the university of texas conflict of interests … assessment & identification of comorbid...

Girish P. Joshi, MB, BS, MD, FFARCSI Professor of Anesthesiology and Pain Management

Director of Perioperative Medicine and Ambulatory Anesthesia

Patient Selection For Ambulatory Surgery: Can Any Patient Be an Outpatient?

THE UNIVERSITY OF TEXAS

SOUTHWESTERN MEDICAL CENTER

AT DALLAS

Conflict Of Interests

• None

O u t l i n e

•  Describe the concerns of ambulatory surgery in challenging patients

•  Understand the approach to determining patient selection for ambulatory surgery

•  Justify appropriate selection of challenging adult patients scheduled for ambulatory surgery –  Sick, elderly, obese, OSA, diabetes mellitus, cardiac

implantable electronic devices

Reengineering in Surgical Paradigm

•  In the US, ~ 70% surgical procedures performed on an outpatient basis

•  Improvements in surgical and anesthetic techniques make more procedures possible in outpatient setting

•  Complex surgical procedures are increasingly performed on complex patients

Source: Intellimarker. Ambulatory Surgical Centers Financial & Operational Benchmarking Study. Fifth Edition. VMG Health, July 2010 (67).

In an ambulatory setting, patient selection influences

perioperative outcome.

Patient Selection Influences Perioperative Outcome

•  Delayed discharge home

•  Reduced efficiency of the ASC

•  Unplanned hospital admission

•  Increased post-discharge complications

•  Unplanned readmission

•  Patient/family dissatisfaction

Joshi, Girish, MB, BS, MD, FFARCSI Patient Selection for Ambulatory Surgery

Suitability For Ambulatory Surgery: Complex and Dynamic Process •  Surgical procedure

–  Cataract, peripheral, cavity

•  Patient’s preoperative health –  ASA Physical status

•  Proposed anesthetic technique –  Local/regional anesthesia vs. GA

•  Suitability of surgical facility –  HOPD, ASC, Office-based

•  Social considerations –  Appropriate caregiver availability

Procedure Considerations

•  Low risk of severe intra- or postop blood loss

•  Tranexamic acid allowed TKA on outpatient basis

•  Postoperative pain easily controlled

•  No need for intensive or prolonged postop care

•  Duration of procedure ??

•  Surgeon’s expertize –  Birkmeyer et al: Surgical Skill and Complication Rates after

Bariatric Surgery. N Engl J Med 2013;369:1434-42

Outpatient Total Knee Arthroplasty

•  Outpatients were younger, had lower comorbidity burden

•  TKA performed on an outpatient basis had lower risk of re-hospitalization

•  Reasons for re-hospitalization –  Inadequate pain control

–  Comorbidities, particularly HF

Lovald S, et al: J Surg Ortho Adv 2014; 23:2–8

Laparoscopic Roux-En-Y Gastric Bypass

•  Bariatric Outcomes Longitudinal Database (n=51,788) lap gastric bypass procedures

•  Median age=45 years; BMI=46.3 kg/m2 •  Patients discharged on an ambulatory basis had

a 13-fold increased risk of 30-day mortality when compared with the LOS of 2 days

•  Ambulatory discharge was associated with a trend toward increased serious complication

Morton JM, et al: Ann Surg 2014; 259: 286- 92

Patient Selection for Ambulatory Surgery: Predictors of Complications

•  ACS-NSQIP database 2005-2010 (n=244,397)

•  Predictors of 72-h perioperative morbidity:

– High BMI – COPD

– Previous PCI/cardiac surgery

– Hypertension – H/o TIA/CVA

– Prolonged operative time Mathis M, et al: Anesthesiology 2013; 119: 1310-21

Unplanned Admission After Ambulatory Surgery

•  Length of surgery more than one hour

•  High (≥3) ASA physical status classification

•  Advanced age (>80 years)

•  High BMI

Whippey A, et al Can J Anaesth 2013; 60: 675-83


ASA Physical Status Scale

Reliability of the ASA Physical Status Scale

•  Inter-rater reliability assessed in a cohort of 10,864 patients

–  ASA 1=5.5%, ASA 2=42%, ASA 3=46.7%, ASA 4=5.8%

•  ASA-PS scale had moderate ability to predict in-hospital mortality and cardiac complications

•  Despite the inherent subjectivity, ASA-PS scale can be used as a measure of preoperative health

Shankar A, et al: Br J Anaesth 2014; 113: 424-32

Patient Considerations

•  Patients with ASA physical status 4 NOT suitable for ambulatory surgery

–  A patient with severe systemic disease that is a constant threat to life

•  Patients with ASA physical status 3 consider other factors

–  A patient with severe systemic disease

Age

Age alone should not be used to determine suitability for

ambulatory surgery.

