Evaluation du risque cardiaque - ICARWEB

Evaluation du risque cardiaque per-opératoire

Marc Licker, MD

Departement de Médecine Aigue1

Evaluation cardio-vasculaire pré-opératoire

1. Importance clinique?

2. Mécanismes des complications CV ?

3. Eléments-clé de la consultation d’anesthésie

2

JAMA Cardiol. 2017;2(2):181-7

10’581’621 hospitalisations, 66 [12] ans, 2004 -13 USA

3% Major CV Complic. (death, myoc infarct, stroke)

Vascular 7.7%

Thoracic 6.5%

Transplantation 6.3%

Neurosurgery 4.5%

General S. 3.9%

ORL

Urol. Orthopedic < 2%

Gyn/Obstetrics

< 0.5%

1. Importance : incidence des complications cardiovasculaires postopératoires

JAMA Cardiol 2017;2(2):181-187

Death

Myoc Infarct

Stroke 0.5% to 0.8%

N = 10’581’621 2004-13

1. Importance : Evolution 2004-13 des complications cardiovasculaires postop

0

2

4

6

8

10

12

14

16

Control

Coronary Artery Disease

Heart Failure

5

159’327 chir. majeure non-card.> 65ans, 8% mortalité opératoire18% pts + Insuffisance Cardiaque, 34% pts + Coronaropathie

Anesthesiology 2008;108:559-67

Impact de la coronaropathie et de l’insuffisance

cardiaque sur la mortalité postopératoire

% o

pe

rati

veM

ort

alit

y

6

30-daydeath

Prolonged

MechanicalVentilation

UnplannedIntubation

Pneumonia

RenalDysfunction

CardiacArrest

UrinaryInfection

Sepsis

Anesth Analg 2014;119:522–32

2005-10, multicenter cohort 673’422 ACS NSQIP Dataset→ 5’967 matched pairs for 0. 9% New or Worsening HF

7

van Diepen S, et al. Circulation 2011;124:289-96

9,3 9,2

2,9

6,4

13,7

11,812,6

15,2

0

2

4

6

8

10

12

14

16

18

20

IC Ischémique IC Non-Ischémique Coronaropathie Fibrillation A

Mortalité 30-J

Ré-Hospitalisation

MortalityRe-hospitalisation

Ischemic HF Non-Ischemic CAD A FibrillationHeart Failure Heart Failure

181614121086420

Fon

ctio

n

Pu

lmo

nai

reHeures Jours Semaine - Mois

Chirurgie

Fon

ctio

n

Mu

scu

lair

e

Force & Masse Musculaire

AtélectasiePneumonieARDS

ArythmieInfarctus Myoc.Insuf. Cardiaque, AVC

Fatigue

Mét

abio

lism

eSN

Sym

pat

hiq

ue

Inflammation

Anesthésie

1. Importance evaluation CV 2. Mécanismes des complications postopératoires

9

Insuffisance Cardiaque

IschémieInfarctus

Arythmie

1. Importance evaluation CV 2. Mécanismes des complications postopératoires

Inflammation, Stimulation SNSDysfonction musculaire

Atélectasies

PneumonieALI

ARDS

PO

SOP

ERA

TOIR

E

PATIENT + Facteurs de RISQUE

CHIRURGIEHémorragie

Inflammation, stimul. SNSHypercoagulation, Stase

ANESTHESIEHypothermie, ↓ VO2

Inhibition SNS & VagaleAtélectase, VILI, Tr. V/PIN

TRA

OP

Insuffisance cardiaque postopératoire

10

▪ Surcharge liquide

▪ Catecholamines (HTA, FC)

1. Importance evaluation CV 2. Mécanismes des complications

Ischémie myocardique

œdème pulmonaire aigu

Type d’Infarctus Myocardique

11

Coronary Stenosis

Pro

babili

ty o

f M

yocard

ial In

farc

t

Landesberg G et al. Circulation 2009; 119:2936-44

70% DO2/VO2

= IM type 2 (stress)

MINS

30% Plaque ruptureStent + thrombose= IM type 1 STEMI

1. Importance evaluation CV 2. Mécanismes des complications

Impact d’un infarctus péri-opératoire sur la survie

12

MI type 1

MI type 2

N=21’842, 23 hôpitaux (13 pays), 2008-13

13

Mortalité 30-J : 1.2%

MINS (cT-Tus > 5 ng/ml): 18% (93% asymptomatique)

MINS + ischémie ECG: 4% (infarctus myoc. type 1)

0

5

10

15

20

< 5 ng/ml 5 -40 ng/ml > 40 ng/ml diff. pré-postop

Mortalité 30-JHR ajusté

1.5%

9.7%

HR

2.8

HR

15.7

JAMA 2017;317(16):1642-1651

2.2 Millions 65%; IC 95% 60-70

Silencieux

1.1 Million

35%; IC 95% 30-40

+ Symptôme d’Ischém.

Monde : > 200 Millions adultes + Chir non-cardiaque majeure

100 Millions > 45 ans + Facteurs de risque CV

1 Million 1.1%; IC 95% 0.9-1.2

0.16 Million 26.3%; IC 95% 18-36

0.27 Million 12.5%; IC 95% 8.8-17.1

0.12 Million 9.7%; IC 95% 5.4-15.8

0.36 Million 7.8%; IC 95% 5.7-10

Décès à 30 Jours postopératoires

91.5 Millions

91%; IC 95% 91-92

Trop postop

0.6 Million (sepsis, TE,...) 0.6%; IC 95% 0.5-0.8

Trop + cause non-card.

3 Millions 3.3%; IC 95% 3.1-3.6

Trop - ECG+

4.6 Millions 4.6%; IC 95% 4.4-4.8

Trop isolée (MINS)

Evaluation cardio-vasculaire pré-opératoire

1. Importance clinique?

2. Mécanismes des complications CV ?

3. Eléments-clé de la consultation d’anesthésie

1. Dépister une maladie CV ?

2. Quel(s) examen(s) complémentaire(s) ?

3. Faut-il traiter une maladie CV ?

4. Faut-il reconditionner/préhabiliter ?

15

Recommandations des sociétés d’anesthésie et cardiologie

16

A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014 Jul 29

The Joint Task Force on non-cardiac surgery: CV assessment and management of the European Society of Cardiology and the European Society of Anaesthesiology. Eur Heart J 2014 Sep 14

Pre-operative evaluation of adults undergoing elective noncardiac surgery. Updated guidelines Eur J Anaesth 2018;35:407-65

Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery

Can J Cardiol 2017;33:17-32

1. Importance risque CV 2. Mécanismes des complications 3. Consultation d’anesthésie

SFAR Evaluation périopératoire du risque cardiaque en chirurgie non-cardiaqueAnn Fr Anesth Réan 2011:30: e5–e29

http://fr.wikipedia.org/wiki/Fichier:Flag_of_the_United_States_(Pantone).svg

17

Les risques CV opératoires dépendent de ….

• Procédure = stress

• Comorbidités

• Capacité fonctionnelle, fragilité


Classes de risque chirurgicale

18


Low Risk High Risk


Score clinique de stratification du Risque CV


Facteurs de risque RCRI 2005 American College

Surgeons NSQIP 2013

Chirurgie majeure + + (code CPT, emergency/elective

Maladie coronarienne + -

Insuffisance Cardiaque + +

Dysfonction Renale + Créat > 2mg/dl + Créat > 1.5mg/dl

Mal. Cérébro-vasculaire + -

Diabète + type 1 + type 1 ou 2

Classe ASA-PS +

Age avancé +

Classe fonctionnelle +

• Plaie

• Indice de masse corp.

