PERIOPERATIVE RISK MITIGATION AND TREATMENT Allen Hayman M

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PERIOPERATIVE RISK MITIGATION AND TREATMENT Allen Hayman, M. D. , FASA

PERIOPERATIVE RISK MITIGATION AND TREATMENT Allen Hayman, M. D. , FASA

Disclosures � � I have no conflicts of interest I wish to disclose Seriously

Disclosures � � I have no conflicts of interest I wish to disclose Seriously – I have no disclosures or conflicts of interest.

What happens when optimization fails? � � Do we cancel? Do we postpone? Do

What happens when optimization fails? � � Do we cancel? Do we postpone? Do we delay? Do we proceed?

Do we have a choice? � � Elective Urgent – Procedure needs to occur

Do we have a choice? � � Elective Urgent – Procedure needs to occur within 24 hours Emergent – Imminent threat to life or limb Time sensitive – e. g. radio-tagged implants (lumpectomy) – Sentinel node biopsy

Elective Cases � � � Risk vs convenience Adult versus pediatric Benefit of waiting

Elective Cases � � � Risk vs convenience Adult versus pediatric Benefit of waiting vs proceeding

What gets you canceled � � � Significant change in medical status Current infection

What gets you canceled � � � Significant change in medical status Current infection New arrhythmia No responsible adult Severe HTN – after anxiolysis

What gets you delayed � Hyperglycemia � POC Glucose >180 � 2 -3 fold

What gets you delayed � Hyperglycemia � POC Glucose >180 � 2 -3 fold increase in MACE � Insulin is protective � NPO status � I had just a sip of coffee with cream on the way in � � Severe HTN – Prior to anxiolysis Asthma

What gets you postponed � � � Current URI NPO Status Unable to obtain

What gets you postponed � � � Current URI NPO Status Unable to obtain IV access COPD/Asthma exacerbation Pneumonia – less than 4 weeks from resolution of symptoms

MACE � Major Adverse Clinical Event

MACE � Major Adverse Clinical Event

Chronic comorbidities requiring optimization � � � Diabetes COPD CAD PVD HTN OSA CVA

Chronic comorbidities requiring optimization � � � Diabetes COPD CAD PVD HTN OSA CVA Pain PONV Allergies Medications

Preoperative vs Intraoperative vs Postoperative � � � Preoperative Intraoperative Postoperative

Preoperative vs Intraoperative vs Postoperative � � � Preoperative Intraoperative Postoperative

Crises vs comorbidity management

Crises vs comorbidity management

Crisis � � � Hypertensive Crisis Respiratory Failure Altered Mental Status Failure to Emerge

Crisis � � � Hypertensive Crisis Respiratory Failure Altered Mental Status Failure to Emerge (wake-up) Chest Pain MH

Case #1 � � � 56 yo male s/p R ankle ORIF. PMH: HTN,

Case #1 � � � 56 yo male s/p R ankle ORIF. PMH: HTN, 1 PPD smoker, Occasional Marijuana, GERD Sign out: � 200 mcg fentanyl, 2 mg dilaudid, 1 g IV tylenol, 30 mg ketorolac, 50 mg ketamine, 4 mg decardon and zofran � General LMA. � Standard induction � � � VS on arrival HR 115; SPO 2 99% on 6 LFM; BP 195/112; RR 28 What do you want to do next?

Hypertensive Crisis -Preop � � Severe hypertension 210/105 � Exaggerated hypotensive responsive to induction

Hypertensive Crisis -Preop � � Severe hypertension 210/105 � Exaggerated hypotensive responsive to induction � Diastolic > 110 � Increased risk of � Dysrhthmias MI Neurologic Complications Renal Failure Hold ACE inhibitors and Angiotensin Receptor Blockers (ARBs)

Hypertensive Crisis - Post � � Defined as sustained BP >180/110 mm. Hg Remedial

Hypertensive Crisis - Post � � Defined as sustained BP >180/110 mm. Hg Remedial causes: � Pain � Nausea and vomiting � Hypoxia and/or hypercarbia � Emergence delirium and agitation � Bladder Distention � Hypothermia with shivering � Hypervolemia � Alcohol and/or opioid withdrawal

Hypertensive Crisis - Post � Consider treatment once prior excluded: � Labetalol 20 mg

