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past or had any perioperative medical or anesthetic-related complications that could occur again. The social history should assess and quantify the amount, duration, and last use of tobacco, alcohol, or illicit substances. It is important to document allergies to medications, foods, and latex as well as to obtain an accurate list of the patients current prescription and over-the-counter medications, including doses and adherence. The family history is relevant primarily for any genetically associated complications such as malignant hyperthermia. The review of systems should include the presence or absence of chest pain and dyspnea and the patients exercise capacity. The physical examination must include the vital signs, assessment of the airway and respiratory status, cardiovascular examination, and documentation of any neurologic deficit.

Preoperative Tests

Screening preoperative test results in otherwise healthy individuals are usually normal and, even when abnormal, rarely affect management (generally <1%) (Table 439-1). Most significant abnormalities can be predicted from the clinical information obtained, which then guides selective testing based on the history, the physical findings, and the planned type of surgery and anesthesia. Most patients undergoing low-risk surgery with local anesthesia require no preoperative testing. Repeat testing should be avoided if recent (within 3 months) results were normal, unless the patients condition or medications have changed.

Perioperative Medications

439
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STEVEN L. COHN

Decisions regarding whether to continue a medication perioperatively should consider the drugs pharmacokinetics (Chapter 28) as well as its effects on the primary disease and perioperative risk, including potential interactions with anesthetic agents. Some medications are essential to continue (e.g., cardiac medications and corticosteroids), whereas others must be discontinued (e.g., oral hypoglycemic agents) or have their dose altered (e.g., insulin and anticoagulants). Still other medications should be started prophylactically to minimize perioperative risk (e.g., anticoagulants for prophylaxis against venous thromboembolism [Chapter 81] and antibiotic prophylaxis for surgical site infection or endocarditis [Chapter 76]). Data are often lacking or conflicting. Table 439-2 briefly summarizes consensus perioperative recommendations for the major classes of drugs.

Each year in the United States, more than 25 million inpatient surgical procedures and an additional 25 million outpatient procedures are performed. Although more than one third of these surgical patients are older than 65 years, overall morbidity and mortality are relatively low, in part because of modern anesthetic and surgical techniques. A crucial aspect of safety is careful preoperative evaluation of the patient, not only by the surgeon and anesthesiologist but also, in many instances, by a general medical consultant or medical subspecialist.

PREOPERATIVE EVALUATION

Cardiac Risk Assessment

A significant proportion of patients who undergo surgery have either known coronary artery disease or risk factors for it, and postoperative cardiac complications are second only to direct surgical complications as a cause of perioperative mortality. The goal is to risk-stratify patients clinically and to determine whether additional testing, new medications, or cardiac interventions will be beneficial.

History and Physical Examination

Operative Risk Assessment

The components of perioperative risk include those related to the patient, procedure, provider, and anesthesia. Anesthetic risk is low, with mortality less than 0.03% in a normal healthy patientAmerican Society of Anesthesiology (ASA) class 1but increasing to 0.2% in ASA class 2 (mild systemic disease), 1.2% in class 3 (severe systemic disease), 8% in class 4 (severe systemic disease that is a constant threat to life), and 34% in class 5 (a moribund patient not expected to survive for 24 hours without surgery). Meta-analysis suggests that when feasible, neuraxial (spinal or epidural) anesthesia may reduce postoperative complications compared with general anesthesia (Chapter 440), but decisions regarding the anesthetic technique should be the responsibility of the anesthesiologist and not be part of the preoperative medical consultation. With respect to the provider, data support a learning curve, with better outcomes when procedures are performed by more experienced, higher-volume surgeons.

Important information includes any history of previous cardiac disease (myocardial infarction [MI], angina, heart failure, arrhythmias, valvular disease), cardiac interventions (coronary artery bypass grafting, percutaneous coronary intervention), cardiac evaluation (noninvasive testing, angiography), risk factors (hypertension, diabetes mellitus, dyslipidemia, cigarette smoking), and associated diseases (peripheral arterial disease, stroke, chronic kidney disease, and chronic obstructive pulmonary disease [COPD]). Current status regarding chest pain or dyspnea, functional capacity, and medications should be assessed. The physical examination serves to confirm findings in the history as well as to assess severity and control of the disease (e.g., heart failure, hypertension, valvar disease). The preoperative electrocardiogram rarely changes management unless it demonstrates evidence of a recent or silent MI, but it is often useful as a baseline against which to compare postoperative tracings.

