Archive for the ‘Preop Evaluation’ Category

Yale Anesthesia Grand Rounds. Apr 28, 2017. Preop Cards Eval: Guidelines vs “Real World”

Wednesday, April 26th, 2017

2017_04_24 Ellis Preop Cardiac Evaluation

PGA NYC Dec 2015: Preoperative Cardiac Evaluation 2015: Guidelines vs “The Real World?”

Saturday, December 12th, 2015

2015_12_12 PGA NYC Ellis Preop Cardiac Evaluation .pptx_Page_01

2015_12_12 PGA NYC Ellis Preop Cardiac Evaluation .pptx



Pt s/p CVA. How long to wait before elective surgery?

Tuesday, July 29th, 2014

The literature has numerous studies examining the effect of timing of surgery after MI and coronary stenting and MACE (major adverse cardiovascular events).  However, for stroke, data is sparse.

Now comes a study from Denmark, published in JAMA.  In Denmark, all medical data is collected (single payer), allowing retrospective databases studies to be done on complete, reliable datasets.  The disadvantage is that it is an ethnically uniform database, which the authors correctly say potentially limits the generalizability of the results.  They looked at “Danish nationwide cohort study (2005-2011) including all patients aged 20 years or older undergoing elective noncardiac surgeries (n=481 183 surgeries)”; 7137 had had prior stroke.

What I found fascinating is that a key part of their data was a nationwide Anesthesia database:

Information on several surgery-related variables, including whether the surgery was acute or elective, was retrieved from the Danish Anesthesia Register, in which all surgeries requiring anesthesia have been registered since mid-2004.

So, what did they find?

In summary, we demonstrated that prior ischemic stroke, irrespective of time between ischemic stroke and surgery, was associated with an adjusted 1.8- and 4.8-fold increased relative risk of 30-day mortality and 30-day MACE, respectively, compared with patients without prior stroke. Second, we demonstrated a strong time-dependent relationship between prior stroke and adverse postoperative outcome, with patients experiencing a stroke less than 3 months prior to surgery at particularly high risk. The risk stabilized after approximately 9 months. Third, the increased relative risks associated with prior stroke were found to be of at least similar magnitudes in low- and intermediate-risk surgeries, as in high-risk surgeries.

Red arrows show the particularly high odds ratios of MACE, death, and new stroke when surgery is performed < 3 months after prior CVA.
Red arrows show the particularly high odds ratios of MACE, death, and new stroke when surgery is performed < 3 months after prior CVA.

Elective surgery in the first 3 months is associated with much higher MACE rates.  These rates stabilize by 9 months s/p CVA.

The authors did multiple analyses to try to limit the confounding effect that early surgery after stroke might indicate a not-elective indication for surgery.  For example, they looked at the association of time after stroke and total knee or hip replacement (without fracture – presumably elective), and found similar elevated rates of MACE in the first 3 months.

There is possible room for improvement, since only 52% of prior CVA patients were chronically on statins, and only 65% on antiplatelet meds (such as aspirin and/or plavix) before surgery.  Indeed, when adjusted for comorbidities, they found that in patients with prior CVA, chronic statins and antiplatelets meds were associated with reductions in postop MACE, including death from any cause.

What are some take away points?

  • Elective surgery should probably wait until 9 months after surgery.
  • This is probably true for low risk and intermediate risk surgeries, not just major ones.
  • These results likely do not apply to CEA or carotid stenting, where the goal is to repair the source of arterial occlusion and/or thromboembolism


At The 2013 NYSSA PGA Meeting

Thursday, December 19th, 2013



Saturday at NY State Society of Anesthesiologists PGA meeting, Dr. Ellis, Anesthesia Camp Course Director, moderated a panel and lectured on Perioperative Beta Blockade. Here are his Power Point slides:

On Friday, Dr. Ellis also lectured at the PGA on Preoperative Cardiac Evaluation. Power Point slides:

Update on Preop Cardiac Eval

Thursday, September 12th, 2013

Less emphasis on traditional CAD risk factors; more emphasis on CHR, arrhythmias, and frailty.



Screening (and Some Rescreening) for Aortic Aneurysms Found Cost Effective

Friday, July 6th, 2012
BMJ 2012; 345 doi: 10.1136/bmj.e4276 (Published 5 July 2012)

Cite this as: BMJ 2012;345:e4276

Objective To assess the cost effectiveness of different screening strategies for abdominal aortic aneurysm in men, from the perspective of a national health service.

Setting Screening units at regional hospitals.

Participants Hypothetical cohort of 65 year old men from the general population.

Main outcome measures Costs (£ in 2010) and effect on health outcomes (quality adjusted life years (QALYs)).

Results Screening seems to be highly cost effective compared with not screening. The model estimated a 92% probability that some form of screening would be cost effective at a threshold of £20 000 (€24 790; $31 460).

Risk for Postoperative Respiratory Failure

Wednesday, November 30th, 2011

Calculator Estimates Risk for Postoperative Respiratory Failure

Five strong predictors for PRF emerged from evaluation of the data:

  • surgery type,
    • The riskiest surgeries were those of the brain, aorta, and foregut/hepatopancreatobiliary region.
  • emergency case,
  • dependent functional status,
  • preoperative sepsis,
  • higher American Society of Anesthesiologists class.

