webdocs slideshow pv 2014 moore perioperative stroke
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Perioperative
StrokeLaurel MooreAssociate ProfessorDirector, Division of Neuroanesthesiology
University of Michigan
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Learning Objectives Mechanisms and timing of stroke
Procedures and comorbidities associated withperioperative stroke
Clinical management options that mayreduce theincidence of perioperative stroke
Significance of early recognition and treatment ofstroke in the postoperative patient
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Outline of Presentation
Brief Review of Perioperative Stroke Preoperative risk reduction
Intraoperative risk reduction
Postoperative recognition and possibletreatment options
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Why care about perioperative stroke?
Perioperative Complication Incidence (range)%
Myocardial infarction 0.0005-5.1
Stroke0.1-3.0
Postoperative visual loss 0.1-0.2
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Incidence of stroke by
procedure
Surgical Procedure Incidence (%)
Noncardiac nonneurologic1
0.1Total hip arthroplasty2 0.2
Vascular noncarotid3, 20 0.4-0.8
Vascular carotid27 0.9
Coronary artery bypass
19, 60
2.0-3.1Double and triple valve replacement61 9.7
Aortic arch procedures with DHA4 19.2
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An updated definition of
stroke for the 21stcenturyWorld Health Organization 1970:
neurologic deficit of cerebrovascular cause that
persists beyond 24 hours
AHA/ASA 2013:
CNS infarction is defined as brain, spinal cord orretinal cell death attributable to ischemia, based on
neuropathological, neuroimaging, and/or
clinical evidence of permanent injury.
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Mechanisms of
Perioperative Stroke
Ischemic
Hemorrhagic
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Classification of Subtypes of
Acute Ischemic Stroke
(TOAST Stroke 1993;24:35-41)
White, Circulation 2005;111:1327-1331
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Watershed Infarction
Bijker, Can J Anaesth 2013;60(2):159-67
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Mechanisms of Stroke
Moore, Neurologic Outcomes of Surgery and Anesthesia, Cambridge Press 2013
Comorbidities:
1. Age
2. TIA/stroke
3. Renal disease4. Female sex
5. Cardiac disease
6. Hypertension
7. Afib
8. Tobacco
High Risk Procedures:
1. CEA2. Cardiopulmonary bypass
3. Open heart
4. Aortic Arch
Perioperative Events:
1. Antiplatelet cessation
2. Statin cessation
3. Afib4. Hypotension
5. Dehydration
6. Hypercoagulable state
7. Inflammatory response
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Cumulative Risk of Stroke
Mashour Anesthesiology 2011;114(6): 1289-96
High Risk 5 risk factors
Stroke incidence 1.9%, OR 21
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Timing of Stroke in THR
Lalmohamed Stroke 2012;43:3225-3229
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Timing of stroke in noncarotid
major vascular surgery
Sharifpour, Anesth Analg 2013;116(2):424-34
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Outline of Presentation
Brief Review of Stroke and Perioperative Stroke
Preoperative risk reduction Intraoperative risk reduction
Postoperative recognition and possible treatment
options
1.Antiplatelet therapy
2.Statin therapy
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Aspirin following cardiac surgeryMangano NEJM 2002;347:1309
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Should ASA be discontinued
preoperatively?
BleedingComplications
CerebrovascularComplications
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Effects of antiplatelettherapy withdrawal
Rebound in platelet activity with
abrupt cessation 5% of nonoperative ischemic stroke
associated with withdrawal of
antiplatelet therapy Strokes generally occur within 2 weeks
of antiplatelet cessation
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We should cease offering
TURP in favour ofalternative surgery options
for anticoagulated patientsBritish Journal of Urology International 2011
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For patients on warfarin who
should receive bridging
therapy?
Patients in atrial fibrillation with h/oof stroke or TIA within 6 months
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Primary and Secondary Stroke
Prevention with Statins
Nassief Stroke 2008;39:1042-1048
Primary stroke prevention
Secondary stroke prevention
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As regards perioperative statins:
Prospective randomized trialscannot
be performed anymorebecause all
vascular patients should receive statin
treatment as secondary prevention of
cardiovascular disease.AF Stalenhoef, J Vasc Surg 2009;49(4):1091
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Outline of Presentation
Brief Review of Perioperative Stroke
Preoperative risk reduction
Intraoperative risk reduction Postoperative recognition and possible treatment
options1.Anesthetic technique
2.Use of -blockers
3.Blood pressure management
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Anesthetics as
Neuroprotectants
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Stroke reduced with Neuroaxial
Anesthesia in THR and TKR
Memtsoudis, Anesthesiology 2013;118(5):1046-1058
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Lancet 2008;371(9627):1839-47
POISE Trial 2008
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Association of perioperative
metoprolol and perioperative stroke
Mashour Anesthesiology 2013
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Stroke incidence with anemia
Metoprolol
Atenolol
Bisoprolol
Ashes, Anesthesiology 2013;119(4):777-787
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The role of intraoperative hypotension
in postoperative stroke
Bijker Anesthesiology 2012;116(3):658-64
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A word about the dangers of
the beach chair position
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Unusually low blood pressure will
eventually result in neurological damage;however, the threshold and duration at
which an association might be found
between a perioperative stroke and
hypotension have not been wellinvestigated. Thus, the exact role of
hypotension in the etiology of perioperative
stroke is still largely unknown.
Bijker and Gelb
Can J Anaesth 2013;60(2):159-67
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Outline of Presentation
Brief Review of Perioperative Stroke
Preoperative risk reduction
Intraoperative risk reduction
Postoperative recognition andpossible treatment options
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Recognition of postoperative
stroke is frequently delayed
0
5
10
15
20
25
30
35
40
0-3 3-8 24 48 >48
Medical Recognition toImaging Time
Last Known Normal to
Imaging Time
#
of
Strokes
Hours post-surgery
Weightman ASA 2012 Abstract A476
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Time is Brain
Kidwell Stroke 2004;35:2662-2665
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Mechanical Thrombolysis
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Suggestions for clinical
management
Stroke is more common than you think
When possible continue anti-platelet rx
Statins and -blockers should continue
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Suggestions for Intraoperative
management Blood pressure goals should be
assessed as % variance from baseline
Prolonged hypotension probably bad
Normocapnia probably good
Induced hypotension for beach chairposition definitely bad
Nitrous oxide okay
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Intraop management cont.
Patients on -blockers may be
more sensitive to anemia
Short-acting or 1-selective -blockers when possible
Glucose levels 80-150 mg/dL
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Conclusions Perioperative stroke is rare but potentially
devastating
Associated co-morbidities are well-defined
Intraoperative associations are not well-defined
Improved recognition of postoperativestroke is necessary before acute interventioncan be considered
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Perioperative Care of Patients at High Riskfor Stroke after Non-Cardiac, Non-
Neurologic Surgery: Guidelines from the
Society for Neuroscience in Anesthesiology
and Critical Care
SNACC Task Force on Perioperative Stroke
George A. Mashour MD PhD, Laurel E. MooreMD, Abhijit V. Lele MD, Steven A Robicsek MD
PhD, Adrian W. Gelb MBChB
http://www.snacc.org/