Cardiac Risk Indices

General Risk Assessment

History and Physical Examination

The medical history and physical examination are the most important components in assessing a patients risk for surgery. The consultation should focus on pertinent medical problems, particularly cardiopulmonary symptoms and diseases that are associated with risk and are likely to influence perioperative management (Chapter 438). The importance of the past surgical history is to determine whether the patient was able to undergo major surgery in the recent

Over the years, a number of risk indices have been proposed to assist in preoperative cardiac evaluation. The most current of these, the revised cardiac risk index (RCRI; Table 439-3), was developed during the evaluation of several thousand patients, was validated in thousands more, and has been incorporated into the consensus guidelines developed by the American College of Cardiology and the American Heart Association. These guidelines, which are updated periodically, use a stepwise strategy based on clinical risk factors, surgery-specific risk, and exercise capacity, combined with a systematic approach to perioperative testing and treatment in patients with known or suspected cardiac disease (Fig. 439-1). Preoperative levels of brain

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TABLE 439-1 RECOMMENDATIONS FOR PREOPERATIVE LABORATORY TESTING

TEST Hemoglobin White blood count Platelet count Prothrombin time Partial thromboplastin time Electrolytes Glucose Renal function Liver function tests Urinalysis Electrocardiogram (<50 years old) Chest radiograph (<50 years old) % ABNORMAL 1.8 0.7 0.9 0.3 6.5 12.7 9.3 8.2 0.4 19.1 29.6 (19.7) 21.2 (4.9) % INFLUENCING MANAGEMENT 0.1 0.0 0.02 0.0 0.1 1.8 0.5 2.6 0.1 1.4 2.6 3.0 INDICATIONS Expected major blood loss, symptoms of anemia, chronic kidney disease Suspected infection, myeloproliferative disorder, myelotoxic medications Bleeding diathesis, myeloproliferative disorder, myelotoxic medications Bleeding diathesis, liver disease, malnutrition, antibiotic use, anticoagulants Bleeding diathesis, anticoagulant use Renal disease, medications affecting electrolytes (e.g., diuretics, digoxin, ACE inhibitor, ARBs) Known DM, steroids, morbid obesity Renal disease, DM, HTN, major surgery, older age, medications affecting renal function Known liver disease, albumin level if at risk for needing postoperative parenteral nutrition No indication unless GU symptoms or instrumentation planned Age >40yr in men or >50yr in women or symptoms/signs of or previous known diagnosis of cardiac disease, DM, or HTN Age >50yr undergoing major upper abdominal or thoracic surgery or symptoms/ signs or previous known diagnosis of cardiac or pulmonary disease

ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; DM = diabetes mellitus; GU = genitourinary; HTN = hypertension. Modified from Smetana GW, Macpherson DS. The case against routine preoperative laboratory testing. Med Clin North Am. 2003;87:7-40.

TABLE 439-2 PERIOPERATIVE MANAGEMENT OF MEDICATIONS

MEDICATION CLASS Anticoagulants (heparins, warfarin)* RECOMMENDATION Continue for minor surgery Discontinue at an appropriate interval before major surgery Consider bridging anticoagulation for patients at high risk for interim thrombosis (see Chapter 37) Continue for minor surgery Discontinue clopidogrel at least 5 days before surgery and prasugrel at least 7 days before surgery If discontinuing aspirin, do so at least 5-7 days before surgery Continue most agents Consider starting -blockers in patients at high risk for perioperative cardiac morbidity (vascular or high-risk surgery) Withhold diuretics on the morning of surgery, especially if signs of volume depletion are present Stop tamsulosin before cataract surgery (floppy iris syndrome) Continue statins Discontinue other agents Continue Continue Withhold oral hypoglycemic agents on the morning of surgery; restart when the patient resumes eating For type 1 diabetes, continue some form of insulin (long acting or intravenous) at all times For type 2 diabetes, decrease the dose of morning intermediate insulin Continue thyroid replacement Continue antithyroid medication and postpone surgery until the hyperthyroidism is controlled May discontinue 3 weeks before surgery only in patients at high risk for perioperative venous thromboembolism; otherwise continue Continue chronic corticosteroids; increase the dosage to account for surgical stress Continue SSRIs but consider withholding them several weeks before CNS surgery Continue tricyclic antidepressants, benzodiazepines, lithium, and antipsychotics Usually discontinue MAOIs 10-14 days before surgery Continue; substitute equianalgesic or higher doses for surgical pain Continue methotrexate Discontinue other DMARDs and anticytokines Continue hypouricemic agents Continue antiseizure medications Consider withholding antiparkinsonian agents briefly Continue agents for myasthenia gravis Discontinue all agents

Antiplatelet drugs

Cardiovascular medications

Lipid-lowering agents Pulmonary agents Gastrointestinal agents Diabetic agents (see text)

Thyroid agents (hypothyroidism and hyperthyroidism) (see text) Oral contraceptives, hormone replacement, and SERMs Corticosteroids (see text) Psychotropic agents

Chronic opioids Rheumatologic agents Neurologic agents Herbal agents

*See also Table 439-8 for more detail. CNS = central nervous system; DMARD = disease-modifying antirheumatic drug; MAOI = monoamine oxidase inhibitor; SERM = selective estrogen receptor modulator; SSRI = selective serotonin reuptake inhibitor. Adapted from Cohn SL, Macpherson DS. Perioperative medication management. In: Cohn SL, Smetana GW, Weed HG, eds. Perioperative Medicine: Just the Facts. New York: McGraw-Hill, 2006.

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natriuretic peptide (BNP) are independent predictors of postoperative cardiac complications, although the definition of an abnormal value has varied among studies. The emphasis of the new guideline is to minimize cardiac testing unless the results are likely to alter management.

