Elective surgery post CVA

[narcusprince]

So how long do you wait? I had a patient show up DOS 3.5 months out of a hemorrhagic CVA with elevated blood pressures. Cancel postpone 6 months 9 months? Obviously if this is life or limb or cancer or emergency surgery proceed to the operating room.

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[BLADEMDA]

Timing is important when it comes to surgery after a stroke, a new study suggests. Researchers are reporting that patients who had an ischemic stroke within 3 months before undergoing elective noncardiac surgery were at relatively high risk for cardiovascular events and mortality but that the risks stabilized after 9 months.

Interestingly, the postsurgery medical fallout was not any greater for stroke patients undergoing higher-risk surgeries than for those having lower-risk procedures, and patients with atrial fibrillation (AF) had less postsurgery risk than those without AF.

These results suggest that patients who have sustained a stroke should wait 9 months before having elective surgery, said lead author Mads E. Jørgensen, MB, research assistant, Department of Cardiology, Gentofte Hospital, University of Copenhagen, Denmark.

However, he stressed that decisions surrounding surgery timing should be made collaboratively between patients and their physicians and on an individual basis. "Doctors have to do an independent evaluation of every single patient, to weigh the pros and cons for surgery," he said.

The study results were published online July 16 in JAMA.


http://www.medscape.com/viewarticle/828447

1. Jørgensen ME et al. Time elapsed after ischemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery. JAMA 2014 Jul 16; 312:269. (http://dx.doi.org/10.1001/jama.2014.8165)
   
   PubMed abstract (Free)

 

[BLADEMDA]

Although observational, the data suggest that, if possible, elective surgery should be deferred until 6 months after a stroke.


http://bja.oxfordjournals.org/content/early/2015/02/17/bja.aev031.full.pdf+html

 

[BLADEMDA]

August 7, 2014

Wait as Long as Possible for Noncardiac Surgery After Stroke

Neil H. Winawer, MD, SFHM reviewing Jørgensen ME et al. JAMA 2014 Jul 16.

Risk for postoperative adverse cardiovascular events was especially high during the first 9 months after stroke.


Stroke is a known risk factor for adverse perioperative outcomes in patients undergoing noncardiac surgery. Whether this relation is time dependent is unclear.

Researchers in Denmark examined a nationwide cohort of adult patients who underwent elective noncardiac surgery between 2005 and 2011. Of the almost half a million patients who underwent noncardiac surgery, 1.5% had histories of stroke (those with prior transient ischemic attacks or hemorrhagic stroke were excluded). Compared with patients who never experienced strokes, those who had prior strokes had higher risk for major adverse cardiovascular events (MACE: a composite of nonfatal myocardial infarction, nonfatal ischemic stroke, and cardiovascular-related death):

• Stroke within 3 months before surgery: odds ratio, 14.2
  
  
• Stroke between 3 and 6 months prior: OR, 4.9
  
  
• Stroke between 6 and 12 months prior: OR, 3.0
  
  
• Stroke ≥12 months prior: OR, 2.5
  

A similar pattern in risk was seen for 30-day mortality. Risk for MACE and all-cause mortality leveled off at 9 months.

COMMENT
This study suggests that, similar to patients who suffer acute myocardial infarctions, patients with acute ischemic stroke are at excess risk for complications immediately following noncardiac surgery. Risk drops significantly at 6 months and stabilizes (although at a level still higher than baseline) at 9 months. Although we await further confirmation of these observational findings, we probably should wait at least 9 months before scheduling stroke patients for elective noncardiac surgery.

 

[BLADEMDA]

So how long do you wait? I had a patient show up DOS 3.5 months out of a hemorrhagic CVA with elevated blood pressures. Cancel postpone 6 months 9 months? Obviously if this is life or limb or cancer or emergency surgery proceed to the operating room.

