peri-operative assessments, pain, fever, oliguria and dvt prophylaxis
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Peri-operative Assessments, Pain, Fever, Oliguria and DVT Prophylaxis. Peter E. Rice, MD Surgical Fundamentals Session #4. Question:. - PowerPoint PPT PresentationTRANSCRIPT
Peri-operative Peri-operative Assessments, Pain, Fever, Assessments, Pain, Fever,
Oliguria and DVT Oliguria and DVT ProphylaxisProphylaxis
Peter E. Rice, MD Peter E. Rice, MD Surgical Fundamentals Session #4Surgical Fundamentals Session #4
ALGORITHMS
Pre-operativeAssessment Fever Oliguria PainDVT Prophylaxis
What are the specific pre-operative laboratory tests and/or evaluations that should be performed to confirm or to rule out medical conditions that are likely to impact a patient’s perioperative course?
Question:
> 3 billion dollars are spent each year on pre-op lab evaluations- and > 60% of these are unnecessary
From the Anesthesiologists Point of View………….From the Anesthesiologists Point of View………….
ClassClass Physical StatusPhysical Status 48 hr mortality48 hr mortalityII No systemic diseaseNo systemic disease 0.07%0.07%
IIII Mild systemic disease; no functional Mild systemic disease; no functional limitation (obese, smoker, HTN)limitation (obese, smoker, HTN)
0.24%0.24%
IIIIII Severe, not incapacitating systemic Severe, not incapacitating systemic disease (CAD, CHF, COPD)disease (CAD, CHF, COPD)
1.4%1.4%
IVIV Incapacitating disease that is a Incapacitating disease that is a constant threat to lifeconstant threat to life
7.5%7.5%
VV Moribund pt. not expected to survive Moribund pt. not expected to survive 24 hrs regardless of surgery24 hrs regardless of surgery
8.1%8.1%
EE Suffix added to classSuffix added to class(emergency)(emergency)
Doubles riskDoubles risk
ASA I
18-39 yrNo labs
Females Preg Test
40-59 yrEKG
Females Preg Test
>60yoSMA-7CXREKG
Lab Tests <35 days acceptable w/o change in condition
CXR <6 months
EKG <2 months
Urine pregnancy on day of surgery
ASA II
Laboratory tests as required byASA I patients and tests as
indicated by the patient’s specificdisease states
CXR in all patients >20 pk-yrsmokers
ASA III
CBC
SMA-12
U/A
CXR
EKG
Upreg
Consult from an appropriate physician
Tests as indicated by the patient’s specific disease state
Tests as Indicated by the Disease State…..Tests as Indicated by the Disease State…..
Systems Assessment
CNS
Pulmonary
GI
Heme/Onc
Medications
Seizure/stroke
PFT’s, ABG, Bronchodilators, Steroids
Liver dz
Renal CBC, Lytes
CBC,INR,PT,PTT
Tests as indicated by the patient’s specific disease state
And the risk of the planned procedure
The History and Physical will uncover the clinical risk of the patient
Hx/PE
?Cardiac Disease-CAD,CHF,Arrhythmia,CVA, PVD
Estimate Clinical Risk
Low risk procedure
High risk procedure
Exercise Stress
Dobutamine w/ Echo
Persantine Thallium
OR
A Special Case…….