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Noninvasive Tests

A resting echocardiogram (Chapter 55) is indicated to evaluate valvular heart disease in patients with clinically suspicious murmurs and to evaluate left ventricular function in patients with heart failure. Other than for the

assessment of aortic stenosis (see later), resting echocardiography is not a reliable predictor of perioperative cardiac events. Exercise testing (with or without imaging) is preferred to pharmacologic stress testing because it assesses functional capacity (see Table 50-3 in Chapter 50), but its use is often limited by a patients inability to achieve the target heart rate. Furthermore, patients with adequate exercise capacity by history rarely require preoperative stress testing.

Pharmacologic Stress Testing

TABLE 439-3 CLINICAL FACTORS IMPORTANT IN ASSESSING PERIOPERATIVE CARDIAC RISK

Revised cardiac risk index criteria* Patients are at risk and may be candidates for perioperative -blockers if they have Ischemic heart disease or at least two of the following: Heart failure defined as S3 or bilateral rales on physical examination or pulmonary edema on chest radiograph Cerebrovascular disease defined as history of transient ischemic attack or history of cerebrovascular accident Insulin-dependent diabetes mellitus Chronic renal insufficiency defined as baseline creatinine of 2.0mg/dL or greater High-risk surgery defined as intrathoracic, intra-abdominal, or suprainguinal vascular surgery
*Lee TH, Marcantonio ER, Mangione CM, etal. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043-1049. Use of -blockers must be individualized and used with caution in patients with heart failure. From Auerbach AD, Goldman L. Assessing and reducing the cardiac risk of non-cardiac surgery. Circulation. 2006;113:1361-1376.

Pharmacologic stress testing (either dipyridamole or adenosine with nuclear imaging [Chapters 56 and 71] or dobutamine echocardiography [Chapters 55 and 71]) is indicated when a patient cannot perform adequate exercise (see Table 71-6 and Fig. 71-3 in Chapter 71). Both tests have equivalent sensitivity for predicting perioperative ischemic complications, whereas stress echocardiography has fewer false-positive results. Dipyridamole and adenosine can cause bronchospasm and are best avoided in patients with symptomatic or severe asthma or obstructive lung disease, but they are preferred in patients with left bundle branch block, in whom exercise or stress echocardiography is more likely to give false-positive results. Quantitatively, the number and extent of reperfusion defects or wall motion abnormalities correlate with the severity of disease, likelihood of complications, and need for further evaluation by angiography. Patients whose clinical condition would warrant stress testing independent of planned surgery should have such testing before elective operations. Otherwise, stress testing is recommended only in patients who are undergoing high-risk surgery (Table 439-4) and have three or more clinical risk factors (Table 439-5; see Table 439-3). Evidence for stress testing in other situations is weak, but it may be considered on an individual basis in patients with one or two risk factors if the results are likely to change management.

Need for emergency noncardiac surgery No Active cardiac conditions* No Low-risk surgery No Functional capacity greater than or equal to 4 METS without symptoms No or unknown

Yes

Operating room

Perioperative surveillance and postoperative risk stratification and risk factor management

Yes

Evaluate and treat per usual guidelines

Consider operating room

Yes

Proceed with planned surgery

Yes

Proceed with planned surgery

3 or more clinical risk factors** Intermediate-risk surgery

1-2 clinical risk factors** Intermediate-risk surgery

No clinical risk risk factors**

Vascular surgery

Vascular surgery

Consider testing if it will change management

Proceed with planned surgery with HR control or consider noninvasive testing if it will change management

Proceed with planned surgery

FIGURE439-1. Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk for patients 50 years or older. *Active cardiac conditions include unstable coronary syndromes (unstable or severe angina, or recent myocardial infarction within the past 30 days), decompensated heart failure, significant arrhythmias, and severe valvular disease. See Table 439-4. Self-reported exercise capacity is considered adequate if the patient can perform 4 or more metabolic equivalents of activity (see Table 50-5 in Chapter 50). **See Table 439-3 (include all risk factors other than type of surgery, which is considered elsewhere in this algorithm). See Table 439-5. See Table 439-6. HR = heart rate; METS = metabolic equivalents. (Adapted from a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine, Society for Vascular Surgery. Fleishmann KE, Beckman JA, Buller CE, etal. 2009 ACCF/ AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol. 2009;54:e13-e118.)

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(i.e., a transdermal clonidine extended-release TTS-2 patch the night before, and 0.2mg orally the night before and morning of surgery) may be an alternative choice based on limited data that such medications also reduce ischemia and possibly perioperative MI and death, especially in patients undergoing major vascular surgery.5 Limited data on prophylactic calcium antagonists or nitrates have not shown major benefits in preventing complications after noncardiac surgery. Statins (Chapter 213) reduce endovascular inflammation and stabilize endothelial plaque. Although the manufacturers package inserts have recommend discontinuing statins before surgery, current data suggest not only that they should be continued perioperatively but also that they should be started prophylactically before surgery in patients who meet criteria for their ongoing use (Chapter 213).6

TABLE 439-4 RISKS OF VARIOUS SURGICAL PROCEDURES

HIGH RISK (CARDIAC RISK >5%) Major vascular surgery Emergent major operations Prolonged procedures with large fluid shifts or significant blood loss INTERMEDIATE RISK (CARDIAC RISK 1-5%) Intraperitoneal or intrathoracic procedures Carotid endarterectomy Endovascular aortic aneurysm repair Head and neck surgery Orthopedic procedures Prostate surgery LOW RISK (CARDIAC RISK <1%) Superficial operations Cataract surgery Breast surgery Ambulatory surgery

