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PAC clearance in patients with neurological diseases recommendations

PAC clearance in patients with neurological diseases recommendations
Dr. Rahi kiran, DM Resident, GMC kota

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PAC clearance in patients with neurological diseases recommendations

  1. 1. Pre-Anesthetic clearance for various operative procedures : Basic requirement in Neurological patients Dr. Rahi Kiran.B SR Neurology GMC Kota
  2. 2. Outline CVA. Epilepsy. Neuromuscular Disorders. Peripheral Neuropathies. Parkinson Disease. Multiple Sclerosis. Alzheimer disease.
  3. 3. Important aspects of neurological diseases for the preoperative treatment 1. Type and characteristics of disease 2. Duration of illness 3. The extent of the disease 4. Patients capability of taking care of him/her-self 5. Type of therapy and interaction with anesthesia 6. Post-operative recovery
  4. 4. Surgical Mortality Probability Model
  5. 5. S-MPM Class Levels and Associated Risk of Mortality
  6. 6. Ischaemic Stroke
  7. 7. “perioperative stroke” defined as a brain infarction of ischemic or hemorrhagic etiology that occurs during surgery or within 30 days after surgery. incidence- ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program database) – more than 550,000 patients-  1 per 1000 cases- (excluding cardiac, carotid, major vascular and neurologic surgery),  6 per 1000 cases after major vascular surgery
  8. 8. High Risk CHADS2 score = 5-6 Recent (within 3 months) stroke or TIA Rheumatic valvular heart disease Moderate Risk CHADS2 score = 3-4 Low Risk CHADS2 score = 0-2 and no prior stroke or TIA Suggested Risk Stratification: Atrial Fibrillation
  9. 9. Suggested Risk Stratification: Mechanical Heart Valves High Risk Any mitral valve prosthesis Older aortic valve prosthesis Recent (within 6 months) TIA or stroke Moderate Risk Bileaflet aortic valve and at least one of: AF, prior stroke or TIA, HTN, T2DM, CCF, age >75 years Low Risk Bileaflet aortic valve without other risk factors for stroke
  10. 10. Antiplatelet Therapy
  11. 11. Continuation of aspirin- regional spinal anesthesia, nerve blocks, dermatological cutaneous surgeries, dental procedures, ophthalmological procedures, peripheral vascular procedures, endoscopies.
  12. 12. Clopidogrel, on the other hand, appears unsafe and should be discontinued 5 to 7 days before. no studies regarding the safety of dipyridamole, alone or in combination with aspirin-advised to withhold it 5 to 7 days preoperatively. Antiplatelet are returned 24 hrs postoperative.
  13. 13. Anticoagulant therapy
  14. 14. Emergency surgery - Warfarin can be reversed with vitamin K and PCC PerioperativeAnticoagulation-minor - interruption may not be required. In major-required-stopped 5 days before surgery bridging after surgery - risk for bleeding- • depends on anticoagulant dose • proximity to surgery
  15. 15. The need for bridging is driven by patients' estimated risk for VTE: In high-risk patients- Benefit > risk In moderate-risk- individual patient risk. In low-risk Benefit < risk- avoid Perioperative bridgingAnticoagulation
  16. 16. Consensus Statement from the Society for Neuroscience in Anesthesiology and Critical Care
  17. 17. Non-vitamin K Antagonist Oral Anticoagulant Drugs
  18. 18. Non-vitamin K Antagonist OAC- mean duration of interruption- 2 days Pre and 1 day postprocedure – depends on Cr Cl Non-vitamin K antagonist oral anticoagulant drugs have a faster onset of action and a shorter half-life than warfarin.
  19. 19. Consensus Statement from the Society for Neuroscience in Anesthesiology and Critical Care 2014  Screen for risk factors of perioperative stroke, most notably remote or recent history of stroke, and communicate such risk to patients and providers (Category B, Level 2)  Consider delaying elective surgical cases in patients with recent stroke until the etiology is investigated and the peak of autoregulatory disturbances has passed (likely at one month) (Opinion-based evidence, Category A).  However, observational studies to date do not suggest a clear relationship between timing of past stroke history and incidence of postoperative stroke (Category B, Level 2).