One Additional NoteOne Additional Note
Patients who are receiving beta-blockers to Patients who are receiving beta-blockers to treat angina, arrhythmias, or hypertensiontreat angina, arrhythmias, or hypertension
Patients undergoing vascular surgery who Patients undergoing vascular surgery who are at high cardiac riskare at high cardiac risk
Patients who are at increased cardiovascular Patients who are at increased cardiovascular riskrisk
advanced ageadvanced age diabetes mellitusdiabetes mellitus renal insufficiencyrenal insufficiency
Perioperative Beta-Blocker Therapy
Fever is a common event but cannot be ignored
Two temperature elevations >38.5 in a 24-hour period
Postoperative Fever T>38.5
Early <48 hours Late >48 hours
Both evaluations begin with History and Physical Exam
•The cause of most postoperative fevers will be elucidated by the history and physical
•Check the comorbidities- transfusion, meds, malignancy, FB, diabetes
•Always check the operative site
Early <48 hours
Physical exam
Wind
Wound
Water
Walk
Wonder Drugs
Late >48 hours Physical Examination
Wound
Respiratory
IV sites
GU
Intra-abdominal
Extremity swelling
cellulitis
drainage
CXR ?AIE
?infected
UA /CX
CT Scan
Duplex
Oliguria
OliguriaAcute oliguria is the excretion of <400cc of urine per day, and is often the earliest sign of impaired renal function
Classification ofAcute Renal
Failure
Prerenal(50%-90% of total cases)Volume depletion
DehydrationHemorrhage
Fluid redistributionCardfiac Failure
Systemic vasodilatationRenovascular obstructive disease
Renal Parenchymal(10-30%)ATN
IschemiaNephrotoxins
GlomerulonephritisVasculitides
Interstitial nephritis
Postrenal(1%-15% of total cases)Obstructive uropathy
Renal pelvis and uretersBladder and urethra
Extravasation
Patient presentswith signs of oliguria
urine output<.5cc/kg/hr
Clinical assessment:Vitals
Check the ChartPhysical ExamUrinary tractobstruction
Administer I.V. fluidchallenge (~10%
circulating volume)isotonic crystalloid
? blood
Urine outputimproves- continue
to monitor
Renal parenchymaldysfunction (UNa>40
mEq/L or FENa>3Stop nephrotoxic drugs
if possibleAvoid contrast agents
Consider loop diuretics
Prerenal dysfunction(UNa<20mEq/L orFENa<1)
Expand intravascular volumeMonitor CVP,PAWP,
?acute renal arterial problems?abdominal compartment
syndrome?CHF
?sepsis
Renal Functionreturns to normal
Continuemonitoring. Avoidhypovolemia and
use of nephrotoxicagents
Renal dysfunctioncontinues orprogresses
Adjust medicationsand fluids
?Renal replacementtherapy CVVH
Renal deteriorationstops or slows
Chronic renal failureensues
Urine output does not resolveRe-evaluate
Administer second IV fluid challenge?CVP
Calculate FENaUrine and Plasma electrolytes
68yo male s/p LAR with loop ileostomy T 37 P 110 BP 110/75 R12 UO 14cc in the last hour
Fe NA = Urine [Na] / Plasma [Na]
Urine [Cr] / Plasma [Na]x100
FeNa < 1% prerenal
FeNa > 2% renal (ATN)
Urinary sodium (meqL) <20 prerenal
>40 renal
Venous ThromboembolismVenous Thromboembolism
DVT
Pulmonary Embolus
National Body Position Statements
o Leapfrog1: • PE is “the most common preventable cause of hospital death in the United States”• Agency for Healthcare Research and Quality (AHRQ)2: Thromboprophylaxis is the number 1 patient safety practice• American Public Health Association (APHA)3: “The disconnect between evidence and execution as it relates to DVT prevention amounts to a public health crisis.”
