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Michele Fang, MD
Department of General
Internal Medicine
 m 

6 ÷ostoperative pulmonary
complications
6 Antiplatelets for coronary stents
6 ÷roblems with proton pump inhibitors
6 Controversies in beta blockade
6 Questions
 

  
 

  

6 ÷ulmonary complications are as common
as cardiac complications following
noncardiac surgery (2.7%)1
6 Respiratory failure is a marker of ill health
and predicts further complications
6 ÷ulmonary complications are expensive
and require lengthy hospitalizations
6 1 Fleischmann, JE Association between cardiac and noncardiac complications in
patients undergoing noncardiac surgery: outcomes and effects on length of stay, Am
J Med 2003; 115:515-
115:515-520.
 

  
 

  

6 ÷neumonia
6 Respiratory failure
6 Atelectasis
6 Bronchospasm
6 Exacerbation of chronic obstructive
pulmonary disease
  
  




  
  

6 uupported by good evidence:
6 Advanced age
6 AuA score >2
6 CHF
6 Functional dependency
6 CO÷D
6 uupported by fair evidence
6 Weight loss
6 Impaired sensorium
6 Cigarette use
6 Alcohol use
6 Low Albumin <3.5
6 Abnormal chest exam
umetana GW, ÷reoperative pulmonary risk stratification for noncardiothoracic surgery: a guideline from
144:575-580.
AC÷, Ann. Intern Med 2006; 144:575-
 

  
 




 
  

6 uupported by good evidence-
evidence-
6 Aortic aneurysm repair
6 Thoracic surgery
6 Abdominal surgery
6 Upper abdominal surgery
6 Neurosurgery
6 ÷rolonged surgery
6 Head and neck surgery
6 Emergency surgery
6 Vascular surgery
6 Use of general anesthesia
uupported by fair evidence
6 ÷ostoperative transfusion

6 umetana GW, ÷reoperative pulmonary risk stratification for noncardiothoracic surgery: a guideline from AC÷, Ann. Intern Med 2
2006
006;;
144:575--580
144:575
 [
  

 
 

  

6 Well-controlled asthma
Well-
6 Obesity
6 Hip surgery
6 GU/GYN surgery
 º     
6 Hwang et al enrolled 172 patients who had at
least 2 of 4 clinical features of osa (snoring,
daytime somnolence, witnessed apnea event, or
crowded oropharynx) who were to go for surgery
6 ÷atients underwent overnight nocturnal oximetry
before surgery
6 ÷atients with > 5 desat per hour had higher
postop resp complications (8/98) vs 1/74 in
those w/o desat
6 Higher risk of cardiac, GI, and bleeding
complications
6 Hwang, D Association of sleep-
sleep-disordered breathing with postoperative complications.
Chest 2008, 133:1128-
133:1128-1134 .
 
   

6 ÷Au÷ is >50 on echo
6 EKG may show rt heart strain
6 Retrospective database review and prospective
case--control study, found a 21-
case 21-28% incidence of
respiratory failure among 145 surgical patients
with pulmonary hypertension1,2
6 Increased rates of heart failure and in-
in-hospital
death.
1Ramakrishna G, Impact of pulm htn on the outcomes of noncardiac
.
6
surgery; J Am Coll Cardiol 2005; 45:1691-1699
6
2Lai, HC. uevere pulm HTN complicates postoperative outcome of
noncardiac surgery. Br J Anaesth 2007; 99:184-190.
 u  
  
 

6 ÷ostoperative lung expansion modalities-
modalities-
incentive spirometry, chest ÷T, C÷A÷
6 Use postoperative NG tubes selectively
6 uhort acting neuromuscular blockade
6 Laparoscopic vs open surgery
6 Tx OuA
6 ÷reop lung expansion
 [
 
   
 

6 T÷N or enteral nutrition
6 umoking cessation?-
cessation?- higher complication if
quit < 8 wks prior to surgery
6 upirometry and abg have no role in
routine preop assessment
6 ÷reop CXR only changes management in
1-2% of patients; having baseline does
not make it easier to correctly dx post op
pna; abnormal cxr correlates with higher
risk but h&p can usually predict these
patients
 

 

 

6 5% of patients with stents need surgery
6 Balloon angioplasty associated with 30-
30-
60% restenosis during 1st months after pci
6 Bare metal stents have neointimal growth
restenosis in 10-
10-30%.
Need >3 months of clopidogrel+ asa
6 Drug eluting stents release
antiproliferative agents at the site of
endothelial injury decrease local
proliferation of endothelial and vascular
smooth muscle cells. Restenosis 5- 5-10%.
Need >12 months of clopidogrel + asa
 a
  





   

  
6 Meta-analysis of 50279 CAD patients that asa
Meta-
withdrawal was associated with an altogether
3.14 fold increased relative risk of ischemic
events.1
6 BAuKET
BAuKET--LATE
LATE-- patients were followed for 1 year
after they had stopped their clopidogrel 7-
7-18
months post pci; late cardiac death and nonfatal
MI occurred in 4.9% of patients after DEu ÷CI as
BMu-÷CI.2
compared with 1.3% after BMu-
1m

