Feeds:
Posts
Comments

Posts Tagged ‘Eckland’

Intra – Operative Myocardial Infarction 

One of the most feared, yet preventable complications is intra-operative / post operative myocardial infarction (heart attack).  Alarmingly, a new paper published on Medscape by Reed Miller suggests that too often we aren’t doing enough to prevent this devastating complication and miss the diagnosis of this condition when it does occur*.

In many cases, patients are asymptomatic, which is no cause for relief – since the thirty day mortality after post-operative infarction is frightening high.  Part of my job in my practice as an acute care nurse practitioner in cardiovascular and thoracic surgery is to perform pre-operative risk stratification and risk reduction for this, and other potentially preventable complications.

There are several important, but easy things we can do to reduce the risk of our patients having a heart attack during or immediately after surgery:

Pre-operative Evaluation:

1. First, screen your patient for the presence of anginal symptoms and associated risk factors – before scheduling an operation.  Surprisingly, many patients are experiencing atypical angina, dyspnea on exertion and other symptoms in their daily lives, yet ascribe these symptoms to “being out-of-shape” or “getting old”.

If there is one thing, I’ve learned after greeting people in the cardiac cath lab to tell them they need heart surgery – it’s that the majority of people tend to ignore or overlook subtle signs until acute chest pain, or an infarction brings them to the hospital.  So, ask you patients about these symptoms, so you aren’t surprised in the operating room.

Ask yourself, What other risk factors do they have?

–     Diabetes, (of any duration) should prompt consideration for pre-operative cardiology workup and a possible exercise stress test.

–     Claudication (peripheral vascular disease), carotid stenosis (or hx of TIAs) or any other history suggestive of arterial disease

–     Elevated cholesterol or unknown cholesterol status, history of cholescystetomy or gallbladder disease or visible xanthomas (particularly on the face)

–    Advanced age – anyone over the age of 65

–    Hypertension, particularly if poorly controlled

–    Anemia, of any origin

–    Poor overall health, poor exercise tolerance (again this may be related to undiagnosed angina)

2. Secondly, Pre-operative Maximization!! This is important for  all major surgeries, but often isn’t implemented for orthopedic, general surgery and other large surgeries.  The other thing to realize is, this isn’t the anesthesia team’s job; it’s the attending surgeon and the primary care physician (jointly).  This means controlled, or correcting all of the items listed  in the previous section (as much as possible):

– cardiac evaluation for patients at medium / high risk for cardiac disease – and having an index of suspicion for people with vague  symptoms.

– treating underlying disease conditions – for example, if your patient has a hemoglobin A1c of 9.0 – delay elective cases until glucose is better managed.  Remember to monitor and manage glucose in the operating room too – unfortunately, this is often only done in cardiac surgery, but it’s important during all surgeries.  Intraoperative Hyperglycemia is an independent risk factor for myocardial infarction/ and is considered a ‘marker’ for infarction.

And check everyone, not just diagnosed diabetics – since hyperglycemia occurs in some normal individuals under physiological stress, and diabetes is grossly underdiagnosed.

Don’t discontinue statins pre-operatively – not only does evidence suggest that statins are protective against intraoperative strokes and sepsis, but the evidence to support discontinuing these medications preoperatively is slim.  Too often, we
discontinue patients needed medications as part of a routine, not an individualized treatment plan.  (Now clopidogrel (Plavix) and warfarin are a little different, but sometimes we continue these medications too – in very
select cases..)

Pre-operative beta blockade – the evidence is overwhelming
in favor of pre-operative beta blockade, yet some people are still neglecting
this (or even stopping these medications in people already on them.)  Continue metoprolol, carvedilol, propanolol, and make sure to ask why patients are taking them in the first place.  “Heart medicine” is an answer that should prompt further investigation.

