Am J Med. 2009 Jan 28. [Epub ahead of print] Links • Perioperative Beta-blockers for Major Noncardiac Surgery: Primum Non Nocere. • Chopra V, Plaisance B, Cavusoglu E, Flanders SA, Eagle KA. • Division of General Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor.
  • 63. • Lancet. 2008 Dec 6;372(9654):1962-76. Epub 2008 Nov 13. Links • Comment in: Lancet. 2008 Dec 6;372(9654):1930-2. Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis. • Bangalore S, Wetterslev J, Pranesh S, Sawhney S, Gluud C, Messerli FH. • Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA.
  • 64. • Anesth Analg. 2007 Jan;104(1):27-41. Links • Comment in: Anesth Analg. 2007 Jan;104(1):1-3. Perioperative beta-blockers for preventing surgery-related mortality and morbidity: a systematic review and meta-analysis. • Wiesbauer F, Schlager O, Domanovits H, Wildner B, Maurer G, Muellner M, Blessberger H, Schillinger M. • Department of Cardiology, Vienna General
  • 65. • Diabetics share the same risks as patients with cardiac ischemia,renal insufficiency or cerebrovascular atherosclerotic disease***(42 Haffner
  • 66. • Risks of the diabtiecs;autonomic dysfunction • Difficult intubation………..see lavoro Nova pub
  • 67. • Anesth Analg. 2008 Dec;107(6):1919-23. Links • The extended Mallampati score and a diagnosis of diabetes mellitus are predictors of difficult laryngoscopy in the morbidly obese. • Mashour GA, Kheterpal S, Vanaharam V, Shanks A, Wang LY, Sandberg WS, Tremper KK. • Department of Anesthesiology, University of Michigan Medical School, Ann Arbor,
  • 68. • J Postgrad Med. 2000 Apr-Jun;46(2):75-9. Links • The palm print as a sensitive predictor of difficult laryngoscopy in diabetics: a comparison with other airway evaluation indices. • Vani V, Kamath SK, Naik LD. • Department of Anaesthesiology, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India.
  • 69. • : Anesth Analg. 1998 Mar;86(3):516-9. Links • Diabetes mellitus and difficult laryngoscopy in renal and pancreatic transplant patients. • Warner ME, Contreras MG, Warner MA, Schroeder DR, Munn SR, Maxson PM. • Department of Anesthesiology, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA. • Limited mobility of the cervical spine or
  • 70. • (44) while : Anesth Analg. 1998 Mar;86(3):516-9. Links • Diabetes mellitus and difficult laryngoscopy in renal and pancreatic transplant patients. • Warner ME, Contreras MG, Warner MA, Schroeder DR, Munn SR, Maxson PM. • Department of Anesthesiology, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA. • Limited mobility of the cervical spine or temperomandibular joint may contribute to increased difficulty of laryngoscopy in patients who have severe diabetes mellitus. The frequency of difficult laryngoscopy in diabetics undergoing renal and/or pancreatic transplants has been reported to be as high as 32%. We retrospectively reviewed the anesthetic records of all adult patients who underwent renal and/or pancreatic transplant and endotracheal intubation from January 1, 1985 to October 31, 1995. Characteristics specifically reviewed included the presence of diabetes mellitus, type of organ donor, age, gender, body mass index, previous difficult laryngoscopy, known characteristics potentially related to difficult laryngoscopy, and degree of difficulty with laryngoscopy. Laryngoscopy was graded as easy, minimally to moderately difficult, and moderately to extremely difficult to perform. Factors associated with any degree of difficult intubation were univariately assessed by using Fisher's exact test. Of 725 patients, 15 (2.1%) were identified as having difficult laryngoscopies, although all underwent successful endotracheal intubations. Factors associated with difficult laryngoscopy were diabetes mellitus (P = 0.002) and characteristics known to be related to difficult laryngoscopy (P = 0.02). These findings confirm an increase in the frequency of difficult laryngoscopy in diabetic patients undergoing renal and/or pancreatic transplant, although no laryngoscopies were rated as moderately to extremely difficult. We conclude that the frequency of difficult laryngoscopy in these diabetic patients is much lower than previous reports have suggested. IMPLICATIONS: Previous studies have suggested that airway management of many diabetic patients may be difficult. Our medical record review of patients with severe diabetes undergoing organ transplants showed that extraordinary techniques were not required to successfully manage their airways. • Difficult Laryngoscopy and • Diabetes Mellitus • Key Words: INTUBATION, TRACHEAL-diabetes • and COMPLICATIONS, DIABETES MELLITUS. • METABOLISM, DIABETES MELLITUS. • To the Editor: • Like the authors, we too were surprised by the extremely • high incidence (32!%) of difficult laryngoscopy in diabetic • renal transplant patients reported by Hogan et al. (1). They • suggested that "stiff joint syndrome," a condition occasionally • seen in type I insulin-dependent diabetics, may have • been a major cause of this finding. Because their results • were so striking, we investigated the incidence of difficult • laryngoscopy and intubation in similar patients at our • institution.