Invasive Therapies

TABLE 439-5 RECOMMENDATIONS FOR STRESS TESTING BEFORE NONCARDIAC SURGERY

RECOMMENDATIONS Stress testing is recommended in high-risk surgery patients with 3 clinical factors. Stress testing may be considered in high-risk surgery patients with 2 clinical factors. Stress testing may be considered in intermediate-risk surgery patients. Stress testing is not recommended in low-risk surgery patients. CLASS* I IIb IIb III LEVEL C B C C

*Class of recommendation: I = evidence and/or general agreement that a given treatment or procedure is beneficial, useful, and effective; II = conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure; IIa = weight of evidence/opinion is in favor of usefulness/efficacy; IIb = usefulness/efficacy is less well established by evidence/opinion; III = evidence or general agreement that the given treatment or procedure is not useful or effective, and in some cases may be harmful. Level of evidence: A = data derived from multiple randomized clinical trials or meta-analyses; B = data derived from a single randomized clinical trial or large nonrandomized studies; C = consensus of opinion of the experts and/or small studies, retrospective studies, registries. See Table 439-4. See Table 439-3. Adapted from Poldermans D, Bax JJ, Boersma E, etal. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur Heart J. 2009;30:2769-2812.

Prophylactic coronary revascularization in patients who have stable cardiac symptoms and no aortic stenosis and do not meet standard criteria for the procedure (Chapter 71) does not appear to reduce perioperative myocardial infarction, death within 30 days, or long-term mortality at an average of 2.7 years in patients who receive appropriate medical therapy.7 Preoperative coronary revascularization is indicated only if the patient meets the criteria for coronary angiography or revascularization independent of the need for surgery, but even then coronary revascularization based on the results of preoperative noninvasive testing has not been shown to improve perioperative outcomes.8 For bare metal stents, data suggest that surgery should be delayed for 4 to 6 weeks after stenting because of the risk for in-stent thrombosis when dual antiplatelet therapy with aspirin and clopidogrel is discontinued early or because of the alternative risk for bleeding if surgery is performed in patients receiving such antiplatelet therapy (Chapter 74). Similar concerns apply with drug-eluting stents, for which the guidelines currently recommend continuing uninterrupted dual antiplatelet therapy for a minimum of 12 months because of the risk for late stent thrombosis. For balloon angioplasty without stenting, a delay of 2 weeks is generally recommended. If antiplatelet therapy has to be discontinued, clopidogrel is usually discontinued 5 to 7 days before (and prasugrel is stopped 7 days before) the noncardiac procedure, and aspirin is continued, if possible. If aspirin also needs to be discontinued, it is usually stopped approximately 1 week before surgery.

Other Cardiovascular Diseases Heart Failure

Heart failure, which is a major risk factor for surgery, requires treatment and optimization before surgery (Chapter 59). Routine use of pulmonary artery catheters does not reduce morbidity or mortality in patients undergoing elective noncardiac surgery.9 At present, there is no evidence that treatment to lower the BNP level or use of -blockers will reduce postoperative complications in patients with heart failure.

Risk Reduction Strategies for Ischemic Heart Disease Medical Therapy

Prophylactic -blockers (e.g., atenolol or bisoprolol) decreased major postoperative cardiac events in small early studies of higher-risk patients, but a number of subsequent studies failed to show a significant benefit. In by far the largest trial of prophylactic perioperative -blockers, a high dose of extended-release metoprolol, started hours before surgery, reduced perioperative MI, but at the expense of increasing strokes and overall mortality, in part owing to more hypotension and bradycardia.1 A meta-analysis confirmed the benefit of -blockers in reducing perioperative MI and the side effect of increasing stroke, but found no statistically significant difference in overall mortality,2 and a review of trials in which bisoprolol was started well before surgery found no relationship with postoperative stroke.3 Until more evidence is available, it seems prudent to avoid starting -blockers immediately before surgery and to avoid them in the settings of emergency surgery, prior cerebrovascular disease, or sepsis (Table 439-6). -Blockers may benefit patients at high risk for MI but not for stroke and are more likely to be beneficial when started at a lower dose well in advance of surgery and titrated to a heart rate of 55 to 70 beats per minute.4 Various recommended regimens are listed in Table 439-7. If a patient has contraindications to -blockers (bronchospasm, bradyarrhythmia, acute heart failure, advanced heart block), an 2-adrenergic agonist

Aortic Stenosis

Patients with symptomatic aortic stenosis who meet the criteria for valve replacement (Chapter 75) independent of their need for surgery should undergo the valve surgery before the noncardiac surgery. However, patients usually survive surgery with intensified care if they refuse valve replacement or time does not permit it. Balloon aortic valvuloplasty may be an option in severe cases. An asymptomatic aortic valve gradient higher than 25 to 30mmHg also carries an increased risk for perioperative complications but is an indication for more careful monitoring rather than valve surgery. Endocarditis prophylaxis is appropriate for patients with mechanical heart valves, previous endocarditis, or complex congenital heart disease undergoing invasive dental or upper respiratory procedures (Chapter 76).