• Steroides

• Ascites (<30 d)

• Sepsis (< 48h)

• Ventilation mécan.

• Cancer étendu

• Hypertension

• Ant. Chir cardiaque

• Dyspnée

• Tabac (< 1yr)

• BPCO sévère

• Dialyse, ARF

20

1. risque CV 2. Mécanismes des complications 3. Consultation d’anesthésie

Evaluation fonctionnelleMET Metabolic Equivalent Task1 MET = consommation d’O2 au repos (3.5 ml/kg/min)

« Combien d’étages d’escaliers pouvez-vous monter sans vous arrêter ? »

• > 6 (> 6 MET)• 3-6• < 3


Evaluation fonctionnelleQuestionnaire Duke Activity Status Index

VO2peak ml/kg/h =

0.43 x DASI + 9.6

Risque (MET)

> 24 Faible (7)

15-23 Interm (4-6)

10-14 Elevé (3-4)

< 10 Très élevé (3)

Les questionnaires sont-ils fiables pour évaluer picVO2 ?

22

METpeakVO2 peakVO2

Duke Activity StatusN=1’401 dans 25 hôpitaux

Wijeysundera DN et al. Lancet. 2018;391:2631-2640

Très

él

evé

Elev

é

Ris

qu

e F

aib

leInterm

MET7

5

3

7

5

3

Questionnaire d’activités physiques → prédiction des complications cardiaques & de la survie à 1 an

23Wijeysundera DN et al. Lancet. 2018 Jun 30;391:2631-2640

24

Time Up and GO

(TUG)

Evaluation de la fragilité (seniors)

Gait Speed Test

SLOW : > 6secFAST : < 5 sec

25

Ann Surg 2013;258:582-8

Colo-rectal surgery

Time Up and GO (TUG)Gait Speed test

Evaluation de la fragilité→ prédire les Complications & la Survie

J Am Heart Assoc. 2018;7:e010139Cardiac surgery

SLOW < 5sec

FAST > 6sec

26


Evaluation fonctionnelle• MET ou Duke Activity Status Index

• Fragilité :

• Mouvements, équilibre: TUG, Gait Speed Test

• Dépendance: Ø, partielle, totale

• Neuro-cognitif: Minimal-Mental State

• Nutrition

28

Guidelines 2014 - 18

Urgence ? Chirurgie ▪ Evaluation &

Traitement postopI/C

Condition Critique ?✓ SCA, angor instable

✓ Décompensation Cardiaque

✓ Valvulopathie critique

✓ Arythmies, tr. conduction

▪ Différer la chirurgie

▪ Evaluer & Traiter avant la chirurgieI/B

Chirurgie Mineure OK ChirurgieI/B

Capacité fonctionnelle > 4 MET

& Ø RCRI (Lee score) ? OK ChirurgieIIa/B28

http://www.americanheart.org/

Capacité Fonctionnelle?

Risque Intermédiaire ?

> 1 FRCV > 2 FRCV

Chirurgie VASC ou

MAJEURE

ChirurgieINTERMEDIAIRE

• Coronaropathie

• Insuffisance cardiaque

• Dysfonction rénale (eGFR < 60 ml)

• Diabète type 1

• AVC

Revised Cardiac

Risk Index

Guidelines 2014

> 2 FRCV

ChirurgieMINEURE

ChirurgieINTERM. MAJEURE

MET > 4

TESTCARDIAQUEX

I A

Tolérance Exercice< 3 MET

négatifTEST

CARDIAQUE

I C II B

CHIRURGIEPCI PAC ?

positif

http://www.americanheart.org/

Consensus de la Société française d’anesthésie et de réanimation (SFAR) et la Société française de cardiologie (SFC)D’après Anne-Claire Nonotte, Jean-Luc Fellahi , Rémi Schweizer

31

Rodseth RN et al. Anesthesiology 2013;119:270-83

Test cardiologique : Information modifier le traitement

Tests cardio Rythme Fonction Structure Perfusion

ECG repos + - - (-)

Echocardio - repos - + + (-)

BNP (NT-pro-BNP) - + - -

Stress test• Scintigraphie Tha

• ECG effort

• Echocardiographie

-

+

-

+

-

++

-

-

++

++

+

++

VO2max - + - +

Coronarographie - - (+) +++

Cathétérisme Droit - + (HTAP) - -

Imagerie RMN

CT-scan

SPECT

-

-

-

+

(-)

+

++

+

+

+

+

++ 32

Coronary CT of Master Athlets : the gray zoneBr J Sports 2018; Nov 9, 99840

volume rendering technique imagesnonobstructive mixed plaque in proximal RCA

nonobstructive calcified plaque in proximal LAD

34

CT-coronary angiography in risk stratification prior to non-cardiac surgery: systematic review & meta-analysis

Koshy AN et al. Heart 2019 Sep;105:1335-42

11 trials: N=3’480, MACE in 252 pts (7.2%)

35


36

From 2010 to 2012, 443 LT recipients, age 52 (8)A coronary artery calcium (CAS) score > 400

8.6% had > 1 CV complications within 30 days after LT CAC > 400 in 11 patients (2.5%)

In the multivariate analysis, predictors of CV complic.- CAC > 400 OR 4.6 (95% CI: 1.1– 18.7)- female sex OR 2.8 (1.4–5.6)

Différences entre les Recommandations des sociétés US, UE et Canadiennes

37

• Utilisent l’évaluation fonctionnelle (tolerance à l’effort) pour orienter les patients ayant des facteurs de risque CV vers un stress test cardiologique

• Utilisent la mesure préopératoire de BNP ou NT-pro-BNP pour le suivipostopératoire avec des ECG et la mesure de Troponine


• Utilisent l’évaluation fonctionnelle (tolerance à l’effort) pour orienter les patients ayant des facteurs de risque CV vers un stress test cardiologique

• Intègrent des tests de fragilité


Tachycardie préop = indicateur d’une issue défavorable

38

2016; 117: 172–81

EvaluationRISQUE Préop

Décisionspartagées

Informations anesth -chirRisque / Bénéfice

Suivi du traitement prescritComportement adapté

Engagement

Risques MODIFIABLES

ACQUISCoronaropathie, Insuf. C. Diabète, Athéromatose Malnutrition, Obésité

Infections, Anémie → FRAGILITE

Habitudes

Tabagisme

Alcoolisme

Sedentarité

→ FRAGILITE

Risques FIXES

INNE

Age

SexeGénétique

ACQUISBPCO

DiabèteDémence

Insuf. Card.→ FRAGILITE

1. Risque CV 2. Mécanismes complications 3. Consultation d’anesthésie: Facteurs de risque

Merci!

40

41

ESA –ESC 2014 / 18 ACC/AHA 2014 CCS 2017

Score clinique risque CV

RCRI 1B(NSQIP) 1B

NSQIP 1B(RCRI) 1B

RCRI

Capacité fonctionnelle

MET Score de Fragilité

ASA-PS, TUGTest d’effort VO2max

MET (or DASI)Risque Faible < 4 Interm 4-6,

élevé 7-10, très élevé >10

Test d’effort VO2max

(MET)

Test cardiologique non-invasif

Ø en routine+ maladie cardiaque

+ facteur de risque CV+ capacité fonctionnelle↓

Ø en routine Ø en routine

Scintigraphie myocardique

(echo de stress)

Scintigraphie M (echo stress)

Angio-CT coronarien

Ø

BNP ou NT-pro-BNP Si FRCV >2 Si FRCV >2 Si FRCV >1

La consultation d’anesthésieLes buts

1. Quel risque opératoire ?

2. Des examens complémentaires sont-ils nécessaires ?

3. Peut-on optimiser la condition du patient en PRE-, PER- et postop?

Indicateurs cliniques, scores (FR)Type & Gravité de la chirurgieTolérance à l’effort (MET)

Standard• ECG ?• RX thorax ?• Labo ?

