Response 1

Respond

to the two of below colleagues patient education needs and informed consent for one of the planned procedures would be. Add APA Style citations 3 each

POST 1

Risk Stratification

Surgical procedures are a common event in the inpatient setting and undoubtedly, throughout our careers, our patients will require these surgical services. Thus, it is imperative that these patients are not only wholly informed of the surgical procedure process but that we also advise them and the proceduralist of the risk versus benefit for the procedure. In the United States, around 27 million patients undergo a non-cardiac procedure every year and of those, 50,000 experience a major adverse cardiac event (MACE) (Polak et al., 2022). To minimize these events from occurring, as providers, we provide risk stratification by looking at several factors as seen in the following cases.

There are several factors that can contribute to a MACE such as heart failure, cardiomyopathy, severe valvular heart disease, chronic renal failure, diabetes mellitus, obesity, reduced functional status etc. (Polak et al., 2022).  Therefore, a thorough history and physical is needed to fully evaluate a patient and stratify their risk for a MACE. The following scenarios have limited information to make a full stratification, however, we can attempt to risk stratify with the information provided.

A 60-year-old female with no previous cardiac history comes in for risk stratification because of a new murmur. The echocardiogram performed was notable for an ejection fraction (EF) of 60% and severe aortic stenosis. She is planned to undergo a total knee replacement. I would begin by using the American College of Cardiology/American Heart Association Algorithm to assess this patient’s cardiac risk beginning with determining the urgency of the surgery (Barak et al., 2006). Although important for pain relief and mobility, total knee replacement is considered an elective procedure as the outcome would not change due to a delay for further evaluation (Hernandez, 2023). Secondly, we will evaluate any cardiac conditions, which this patient presented with new murmur and severe aortic stenosis on echocardiogram despite a preserved EF. Thirdly, we consider the risk of the procedure, orthopedic procedures are considered intermediate risk. Fourth, we consider the patients functional capacity, due to the nature of this procedure, we can infer that her mobility is likely affected and therefore, we will say she has < 4 mets equivalent. Therefore, this patient is undergoing an elective intermediate risk surgery with new onset murmur, AS, and < 4 met equivalents in functional capacity. Lastly, we will consider the RCRI, or the Revised Cardiac Risk Index, which considers, elevated risk surgery, history of ischemic heart disease, history of CHF, history of cerebrovascular disease, pre-operative treatment with insulin, and pre-operative creatinine >2 mg/dL. This patient gets 1 point due to the elevated risk surgery which gives a 6.0% 30-day risk of death, MI, or cardiac arrest (Duceppe et al., 2017).  The most concerning risk for this patient would be her new AS as severe AS has shown to have double the rate of 30-day mortality and suffer a post operative MI 3 times more often (Polak et al., 2022). Therefore, determining her symptoms with AS would be imperative as well as determining its effect on EF, which is preserved in this patient. According to the algorithm, the patient can continue with surgery as planned, focus should be on controlling heart rate and blood pressure and monitoring during anesthesia with TEE/Swan and post operatively.

Our next patient is a 25-year-old male who is undergoing an emergency cholecystectomy, he is an active individual who plays basketball for over an hour times 3 days a week. He has no previous cardiac, medical, or surgical history. Due to the nature of this surgery and its urgency, we would not delay the procedure for a cardiac workup, this patient would be at an increased perioperative risk for MACE regardless of their baseline. However, his age, lack of medical conditions as well as his active functional capacity would otherwise place him as low risk for MACE.

Our last patient, a 75-year-old female with history of coronary artery disease with previous coronary artery bypass graft (CABG), previous percutaneous intervention (PCI), hypertension, and hyperlipidemia is being risk stratified for a hip replacement due to mobility challenges related to pain. Her previous echocardiogram is notable for an EF 55-60% with no wall motion abnormality and she is asymptomatic otherwise. Applying the algorithm, this is an elective procedure, history of CABG and PCI, however, no active cardiac conditions, intermediate risk surgical procedure, functional capacity likely < 4 met equivalents and RCRI of 2 points which equals 10.1% 30-day risk of death, MI, or cardiac arrest. My concern with this specific patient would be her dual antiplatelet therapy for her history of PCI, so determining the time from PCI to procedure is imperative as DAPT will increase risk of bleeding. If this patient had PCI performed >12 months, then DAPT may be stopped preoperatively for their procedure (Chaudhry & Cohen, 2017). According to the algorithm, our recommendation would be to continue with surgery as planned, focus should be on controlling heart rate and blood pressure and monitoring during anesthesia with TEE/Swan and post operatively.

Applying the concepts of risk stratification takes time and research to consider all aspects of patient’s condition. However, it is paramount for the safety of the patient and for them to make an informed decision about their surgical procedure both by the patient and the proceduralist.  

References

Barak, M., Ben-Abraham, R., & Katz, Y. (2006). Acc/aha guidelines for preoperative cardiovascular evaluation for noncardiac surgery: A critical point of view. Clinical Cardiology, 29(5), 195–198. 

https://doi.org/10.1002/clc.4960290505
Links to an external site.