Hypertension

Hypertension with blood pressure lower than 110mmHg diastolic or 180mmHg systolic without significant target organ damage does not increase the risk for major perioperative cardiac complications. Even when the preoperative diastolic blood pressure is higher, limited data suggest that surgery is safe after additional antihypertensive therapy.

Arrhythmias

Although patients with arrhythmias have increased perioperative risk, the risk is increased because the arrhythmias are usually markers of more serious

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TABLE 439-6 RECOMMENDATIONS FOR PERIOPERATIVE -BLOCKER THERAPY*

2009 RECOMMENDATIONS OF AMERICAN HEART ASSOCIATION/AMERICAN COLLEGE OF CARDIOLOGY (ACCF/AHA) CLASS I 1. -Blockers should be continued in patients undergoing surgery who are receiving -blockers for treatment of conditions with ACCF/AHA class I guideline indications for the drugs (level of evidence: C). 1. -Blockers are recommended in patients who have known ischemic heart disease or myocardial ischemia according to preoperative stress testing (level of evidence: B). 2. -Blockers are recommended in patients scheduled for high-risk surgery (level of evidence: B). 3. Continuation of -blockers is recommended in patients previously treated with -blockers because of ischemic heart disease, arrhythmias, or hypertension (level of evidence: C). 1. -Blockers should be considered for patients scheduled for intermediate-risk surgery (level of evidence: B). 2. Continuation in patients previously treated with -blockers because of chronic heart failure with systolic dysfunction should be considered (level of evidence: C). RECOMMENDATIONS OF EUROPEAN SOCIETY OF CARDIOLOGY

CLASS IIA 1. -Blockers titrated to heart rate and blood pressure are probably recommended for patients undergoing vascular surgery who are at high cardiac risk owing to coronary artery disease or the finding of cardiac ischemia on preoperative testing (level of evidence: B). 2. -Blockers titrated to heart rate and blood pressure are reasonable 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: C). 3. -Blockers titrated to heart rate and blood pressure are reasonable for patients in whom preoperative assessment identifies coronary artery disease or high cardiac risk, as defined by the presence of more than 1 clinical risk factor, who are undergoing intermediate-risk surgery (level of evidence: B). CLASS IIB 1. The usefulness of -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 in the absence of coronary artery disease (level of evidence: C). 2. The usefulness of -blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking -blockers (level of evidence: B). CLASS III 1. -Blockers should not be given to patients undergoing surgery who have absolute contraindications to -blockade (level of evidence: C). 2. Routine administration of high-dose -blockers in the absence of dose titration is not useful and may be harmful in patients not currently taking -blockers who are undergoing noncardiac surgery (level of evidence: B). 1. Perioperative high-dose -blockers without titration are not recommended (level of evidence: A). 2. -Blockers are not recommended in patients scheduled for low-risk surgery without risk factors (level of evidence: B). 1. -Blockers may be considered in patients scheduled for low-risk surgery with risk factor(s) (level of evidence: B).

*See Table 439-5 for definitions of class of recommendation and level of evidence. See Table 439-3. See Table 439-4. Reproduced from Poldermans D, Bax JJ, Boersma E, etal. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur Heart J. 2009;30:2769-2812.

heart disease or cause hemodynamic problems. Patients with tachyar rhythmias and bradyarrhythmias should generally be treated as in the nonoperative setting (Chapters 64 and 65), except for the special circumstance of anticoagulation in the perioperative setting (Chapter 37).

status, an altered mental state, and suppressed immune status from chronic steroid use, alcohol use, or diabetes may also increase the risk for postoperative pulmonary complications.

Pulmonary Risk Assessment

Procedure-Related Factors

Postoperative pulmonary complications are as common as cardiac complications and are associated with significant morbidity and mortality. Major complications include respiratory failure (e.g., reintubation, prolonged mechanical ventilation), pneumonia, atelectasis requiring bronchoscopy, and to a lesser degree, bronchospasm or an exacerbation of COPD requiring treatment and prolonged length of stay. Many postoperative pulmonary complications are due to exaggerations of the usual postoperative changes in pulmonary function: decreased lung volumes, diaphragmatic dysfunction, ventilationperfusion mismatches and shunting, hypoventilation, hypoxemia, and impaired defense mechanisms. Pulmonary risk factors can be divided into patient-related and procedure-related factors, the latter of which includes the type of surgery, anesthesia, and related factors.

Patient-Related Factors

The most important predictor of postoperative pulmonary complications is the type of surgery and proximity of the surgical incision to the diaphragm. Pulmonary function decreases by approximately 50% after intrathoracic surgery, upper abdominal procedures, and abdominal aortic aneurysm repair and does not fully return to normal for several weeks. Lower abdominal surgery is associated with a 25% decrease in pulmonary function. Laparoscopic procedures are usually associated with lower rates of postoperative pulmonary complications and shorter hospital stays than open procedures. Neuraxial anesthesia (epidural or spinal) may be associated with decreased risk when compared with general anesthesia, but the decision about which type of anesthesia to use is best left to the anesthesiologist. Emergency surgery, prolonged duration of anesthesia or surgery (>2 to 6 hours), and routine postoperative nasogastric tube use increase the risk for postoperative pulmonary complications.