• CardiovasculairesUS-Coeur ? US-Carotide ?

• Stress: Echocardio, Scinti ?• Angio-CT Cœur ?• Angio Coronarienne ?

Pulmonaires• Spirométrie, pléthysmographie• Gazométrie, DLCO

• Médicament(s)Arrêt / poursuite, introduction• Antiplaquettaire, anticoagulant• B-B, anti-Ca, IECA/Anti-AngII• …

• Intervention(s) préalable • Revascularisation myocardique• Pacing / débfibrillateur• Correction d’une sténose (ex.: TAVI)• CPAP, bi-PAP 43

Risque CV clinique Chirurgie Capacité Fonctionnelle

ECG -ECG +ECG +

Ø> 1 FRCVAge > 65

MineureIntermédiaire

Majeure

BonneDiminuéeDiminuée

Echocardio TT -ETT +

Ø> 1 ou Souffle Card, signes d’Insuf Card

- BonneDiminuée

BNP NT-pro-BNP –+

Ø Min.- Interm. Bonne

44

Décès à 30 Jours postopératoires

Preoperative Cardiovascular Risk Stratification

Risk factors RCRI

Lee 2005

MICA 2011

Guptka

Sabate2011

American College

Surgeons NSQIP 2013

Major Surgery + + + (code CPT, emergency/elective

Coronary Artery Disease + + -

Heart Failure + + +

Renal Dysfunction + + +

Stroke + + -

Diabetes mellitus + (insuline) + (oral, insuline)

Peripheral Arteriopathy + -

ASA Class + +

Advanced age + +

Functional class + +

Abnormal ECG + -

*RCRI, Revised Cardiac Risk Index MICA, Myocardial Infaction or Cardiac Arrest

ACS NSQIP, National College of Surgeons’National Surgical Quality Improvement Project

Predicteurs des Complications Cardio-Pulmonaires

• ASA classes 3-4

• Performance status

• Physical fitness

• Alcohol, smoking

• Chemo-therapy

• Coronary artery disease

• Congestive Heart Failure

• Peripheral Arteriopathy

• Cerebro-vasc. disease

• Renal Dysfunction

• Diabetus mellitus

• Age

• Low SpO2 (<95%)

• Respiratory infection

• Emergency surgery

• Upper abdominal or Thoracic S.

• Duration of Surgery (> 120 min)

RevisedCardiac Risk

Index51

LungARISCAT

Score

52

Sheth TE et al. British Medical Journal 2015;350:h1907

Cardiovascular Death: 1% (n=8)

Myocardial Infarct : 7% (n= 71)

4% Normal coronary artery

24% Non-obstructive CAD

41% (29) : Obstructive CAD

31% (22) : Extensive CAD

N=955 pts + CV Risk factors

Major or Intermed. Surgery

Prédiction des complications cardiovasculaires postopératoires

53CCTA → overestimates risk of postop MACE (5x)

C Index = 0.62

Surgery in ElderlyMortality after Hip Fracture Repair

54

Olmsted County, Minnesota, 1988-2004 (N=1’212)

With preop HF

No preop HFMortality

Cullen MVV et al. J Hosp Med 2011;6:507-12

Preop HF N = 327 (27%)

No preop HF N = 885 (73%)

Periop

death

55

Perioperative Cardiovascular Protection

Learning objectives

1. Why is it important ?

2. Mechanisms of CV complications

2. Periop protective interventions

Myocardial

infarct Heart

Failure

Arrhythmia

Mechanisms of postop Cardio-Vascular complications

Prexisting CV disease

• Coronary AD

• Heart Failure

• Valvular disease

• Arrythmias

• Pulm. HT

56

Surgical stress

❑ Inflammation

❑ NeuroendocrineTachycardia, HT

❑ VO2Fever

Periop Adverse Events

Anemia, Hypovolemia

Hypo- Hypertension

Hypoxemia

Sepsis

Myoc infarct

Heart Failure

Arrhythmias

Fronczek J et al. External validation of the Revised Cardiac Risk Index and National Surgical QualityImprovement Program Myocardial Infarction and Cardiac Arrest calculator in noncardiac vascular surgery. Br J Anaesth. 2019 Oct;123(4):421-429

Dhir S1, Dhir A2 The Global Perspective of Cardiovascular Assessment for Noncardiac Surgery: Comparisons from Around the World. J Cardiothorac Vasc Anesth. 2019 Aug;33(8):2287-2295

Kaw R et al. Predictive Value of Stress Testing, Revised Cardiac Risk Index, and Functional Status in Patients Undergoing Noncardiac Surgery. J Cardiothorac Vasc Anesth. 2019 Apr;33(4):927-932

Tateosian VS1, Richman DC2. Preoperative Cardiac Evaluation for Noncardiac Surgery. AnesthesiolClin. 2018 Dec;36(4):509-521

Fleisher LA. The Value of Preoperative Assessment Before Noncardiac Surgery in the Era of Value-Based Care. Circulation. 2017 Nov 7;136(19):1769-1771

Wijeysundera DN1 Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet. 2018 Jun 30;391(10140):2631-2640.

Go G et al. Negative predictive value of dobutamine stress echocardiography for perioperative riskstratification in patients with cardiac risk factors and reduced exercise capacity undergoing non-cardiacsurgery. Intern Med J. 2017 Dec;47(12):1376-1384

57

https://www.ncbi.nlm.nih.gov/pubmed/?term=Fronczek%20J%5bAuthor%5d&cauthor=true&cauthor_uid=31256916

https://www.ncbi.nlm.nih.gov/pubmed/31256916

https://www.ncbi.nlm.nih.gov/pubmed/?term=Dhir%20S%5bAuthor%5d&cauthor=true&cauthor_uid=31060932

https://www.ncbi.nlm.nih.gov/pubmed/?term=Dhir%20A%5bAuthor%5d&cauthor=true&cauthor_uid=31060932



https://www.ncbi.nlm.nih.gov/pubmed/?term=Tateosian%20VS%5bAuthor%5d&cauthor=true&cauthor_uid=30390775

https://www.ncbi.nlm.nih.gov/pubmed/?term=Richman%20DC%5bAuthor%5d&cauthor=true&cauthor_uid=30390775



https://www.ncbi.nlm.nih.gov/pubmed/?term=Wijeysundera%20DN%5bAuthor%5d&cauthor=true&cauthor_uid=30070222




Currently, 3 major Society Guidelines:

1. the 2014 ACC/AHA Guidelines

2. the 2014 European Society of Cardiology/European Society of Anesthesiology,2

3. the 2017 Canadian Cardiovascular Society (CCS), that address preoperative assessment

Clear differences (interpretation) between 1 and 2; 3 has new updated evidence

Until recently, we include the assumption that surgery was indicated and would occur.