“PRF develops in approximately 3% of patients, and more than 25% of them die within 30 days. Up to 40% of postoperative complications after abdominal and vascular surgeries are pulmonary in nature.

The study, from Himani Gupta, MD and colleagues from the University of Pittsburgh in Pennsylvania and Creighton University in Omaha, Nebraska, considers all surgeries and distinguishes PRF from other pulmonary complications. Data are from the American College of Surgeons’ National Surgical Quality Improvement Program, which represents more than 180 hospitals.”











Don Poldermans, of DECREASE beta blocker trials, fired.

Tuesday, November 29th, 2011

I’ve always been concerned about the generalizability of Poldermans’ work.  A PubMed search of his name and “vascular surgery” returns over 150 references.  His work has continued to support perioperative beta blockade while other studies, such as POISE, have found adverse outcomes.  He is lead author of the European Society of Cardiologists Perioperative Guidelines for Noncardiac Surgery.

Now, Prof Poldermans has been fired by Erasmus University, among allegations:

The professor is accused of faking academic data and compromising patient trust, the paper says. In particular, he failed to obtain patient consent for carrying out research and recorded results ‘which cannot be resolved to patient information,’ the university said.

Don Poldermans has spent years researching the risk of complications during cardio-vascular surgery and has some 500 publications to his name.

A spokesman for Poldermans told the paper he admitted not keeping to research protocols but denied faking data.

The ESC has therefore stated:

In its statement, the ESC said that the society is reviewing this document “in order to decide if these need to be re-examined in the light of recent events. A new statement will be issued by the ESC once a decision has been reached.”

Video: Aug 2011 lecture Periop Myocardial Ischemia and Infarction

Tuesday, August 23rd, 2011

Medical University of South Carolina Grand Rounds

Dr. John E. Ellis

Start watching video at 2:20

Surgery shortly after an MI still contraindicated?

Thursday, May 12th, 2011

An administrative database from the state of California suggests that surgery in the first month after an MI greatly increased the chances of reinfarction, and significantly increased the risk of death.  Vascular patients actually had lower RRs than other NCS, suggesting that the atherosclerotic burden is more uniformly increased in vascular patients compared to others (hips, colon resection), or that clinicians were more careful and/or attuned to caring for the vascular patients.

RESULTS: Postoperative MI rate for the recent MI cohort decreased substantially as the legth of time from MI to operation increased (0-30 days = 32.8%, 31-60 days = 18.7%, 61-90 days = 8.4%, and 91-180 days = 5.9%), as did 30-day mortality (0-30 days = 14.2%, 31-60 days = 11.5%, 61-90 days = 10.5%, and 91-180 days = 9.9%). MI within 30 days of an operation was associated with a higher risk of postoperative MI (RR range = 9.98-44.29 for the 5 procedures), 30-day mortality (RR range, 1.83-3.84), and 1-year mortality (RR range, 1.56-3.14).

CONCLUSIONS: A recent MI remains a significant risk factor for postoperative MI and mortality following surgery. Strategies such as delaying elective operations for at least 8 weeks and medical optimization should be considered

Many things have changed since Rao and El-Etr‘s classic paper:

  • TnI and CKMB are much more sensitive and more likely to be used as a screening tool than simply after symptoms occur.  Therefore, we suspect that the MIs detected in th 21st century may be smaller than in the past, but more prevalent.
  • PCI and more optimal medical Rx are available today, which might reduce the likelihood and lethality of reinfarction

The authors did not address the impact of medical Rx nor revascularization in this study.  However, the same group (least publishable units?) published another paper suggested that preop PCI or CABG protects against reinfarction.   They state:

Patients with a recent MI who were revascularized before surgery had an approximately 50% decreased rate of reinfarction (5.1% versus 10.0%; p < 0.001) and 30-day (5.2% versus 11.3%; p < 0.001) and 1-year mortality (18.3% versus 35.8%; p < 0.001) compared with those who were not. Stenting within 1 month of surgery was associated with a trend toward increased reinfarction (relative risk: 1.36; 95% CI, 0.96-1.97), and coronary artery bypass graft was associated with a decreased risk (relative risk: 0.70; 95% CI, 0.55-0.95).

Again, there are selection biases:

  • Emergent cases are probably too sick to wait for revascularization.
  • Some sick/frail patients may not be felt to be good candidates for revascularization.

In fact, only ~12% of revascularizations occurred in the 3 months before surgery.  At surgery < 1 month after original MI, reinfarction rates were high (~1/3) and no lower in the revascularization group.

For patients undergoing vascular surgery, early revascularization (within 1 month of MI) was associated with lower reinfarction rates compared with no revascularization (21.3% versus 34.2%; p = 0.026). In contrast, for those undergoing nonvascular surgery, reinfarction rates were greater for revascularized patients (40.4% versus 31.6%; p = 0.038). Patients undergoing vascular surgery were more likely to receive CABG than PTCA (53.7% versus 46.3%), but the reverse was true for nonvascular surgery (41.2% versus 58.8%) (p < 0.001). This pattern of revascularization was also seen for patients undergoing surgery within 1 month of MI (vascular: 43.8% CABG versus 56.3% PTCA; nonvascular: 32.9% CABG versus 67.1% PTCA; p = 0.10).

Lastly, the authors mention that the CARP trial did not show survival benefits for coronary revascularization before vascular surgery, but did suggest lower rates of MI after CABG than PCI, as these authors have also shown.

The debates continue!