Perioperative Evaluation (Schneider - 10/4/23)

Sorry, there is no recording available for this session. 

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Thank you to our very own Dr. Dave Schneider for an excellent presentation on Perioperative Evaluation. Unfortunately, I forgot to hit "record" on the zoom meeting, so we do not have a recorded version of his presentation. Sorry about that!

My notes:

First off, "clearance for surgery" is not our job!  Our job is to assess each patient's perioperative risks and optimize and manage those risk factors as they head into surgery. Do note that there are gender and race disparities in those who receive surgical interventions (BIPOC patients receive fewer PCI interventions, fewer orthoplasties and have increased mortality when undergoing these procedures).

The new-ish term for perioperative cardiovascular complications is Myocardial Injury after Non-Cardiac Surgery (aka MINS). 5-19% of surgical patients will experience MINS, 84% will be asymptomatic. MINS is associated with increased morbidity and mortality.

The American College of Cardiology (ACC) last updated their Guidelines for Perioperative Cardiovascular Evaluation and Management for patients undergoing non-cardiac surgery in 2014. These old guidelines are available here. The flow diagram is a doozy and the recommendations are confusing: 

In classic Schneider-fashion, Dr. Schneider invented an acronym to summarize their 2014 recommendations. It is called E-A-R-L-I

E: Emergent: if a surgery is emergent--> take patient to the OR and deal with the negative outcomes later

A: ACS: if the patient has s/sx of ACS, manage per guidelines

R: Risk assess --> use any of several tools (e.g. RCRI, NSQUIP calculator, MICA calculator, see below for more info)

L: Limitation of function --> if patient unable to  perform at 4 METs using the Duke Activity Scale, optimize their functional status before proceeding to surgery

I: Impact on decision? --> Yes or No? If the cardiac stress test outcome will change how/when you will proceed with surgery, then go ahead with a stress test. If not, then proceed to the OR.

The European Society of Cardiology (ESC) updated their guidelines on perioperative management more recently in 2022. And their guidelines are much more simple than those of the ACC. They are summarized here by the ACC. In essence, they say: 

Is the surgery. . .

Emergent? -->  Proceed to surgery without delay, cardiac testing is not feasible

Urgent? --> Proceed to surgery without unnecessary delay (using a multidisciplinary team to determine about individualized cardiac testing)

Time-Sensitive? --> Do the surgery ASAP

Their guidelines are summarized in this lovely flow charts. Don't you just love flow charts?

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Should you check a Hemoglobin and Renal function in all patients pre-operatively? The answer is no, but your should check in intermediate and high risk patients. 

Don't forget, for everyone, advise smoking cessation!

There are two risks to consider in evaluating patients: 1) the risk of the surgery itself (e.g. highest risk includes intra-thoracic, vascular) and 2) the risk of the patient

• If the surgery is low risk, no CV assessment needs to be made
• If the surgery is intermediate risk, and the patient is either >65 or with CV risk factors, get an EKG and check functional capacity
• If the surgery is HIGH risk, consider EKG and biomarkers** for patients older than 45, definitely get them for patients >65 or with CV risk factors. If the patient has known CVD, get a cardiology consultation and make a multidisciplinary decision. 

**Note: Biomarkers referred to above include BNP and/or Cardiac Troponin (also in table above). They have been shown to predict MI. Either one is predictive and do not change outcomes. 

There are several risk calculators to help you determine your patient's  risk level:

1) Revised Cardiac Risk Index (RCRI), which Dr. Schneider shortens to DRC4 (diabetes, risky surgery, CAD, CHF, CVD, Cr>2)

2) The NSQUIP calculator

3) Gupta's Perioperative MICA calculator

Each calculator is slightly different and variably useful depending on the patient in front of you. All three of these have been validated and you should get familiar with all of them.

Okay, now for a few pearls:

• There is NO benefit to coronary revascularization before surgery.
• Labs and other tests should only be done pre-operatively if you were going to do them anyway
• Coag testing is usually unnecessary unless patient is on warfarin. Family Hx and PMH are just as predictive of bleeding (e.g. if patient has history of prior bleed, or family member has bleeding problem, patient has higher risk of bleed)
• Only get a pre-op EKG if the patient has known CVD, CV risk factors >65 and they are having an intermediate/high risk surgery
• TTE only needed if patient has known valvular lesion and no TTE in the last year. You may consider if new onset dyspnea or change in status of their HF
• Pre-op CXR is NOT recommended (Choosing Wisely, ACR 2017)

What about medications?

Statins: if a patient is on a statin, continue it (okay to miss a few days due to NPO, etc.). Perioperative initiation is reasonable if someone is getting vascular surgery

Beta blockers: if patient is already on BB, continue them perioperatively (perioperative withdrawal has 4x increased mortality). You may consider decreasing BB dose due to risk of hypotension after surgery. You can consider starting a BB at least one week (up to 28 days) prior to cardiac surgery if high risk patient and high risk surgery. 

Other anti-hypertensives: post-op hypotension is a common problem. Consider holding all BP meds on day of surgery, add them back slowly post-op, ?one at a time

ASA: it is okay to go to the OR on aspirin. Also okay to stop ASA in high bleeding risk patients (e.g. those on DOAC or warfarin as well). Continuing ASA has been shown to be cardioprotective: decreased MI by 56% and decreased composite CV outcomes. There is a non-significant increased bleeding risk if you continue ASA.

