EXAMENS PRE INTERVENTIONNELS SYSTEMATIQUES

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1 EXAMENS PRE INTERVENTIONNELS SYSTEMATIQUES
POMMIER Maxime Anesthésie #doncRéa ILM, Mars 2017

2 DEFINITION Examens réalisés en routine
En dehors de signes d’appel anamnésiques ou cliniques Avant une procédure chirurgicale ou non chirurgicale, diagnostique ou thérapeutique Réalisée sous anesthésie

3 UTILITE Diagnostiquer une pathologie ou un état non suspecté à l’interrogatoire et/ou à l’examen clinique Servir de référence pour apprécier l’évolution postopératoire, ou de prérequis pour traiter une éventuelle complication Participer à une évaluation du risque

4 JUSTIFICATION

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6 Mon ennemi: c’est la FINANCE!!!
Il en ressort une dépense estimée à 2,4 Md€ en 2011, année la plus récente pour laquelle les données sont disponibles. Cour des comptes, 2011

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9 Stratification selon Type de chirurgie
Gravité des patients (score ASA)

10 Madame P… Madame P… 67 ans Cs anesthésie pour PTG ATCD: TTT
1 AVB (RAS) Cholecystectomie il y a 5 ans (RAS) HTA Dyslipidémie TTT Statine/ IEC Examen clinique IMC: 31kg/m2 Auscultation cardiopulmonaire: RAS TA: 145/90mmHg Effort limité par arthrose genou Stratégie anesthésique: rachianesthésie + bloc fémoral

11 Demandez vous les examens biologiques suivants?
Numération sanguine Ionogramme sanguin Détermination du groupe sanguin Recherche de RAI Bilan d’hémosase

12 Demandez vous les examens biologiques suivants?
Numération sanguine ✓ Ionogramme sanguin ✓ Détermination du groupe sanguin ✓ Recherche de RAI ✓ Bilan d’hémosase ✗

13 Hb pré-interventionnelle et chirurgie intermediaire
Meta analyse: 49 études: PTH, PTG Anémie pré-interventionnelle: 24% Anémie post-op: 51% Anémie pré-interventionnelle associée au risque de transfusion (45%), d’infections post opératoires, mortalité, durée hospitalisation prolongée et récupération fonctionnelle médiocre ABSTRACT A systematic search was conducted to determine the characteristics of perioperative anemia, its association with clinical out- comes, and the effects of patient blood management interventions on these outcomes in patients undergoing major orthopedic surgery. In patients undergoing total hip or knee arthroplasty and hip fracture surgery, preoperative anemia was highly prevalent, ranging from 24 􏰄 9% to 44 􏰄 9%, respectively. Postoperative anemia was even more prevalent (51% and 87 􏰄 10%, respectively). Perioperative anemia was associated with a blood transfusion rate of 45 􏰄 25% and 44 􏰄 15%, postoperative infections, poorer physical functioning and recovery, and increased length of hospital stay and mortality. Treatment of preoperative anemia with iron, with or without erythropoietin, and perioperative cell salvage decreased the need for blood transfusion and may contribute to improved patient out- comes. High-impact prospective studies are necessary to con- firm these findings and establish firm clinical guidelines. Spahn. Anesthésiology 2010

14 Hb pré-interventionnelle et chirurgie intermediaire
Relation entre anémie pré-interventionnelle et mortalité à 90j (7500 chirurgies non cardiaques) Background: Preoperative anemia is an important risk factor for perioperative red blood cell transfusions and has been shown to be independently associated with adverse outcomes after noncardiac surgery. The objective of this observational study was to measure the prevalence of preoperative anemia and assess the relationship between preoperative anemia and postoperative mortality (90j). Methods: Data were retrospectively collected on 7,759 consecutive noncardiac surgical patients at the University Health Net- work between 2003 and Preoperative anemia was defined as a hemoglobin concentration less than 12.0 g/dl for women and less than 13.0 g/dl for men. The unadjusted and adjusted relation- ship between preoperative anemia and mortality was assessed using logistic regression and propensity analyses. Results: Preoperative anemia was common and equal be- tween genders (39.5% for men and 39.9% for women) and was associated with a nearly five-fold increase in the odds of post- operative mortality. After adjustment for major confounders using logistic regression, anemia was still associated with in- creased mortality (odds ratio, 2.36; 95% confidence interval, 1.57–3.41). This relationship was unchanged after elimination of patients with severe anemia and patients who received trans- fusions. In a propensity-matched cohort of patients, anemia was associated with increased mortality (odds ratio, 2.29; 95% confidence interval, 1.45–3.63). Conclusions: Anemia is a common condition in surgical patients and is independently associated with increased mortality. Although anemia increases mortality independent of transfusion, it is associated with increased requirement for transfusion, which is also associated with increased mortality. Treatment of preoperative anemia should be the focus of investigations for the reduction of perioperative risk. Beattie. Anesthesiology 2009