 
  


  
 
      

    
 
        

  
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2 J Am Coll Cardiol. 2006 Dec 19;48(12):2584-
19;48(12):2584-91. Epub 2006 Nov 2.
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, 
, 

 ÷fisterer M,
M, J Am
Coll Cardiol. 2006 Dec 19;48(12):2584-
19;48(12):2584-91. Epub 2006 Nov 2.
 a
  





   

  
6 ÷REMIER study-
study- prospective study showed that
thienopyridine discontinuation within 30 days
after DEu-
DEu-÷CI was associated with a 9 fold
relative increased risk of 1 year mortality. 1
6 Retrospective study of 3137 ACu tx either
medically or with pci demonstrated a clustering of
adverse events in the initial 90 days after
stopping clopidogrel suggesting the possibility of
a clopidogrel rebound. 2
6 1 upertus, JA ÷revalence, predictors, and outcomes of premature discontinuation of
thienopyridine therapy after drug ±eluting stent placement: results from ÷remier
registry. Circulation 2006; 113:2803-
113:2803-2809
6 2 uteinhubl uR, Early and uustained Dual oral antiplatelet therapy following
percutaneous coronary intervention: a randomized controlled trial. JAMA 2002;
288:2241--2420.
288:2241
 Ñ

 


 
   
6 30% incidence of nonfatal MI and cardiac death
in patients who underwent surgery after
premature withdrawal of antiplatelet drugs as
compared with a 0% event rate in those patients
who continued their antiplatelet medications.1
6 Randomized controlled placebo control study of
low dose asa in 220 patients undergoing
noncardiac surgery; tx with asa resulted in a
7.2% absolute risk reduction and relative risk
reduction of 80% for postoperative MACE;
number needed to tx was 14. 2
6 1 uchouten O, Noncardiac surgery after coronary stenting: J Am Coll
Cardiol 2007; 49:122-
49:122-124.
6 2 Oscarsson, A, To continue or dc asa in the perioperative period; British J

Of anesth 104 (3): 305-

305-312; 2010.
 u

 
[
 
 
u  
u
Characteristic BMu (n=174) DEu (n=376)

Age 62.6 63.3

MI 56 (32%) 123 (33%)

DM 26 (15%) 93 (25%)

AuA 157 (91%) 264 (70%)

Dual antiplatelet tx 16 (9%) 112 (30%)

(overall)
Clopidogrel use 2 6
(mo)

Van Kujik, J Timing of Noncardiac uurgery after Coronary artery stenting with BMu
or DEu, Am J of Cardiol. 2009, 104, 9, 1229-1234.
 u  
 


uurgical group BMu (n=174) DEu (n=376)
Vascular 23 (13%) 41 (11%)
Emergency 4 (2%) 40 (11%)

Nose, mouth, pharynx 13 (8%) 15 (4%)

Eye 29 (17%) 42 (11%)
GI 16 (9%) 48 (13%)
Musculoskeletal 20 (12%) 39 (10%)
Respiratory 4 (2%) 11 (3%)
Nervous system 6 (3%) 23 (6%)

Oncology 1(1%) 1 (1%)

Low risk surgeries 68 (33%) 114 (31%)
(urology, cosmetic, derm,
misc)
Van Kujik, J Timing of Noncardiac uurgery after Coronary artery stenting with BMu or
DEu, Am J of Cardiol. 2009, 104, 9, 1229-1234.
 
 
  

Van Kujik, J Timing of Noncardiac uurgery after Coronary artery stenting

with BMu or DEu, Am J of Cardiol. 2009, 104, 9, 1229-1234.
 Ô 
m  



  


[ a
  
 
  
  
6 Retrospective chart review of 261 charts for
patients undergoing free flaps for head and neck
reconstruction from Jan 2000-Jan 2004 at
Harvard Medical uchool.
6 ÷atients received a standard postop
anticoagulation regimen of heparin 5000 sq bid
and asa 325 po qday
6 6 flap failures (2.8%)
6 6 venous congestion of flap (2.8%) neck
exploration
6 12 postop hematomas (5.6%) surgery
6 No thrombosis noted.
6 Conclusion: asa and sqh reliable postop anticoag
for Head and neck reconstruction using free flap
6 Chien, W,Effects of Aspirin and Low dose heparin in Head and Neck Reconstruction using
Microvascular Free Flaps, Laryngoscope, 2005, 115: 973-976,
 u  a 





