• Committee on Perioperative Evaluation (CAPO), Brazilian Society of Cardiology. Urgent surgery. In: I guidelines for perioperative evaluation. Arq Bras Cardiol 2007;89(6):e208-9.

This is the current release of the guideline.

Any condition requiring surgery

Evaluation
Prevention
Risk Assessment
Treatment

Anesthesiology
Cardiology
Critical Care
Surgery

Physicians

• To refine and unify the terminology used by the entire multidisciplinary team, including the patients and their family
• To establish new routines, change indication for surgery according to the information obtained during the perioperative evaluation

Any patient who requires surgery

Perioperative Monitoring

1. Electrocardiography, including ST interval monitoring in coronary artery disease
2. Biomarker assays of myocardial injury (troponin)
3. Use of Swan-Ganz catheter in limited cases
4. Transthoracic echocardiogram in special situations
5. Intra-aortic balloon pump in extremely severe situations

Therapy

1. Beta-blockers
2. Nitrates (see "Contraindications" field)

Perioperative cardiac morbidity and mortality rate

Searches of Electronic Databases

Not stated

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

1. Sufficient evidence from multiple randomized trials or meta-analyses
2. Limited evidence from single randomized trial or non-randomized studies
3. Evidence only from case reports and series
4. Expert opinion or standard of care

Systematic Review

Not stated

Expert Consensus

The participants of these guidelines were chosen among health sciences specialists with hands on and academic experience, thus being characterized as clinical researchers.

The adopted methodology and evidence levels were the same as those used in earlier documents by the Brazilian Society of Cardiology.

Recommendations

• The guidelines must be based on evidences.
• Class division must be used when applicable.
• Degrees of recommendation must be used when applicable, according to the levels of evidence.

Degree or Class of Recommendation

Class I: Conditions for which there is evidence for and/or general agreement that the procedure/therapy is useful and effective

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of performing the procedure/therapy

Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy

Class IIb: Usefulness/efficacy is less well established by evidence/opinion

Class III: Conditions for which there is evidence for and/or general agreement that the procedure/therapy is not useful/effective and in some cases may be harmful

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Not stated

The definitions for levels of evidence (A-D) and classes of recommendation (I-III) are provided at the end of the "Major Recommendations" field.

Urgent Surgery

Perioperative Monitoring

• Electrocardiogram (ECG) daily (in addition to those done before surgery) until the third postoperative day; Class I, Level of Evidence C
• Myocardial injury markers: Biomarker assays (troponin) should be done daily until the third day after surgery; Class I, Level of Evidence A
• Swan-Ganz catheter: given the controversies regarding the use of this catheter, its use should be restricted to hemodynamically unstable patients immediately before surgery or those at high risk of instability; Class IIb, Level of Evidence B
• Monitor the ST segment in the intra and early postoperative periods with at least 2 precordial leads (V4 and V5) in coronary artery disease (CAD) patients; Class IIb, Level of Evidence C
• Transthoracic echocardiogram: given the short time available before an urgent procedure for this type of test, it should not be requested routinely but in special situations where diagnostic doubts exist, such as hypertrophic cardiomyopathy and/or valvular disease (Raymer & Yang, 1998; Haering et al., 1996). Recommendations and Levels of Evidence are the following:

  Class I

  • Clinical suspicion of aortic stenosis; Level of Evidence B

  Class IIa

  • Patients with CHF without previous assessment of ventricular function; Level of Evidence D
  • Grade III obesity; Level of Evidence D
  • Preoperative assessment of liver transplant; Level of Evidence D

  Class IIb

  • Detection of valvular heart disease; Level of Evidence B

  Class III

  • Routinely for all patients; Level of Evidence D

• Intra-aortic balloon pump: given the scarcity of literature data on this device, its use should be restricted to patients at high cardiac risk and with high-risk non-cardiac surgeries; Class IIb, Level of Evidence D.