AS health moves from volume to value, shared decision around the risks and benefits of surgery has taken on increasing importance

58

Risk indices have improved over the years.The American College of Surgeons National Surgical Quality Improvement Program risk calculator has greater perioperative discriminatory ability than previous indices.The future challenge will be to incorporate the calculation of short- and longterm risk into the preoperative discussion, especially given the efficiency pressures on many practices

The Value of Preop Assessment Before Noncardiac Surgery in the Era of Value-Based Care Lee A. Fleisher

• Pts with very poor exercise capacity who cannot improve with an exercise regimen will likely not receive benefit from surgery given the probability of complications and prolonged recovery

• The potential benefit of more formal assessment of exercise capacity and prehabilitation within the value framework should lead to more patient-centered care

• strength of the recommendations may differ in incorporating biomarker testing into perioperative care:

• ACC and AHA have advocated the use of functional capacity as a key discriminator of the need for testing, although the evidence is scant (await the MET trial)

• the CCS advocates the use of preoperative brina natriuretic peptide biomarkers (more than determining functional capacity)

• Patients with stents• Currently preop assessment is focused on periop antiplatelet treatment (ACC/AHA 2016)• One remaining questions: in surgery at risk of bleeding, should AAS be continued in pt with “mature” stent (POISE 2 showed

an increased risk of bleeding with AAS; an Italian registry analysis showed increased risk of stent thrombosis if AAS was discontinued; management of GpIIbIIIa inhibitors?) → discussion between cardiologist, surgeons ans anesthesiologists

• Postop surveillance• Troponin monitoring (different between CCS and AHA/ACC); predictive value of isolated Tp elevations (MINS) after

noncardiac surgery (are they really related to myocardial ischemia

• Trend to move from extensive preop testing to more targeted surveillance and treatment

• Key question will be ensuring that patients make the most informed decision regarding the indication for surgery given the patient’s trajectory for recovery, including returning to baseline or improved functional status and health

59

60

Canadian CV Society

Pro-BNP preop ++> 65 yr or 45-65 with CV

disease or RCRI > 1

Transthor. echo (at rest)Coronary CT, angiographyCPETMyocardial scintigraphy

No

Aspirin initiation Aspirin continuation

NoNo

Except Carotid end., pts with recent stents

Alpha-2 Agonists No

ACEI or Angio II R blocker Withhold 24h preop

Smoking cessation Yes

Troponin postop 48h If elevated preop pro-BNPIf RVRI > 1 or > 65 yr

If 45-65 with CV disease

Postop statin & aspirin If periop myocardialinjury/infarct

Computed tomographic coronary angiography in risk stratification prior to non-cardiac surgery: a systematic review and meta-analysis


11 trials: N=3’480, MACE in 252 pts (7.2%)

Perioperative MACE • severity & extent of CAD (no CAD 2.0%; non-obstructive 4.1%;

obstructive single-vessel 7.1%; obstructive multivessel 23.1%) Multivessel disease (MVD) OR 8.9, 95% CI 5.1 to 15.3)

• CAC score: ≥100 OR 5.1, ≥1000 OR 10.4)

• In a cohort deemed high risk by established clinical indices:

→ absence of MVD on CTA = negative predictive value of 96% (95% CI 92.8 to 98.4) for predicting freedom from MACE

63

64Koshy AN et al. Heart 2019 Sep;105:1335-42

65

Preop CV Risk factorsNT-proBNP – hsCRP

Curr Opin Crit Care 2011;17:409-15 65

66

Reniten (ACE Inhibitor), Sintrom, Statine

2. Influence of CV medications ?

Cardiac Risk ?

Cardiac Protection ?

67

Anesth Analg 2014;

119:1053–63

Quel bilan CV pré-op ?

69

1. Score clinique

2. Troponin

Preoperative Risk Assessment & Optimization in Patients with Lung Cancer

1. Outcome : survival & complications?

2. Predictive factors ?

3. Impact of postoperative complications ?

4. How to prevent complications & improve outcome ?

70

Differences & Similarities between Thoracic and non-thoracic surgery

71

Thoracic surgery Non-Thoracic surgery

Patient preop status

• Indication Lung Cancer Cancer, Vascular d.,

• COPD ++ (20-30%) < 20%

• CV disease < 20% Up to 80%

• Smokers 50-80% < 60%

Intraop : need for OLV Yes No

Postoperative complications

• Pulmonary complic. +++ ++

• Cardiovascular + (arhythmias) + (MI)

• Renal dysfct + +

• Wound infection ++ +

• Admission in ICU 5-10% 5-10%

72

1. Outcome : epidemiology of cancer in Europe

Stage 1 : LocalizedStage 2: Larger (>5 cm) or

spread to local lymph node (18%)

SURGERY

Stage 4: Advanced or metastatic (51%)

Chemotherapy & Palliative RXtherapy

Stage 3: locally advanced (24%)

Chemotherapy & Rxther+/- SURGERY

Brain

Bone

Liver Adrenals73

1. Outcome : current treatments of lung cancer

Lung Cancer 2000-2007

5-y survivalFrom 10% to 18%

74

1. Outcome : survival of patients with lung cancer

75

1. Outcome : survival of patients with lung cancer

N=405’580 patients with NSCLC (SEER program), from 1988 to 2008,

Onco Targets Ther 2017; 10: 4295–4303

Surgery Non-surgicalmanagement

76

in EU : only 20% to 30% of patients with NSCLC undergo surgery

in USA : up to 40% of patients with NSCLC undergo surgery

77

• N = 3’363 from January 1st 2007 to 31 December 2011

Green A et al. EJCTS 2016; 49:589–94

Respiratory Failure Cancer Recurrence

CardioVasc problems (IM, HF, Stroke)

78

6-Month7%

90-Day5%30-Day

2%

1-Year14%

Mu

scu

lar

Fun

ctio

n

Muscular Strength & Mass

Pu

lmo

nar

yFu

nct

ion

Hours - Days Weeks - MonthsIn

flam

mat

ion

Surgery

1. Outcome : Mechanisms of Complications & Fatigue

Met

abio

lism

Sym

pat

het

icN

S

Thrombosis

Plaque rupture

AtelectasisPneumoniaBP FistulaARDS

ArrhythmiaMyoc – InfarctHeart Failure, Stroke

WeaknessFatigue

Anesthesia

80Fernandez FG et al. J Thorac Cardiovasc Surg 2018;155:1254-64

STS Database, 2002 - 2013, N= 29’899

30-d Mortality 2.4% 90-d Mortality 4.5%

Morbidity 20% → prolonged hospital stay

Blood transfusion 8.5%

Atrial Fibril. 14% Myocardial infarct 0.5%

Pneumonia 4.3% Kidney injury 1.4%

Re-intubation 3.8% Delirium 2%

Wound infect. 0.6% Sepsis 0.8%

DV Thrombosis 0.6% Pulm. Embolism 0.5%

1. Outcome : early mortality & Morbidity complications after lung resection

81J Thorac Cardiovasc Surg 2018;155:1254-64

STS Database, 2002 - 2013, N= 29’899

2. Predictive factors : Causes of early mortality after lung resection


STS Database, 2002 - 2013, N= 29’899

2. Predictive factors : Causes of mortality after lung resection

83Nojiri T et al. Ann Surg Oncol 2017;24:1135-42

Prospective database N=675, 2007-12

Cancer recurrence48% with PPCs17% without PPCs

2. Predictive factors : Long-term impact of PPCs & Cancer recurrence

84

3. Preoperative assessment : the «classic» approach→ Organ specific

1. ASA (American Society of Anesthesiology Physical Status):

• Score I to IV• (poorly) predict postop outcome

2. RCRI (Revised Cardiac Risk Index):

• 6 items (Major surgery, HF, CAD, Diabetes, Stroke, Renal dysfunction, vascular disease)• Predict early cardiovascular complications