  20. 20. Consensus Statement from the Society for Neuroscience in Anesthesiology and Critical Care 2014  Medically manage AF and continue anticoagulation for minor surgeries or those in which high blood loss is unlikely. Discontinue anticoagulation in surgical patients at high risk of bleeding (with appropriate bridging), but resume as soon as the risk of surgical bleeding is considered to be low (Opinion-based evidence, Category A). There is no evidence to suggest that continuation of aspirin in patients at risk for vascular complications reduces the risk of stroke after noncardiac surgery (Category A, Level 3).
  21. 21. Consensus Statement from the Society for Neuroscience in Anesthesiology and Critical Care 2014 Continue beta blockers and statins throughout the perioperative period in patients already taking them (Opinion- based evidence, Category A with respect to stroke risk). Intraoperative metoprolol administration may place patients at increased risk for stroke (Category B, Level 1). Beta blockers with a short duration of action such as esmolol should be considered for intraoperative use (Category A). Intraoperative hypotension should be defined as a percent reduction from baseline blood pressure(>20%) rather than an absolute value (Category B, Level 1).
  22. 22. Carotid bruit or stenosis symptomatic or asymptomatic carotid stenosis with stroke or TIA in the preceding 6 months
  23. 23. asymptomatic carotid bruit Poor predictor of underlying carotid stenosis  only 40 to 60 percent of asymptomatic patients with audible bruits will have hemodynamically significant lesions The risk for stroke - 2 % per year further evaluation - not warranted in these situations. (uptodate.com) high-grade, hemodynamically significant bilateral asymptomatic stenosis may benefit from revascularization
  24. 24. Cardiovascular risk  patients with carotid artery disease are more likely to die from IHD than CVA- strong association  cardiac death rate is approximately 5 % per year for patients with asymptomatic bruits, TIAs, or stroke  35% of patients with CVA or symptomatic carotid bruits have CAD-So cardiac evaluation is a must  In asymptomatic carotid artery disease -needs further studies. Management of coexistent carotid artery and coronary artery disease.R A Graor and N R HetzerStroke. 1988;19:1441-1444.
  25. 25. Subarachnoid Hemorrhage
  26. 26. SAH- increased sympathetic outflow-Cardiac ischemia - increased cardiac afterload or impair contractility Preoperative evaluation-ECG, echo ,electrolyte Maintain adequate hydration and euvolemia -to minimize the risk of vasospasm. mABP within the autoregulatory range to prevent rebleeding due to ruptured aneurysm. Subarachnoid Hemorrhage
  27. 27. Epilepsy
  28. 28.  The risk of perioperative seizures is proportional to the frequency of seizures at baseline.  Multiple surgical factors increase the risk - alterations in maintenance AED therapy, physical and psychological stressors  pro-convulsive anesthetics.  It is preferable to maintain AED therapy as close to baseline as possible perioperatively.
  29. 29. Causes of seizures in perioperative patients breakthrough seizure poor seizure control prior to surgery subtherapeutic drug levels sleep deprivation.
  30. 30. instruct to take their regularly scheduled morning AEDs with sips of water. Baseline oral AEDs -reinitiated as soon as feasible after surgery. If enteral options are not available, use intravenous AEDs.