1. The Leapfrog Group Hospital Quality and Safety Survey. Available at: www.leapfrog.medstat.com/pdf/Final/doc
2. Shojania KG, et al. Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. AHRQ, 2001. Available at: www.ahrq.gov/clinic/ptsafety/
3. White Paper. Deep-vein thrombosis: Advancing awareness to protect patient lives. 2003. Available at: www.alpha.org/ppp/DVT_White_Paper.pdf
Rationale for DVT Rationale for DVT ProphylaxisProphylaxis
High Prevalence of DVTHigh Prevalence of DVT Adverse Consequences of DVTAdverse Consequences of DVT Efficacy and effectiveness of Efficacy and effectiveness of
thromboprophylaxisthromboprophylaxis Highly efficacious in prevention of DVTHighly efficacious in prevention of DVT Highly efficacious in prevention of symptomatic DVT Highly efficacious in prevention of symptomatic DVT
and fatal PEand fatal PE DVT prevention prevents PEDVT prevention prevents PE Cost effectiveness has been demonstratedCost effectiveness has been demonstrated
Absolute Risk of DVT in Absolute Risk of DVT in Hospitalized PatientsHospitalized Patients
Patient GroupPatient Group DVT Prevalence, %DVT Prevalence, %Medical patientsMedical patients 10-2010-20General surgeryGeneral surgery 15-4015-40Major GYN surgeryMajor GYN surgery 15-4015-40Major GU surgeryMajor GU surgery 15-4015-40NeurosurgeryNeurosurgery 15-4015-40StrokeStroke 20-5020-50Hip or Knee surgeryHip or Knee surgery 40-6040-60Major TraumaMajor Trauma 40-8040-80Spinal Cord InjurySpinal Cord Injury 60-8060-80Critical Care patientsCritical Care patients 10-8010-80
Thromboprophylaxis Reduces Thromboprophylaxis Reduces DVT EventsDVT Events
Pulmonary Embolus is the most common Pulmonary Embolus is the most common preventable cause of hospital deathpreventable cause of hospital death
Risk Factors for DVTRisk Factors for DVT SurgerySurgery TraumaTrauma Immobility, paresisImmobility, paresis MalignancyMalignancy Cancer therapyCancer therapy Previous VTEPrevious VTE Increasing ageIncreasing age Pregnancy and postpartumPregnancy and postpartum Estrogen-containing oral Estrogen-containing oral
contraception or HRTcontraception or HRT Selective estrogen receptor Selective estrogen receptor
modulatorsmodulators Acute medical illnessAcute medical illness
Heart or respiratory failureHeart or respiratory failure Inflammatory bowel diseaseInflammatory bowel disease Nephrotic syndromeNephrotic syndrome Myeloproliferative disordersMyeloproliferative disorders Paroxysmal nocturnal Paroxysmal nocturnal
hemoglobinuriahemoglobinuria ObesityObesity Smoking Smoking Varicose veinsVaricose veins Central venous Central venous
catheterizationcatheterization Inherited or acquired Inherited or acquired
thrombophiliathrombophilia
MethodsMethods of Prophylaxisof Prophylaxis Mechanical MethodsMechanical Methods
Graduated Compression StockingsGraduated Compression Stockings Intermittent Pneumatic Compression deviceIntermittent Pneumatic Compression device Venous foot pumpVenous foot pump
StudiesStudies Not blindedNot blinded High rate of false negative scansHigh rate of false negative scans Compliance in true practice – poorCompliance in true practice – poor
Acceptable optionAcceptable option High risk for bleeding High risk for bleeding Adjunct to anticoagulant prophylaxisAdjunct to anticoagulant prophylaxis
Improves efficacy when used in combination with anticoagulant Improves efficacy when used in combination with anticoagulant prophylaxisprophylaxis
AnticoagulantsAnticoagulants Most widely used and studied prophylaxisMost widely used and studied prophylaxis Before 1987, only heparin and warfarin were availableBefore 1987, only heparin and warfarin were available Now,Now,
4 low molecular weight heparins4 low molecular weight heparins1 Factor Xa inhibitor1 Factor Xa inhibitor3 direct thrombin inhibitors3 direct thrombin inhibitors1 coumarin derivative1 coumarin derivative
Unfractionated HeparinUnfractionated Heparin