15 Network for Advancement of Transfusion Alternative
Goodnough, BJA, 2011

16 Hb pré-interventionnelle et chirurgie intermediaire
Lors d’une intervention à risque mineur, quel que soit l’âge, il est recommandé de ne PAS prescrire un hémogramme avant l’acte (GRADE 1–). Lors d’une intervention à risque intermédiaire ou élevé, quel que soit l’âge, il est recommandé de prescrire un hémogramme avant l’acte pour son caractère pronostique ou d’aide à l’élaboration d’une stratégie transfusionnelle (GRADE 1+).

17 Plaquettes pré-interventionnelles et chirurgie intermediaire
patients chir non cardiaque Background: Most studies examining the prognostic value of preoperative coagulation testing are too small to examine the predictive value of routine preoperative coagulation testing in patients having noncardiac surgery. Methods: Using data from the American College of Surgeons National Surgical Quality Improvement database, the authors performed a retrospective observational study on 316,644 patients having noncardiac surgery who did not have clinical indications for preoperative coagulation testing. The authors used multivariable logistic regression analysis to explore the association between platelet count abnormalities and red cell transfusion, mortality, and major complications. Results: Thrombocytopenia or thrombocytosis occurred in 1 in 14 patients without clinical indications for preoperative platelet testing. Patients with mild thrombocytopenia (101,000–150,000 μl−1), moderate-to-severe thrombocytopenia (<100,000 μl−1), and thrombocytosis (≥450,000 μl−1) were significantly more likely to be transfused (7.3%, 11.8%, 8.9%, 3.1%) and had significantly higher 30-day mortality rates (1.5%, 2.6%, 0.9%, 0.5%) compared with patients with a normal platelet count. In the multivariable analyses, mild thrombocytopenia (adjusted odds ratio [AOR], 1.28; 95% CI, 1.18–1.39) and moderate-to-severe thrombocytopenia (AOR, 1.76; 95% CI, 1.49–2.08), and thrombocytosis (AOR, 1.44; 95% CI, 1.30–1.60) were associated with increased risk of blood transfusion. Mild thrombocytopenia (AOR, 1.31; 95% CI, 1.11–1.56) and moderate-to-severe thrombocytopenia (AOR, 1.93; 95% CI, 1.43–2.61) were also associated with increased risk of 30-day mortality, whereas thrombocytosis was not (AOR, 0.94; 95% CI, 0.72–1.22). Conclusion: Platelet count abnormalities found in the course of routine preoperative screening are associated with a higher risk of blood transfusion and death. Mild thrombocytopenia, moderate-to-severe thrombocytopenia, and thrombocytosis were each associated with increased risk of blood transfusion [Low quality].   Mild and moderate-to-severe thrombocytopenia were also associated with increased risk of 30- day mortality [Low quality].   Moderate-to-severe thrombocytopenia was associated with increased risk of postoperative pulmonary and renal complications [Low quality].   Mild thrombocytopenia was associated with increased risk of renal complications [Low quality].   Thrombocytosis was associated with increased risk of with pulmonary, renal, sepsis, wound and thromboembolic complications [Low quality].   There was no clear association between platelet count and cardiac complications, central nervous system complications or graft failure [Very low quality]. Glance, anesthesiology, 2014

