 |
| Practical: the most comprehensive preoperative cardiac risk assessment strategy |
What the physicians are worried about is how to evaluate the risks objectively. In the current "tight" medical environment, they do not evade or take on too many "responsibility".
European Guide to ESC/ESA Non-Heart Surgery: Cardiovascular Assessment and Management in Europe and Perioperative Cardiovascular Assessment and Treatment Guide for ACC/AHA Non-Heart Surgery in the United States, Objectively Evaluate and Treat Preoperative Surgery The cardiovascular risk presents a detailed strategy. However, the guidelines for Europe and the United States also have "acclims" in the country, and they need to be adjusted in line with domestic realities.
1. The following conditions should delay the elective surgery
If you have the following cardiovascular instability, first check if it is an emergency operation. If it is not an emergency operation, you should consider postponing and handling the heart problem first. The author integrates the following three points according to the guidelines:
Acute coronary syndrome (ACS), acute heart failure, severe aortic stenosis, severe mitral stenosis with pulmonary hypertension.
So how do you deal with it? When can I consider surgery?
After ACS revascularization, the best surgery should be delayed until 14 days after balloon dilation, 30 days for bare metal stent placement, and 1 year after drug stent placement. However, if a second-generation drug stent is placed and the risk and benefit are assessed, the waiting time can be shortened to 3 - 6 months.
Acute heart failure, stable heart function 3 months after surgery.
Symptomatic severe aortic stenosis is recommended to change the flap first. If the bioprosthesis is replaced, warfarin is required for anticoagulation for 6 months. Severe mitral stenosis with pulmonary hypertension may be considered for percutaneous mitral valvuloplasty.
It should be noted that cardiovascular instability does not include:
Stability coronary heart disease. For coronary heart disease, it is mainly to see if it is stable, not the degree of vascular stenosis.
The stable period of chronic heart failure is not in this category. Optional surgery can be considered.
In the case of valvular disease, it is necessary to pay attention to the symptoms of "symptomatic", "severe" and "stenosis". Other valvular heart disease (aortic regurgitation, mitral regurgitation) is not in this category. Surgery can be considered.
After examining cardiovascular instability, surgery is achievable, and the next step is to assess risk and control risk.
2. Metabolic equivalent (MET) is an important indicator
The most important tool for preoperative cardiovascular risk assessment is not ECG, cardiac ultrasound or coronary CTA, but Metablic equivalent (MET), a simple indicator that can be obtained by medical history.
Metabolic equivalent is an important indicator of relative exercise intensity, which simply reflects the patient's activity tolerance. Divided into 1 to 10 grades, 1 MET stands for dressing, eating, etc. 4 METs stands for 2 stairs, 10 METs stands for playing, swimming, climbing, etc.
The US guidelines recommend that patients with elevated risk of adverse cardiac events (MACE) but excellent metabolic equivalents (>10 METs) undergo surgery without further exercise testing and cardiac imaging (IIa, B). MACE may be reasonable for patients with elevated risk but good metabolic equivalents (4 ≤ METs < 10) without further exercise testing and cardiac imaging and surgery (IIb, B).
There are similar recommendations in the European guide.
Therefore, after reviewing the cardiovascular instability mentioned above, the patient should ask the patient three key questions before surgery:
Can life take care of itself? Will the upper 2 stairs be asthmatic? What sports do you usually do?
According to the European and American guidelines, even patients with high cardiovascular risk, if the patient can easily walk above two levels of stairs, the activity tolerance is greater than 4 METs, the examination does not need to do more, surgery can be performed.
3. Quantitative risk assessment: NSQIP, RCRI
The quantitative evaluation tool has the advantages of being objective and the disadvantages are cumbersome and inconvenient to use. It is impossible for clinicians to remember the risk score criteria for a strip. So, under what circumstances do you need to count these cumbersome ratings?
As mentioned above, it is recommended to postpone non-emergency surgery in cases of cardiovascular instability. If the metabolic equivalent is ≥ 4 METs, surgery may be considered for patients with elevated MACE risk. So what happens when the metabolic equivalent < 4 METs? At this time, a quantitative risk assessment (NSQIP, RCRI) is required.
The National Surgery Quality Improvement Program (NSQIP) can be used to assess the risk of surgical complications (scan the QR code below to access the website). Enter the name of the operation (to determine high- and low-risk surgery), age, gender, mobility, history of hormone use, presence of ascites within 30 days, sepsis within 48 hours, mechanical ventilation, metastasis, diabetes, hypertension, COPD, heart failure , dyspnea, smoking, dialysis, acute renal failure, height, weight and other parameters, in addition to cardiovascular risk, a series of complications (pulmonary infection, urinary tract infection, deep vein thrombosis, renal failure, etc.) Objectively quantify risks.