Potentiates inactivation of Potentiates inactivation of activated enzymes of activated enzymes of clotting cascade, via clotting cascade, via binding to antithrombin IIIbinding to antithrombin III
Effective in preventing DVT Effective in preventing DVT in low and moderate risk in low and moderate risk patientspatients
Does not increase risk of Does not increase risk of hemorrhagehemorrhage
Low Molecular Weight HeparinLow Molecular Weight Heparin
Higher bioavailability; stable and Higher bioavailability; stable and predictable antithrombotic predictable antithrombotic activityactivity
Can be administered once-dailyCan be administered once-daily
Lower risk of thrombocytopeniaLower risk of thrombocytopenia
More effective for high risk More effective for high risk prophylaxis than heparinprophylaxis than heparin
General SurgeryGeneral Surgery 46 RCT Low Dose Unfractionated Heparin 46 RCT Low Dose Unfractionated Heparin
v. placebo or no proph.v. placebo or no proph. Reduced Reduced
DVT 22 to 9%DVT 22 to 9% Symptomatic PE 2 to 1.3%Symptomatic PE 2 to 1.3% Fatal PE 3 to .8%Fatal PE 3 to .8%
Meta-analysis Meta-analysis No increase in wound hematoma or bleedingNo increase in wound hematoma or bleeding
General SurgeryGeneral Surgery LMWH (LMWH (LovenoxLovenox))
Meta-analysis Meta-analysis (Douketis Arch Intern Med (Douketis Arch Intern Med 2002)2002) 70 % reduction DVT v. no prophylaxis70 % reduction DVT v. no prophylaxis
Nine meta-analysis and systematic reviewsNine meta-analysis and systematic reviews No difference in DVT LMWH and UFHNo difference in DVT LMWH and UFH Some trials fewer hematomas and bleeding Some trials fewer hematomas and bleeding
complications with LMWHcomplications with LMWH No difference in total mortality, fatal PE between No difference in total mortality, fatal PE between
LDUH 5000 units TID and LMWHLDUH 5000 units TID and LMWH
General SurgeryGeneral Surgery Low RiskLow Risk
Minor Surgery (hernia repair, outpatient Minor Surgery (hernia repair, outpatient surgery)surgery)
< 40 years of age< 40 years of age No additional risk factorsNo additional risk factors
RiskRisk DVT DVT Calf – 2%Calf – 2% Proximal – 0.4%Proximal – 0.4% PEPE Clinical – 0.2%Clinical – 0.2% Fatal - <0.01%Fatal - <0.01%
Prevention StrategiesPrevention Strategies No specific prophylaxis; early mobilizationNo specific prophylaxis; early mobilization
General SurgeryGeneral Surgery Moderate RiskModerate Risk
Minor Surgery with additional risk factorsMinor Surgery with additional risk factors Age 40-60 with no risk factorsAge 40-60 with no risk factors Major surgery, < 40 with no risk factorsMajor surgery, < 40 with no risk factors
RiskRisk DVTDVT Calf - 10-20%Calf - 10-20% Proximal - 2-4%Proximal - 2-4% PEPE Clinical - 1-2%Clinical - 1-2% Fatal - 0.1-0.4 %Fatal - 0.1-0.4 %
Prevention StrategiesPrevention Strategies LDUH (5,000 units q 12 hours, start 1-2 hrs pre-op)LDUH (5,000 units q 12 hours, start 1-2 hrs pre-op) LMWH ( 30mg daily)LMWH ( 30mg daily)
Graduated Compression StockingsGraduated Compression Stockings Intermittent Pneumatic Compression DevicesIntermittent Pneumatic Compression Devices
General SurgeryGeneral Surgery High RiskHigh Risk
Non-major surgery in age > 60 yr. or have additional Non-major surgery in age > 60 yr. or have additional risk factorsrisk factors
Major Surgery > 40 or have additional risk factorsMajor Surgery > 40 or have additional risk factors RisksRisks
DVTDVT Calf – 20-40%Calf – 20-40% Proximal – 4-8%Proximal – 4-8% PEPE Clinical – 2-4 %Clinical – 2-4 % Fatal – 0.4-1.0%Fatal – 0.4-1.0%
Prevention StrategiesPrevention Strategies LDUH (5,000 U q LDUH (5,000 U q 8 hours8 hours)) LMWH ( 30mg q 12h)LMWH ( 30mg q 12h)
General SurgeryGeneral Surgery Highest RiskHighest Risk
Surgery in patients with multiple risk factorsSurgery in patients with multiple risk factors RiskRisk