COPD (Chapter 88) increases the risk for postoperative pulmonary com plications approximately twofold, depending on its severity, whereas wellcontrolled asthma (Chapter 87) does not increase risk. Active cigarette smokers are at increased risk, mainly related to the number of pack years smoked; smoking cessation at least 4 to 8 weeks before surgery may reduce the risk. Obstructive sleep apnea (Chapter 100), typically associated with obesity, confers an increased risk for hypercapnia and hypoxemia, and obese patients are at increased risk for atelectasis. Advanced age, poor functional

Pulmonary Function Tests

In general, pulmonary function tests (Chapter 85) are no more predictive of pulmonary complications than is clinical risk assessment alone. Such testing may be more helpful in assessing risk for lung resection surgery when it can predict the function of the remaining lung mass. However, even a postoperative predicted forced expiratory volume in 1 second (FEV1) of less than 800mL for lung resection, which is thought to portend a very high risk for death or prolonged mechanical ventilation, is not an absolute

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intermediate-acting insulin on the morning of surgery and are then given short-acting insulin on a sliding scale and correction dose based on fingerstick monitoring (Chapter 236). Continuous intravenous insulin, which provides tighter glucose control but is associated with more episodes of hypoglycemia and requires a monitored setting, is typically used in patients undergoing cardiac surgery and in critically ill patients. There are no validated guidelines regarding the management of patients taking long-acting basal insulin (glargine). In general, it should be continued, but its dose may be reduced for ambulatory surgery or in patients with tight control. Regardless of the mode of treatment, frequent monitoring of the glucose level is critical.

TABLE 439-7 PROTOCOLS FOR PROPHYLACTIC PERIOPERATIVE -BLOCKERS*

GENERAL PRINCIPLES Start -blocker at least 1 week before surgery (if possible). Titrate the dose to an ideal target heart rate of 55-70 beats/min. Use half the dose if the heart rate is <65 beats/min, if systolic blood pressure is <120mmHg, or in a small elderly or frail patient. Hold the dose if the heart rate is <55 beats/min or systolic blood pressure is <100mmHg. Continue -blocker postoperatively for at least 1-4wk (or indefinitely if independent criteria such as known coronary artery disease, peripheral arterial disease, or hypertension are present). Taper the dose if discontinuing. Before increasing the dose for postoperative tachycardia, evaluate the patient for other potential causes, including pain, bleeding, and sepsis (where -blockers may be detrimental). SPECIFIC DRUGS: ATENOLOL, BISOPROLOL, OR METOPROLOL Preoperatively (recommended starting dose, then titrate to the target heart rate): Atenolol: start at 25mg orally daily Bisoprolol: start at 5mg orally daily at least 7 days before surgery Metoprolol: start at 25-50mg orally twice daily up to 30 days preoperatively Day of surgerycontinue the usual dose or increase the oral dose to control the heart rate or give additional intravenous (IV) doses (atenolol or metoprolol, 5-10mg) as needed if unable to take orally. Esmolol can also be used (500-g/ kgIV loading dose over a 1-min period; then infuse at 50-200 g/kg/min and titrate to the target heart rate) Postoperativelycontinue the usual preoperative dose: Atenolol: 25-100mg orally daily for at least 7 days Bisoprolol: 2.5-5mg orally daily for at least 30 days Metoprolol: 25-100mg orally twice daily for at least 14 days Substitute IV atenolol or metoprolol (5-mg doses) as needed if unable to take medication orally
*See Table 439-6 for indications.

Exogenous Corticosteroids and Adrenal Insufficiency

contraindication to surgery. Preoperative arterial blood gas evaluation is also of little benefit in predicting postoperative pulmonary complications.

Risk Reduction Strategies

Unfortunately, many of the risk factors for postoperative pulmonary complications cannot be modified. Inhaled bronchodilators (-agonists and anticholinergics) and steroids can optimize the respiratory status of patients with COPD and asthma. Broad-spectrum antibiotics should be used to treat exacerbations caused by bacterial infection. Chest physiotherapy may be helpful. Smoking should be stopped at least 8 weeks before surgery, if possible. Lung expansion maneuvers (either incentive spirometry or deep-breathing exercises) can significantly improve pulmonary function, minimize atelectasis, and reduce risk, especially for thoracic and upper abdominal surgery. Pain control (Chapter 29) improves pulmonary function by allowing deeper breathing. Epidural analgesia and patient-controlled intravenous analgesia reduce postoperative pulmonary complications and, when possible, are preferable to parenteral narcotics.