Outpatient Laparoscopic Cholecystectomy in the Elderly

•  Analysis of the NSQIP database (2007-2010) •  Elderly (>65 yr) undergoing elective lap chole

on an outpatient basis (n=7499) compared with inpatients (n=7799)

•  Predictors of inpatient admission and mortality –  ASA 4, CHF, bleeding disorder, CRF on dialysis

•  Factors that did not influence admission –  Diabetes mellitus, BMI, smoking status

Rao A, et al: Am Coll Surg 2013; 217: 1038-43


Age and Ambulatory Surgery

•  Age > 80 years is an indicator of increased perioperative risk –  Whippey A, et al: Can J Anesth 2013; 60: 675-83

–  Fleischer LA, et al: Arch Surg 2004; 139: 67-72

•  Consider post-discharge issues

–  Increased need for supervision

–  Social issues such as elderly or debilitated partner

Obese Patients

For Ambulatory Surgery

Ambulatory Surgery in Obese Systematic Review: Results

•  106,119 patients (prospective cohort trials = 62,476 and retrospective trials = 43,643)

•  Bariatric surgery population = 39,548, and systematic review patients n=2549

•  Obese had increased respiratory events

–  O2 desaturation, need for O2 supplementation

–  Stridor/laryngospasm, airway obstruction

Joshi GP et al: Anesth Analg 2013; 117: 1082-91

Systematic Review: Results

•  No differences in unanticipated admission rate –  Obese and non-obese cohorts

–  Studies of bariatric and non-bariatric surgery

•  BMI in non-bariatric surgery studies around 30

•  BMI in bariatric surgery studies was around 40 –  Rigorous preoperative preparation

•  Super obese (BMI>50) higher risk of complications


Selection of a Obese Patient For Ambulatory Surgery

Known or Presumed OSA

Preoperative Assessment & Identification of Comorbid Conditions

[OSA, Hypoventilation, Cardiovascular, Difficult airway, DM]

Comorbid Conditions Optimized

Comorbid Conditions NOT optimized

Not Suitable For Ambulatory Surgery

BMI<40 kg/m2

Proceed With Ambulatory Surgery

Joshi GP, et al: Anesth Analg 2013; 117: 1082-91 * Joshi GP, et al: Anesth Analg 2012; 115: 1060-8

BMI 40-50 kg/m2 BMI>50 kg/m2

Follow SAMBA-OSA Recommendations *


OSA Patients


•  Scientific literature on safety and perioperative management of OSA patients is sparse and of limited quality

Anesthesiology 2014; 120:268-86

ASA-Scoring System For OSA Patients

A.  Severity of OSA (0-3 pts) B.  Invasiveness of surgery/anesthesia (0-3 pts) C.  Requirements for postoperative opioids (0-3 pts) •  Overall score (0-6): A + greater of B or C

–  Score ≥4 increased risk from OSA –  Score 5 or 6 significantly increased risk from OSA

Not suitable for ambulatory surgery

•  Intra-abdominal and upper airway surgery are not suitable for ambulatory surgery

Anesthesiology 2014; 120:268-86

Joshi GP et al: Anesth Analg 2012; 115: 1060–8

SAMBA-OSA Systematic Review

•  No difference in complications between OSA and non-OSA patients undergoing ambulatory surgery

•  Most studies used standardized, protocolized approach to patient care –  Emphasis on preoperative diagnosis –  Emphasis on use of non-opioid analgesics to

minimize opioid use –  Emphasis on postoperative care particularly

use of CPAP after discharge Joshi GP et al: Anesth Analg 2012; 115: 1060–8

Selection of a OSA Patient For Ambulatory Surgery

Patient With Known OSA Patient With Presumptive

Diagnosis of OSA

Optimized Comorbid Conditions

AND Able to use CPAP after

discharge

Patients With Non-optimized

Comorbid Conditions

Optimized Co-morbid Conditions

AND Postoperative opioids can be limited by using non-

opioid analgesic techniques

Not Suitable For Ambulatory Surgery,

may benefit from diagnosis and treatment




No guidance can be provided for airway surgery


Surgery For OSA in An Ambulatory Setting

•  Systematic review of 18 studies (2160 patients) •  No deaths or major catastrophic events •  Overall adverse event rate = 5.3% •  Respiratory complications = 1.5%

–  Majority were O2 desaturations, and were not clinically significant

•  Readmission rate 0.4% •  OSA surgery performed on an outpatient basis

is generally safe •  Exceptions: tongue base surgery, high AHI,

high postop opioid requirements Rotenberg B: Curr Anesthesiol Rep 2014; 4: 10-8

Laryngopharyngeal Surgery in OSA

•  Analysis of the National Survey of Ambulatory Surgery

•  No increase in airway surgery over a decade

•  Unplanned readmission rate <4%

•  No mortality or serious complications

•  Minor complications: 9% Mahboubu H et al: JAMA Otolaryngol Head Neck Surg 2013; 139: 28-31

Diabetic Patients


Glycemic Control Guidelines

Is there a preoperative blood glucose level above which one should postpone elective surgery?