DVT Calf – 40-80%DVT Calf – 40-80% Proximal – 10-20%Proximal – 10-20% PE Clinical – 4-10%PE Clinical – 4-10% Fatal - 0.2 - 5%Fatal - 0.2 - 5%
Prevention StrategiesPrevention Strategies LDUH ( 5,000 q 8 hours)LDUH ( 5,000 q 8 hours)
oror LMWH ( 30mg q12h)LMWH ( 30mg q12h)
withwith GCS and/or IPCGCS and/or IPC
General SurgeryGeneral Surgery Special ConsiderationsSpecial Considerations
High Risk of BleedingHigh Risk of Bleeding Properly fitted GCS and/or IPC Properly fitted GCS and/or IPC
Major Cancer SurgeryMajor Cancer Surgery Post hospital discharge prophylaxis with LMWH for Post hospital discharge prophylaxis with LMWH for
2-3 weeks2-3 weeks
Prolonged prophylaxis in abdominal and pelvic cancer Prolonged prophylaxis in abdominal and pelvic cancer reduced DVT 12 to 5%reduced DVT 12 to 5%
Bergqvist NEJM 2002Bergqvist NEJM 2002
Vascular SurgeryVascular Surgery RiskRisk
Aortic Surgery - DVT – 0.9 - 12 %Aortic Surgery - DVT – 0.9 - 12 % No prophylaxis No prophylaxis – 41%– 41%
Femorodistal – DVT – 0.7 – 9%Femorodistal – DVT – 0.7 – 9% No No prophylaxis – 18%prophylaxis – 18%
No routine prophylaxis in patients without risk No routine prophylaxis in patients without risk factors factors
LDUH or LMWH in patients with risk factorsLDUH or LMWH in patients with risk factors
Recommendations in LaparoscopyRecommendations in Laparoscopy European Association for Endoscopic SurgeryEuropean Association for Endoscopic Surgery
Intraoperative IPC for all prolonged laparoscopic Intraoperative IPC for all prolonged laparoscopic proceduresprocedures
SAGESSAGES Same thromboprophylaxis options with Same thromboprophylaxis options with
laparoscopic procedures as for the equivalent laparoscopic procedures as for the equivalent open surgical proceduresopen surgical procedures
ACCPACCP No risk factors – aggressive early mobilization No risk factors – aggressive early mobilization
With risk factors – LDUH, LMWH, IPC or GCSWith risk factors – LDUH, LMWH, IPC or GCS
Major TraumaMajor Trauma Highest Risk of all Hospitalized PatientsHighest Risk of all Hospitalized Patients Risk – without Rx exceeds 50%Risk – without Rx exceeds 50%
DVT Calf – 40-80%DVT Calf – 40-80% Proximal – 10-20%Proximal – 10-20% PE Clinical – 4-10%PE Clinical – 4-10% Fatal - 0.2 - 5%Fatal - 0.2 - 5%
Risk with routine thromboprophylaxisRisk with routine thromboprophylaxis DVT Calf – 27%DVT Calf – 27% Proximal – 7%Proximal – 7%
Increased Risk FactorsIncreased Risk Factors Spinal Cord injury, lower extremity or pelvic Fx, need for Spinal Cord injury, lower extremity or pelvic Fx, need for
surgery, increasing age, surgery, increasing age, femoral venous linefemoral venous line insertion or insertion or major venous repair, prolonged immobility, prolonged major venous repair, prolonged immobility, prolonged ventilatory support and longer duration of hospital stay, +/- ventilatory support and longer duration of hospital stay, +/- ISSISS
Trauma RecommendationsTrauma Recommendations All patients with at least one risk factor All patients with at least one risk factor
receive thromboprophylaxisreceive thromboprophylaxis LMWH as soon as considered ‘safe’LMWH as soon as considered ‘safe’ If LMWH delayed – BootsIf LMWH delayed – Boots Continued thromboprophylaxis until mobility Continued thromboprophylaxis until mobility
adequateadequate Duplex ultrasound screening – high risk and Duplex ultrasound screening – high risk and
suboptimal prophylaxis or no prophylaxissuboptimal prophylaxis or no prophylaxis
PainPain
An unpleasant sensory and emotional An unpleasant sensory and emotional experience associated with actual or experience associated with actual or
potential tissue damage, or described potential tissue damage, or described in terms of such damage.in terms of such damage.
““Pain is whatever the Pain is whatever the experiencing person says it experiencing person says it
is and exists whenever is and exists whenever he/she says it does.”he/she says it does.”
