POMTOM 12: Perioperative management of renin-angiotensin-aldosterone system antagonists

POMTOM 12: Perioperative management of renin-angiotensin-aldosterone system antagonists

Key points

·       If a patient is maintained on ACEI/ARB treatment before surgery, it is reasonable to withhold it temporarily to prevent hypotension during induction of anaesthesia[1,2]. As most ACEI/ARBs have short half-lives, cessation 24 hours prior to surgery appears the most pragmatic approach. Although a ‘withdrawal’ state from abrupt cessation of those drugs is theoretically plausible, there is no reliable evidence supporting that.

·       In patients on ACEI/ARB treatment for heart failure, it is reasonable to continue it during the perioperative period under close monitoring. If patients are not on those agents pre-operatively, it is recommended to start them after the first post-operative week[2].

·       If a patient is on ACEI/ARB treatment pre-operatively, it should be resumed as soon as possible following the surgical procedure [1,2]. Once the patient is haemodynamically stable, the risks associated with post-operative RAAS inhibition are outweighed by the benefits provided that renal function is not compromised.

·       If a patient is not on ACEI/ARB therapy, evidence hitherto available does not support starting it pre-operatively (other than possibly in patients undergoing CABG [3]). Further research is warranted to better clarify whether this approach brings any benefit for perioperative or long-term outcomes.

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POMTOM 11: Postoperative Cognitive Dysfunction

POMTOM 11: Postoperative Cognitive Dysfunction

Post operative cognitive decline is a well recognised phenomenon in cardiac surgery, and is becoming increasingly more important for an ageing population facing general surgery

•      The consequences include earlier retirement, the use of more social services, and earlier mortality

•      There is significant overlap in risk factors with dementia and delirium, and this reflects one of the challenges of nomenclature and diagnosis: that it is a non-homogenous process

•      As yet, there is no consensus on the most appropriate diagnostic tool, and although the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) are the most common so far, these are still open to bias and interpretation

•      Consenting patients is a challenge, particularly in the face of incomplete research, data, and incidence. 

•      The pathophysiology is still unclear, although various hypotheses have suggested inflammatory, embolic, biochemical, and protein imbalances as possible factors.

•      Anaesthetic management includes careful risk-assessment, avoidance of contributory drugs (sedatives, opioids, anticholinergics, increased depth of anaesthesia), and good post-operative care and re-orientation

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POMTOM 10: Cardiopulmonary Exercise Testing

POMTOM 10: Cardiopulmonary Exercise Testing

Key Points

·       Cardiorespiratory function is an independent predictor of perioperative morbidity and mortality

·       Cardiopulmonary exercise testing is a non-invasive, integrated assessment of cardiovascular and pulmonary function both at rest and under stress.

·       Improved perioperative outcome is related to the ability to increase oxygen consumption in response to surgical stress

·       CPET can be used to identify patients who are less able to meet the increased oxygen delivery demands of major surgery so informing perioperative planning including preoperative optimization and allocation of postoperative critical care resources

·       A low preoperative VO2 max is associated with an increased risk of post-operative complications and mortality. The lower the VO2 max, the higher the risk.

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POMTOM 9: Preoperative exercise

POMTOM 9: Preoperative exercise
  • Physical inactivity is the fourth leading risk factor for global mortality

  • Prolonged physical inactivity leads to reduced aerobic capacity and loss of muscle mass

  • Less than one-third of adults currently undertake the recommended levels of physical activity

  • Preoperative exercise should be encouraged and can improves the body’s ability to withstand the physiological demand of major surgery and reduce the risk of adverse postoperative outcomes

  • Successful prehabilitation relies on co-ordinated team working between patients and perioperative teams across primary and secondary care

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POMTOM 8: The importance of pain management in perioperative outcomes

POMTOM 8: The importance of pain management in perioperative outcomes

·       Analgesic methods should be considered early in the perioperative planning process

·       Analgesia should be considered on a patient- and procedure-specific basis

·       Optimal analgesia reduces length of hospital stay and improves patient satisfaction

·       Analgesia is a vital component of a complete enhanced recovery programme

·       Regional analgesic blocks are a crucial element of multimodal opioid sparring analgesia

·       “Alternative” therapies have limited evidence of efficacy but offer potential sources of analgesia in selected patients

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POMTOM 7: Prehabilitation and Patient Optimisation

POMTOM 7: Prehabilitation and Patient Optimisation

Prehabilitation programmes involve a multimodal approach to the patient incorporating psychological, behavioural and physical elements.