– Consider and re-consider before discontinuing Aspirin.  In our thoracic (and cardiac ) surgery patients – we always continue aspirin, safely, and have had no increase in bleeding complications.  Often, surgeons can very safely operate on patients taking aspirin – but discontinuing it in these patients may contribute to the risk of intraoperative/ postoperative infarction.

Intraoperatively:

–  Control that heart rate!  We KNOW through decades of research that
slower is better.  Keep the heart rate at sixty or below to reduce cardiac demand.

–   Prevent hypotension – keep the MAP at 70 or above (and be particularly intolerant of hypotension in anyone with a cardiac history –you don’t want to collapse those grafts.
Remember that patients with vasculopathic disease don’t tolerate low
blood pressure as well as you or I – and don’t allow it (low blood pressure) to happen.

–    Monitor for changes in telemetry during the case.

–    Monitor and control hyperglycemia (as mentioned above.)

Article Re-Post from Medscape (Reed Miller):

MIs After Noncardiac Surgery are Often Overlooked

April 20, 2011 (Hamilton, Ontario) — A new study from the Perioperative Ischemic Evaluation (POISE) trial suggests that monitoring non–cardiac-surgery patients for asymptomatic MIs in the first few days after surgery could dramatically reduce their short-term mortality risk [1].

The study shows that “consistently, all over the world, people are at substantial risk of suffering a heart attack after surgery, and if they do, they’re at substantial risk to die or suffer a major event in the coming days, and we need to do a better job to detect them and manage them,” primary author Dr PJ Devereaux (McMaster University, Hamilton, ON) told heartwire. “We want to make the broader cardiology world aware that this is a huge emerging epidemic that’s going to confront cardiology, because there are 200 million adults having surgery every year in the world. . . . We need to get a lot more aggressive about monitoring for these events and recognizing that the majority of people won’t have symptoms when they have these events.”

Devereaux and colleagues followed 8351 patients at 190 centers in 23 countries with four cardiac biomarker assays for three days postsurgery. All of the patients were part of the original POISE trial, reported by heartwire, which showed that beta blockers reduce the risk of MI but increase the risk of severe stroke and overall death in patients undergoing non–cardiac surgery (including orthopedic, cancer, and noncardiac vascular surgeries). Results of the new study by Devereaux et al are published in the April 19, 2011 issue of the Annals of Internal Medicine.

“Surgery is sort of the ultimate stress test. It does everything that is relevant to causing acute coronary syndrome. It’s very proinflammatory, and it activates the sympathetic system, coagulation, and platelets. That’s why we have this problem of people having myocardial infarction after surgery, [and yet until now] there’s not that much research on the outcomes of heart attacks after surgery,” Devereaux told heartwire. Patients and physicians are often unaware of an MI during this early postoperative period because most of the patients are on high doses of narcotics that “blunt the discomfort of the surgery but may mask ischemic symptoms,” Devereaux said.

Within 30 days of randomization, 415 patients in the study (5.0%) showed evidence of a perioperative MI, defined as either autopsy findings of acute MI or an elevated level of a cardiac biomarker or enzyme assay plus ischemic symptoms, development of pathologic Q waves, ischemic changes on electrocardiography, coronary artery intervention, or cardiac imaging evidence of MI. Nearly three-quarters of the MIs happened within 48 hours of the surgery, but almost two-thirds of the MI patients did not did not experience ischemic symptoms. In fact, patients with a periprocedural MI without ischemic symptoms had a higher mortality rate (12.5%) than those who had symptoms (9.7%).

The short-term prognosis for patients who suffer periprocedural MIs is very poor, with 11.6% mortality at 30 days postprocedure compared with 2.2% for patients who did not suffer a periprocedural MI (p<0.001). Furthermore, Devereaux noted that a recent meta-analysis by his group found that people who suffer a periprocedural MI continue to be at higher risk for death than those who do not for at least a year after the surgery.

Nobody thinks twice about being incredibly assertive about managing an MI in the emergency room . . . [and yet] those MIs have a much better prognosis than these MIs, and we’re ignoring these MIs for the most part.