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19 € 11,43

20 Ionogramme pré-interventionnel et chirurgie intermediaire
526 patients. Chirurgie orthopédique (PTG/PTH) 27% IRC n=142 BACKGROUND: Reduced estimated glomerular filtration rate (eGFR) is strongly associated with increased cardiovascular risk and all-cause mortality. Associations with morbidity in elective, moderate-risk noncardiac surgery have not been explored. We hypothesized that chronic kidney disease (CKD) would be associated with excess morbidity after elective, moderate-risk orthopedic surgery. METHODS: Patients undergoing elective orthopedic joint replacement procedures were studied, representing a large proportion of global surgical procedures and characterized by highly homogeneous anesthetic and surgical practice. eGFR was calculated from routine creatinine measurements using the Modification of Diet in Renal Disease equation. CKD was defined as eGFR < 60 mL/min/1.73 m². Cardiac risk (Revised Cardiac Risk Index) and evidence-based, perioperative factors associated with perioperative morbidity (operative time, blood loss, perioperative temperature) were also recorded prospectively. The primary end point was postoperative morbidity, recorded prospectively using the postoperative morbidity survey. Morbidity differences were analyzed between patients with CKD and normal preoperative renal function (χ² test for trend) and presented as hazard ratio (HR) or odds ratio (OR) with 95% confidence intervals (95% CIs). The secondary end points were time to hospital discharge and time to become morbidity free (analyzed by log-rank test), both between and within CKD compared with normal renal function patients. Multiple regression analysis was performed to assess the association of CKD, perioperative factors with morbidity, and length of hospital stay. RESULTS: Postoperative morbidity survey was recorded in 526 patients undergoing elective orthopedic surgery. CKD patients (n = 142; 27%) sustained excess morbidity on postoperative day 5 (OR 2.1 [95% CI: ]; P < ). CKD patients took longer (HR 1.6 [95% CI: ]) to become morbidity free (log-rank test, P < ). Time to hospital discharge was delayed by 4 days in CKD patients (HR 1.4 [95% CI: ]; P = ; log-rank test). CKD patients sustained more pulmonary (OR 2.2 [95% CI: ]; P = 0.002), infectious (OR 1.7 [95% CI: ]; P = 0.01), cardiovascular (OR 2.4 [95% CI: ]; P = 0.01), renal (OR 2.3 [95% CI: ]; P < 0.00,001), neurological (OR 4.3 [95% CI: ]; P = 0.005), and pain (OR 1.8 [95% CI: ]; P = 0.04) morbidities. Further stratification of CKD revealed preoperative eGFR ≤ 50 mL/min/1.73 m(2) to be associated with more frequent morbidity and longer hospital stay, independent of age. Multiple regression analysis identified CKD (P = 0.006) and congestive cardiac failure (P = 0.002) as preoperative factors associated with prolonged hospital stay. CONCLUSIONS: A substantial minority of patients with CKD undergoing elective orthopedic procedures are at increased risk of prolonged morbidity and hospital stay. Preoperative eGFR may enhance perioperative risk stratification beyond traditional risk factors. Ackland, AnaesAnalg, 2011

21 Ionogramme pré-interventionnel et chirurgie intermediaire
2323 patients de chirurgie non cardiaque (735 orthopédie) Background. Chronic kidney disease is an independent predictor of perioperative cardiovascular morbidity and mortality. We analysed the preoperative estimated glomerular filtration rate (eGFR) as a risk factor for perioperative major adverse cardiovascular and cerebrovascular events (MACCE) in non-cardiac surgery. Methods. In a post hoc analysis of the ANESCARDIOCAT database, patients were classified into six stages of eGFR calculated with the abbreviated Modification of Diet in Renal Disease Study and the Chronic Kidney Disease Epidemiology Collaboration equations: .90 (1), 60–89.9 (2), 45–59.9 (3a), 30–44.9 (3b), 15–29.9 (4), and ,15 (5) ml min m22. We analysed differences in MACCE, length of hospital stay, and all-cause mortality between eGFR stages. Results. The eGFR was available in 2323 patients. Perioperative MACCE occurred in 4.5% of patients and cardiac-related mortality was 0.5%. Five hundred and forty-three (23.4%) patients had an eGFR of ,60 ml min m22 and 127 (5.4%) had an eGFR below 45 ml min m22. Logistic regression analysis showed that MACCE increased with eGFR impairment (P,0.001), with a marked increase from stage 3b onwards (odds ratio 1.8 vs 3.9 in 3a and 3b, respectively, P1⁄40.047). All-cause mortality was not related to eGFR (P1⁄40.071), but increased substantially between stages 3b and 4. The length of stay correlated with eGFR (P,0.001). Conclusions. Perioperative MACCE increase with declining eGFR, primarily when ,45 ml min m22. We recommend the use of preoperative eGFR for cardiovascular risk assessment. Mases, BJA, 2014

22 Ionogramme pré-interventionnel et chirurgie intermediaire
Impact thérapeutique découverte anomalie fortuite: natrémie, urée, créatinine: 0% kaliémie: 0,4% glycémie: 6,8% % complications chez sujets asymptomatiques:0-1,4% VPP complications: natrémie: 0% urée: 0-6% kaliémie, créatinine: 0-7 % glycémie: 14,3%

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24 Ionogramme pré-interventionnel et chirurgie intermediaire
Il est probablement recommandé d’évaluer la fonction rénale pré-interventionnelle par l'estimation du débit de filtration glomérulaire chez les patients à risque devant bénéficier d’une chirurgie intermédiaire ou majeure. (Grade 2 +) FdR: hypertension, diabète, polykystose rénale, antécédents familiaux d’insuffisance rénale ou consommation prolongée d’AINS ou d’aspirine IEC/ARA II (?), AOD (?)