A patient with a history of hemorrhagic stroke is even more at risk of a MACE than one with a thrombotic CVA. The best available evidence we have at this time is to delay elective surgery for at least 9 months, perhaps even 12 months, along with good BP control.

http://stroke.ahajournals.org/content/46/7/2032.long

 

[Noyac]

I always thought it was 6months.
What was the cause of the CVA?
Whats the procedure?

 

[Planktonmd]

I think that it is mainly a guessing game when it comes to when is the ideal time to perform elective surgery after a CVA!
Logically the etiology of the stroke should be a determining factor in deciding the risk to re stroke perioperatively. So a patient who had an ischemic stroke from a carotid thrombus and did undergo a CEA, maybe at less risk than an ischemic stroke of cardiac origin caused by Afib if we have to stop the anticoagulants for surgery?
And the extent of the stroke or residual symptoms may be a factor in determining how well the patient tolerates anesthesia and perioperative stress?
The existing comorbidities should also be considered (CAD, DM, HTN, Renal disease...).
We simply don't know!

 

[Laryngophed]

I think the truly gray area is the elective, not-so-elective cancer related operation. I did a tumor excision on an older guy whose sarcoma of the forearm and a 2L O2 dependence were his only problems. Sailed through the operation. VSS pre-induction, post-induction, through emergence, and in the PACU. Back to baseline O2 use before I finished the chart in the PACU, wide awake, had some pain and requested a block. (Surgeon likes post-op blocks.) Pain team did a flawless supraclavicular SS. He flew through the day. Sent him home. Embolic event that night at home. Transferred from OSH to our place. Symptoms resolved in approximately 72 hours. Oh and guess what - the margin came back positive. And the block didn't offer that much relief. Surgeon wants clean up the margins.

How long do you wait?

 

[urge]

I think the truly gray area is the elective, not-so-elective cancer related operation. I did a tumor excision on an older guy whose sarcoma of the forearm and a 2L O2 dependence were his only problems. Sailed through the operation. VSS pre-induction, post-induction, through emergence, and in the PACU. Back to baseline O2 use before I finished the chart in the PACU, wide awake, had some pain and requested a block. (Surgeon likes post-op blocks.) Pain team did a flawless supraclavicular SS. He flew through the day. Sent him home. Embolic event that night at home. Transferred from OSH to our place. Symptoms resolved in approximately 72 hours. Oh and guess what - the margin came back positive. And the block didn't offer that much relief. Surgeon wants clean up the margins.

How long do you wait?

I would assume that neurology is seeing him for the new stroke. Why don't you ask them?

I would do it after telling the patient either the cancer or the strokes will kill him. It is up to him which one.

 

[narcusprince]

The procedure in my case was a screening colonoscopy. I chose to delay the procedure after 6 months with better bp control and the endoscopist referred the patient to a pcm for better control. This is a grey area.

 

[deleted162650]

Pain team did a flawless supraclavicular SS. And the block didn't offer that much relief.

 

[Laryngophed]

I would assume that neurology is seeing him for the new stroke. Why don't you ask them?

I would do it after telling the patient either the cancer or the strokes will kill him. It is up to him which one.

Neurology says "patient free to have regional/local anesthesia ASAP." No recommendations for or against general anesthetic. And remember, the block, which was picture perfect did not offer him much relief. But how long do you wait before a general?

 

[Laryngophed]

Pain was 6-7 pre-block, 5-6 after the block. I reviewed the image, LA obviously bathes the nerves. Just not much relief offered. And he was tough. Didn't complain about the pain, had to be prodded to give a number.

 

[Arch Guillotti]

How long do you wait?

I wouldn't wait.

 

[urge]

Neurology says "patient free to have regional/local anesthesia ASAP." No recommendations for or against general anesthetic. And remember, the block, which was picture perfect did not offer him much relief. But how long do you wait before a general?

So, you write back to them that patient needs GA and wait for them to answer.

 

[Planktonmd]

Pain was 6-7 pre-block, 5-6 after the block. I reviewed the image, LA obviously bathes the nerves. Just not much relief offered. And he was tough. Didn't complain about the pain, had to be prodded to give a number.