Regression analysis of the data showed that relatively simple therapies could have prevented many of these deaths. In the study, patients on aspirin had about half the 30-day mortality risk as those not on aspirin, while statins reduced the 30-day mortality rate by about three-quarters. Only 64.8% of patients who suffered an MI in the trial were on aspirin, only 17.8% were receiving clopidogrel or ticlopidine, 52.0% were receiving a statin, and 55.4% were receiving an ACE inhibitor or angiotensin-receptor blocker.

“Patients expect us to look for things that are modifiable and change their risks of very serious events quickly, and perioperative MI is definitely in that category,” Devereaux said. “Nobody thinks twice about being incredibly assertive about managing an MI in the emergency room, which is completely appropriate, but those MIs have a much better prognosis than these MIs, and we’re ignoring these MIs for the most part.”

Commenting on the study by Devereaux et al, Dr Adrian Banning (John Radcliffe Hospital, Oxford, UK) told heartwire, “We are not optimizing medical therapy before surgery. There are existing guidelines and risk scores that are probably underused. Preoperative testing for ischemia and revascularization is probably overused in a minority of patients, leaving an occult majority without simple medical measures that are likely to be beneficial–including aspirin, statins, and good perioperative blood-pressure control.”

More Research Needed to Clarify Who Is at Risk and How to Treat Them

Devereux’s group is currently enrolling patients into the 40 000-patient prospective cohort VISION study, which is intended to define the optimal approach for predicting major perioperative vascular events, the extent to which troponin measurement after surgery can identify asymptomatic MIs, and these patients’ risk of vascular-related death within one year.

The first 20 000 patients in the study have been monitored with “fourth-generation” troponin assays, and the next 20 000 will be monitored with higher-sensitivity troponin assays. Commenting on the research, Dr Stephen Ellis (Cleveland Clinic, OH) pointed out that with the advent of highly sensitive troponin tests, more research will be needed to define what degree of troponin change is clinically important. “I’m sure there’s some level of troponin where you see a bump that doesn’t mean anything.” For example, Banning and colleagues recently completed a study that suggests the current standard troponin cutoff used to detect an MI has been arbitrarily set too low and leads to an overestimate of the number of MIs.

Dr John French (University of New South Wales, Australia) added that future research should also try to risk-stratify these patients by collecting both pre- and postprocedural troponin levels. Elevated preprocedural troponin may also be a risk marker, he told heartwire.

Devereaux hopes there will also soon be a large national trial to evaluate the best way to manage non–cardiac-surgery patients in the vulnerable perioperative period. Ellis agreed that “we don’t really understand the benefits of some of the medical treatments that we have in our armamentarium in this patient population. . . . There may be some other treatments that are less utilized at present that could cut down on the incidence of perioperative infarction.”

Banning agreed that further research is needed to understand how to prevent these perioperative MIs, not merely detect them. “Troponin measurement postoperatively can help define a risk group with adverse outcome, [but] it is uncertain that we can influence that adverse outcome once the event has happened in those patients already on optimal medical therapy,” he said. “There will be a group identified by routine troponin testing where this event is the first declaration of occult coronary disease, and perhaps this group potentially has the most to gain.”

Although the best approach to managing these patients has yet to be clearly defined, Devereaux emphasized that “in the short term, there’s a lot of intuitive things that we can do better that will likely improve the outcomes, and there’s lots of reasons to be optimistic that, even if we just start monitoring them, we can improve the outcomes.” Devereaux recommends that physicians caring for a surgery patient order a troponin test sometime between six and 12 hours after the surgery and then repeat tests for the first three days after surgery.

His institution has made perioperative MI prevention a priority for its cardiologists. “We’ve changed cardiology from regular cardiology to cardiology and perioperative vascular medicine,” he said. All surgery patients’ cardiac biomarkers are monitored, and the patients are triaged to the coronary care unit or less-intensive care based on their MI risk. He expects his group will be able to present data on the impact of this approach within the next year.