  • 71. Heart failure as a risk factor
  • 72. Hammill BG,Curtis,LH,Bennett-Guerrior E,O’Connor,CM,Jollis JC,Schulman KA,Hernandez AF.Impact of heart failure on patients undergoing major noncardiac surgery.Anesthesiology 2008;108:559- 67 • Medicare 5% standard analytic files • Inpatients fee for service claims 2000-20004 • Patients >65 for major noncardiac surgery: – Carotid endarterectomy – Lower extr bypass – Open AAA – Hip replacement – Knee replacement – Spinal fusion – Above and below knee amputation – Open and laparoscopic cholecystectomy – Cancer resection abdominal,lung,colon
  • 73. Hammill et al.Impact of heart failure on patients undergoing major noncardiac surgery.Anesthesiology • Main outcome : – Operative mortality – 30 days readmission
  • 74. Hammill et al. Impact of heart failure on patients undergoing major noncardiac surgery.Anesthesiology 2008;108(4): 559-567 • I pazienti di età ≥65 anni • inseriti nel programma assicurativo statunitense Medicare • sottoposti, tra il 2000 e il 2004, ad uno tra tredici tipi di chirurgia maggiore non- cardiaca. • esclusi dall’analisi i pazienti con insufficienza renale terminale e quelli che non avessero soddisfatto, da almeno un anno, i criteri Medicare® per la sottoscrizione di una polizza. • 159.327 interventi,: 18% eseguiti in pazienti con insufficienza cardiaca e il 34% in pazienti con cardiopatia ischemica. • I rischi relativi corretti di mortalità e riammissione per i pazienti con insufficienza cardiaca, rispetto a quelli che non presentavano né insufficienza cardiaca né cardiopatia ischemica, erano 1.63 (intervallo confidenza 95%: 1.52-1.74) e 1.51 (intervallo confidenza 95%: 1.45-1.58), rispettivamente. • I rischi relativi corretti di mortalità e riammissione per i pazienti con cardiopatia ischemica, rispetto a quelli che non presentavano né insufficienza cardiaca né cardiopatia ischemica, erano 1.08 (intervallo confidenza 95%: 1.01-1.16) e 1.16 (intervallo confidenza 95%: 1.12-1.20), rispettivamente.
  • 75. Characteristics of the study population by disease group heart faliure Cad normal età 79,4 75,3 75,6 Masch i% 42 48,8 34,4 nerii% 8,5 5,2 5,6 teaching hospitali% 16,9 19,7 16,3 admitted form a skilled nursing facilityi% 1,5 0,4 0,4 urgent admissioni% 19,2 13,8 14,5 emergent admissionji% 30 19 16,7 COPDi% 45,1 31,1 22,2 CADi% 81 100 0 dementiai% 9,1 5,1 4,1 diabetesi% 43,4 30,5 19,6 histrory of strokei% 26,9 21,5 11,4 hypertensioni% 86,4 82,4 66,8 periph vasc.diseasei% 46,3 36,3 17,9 renal diseasei% 15,2 5,2 2,7
  • 76. Operative mortality HF CAD normal total 8 3,1 2,4 > Knee amput 25.8 18 16 <knee amput 12.8 10.4 7.2 Carotid endarterec tomy 2,5 1,2 0,9 Colon cancer resection 11.9 6.3 5.4 Hip replacement 8.4 3.9 2.8 Knee replacement 0.9 0.4 0.3 Laparoscopic cholecystectomy 5.6 2.1 1.8 Lower extremity bypass 8.1 3.7 4.1 Open AAA repair 10.3 5.8 4.8 Other abdominal cancer resections 11.8 4.3 4.9 Pulmonary cancer resection 10.2 6.0 4.1
  • 77. 30 day readmission HF CAD normal total 17.1 10.8 8.1 > Knee amput 25.2 21.6 18.9 <knee amput 24.1ns 23.4ns 19.9 ns Carotid endarterectomy 15.2 10.8 8.7 Colon cancer resection 18 13.2 10.5 Hip replacement 16.6 10.3 8.8 Knee replacement 9.9 6.2 4.7 Laparoscopic cholecystectomy 16.4 10.1 8.4 Lower extremity bypass 27.2 18.2 16.2 Open AAA repair 14.8 10.3 11.4 Other abdominal cancer resections 17.3 12.6 11.8 Pulmonary cancer resection 17.4 15.5 11.3 Spinal fusion
  • 78. Effect of heart failure and CAD on mortality per procedure
  • 79. Operative mortality and readmission rate for HF patients with or without CAD
  • 80. Conclusion from the study of Hammil et al • Heart Failure patients : –mortality risk 63% –Readmission risk 51%