25 Ionogramme pré-interventionnel et chirurgie mineure
Il est recommandé de ne PAS prescrire d’examen biochimique sanguin pré-interventionnel systématique, en dehors de signes d’appel anamnestiques ou cliniques, dans le contexte d’une chirurgie mineure (GRADE 1).

26 € 11,43 € 8,48

27 Groupe sanguin et RAI En cas d’intervention à risque de transfusion ou de saignement nul à faible, il est recommandé de ne PAS prescrire de groupage sanguin et de RAI (GRADE 1–). En cas d’intervention à risque de transfusion intermédiaire ou élevé ou de saignement important, il est recommandé de prescrire un groupage sanguin et une RAI (GRADE 1+).

28 En fait cette patiente a déjà eu une RAI il y a 8 jours
En fait cette patiente a déjà eu une RAI il y a 8 jours. redemandez-vous une RAI? Il est recommandé de prescrire la prolongation de durée de validité de la RAI négative de trois à 21j s’il a été vérifié l’absence de circonstances immunisantes (transfusion, grossesse ou greffe) dans les six mois précédents) (GRADE 1+).

29 € 11,43 € 8,48 € 19,71

30 Bilan hémostase Patients asymptomatiques => prévalence 1/40 000
Déficits congénitaux en facteurs de coagulation et troubles congénitaux des fonctions plaquettaires à risque hémorragique => prévalence globale 1/6 500. Patients asymptomatiques => prévalence 1/40 000 Janvier. AFAR 1998;17 Troubles acquis: les + fréquents 5% pop: antiplaquetaires 1% pop: AVK

31 TCA TP/INR quatre tests ne permettent pas d’explorer l’intégralité du système hémostatique. Certains déficits potentiellement à risque hémorragique ne perturbent pas le TCA ni le TP ; c’est le cas par exemple du déficit en facteur XIII. De la même manière, les thrombopathies ne perturbent pas les temps de coagulation standard et peuvent même ne pas être détectées pas le PFA‐100®. Enfin, la fonction hémostatique in vivo ne fait pas seulement intervenir le système de la coagulation mais également les vaisseaux et cellules endothéliales, puis dans un second temps le système de la fibrinolyse pour détruire le thrombus. Thrombopathies? Autres intervenants de la fonction hémostatique (vaisseaux, endothelium)?

32 48 études / qualité méthodologique de bas grade (obervationnelles ou série de cas)
Tests Nb de sujets total Modifications de prise en charge % de résultats anormaux dans population non selectionnée % de résultats anormaux dans population séléctionnée par examen clinique TP 18688 0-0,5% 0%-29% TCA 29204 0-0,9% 0%-16% Num Pl 13103 0-0,26% 0%-17% Bilans standards 27606 0-15% (toute modif=répétition test, chirurgie repoussée, intervention thérapeutique,…) 0-0,57% d’interventions correctrices 0,5%-16% Jusqu’à 40% Chiffres raportés= anomalies observées lors d’un premier dosage/ qques études précose le pourcentage d’anomalies retrouvées après contrôle: presque la moitié des anomalies détéctées chez un patient asympto n’étaient pas retrouvées lors contrôle du test. Intervention correctrice = substition en facteur ou traitement spécifique

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34 As many situations not related to hemorrhage are associated with perturbations of the PTT, a prolonged PTT is not strongly predictive of hemorrhage nor does a normal PTT provide shelter against hemorrhagic risk. As many situations not related to hemorrhage are associated with perturbations of the PTT, a prolonged PTT is not strongly predictive of hemorrhage nor does a normal PTT provide shelter against hemorrhagic risk.

35 Pré‐interventionnel vs post‐interventionnel :
pas de corrélation 101 patients, 3 groupes, hémostase pré‐interventionnelle (2 hématologues) – pasderisquehémorragique – risquehémorragiquemodéré – risquehémorragiqueélevé saignement intra et post‐opératoire, 3 groupes (chirurgien unique + anesthésiste) – saignement habituel ou pasdesaignement – majoration du saignement– hémorragie majeure Eika C, Scand J Haematol, 1978

36 Prédiction du risque hémorragique péri interventionnel?
Performances mauvaises bien que viariable d’une étude à l’autre (20 etudes) Les examens standars d’hémostase systématiques ne permettent pas de predire le risque hémorragique péri interventionnel Les examens d’hémostase systématiques ne permettent pas de prédire le risque hémorragique péri interventionnel

37 Bilan hémostase Il est recommandé de ne PAS prescrire de façon systématique un bilan d’hémostase chez les patients dont l’anamnèse et l’examen clinique ne font pas suspecter un trouble de l’hémostase, quel que soit le grade ASA, quel que soit le type d’intervention, et quel que soit l’âge de ces patients à l’exclusion des enfants qui n’ont pas acquis la marche (GRADE 1-). quel que soit le type d’anesthésie choisi (anesthésie générale, anesthésie neuraxiale, blocs périphériques ou techniques combinées), y compris en obstétrique (GRADE 1-).

