Perioperative Management Of Aortic Regurgitation And Rheumatoid Lung Vs. Tuberculosis

Hospital Medicine Grand Rounds “The role of the peri-operative evaluation in safe patient outcomes: an initial patient dissatisfaction with a happy ending” Moises Auron MD FAAP Feb 11, 2009

Case presentation • 55 y/o male • CC: Tracheostomy and subglotic stenosis • Referred for pre-operative evaluation for a laser dilatation of the subglottic stenosis • Surgery scheduled for the next day. • Patient travelled from Boston, MA.

PMH • • • • •

HTN (10 years) Tracheostomy G-tube on enteral feeding MVA 4 months ago with complicated ICU stay: prolonged intubation. D/C to SNF, and recent D/C to home 1 week prior to preoperative visit.

PSH • Evacuation of subdural hematoma • Pleural tube placement for closed chest injury • Exploratory laparotomy with splenectomy and small bowel resection. • ORIF hip fracture • Tracheostomy • Gastrostomy

Medications • • • • • • • •

Esomeprazole 20 mg daily Poly-ethylen-glycol 17 g daily Indapamide 2.5 mg daily Aliskiren 150 mg daily Clonidine 0.2 mg bid Gabapentin 600 mg tid Aspirin 81 mg daily Oxycodone 10 mg po q6h prn (pain)

Social • Smoking 30 ppy (not smoking currently since accident 4 months ago). • No EtOH intake. • No Drugs. • Prosecution lawyer, married for 25 years, 2 children.

Pre-operative assessment • Able to walk indoors with a walker (1.5 mets) but is mostly in wheelchair – Chest discomfort when straining (“because I had a chest tube”) – Needs 4 pillows to sleep, orthopnea, no PND – Edema managed with indapamide

• Denied any complications with anesthesia.

Circulation. 2007;116:1971-1996

Physical examination • • • •

BP 205/70 HR 90 RR 16 Gen: anxious, head tremors Neck: Carotid pulsations appreciated. Trach. Cor: S4, 3/6 diastolic murmur in Right 2nd IC space with presence of diastolic murmur in apical area • Chest: CTA BL • Abd: S, NT, ND, BS+, pulsatile liver, GT • Ext: brisk pulses, pulsating capillary nail bed

What do you think?

Signs of aortic insufficiency • • • • • • • •

Austin Flint murmur Corrigan’s pulse de Musset's sign Quincke’s sign Traube's sign Duroziez’s sign Lighthouse sign Landolfi’s sign

• • • • • • • • •

Becker’s sign Müller’s sing Mayen’s sign Rosenbach’s sign Gerhardt’s sign Hill’s sign Lincoln’s sign Sherman’s sign Ashrafian’s sign

Babu AN, et al. Ann Intern Med. 138 (9): 736–42. Ashrafian H. Int J Cardiol. 2006 Mar 8;107(3):421-3.

Signs of aortic insufficiency • Austin Flint murmur – diastolic “rumble” in mitral area

Babu AN, et al. Ann Intern Med. 138 (9): 736–42. Ashrafian H. Int J Cardiol. 2006 Mar 8;107(3):421-3. http://www.med.yale.edu/intmed/cardio/echo_atlas/entities/aortic_regurgitation.html

• • • • • • • •

Large-volume, 'collapsing' pulse Bounding peripheral pulses (waterhammer) Low diastolic BP and increased pulse pressure Corrigan’s pulse (rapid upstroke and collapse of the carotid artery) de Musset's sign (head nodding in time with the heart beat) Quincke’s sign (pulsation of the capillary bed in the nail) Traube's sign (systolic and diastolic murmurs described as 'pistol shots' heard over the femoral artery when it is gradually compressed) Duroziez’s sign (double sound heard over the femoral artery when it is compressed distally) Babu AN, et al. Ann Intern Med. 138 (9): 736–42. Ashrafian H. Int J Cardiol. 2006 Mar 8;107(3):421-3.