3. ARISCAT (Assess Respiratory Risk in Surgical Patients in Catalonia)

• 7 items (age, preop SpO2, anemia, resp. infection, major surgery, duration surg., emergency)

• Predict postop pulmonary complications (PPCs)

4. STOP-BANG (risk of postop apnea):

• 8 items (Snoring, Tiredness, Observed apnea, bP, BMI, Age, Neck circumf., Gender)

• Predict postop hypoxemia

Possum : Physiological & Operative Severity Score for the enUmeration of Morbidity & Mortality

Operative (6 items)

• Type of operation

• Number of procedures

• Blood loss

• Peritoneal contamination

• Extent of malignancy

• Elective / emergency

Physiological (12 items)

• Age

• Cardiac status

• ECG

• Respiratory status

• Blood Pressure

• Heart Rate

• Glasgow Coma Score

• Hemoglobin

• White Blood Cells

• Urea

• Sodium

• Potassium

→Scoring system for auditing general, digestive,

vascular, bariatric, orthopedic surgery

→Complex (research)

Copeland G et al. Br J Surg 1991;78:355-60

3. Preoperative assessment : the «academic» approach→ POSSUM

Signes de déconditionnement

1. MET (Metabolic Task Equivalent)• « How many stairs can you climb, … distance walk … ? »• 1 MET = VO2 at rest, 2 MET = 2x VO2 rest,…• Very High Risk< 2-3 MET, High Risk < 4-5,… Fit > 10 MET

2. Duke Activity Status Index• Questionnaire based on DLA (12 items)• Better than MET to estimate VO2 max

3. Six Minute Walk Test or Shuttle test • Simple, reproductible• Intermediate predictor for PPCs

4. Cardiopulmonary Exercise Test• Need material, logistics, reproductible• Better predictor for early and late outcome (< 16 ml/kg/min = interm. risk)86

3. Preoperative assessment : the «functional» approach

Org

an

fu

ncti

on

Age

Functional impairment

Myoc.

InfarctF

un

cti

on

al

Re

se

rve

0 20 30 40 50 60 70 80 90

Cancer

SurgeryUnfit

3. Preop assessment : Modern approach→ assess FRAILTY in elderly

89

Am J Surg. 2013 October ; 206(4): 544–550

7 frailty traits measured preop

- Katz Score ≤5

- Timed Up and-Go ≥15 seconds,

- Charlson Index ≥3

- Anemia < 35% Hct

- Mini-Cog score ≤3

- Albumin < 3.5 g/L

- > 1 fall within last 6 months

• Nonfrail: 0–1 trait• Pre-frail: 2–3 traits • Frail: ≥4 traits

Patients ≥65 years undergoing elective colorectal or cardiac surgery

Am J Surg. 2013 October ; 206(4): 544–550

3. Preop assessment : Modern approach→ assess FRAILTY

Preop RISK Evaluation

ComorbidityManagement

Collaborative Decision-making

Collaborative Behavioural change

MODIFIABLE

ACQUIREDCoronary AD

Diabetes Arterial DAnemia, malnutrition

Infections (mouth)

→ FRAILTY

LIFESTYLEObesitySmokingAlcohol

Sedentarity→ FRAILTY

FIXED

INNATE

Age

SexGenetics

ACQUIREDCOPD

DiabetesDementia

Heart Failure

1. Outcome, 2. Predictive factors 3. Preop assessment : Fixed vs Modifiable Risk Factors

MODERN CONCEPT OF PERIOPERATIVE INTEGRATIVE MEDICINE

91

• …Mrs Smith, 77yr has a lung cancer.

• Clinical, biological and pathological data are electronically communicated to a multidisciplinary care team to balance the relative benefits and harms of chemotherapy and surgery

• Mrs Smith is empowered to be fully involved in shared decision-making with an individualized pathway for her pre-operative journey.

• Optimisation of physical and psychological function starts in parallel with the evaluation of treatment options.

1. Outcome, 2. Predictive factors 3. Preop assessment 4. How to optimize patient condition

92

Patient Empowerment

Case-manager

Enhanced Recovery After SurgeryPreop – Intraop & Postoperative Processes


❑ Oral & Dental Care • Mechanical removal of dental biofilm

or plaques

• Use of oral disinfectants

93

1. PATIENT EDUCATION & EMPOWERMENT

❑ Tobacco cessation

❑ Alcohol withdrawal


94

2. NUTRITIONAL ASSESSMENT & CORRECTION


95

Minimal level of functioning

PREHABILITATION

FitSurgery

Unfit

Fun

ctio

nal

Sta

tus

Death

Complications


3. EXERCISE TRAINING PRESCRIPTION

Endurance

Inspiratory Muscle Tr.

96

SurgeryPreoperative (1 – 4 weeks) Postoperative

3. EXERCISE TRAINING MODALITIES Hospital, Fitness center, Home-basedW & W/o Supervision

Improve Preoperative Function

• peakVO2 + 12% (95%CI 5-65)

• Max Inspir P + 13 mmHg (95%CI 7-19)

• 6Min Walk T + 47 m (95%CI 36-54)

97


3. EXERCISE TRAINING EFFICACY META-ANALYSIS 28 RCTs (N=2’040)

• Thoracic S. 0.33 (0.21 – 0.51)

• Cardiac S. 0.44 (0.29 - 0.67)

• Abdominal S. 0. 40 (0.21 – 0.77)

Improve Postop Outcome→ lower incidence PPCs OR (95%CI)

• Endurance T 0.39 (0.21 – 0.61)

• Respiratory MT 0.60 (0.36 - 0.91)

• Combined T 0. 28 (0.15 – 0.51)

BUT, no benefit on :• 30-day-Mortality • Cardiovascular complic.

98

PREOP EXERCISE TRAINING & PPCS

DURATION OF TRAINING

<2 Weeks OR 0.32 (0.2 – 0.5)

2-4 Weeks OR 0.50 (0.3 – 0.8)

99

BMJ 2018

Multi-center RCT in NZ, Australia;

Upper Abdominal Surgery, N= 441

30 min education, teachingHow to breath

PPC

100

Mortality

Preop education : respiratory breathing by experienced physiotherapists

Boden I et al. BMJ. 2018 Jan 24;360:5916

IN 2025, MR SMITH PERIOP MANAGEMENT…

• …Mrs Smith has been optimized with diet, physical exercise and, with meditation or self-hypnosis, she feels a level of control to minimize her anxiety.

• an individualised ‘e-health navigator’ guides her nutrition, exercise and psychology programme.

• … investigations and chemoradiotherapy are carried out.

• Following surgery, Mrs Smith is prepared for the expectation that she will drink, eat and mobilize the same day, and be discharged from hospital 2 days after her operation.

• Her ‘e-health navigator’ guides her recovery phase, and 6 weeks later she returns to her baseline level of function, physically and mentally.

101


Preoperative exercise training

• Short period of time• 1 to 4 weeks

• Medical prescription• Type of exercise• Goals : duration, intensity, repetition

• Settings• home, fitness center or hospital, or combination

• Supervision• Coaching, Monitoring

102

Aerobic Training (Endurance)

103

Inspiratory Muscle Training

Stretching, Relaxation

Power, Resistance

How does it work ?

