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Cardiac Surgery Pre-Op Part 1

Michael Grant MD and Neda Frayha, MD
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We all know what to do in pre-op visits for non-cardiac surgery. But guidelines on the pre-op management of cardiac surgery patients are hard to find. Neda sat down with Dr. Michael Grant, a cardiac anesthesiologist at the Johns Hopkins University School of Medicine, to learn what we need to worry about (and what our pre-op evaluations should include) when our patients go off to cardiac surgery.

 

Pearls:

  • For cardiac surgery pre-op preparation:

    • Continue aspirin, statins and beta-blockers

    • Aim for intensive glucose control

    • Hold antiplatelets and anticoagulants

  • There’s been a shift from getting patients into the operating room and instead optimizing them with nutrition, exercise and lifestyle - a place where primary care will play an important role.

 

  • Surgical prep

    • Approach to each case differs but general framework around 3 questions:

      • 1. Are there other kinds of disease they should be addressing while in the operating room?

      • 2. Are there different ways to approach cardiopulmonary bypass, anatomical considerations

      • 3. Risk for postoperative complications

    • Diagnostics:

      • CT of chest, abdomen and pelvis with angiogram component

        • Understand anatomy which guides approach to sternotomy

        • Characterize vascular disease and identify reasonable bypass targets

      • Echocardiogram

        • Identify valvular or aortic disease that may need repair

    • STS (Society of Thoracic Surgery) risk calculator

      • Sense of risk for complications like renal impairment, liver disease, delirium

      • Identify patients who may need special level of care

  • Anesthesia prep

    • Framework from anesthesia centers around ability to safely anesthetize patient:

      • Echocardiogram:

        • Valvular disease

        • Pulmonary hypertension

      • Airway assessment

        • Mallampati score

      • Opioid use: traditionally cardiac surgery cases are managed exclusively with opioids during and after surgery. With opioid epidemic, now more effort being put into opioid reduction/minimization

      • Allergies

      • Esophageal disease: lots of transesophageal echo for cardiac surgery

  • Medical management

    • Medications:

      • Aspirin (81mg or 325mg): continue as it actually reduces risk and does not increase risk of bleeding after surgery ** differs from non-cardiac surgery where aspirin is often held **

      • Antiplatelets (clopidogrel or ticagrelor): data are more controversial but generally withhold for 5 days (clopidogrel) or 7 days (ticagrelor and prasugrel) because of some increased risk of bleeding and transfusion rates

      • Warfarin: stop before surgery with enough time to reverse effects

      • Statin: start (if not already on it) and continue

      • Beta-blockers: start (if not already on it) and continue

      • ACE-inhibitors: hold 24-48 hours ahead of surgery given risk of post-op hypotension

      • Insulin: unlike other surgeries and general medicine, tight glycemic control perioperatively is still the norm in cardiac surgeries given the data

        • A1c may actually be more predictive of post-op complications so < 8 is desirable and being above that goal may delay surgery

    • Nutrition: Optimize where at all possible

      • Supplementation with protein

      • Patients may have clear liquids or carbohydrate-heavy drink up to 2 hours before surgery

    • Encourage cessation of tobacco and alcohol

  • Pre-op Testing:

    • Labs: CBC (anemia), PT/PTT/INR (coagulopathy), CMP (kidney, liver disease), urinalysis (insidious infection), A1c, albumin

      • Those with infected urine have much higher rates of surgical infection afterwards

    • Imaging: NO longer need pulmonary function tests or chest X-rays

      • Formal teeth examination to make sure no cavities need to be addressed

      • Carotid duplex (address carotid disease before operation or change management in operating room by optimizing brain perfusion)

    • Existing cardiac hardware: formal interrogation and reprogramming

      • Not all ICDs/pacemakers are deactivated by a magnet anymore

 

REFERENCES:

  1. Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg. 2019. Epub ahead of print.

  2. Hillis LD, Smith PK, Anderson JL. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. J Am Coll Cardiol. 2011; 58:e123-210.

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Primary Care RAP November 2019 Written Summary 1 MB - PDF

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