Therapy

• Beta-blockers: recommendation for its perioperative prophylactic use in urgent noncardiac surgeries is based on studies of elective surgeries that show reduced acute myocardial infarction, death and post-discharge events. The Recommendations and Levels of Evidence are the following:

  Class I

  • High-risk (American College of Physicians [ACP] Classes II and III) and CAD patients; Level of Evidence A
  • Class IIb
  • Two or more cardiovascular risk factors (>65 years, hypertension, smoking, diabetes and total cholesterol >240mg/dl) (Mangano et al., 1996); Level of Evidence B

  Class III

  • Patients with contraindication to beta-blockers; Level of Evidence B

• Nitrates: contraindicated for the prophylaxis of ischemia (Dodds et al., 1993); Class III, Level of Evidence C

Definitions:

Levels of Evidence

1. Sufficient evidence from multiple randomized trials or meta-analyses
2. Limited evidence from single randomized trial or non-randomized studies
3. Evidence only from case reports and series
4. Expert opinion or standard of care

Class of Recommendation

Class I: Conditions for which there is evidence for and/or general agreement that the procedure/therapy is useful and effective

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of performing the procedure/therapy

Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy

Class IIb: Usefulness/efficacy is less well established by evidence/opinion

Class III: Conditions for which there is evidence for and/or general agreement that the procedure/therapy is not useful/effective and in some cases may be harmful

None provided

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

• Effective use of perioperative cardiovascular monitoring and treatment
• Prevention of perioperative complications
• Prevention of perioperative mortality

Not stated

Nitrates are contraindicated for the prophylaxis of ischemia.

• Data or scientific evidences are not always available to allow all the different situations to be analyzed. As customary in medical practice, minute analysis of the patient and problem and the common sense of the team must prevail.
• The surgical intervention does not finish when the patient is bandaged or leaves the operating room. The concept of the word perioperative includes the need for a postoperative surveillance whose intensity is determined by the individual level of risk of the patient.

An implementation strategy was not provided.

Getting Better
Living with Illness
Staying Healthy

Effectiveness
Safety

• Committee on Perioperative Evaluation (CAPO), Brazilian Society of Cardiology. Urgent surgery. In: I guidelines for perioperative evaluation. Arq Bras Cardiol 2007;89(6):e208-9.

Not applicable: The guideline was not adapted from another source.

2007

Brazilian Society of Cardiology

Brazilian Society of Cardiology

Not stated

Writing Committee Members: Danielle Menosi Gualandro; Claudio Pinho; Gilson Feitosa; Bruno Caramelli

Task Force Members: Alina Coutinho Rodrigues Feitosa; Beatriz Ayub; Bruno Caramelli; Carisi A. Polanczyk; Carolina L. Zilli Vieira; Claudio Pinho; Daniela Calderaro; Danielle Menosi Gualandro; Denise Iezzi; Dirk Schreen; Dimas T. Ikeoka; Elbio Antonio D'Amico; Elcio Pfeferman; Emerson Quintino de Lima; Emmanuel de Almeida Burdmann; Fábio Santana Machado; Filomena Regina Barbosa Gomes Galas; Gilson Soares Feitosa-Filho; Heno Ferreira Lopes; Henrique Pachón; João César Nunes Sbano; José Augusto Soares Barreto Filho; José L. Andrade; Roberto Henrique Heinisch; Luciana Moraes dos Santos; Luciana S. Fornari; Ludhmila Abrahão Hajjar; Luis Eduardo P. Rohde; Luiz Francisco Cardoso; Marcelo Luiz Campos Vieira; Maristela C. Monachini; Pai Ching Yu; Paula Ribeiro Villaça; Paulo Grandini; Renato S. Bagnatori; Roseny dos Reis Rodrigues; Sandra F. Menosi Gualandro; Walkiria Samuel Avila; Wilson Mathias Jr.

Support: Committee on Perioperative Evaluation (CAPO), Brazilian Society of Cardiology

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI Institute on June 3, 2008. The information was verified by the guideline developer on July 2, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. For reproduction of these guidelines, please contact Bruno Caramelli, Comissão de Avaliacão Perioperatória da Brasileira de Cardiologia – CAPO, Alameda Santos, 705 - 11° andar, São Paulo SP, Brazil CEP: 01419-001.