·       Early evaluation and risk stratification of patients facilitates a patient specific prehabilitation programme

·       Preoperatively patients may be more receptive to interventions than postoperatively

·       Functional capacity is reduced after major elective surgery

·       Prehabilitation programmes can help to attenuate this reduction in functional capacity

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POMTOM 6: Frailty in perioperative medicine

POMTOM 6: Frailty in perioperative medicine

As the number of older people increases the incidence of diseases amenable to definitive surgical intervention will increase. This will result in a greater number of older people undergoing surgery. Issues that become more prevalent with ageing, such as multimorbidity, functional dependence and frailty, contribute to adverse events after surgery. Older people therefore are at greater risk of poor postoperative outcome than their younger counterparts. Identifying issues such as frailty early can facilitate timely shared decision-making, resource planning and optimisation of heath to improve outcome.

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POMTOM 5: Assessing perioperative risk

POMTOM 5: Assessing perioperative risk

    Risk assessment and communication is essential to ensure informed consent

·         There are many scoring systems available, with variable evidence base and validation

·         Functional capacity assessment is increasingly comprehensive with a growing evidence base

·         UK based and validated scoring systems are being developed (e.g. SORT and PQIP)

·         Frailty scoring is also increasingly topical and provides a useful adjunct to formal organ based risk scoring

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POMTOM 4: Goal Directed Therapy and the prinicple of advanced haemodynamic monitoring

POMTOM 4: Goal Directed Therapy and the prinicple of advanced haemodynamic monitoring

At a time when the NHS is being faced with an ageing population with increasing complex needs and limited budget and resources, healthcare professionals need to be acutely aware that whilst we provide our patients with the best possible care we are mindful of cost effectiveness. Around 21.8% of operations performed in the UK are on ASA III-V patients, 42.3% of those being non-elective1. About 10% of all patients undergoing surgery in the UK are at high risk of complications and these then go on to account for 80% of postoperative deaths2.  As doctors we should be using evidence based medicine in a patient specific fashion to try and prevent post-operative complications and thus reduce length of stay. To be able to do this we should be using goal directed therapy which will normally require some kind of advanced haemodynamic monitoring.

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POMTOM 3: Enhanced Recovery – Pathways to Better Care

POMTOM 3: Enhanced Recovery – Pathways to Better Care

       Enhanced recovery after surgery (ERAS) pathways incorporate multimodal packages of perioperative interventions that reduce postoperative complications and hospital length of stay.

·         A reduction in the surgical stress response and maintenance of postoperative physiological function underlies the benefits of ERAS.

·         ERAS pathways begins pre-admission with risk stratification and optimisation of patients.

·         Anaesthetic factors, including monitoring anaesthetic depth and neuromuscular blockade, play an important role.

·         Multimodal, opiate-sparing analgesia is a cornerstone of ERAS and facilitates other ERAS goals, such as early enteral nutrition and early mobilisation.

·         The effect of anaesthesia and analgesia on cancer outcomes is becoming more relevant, leading to the concept of Enhanced Survival.

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POMTOM 2: Assessment of volume status and fluid responsiveness in intensive care

POMTOM 2: Assessment of volume status and fluid responsiveness in intensive care

It is a typical morning intensive care round. There is a septic, mechanically ventilated patient, who remains hypotensive despite aggressive fluid therapy overnight. The patient is dependent on vasopressors to meet with the targets of ‘early goal directed therapy’. A lively debate ensues with someone advocating a fluid bolus, whilst someone else feels the patient is already overloaded. How can the conflict be resolved? How can volume status be accurately assessed?

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