What about patients with recent drug eluting stents (DES)? Delay elective surgery for up to 6 months if possible so as not to interrupt DAPT. 

Dental Care for Primary Care (Gonzalez, 4/14/2021)

Great thanks and Happy Birthday to our Grand Rounds speaker this week, Gina Gonzalez, DDS for a comprehensive review of what primary care doctors should know about dental care: Oral Health for the Primary Care Provider. Dr. Gonzalez took us from the cradle to the grave (or crib to casket, so to speak) and motivated me to schedule a dental preventive visit ASAP! 

She reminded us that the mouth is an important part of the body, and when medical providers are seeing patients, we should definitely be examining their mouths, giving them preventive dental care recommendations, and screening for oral cancers. 

For those of you who missed it, a link to the video recording can be found HERE. For those of you who prefer the summary, here are my summary notes:

Tooth decay and periodontal disease are 100% preventable

• 92% of US adult have dental disease, 50% have gum disease, 5% of adults are edentulous
• 42% of US children have early childhood cavities (i.e. in baby teeth)
• Fluoride reduced decay by 50%

Pediatrics:

Prevention

• Cavities are an infectious disease! Strep mutans is the oral bacteria transmitted from adults' mouths to babies' mouths Pro tip: don't kiss babies on the mouth (you'll give them your bacteria)
• A baby's first visit to the dentist should be as soon as baby has its first tooth (parental education: how to care for the mouth, fluoride-- remember, in Sonoma County, we don't have fluoridated water, so parents need to use fluoride supplement or a fluoride containing toothpaste)
• To get a good look in a baby's mouth during your exam, try doing a knee-to-knee exam (see photo), in which the baby straddles parent and head is in examiner's lap 

  

  knee to knee dental exam position

  
  
• Kids should NOT use toothpaste unless they know to spit OR parents can put about 1/4 size of pea (can wipe away, is not harmful)
• Breastmilk (and formula ) both have a lot of carbs--> don't forget to wipe down baby's mouth after they feed
• Fruits and veggies that contain fluoride include: grapes, spinach, oatmeal and carrots
• Brush baby's teeth every day!
• Early childhood caries can be prevented: no fall asleep after nursing/bottle without wiping the teeth, only water in the bottle, clean
• No soda!

Pathology

• Rarely, infants are born with a neonatal tooth (often rudimentary root), which be easily extracted, particularly if they are making problems with breastfeeding
• Silver diamide fluoride is treatment for ECC (it may be ugly but STOPS the decay and avoids general anesthesia, capping, etc.)
• When a child is getting their adult teeth, two rows of teeth is normal, usually teeth come out on the own, don't worry!
• If a child's tooth comes out due to trauma, put the tooth back in child's mouth while you seek care; if you are worried they cannot safely do so, put the tooth in your own mouth (saliva is good for preserving the root). A third choice is to put it in milk (not water, which is dehydrating)
• In children, purulent abscess can form due to trauma or decay; if you see one, they critically need treatment 

Adults

Prevention

• Advise adults to floss their teeth before they brush: fluoride goes into cleaner space
• Power brushes can remove more plaque than traditional toothbrush
• Tongue hygiene brush is a good idea
• Drink water that is similar to pH of saliva (6.-7.6), bubbly water is acidic, saliva lubricates and bathes your teeth

Pathology

• Tooth decay is a result of poor hygiene, poor diet, genetics, prescription medications (e.g. SSRI, BP meds can cause a lot of dry mouth, leading to cervical decay--> add fluoride, brushing)
• soda is bad! 46gm sugar, very low pH
• Periodontitis is irreversible gum disease; it requires urgent and imperative tooth care
• As teeth decay and become abscess, infection can go through the bone, full of pus, hard to numb 
• As patients age, elders tend to drop out of routine care (transportation); don't forget to talk about how they are accessing dental care at well check visits
• Edentulism is a travesty! When teeth removed, you lose proprioception, start chewing funny, lose pressure to eat, get jaw collapse--> poor appetite, failure to thrive. Dental implants (with dentures attached) are superior!

Oral cancer screening is important and quick!

• grab a gauze, pull the tongue out!
• All you need: 2x2 gauze, tongue depressor and flashlight
• high risk locations for oral cancer: floor of the mouth, lateral borders of the tongue, junction of the hard and soft palate, and posterior oropharynx
• to do a cancer exam:
• look at skin of face, scaling, irregular and dark changes, particular attention to ear
• palpate back of neck, clavicular nodes, SCM, submandibular and sublingual glands
• eyes: Movement, melanoma, sclera
• look in nose
• look at vermillion border of mouth
• palpate bimanually to feel for anything fixed, parotid gland (tenderness occlusion), check joints (pops/clicks, jaw deviation)
  
• lateral border of tongue, floor of mouth, symmetry, gums/bones/teeth
• palpate inside mouth, junction of hard/soft palate
• look for symmetry!
• can be done in 3 minutes!
• oral cancer risks: tobacco, alcohol, vaping

Okay, now for a quiz: are these oral lesions benign or cancerous? Name these abnormalies (answers below)

A.

B.

C. 

D.

E.

F.

G.

H.

I.

J.

K.

A. black hairy tongue (benign) B. oral lichen planus C. Pyogenic granulomas (aka "pregnancy tumors") (benign) D. fordyce granules (benign) E. Geographic tongue (benign) F. Labial HSV G. Oral HPV H. Squamous cell cancer I. Squamous cell cancer  J. verrucous carcinoma K. precancerous lesion from snuff