  • 81. Hernandez AF, Whellan DJ, Stroud S, Sun JL, O’Connor CM, Jollis JG. Outcomes in heart failure patients after major noncardiac surgery. J Am Coll Cardiol. 2004;44(7):1446-1453 • OBJECTIVES: The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery. BACKGROUND: There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients. METHODS: Using the 1997 to 1998 Standard Analytic File 5% Sample of Medicare beneficiaries, we identified patients with HF who underwent major noncardiac surgery. A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery. Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups. RESULTS: Of 23,340 HF patients and 28,710 CAD patients, 1,532 (6.56%) HF patients and 1,757 (6.12%) CAD patients underwent major noncardiac surgery. There were 44,512 patients in the Control group with major noncardiac surgery. After accounting for demographic characteristics, type of surgery, and comorbid conditions, the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 11.7%, CAD 6.6%, and Control
  • 82. PHILLIPS, FRANKLIN A. MICHOTA,W. H. WILSON TANG, CHRISTOPHER M. WHINNEY, ASHOK PANNEERSELVAM, ERIC D. HIXSON,MARIO GARCIA, GARY S. FRANCIS, AMIR K. JAFFER. Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac Surgery.Mayo Clin Proc. 2008;83(3):280- 288 • il rischio operatorio viene minimizzato dalla ottimizzazione preoperatoria effettuata dal servizio di medicina interna ,con abbattimento notevole della mortalità e morbilità :solo la sopravvivenza ad un anno è ridotta rispetto ai pazienti di controllo,come è logico attendersi in ogni caso in pazienti portatori di malattia cronica seria.
  • 83. YE OLIVIA XU-CAI, DANIEL J. BROTMAN, CHRISTOPHER O. PHILLIPS, FRANKLIN A. MICHOTA,W. H. WILSON TANG, CHRISTOPHER M. WHINNEY, ASHOK PANNEERSELVAM, ERIC D. HIXSON,MARIO GARCIA, GARY S. FRANCIS, AMIR K. JAFFER. Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac Surgery.Mayo Clin Proc. 2008;83(3):280-288
  • 84. Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI, DANIEL J. BROTMAN, CHRISTOPHER O. PHILLIPS, FRANKLIN A. MICHOTA,W. H. WILSON TANG, CHRISTOPHER M. WHINNEY, ASHOK PANNEERSELVAM, ERIC D. HIXSON,MARIO GARCIA, GARY S. FRANCIS, AMIR K. JAFFER. Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac Surgery.Mayo Clin Proc. 2008;83(3):280-288
  • 86. YE OLIVIA XU-CAI, DANIEL J. BROTMAN, CHRISTOPHER O. PHILLIPS, FRANKLIN A. MICHOTA,W. H. WILSON TANG, CHRISTOPHER M. WHINNEY, ASHOK PANNEERSELVAM, ERIC D. HIXSON,MARIO GARCIA, GARY S. FRANCIS, AMIR K. JAFFER. Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac Surgery.Mayo Clin Proc. 2008;83(3):280-288 • Our data suggest that perioperative mortality is surprisingly low (<2%) in patients with clinically stable HF— regardless of EF— undergoing elective noncardiac surgery. • At 1 year, crude mortality rates for patients with HF with reduced EF (13.5%) or with preserved EF (6.3%) were significantly higher than for controls (3.1%). However, we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months. This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF, particularly those with low EF, represents the background mortality expected in patients with chronic illnesses. • Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF
  • 87. Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery Preoperative evaluation at the Internal Medicine Preoperative Assessment Consultation and T reatment (IMPACT) Center at the Cleveland Clinic
  • 88. Unrecognized MI and silent myocardial ischemia • Unrecognized MI:, determined by rest wall motion abnormalities in the absence of a history of MI. • Silent myocardial ischemia ;stress-induced wall motion abnormalities in the absence of angina pectoris • 23 and 28% respectiverly in pts undergoing major vascular surgery! – Feringa HH, Karagiannis SE, Vidakovic R, Elhendy A, ten Cate FJ, Noordzij PG, van Domburg RT, Bax JJ, Poldermans D. The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery. Coron Artery Dis. 2007 Nov;18(7):571-6.