Hypertensive Crisis - Post � Consider treatment once prior excluded: � Labetalol 20 mg bolus repeat Q 10 mins. 5 -10 min onset 2 -4 hour duration � Nicardipine Infusion 5 -15 mg/hr IV infusion 5 -15 min onset 1. 5 ->4 hour duration � Hydralazine 10 -20 mg bolus 10 -20 min onset 1 -4 hour duration � Resume preoperative antihypertensives

Hypertensive - Post � � Typically treated in PACU if SBP > 180 or

Hypertensive - Post � � Typically treated in PACU if SBP > 180 or diastolic > 110 No known benefit from initiation of new therapy in the perioperative period to achieve "normal BP values. " Hypertension vs hypertensive crisis Evidence of neurologic signs � � Evidence of cardiovascular emergency � � Agitation, delirium, stupor, visual disturbances, seizures, stroke Acute coronary syndrome, decompensated heart failure, aortic dissection Pregnancy � SBP > 160 or DBP > 110 if persisting for > 15 mins

Case #2 � � � 25 yo male body builder s/p R knee arthroscopy.

Case #2 � � � 25 yo male body builder s/p R knee arthroscopy. 6’ 3” 140 kg PMH: unremarkable – 2 prior knee scopes without incident Sign out: GA with LMA – Sevoflurane 200 mcg fentanyl, 1 g IV tylenol, 30 mg ketorolac, 4 mg decardon and zofran Surgeon is in a foul mood (do you know what’s the difference between an orthopod and a puppy? ) – they really struggled to do this procedure. Complained the whole time about how big the leg was and how stiff the patient was � LMA didn’t seat great. CO 2 got pretty high towards the end. That, along with the surgeon chirping almost got him intubated. � � VS on arrival: � � � � SPO 2 100%; HR 126 with frequent PVCs; RR 32; T 39. 1 C Anesthesiologist – “He’s very hyperdynamic. We definitely cooked ‘em. I’m pretty sure he’s taking “supplements. ” Let’s give him another 100 mcg of fentanyl. I’m going to go see my next knee. What do you do? What do you suspect? Treatment? Labs? Next steps?

Malignant Hyperthermia � � Approximately ½ of patients who develop MH have one or

Malignant Hyperthermia � � Approximately ½ of patients who develop MH have one or two uneventful exposures Triggering agents � Volatile anesthetics � Succhinylcholine � � � Accumulation of myoplasmic calcium causes sustained muscle contraction Most cases secondary to abnormal RYR 1 or DHP receptors Sustained contraction leads to muscle breakdown and rhabdomyolysis, anaerobic metabolism, acidosis, and their sequelae

MH metabolism

MH metabolism

Clinical Presentation � Marked Hyperthermia – Minutes to hours � Extremely unlikely for hyperthermia

Clinical Presentation � Marked Hyperthermia – Minutes to hours � Extremely unlikely for hyperthermia to occur greater than 10 minutes after cessation of triggering agent � � � Muscle rigidity Sinus tachycardia Peaked T-waves PVCs Mottled skin in infants Myoglobinuria � Brownish, cola, or tea-colored urine � Indication of rhabdomyolysis � Peaks about 14 hours after MH episode

Treatment � Dantroline – 2. 5 mg/kg followed by 1 mg/kg until signs have

Treatment � Dantroline – 2. 5 mg/kg followed by 1 mg/kg until signs have abated � Generic Dantroline Lyophilized powder Slowly solubilized Large volume – 20 mg vial in 60 ml of sterile water � New Dantroline – Ryanodex 250 mg vials- reconstituted in 5 ml of sterile water No warming necessary � Malignant Hyperthermia Association of the United States (MHAUS) � � � Cooling � � Ice Fan Treat hyperkalemia � � 1 -800 -644 -9737 Mhaus. org Calcium, Bicarb, insulin, glucose, kayexelate Check labs Bladder catheter

Case #3 � � 49 yo female s/p lap gastric sleeve PMH: � HTN;

Case #3 � � 49 yo female s/p lap gastric sleeve PMH: � HTN; Migraines; OSA – Bi. PAP; BMI 68, GERD; PONV � Sign out: � Very difficult intubation. Numerous laryngoscopies � Uneventful procedure � Laryngospasm with extubation – Desat to 60%. Broke with propofol and positive pressure � VS in PACU: � SPO 2 92% on 10 LFM; HR 106; RR 26; BP 167/95; T 36. 5 C � � Are you happy with the current situation? Concerns

Case #3 (continued) � � � Pt now with increasing somnolence – SPO 2

Case #3 (continued) � � � Pt now with increasing somnolence – SPO 2 now 89% with 10 LFM and bibasilar crackles What next? Interventions? Labs? What are you concerned about?