38 Bilan hémostase Un bilan d’hémostase devra être réalisé en cas d’hépatopathie, de malabsorption/malnutrition, de maladie hématologique, ou de toute autre pathologie pouvant entraîner des troubles de l’hémostase, ou de prise de médicaments anticoagulants, même en l’absence de symptômes hémorragiques.

39 Bilan hémostase Il est recommandé d’évaluer le risque hémorragique d’après l’anamnèse personnelle et familiale de diathèse hémorragique et d’après l’examen physique (GRADE 1+). Il faut probablement utiliser un questionnaire standardisé à la recherche de manifestations hémorragiques pour évaluer l’anamnèse personnelle et familiale (GRADE 2+).

40 Nombreux questionnaires disponibles Très peu sont utilisés en pratique
Aucun validé Très peu sont utilisés en pratique

41 Questionnaire standardisé
1/ Tendance aux saignements prolongés/inhabituels (saignement de nez, petite coupure) ayant nécessité une consultation médicale ou un traitement 2/ Tendance aux ecchymoses/hématomes importants (de plus de 2 cm sans choc) ou très importants pour un choc mineur 3/ Saignement prolongé après une extraction dentaire 4/ Saignement important après une chirurgie (notamment saignement après circoncision ou amygdalectomies) 5/ Pour les femmes : – Ménorragies ayant conduit à une consultation médicale ou un traitement (contraception orale, antifibrinolytiques, fer, etc...) ? – Hémorragie du post- partum ? 6/ Antécédents dans la famille proche de maladie hémorragique (Willebrand, hémophilie, autre...) ?

42 € 11,43 € 8,48 € 19,71 € 13,5

43 Demandez vous un ECG pré-interventionnel?
Oui ✓

44 ECG pre interventionnel
Quel que soit l’âge. Il est recommandé de ne PAS prescrire un nouvel ECG lorsqu’un tracé datant de moins de 12 mois est disponible, en l’absence de modifications cliniques (GRADE 1).

45 ECG pre interventionnel
Il est recommandé de ne PAS prescrire un ECG pour une intervention mineure (GRADE 1-).

46 ECG pre interventionnel et chirurgie intermediaire ou majeure
Avant 65 ans. Il est recommandé de ne PAS prescrire un ECG 12 dérivations de repos avant une intervention à risque intermédiaire ou élevé (sauf interventions artérielles) en dehors de signes d’appel cliniques et/ou de facteurs de risques (FDR) et/ou de pathologies cardiovasculaires (GRADE 1-). Après 65 ans. Il faut probablement prescrire un ECG 12 dérivations de repos avant toute intervention à risque élevé ou intermédiaire même en l’absence de signes cliniques, de FDR et/ou de pathologies cardiovasculaires (GRADE 2+).

47 ECG pré interventionnel
ECG < 12 mois ? OUI NON Type de chirurgie À risque mineur À risque intermediaire/majeur Age < 65 ans > 65 ans en dehors de signes d’appel cliniques et/ou de facteurs de risques (FDR) et/ou de pathologies cardiovasculaires

48 ECG pre interventionnel
Facteurs prédictifs d’ECG anormal en pré-interventionnel Age is often the sole criterion for determining the need for preoperative electrocardiograms. However, screening electrocardiograms have not been shown to add value above clinical information. This study was designed to determine whether it is possible to target electrocardiograms ordering to patients most likely to have an abnormality that would affect management and if age alone is predictive of significant electrocardiograms abnormalities. METHODS: A list was developed of electrocardiograms abnormalities considered significant enough to impact management, as well as a list of patient factors believed to increase cardiovascular risk. electrocardiograms in all patients over 50 yr of age presenting for preoperative evaluation during a 2-month period were reviewed. RESULTS: A total of 1,149 electrocardiograms were reviewed, with 89 patients (7.8%) having at least one significant abnormality. These patients were compared with a group of 195 patients who had electrocardiograms that did not contain significant abnormalities. Patients at higher risk of having a significantly abnormal electrocardiograms that would potentially affect management were those older than 65 yr of age or who had a history of heart failure, high cholesterol, angina, myocardial infarction, or severe valvular disease. Five patients (0.44%) had an abnormal electrocardiograms in the absence of risk factors. The sensitivity of the model is 87.6%. CONCLUSION: Age greater than 65 yr remains an independent predictor for significant preoperative electrocardiograms abnormalities. The specific clinical risk factors that were found have a high sensitivity and identified all but 0.44% of patients with electrocardiograms abnormalities that may affect preoperative management. Corell, Anesthesiology 2009 Corell, Anesthesiology 2009