Why wouldn't the supraclavicular block offer relief for forearm pain???
It must be one of those "fellowship trained" regional anesthesiologists who did a masturbatory crappy block using 5 ml of local anesthetic!

 

[BLADEMDA]

Reached for a comment, Ralph Sacco, MD, Department of Neurology, Miller School of Medicine, University of Miami, Florida, said the study indicates that doctors should perhaps "think more clearly about the time windows" for elective procedures following stroke. "If you can delay it, it may be worth delaying it for 9 months; if you can't, it may mean that you have to do it more carefully, paying attention to stroke preventative medications around the time of surgery."


He pointed out that stroke patients who are undergoing surgery often have medications discontinued before the procedure. "One medication we are always concerned about as neurologists is antithrombotic medications. Often they get discontinued because of the risk of bleeding with surgery, so maybe it does call into question whether, if possible, we could continue antithrombotic therapy around the time of surgery, if it's safe."

Dr. Sacco also said the quality of life of stroke survivors should be considered. Cosmetic surgery, such as breast reduction, is "truly elective" and could be postponed, but putting off hip replacement or lumbar surgery may mean leaving a patient in intractable pain and severely compromising his or her enjoyment of life. "It depends on how we define elective," said Dr. Sacco.

At the end of the day, he added, the study is important in that it alerts physicians to the increased risk for stroke and vascular events among stroke survivors following elective noncardiac surgery. "Stroke survivors are always at risk for a recurrent stroke, so we need to be more careful and more diligent about ways to prevent a second stroke among our stroke survivors, particularly around the time of elective surgery."

 

[BLADEMDA]

So, you write back to them that patient needs GA and wait for them to answer.

Do the case after explaining to the patient his increased risk for a second stroke. Perhaps, an arterial line with close beat to beat monitoring of BP control would help in this patient.

I think anyone who does truly elective surgery on a patient with a recent CVA (less than 6 months) is deviating from the standard of care.

 

[Ignatius J]

Do the case after explaining to the patient his increased risk for a second stroke. Perhaps, an arterial line with close beat to beat monitoring of BP control would help in this patient.

I think anyone who does truly elective surgery on a patient with a recent CVA (less than 6 months) is deviating from the standard of care.

It's a mixed bag when you get elderly patients. Is a TURP in a completely obstructed patient elective? A TURBT for bladder cancer? A ureteroscopy for painful, debilitating kidney stones? A fistula for dialysis? i would weight the risks and benefits of treatment and explain them to the patient.

Yeah, you are at an increased risk of stroke but I understand you can't even get out of bed with that kidney stone.

 

[Planktonmd]

Do the case after explaining to the patient his increased risk for a second stroke. Perhaps, an arterial line with close beat to beat monitoring of BP control would help in this patient.

I think anyone who does truly elective surgery on a patient with a recent CVA (less than 6 months) is deviating from the standard of care.

If you ask me what you hate the most about the practice of medicine today I would tell you without hesitation: the f*cking "STANDARD OF CARE" ...
It symbolizes the descent of our profession into a lawyer controlled administrator dictated world of ****!!!

 

[BLADEMDA]

It's a mixed bag when you get elderly patients. Is a TURP in a completely obstructed patient elective? A TURBT for bladder cancer? A ureteroscopy for painful, debilitating kidney stones? A fistula for dialysis? i would weight the risks and benefits of treatment and explain them to the patient.

Yeah, you are at an increased risk of stroke but I understand you can't even get out of bed with that kidney stone.

I practice in the real word so I understand the difference between "elective" and "necessary" surgery especially in the elderly population. The key take away point is that a patient who has had a CVA is at increased risk of a second CVA due to the "surgical stress response" which is not abolished under anesthesia. If the patient can wait the full 9 months for his/her elective total knee replacement after a mild CVA then that is the best course of action. However, Appendicitis, Perforated Bowel, Ureteral Obstruction secondary to a calculus, etc. are conditions that may require surgical intervention prior to any waiting period post CVA.