Classes of drugsClasses of drugs
Opioid analgesicsOpioid analgesics
Nonsteroidal anti-inflammatory drugs Nonsteroidal anti-inflammatory drugs (NSAIDS) ((NSAIDS) (Aspirin, Motrin, ToradolAspirin, Motrin, Toradol))
Opioid AnalgesicsOpioid Analgesics
Schedules of Controlled Schedules of Controlled NarcoticsNarcotics
Schedule I:Schedule I: Unacceptable potential for Unacceptable potential for abuse: abuse: Heroin, Cocaine, LSDHeroin, Cocaine, LSD
Schedule II:Schedule II: High potential for abuse and High potential for abuse and dependence: dependence: opioids, amphetaminesopioids, amphetamines
Schedule III:Schedule III: Intermediate potential for Intermediate potential for abuseabuse: codeine+ acetaminophen, : codeine+ acetaminophen, hydrocodone + acetaminophenhydrocodone + acetaminophen
Schedules of Controlled Schedules of Controlled NarcoticsNarcotics
Schedule IV:Schedule IV: Less abuse potential than Less abuse potential than schedule III, minimal dependence: schedule III, minimal dependence: lorazepam alprazolam, diazepamlorazepam alprazolam, diazepam
Schedule V:Schedule V: minimal abuse potential: minimal abuse potential: codiene cough syrup, lomotilcodiene cough syrup, lomotil
ActionAction
Binds to opiate receptors in the central Binds to opiate receptors in the central nervous system. nervous system.
Alters the perception of and response to Alters the perception of and response to painful stimulipainful stimuli
Produces generalized Produces generalized CNS depressionCNS depression
CNS side effects of opioidsCNS side effects of opioids Respiratory depressionRespiratory depression Hypotension, orthostatic hypotensionHypotension, orthostatic hypotension Constipation, nausea,vomitingConstipation, nausea,vomiting Urinary retentionUrinary retention ConfusionConfusion RashRash
Contraindications & Contraindications & PrecautionsPrecautions
Contraindications:Contraindications: HypersensitivityHypersensitivity
Precautions: Precautions: ElderlyElderly Respiratory diseasesRespiratory diseases Head traumaHead trauma Liver or kidney diseaseLiver or kidney disease Opioid addictionOpioid addiction
MorphineMorphine Prototype opioid analgesicPrototype opioid analgesic Equianalgesic doses of opioidsEquianalgesic doses of opioids Indications:Indications:
Severe pain Severe pain Pulmonary edema Pulmonary edema Pain associated with myocardial infarction. Pain associated with myocardial infarction.
Morphine administration routesMorphine administration routes
Many preparations & routes:Many preparations & routes: Oral: tablets, extended release (MS Contin)Oral: tablets, extended release (MS Contin) elixir (Roxanol)elixir (Roxanol) Sublingual tablets: 10 mg, rapidly absorbedSublingual tablets: 10 mg, rapidly absorbed IMIM IV, PCAIV, PCA EpiduralEpidural
Postoperative painPostoperative pain Regular & frequent dosing intervals in Regular & frequent dosing intervals in
early postop period, then PRNearly postop period, then PRN PCA, Epidural, IVPCA, Epidural, IV Opioid Opioid ++ NSAID NSAID Switch to oral dosing when taking poSwitch to oral dosing when taking po
Medicate prior to anticipated painMedicate prior to anticipated pain Ambulation & physical therapyAmbulation & physical therapy Dressing changesDressing changes
PCA: patient controlled PCA: patient controlled analgesiaanalgesia
Self-administration of IV analgesicSelf-administration of IV analgesic Very effective Very effective Prevents delaysPrevents delays Reduces patient anxietyReduces patient anxiety
PCA dosingPCA dosing ExampleExample
Morphine PCA Morphine PCA 30mg/30ml30mg/30ml
Basal rate 1 mg/hr Basal rate 1 mg/hr Demand dose 1-2 mgDemand dose 1-2 mg Lockout 6-8 minutesLockout 6-8 minutes 4 Hour Max4 Hour Max
QUESTIONS ?