What cardiac risk assessment and management strategies are recommended for patients undergoing laparoscopic colectomy?

From the Guidelines

Cardiac risk assessment for patients undergoing laparoscopic colectomy should follow a stepwise approach, as outlined in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1.

Key Steps in Cardiac Risk Assessment

• Determine the urgency of surgery and identify patients with acute coronary syndrome (ACS) who require cardiology evaluation and management
• Estimate the perioperative risk of major adverse cardiac events (MACE) using tools such as the Revised Cardiac Risk Index (RCRI) or the American College of Surgeons NSQIP Surgical Risk Calculator
• Patients with low risk of MACE (<1%) can proceed to surgery without further testing, while those with elevated risk may require further evaluation, including functional capacity assessment and pharmacological stress testing

Management Strategies

• Beta-blockers should be continued in patients already taking them, but not routinely started preoperatively unless specifically indicated 1
• Statins should be continued or initiated in high-risk patients
• Aspirin may be continued perioperatively in patients with coronary stents or established cardiovascular disease, balancing bleeding and thrombotic risks
• Intraoperative management should focus on maintaining hemodynamic stability, with careful fluid management and monitoring of blood pressure and heart rate
• Postoperative care should include early mobilization, optimal pain control, and vigilant monitoring for cardiac complications

Additional Considerations

• The pneumoperitoneum created during laparoscopy can increase systemic vascular resistance and decrease cardiac output, potentially stressing patients with underlying cardiac disease
• A multimodal approach to perioperative care, including preoperative optimization, intraoperative management, and postoperative care, can help reduce cardiac risk and improve outcomes in patients undergoing laparoscopic colectomy 1

From the Research

Cardiac Risk Assessment for Laparoscopic Colectomy

• The Revised Cardiac Risk Index (RCRI) is a useful tool for identifying patients with high postoperative mortality risks undergoing elective colon cancer surgery 2.
• A study found that 90-day postoperative mortality increased from 2.4% in patients with RCRI 1 to 10.1% in patients with RCRI ≥ 4, with an adjusted 90-day postoperative mortality increasing linearly with an increasing RCRI score 2.
• Cardiovascular performance is altered during laparoscopic colectomy, with significant increases in systemic vascular resistance and decreases in cardiac index and ejection fraction area after peritoneal insufflation 3.
• Trendelenburg's positioning can augment ventricular preload and performance, resulting in significant increases in pulmonary capillary wedge pressure, cardiac index, and ejection fraction area compared to insufflation 3.

Management Strategies

• The American College of Surgeons NSQIP Surgical Risk Calculator can be used to estimate preoperative risk for laparoscopic colectomy, but its accuracy may be affected by outliers 4.
• A study found that actual length of stay was higher than predicted, but occurrence of any complication was significantly lower than predicted, suggesting that the risk calculator may not accurately predict outcomes in all patients 4.
• The adoption of laparoscopy for elective colorectal resection has increased over time, with a significant reduction in the risk of transfusions, wound infections, and composite of adverse events compared to open surgery 5.
• Patient-specific factors, such as age, sex, and comorbidities, should be taken into account when assessing cardiac risk and developing management strategies for laparoscopic colectomy 5.

Additional Considerations

• There is no direct evidence from the provided studies on the specific bowel preparation methods for colonoscopy in relation to cardiac risk assessment for laparoscopic colectomy 6.
• However, it is essential to consider the overall health and medical comorbidities of the patient when developing a management strategy for laparoscopic colectomy, including cardiac risk assessment and bowel preparation 6.