Signs of aortic insufficiency • • • • • • • •

Lighthouse sign (blanching & flushing of forehead) Landolfi’s sign (alternating constriction & dilatation of pupil) Becker’s sign (pulsations of retinal vessels) Müller’s sing (pulsations of uvula) Mayen’s sign (diastolic drop of BP>15 mm Hg with arm raised) Rosenbach’s sign (pulsatile liver) Gerhardt’s sign (enlarged spleen) Hill’s sign- a ≥ 20 mmHg difference in popliteal and brachial systolic cuff pressures. • Lincoln’s sign (pulsatile popliteal) • Sherman’s sign (dorsalis pedis pulse is quickly located & unexpectedly prominent in age>75 yr) • Ashrafian’s sign (Pulsatile pseudo-proptosis)

Pre-operative optimization • EKG: NSR, left axis deviation, LVH, PVC’s • Labs: creatinine 1.5 (GFR 51 by MDRD)

IS HE OPTIMALLY PREPARED?

Circulation. 2007;116:1971-1996

Circulation. 2007;116:1971-1996

Circulation. 2007;116:1971-1996

Clinical risk factors: RCRI

Lee, et al. Circulation. 1999; 100: 1043 – 1049.

Despite patient’s anger and yelling… …he was “not cleared for surgery” and was sent to the ER: - Aortic regurgitation with severe symptoms -

NYHA III-IV Orthopnea Hypertensive urgency with wide pulse pressure Unclear evolution – surprising that was not diagnosed in recent hospitalization

Aortic regurgitation: Etiology • • • • • • • • • •

Idiopathic dilatation (annuloaortic ectasia) Congenital (bicuspid valves) Calcific degeneration (accompained by AS) Rheumatic disease Infective endocarditis Systemic hypertension (cystic medial necrosis) Myxomatous degeneration Dissection of the ascending aorta Marfan syndrome Traumatic injuries Circulation 2008;118;e523-e661

Aortic regurgitation: Etiology • • • • • • • • • • •

Ankylosing spondylitis Syphilitic aortitis (tertiary) Rheumatoid arthritis Osteogenesis imperfecta Giant cell aortitis Ehlers-Danlos syndrome Reiter’s syndrome Whipple disease Discrete subaortic stenosis Ventricular septal defects with prolapse of an aortic cusp. Anorectic drugs (Fenfluramine, dexfenfluramine) Circulation 2008;118;e523-e661

Natural history of AR

Circulation 2008;118;e523-e661

Natural history of chronic AR Asymptomatic Patients With Normal EF • Variables associated with higher risk (likelihood of death, symptoms, and/or LV dysfunction): – Age – LV end-systolic dimension • > 50 mm had a dysfunction - 19% per year. • 40 to 50 mm - 6% per year, • < 40 mm – 0%.

– LV end-diastolic dimension – LV ejection fraction during exercise. Circulation 2008;118;e523-e661

TTE 1. Dilated LV size (300 cc end-diastolic volume) with moderate LVH. EF=50%. -

Left Ventricle ID(dia - cm):6.5 Left Ventricle ID(sys - cm):3.6

2. Normal RV size and function 3. Bicuspid aortic valve. Severe (4+) AR with holodiastolic flow reversal in the descending arch. 4. Mildly dilated Aorta with effacement of the S-T junction. Aortic sinus(cm) - 4.3. Sino-tubular Junction(cm) - 3.5. Ascending Aorta(cm) - 3.8. Aortic Arch(cm) - 3.7. 5. Bi-atrial enlargement. LA index=28ml. 6. Trivial TR. RVSP=41mmHg c/w mild PHTN

LV Catheterization LEFT MAIN: Normal. LEFT ANTERIOR DESCENDING: 20-25% narrowing proximal mid and distal segment. CIRCUMFLEX ARTERY: Minimal irregularities. RIGHT CORONARY ARTERY: mild narrowing about 30% in the mid third. LEFT VENTRICLE: Dilated. End diastolic size is increased. End systolic size is significantly increased. EF 35-40%. There are some PVC's and some mild mitral regurgitation. AORTIC VALVE: Bicuspid. There is 4+aortic regurgitation. There is partial effacement of the sino-tubular junction on the right side. The ascending aorta is mildly dilated. DIAGNOSIS: 1. Severe aortic regurgitation secondary to bicuspid aortic valve. 2. Moderately severe left ventricular dysfunction. 3. Mild coronary artery disease. 4. Mild dilatation of the ascending aorta.

http://www.med.yale.edu/intmed/cardio/echo_atlas/entities/aortic_regurgitation.html

Circulation 2008;118;e523-e661

Immediate Postoperative TEE LV systolic function is normal. RV systolic function is normal. Bioprosthetic valve (Carpentier-Edwards #27). There is no aortic regurgitation.

