Locally Agreed Guidelines May Reduce Inappropriate Preoperative 当地的指导方针可能减少不适当的术前课件.ppt

1、Locally Agreed Guidelines May Reduce Inappropriate Preoperative Echocardiography RequestsDr Sheila Carey Anaesthetic SpRNorthern DeaneryBackground:Preoperative Echocardiography Assessment of perioperative cardiac risk is part of anaesthetic preoperative assessment.Echocardiography can give useful in

2、formation on cardiac function but has its limitations.Background:Sunderland Experience Disquiet from cardiology regarding quality and appropriateness of echo requests.Uncertainty about indications for pre-operative echo amongst PAAC staff and junior surgical medical staff.Aims Audit all preoperative

3、 echocardiogram requests Produce local guidelines Survey local consultant opinion regarding pre operative echo Literature review Evaluate impact of guidelinesPreoperative Echo Survey:Who needs investigating?New murmur with other indicators of AS New murmur with no suggestive features of AS Stable an

4、gina Decompensated heart failure Known AS.No change in symptoms,no recent echo(1 year)Published Literature/Guidance ACC/AHA Guideline Recommendations for pre-op non-invasive evaluation LV Function Patients with current or poorly controlled HF*(Class I)Patients with prior HF/patients with dyspnoea un

5、known origin(Class II)Valvular heart disease If a murmur is present,the clinician will need to decide whether or not it represents significant valvular disease AS poses the greatest riskPublished Literature/Guidance NCEPOD 1994/5 Patient with ESM in association with LVH or myocardial ischaemia shoul

6、d be referred for assessment 2001 Patients can be asymptomatic despite mod severe AS and hence an asymptomatic cardiac murmur should be investigated preoperatively by echocardiography NCEPOD recognises the spiralling increase in workload this causes but echocardiography services should be accorded a

7、n appropriate priority with regards fundingPublished Literature/Guidance Appropriateness Criteria for TTE and TOE(ACCF/ASE/ACEP et al)Symptoms due to suspected cardiac aetiology(not previously investigated)(9)Initial investigation of murmur where there is reasonable suspicion of valvular or structur

8、al disease(9)Re-evaluation of a patient with known valvular heart disease with a change in clinical status(9)Routine(yearly)evaluation of an asymptomatic patient with severe stenosis(7)Published Literature/Guidance Pandit(2004)Maximising the benefit from pre-operative cardiac evaluation The uninvest

9、igated murmur NCEPOD guidelines extremely cautious Implementation would increase demand greatly on echo services Local guidelines should be jointly developedProposed Guidelines for Preoperative Echocardiography1)Dyspnoea of unknown origin where there is suspicion of cardiac component or known IHD wi

10、th poor functional capacity.2)Previously undiagnosed systolic murmur with elements suggestive of aortic stenosis,ECG abnormalities or symptoms.3)Known aortic stenosis with a change in symptoms since last echo,or if due for routine follow-up echo 4)Patients with current/poorly controlled heart failur

11、e(NYHA grade III-IV)and no echo in past two years confirming moderate-severe LV dysfunction.Review of Echocardiogram requests Preoperative requests collected over a 6 week period.Reviewed by Consultant Cardiologist to determine appropriateness.Inappropriate requests patient note review.Indications c

12、ompared against new guidelinesResults Twenty eight requests for preoperative echocardiography 7/28(25%)deemed as acceptable by Cardiology 21(75%)unacceptable requests 14 murmurs/added sounds 4 Left ventricular Function 3 nature of surgeryAnalysis of Unacceptable Requests 16 Unacceptable requests fro

13、m Trauma&Orthopaedic Department 12 sets of notes reviewed 9 requests could have been prevented(75%)using guidelinesConclusions 1 No consensus amongst senior medical staff regarding who requires investigation Personal preference probably dictates choice except when clear cut suspicion of AS Advice gi

14、ven to other staff,(e.g.trainees,PAAC nurses)likely to be inconsistent Guidelines may improved thisSunderland echocardiogram requestConclusions 2 A significant proportion preoperative echocardiogram requests are unacceptable Retrospective application of guidelines suggests inappropriate requests cou

15、ld be reduced Potential for a rise in number of requests if patients selected more appropriatelyLimitations Cardiology review subjective Retrospective analysis Prospective Audit needed to clarify the effect of introducing guidelinesRecommendations Investigation should only be considered if management will be affected Information given on request form has to be relevant and detailed Local guidelines can help direct appropriate use of resources