49 ECG pre interventionnel
ECG pré-interventionnel anormal et prédiction survenue de complications post-opératoires?? => Peu études bien menées avec niveau de preuve interessant…

50 € 11,43 € 8,48 € 19,71 € 13,5 € 14,26

51 Risque cardiaque péri-opératoire chez le coronarien
Il est recommandé d’évaluer le risque périopératoire, chez un patient à risque de maladie coronaire et opéré d’une intervention de chirurgie non cardiaque sur les critères suivants (GRADE 1+ Accord fort) : risque lié à l’intervention chirurgicale ; risque lié à l’état cardiaque du patient ; capacité à effectuer un effort. Prise en charge du coronarien opéré en chirurgie non cardiaque RFE SFAR et société francaise de cardiologie 2011/ revus en 2014 sans grande modifications

52 risque lié à l’intervention chirurgicale
Chirurgie à faible risque (Evt <1%) Xie superficielle Xie mammaire Xie ophtalmologique Tt act de Xie ambu Procédures endoscopiques Chirurgie à risque intermediaire (Evt <1-5%) intra ou retropéritonéale, Thoracique Carotidienne Tête-cou Orthopédique Prostatique Xie à fort potentiel hémorragique Chirurgie à risque majeur (Evt >5%) Xie aortique Vasculaire majeure Vasculaire périphérique Xie fracture de hanche du sujet agé Pearse, Critical Care, 2006

53 risque lié à l’état cardiaque du patient
Lee, circulation, 1999

54 Background—Cardiac complications are important causes of morbidity after noncardiac surgery. The purpose of this prospective cohort study was to develop and validate an index for risk of cardiac complications. Methods and Results—We studied 4315 patients aged 􏲵50 years undergoing elective major noncardiac procedures in a tertiary-care teaching hospital. The main outcome measures were major cardiac complications. Major cardiac complications occurred in 56 (2%) of 2893 patients assigned to the derivation cohort. Six independent predictors of complications were identified and included in a Revised Cardiac Risk Index: high-risk type of surgery, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and preoperative serum creatinine 􏰈2.0 mg/dL. Rates of major cardiac complication with 0, 1, 2, or 􏲵3 of these factors were 0.5%, 1.3%, 4%, and 9%, respectively, in the derivation cohort and 0.4%, 0.9%, 7%, and 11%, respectively, among 1422 patients in the validation cohort. Receiver operating characteristic curve analysis in the validation cohort indicated that the diagnostic performance of the Revised Cardiac Risk Index was superior to other published risk-prediction indexes. Conclusions—In stable patients undergoing nonurgent major noncardiac surgery, this index can identify patients at higher risk for complications. This index may be useful for identification of candidates for further risk stratification with noninvasive technologies or other management strategies, as well as low-risk patients in whom additional evaluation is unlikely to be helpful. (Circulation. 1999;100: )

55 capacité à effectuer un effort
L'équivalent métabolique (Metabolic Equivalent of Task, MET) est une méthode permettant de mesurer l'intensité d'une activité physique et la dépense énergétique. On définit le MET comme le rapport de l'activité sur la demandedu metabo de base. MET 0.9 (sommeil)->18 (course 17,5km/h. plus activité physique est élevée, plus le nombre de MET est élevé.

56 ECBU et portage Staph Aureus
La patiente arrive avec un ECBU et un dépistage du portage de SA prescrit par son chirurgien. Est-ce nécessaire? Oui Non ✓

57 Self-reported exercise tolerance and the risk of serious perioperative complications
Reilly DF, McNeely MJ, Doerner D, et al. Self-reported exercise tolerance and the risk of serious perioperative complications. Arch Intern Med. 1999;159(18): Impaired exercise tolerance during formal testing is predictive of perioperative complications. However, for most patients, formal exercise testing is not indicated, and exercise tolerance is assessed by history. OBJECTIVE: To determine the relationship between self-reported exercise tolerance and serious perioperative complications. METHODS: Our study group consisted of 600 consecutive outpatients referred to a medical consultation clinic at a tertiary care medical center for preoperative evaluation before undergoing 612 major noncardiac procedures. Patients were asked to estimate the number of blocks they could walk and flights of stairs they could climb without experiencing symptomatic limitation. Patients who could not walk 4 blocks and climb 2 flights of stairs were considered to have poor exercise tolerance. All patients were evaluated for the development of 26 serious complications that occurred during hospitalization. RESULTS: Patients reporting poor exercise tolerance had more perioperative complications (20.4% vs 10.4%; P<.001). Specifically, they had more myocardial ischemia (P = .02) and more cardiovascular (P = .04) and neurologic (P = .03) events. Poor exercise tolerance predicted risk for serious complications independent of all other patient characteristics, including age (adjusted odds ratio, 1.94; 95% confidence interval, ). The likelihood of a serious complication occurring was inversely related to the number blocks that could be walked (P = .006) or flights of stairs that could be climbed (P = .01). Other patient characteristics predicting serious complications in multivariable regression analysis included history of congestive heart failure, dementia, Parkinson disease, and smoking greater than or equal to 20 pack-years. CONCLUSION: Self-reported exercise tolerance can be used to predict in-hospital perioperative risk, even when using relatively simple and familiar measures. Reilly, Arch Intern Med, 1999