Fast-twitchSlow-twitch

Classification based on: Myosin subtype, ATPase, metabolism, twitch, fatigability

Intermediate

GlycolyticOxidative Mixed Oxydative-glycolytic

Type 1 Type 2A Type 2X Type 2B

TRAINING

Hyperplasia

Endurance

Hypertrophy

Resistance

Endurance Training

105AMPK, adénosine mono-P kinase; CaMK, calmoduline kinase; PGC-1a, coactivateur 1α du récepteur γ activé par le proliférateur du

peroxisome; GLUT4, transporteur de glucose membranaire; ROS, radical oxygen species

ROS ++ ROS +

Angio-

genese

1. Postop complications 2. Modern periop context 3. Solutions to improve outcome

VO2max

Max Inspir P

106

peakVO2

IMPACT OF PREHABILITATION ON FUNCTIONAL PARAMETERS

6 Min Walk T

+ 12% (5 –

65)

+ 13 mmHg (7 –19)

+ 47 m (36 –

54)

107

Cardiac surgery

Thoracic surgery

Abdominal surgery

OR 0.33 (0.2 – 0.5)

NNT 5Number Needed to

Treat to avoid 1 complications

PREHABILITATION & POSTOPERATIVE PULMONARY COMPLICATIONS

Max Inspir P

108

peakVO2


6 Min Walk T

+ 12% (5 –

65)

+ 13 mmHg (7 –19)

+ 47 m (36 –

54)

109

Cardiac surgery

Thoracic surgery

Abdominal surgery

OR 0.33 (0.2 – 0.5)




Aerobic Endurance T

Inspiratory Muscle T

110


TYPE OF TRAINING

OR 0.39 (0.2 –

0.6)

OR 0.60 (0.36 –

0.99)

Combined Training

OR 0.28 (0.15 –

0.5)

But, some limittiona…

• 20-30% are unable to attend the program• Too far from hospital• Poor motivation• Exercise program not adapted to patient

• Some patients do not respond (?)

111

113

People > 65yr10 % → 30%

Cognitive disorders after surgery

115Can Anesth 2011; 58:216–223


J Thorac Cardiovasc Surg 2018;155:1254-64

• From 2007 to 2017, N=697 Mortality 30-d: 0.9%, 90-d 1.4%

Causes of death at 30 days 90 days

30 Day MortalityCardiovasc 33% Pulmonary 67%

90 Day MortalityCardiovasc 30%Pulmonary 60%

117

118

Eur J Cardio-Thor Surg 2017;52: 1041–48N=62’774, 2007-2016 (VATS 21%)

30-D Mortality 2.6%, Morbidity 18.5%

2. Predictive factors

119Adapted from Files et al. Critical Care 2015: 19:266

1. Why is it important : From Physiology to Clinical applications

• 250 millions operations are performed worldwide

• 1-3% early mortality

• Pulmonary C. > Wound infection > Cardiac C. Economic burden : prolonged hospital stay, ICU

admission

Prognostic implications : reduced survival and qualityof life

120

1. Why is it important: EPIDEMIOLOGY of postoperative complications

• > 50% surgeries performed in pts > 65yrs

2015;150:1034-40

National Cancer Data Base (~1’500 Hospitals, ~70% of all cancers)

→ Identification of hospitals with lowest and highest mortality, 01.2005 to 12.2006

NO difference regarding :

o Neoadjuvant tretament

o Use of Epidural catheter

o Use of beta-blockers

o Intraop monitoring

o AB prophylaxis

o VT prophylaxis

o Open vs VATS121

Correct management of Cardio-Pulm Complications

→ better outcome

LowMortality (%)

LowMortality (%)

High Mortality (%)

High Mortality (%)

LowMortality (%)

JAMA 2015;150:1034-40

Hospitals with lower mortality

- Preop risk management- Protective organ strategies- Early detection of postop

complication (PC)- Appropriate treatment of PC

Thoracic SurgeryRisk factors for mortality & morbidity

Preop condition

• ASA classes 3-4

• Cardiovasc. Condition (RCRI)

• Alcohol, tobacco

• Physical fitness (METs, VO2max)

• COPD

• Lung Volume: ppo FEV1 < 40%

• Diffusion capacity: ppoD <40%

• Extent of resection

• VATS < Thoracotomy

• Duration of M. Ventilation

• Ventilatory strategy

Surgery -Anesthesia

N=202’914, from 2004 to 2013

J Cancer Res Clin Oncol 2018;144:145–55

5-y survival20.4%

10-y survival11.5%

1. Outcome

126

2. Causes of death in pts with NSCLCJ Cancer Res Clin Oncol 2018;144:145–55

--- Lung Cancer (88% deaths)

127

• n = 3363 from January 1st 2007 to 31 December 2011

Green A et al. EJCTS 2016; 49:589–94

128

Mortality after Lung Cancer Surgery

1. Current survival & early/late mortality ?

2. Causes of mortality & Predictive factors ?

3. Impact of postoperative complications &

Failure to Rescue ?

4. Improved outcome in patients with LC ?129

4. How to improve outcome in patients with LC

Preoperative management• Better detection of « operable » patients with CT-scan, gated-MRI

→ Increase the number of patients with early disease stage

• Chemo-RX-photodynamic therapy

• Immune system enhancement

→ Noninvasive curative treatment

• PREHABILITATION : → Improve physiological reserve to sustain surgical stress

Physical exercise training

Nutritional and psychological support130

CONCLUSION

4. How to reduce early post-thoracotomy mortality

Intra-operative management

• Minimally invasive surgical approach (e.g., VATS)

• Lung isolation (experts!) & Lung protective ventilation

• Hemodynamic homeostasis (BP, fluids titration, Hb, …)

• Appropriate analgesia

131

CONCLUSION

Postoperative

• Physiotherapy (respiration, mobilization), resume oral intake,…

• Remove as soon as possible cathters, drains

• Selective admission in ICU/intermediate care

Eur J Epidemiol 2019 Jul 16

5-Yr Survival (%)

9.4 (8.1-10.8) 14 (12.3 – 15.2) 18 (16.4 – 19.5) 20 (19.2 – 21)

132

5 yr survival35%

5 yr survival8%

5 yr survival40%

5 yr survival15%

7%

6%

N=4’780 from the SEER database, from 2004 to 2014

133

• N=10’991, operation between 2004-2010

• 30-Day mortality = 3.0% 90-Day mortality = 5.9%

• Risk factors (90-d death)

• Age > 75

• Poor physical performance

• Bi-lobectomy, Pneumonectomy

Powell HA, et al. Thorax 2013;68:826–34

134

Service d’AnesthésiologieDépartement de Médecine Aigue

Marc Licker

PATIENT’S EMPOWERMENT

TO IMPROVE OUTCOME AFTER SURGERY

patient’s optimization to improve postoperative outcome

Learning objectives

1. Postoperative complications : why is it important!o From physiology to clinical applicationso Epidemiologyo Preoperative risk evaluation

2. Modern context of perioperative medicine

o An example …

o Enhanced Recovery After Surgery (ERAS) Program

3. Are there solutions ?o Patient’s education: risk controlo Concept of prehabilitationo Encouraging results with exercise training

137

138

FATIGUE

Organ dysfonction

COMPLICATIONS

Neuro-humoral

Inflammatory

Response

Anesthesia

Surgery

1. Postop complications

WHY IS IT IMPORTANT : From physiology to clinical applications

LowSpO2

Dyspnea

Œdema

Oliguria

HTATachycardia

Anemia

Cognitive disorders

PAIN

FEVER

139Adapted from Files et al. Critical Care 2015: 19:266

1. Why is it important : From Physiology to Clinical applications

• 250 millions operations are performed worldwide

• 1-3% early mortality

• Pulmonary C. > Wound infection > Cardiac C. Economic burden : prolonged hospital stay, ICU

admission

Prognostic implications : reduced survival and qualityof life

141

1. Why is it important: EPIDEMIOLOGY of postoperative complications

• > 50% surgeries performed in pts > 65yrs

142

8.5% 9.5%

> 65 ans 18 %

25 %en 2030

Non-Frail versus FrailImpact on postoperative outcome

143

BetterOutcome

Poor Outcome

BetterOutcome

Poor Outcome

1. Postoperative complications Preop Risk Assessment: FRAIL or not

Cardiovascular D.Pulmonary D.