•  No evidence that any particular blood glucose level is harmful for outpatients

•  First step in decision making: assess for significant complications of hyperglycemia such as severe dehydration, ketoacidosis, and hyperosmolar non-ketotic states

•  Postpone surgery of these conditions are present

Preoperative Blood Glucose Level

•  Good long-term control: proceed with surgery

•  Poor long-term control: consider comorbidities

and risks of surgical complications (e.g.,

delayed wound healing and wound infection)

•  Decision to proceed made in conjunction with

the surgeon


Proceed After BGL Correction or Correct BGL in the Operating Room

•  Rapid correction of BGL not necessary

•  Timing of BGL correction based upon available time in the preop period duration of surgery

Patients With Cardiac Disease


Stepwise approach to perioperative cardiac assessment for CAD.Colors correspond to the Classes of Recommendations in Table 1.

Fleisher L A et al. Circulation. 2014;130:2215-45

Perioperative Cardiac Assessment Perioperative Myocardial Infarction or Cardiac Arrest Risk Calculator

Perioperative*Myocardial*Infarction*or*Cardiac*Arrest*Risk*Calculator

Age 65 Enter actual.age.in.years Estimated.risk.probability.for.perioperative.MICA: 0.28%

.

ASA.Class 3 Enter 1.F.5.for.American.Society.of.Anesthesiologists'.Class *.

ASA.Classification: Percentile Percent.Risk

1..A.normal.healthy.patient. 25th.percentile 0.05%

2..A.patient.with.mild.systemic.disease. 50th.percentile 0.14%

3..A.patient.with.severe.systemic.disease. 75th.percentile 0.61%

4..A.patient.with.severe.systemic.disease.that.is.a.constant.threat.to.life. 90th.percentile 1.47%

5..A.moribund.patient.who.is.not.expected.to.survive.without.the.operation. 95th.percentile 2.60%

99th.percentile 7.69%

Creatinine 0 Enter 2.for.missing.value

(preoperative) . 1.for.>=1.5.mg/dL

0.for.<1.5.mg/dL

Functional.Status 0 Enter 2.for.patients.with.totally.dependent.functional.status

(preoperative) . 1.for.patients.who.have.partially.dependent.functional.status

0.for.those.who.are.totally.independent

Procedure: 10 Enter 1.for.Anorectal 12.for.Neck.(Thyoid.and.Parathyroid)

. 2.for.Aortic 13.for.Obstetric/Gynecologic

3.for.Bariatric 14.for.Orthopedic.and.nonFvascular.Extremity

4.for.Brain 15.for.Other.abdominal

5.for.Breast 16.for.Peripheral.Vascular

6.for.Cardiac 17.for.Skin

7.for.ENT.(except.thyroid/parathyroid) 18.for.Spine

8.for.Foregut/Hepatopancreatobiliary 19.for.nonFesophageal.Thoracic

9.for.Gallbladder,.appendix,.adrenal.and.spleen 20.for.Vein

10.for.Hernia.(ventral,.inguinal,.femoral) 21.for.Urology

11.for.Intestinal

Authors: Prateek.K.Gupta,.MD Methodology.in:. Circulation..2011.Jul.26;124(4):381F7..Epub.2011.Jul.5.

Himani.Gupta,.MD

Abhishek.Sundaram,.MD

Manu.Kaushik,.MBBS

Xiang.Fang,.PhD

Weldon.J.Miller,.MS

Dennis.J.Esterbrooks,.MD

Claire.B.Hunter,.MD

Iraklis.I.Pipinos,.MD

Jason.M.Johanning,.MD

Thomas.G.Lynch,.MD

R.Armour.Forse,.MD.PhD

Syed.M.Mohiuddin,.MD

Aryan.N.Mooss,.MD

From: Department.of.Surgery,.Creighton.University,.Omaha,.NE.68131

[email protected]

Department.of.Medicine,.Creighton.University,.Omaha,.NE.68131

[email protected]

Department.of.Surgery,.Creighton.University,.Omaha,.NE.68131

[email protected]

Department.of.Medicine,.Creighton.University,.Omaha,.NE.68131

[email protected]

Biostatistical.core,.Creighton.University,.Omaha,.NE.68131

[email protected]

School.of.Medicine,.University.of.Pittsburg,.Pittsburg,.PA.15261

[email protected]

Department.of.Cardiology,.Creighton.University,.Omaha,.NE.68131

[email protected]


[email protected]

Department.of.Surgery,.University.of.Nebraska.Medical.Center,.Omaha,.NE.68154

[email protected]