  31. 31. Generally, lower dosages of anesthetics (eg, etomidate) tend to be pro-convulsive, while higher dosages tend to be anticonvulsive. Exceptions are opioids -only pro- convulsive. Anticonvulsant anesthetic drugs like barbiturates, benzodiazepines, propofol, halothane, or isoflurane should be Considered
  32. 32. Acute perioperative seizure management In contrast with phenytoin and fosphenytoin, levetiracetam is not a/w- • hypotension during administration, • has more reliable pharmacokinetics, • does not require serum level monitoring, • does not cause tissue injury with extravasation
  33. 33. Neuromuscular Disease
  34. 34. preoperative pulmonary assessment-PFT, Complications if- scoliosis FVC<40%. if FVC <30%, preoperative - use NIPPV, If peak cough flow (PCF) <270 L/min- use mechanically assisted cough  Preoperative cardiac assessment –ECG and echo  Dysphagia - common - with a prevalence of up to 62% after endotracheal intubation.
  35. 35. Succinylcholine is contraindicated - risk of rhabdomyolysis and hyperkalemia due to sarcolemmal membrane instability. myotonic reaction can be treated with phenytoin (4-6 mg/kg/d) or quinine (0.3-1.5 g/d)
  36. 36. Myasthenia Gravis
  37. 37. After achieving remission also, can experience life- threatening complications - crisis In general, patients should keep taking anticholinergic medications as well as immunosuppressants. unpredictab sensitive to nondepolarizing NMBAs and are resistant to succinylcholine, a depolarizing NMBA.  Patients with LEMS are very sensitive to both depolarizing and nondepolarizing NMBAs.
  38. 38. Risk factors that increase the likelihood of postoperative respiratory insufficiency- • duration of the disease longer than 6 years, • history of chronic respiratory disease, • treatment doses of pyridostigmine >750 mg/day, preoperative vital capacity under 3 L • Serum antiacetylcholine receptor antibody >100 nmol/mL , • More pronounced decremental response (18 to 20 percent) on low frequency RNST
  39. 39. , Pyridostigmine interfere with neuromuscular blocking agents Considering the risk of respiratory complications, the value of discontinuing pyridostigmine is questionable (1 mg IV is equivalent to 10mg IM & 30 mg PO). Neurologist view: the patient should take their medication..
  40. 40. a/e azathioprine do not interact with anesthetics- may prolong the effect of succinylcholine If possible, severe myasthenia gravis should be stabilized prior to surgery using – IVIg/ PLEX Elective surgery timing – stable phase of the disease, requiring minimal immunomodulatory medication, as early in the day as possible
  41. 41. In postoperative period-start pyridostigmine with half of the preoperative dose -12 hours after the procedure, increasing to the full dose over next 2 days - to avoid cholinergic crisis. IV neostigmine –rescue For patients on steroids-a boosting dose of IV MPS can before extubation.
  42. 42. Glucocorticoids continue their glucocorticoid regimen perioperatively •less than three weeks, •morning prednisone (<5 mg) for any duration, •<10 mg prednisone every other day stress-dose glucocorticoids prior to induction •On prednisone >20 mg/day for three weeks •for patients with Cushingoid appearance,
  43. 43. Motor Neuron Disease(MND)
  44. 44.  the risk of aspiration pneumonia  Nondepolarizing neuromuscular blocking agents cause prolonged and pronounced neuromuscular blockade hyperkalemia with administration of succinylcholine,
  45. 45. Peripheral Neuropathy
  46. 46. (CMTD)Patients with Charcot-Marie-Tooth disease tolerate anesthesia with few complications. In HNPP, careful surgical position is a key consideration to avoid entrapment neuropathies. GBS-dysautonomia-cardiovascular instability during surgery.
  47. 47. Occurs more with halothane and depolarizing muscle relaxants. reported in various muscle diseases, such as channelopathies, central core disease and mini-core disease Preoperative dantrolene should be considered in at risk patients. Malignant Hyperthermia Syndrome
  48. 48. Parkinson Disease
  49. 49. A.The primary - is the timing of medications. Abrupt cessation of levodopa a/w parkinsonism– hyperpyrexia syndrome-hyperpyrexia, dysautonomia, and increased creatine kinase. To avoid this –allowed to continue their levodopa medication up to the moment of the surgery & restarted as soon as possible. One exception is that antiparkinsonian drugs are often held the morning of surgery for deep brain stimulators.