Org

an

fu

ncti

on

Age


Fu

nc

tio

na

l

Re

se

rve

0 20 30 40 50 60 70 80 90

1. Postoperative complications Preop Risk Assessment: AGING & functional impairment

High Physical Activity = FIT

145

5h36 !

Org

an

fu

ncti

on

Age


Myoc.

InfarctF

un

cti

on

al

Re

se

rve

0 20 30 40 50 60 70 80 90

1. Postoperative complications Preop Risk Assessment: AGING & functional impairment

Cancer

SurgeryUnfit

148

Patient

Case-managerMonitoring

Enhanced Recovery After SurgeryPreop – Intraop & Postoperative Processes

1. Postoperative complications 2. Modern context of perioperative medicine

patient’s optimization to improve postoperative outcome

1. Postoperative complications : why is it important!

o From physiology to clinical applications

o Epidemiology

o Preoperative risk evaluation

2. Modern context of perioperative medicine

o An example …

o Enhanced Recovery After Surgery (ERAS) Program

3. Are there solutions ?o Patient’s education: risk controlo Concept of prehabilitationo Results with preop exercise training

149

1. Oral hygiene• Mechanical removal of dental biofilm

or plaques

• Use of oral disinfectants

150

1. Postop complications 2. Context of periop med 3. Solutions to improve outcome

Patient EDUCATION & EMPOWERMENT

2. Tobacco cessation

3. Alcohol withdrawal

151

NUTRITIONAL ASSESSMENT & CORRECTION

1. Postop complications 2. Modern context of periop med 3. Solutions to improve outcome

152

Minimal level of functioning

PREHABILITATION

FitSurgery

Unfit

Fun

ctio

nal

Sta

tus

Death

Complications

Concept of Prehabilitation → Exercise training


Preoperative exercise training

• Short period of time

• 1 to 4 weeks

• Medical prescription

• Type of exercise

• Goals : duration, intensity, repetition

• Settings

• home, fitness center or hospital, or combination

• Supervision

• Coaching, Monitoring

153

Aerobic Training (Endurance)

154

Inspiratory Muscle Training

Stretching, Relaxation

Power, Resistance

How does it work ?

Fast-twitchSlow-twitch

Classification based on: Myosin subtype, ATPase, metabolism, twitch, fatigability

Intermediate

GlycolyticOxidative Mixed Oxydative-glycolytic

Type 1 Type 2A Type 2X Type 2B

TRAINING

Hyperplasia

Endurance

Hypertrophy

Resistance

Endurance Training

156AMPK, adénosine mono-P kinase; CaMK, calmoduline kinase; PGC-1a, coactivateur 1α du récepteur γ activé par le proliférateur du

peroxisome; GLUT4, transporteur de glucose membranaire; ROS, radical oxygen species

ROS ++ ROS +

Angio-

genese


VO2max

High Intensity Interval Training2-3 series 4 x 1 min + Recuperation 4 x 1 min

Echauffement

100% HRmax

Re

cup

era

tio

n

Re

cup

era

tio

n

Re

cup

era

tio

n5 min


PREOP EXERCISE TRAININGDOES IT WORK IN PATIENTS UNDERGOING MAJOR SURGERY ?

158

28 RCTs , N=2’040

2 Oesophageal s. (N=301)

10 Thoracic surgery (N=563)

6 Cardiac surgery (N=628)

10 Abdominal surg (N=536)

1. Postop complications 2. Modern periop context 3. Solutions to improve outcomeAssouline B, Cools E & Licker M

Max Inspir P

159

peakVO2


6 Min Walk T

+ 12% (5 –

65)

+ 13 mmHg (7 –19)

+ 47 m (36 –

54)

160

Cardiac surgery

Thoracic surgery

Abdominal surgery

OR 0.33 (0.2 – 0.5)




Aerobic Training

Inspiratory Muscle Tr.

161

PREOP EXERCISE TRAINING = EFFECTIVE INTERVENTION

TO PREVENT POSTOPERATIVE PULMONARY COMPLICATIONS

SurgeryPreoperative (1 – 4 weeks) Postoperative

Aerobic Endurance T

Inspiratory Muscle T

162


TYPE OF TRAINING

OR 0.39 (0.2 –

0.6)

OR 0.60 (0.36 –

0.99)

Combined Training

OR 0.28 (0.15 –

0.5)

163


DURATION OF TRAINING

<2 Weeks OR 0.32 (0.2 –0.5)

2-4 Weeks OR 0.50 (0.3 –0.8)

But, some limittiona…

• 20-30% are unable to attend the program• Too far from hospital• Poor motivation• Exercise program not adapted to patient

• Some patients do not respond (?)

164

165

BMJ 2018

Multi-center RCT in NZ, Australia;

Upper Abdominal Surgery, N= 441

30 min education, teachingHow to breath

Pu

lmo

nar

y C

om

plic

atio

ns

166

Mortality

Preop education : respiratory breathing by experienced physiotherapists

Boden I et al. BMJ. 2018 Jan 24;360:5916

New project

167

Preop exercise training to prevent postoperative pulmonary

complications in patients undergoing thoracic or abdominal

surgery:a multicentre Randomized Controlled Trial

Single education & teaching session (1h) : HOME-Based intervention- Endurance training (>10’000 steps/day)- Inspiratory muscle training- stop smoking/alcohol

Interactions Patient - Health Care Professionals : - Patient adhesion to program- Supervision, counselling, ….

Thank you !

168

Postoperative Muscle Weakness

Organ cross-talks→Metaboreflex

Modified from Dempsey J et al. Respir Physiol & Neurobiol 2006; 151:242–50

Phrenic n. discharge

Fatiguing contractions• Diaphragm (intercostal muscles)

• Expiratory & Accessory muscles

Sympathetic NS hyperactivity• Limb flow & O2 availability•Muscle fatigue

• Ambulation

Work of Breathing

Trial sequential analysisPreHabilitation & PPCs: Meta-analysis of RCTs

170

171

500’148 habitantsCroissance annuelle 1.02% (1996-2018)

> 65 ans 16.5%

28 %en 2030

IN 2025, MRS SMITH PERIOP

MANAGEMENT…• …Diet, physical exercise, psychology and co-existing

conditions are all optimised

• Mrs Smith feels a level of control that minimizes her anxiety.

• She uses an individualised ‘electronic health navigator’ to guide her nutrition, exercise and psychology programme.

• …in parallel the investigations and chemoradiotherapy is carried out.

• Following surgery, Mrs Smith is prepared for the expectation that she will drink, eat and mobilise the same day, and is discharged from hospital only 2 days after her operation.

• Her ‘electronic health navigator’ guides her recovery phase, and 6 weeks later she returns to her baseline level of function, both physically and mentally.