The stress of surgery activates the hypothalamic-pituitary-adrenal (HPA) axis, which in turn stimulates release of adrenocorticotropic hormone (ACTH) and subsequent secretion of cortisol (Chapter 234), but a patient who is taking exogenous corticosteroids may have suppression of the HPA axis and not be able to respond to this stress adequately. As a result, hypotension and shock may occur. In general, a daily dose equivalent to 5mg or less of prednisone (Chapter 234), alternate-day short-acting therapy, or corticosteroids given for less than 3 weeks do not cause clinically significant HPA suppression, so no supplemental therapy is indicated. Conversely, doses greater than 20mg/day of prednisone for longer than 3 weeks usually suppress the HPA axis and warrant perioperative supplemental corticosteroids. In patients who are taking intermediate dosing regimens or who took large doses in the past year but are not taking corticosteroids or are taking lower doses now, the options are to perform an ACTH (cosyntropin) stimulation test, if time permits, and treat only patients with an inadequate response (Chapter 234) or to prescribe supplemental corticosteroids empirically. When supplemental corticosteroids are appropriate, short-term therapy tailored to the level of expected stress can provide protection without adverse effects on wound healing and with only short-term problems with glucose intolerance and fluid retention. For minor procedures or local anesthesia, the recommended approach is to give the patients usual dose before surgery without further supplementation. For moderate surgical stress (e.g., open cholecystectomy, lower extremity vascular surgery), a reasonable approach is 50mg of hydrocortisone intravenously before surgery, followed by 25mg every 8 hours for 1 to 2 days, and then the patients usual dose. For major surgical stress, patients are typically given 75 to 100mg of hydrocortisone intravenously before induction of anesthesia, followed by 50mg every 8 hours for 1 to 3 days until the stressful period resolves, and then their usual dose. An inadequately treated or undiagnosed hyperthyroid patient is potentially at risk for thyroid storm postoperatively. Elective surgery should be postponed in patients who are symptomatic or have resting tachycardia until they are euthyroid. Treatment of a thyrotoxic patient undergoing urgent or emergency surgery includes a combination of -blockers, antithyroid agents, and iodine to control the resting heart rate to less than 90 beats per minute, as well as prophylactic corticosteroid supplementation, as used for thyroid storm (Chapter 233). Conversely, patients with mild to moderate hypothyroidism tolerate surgery reasonably well. Patients with markedly symptomatic hypothyroidism should be treated with oral levothyroxine (T4) for several weeks before elective surgery. For emergency surgery, intravenous liothyronine (T3) or T4 (200 to 300 g intravenously, then 50 to 100 g/day) and supplemental corticosteroids (hydrocortisone, 100mg intravenously, then 25 to 50mg every 6 hours; also correct fluid and electrolyte abnormalities) should be given. Myxedema coma is a rare complication of surgery.

Thyroid Disease

Endocrine Conditions

Diabetes Mellitus

The major risks associated with surgery in diabetic patients are cardiac complications and wound infections. Complications are probably related more to associated diseases and end-organ involvement (coronary artery disease, chronic kidney disease, and autonomic neuropathy) than to the glucose level itself. Significantly, elevated glucose levels may impair wound healing and interfere with leukocyte defense mechanisms. However, current recommendations suggest a glucose target level of 140 to 180mg/dL rather than tight perioperative control. Patients whose diabetes is controlled by diet require only perioperative glucose monitoring (fingersticks) with short-acting insulin coverage on an as-needed basis. Patients taking oral hypoglycemic agents (Chapter 237) should not take them on the morning of surgery (chlorpropamide should be stopped 2 to 3 days before and metformin preferably 1 day before) and should be monitored with sliding-scale insulin coverage as needed. Patients taking insulin are most often given half to two thirds of their usual

Liver Disease

Routine preoperative testing of liver function is not recommended, but elective surgery should be avoided in patients with acute viral or alcoholic hepatitis. Patients with stable mild chronic hepatitis tolerate surgery well. Patients with alcoholic liver disease or cirrhosis are at risk for postoperative complications, including bleeding, infection, poor wound healing, and delirium. The severity of disease as assessed by Child-Turcotte-Pugh criteria and the MELD (Model for End-Stage Liver Disease) score (Chapter 157) can be used to estimate risk; the MELD score is thought to be more predictive of outcome. Aggressive treatment of coagulopathy, ascites, and encephalopathy is indicated before surgery.

TABLE 439-8 APPROACH TO ANTICOAGULATION IN THE PERIOPERATIVE PATIENT

Low thromboembolic risk/low bleeding risk Continue anticoagulant therapy with INR in therapeutic range. Low thromboembolic risk/high bleeding risk Discontinue anticoagulant therapy 5 days before the procedure. Start LMWH prophylaxis once daily or UFH IV 1 day after acenocoumarol interruption and 2 days after warfarin interruption. Administer the last dose of LMWH at least 12hr before the procedure or give UFH IV up to 4hr before surgery. Resume LMWH or UFH at the preprocedural dose 1-2 days (at least 12hr) before the procedure according to haemostatic status. Resume anticoagulant therapy 1 to 2 days after surgery at the preprocedural dose + 50% boost dose for 2 consecutive days according to the hemostatic status. LMWH or UFH is continued until the INR has returned to therapeutic levels. High thromboembolic risk Discontinue anticoagulant therapy 5 days before the procedure. Start therapeutic LMWH twice daily or UFH IV 1 day after acenocoumarol interruption and 2 days after warfarin interruption. Administer the last dose of LMWH at least 12hr before the procedure or give UFH IV up to 4hr before surgery. Resume LMWH or UFH at the preprocedural dose 1-2 days (at least 12hr) after the procedure according to hemostatic status. Resume anticoagulant therapy 1-2 days after surgery at the preprocedural dose + 50% boost dose for 2 consecutive days according to haemostatic status. LMWH or UFH is continued until the INR has returned to therapeutic levels.
LMWH = low-molecular-weight heparin; INR = international normalized ratio; IV = intravenous; UFH = unfractionated heparin. Reproduced from Poldermans D, Bax JJ, Boersma E, etal. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur Heart J. 2009;30:2769-2812.