The risk grading of the surgery itself is the main influencing factor. It should be noted that the risk of surgery is definitely not differentiated by "local anesthesia", "waist hemp" and "general anesthesia", but the surgery itself. Occasionally, I will receive a consultation form to write "General anesthesia surgery." Instead, I have not mentioned anything about surgery. Such doctors have a misunderstanding of the risk of surgery.
It can be seen that common operations such as thyroid, ophthalmology, and prostate resection are classified as low-risk surgery. The guidelines state that if a patient underwent a low-risk procedure (such as an eye surgery), even if there are multiple cardiovascular risk factors, the risk of serious adverse events during surgery is low; if the patient undergoes major vascular surgery, even if they coexist There are very few vascular risk factors, and the risk of serious adverse events during surgery is still high.
Modified Cardiac Risk Index (RCRI) is an off-line assessment method involving 6 predictors: creatinine ≥ 2 mg/dl, heart failure, insulin-dependent diabetes mellitus, transthoracic, abdominal surgery or large vascular surgery above the groin, previous stroke or transient Ischemic ischemic attack, ischemic heart disease; 0 to 1 predictors are low risk, ≥ 2 predictors are associated with increased risk.
What should patients with high cardiovascular risk after NSQIP and RCRI scores? The author concludes that there are three main points:
- Multidisciplinary consultation
- Fully improved inspection
- Fully address the risk to patients
When the process goes to this step, it is not an individual or a single discipline that can decide to deal with the solution. Multidisciplinary consultations, including surgery, cardiology, anesthesiology, and related departments, are needed to develop best practices and share risks. Then fully improve the relevant examinations: including ECG, cardiac ultrasound, drug load test, coronary CTA, and even coronary angiography. Based on the calculated and discussed results, the patient and the family are fully communicated to determine whether to have surgery or to postpone the operation.
4. Risk management of various cardiovascular diseases
Coronary heart disease
Coronary heart disease is the most common complication, with the following details. Here specifically refers to the stability of coronary heart disease, the situation of ACS has been discussed above, it is recommended to revascularization.
1. Do you need to revascularize first?
The guidelines suggest that stable coronary heart disease generally does not consider revascularization. Unless high-risk coronary heart disease patients are at high risk of surgery (IIb, B).
So what is high-risk coronary heart disease? According to the European "2013 ESC Stability Coronary Artery Management Guide", it can be simply defined as obvious left main disease, three-vessel disease, and proximal anterior descending lesion.
Therefore, for example, patients undergoing partial hepatectomy (high-risk surgery), such as coronary artery is a three-vessel disease, or more than 50% of left main stenosis, more than 70% of anterior descending stenosis, can consider revascularization ( PCI or CABG) is a category IIb recommendation. If it is only a circumflex artery or a single-vessel disease of the right coronary artery, etc., no matter whether the stenosis is multiple, it is not recommended to perform revascularization first.
The means of revascularization included balloon dilatation (surgery delayed for 14 days), bare metal stent placement (30 days), and drug stent placement (1 year). If a second-generation drug stent is placed and the risk and benefit are assessed, the waiting time can be shortened to 3 to 6 months. If it is intended to be operated as soon as possible, and the lesion should not be used with bare stents, consider CABG.
2. Antiplatelet drug adjustment
Another key issue in the adjustment of antiplatelet drugs, how to stop before surgery, how to resume use after surgery.
In general, aspirin is recommended to be discontinued for 7 to 10 days before surgery, and telgrelor and clopidogrel are recommended to be discontinued for 5 days. According to the risk of bleeding after surgery, it is best to resume the use of antiplatelet drugs as soon as possible after 24 h to 48 h.
The use of low molecular weight heparin bridging has proven to be ineffective during the discontinuation of antiplatelet agents and may also increase the risk of surgical bleeding.
3. Perioperative management
The guide recommends that patients with high-risk coronary heart disease should be examined for troponin 48-72 hours before and after surgery.
In addition, it is necessary to pay attention to the symptoms of myocardial ischemia such as chest tightness, chest pain, and cold sweat. Avoid coronary insufficiency caused by hypotension during and after surgery. On the drug side, ACEI / ARB, statins and other secondary prevention drugs for coronary heart disease should continue to be used. It is also recommended to use beta blockers in patients with high ischemic risk and to restore antiplatelet drugs as soon as possible.
Atrial fibrillation
Atrial fibrillation is primarily a problem involving anticoagulation. In patients who used warfarin anticoagulation, warfarin was discontinued, low-molecular-weight heparin was used for anticoagulation, and then discontinued 1 hour before surgery. After surgery, low molecular weight heparin and warfarin were used according to the risk of bleeding.
Heart failure
Perioperative management: pay attention to the amount of intake and output, control the amount of fluid and the speed of fluid (usually 1 ml / kg / h), pay attention to the increase in heart rate, shortness of breath, increased lung snoring and other symptoms of heart failure. Use cardiac and diuretic drugs to detect pro-NT-BNP or BNP and adjust cardiac function to a better state.