Chaudhry, W., & Cohen, M. C. (2017). Cardiac screening in the noncardiac surgery patient. Surgical Clinics of North America, 97(4), 717–732. 

https://doi.org/10.1016/j.suc.2017.03.010
Links to an external site.

Duceppe, E., Parlow, J., MacDonald, P., Lyons, K., McMullen, M., Srinathan, S., Graham, M., Tandon, V., Styles, K., Bessissow, A., Sessler, D. I., Bryson, G., & Devereaux, P. (2017). Canadian cardiovascular society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery. Canadian Journal of Cardiology, 33(1), 17–32. 

https://doi.org/10.1016/j.cjca.2016.09.008
Links to an external site.

Hernandez, N. (2023). Total knee replacement: A patient’s guide. UW Medicine Orthopaedics and Sports Medicine. 

https://orthop.washington.edu/patient-care/articles/knee/total-knee-replacement-a-patients-guide.html
Links to an external site.

Polak, S., Romero, K., Berg, A., Patel, N., Jamei, M., Hermann, D., & Hanna, D. (2022). Cardiac risk assessment. Journal of pharmacokinetics and pharmacodynamics, 45(3), 457–467. 

https://doi.org/10.1007/s10928-018-9580-2
Links to an external site.

POST 2

Case #1: A 60-year-old Female With a New Murmur

The patient’s case is classified as intermediate risk. Echocardiogram assessment shows that the patient has an injecting fraction of 60%. An ejection fraction determines the amount of blood that leaves the heart in one heartbeat. An injection fraction of 60% is considered standard for this age, so the patient is not at risk for heart failure. The patient has no cardiac history, meaning there is no evidence of heart disease or cardiac abnormalities. However, the patient has severe aortic stenosis, which prevents the valves from opening and closing properly, thus straining the heart as it pumps the blood to the rest of the body (Goel et al., 2018). Surgery is not recommended for patients with severe aortic stenosis because of concerns that it will cause further complications. In addition, a patient with this condition already has limited stroke volume, and any significant systemic vascular resistance could result in perfusion pressure. Therefore, spinal anesthesia should be avoided. The patient requires a total knee replacement. Knee injury is considered a safe procedure with rare complications (UCLA Health, n.d.). Almost all patients recover from knee replacement surgery without complications. However, caution is advised because surgery has a significant impact on hemodynamics and blood loss.

Case #2: A 25-year-old Male and Preoperative Risk Stratification

The preoperative examination shows that the young patient is at low risk. First, the patient does not have any chronic disease. He also has no cardiac, medical, or surgical history and is always active in sports. The patient plays basketball three hours per week and has no exertional symptoms during or immediately after physical exercise. His lungs and heart appear to be in perfect condition to support his active lifestyle. Although the patient will undergo major surgery to remove his gallbladder, no further complications are expected after surgery (UCLA Health, n.d.). Since his vital organs are in good condition, the surgery will not expose him to the risk of operative mortality and hospital readmission. Moreover, age significantly impacts recovery after surgery, and because the patient is relatively young, he is likely to recover more quickly. The patient was active before the surgery and is likely to be physically fit, which increases the likelihood of a better surgical outcome. Specifically, healthier and fitter individuals recover faster and experience less pain and fewer surgical and postoperative complications. Therefore, the patient is recommended to undergo the proposed emergency cholecystectomy surgery.

Case #3: A 75-year-old Female With a History of Coronary Artery Disease

Preoperative analysis shows that the patient is at high risk. She is 75 years old. Because of her age, it will take her a long time to recover from hip replacement surgery. The patient needs careful care as she cannot move due to hip pain. Additionally, she has a history of several complex conditions, such as hypertension, hyperlipidemia, and coronary artery disease, which are obstacles to surgery (National Association of Community Health Centers, 2019). A patient with such a history is at high risk for postoperative mortality upon any surgical procedure. Heart disease is the leading cause of complications after common surgeries. In addition, one must be active after the operation to strengthen muscles and speed recovery. The patient’s functional status cannot be determined due to hip pain, so it is not possible to predict her recovery. Furthermore, she has an ejection fraction of 55–60%, which is considered low normal and could predispose her to sudden cardiac arrest. Because of the high potential risk of post-surgery complications and mortality, it is advisable to help the patient manage her hip condition and relieve pain rather than perform the proposed surgical procedure. The treatment process should focus on reducing the cost of care, alleviating pain, and achieving positive patient outcomes.

References

Goel, N., Kumar, M. G., Barwad, P., & Puri, G. D. (2018). Noncardiac surgery in two severe aortic stenosis patients: General or epidural anesthesia? Saudi Journal of Anaesthesia, 12(2), 367–369. 

https://doi.org/10.4103%2Fsja.SJA_648_17
Links to an external site.

National Association of Community Health Centers. (2019). Population health management: Risk stratification. 

https://www.nachc.org/wp-content/uploads/2019/03/Risk-Stratification-Action-Guide-Mar-2019
Links to an external site.

UCLA Health. (n.d.). Risk stratification – Anesthesiology. Center for High Quality Health Care Services. 

https://www.uclahealth.org/departments/anes/referring-providers/risk-stratification
Links to an external site.