  50. 50. B.On MAO-Bs- fatal serotonergic syndrome when combined with meperidine or dextromethorphan- if not used, surgery is safe. C.both PD and levodopa treatment are associated with hypotension D.longer hospital stays and increased risk of infections
  51. 51. Avoid-Thiopental, Ketamine, succinylcholine,halothane An interruption of >6 to 12 hours - severe muscle rigidity interfering with the ventilation management. Alternatives routes include parenteral (Apomorphine,Benztropine)
  52. 52. Multiple Sclerosis
  53. 53. Some reports -regional anesthesia may worsen multiple sclerosis - stress of surgery, fever, or infection. Preoperatively- advised that surgery and anesthesia could produce a relapse testing urinalysis for UTI - Bladder dysfunction Succinylcholine-hyperkalemia, nondepolarizing NMBA- unpredictable response
  54. 54. Patients treated with corticosteroids may need steroid supplementation during the perioperative period. Baclofen is not available for injection, and abrupt withdrawal may precipitate seizures or hallucinations. Interferons and glatiramer acetate can be continued throughout the perioperative period.
  55. 55. Alzheimer Disease (Dementia) cholinesterase inhibitors -impair hepatic function requiring careful use of halogenated, volatile anesthetics. Glycopyrrolate should be used instead of atropine or scopolamine if anticholinergic drugs are necessary. Using anesthetic agents like propofol or sevoflurane may hasten postanesthetic recovery of mental status.
  56. 56. BASIC PREOPERATIVE EVALUATION complete history and physical and neurological examination  review of medical records and prior consultations Several chronic conditions such as diabetes, hypertension, heart disease, arrhythmias, and epilepsy Routine laboratory tests, including CBC, coagulation parameters, serum chemistry, X ray- smoking, recent URTI, COPD and CVS ds
  57. 57. BASIC PREOPERATIVE EVALUATION Previously performed tests that show normal results within last 6months can be used if there has been no intervening clinical event Urinalysis –if susceptible to UTI Malnourished patients- albumin level ECG- h/o CVS/RS diseases, male >45 yrs and women>50 yrs, h/o multiple risk factors
  58. 58. a history of stroke or TIA CD/MRA/CTA if previous evaluation not done or status worsened since the stroke asymptomatic highgrade stenosis CT/MRI AND CTA/MRA If judged to be symptomatic or hemodynamically significant preoperative carotid revascularization TEE- a history of stroke of undetermined etiology before cardiac surgery to evaluate for aortic sources of embolization.
  59. 59. Epilepsy- Imaging and EEG-if not done/poor control with good compliance, routine drug levels are not required perioperatively in the absence of breakthrough seizures PD- PFT, if dysphagia- barium swallow Neuromuscular Diseases-ECG, Echo,PFT,- avoid Sch, NMBA (even if asymptomatic) Multiple Sclerosis-Urine exam, replace baclofen with diazepam Dementia- investigate for reversible etiologies prior to surgery- explain risk of delirium
  60. 60. References 1. Perioperative Care of Patients at High Risk for Stroke during or after Non- Cardiac, Non-Neurologic Surgery: Consensus Statement from the Society for Neuroscience in Anesthesiology and Critical Care.J Neurosurg Anesthesiol 2014;00:000–000 2. www.uptodate.com 3. Perioperative Management of Neurological Conditions Dhallu et al Health Services Insights Volume 10: 1–8, 2017 4. www.emedicine@medscape.com 5. Schiavi et al Preoperative Preparation of the Surgical Patient with Neurologic Disease. Med Clin N Am 93 (2009) 1123–1130 6. Preoperative evaluation of patients with neurological disease. Seminars in neurology/volume 28, number 5 2008 7. https://health.ucsd.edu/specialties/anticoagulation/providers/perioperative/ procedure-recommendations/Pages/ophthalmology.aspx