This study was supported by the Canadian Institutes of Health Research, the Commonwealth Government of Australia’s National Health and Medical Research Council, the Instituto de Salud Carlos III in Spain, the British Heart Foundation, and AstraZeneca.

part of patient education series – Ask your doctor about your risk for peri-operative MI, and what he’s doing to reduce your risk.

* Diagnosing MI after surgery is another article.

Advertisements

Read Full Post »

There are plenty of reasons to consider medical tourism, and it’s not all about money.  While financial considerations may be the driving force today – I expect that to change over the next ten years as the developing surgeon shortage becomes more acute.  American surgeons are becoming older – and we aren’t attracting, training or replacing enough of them to keep up with demand.. Right now the shortage isn’t noticeable… or Is it?

A new article on Medscape (free subscription required, but multiple pages, and difficult to re-post) from the Annals of Surgery discusses increasing wait times for cancer surgery..

The surgeon shortage is expected to impact all specialties, but particularly cardiothoracic surgery where differing experts predict a 2,000 surgeon shortage by either 2020 (9 years!) or 2030, just as they estimate demand will double.  Currently, there are only about 4,500 cardiothoracic surgeons, if that gives you an idea of the scope of the problem.. Right now, the average age of these surgeons is 56 – 57 years old – and training programs are only at 65 – 67% occupancy..

(I can post references if anyone would like for these statistics.)

Read Full Post »

A select number of autographed copies of Hidden Gem: A Guide to Surgical  Tourism in Cartagena, Colombia are now available on Ebay. 

I’ve had numerous requests for signed copies.  Since I live in St. Thomas, this creates quite the hassle for readers, shipping books back and forth, so I have ordered a few to be placed for sale on eBay, in the travel section.

http://cgi.ebay.com/ws/eBayISAPI.dll?ViewItem&item=170527053422

Read Full Post »

Hidden Gem: The unvarnished truth!

Guide to Surgical Tourism in Cartagena, Colombia

Welcome to everyone who came here after reading about the book in print ads!  This is the book page for Hidden Gem, a new guide book for surgical tourism.  As an independent writer, who is unsupported by large book publishing companies, medical tourism agencies or other large agenda driven corporations – National advertisement and fancy ad campaigns are out of reach.

Don’t be fooled by the lack of hype or flash.  This book has substance, and unvarnished truth.  There are no ads in my book. I didn’t sell space/ pages, or ratings to any company for financial backing, or help selling my book.  I didn’t ask for, expect or receive any favors, freebies, gifts or money from any of the people or places I interviewed for this book. That makes me different from most of the guide books out there! 

 The majority of guide books, especially the large ones, make money by selling ad space/ or featured property space in their books.  The triple AAA star ratings that hotels and restaurants have?  Well, they bought and paid for the ‘priviledge’ of having AAA include them in their books..

This book is also unique because it’s written by a healthcare provider, for consumers. It’s written in everyday language that doesn’t require readers to be doctors or medical personnel to understand.

As a practicing health care provider, I also know that the best health care is unrelated to flashy, expensive ad campaigns, marble floors in hospital lobbies, or gourmet catered meals in private suites.  Marble floors are elegant; catered meals are nice but they won’t improve your health, or prevent you from catching a hospital-acquired infection.  (Though the psychology of marble floors does suggest cleanliness; in reality the general sanitation of a facility is a much more rigorous process that takes place out of the public eye.

With that introduction; let me welcome readers again to my website.  Have a look around, and if this product interests you, click on one of the links on this site, or request it at your local bookstore..

 https://www.createspace.com/3450944

Read Full Post »

I’d like to welcome all my long time readers to my new Amazon.com Author’s page.  I have added this blog to my Amazon page, so viewers to either page will be able to keep up with book news, and events.

Hidden Gem: Best book ever written!

Guide to Surgical Tourism in Cartagena, Colombia

Read Full Post »