Elective surgery and recent TIA/stroke

[EtherLord]

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I am aware of data that increased risk of MACE levels off after 9 months. Significant increase in risk of MACE within 3 months. How long do you all wait?

 

[BLADEMDA]

A TIA is not a CVA. Also, the type of CVA matters in the timing of elective surgery. IMHO, best to wait 9-12 months after a CVA prior to truly elective surgery.

Elective surgery post CVA

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.

forums.studentdoctor.net

 

[deleted171991]

A TIA is not a CVA. Also, the type of CVA matters in the timing of elective surgery. IMHO, best to wait 9-12 months after a CVA prior to truly elective surgery.

Elective surgery post CVA

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.

forums.studentdoctor.net

In my book, a TIA may be even worse. It can be the mark of an unstable plaque/clot somewhere. TIA vs CVA are like unstable angina vs MI.

To me, every decision is risks vs benefits from multiple standpoints. Which also include risks vs benefits for my career.

 

[BLADEMDA]

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.

Timing of Elective Surgery After Ischemic Stroke

Jørgensen and coauthors conducted a nationwide cohort study in Denmark among patients undergoing elective noncardiac surgeries to assess the safety and importance of time elapsed between stroke and surgery in the risk of perioperative cardiovascular events and mortality. Sacco and Dong comment...

jamanetwork.com

 

[EtherLord]

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.

Timing of Elective Surgery After Ischemic Stroke

Jørgensen and coauthors conducted a nationwide cohort study in Denmark among patients undergoing elective noncardiac surgeries to assess the safety and importance of time elapsed between stroke and surgery in the risk of perioperative cardiovascular events and mortality. Sacco and Dong comment...

jamanetwork.com

I’m glad you mentioned the distinction of TIa. If this is the Danish group, I believe they excluded TIAs. However, I don’t think they are necessarily less risky as was mentioned above.

 

[BLADEMDA]

I’m glad you mentioned the distinction of TIa. If this is the Danish group, I believe they excluded TIAs. However, I don’t think they are necessarily less risky as was mentioned above.

But, if the TIA was very mild and the patient has no deficits along with a full work-up I feel comfortable proceeding after 6 months with a note from his/her Neurologist showing a normal Brain Scan and low risk for further TIAs.

In the end, we can't control outcomes but must use our best judgment and peer reviewed evidence to provide good patient care.

 

[psychbender]

But, if the TIA was very mild and the patient has no deficits along with a full work-up I feel comfortable proceeding after 6 months with a note from his/her Neurologist showing a normal Brain Scan and low risk for further TIAs.

Sooooo, in other words, you wouldn't take a post-TIA pt to the OR for elective surgery until after six months. I don't think I've ever met a neurologist that would put that in a chart.

 

[BLADEMDA]

I come across patients who frequently have had TIAs or CVAs. My patient population is elderly with multiple medical problems. I like to make sure patients with TiAs have had a full workup and seen the appropriate specialists. If they have no deficits and been thoroughly evaluated I obtain records/notes from those specialists. Typically, I’m fine with elective surgery 6 months after a TIA.

 

[Arch Guillotti]

I come across patients who frequently have had TIAs or CVAs. My patient population is elderly with multiple medical problems. I like to make sure patients with TiAs have had a full workup and seen the appropriate specialists. If they have no deficits and been thoroughly evaluated I obtain records/notes from those specialists. Typically, I’m fine with elective surgery 6 months after a TIA.

That's great but when they show up the day of surgery and don't have access to the records or scans you just do the case anyway.

 

[BLADEMDA]

That's great but when they show up the day of surgery and don't have access to the records or scans you just do the case anyway.

Fortunately, I’m no longer working at any facility where that occurs. My elective cases are now “screened” prior to surgery so this hasn’t happened to me recently. I certainly understand from my younger days the pressure to do cases without any screening at all. A recent TIA in today’s climate requires a proper workup and certainly a consideration of the type of surgery combined with any delay like 3-6 months for purely elective, moderate risk surgery.

 

[jwizle]

Hey guys,

I'm working on preop guidelines for elective surgery and could use your help. Specifically, do you guys have any good data on the best timing for surgery for patients with ESRD on HD. minimum 7 hours after HD session? day after HD?

also, any good data on potassium and elective surgery? hyponatremia? hypernatremia?

 

[BLADEMDA]

We have discussed these topics over the years. I suggest you do a search.

I agree about waiting 7 hours after HD to do elective surgery.
That said, for decades I routinely did surgery on Renal failure patients right after HD and did notice increased hypotension. But, with careful monitoring and aggressive use of pressors these patients can be Anesthetized safely. The combo of heart disease, diminished EF/heart failure and recent HD can really put patients at increased risk of MACE in the OR.

 

[BLADEMDA]

Conclusions
Post-anesthetic hypotension within 48 hours was more common in those with < 7 hours interval between dialysis and anesthesia. Therefore, if surgical urgency permits, a delay of ≥7 hours may limit postoperative hypotension. More precise associations should be obtained through a prospective study.

 

[BLADEMDA]

Gajdos and colleagues found that patients on long-term dialysis undergoing nonemergent procedures are at high risk for complications and have an operative mortality rate of 13%.1 Results from this study represent a more realistic estimate of operative risk in dialysis patients than the 1% to 6% operative mortality rate reported in single-center series.2-4 These findings highlight the importance of dialysis dependence as a risk factor for poor surgical outcomes. It should be considered along with old age and functional dependence as a characteristic that identifies patients at extremely high risk. Identifying high-risk patients informs surgical decision making, allows patients to be appropriately counseled about the risks of surgery, and should prompt efforts aimed at preoperative optimization.