Look at the relative risk at 3 months vs 1 month:

• Stroke within 3 months before surgery: odds ratio, 14.2
  
  
• Stroke between 3 and 6 months prior: OR, 4.9
  
  
• Stroke between 6 and 12 months prior: OR, 3.0
  
  
• Stroke ≥12 months prior: OR, 2.5

 

[Ignatius J]

I practice in the real word so I understand the difference between "elective" and "necessary" surgery especially in the elderly population. The key take away point is that a patient who has had a CVA is at increased risk of a second CVA due to the "surgical stress response" which is not abolished under anesthesia. If the patient can wait the full 9 months for his/her elective total knee replacement after a mild CVA then that is the best course of action. However, Appendicitis, Perforated Bowel, Ureteral Obstruction secondary to a calculus, etc. are conditions that may require surgical intervention prior to any waiting period post CVA.

Look at the relative risk at 3 months vs 1 month:

• Stroke within 3 months before surgery: odds ratio, 14.2
  
  
• Stroke between 3 and 6 months prior: OR, 4.9
  
  
• Stroke between 6 and 12 months prior: OR, 3.0
  
  
• Stroke ≥12 months prior: OR, 2.5

Oh yeah. I totally agree. And these are all very interesting findings.

 

[BobLoblaw78]

Bump.

What do you do with elective colonoscopies and EGD's?

I have made it policy with push back on these because it is just propofol... (And a stroke is just a clot). I don't think these issues have as much to do with blood pressure as it does arrhythmias, autonomic outflow and stress response. One of our providers stated that they don't stress the patient. I think if they are not stressing the patient then they obviously do not need anesthesia!!

I think 6 months is very reasonable for elective endoscopy procedures. The gray areas I am more likely to go ahead (i.e. patient with repeated aspiration issues has much more benefit than risks). But not the screening colonoscopy on 99 year old with stroke 2 months ago.

Agree or disagree?

 

[Mman]

Bump.

What do you do with elective colonoscopies and EGD's?

I have made it policy with push back on these because it is just propofol... (And a stroke is just a clot). I don't think these issues have as much to do with blood pressure as it does arrhythmias, autonomic outflow and stress response. One of our providers stated that they don't stress the patient. I think if they are not stressing the patient then they obviously do not need anesthesia!!

I think a majority of the risk from surgeries in terms of MACE/stroke is related to the amount of tissue damage during the surgery which releases tissue factor and induces clotting cascades which can help precipitate MI or stroke by having clots form somewhere you don't want them (coronaries or intracranial vessels) instead of just where you do want them (at the site of tissue damage to stop bleeding and promote healing. An endoscopy or colonoscopy isn't causing that same degree of tissue damage.

Now do procedures also cause sympathetic stimulation and activation of adrenergic receptors? Of course. But in my mind the risk of MACE or death or stroke is more similar for a colonoscopy compared to something like a cataract extraction as opposed to a more invasive surgical procedure. And for cataracts if you aren't having chest pain in preop holding and can lay flat, you are probably going to be fine.


but that's just me

 

[nimbus]

Bump.

What do you do with elective colonoscopies and EGD's?

I have made it policy with push back on these because it is just propofol... (And a stroke is just a clot). I don't think these issues have as much to do with blood pressure as it does arrhythmias, autonomic outflow and stress response. One of our providers stated that they don't stress the patient. I think if they are not stressing the patient then they obviously do not need anesthesia!!

I think 6 months is very reasonable for elective endoscopy procedures. The gray areas I am more likely to go ahead (i.e. patient with repeated aspiration issues has much more benefit than risks). But not the screening colonoscopy on 99 year old with stroke 2 months ago.

Agree or disagree?

I would argue that a 99yo should never get a screening colonoscopy. Any GI who does that is an idiot.

 

[Psai]

Bump.

What do you do with elective colonoscopies and EGD's?

