Perioperative MedicinePerioperative MedicineBeyond Cardiac Beyond Cardiac
ClearanceClearance
Pamela Pride MDPamela Pride MDJuly 31, 2012July 31, 2012
MUSCMUSC
ObjectivesObjectives Define the management of
anticoagulation List the VTE risk factors List the modes of prophylaxis Differentiate stress dose steroids Identify causes and management of
postoperative fever
Key MessagesKey Messages Patients on chronic anticoagulation with high risk of
thrombosis should be bridged preoperatively with short acting anticoagulation (i.e. heparin gtt or enoxaparin)
Recommending LMWH for post op DVT prophylaxis is rarely incorrect.
Recommendations regarding stress dose steroids for patients on chronic glucocorticoids are available, although data supporting their routine use is lacking.
Fevers in the first 48 hours post op are common and routine work up with chest xray, blood and urine cultures is not indicated in an otherwise asymptomatic patient.
Perioperative MedicinePerioperative MedicineBeyond Cardiac Beyond Cardiac
ClearanceClearance Management of anticoagulationManagement of anticoagulation VTE prophylaxisVTE prophylaxis Stress dose steroidsStress dose steroids Postoperative feverPostoperative fever
Antiplatelet Therapy and SurgeryAntiplatelet Therapy and Surgery
Anticoagulation and Anticoagulation and SurgerySurgery
To bridge or not bridgeTo bridge or not bridgeBridgeBridge
Dual prosthetic or old Dual prosthetic or old valvevalve
VTE w/in 3 monthsVTE w/in 3 months Pregnancy and PVPregnancy and PV PV with embolism in past PV with embolism in past
6 months6 months Afib with chad score Afib with chad score ≥ 5≥ 5 Bileaflet valve with Bileaflet valve with
additional risk factorsadditional risk factors
Don’t BridgeDon’t Bridge Bileaflet AVBileaflet AV VTE >12 months agoVTE >12 months ago Afib with chad score Afib with chad score ≤ 2 ≤ 2
and no hx of cva/tiaand no hx of cva/tia
Venous Thromboembolism Venous Thromboembolism ProphylaxisProphylaxis
VTE Risk FactorsVTE Risk Factors SurgerySurgery TraumaTrauma ImmobilityImmobility MalignancyMalignancy Hx of VTEHx of VTE Advanced ageAdvanced age Pregnancy/HRTPregnancy/HRT Organ failureOrgan failure IBDIBD
Nephrotic syndromeNephrotic syndrome Myeolproliferative d/oMyeolproliferative d/o PNHPNH ObesityObesity Tobacco abuseTobacco abuse Varicose veinsVaricose veins CV cathetersCV catheters ThrombophiliaThrombophilia
Modes Of ProphylaxisModes Of Prophylaxis
LDUHLDUH LMWHLMWH ASAASA CoumadinCoumadin GCSGCS
Foot pumpersFoot pumpers FondaparinuxFondaparinux Early mobilizationEarly mobilization IPCIPC IVC filterIVC filter
VTE Prophylaxis Made EasyVTE Prophylaxis Made Easy“KISS”“KISS”
Recommend LMWH unless risk of bleeding is Recommend LMWH unless risk of bleeding is high, then use mechanical prophylaxishigh, then use mechanical prophylaxis
However…………….However…………….
VTE ProphylaxisVTE ProphylaxisSpecial CircumstancesSpecial Circumstances
Warfarin vs. LMWH vs. fondaparinuxWarfarin vs. LMWH vs. fondaparinux How long to treat?How long to treat?
HipsHips KneesKnees
Bariatric surgeryBariatric surgery Renal insufficiencyRenal insufficiency HITHIT
Adrenal Physiology Adrenal Physiology Baseline daily cortisol secretion 8-Baseline daily cortisol secretion 8-
10mg10mg Surgical stress increases baseline Surgical stress increases baseline
secretionsecretion Exogenous steroids inhibit CRH and Exogenous steroids inhibit CRH and
ACTH secretion ACTH secretion Adrenal atrophy may result and Adrenal atrophy may result and
blunt normal responseblunt normal response
Who is at risk for HPA Who is at risk for HPA suppression?suppression?
Assume Assume suppressionsuppression
Greater than Greater than 20mg/d prednisone 20mg/d prednisone for more than 3 for more than 3 weeksweeks
Clinically Clinically CushingoidCushingoid
Assume No Assume No SuppressionSuppression
Any dose for less Any dose for less than 3 weeksthan 3 weeks
Less than 5mg/d Less than 5mg/d prednisone for any prednisone for any durationduration
Alternate day Alternate day regimenregimen
Stress Dose SteroidsStress Dose Steroids Minor surgical stressMinor surgical stress
Take usual morning doseTake usual morning dose Moderate surgical stressModerate surgical stress
Take usual morning dose plus 50mg IV HCT Take usual morning dose plus 50mg IV HCT prior to surgery and 25mg IV q8hours for 3 prior to surgery and 25mg IV q8hours for 3 dosesdoses
Major surgical stressMajor surgical stress Take usual am dose plus 100mg IV HCT prior Take usual am dose plus 100mg IV HCT prior
to surgery and 50mg IV q8 for 3 doses, then to surgery and 50mg IV q8 for 3 doses, then taper by 50% each daytaper by 50% each day
What does the data show?What does the data show?
Data limited by few RCTs and low Data limited by few RCTs and low sample sizessample sizes
1-2% incidence of adrenal insufficiency 1-2% incidence of adrenal insufficiency when steroids completely withheldwhen steroids completely withheld
No difference between stress dose and No difference between stress dose and maintenance dose maintenance dose
Patients with adrenal crisis respond to Patients with adrenal crisis respond to “rescue” stress dose steroids“rescue” stress dose steroids
Surgical Patients on Surgical Patients on Chronic Steroids-Chronic Steroids-
SummarySummary Post op adrenal insufficiency is a rare Post op adrenal insufficiency is a rare
but serious complicationbut serious complication With holding steroids completely leads With holding steroids completely leads
to higher rates of crisisto higher rates of crisis Data suggests that maintenance dosing Data suggests that maintenance dosing
with close post-op monitoring is with close post-op monitoring is advisableadvisable
If decision is made to give stress dose If decision is made to give stress dose steroids, follow previous listed recssteroids, follow previous listed recs
Postoperative FeverPostoperative Fever Common, related to cytokinesCommon, related to cytokines History and physical exam only History and physical exam only
recommended for first 48 hours recommended for first 48 hours postoppostop
ReferencesReferences Vinik R, et al. Periprocedural
antithrombotic management:A review of the literature and practical approach for the hospitalist physician. J Hosp Med 4(9) 551-9 November 2009
Guyatt, G, et al. Antithrombotic Therapy and Prevention of Thombosis 9th Ed: ACCP Guidelines. Chest November 2012 Issue 2 Supplement
Badillo A, Sarani B, and S Evans. Optimizing Use of Blood Cultures in the Febrile Postoperative patient. J Am Coll Surg 194(4):477 2002
Axelrod L. Perioperative Management of Patients treated with glucocorticoids. Endocrinol Metab Clin North Am. June 32(2)367:-83 2003.