  • 89. .N-TERMINAL PRO-BRAIN NATRIURETIC PEPTIDE .ENDOGENOUS NITRIC OXIDE SYNTHASE INHIBITOR ASYMMETRIC DIMETHYLARGININE . POLYMORPHISMS IN PLATELET GLYCOPROTEIN (GP) IIIA AND GPIB[ALPHA] Laboratory markers for cardiac risk after noncardiac surgery
  • 90. Laboratory markers for cardiac risk after noncardiac surgery • Elevated NT-proBNP levels are independently associated with an increase in the risk of perioperative cardiovascular KO – Yun KH, Jeong MH, Oh SK, Choi JH, Rhee SJ, Park EM, Yoo NJ, Kim NH, Ahn YK, Jeong JW.Preoperative plasma N-terminal pro-brain natriuretic peptide concentration and perioperative cardiovascular risk in elderly patients.Circ J.2008 Feb;72(2):195-9. – Leibowitz D, Planer D, Rott D, Elitzur Y, Chajek-Shaul T, Weiss ATBrain natriuretic peptide levels predict perioperative events in cardiac patients undergoing noncardiac surgery: a prospective study. Cardiology. 2008;110(4):266-70. Epub 2007 Dec 12. • per 0.1-micromol/L increment in plasma ADMA concentration, the odds ratio to experience the primary end point increased by 1.26 – Maas R, Dentz L, Schwedhelm E, Thoms W, Kuss O, Hiltmeyer N, Haddad M, Klöss T, Standl T, Böger RH.Elevated plasma concentrations of the endogenous nitric oxide synthase inhibitor asymmetric dimethylarginine predict adverse events in patients undergoing noncardiac surgery. Crit Care Med. 2007 Aug;35(8):1876-81 • Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha]. Pro33 and Met145 genotypes were independent predictors of composite ischemic outcome – Faraday, Nauder , Martinez, Elizabeth A. Scharpf, Robert B. Kasch-Semenza, Laura ; Dorman, Todd ; Pronovost, Peter J. Perler, Bruce ; Gerstenblith, Gary Bray, Paul F. Fleisher, Lee A. Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients. Anesthesiology. 101(6):1291-1297, December 2004.
  • 91. Ma…..gli eventi avversi emodinamici intraoperatori come vengono raccolti e definiti? • Esame delle cartelle di anestesia scritte a mano……………………………………….. • raccolta automatica dei dati – Anesth Analg. 2004 Mar;98(3):569-77,The incidence and prediction of automatically detected intraoperative cardiovascular events in noncardiac surgery.Röhrig R, Junger A, Hartmann B, Klasen J, Quinzio L, Jost A, Benson M, Hempelmann G – gli eventi cardiovascolari avversi si accompagnavano ad una aumentata mortalità (2.1% versus 1.0%). – Però questi eventi non erano previsti nè dalla classificazione ASA né dall’ indice di rischio cardiaco riveduto e corretto Revised Cardiac Risk Index (RCRI)
  • 92. Levels of Thromboembolism Risk in Surgical Patients Without Prophylaxis
  • 93. Livelli di rischio tromboembolico in pazienti senza profilassi (Goertz et al 114 AHA/ACC DVT PE Livello di rischio polpac cio prossimale Evento clinico fatale Strategia di prevenzione con successo Basso: Chir minore in paz <40 anni senza fattori di rischio 2 0.4 0.2 <0.01 No profilassi,deambulazione precoce,aggressiva Moderata: Chir minore in paz con fattori di rischio aggiuntivi; Chir in paz 40-60 anni senza fattori di rischio aggiuntivi 10-20 2-4 1-2 0.2- 0.4 Hep(ogni 12 h),LMWH <3400,GCS,IPC Alta: chir in paz>60 a tra 40-60 con fatt.di rischio(VTE,cancro,ipercoagulabilità molecolare) 20-40 4-8 2-4 0.4-1 HEP ogni 8 h,LMWH>3400,Ipc Altissima: Chir in paz con fattori di rischio multipli Artroprotesi anca ,ginocchio Frattura anca Trauma maggiore Trauma midollare spinale 40-80 10-20 4-10 0.2-5 LMWH>3400,fondaparinux, Vit K antag p os(INR 2-3),IPC o GCS+LMWH o Hep IPC;cpmpressione penumatica intermittente, Hep;eparina non frazionata
  • 94. • J Am Coll Surg. 2007 Jun;204(6):1211-21. Links • Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery: results from the patient safety in surgery study. • Rogers SO Jr, Kilaru RK, Hosokawa P, Henderson WG, Zinner MJ, Khuri SF. • Department of Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA 02115, USA.
  • 95. • J Oral Maxillofac Surg. 2007 Jun;65(6):1149- 54. Links • Oral surgery in patients on anticoagulant treatment without therapy interruption. • Ferrieri GB, Castiglioni S, Carmagnola D, Cargnel M, Strohmenger L, Abati S. • Department of Medicine, Università degli Studi di Milano, Milano, Italy. [email protected]
  • 99. Choice of Anesthetic Technique and Agent • Recommendations for Use of Volatile Anesthetic Agents • CLASS Iia 1. It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia. (Level of Evidence: B)