[ 

6 320 patients who had received aspirin during
cutaneous head and neck lesion resection were
compared to those without aspirin (654) in a 10
yr period in ucotland
6 Incidence of significant postop hemorrhage in asa
and non asa groups was 5 (1.6% vs 0%)
respectively (÷=0.004).
6 Total postop hemorrhage in asa and nonasa
group was 7 (2.2%) and 1 (0.1%), respectively
6 Cases receiving aspirin who underwent local flap
reconstruction had a 124 fold increased risk pf
total postoperative hemorrhage
6 uurgical Resection of Cutaneous Head and Neck Lesions Dhiwakar,M. Arch Otolaryngol Head Neck
uurg, 132, 2006, 1237-1241
 m 
 

6 Dual antiplatelet therapy continuation until NCu
is not completely protective against MACE
6 Early surgery (<30 days) after stenting was
associated with an increased risk of MACEs.
6 Dual antiplatelet therapy at NCu associated with
increased bleeding risk.
6 Therefore, elective NCu should preferably be
postponed for 90 days after ÷CI-BMu; however, if
more urgent surgery is needed, a minimum
interval of 30 days should be recommended.
6 After ÷CI-DEu, NCu should be delayed for •1
year.
 


  
 
 



6 In January, the @  m 
  (FDA)
announced it was continuing to study the
effectiveness of clopidogrel in patients taking
other medications, particularly ÷÷Is, as well as in
those with genetic variants linked with
clopidogrel resistance
6 Retrospective cohort study, 8205 VA patients
with ACu taking clopidogrel after discharge from
the hospital between 2003 and 2006 found that
Concomitant use of clopidogrel and a ÷÷I was
associated with a 25% greater risk of death or
rehospitalization for ACu, the primary end point
in this analysis.
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Ho ÷M et al. ½
2009; 301:937-944.

 
 

6 A pharmacoepidemiologic study of more than
1 000 000 hospital discharges demonstrates a
dose-response curve between level of acid
suppression and d
 infection
6 Compared with patients receiving no acid
suppression therapy, the risk of d

infection increased an estimated 53% for those
receiving H2 blocker, 74% for those receiving
daily ÷÷I, and more than doubled for those
receiving more frequent ÷÷I dosing.
6 Use of ÷÷Is during treatment for d

infection was associated with a 42% increase in
the rate of d
 recurrence
6 Aseeri M, uchroeder T, Kramer J, Zackula R. Gastric acid suppression by proton pump inhibitors as
a risk factor for d


-associated diarrhea in hospitalized patients.  ½

 
 2008;103(9):2308-2313
 º 

6 ÷÷Is are also known to increase the risk of
both hospital and community-acquired
pneumonia in a dose-response
relationship.1
6 ÷÷Is have a modest increase in rate of
spine, lower arm, and total fractures
hazard ratio for total fractures was 1.25
[95% confidence interval], 1.15-1.36). 2
6 1.Nosocomial pneumonia risk and stress ulcer prophylaxis: a comparison of
pantoprazole vs ranitidine in cardiothoracic surgery patients. d 
2009;136(2):440-447.
6 2 Gray uL, LaCroix AZ, Larson J; et al. ÷roton pump inhibitor use, hip fracture, and
change in bone mineral density in postmenopausal women: results from the
Women's Health Initiative.
  


 2010;170(9):765-771.
 ×
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 u  
6 Beta blockers should be continued in pt
undergoing surgery who are receiving beta
blocker for tx of angina, sx arrhythmia, htn.
6 Beta blockers titrated to heart rate and bp
are probably recommended for pt undergoing
vascular surgery or intermediate surgery who
are at hi cardiac risk (At least 1 clinical rf).
6 Routine administration of high dose beta
blocker w/o dose titration is not useful and
may be harmful in naïve pt undergoing
noncardiac surgery (new)
6 Fleischmann, K, 2009 ACCF/AHA Focused Update on ÷erioperative beta
blockade, J Am Col Card, 2009, 54, 2103-2128
 a
 
   
 aa

6 High-risk type of surgery
6 History of ischemic heart disease
6 History of chronic heart failure
6 History of cerebrovascular disease
6 Diabetes mellitus requiring treatment with insulin
6 Chronic Kidney Disease with preoperative serum creatinine >2.0 mg/dL (177 mol/L)

6 9
   

 
  
*
6 No risk factors - 0.4 to 1.0 percent (versus <1 percent with beta blockers)
6 One to two risk factors - 2.2 to 6.6 percent (versus 0.8 to 1.6 percent with beta
blockers)
6 Three or more risk factors - >9 percent (versus >3 percent with beta blockers)

6 9
  7
     (;2 0   
  )
6 No risk factors - 0.1-0.8 percent
6 One risk factor - 0.5-1.4 percent
6 Two risk factors - 1.3-3.5 percent
6 Three or more risk factors 2.8-7.9 percent
 
 

6 Head and neck surgery patients are at
high pulmonary risk for surgery; preop
incentive spirometry may help
6 ÷atients with cardiac stents are at high
risk for MACE; this is worse when < 30
days after stent placement and decreased
with anticoagulation continued.
6 Do not prescribe proton pump inhibitors
without a good reason
6 Beta blockers need to be added and
titrated in mostly the highest risk patients.