Case presentation • 56 y/o polish male (living in USA for the past 5 years). • CC: Sigmoid adenocarcinoma • Referred for preoperative evaluation for sigmoidectomy and probable primary anastomosis • Surgery scheduled for the next day.

HPI • 2 months with several episodes of hematochezia - colonoscopy showed a villotubular adenomatous polyp with focal areas of adenocarcinoma in-situ.

Review of Systems • Nocturnal diaphoresis • Pleuritic chest pain • Dry cough

Under further questioning: • 5 months of nocturnal fever (100F) and diaphoresis, – generalized arthralgias and bilateral ankle edema. – A non-erosive arthritis was diagnosed and treated empirically with prednisone (PDN), but no definite diagnosis was made.

HPI…. • 2 months prior to visit was hospitalized for presumed pneumonia receiving i.v. antibiotics; PDN was stopped. • A chest CT scan revealed intra-thoracic lymphadenopathy and interstitial lung infiltrates.

HPI • PPD and IFN test for TB were positive • BAL: Negative AFB stain and mycobacterial cultures • Patient has history of BCG administration. • An axillary lymph node biopsy showed benign hyperplasia.

PMH, FH and PSH • PMH – Well controlled HTN for 5 years – No surgeries

• Social H – – – –

Smoker 16 ppy. No EtOH or drugs. Literature teacher Wife is an internist physician trained in Poland and works as Physician assistant in US.

• FH – Colon CA.

Medications • • • • • •

HCTZ 12.5 mg daily Atenolol 50 mg daily Multivitamin 1 tablet daily Fish oil 1 tablet daily Acetaminophen 1 g po qid prn Sildenafil 50 mg prn

Preoperative assessment • Able to climb a flight of stairs (> 4 mets) • No previous anesthetic complications • No active cardiac symptoms

Physical exam • BP 140/85 HR 67 RR 22 SpO2 94% (RA) • HEENT: PERRL, EOMI, MMM • Neck: supple, anterior cervical LAD – mobile, increased in consistency, no goiter • Cor: RRR, normal S1, S2, no MRG • Chest: Decreased left breath sounds, no egophony or fremitus, minimal dullness on percussion on L • Abdomen: S, NT, ND, BS+, no masses • Extremities: Limitation of ROM of elbows, with discrete swelling and erythema of ankles bilaterally, no palpable synovitis.

Pre-operative assessment EKG: NSR, HR 65 Labs: WNL

Is he optimally prepared?

Despite angry complaints…. • Surgery was delayed • Active symptoms suggestive of systemic inflammatory process warrant further assessment • An urgent ID evaluation was requested – High risk for TB

WHAT TESTS WOULD YOU ORDER?

Further evaluation

Perioperative implications of pleural effusion • • • • •

Restrictive ventilatory defect ↓ VC ↓ FRC ↓ TLC V/Q mismatch  Hypoxemia – Atelectasis – ventricular diastolic collapse (tamponade) ↓ C.O Gilmartin, et al. Thorax 1985; 40:60–65. Agusti, et al. Am J Respir Crit Care Med 1997; 156:1205– 1209.

Pleural effusion and mechanical ventilation

Graf J. Current Opinion in Critical Care 2009; 15:10–17.