Drugs: Continue to optimize the use of ACEI / ARB, beta blockers, aldosterone receptor antagonists to improve the prognosis of heart failure. It should be noted that unless the beta blocker has sufficient titration time, it is not recommended to use a large dose of beta blocker before surgery because it may worsen heart failure in the short term.
hypertension
Control objectives: Guidelines recommended, systolic blood pressure < 180 mmHg, diastolic blood pressure < 110 mmHg, without delaying the operation time (IIb, b). However, if the time is sufficient for elective surgery, the target of adjustment is 140/90 mmHg or less.
Causes of increased blood pressure during perioperative period: surgical anxiety, surgical incision pain, hypoxia, excessive fluid intake, flatulence, urine retention, nausea, vomiting, etc. Preoperative blood pressure control, postoperative blood pressure is significantly elevated, need to rule out the incentives.
Drug selection: You can use antihypertensive drugs with quick onset. After the blood pressure reaches the standard, you can operate as soon as possible, such as CCB-type nifedipine sustained release agent. Patients with systolic blood pressure above 160 mmHg can start with ACEI / ARB. Diuretics should be used with caution as they can aggravate surgical-related fluid loss.
Valvular disease
Symptomatic aortic stenosis, severe mitral stenosis with pulmonary hypertension, the valve should be treated first, and then surgery.
Severe mitral regurgitation, severe aortic regurgitation, such as stable cardiac function, feasible surgery (IIa, C). Asymptomatic severe stenosis of the aortic valve and severe stenosis of the mitral stenosis require assessment of risk and benefit and decide whether to treat the valve first.
Patients undergoing bioprosthetic replacement require anticoagulation for half a year, while mechanical flap patients require lifelong anticoagulation, so heart surgery should choose a biological flap. If surgery is required during anticoagulation, warfarin can be discontinued for low molecular weight heparin bridging.
Arrhythmia
The frequent room does not affect the surgery.
If there is ventricular tachycardia, you should consult a cardiovascular medicine department to determine whether it has a special ventricular tachycardia. For idiopathic ventricular tachycardia, the risk associated with surgery is small, and the authors may be given anti-arrhythmia drugs (lidocaine, reachable dragon).
Perioperative bradycardia is common, especially after anesthesia. Care should be taken to review the electrolyte.
Pay attention to the past and present whether there are symptoms of syncope, sputum, dizziness, blood pressure, or ECG monitoring, and observe whether there is a long R-R interval greater than 3 seconds. If you can consider a temporary pacemaker. If you have no symptoms, normal blood pressure, and heart rate less than 40 bpm, you can temporarily use atropine or isoproterenol to increase your heart rate.
5. Combining domestic actual adjustment strategies
The European and American guidelines are well-founded. However, it is also necessary to combine domestic realities. Some recommendations are difficult to implement in China, such as:
1. In the guidelines, for asymptomatic patients undergoing low-risk surgery, there is no need to routinely rest 12-lead ECG (III, B).
All patients in the country routinely performed an electrocardiogram. Although postoperative angina pectoris and myocardial infarction are low-probability events, if there is a medical dispute in the event of a medical dispute, the ECG of 20 yuan before surgery is not done, it is hard to say.
2. In the guide, there are reasons for unexplained breathing difficulties, or heart failure. If you have not reviewed the color ultrasound in 1 year or have increased difficulty in breathing, it is recommended to do color ultrasound. Conventional heart color Doppler (III, B) is not recommended.
The US color ultrasound will cost 5,000 yuan at a time. And about 300 yuan in the country. In fact, the indications for the heart color ultrasound are far less strict. Heart color ultrasound can be further evaluated when there is a heart disease or an electrocardiogram that has difficult to resolve changes. When coronary heart disease is highly suspected, coronary CTA or coronary angiography may be used to confirm the diagnosis.
3. Whether to stop aspirin before surgery is a measure of the risk of bleeding and embolism. For patients who are receiving aspirin and have a risk or risk factor for thromboembolism, if non-cardiac surgery is planned, it is recommended to continue taking aspirin during surgery.
Not stopping aspirin before surgery is not feasible most of the time in the country. First, most surgeons do not have experience in surgery based on aspirin, fearing bleeding. Secondly, there are not many physicians who are willing to take this risk. In the unlikely event of a major bleeding in the operation, how can you tell the reason why it is not aspirin?
In summary, cardiovascular risk assessment should be performed before surgery. Cardiovascular instability (ACS, acute heart failure, symptomatic aortic stenosis) should be investigated first, then MET should be assessed, and risk quantification scores should be calculated if necessary (NSQIP, RCRI). ). While referring to the European and American guidelines, we must consider the actual situation in the country. Surgery should be done well, and the risks should be managed.
No comments:
Post a Comment