-blockers for perioperative MI. However, there is no evidence that con tinuation of chronic -blockade increases risk for postoperative stroke. There is no evidence to support preoperative intervention in patients with asymptomatic bruits before noncardiac surgery. The general recommendation is to delay elective surgery for at least 2 to 4 weeks after a stroke.

1. Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008; 371:1839-1847. 2. Bangalore S, Wetterslev J, Pranesh S, et al. Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis. Lancet. 2008;372:1962-1976. 3. van Lier F, Schouten O, Hoeks SE, et al. Impact of prophylactic beta-blocker therapy to prevent stroke after noncardiac surgery. Am J Cardiol. 2010;105:43-47. 4. Dunkelgrun M, Boersma E, Schouten O, et al. Bisoprolol and fluvastatin for the reduction of perioperative cardiac mortality and myocardial infarction in intermediate-risk patients undergoing noncardiovascular surgery: a randomized controlled trial (DECREASE-IV). Ann Surg. 2009;249: 921-926. 5. Wijeysundera DN, Bender JS, Beattie WS. Alpha-2 adrenergic agonists for the prevention of cardiac complications among patients undergoing surgery. Cochrane Database Syst Rev. 2009;4: CD004126. 6. Schouten O, Boersma E, Hoeks SE, et al, for the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. Fluvastatin and perioperative events in patients undergoing vascular surgery. N Engl J Med. 2009;361:980-989. 7. McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351:2795-2804. 8. Poldermans D, Schouten O, Vidakovic R, et al. A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: the DECREASE-V Pilot Study. J Am Coll Cardiol. 2007;49:1763-1769. 9. Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med. 2003;348:5-14.

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SUGGESTED READINGS
Bradley KA, Rubinsky AD, Sun H, et al. Alcohol screening and risk of postoperative complications in male VA patients undergoing major non-cardiac surgery. J Gen Intern Med. 2011;26:162-169. Postoperative complications were more likely with AUDIT-C scores of 5 or more within a year of surgery. Brienza N, Giglio MT, Marucci M. Preventing acute kidney injury after noncardiac surgery. Curr Opin Crit Care. 2010;16:353-358. Review. Fleisher LA, Beckman JA, Brown KA, et al. 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in Collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine, and Society for Vascular Surgery. J Am Coll Cardiol. 2009;54:2102-2128. Consensus guidelines. Lobo SM, Rezende E, Knibel MF, et al. Early determinants of death due to multiple organ failure after noncardiac surgery in high-risk patients. Anesth Analg. 2011;112:877-883. Multiorgan failure is the leading cause of death in high-risk noncardiac surgery; risk factors include peritonitis, diabetes, unplanned surgery, high central venous pressure, tachycardia, abnormal pH, and elevated serum lactate levels. Poldermans D, Bax JJ, Boersma E, et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur Heart J. 2009;30:2769-2812. Consensus guidelines.

Hematologic Problems
Anemia is associated with an increased risk for postoperative complications, but operative patients generally tolerate hemoglobin levels as low as 7g/dL. Preoperative transfusion should not be triggered solely by the hemoglobin level but should also consider the expected blood loss from the surgical procedure and the patients comorbid conditions. For patients with cardiopulmonary disease, however, a goal of 10g/dL is typically recommended for major surgery. Patients without a personal or family history of abnormal bleeding require no preoperative testing of coagulative function, but those with such a history should be evaluated. Ideally, the prothrombin time should be within 3 seconds of control (international normalized ratio <1.5), the partial thromboplastin time within 10 seconds of control, and the platelet count above a minimum of 50,000, depending on the type of surgery. The approach to perioperative anticoagulation, both in terms of prevention of venous thromboembolism and for the management of a patient taking warfarin, aspirin, or other antithrombotic medications, is described elsewhere (Chapter 37). For patients already on anticoagulants, perioperative recommendations depend on the short-term risks for thromboembolism and bleeding (Table 439-8).

Renal Disorders

Chronic kidney disease is an independent risk factor for postoperative cardiovascular events and death. Patients with chronic kidney disease typically have other comorbid diseases and may also have fluid and electrolyte abnormalities, anemia, and bleeding diatheses, which should be treated and optimized before surgery. Patients maintained on dialysis should ideally undergo dialysis the day before surgery to optimize their volume status, prevent hyperkalemia, and minimize acute shifts in acid-base balance.

Neurologic Problems

The risk for a postoperative stroke in unselected patients after general surgery is less than 0.5%, but patients with a history of stroke, older patients, and those undergoing vascular surgery, especially carotid surgery, have higher risk. Patients with symptomatic carotid bruits require further investigation and possible intervention before elective surgery (Chapter 414). Patients who newly receive perioperative -blockers are at increased risk for stroke,2 and the risk must be balanced against the protective effect of