I have made it policy with push back on these because it is just propofol... (And a stroke is just a clot). I don't think these issues have as much to do with blood pressure as it does arrhythmias, autonomic outflow and stress response. One of our providers stated that they don't stress the patient. I think if they are not stressing the patient then they obviously do not need anesthesia!!

I think 6 months is very reasonable for elective endoscopy procedures. The gray areas I am more likely to go ahead (i.e. patient with repeated aspiration issues has much more benefit than risks). But not the screening colonoscopy on 99 year old with stroke 2 months ago.

Agree or disagree?

What are you screening for? The colon cancer that they might get when theyre 110?

 

[BobLoblaw78]

What are you screening for? The colon cancer that they might get when theyre 110?

That actually did happen to my friend and why I put it. Nice 94 year old guy for screening colonscopy. Perforation then colon resection with ostomy for his remaining time on hospice. But at least there was no cancer....

Mman: there definitely is not as much stress with a colonoscopy or sedation. Although, most endoscopy procedures are more than light or moderate sedation. The literature showing increased morbidity and mortality included cases involving cornea, skin excision, breast biopsy and central lines. These are not much or any more than a 10 minute colonoscopy with biopsy, etc. I have a degree of doubt, so I came here to ask people like you and I appreciate the feedback.

 

[facted]

How often are you guys doing TEEs after strokes?

Used to see it a lot at my old gig and these patients would have a stroke and then 2 or 3 days later we're on a goose chase for a patent foramen ovale, meanwhile BP is all over the place during the TEE. Thoughts?

 

[BLADEMDA]

I doubt a TEE or colonoscopy qualifies as "surgery" per se. We do these all the time after some significant morbidity has recently occurred to the patient.

 

[facted]

I doubt a TEE or colonoscopy qualifies as "surgery" per se. We do these all the time after some significant morbidity has recently occurred to the patient.

Agree but the issue is not the insult of the "surgery". It's the charge in hemodynamics with your anesthesia.

 

[Mman]

Agree but the issue is not the insult of the "surgery". It's the charge in hemodynamics with your anesthesia.

hopefully there isn't much change in hemodynamics with an appropriate anesthetic.

 

[facted]

hopefully there isn't much change in hemodynamics with an appropriate anesthetic.

For a TEE after a stroke?! Even with Topicilization and a good amount of prop I've seen the BP jump 20-30 pts when they stick the probe in.

My point is, you're altering all the hemodynamics and cerebral prefusion parameters in search of a PFO which is unlikely to be there and which you're blu going to treat acutely anyway.

Why not wait at least a few weeks until things settle down?

 

[Mman]

For a TEE after a stroke?! Even with Topicilization and a good amount of prop I've seen the BP jump 20-30 pts when they stick the probe in.

My point is, you're altering all the hemodynamics and cerebral prefusion parameters in search of a PFO which is unlikely to be there and which you're blu going to treat acutely anyway.

Why not wait at least a few weeks until things settle down?

I'm assuming that patient population has swings of BP of > 50 points in their day to day life.

 

[Noyac]

Agree but the issue is not the insult of the "surgery". It's the charge in hemodynamics with your anesthesia.

What change? I know we all like to pound our chest here but really, I curious as to what changes. All you have to do is stun the pt. That has zero hemodynamics effects as far as I have ever seen. Control all hemodynamics as on.y a well trained anesthesiologist can do. Next case. Seriously.

 

[Noyac]

I'm assuming that patient population has swings of BP of > 50 points in their day to day life.

So?

Edit:
Sorry, I believe you and I are saying the same thing.

 

[Noyac]

For a TEE after a stroke?! Even with Topicilization and a good amount of prop I've seen the BP jump 20-30 pts when they stick the probe in.

My point is, you're altering all the hemodynamics and cerebral prefusion parameters in search of a PFO which is unlikely to be there and which you're blu going to treat acutely anyway.

Why not wait at least a few weeks until things settle down?

You will spend much more time cancelling the case for no good Eason then you wou,d if yo7 did the 15 min case and moved on.

Not that that is a good reason but “big picture, man”!