58 - risque lié à l’intervention chirurgicale ;
-risque lié à l’état cardiaque du patient ; -capacité à effectuer un effort.

59 ECBU et portage Staph Aureus
La patiente arrive avec un ECBU et un dépistage du portage de SA prescrit par son chirurgien. Est-ce nécessaire? Oui Non

60 3 centres (UK, Espagne, Portugal)
2497 patients 3 centres (UK, Espagne, Portugal) ECBU systématique avant PTH/PTG, pas de consigne pour PeC thérapeutique de l’IU 12,1% ASB/ 1,7% PJI Background. Infection is a major complication after total joint arthroplasty. The urinary tract is a possible source of surgical site contamination, but the role of asymptomatic bacteriuria (ASB) before elective surgery and the subsequent risk of infection is poorly understood. Methods. Candidates for total hip or total knee arthroplasty were reviewed in a multicenter cohort study. A urine sample was cultured in all patients, and those with ASB were identified. Preoperative antibiotic treatment was decided on an individual basis, and it was not mandatory or randomized. The primary outcome was prosthetic joint infection (PJI) in the first postoperative year. Results. A total of 2497 patients were enrolled. The prevalence of ASB was 12.1% (303 of 2497), 16.3% in women and 5.0% in men (odds ratio, 3.67; 95% confidence interval, 2.65–5.09; P < .001). The overall PJI rate was 1.7%. The infection rate was significantly higher in the ASB group than in the non-ASB group (4.3% vs 1.4%; odds ratio, 3.23; 95% confidence interval, 1.67–6.27; P = .001). In the ASB group, there was no significant difference in PJI rate between treat- ed (3.9%) and untreated (4.7%) patients. The ASB group had a significantly higher proportion of PJI due to gram- negative microorganisms than the non-ASB group, but these did not correlate to isolates from urine cultures. Conclusions. ASB was an independent risk factor for PJI, particularly that due to gram-negative microorganisms. Preoperative antibiotic treatment did not show any benefit and cannot be recommended. Sousa, Clin Infect Dis. 2014

61 Sousa, Clin Infect Dis. 2014

62 ECBU SFAR 2012

63 ECBU Il est recommandé de ne PAS dépister et de ne PAS traiter les colonisations urinaires avant arthroplastie réglée de hanche ou de genou (D-II). SPILF 2014

64 ECBU Toutefois, en contexte d’urgence, pour la chirurgie de hanche post-traumatique chez le sujet âgé, […] le traitement d’une colonisation urinaire ou la prise en compte des bactéries à gram négatif dans l’antibioprophylaxie chirurgicale peuvent être utiles .. Toutefois, en contexte d’urgence, pour la chirurgie de hanche post-traumatique chez le sujet âgé, le risque lié à une infection urinaire pauci-symptomatique doit être pris en compte. En effet, sur ce terrain, les infections précoces de prothèse dues à des bactéries à gram négatif ne sont pas rares. Dans ce contexte, le traitement d’une colonisation urinaire ou la prise en compte des bactéries à gram négatif dans l’antibioprophylaxie chirurgicale peuvent être utiles de même que l’indication de pose et/ou le maintien du sondage vésical jusqu’à cicatrisation de la plaie opératoire chez les patients incontinents.

65 ECBU En pratique, “les colonisations urinaires ne sont à depister et à traiter qu’avant une procédure urologique invasive programmée et chez les femmes enceintes”

66 € 17,55

67 Dépistage contamination nasale SA
22% 5% 2,8% Staphylcoccus decolonization prior to surgery is used to prevent surgical site infections (SSIs) after total joint arthroplasty (TJA). To determine if current treatment protocols result in successful decolonization of methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA), 106 consecutive patients were screened for nasal MSSA/MRSA colonization pre-operatively and on the day of surgery. Colonized patients used intranasal mupirocin twice a day and chlorhexidine showers daily 5 days prior to surgery. Pre-operatively, 24 joints (22.0%) were positive for MSSA colonization and 5 joints (4.6%) were positive for MRSA colonization. On the day of surgery, 3 joints (2.8%) who underwent decolonization were positive for MSSA colonization and 0 joints were positive for MRSA colonization. The reduction in MSSA colonization was significant (P < 0.001), while the eradication of MRSA colonization approached statistical significance (P = 0.063). Current decolonization protocols using intranasal mupirocin and chlorhexidine washes are effective for reducing MRSA/MSSA colonization. 0% Chen, journal of arthroplasty, 2013

68 Méta-analyse incluant les sept études évaluant l’impact de la décolonisation de S. aureus sur le taux d’iso à S. aureus après chirurgie orthopédique.