[email protected]


[email protected]

Department.of.Surgery,.Creighton.University,.Omaha,.NE.68131

[email protected]


[email protected]


[email protected]

Acknowledgement:

Christopher.Franck,.MS

Department.of.Statistics,.Virginia.Tech,.VA.24060

[email protected]

Gupta PK, et al: Circulation 2011; 124: 381-7; http://www.surgicalriskcalculator.com

ACS NSQIP: Surgical Risk Calculator

http://www.riskcalculator.facs.org

1/4/15 6:54 PMPatient Information - ACS Risk Calculator

Page 1 of 2http://www.riskcalculator.facs.org/PatientInfo/PatientInfo

Height (in)

Weight (lbs)

Risk Calculator Homepage About FAQ ACS Website ACS NSQIPWebsite

Enter Patient and Surgical Information

Procedure 49525 - Repair inguinal hernia, sliding, any age Clear

Begin by entering the procedure name or CPT code. One or more procedures willappear below the procedure box. You will need to click on the desired procedure toproperly select it. You may also search using two words (or two partial words) by

placing a ‘+’ in between, for example: “cholecystectomy+cholangiography”

Reset All Selections

Are there other potential appropriatetreatment options?

Other SurgicalOptions

Other Non-operative options None

Please enter as much of the following information as you can to receive the bestrisk estimates.

A rough estimate will still be generated if you cannot provide all of the informationbelow.

Age Group 65-74 years Diabetes Oral

Sex MaleHypertension requiring

medication Yes

Functional status Independent Previous cardiac event No

Emergency case NoCongestive heart failure

in 30 days prior tosurgery

No

ASA class III - Severe systemic disease

Wound class Clean Dyspnea None

Steroid use for chroniccondition No

Current smoker within 1year No

Ascites within 30 daysprior to surgery No History of severe COPD No

Systemic sepsis within48 hours prior to

surgeryNone Dialysis No

Acute Renal Failure No

Ventilator dependent NoBMI Calculation:

66

Disseminated cancer No 270

1/4/15 6:54 PM- ACS Risk Calculator

Page 1 of 2http://www.riskcalculator.facs.org/Outcome

0% (Better) 100% (Worse)

Risk Calculator Homepage About FAQ ACS Website ACS NSQIP Website

Procedure 49525 - Repair inguinal hernia, sliding, any ageChange Patient Risk FactorsRisk

FactorsAge: 65-74, Male, ASA III, Diabetes (oral), HTN,

Obese (Class3)

Outcomes EstimatedRisk

Chanceof

OutcomeSerious

Complication 2% AboveAverage

Any Complication 4% AboveAverage

Pneumonia <1% AboveAverage

CardiacComplication <1% Above

Average

Surgical SiteInfection 1% Above

Average

Urinary TractInfection <1% Above

Average

VenousThromboembolism <1% Above

Average

Renal Failure <1% AboveAverage

Return to OR 1% AboveAverage

Death <1% AboveAverage

Discharge toNursing or Rehab

Facility1% Above

Average

Predicted Length of Hospital Stay: 0.5 days

Surgeon Adjustment of RisksThis will need to be used infrequently, but surgeons mayadjust the estimated risks if they feel the calculated risks

are underestimated. This should only be done if thereason for the increased risks was NOT already entered

into the risk calculator.

1 - No adjustment necessary

Step 3 of 4

Patients With CIED



Crossley GH et al: Heart Rhythm 2011; 8: 1114-54

Management of Pacemaker Patients

•  Rendering PM asynchronous, even in PM-dependent patients, not always required

•  Render asynchronous, by programming or by a magnet, only if significant inhibition is observed

•  Caution: pacemakers with special algorithms (e.g., rate responsive devices, MV sensors, search hysteresis/ capture, battery extenders)

Crossley GH et al: Heart Rhythm 2011; 8: 1114-54

Preoperative Considerations in Patients With Implantable Cardioverter Defibrillator

No Is EMI likely

Yes Proceed Yes

No Is the patient pacemaker

dependent? Reprogram

ICD

Proceed With Surgery

Use a Magnet

Is the Procedure below umbilicus

No

Based on Crossley GH et al: Heart Rhythm 2011; 8: 1114-54

Why is the patient in the hospital?

Will hospitalization improve outcome?

Future!

S u m m a r y

•  Complex ambulatory surgical procedures will increasingly be performed on complex patients

•  Patient selection is complex and dynamic process •  First step in determining appropriate patient

selection includes preoperative assessment and identification of any comorbid conditions, which should be optimized to minimize risks

•  Developing and implementing clinical pathways should improve the process of patient selection

Thank You. Questions

The Art of Anesthesia


the university of texas conflict of interests … assessment & identification of comorbid...

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