172

Aerobic fitness = good predictor of outcome

173Imboden MT etal. Cardiorespiratory Fitness and Mortality in Healthy Men and Women. J Am Coll Cardiol 2018;72:2283-2292.

1. Postoperative complications 2. Preop Risk Assessment: Aerobic Fitness

peakVO2 = Good predictor of Cardiac & Respiratory Complications

174

Lung Cancer Surgery

1. Hennis PJ et al. CPET predicts postoperative outcome in patients undergoing gastric bypass surgery. Br J Anaesth 2012;109:566-712. Wijeysundera DN et al. Assessment of functional capacity before major non-cardiac surgery. Lancet. 2018;391:2631-26403. Licker M et al. Impact of aerobic exercise capacity and procedure-related factors in lung cancer surgery. Eur Respir J 2011;37:1189-98


175

Cardio-Pulmonary Exercise Test

Low peakVO2< 15 ml/kg/min

High VE/VCO2

> 35-40

Peak VO2, VE/VCO2 & Anaerobic threshold

Anaerobic threshold< 10 ml/kg/min

176

Respiratory Muscle Weakness in Thoracic Pts

Maximal Inspiratory Pressure (MIP)

Refai M et al. Eur J Cardio-Thor Surg 2014;45:665–70

After max exerciseAt rest

177

2011;254:1044–49

Myofibrillar dysfunctiondiaphragm

• Catabolic pathway• Immobilization, Inflammation

• E3-ligases MuRF-1 degradation of Myosin HC 2A

Muscle biopsies in pts undergoing thoracotomies with OLV (2h)

Dia

ph

ragm

Lati

ssim

us

do

rsis

Myosin Heavy Chain (MHC)

Enhanced Recovery After Surgery(ERAS) Program

• Standardisation and streamlining of immediate peri-operative processes with relevant patient benefit.

• Ideally peri-operative medicine should encompass patient-centred, multidisciplinary and integrated medical care from the moment of contemplation of surgery until full recovery .

• ERAS should embrace collaborative decision-making, prehabilitation, proactive management of comorbidities and individualised postoperative care.

178

Cardio-Pulmonary Exercise Test (CPET) = Gold Standard

Low peakVO2< 15 ml/kg/min

High VE/VCO2

> 35-40

Anaerobic threshold< 10 ml/kg/min


peakVO2 = Good predictor of Cardiac & Respiratory Complications

180

Lung Cancer Surgery

1. Hennis PJ et al. CPET predicts postoperative outcome in patients undergoing gastric bypass surgery. Br J Anaesth 2012;109:566-712. Wijeysundera DN et al. Assessment of functional capacity before major non-cardiac surgery. Lancet. 2018;391:2631-26403. Licker M et al. Impact of aerobic exercise capacity and procedure-related factors in lung cancer surgery. Eur Respir J 2011;37:1189-98


Non-invasive tools to predict postop outcome1. MET (Metabolic Task Equivalent)

• « How many stairs can you climb ? »

• 1 MET = VO2 at rest, 2 MET = 2x VO2 rest,…

• Very High risk < 2-3 MET, High Risk < 4-5,… Fit > 10 MET

2. Duke Activity Status Index (1,2)• Questionnaire based on Daily life activities (12 items) (1)

• More reliable than MET to estimate peakVO2 (2)

3. Six Minute Walk Test (3)• Simple, reproducible

• Moderate predictor of outcome

4. Shuttle Walk test (3) • Simple reproducible, substitute for 6MWT

1. Coute RA et al. Electronically self-assessed functional capacity and exercise testing: A comparison of the Duke Activity Status Index and Patient-Reported Outcomes Measurement Information System tools. Am Heart J 2017;188: 82-862. Wijeysundera DN et al. Assessment of functional capacity before major non-cardiac surgery. Lancet. 2018;391:2631-2640Moran J et al. The preoperative use of field tests of exercise tolerance to predict postoperative outcome in intra-abdominal surgery: a systematic review. J Clin Anesth 2016; 35:446-455

1. Postoperative complications 2. Preop Risk Assessment: Exercise Capacity/Tolerance

Duke Activity Status Index

182

183

1. Postoperative complications 2. Preop Risk Assessment: New tools of functionality

Gait Speed test (5m)Walk 5 m, repeated 3x

▪ > 6 sec = Slow

▪ < 6 sec = Fast

Time Up and GO (TUG)

184

Geriatric Evaluation Functionality Indicators→ Postop Clinical Outcome

JACC 2010 2010;56:1668-78 Ann Surg 2013;258:582-8

Time Up and GO (TUG)Gait Speed test

Multimodal Perioperative Protection

Pre

op

era

tive

•Clean lungs & airways• Stop smoking & OH

EXERCISE !Muscles, Heart & Lung

Intr

aop

erat

ive

• Lung isolation /separation• Protective lung ventilation

✓ P Inspir < 20 cmH20✓ VT 4-8 ml/kg IBW✓ PEEP 5-10 cmH20✓ Recruitment

• Low-opiate anesthesia• Restrictive fluid management

Fast-Track surgeryVATS (> open)

Po

sto

per

ativ

e

• Analgesia• Control Fluid balance

Early extubation

MOBILIZE !ALL muscles

CLEAR the AIRWAYSRECRUIT the LUNG

RESPIRATORY Muscles

Impact of Rehabilitation in chronic diseases

Strong evidence for clinical benefits in patients with

• Chronic Obstructive Pulmonary Disease

• Heart Failure, Coronary Artery Disease

• Cerebrovascular & NeurologicalDdisease

• Diabetus mellitus

• Sedentary persons

186

… But, requires long term training (months)combined with diet, behavioral changes …

Volatil anesthetics > propofol II B

Restrictive vs goal-directed fluid loading ?

IMPACT OF PERIOPERATIVE CARE IN THORACIC PATIENT

Open Lung Ventilation (LowVT + PEEP + Recruit; PI<

20)

II B

FIO2 (<60%)? PEEP? Recruitment ? -

Interventions Evidence

Risk assessment for complications II B

Alcohol – Tobacco arrest II C

Dental & oral care II C

Nutrition assessment & correction II C

PRE-

Op

INTRA-

Op

Post -

Op

Exercise training (endurance, IMT, combined) II A

Optimal analgesia, early mobilization, NIV, HFNO2, control fluids, remove chest tubes, vasc. canula, urinary c.

??

Normothermia (body & fluid warming) IIA

Mechanisms of Postop pulmonary complications

188

Preoperative

• Weak muscles, low peakVO2

• Airway obstruction

• Infection

• Alcohol, tobacco

• COPD, lung fibrosis

Intraoperative

• High inspiratory pressure (MV)

• Surgical

Awake preop

Elastic LUNG Recoil

Elastic CHEST Recoil

Atelectasis

PostoperativeInflammation

Muscle weakness

Anesthesia

Mechanical ventilation

X X

XX

FRC

MECHANISMS OF POSTOP PULMONARY COMPLICATIONS

IC

RV RV

Pneumonia

Resp. Failure

190

Impaired Postop respiratory function

Postop

Estenne M et al. Thorax 1985;40:293-99

1st day after thoracic surgery

• Restrictive lung syndrome

FRC

• Lower Max Inspir. P (-50%)

« shallow breathing »▪ Smaller VT

Lunardi ACet al. Respir Physiol Neurobiol2013;186:40-44

Evaluation du risque cardiaque - ICARWEB

Documents

Transcript of Evaluation du risque cardiaque - ICARWEB