• ID requested evaluation by Thoracic surgery • Unsuccessful US-guided thoracentesis • Thoracoscopy with pleural fluid drainage and pleural biopsy were done

http://www.thoracicmedicine.org

Perioperative air safety • Each cough = 600,000 droplets • Subsequently evaporate to form much smaller invisible droplet nuclei of up to 5 microns in size • Particles < 10 microns can reach the alveoli • Most concerning microorganism is Mycobacterium tuberculosis Hickle R. Acta Anaesthesiol Scand Suppl. 1997;111:241-7.

Perioperative air safety • Cough inducing procedures – Extubation – Suctioning – Average cough in PACU = 32 times during first 40 minutes of recovery

• Cost analysis study estimated the expense associated with an episode of unprotected exposure to TB in the PACU: – $57,000 to $74,000 Hickle R. Acta Anaesthesiol Scand Suppl. 1997;111:241-7.

Perioperative air safety • N95 respirator prevents passage of 95% of particles > 0.3 microns • Minimize personnel exposed • Isolation with negative pressure • Direct transfer to OR • Bacterial filter in ETT • Careful cleansing of OR and leaving room closed until air is completely changed Neil J. AORN J. DEC 2008; 88 (6): 942-958

Perioperative air safety • Schedule aerosol-generating procedure at the end of the day • Attempt to do the procedure in the patient’s room • Use disposable anesthesia equipment

Neil J. AORN J. DEC 2008; 88 (6): 942-958

Patient with active pulmonary TB • Higher risk for temperature disregulation, hypoxemia and hypoventilation. – Fever ↑ metabolic rate and cardiac output

• Hypoxemia and hypoventilation occur due to anatomical lesions and necrotic lung parenchyma; atelectasis; pleural effusion • Malnutrition and weakness  ↓ secretions clearance and ineffective cough • ↓ inspiratory and expiratory effort  hypoventilation. Neil J. AORN J. DEC 2008; 88 (6): 942-958

Pleural biopsy – Fibrinous pleuritis with mesothelial hyperplasia. – AFB stain was negative as well as mycobacterial cultures. Fungal serologies were negative. – Pleural fluid is an exudate

Light RW. NEJM. 2002; 346 (25): 1971-1977

Yataco JC, Dweik R. CCJM. 2005; 72(10): 854-872.

Ancillary testing • • • • •

ESR 99 CRP 11 Positive Rheumatoid factor Positive anti-CCP antibodies ANA, ANCA and hepatitis serology: negative • Complement was normal. • Pleural fluid Rheumatoid factor positive

Pleural rheumatoid factor Can be elevated in: • Rheumatoid arthritis • SLE • Malignancy • Pneumonia • Tuberculosis Yataco JC, Dweik R. CCJM. 2005; 72(10): 854-872.

Rheumatology consult • Considered that patient could undergo surgery. • Treatment would be started after surgery. • C-spine flexion and extension X-Rays were normal.

Preoperative lateral flexionextension C-spine X-Rays • Progression of peripheral joint erosion parallels cervical spine disease • RF seropositivity associated with higher incidence of cervical spine involvement • C-spine involvement affects 15-86% of patients with RA • Patients with erosive RA – 30-40% have C-spine disease Macarthur A, et al. Can J Anaesth. 1993; 40: 154-9. Crosby ET. Can J Anaesth. 1990; 37: 77-93.

• Patient underwent sigmoidectomy with primary colorectal anastomosis. No further chemotherapy was advised.

http://nyp.org/masc/colorectal.htm

Post-operative • Prednisone and methotrexate were started with progressive improvement of articular and pulmonary symptoms. • Subsequently hydrocloroquine was added and prednisone dose was decreased. • ESR and CRP normalized after 3 months and symptoms improved dramatically.

Clinical conundrum • Pleuritis and interstitial lung disease are the most frequent pleuropulmonary manifestations of rheumatoid arthritis. • Co-existence of constitutional symptoms in a smoker patient with presumed TB as well as with a recent diagnosis of sigmoid cancer.

Take home message • • • • • •

Make precise diagnoses Evaluate the extent of organ disease Optimize medical diagnoses Assess and describe physiologic limitations Ensure adequate post-operative follow-up Regardless of the patient's desire to "proceed with surgery" - we have an obligation to do what is in the patient's best interest and to provide the surgical team with the service that they expect....