69 Aucune recommandation ne peut être émise sur le bénéfice de la décolonisation du portage de Staphylococcus aureus sur le taux d’infection du site opératoire à S. aureus chez les patients relevant d’une chirurgie orthopédique prothétique programmée. (C3)

70 € 17,55 € 44,5 € 27 €53,88

71 Madame P… Madame P… 67 ans Cs anesthésie pour chirurgie Canal Carpien
ATCD: 1 AVB (RAS) Cholecystectomie il y a 5 ans (RAS) HTA Dyslipidémie TTT Statine/ IEC

72 Demandez vous les examens biologiques suivants?
Numération Formule sanguine Ionogramme sanguin Détermination du groupe sanguin Recherche de RAI Bilan d’hémosase

73 Demandez vous les examens biologiques suivants?
Numération Formule sanguine ✗ Ionogramme sanguin ✗ Détermination du groupe sanguin ✗ Recherche de RAI ✗ Bilan d’hémosase ✗

74 Examens pré-interventionnels systématiques et chirurgie mineure
Bilan systématique vs bilan sélectif ou pas de bilan Chirurgie de la cataracte NS Background—Cataract surgery is practiced widely and substantial resources are committed to an increasing cataract surgical rate in developing countries. With the current volume of cataract surgery and the increases in the future, it is critical to optimize the safety and cost-effectiveness of this procedure. Most cataracts are performed on older individuals with correspondingly high systemic and ocular comorbidities. It is likely that routine preoperative medical testing will detect medical conditions, but it is questionable whether these conditions should preclude individuals from cataract surgery or change their perioperative management. Objectives—(1) To investigate the evidence for reductions in adverse events through preoperative medical testing, and (2) to estimate the average cost of performing routine medical testing. Selection criteria—We included randomized clinical trials in which routine preoperative medical testing was compared to no preoperative or selective preoperative testing prior to age- related cataract surgery. Main results—The three randomized clinical trials included in this review reported results for 21,531 total cataract surgeries with 707 total surgery-associated medical adverse events, including 61 hospitalizations and three deaths. Of the 707 medical adverse events reported, 353 occurred in the pretesting group and 354 occurred in the no testing group. Most events were cardiovascular and occurred during the intraoperative period. Routine preoperative medical testing did not reduce the risk of intraoperative (OR 1.02, 95% CI 0.85 to 1.22) or postoperative medical adverse events (OR 0.96, 95% CI 0.74 to 1.24) when compared to selective or no testing. Cost savings were evaluated in one study which estimated the costs to be 2.55 times higher in those with preoperative medical testing compared to those without preoperative medical testing. There was no difference in cancellation of surgery between those with preoperative medical testing and those with no or limited preoperative testing, reported by two studies. Keay et al, Cochrane Database 2009

75 Examens pré-interventionnels systématiques et chirurgie mineure
Lors d’une chirurgie à risque mineur, il est recommandé de ne pas réaliser un dosage de l’hémoglobine avant l’acte chirurgical. (Grade 1 -) Il n’est pas recommandé de prescrire d’examen biochimique pré- interventionnel systématique, en dehors de signes d’appel anamnestiques ou cliniques, dans le contexte d’une chirurgie mineure. (Grade 1 -)

76 Examens pré-interventionnels systématiques et chirurgie mineure
En cas de chirurgie à risque de transfusion ou de saignement nul à faible, il n’est pas recommandé de réaliser les groupages sanguins et la RAI. (GRADE 1-) Pour les chirurgies/interventions mineures : En l’absence de signes cliniques ou de pathologie cardiovasculaire, quel que soit l’âge du patient, il est recommandé de ne pas prescrire systématiquement un ECG pré-interventionnel, même si le patient a des facteurs de risques cardiovasculaires. (Grade 1-)

77 Examens pré-interventionnels systématiques et chirurgie mineure
PAS DE BILAN EN CHIRURGIE À RISQUE MINEUR en dehors de la présence de signes cliniques ou anamnestiques y compris chez le sujet ASA III et/ou âgé

78 Examens pré-intervenionnels systématiques
CONCLUSION

79