Case #3 (continued) � � � SPO 2 now 85% with pt coughing up

Case #3 (continued) � � � SPO 2 now 85% with pt coughing up pink frothy sputum. Endorsing significant SOB Treatment Options

Postoperative Pulmonary Complications � Traditional: � Bronchospasm � Atelectasis � Pneumonia � Chronic lung

Postoperative Pulmonary Complications � Traditional: � Bronchospasm � Atelectasis � Pneumonia � Chronic lung disease exacerbation � Expanded � Acute upper airway obstruction � OSA complications � Pleural Effusions � Chemical pneumonitis � Pulmonary edema � Abdominal compartment syndrome – hypoxia � Tracheal laceration or rupture

Atelectasis � � � Probably the most common postop pulmonary complication Increased WOB and

Atelectasis � � � Probably the most common postop pulmonary complication Increased WOB and Hypoxia Tends to occur after leaving PACU Most severe POD #2 Continues through POD#4 -#5 Causes: � Decreased compliance � Impaired regional ventilation � Retained airway secretions � Postoperative pain preventing deep breathing

Atelectasis - Mgmt � Minimal respiratory secretions � CPAP � Lung recruitment strategies �

Atelectasis - Mgmt � Minimal respiratory secretions � CPAP � Lung recruitment strategies � Abundant respiratory secretions � Frequent suctioning � Chest physiotherapy Postural drainage Percussion � Bronchoscopy – little to no benefit � CPAP contraindicated

Bronchospasm � Clinical manifestations � � � � Wheezing Dyspnea Chest tightness Tachypnea Small

Bronchospasm � Clinical manifestations � � � � Wheezing Dyspnea Chest tightness Tachypnea Small tidal volumes Prolonged expiratory time Hypercapnia Causes � � � Aspiration Histamine release (Opiates, atracurium) Allergic response Asthma/COPD Tracheal stimulation Common once the bronchodilatory effects of inhaled anesthetics wear off

Bronchospasm - treatment � � � Treat the underlying cause Remove potential contributors Pharmacotherapy

Bronchospasm - treatment � � � Treat the underlying cause Remove potential contributors Pharmacotherapy � Short-acting inhaled Beta-2 -agonists Albuterol Metaproterenol � Short acting anticholinergic agent Ipratropium bromide May have additive effect on bronchodilation

Acute Upper Airway Obstruction � � Typical in the immediate postoperative period Stridor -

Acute Upper Airway Obstruction � � Typical in the immediate postoperative period Stridor - Incomplete Aphonia - Complete May include: � Respiratory distress � Dypnea, tachycardia and diaphoresis � � Medical emergency – May need intubation Treatment: � Bronchodilating medications � Racemic epi neb � IV steroids � Potential diuresis

OSA Exacerbation � � Defined as the repetitive complete or partial collapse of the

OSA Exacerbation � � Defined as the repetitive complete or partial collapse of the upper airway during sleep Exacerbation: � � More frequent or severe episodes of desaturations New or worse hypercapnia Usually occurs within 24 -48 hours Patients with postop hypoxia/hypercapnia: � Increased likelihood of adverse outcomes � Reintubation MI Arrhythmias Hypoxic encephalopathy Death Contributing factors: � � Anesthetic agents Sedatives Opioids Supine position

Chemical Pneumonitis � � Aspiration of gastric contents Clinical features: More common – Peds

Chemical Pneumonitis � � Aspiration of gastric contents Clinical features: More common – Peds and OB Full recovery is the usual outcome if no below in 2 hours: � Cough � Wheeze � >10 percent desat � � Can progress to pneumonia or ARDS Monitored closely for 24 -48 hours

Chemical Pneumonitis - Treatment � Supportive: � Supplemental oxygen � Noninvasive mechanical ventilation �

Chemical Pneumonitis - Treatment � Supportive: � Supplemental oxygen � Noninvasive mechanical ventilation � Conventional ventilation � � Prophylactic corticosteroids or antibiotics is not indicated If clinical findings unresolved after 48 hours, abx may be considered

Pulmonary Edema � Cardiogenic � Usually within 36 hours if fluid retention exceeds 67

Pulmonary Edema � Cardiogenic � Usually within 36 hours if fluid retention exceeds 67 m. L/kg/day � Noncardiogenic � Postoperative – secondary to negative pressure pulmonary edema � Combination of both

Negative Pressure Pulmonary Edema � Causes � Laryngospasm � Upper airway obstruction � Clinical

Negative Pressure Pulmonary Edema � Causes � Laryngospasm � Upper airway obstruction � Clinical signs (immediate or delayed) � Signs of acute upper airway obstruction � Dyspnea with pink frothy sputum � Bilateral infiltrates on CXR � Patient predisposition � Obesity � Short, thick neck � OSA � Acromegaly � ENT surgery

Negative Pressure Pulmonary Edema (continued) � Mechanism Negative intrathoracic pressure causes increased blood flow

Negative Pressure Pulmonary Edema (continued) � Mechanism Negative intrathoracic pressure causes increased blood flow to R heart Pulmonary vascular bed dilates Negative pressure around the capillary beds invites intravascular fluid to be drawn into the interstitial space � Worsens gas exchange which triggers: � � � � Hypoxemia Catecholamine release Systemic and pulmonary htn Acute increase in afterload Worsens transcapillary fluid efflux Increases interstitial and alveolar edema Treatment: � � Supportive Bronchodilators CPAP Diuresis

Case #4 � � 2 yo male s/p T&A PMH: � � Sign out:

Case #4 � � 2 yo male s/p T&A PMH: � � Sign out: � � � � � Easy intubation after crying inhalational induction Woke up “wild” in OR. Received Dexmedetomidine and propofol. Brought to PACU with oral airway in place Meds: 2 mg decadron; 3 mg zofran, 20 mcg fentanyl, 2 mg morphine VS in PACU: � � 20 kg. Passive smoke exposure SPO 2 96% on 6 L blow-by; HR 116; RR 24; BP 106/42 5 mins after sign out the patient coughs and spits out the oral airway. He has obvious respiratory effort. How do you verify oxygenation and ventilation? You can’t confirm air movement. Next steps?

Case #4 (continued) � � Laryngospasm broke with positive pressure via bag mask ventilation

Case #4 (continued) � � Laryngospasm broke with positive pressure via bag mask ventilation Now with inspiratory stridor � Difference between Wheezing and Stridor? � � � Concerns? Treatment? Testing?

Case #5 � � 82 yo male s/p 4 hour TURP. PMH: � �

Case #5 � � 82 yo male s/p 4 hour TURP. PMH: � � Sign out: � � � � Uneventful propofol TIVA with LMA 2. 5 L of LR 150 mcg fentanyl, 2 mg dilaudid, scopolamine patch, 4 decadron, 4 mg zofran, 2 mg atropine for significant intraop bradycardia (30’s) VS in PACU: � � BMI 45, OSA with CPAP, HTN, CAD s/p CABG, H/O TIAs, CRI with preop Cr of 1. 4, severe PONV SPO 2 94% 10 LFM, Oral airway in place, HR 62, BP 124/78, RR 8, T 37. 5 C 60 mins in PACU – Pt still unarousable. What do you do? What do you think this is? Labs?

Case #5 (continued) � � � POC glucose 45 Pupils pinpoint Pt is red,

Case #5 (continued) � � � POC glucose 45 Pupils pinpoint Pt is red, warm, no secretions despite OA in place � You check and notice bilateral scopolamine patches with no date on one of them � Labs – Na 125

Case #5 (continued) � � � Let’s now break out our magic wand rectify

Case #5 (continued) � � � Let’s now break out our magic wand rectify all the prior issues. Pt is still not arousable Next steps?

Delayed Emergence � � Unresponsive or heavily sedated 30 -60 mins after d/c of

Delayed Emergence � � Unresponsive or heavily sedated 30 -60 mins after d/c of anesthetic Risk factors: � � � Combinations of anesthetic and adjuvant agents Preoperative prescriptions and street drugs Hepatic or renal insufficiency Age and weight Hypothermia Hypothyroid Opioids Benzodiazepines Sedative-hypnotic agents Inhalational anesthetics Anticholinergic agents Neuromuscular blocking agents

Delayed Emergence - continued � Hypoxemia/hypercapnia � � Temperature and metabolic derangements � �

Delayed Emergence - continued � Hypoxemia/hypercapnia � � Temperature and metabolic derangements � � � � � Hypothermia Hyperthermia Glucose � � Arterial Blood Gas POC Glucose Sodium Hypermagnesemia Hypercalcemia Acute Stroke Seizures Hypoxic-ischemic encephalopathy Elevated ICP Prior Neurologic deficits

Case #6 � � 72 yo female s/p 4 hour emergent ex lap for

Case #6 � � 72 yo female s/p 4 hour emergent ex lap for small bowel perforation PMH: � � Sign out: � � � T 10 epidural placed with difficulty (multiple attempts). 1/8% marcaine infused at 8 cc/hour during case with 5 cc bolus of ¼% right before transfer to PACU EBL 2500 cc, transfused 2 U PRBCs, urine 50 cc during case (concentrated) R IJ TLC placed after induction Pt hypotensive throughout – phenylephrine gtt at 4 mcg/kg/min 4 L LR, 100 mcg fentanyl, 10 mg morphine, 4 mg decadron/zofran, reversed with suggamadex VS in PACU � � BMI 16, CAD with ischemic cardiomyopathy and LVEF 35%, stable angina, CRI with Cr 1. 6, 1 PPD smoker with O 2 dependent COPD, daily albuterol, currently taking 40 mg oral prednisone/day, DM II, Greenfield filter for recurrent DVTs SPO 2 90% on 10 LFM, HR 60, BP 60/30 (84/62 when leaving OR), RR 8, T 38. 5 C Where do you start?

Hypotensive Emergencies � Hypovolemic Shock � Hemorrhagic � Nonhemorrhagic � � � � Septic

Hypotensive Emergencies � Hypovolemic Shock � Hemorrhagic � Nonhemorrhagic � � � � Septic Shock Anaphylactic Shock Cardiogenic Shock Arrhthymogenic Shock Local anesthetic systemic toxicity Tension pneumothorax Pulmonary embolus Left ventricular outflow tract obstruction

Local Anesthetic Systemic Toxicity � Signs and symptoms Tinnitus, circumoral numbness, metallic taste, agitation,

Local Anesthetic Systemic Toxicity � Signs and symptoms Tinnitus, circumoral numbness, metallic taste, agitation, dysarthria, seizures, loss of consciousness, respiratory arrest � Hypotension, bradycardia, ventricular arrhythmias, CV collapse � � Treatment 100% oxygen Suppress seizures – benzos preferred – Avoid large doses of propofol � Lipid emulsion therapy � Arrange for cardiopulmonary bypass � ACLS: � � Avoid vasopressin, calcium channel blockers, beta blockers and local anesthetics Amiodarone as first line

Lipid Emulsion Therapy � � � � 20% Lipid Emulsion Adults > 70 kg

Lipid Emulsion Therapy � � � � 20% Lipid Emulsion Adults > 70 kg – Bolus 100 ml over 2 -3 mins followed by 250 ml infusion over 15 -20 mins Children or adults < 70 kg – 1. 5 ml/kg over 2 mins followed by 0. 25 ml/kg/min infusion Repeat bolus once or twice and double infusion rate for persistent CV instability Continue infusion for at least 10 mins after hemodynamic stability achieved Max dose lipid emulsion 12 ml/kg Institute cardiopulmonary bypass if unresponsive to lipid emulsion and ACLS (Note – Propofol is not a substitute for lipid emulsion)

Hypotension – initial treatment � � Ensure accuracy of blood pressure measurement Initial �

Hypotension – initial treatment � � Ensure accuracy of blood pressure measurement Initial � 250 -500 cc fluid bolus � Vasopressors Phenylephrine 40 -100 mcg increments – followed by infusion Ephedrine 5 -10 mg increments � Treatment of Severe or refractory � Diluted IV epinephrine 10 -50 mcg � Norepinephrine 4 -8 mcg � Vasopressin 1 -2 units � Evaluate for hypotensive emergencies