Peri-operative Assessments, Pain, Fever, Oliguria and DVT Prophylaxis

1. Peri-operative Assessments, Pain, Fever, Oliguria and DVT Prophylaxis Peter E. Rice, MD Surgical Fundamentals Session #4

3. Question: 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? > 3 billion dollars are spent each year on pre-op lab evaluations- and > 60% of these are unnecessary

4. From the Anesthesiologists Point of View………….

5. Lab Tests <35 days acceptable w/o change in condition CXR <6 months EKG <2 months Urine pregnancy on day of surgery

7. 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

8. Tests as Indicated by the Disease State….. CNS Seizure/stroke Pulmonary PFT’s, ABG, Bronchodilators, Steroids GI Liver dz Systems Assessment Renal CBC, Lytes Heme/Onc CBC,INR,PT,PTT Medications

9. Tests as indicated by the patient’s specific disease state And the risk of the planned procedure

10. The History and Physical will uncover the clinical risk of the patient

13. A Special Case……. Low risk procedure OR Hx/PE ?Cardiac Disease-CAD,CHF,Arrhythmia,CVA, PVD Estimate Clinical Risk High risk procedure Exercise Stress Dobutamine w/ Echo Persantine Thallium

14. One Additional Note Patients who are receiving beta-blockers to treat angina, arrhythmias, or hypertension Patients undergoing vascular surgery who are at high cardiac risk Patients who are at increased cardiovascular risk advanced age diabetes mellitus renal insufficiency Perioperative Beta-Blocker Therapy

15. Fever is a common event but cannot be ignored Two temperature elevations >38.5 in a 24-hour period

16. Postoperative Fever T>38.5 Late >48 hours Early <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

17. Early <48 hours Physical exam Wind Wound Water Walk Wonder Drugs

18. cellulitis Wound drainage Respiratory CXR ?AIE IV sites ?infected Physical Examination Late >48 hours GU UA /CX Intra-abdominal CT Scan Extremity swelling Duplex

19. Oliguria Acute oliguria is the excretion of <400cc of urine per day, and is often the earliest sign of impaired renal function Oliguria

21. 68yo male s/p LAR with loop ileostomy T 37 P 110 BP 110/75 R12 UO 14cc in the last hour

22. 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

23. Venous Thromboembolism DVT Pulmonary Embolus

24. National Body Position Statements • 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.” • The Leapfrog Group Hospital Quality and Safety Survey. Available at: www.leapfrog.medstat.com/pdf/Final/doc • Shojania KG, et al. Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. AHRQ, 2001. Available at: www.ahrq.gov/clinic/ptsafety/ • White Paper. Deep-vein thrombosis: Advancing awareness to protect patient lives. 2003. Available at: www.alpha.org/ppp/DVT_White_Paper.pdf

25. Rationale for DVT Prophylaxis • High Prevalence of DVT • Adverse Consequences of DVT • Efficacy and effectiveness of thromboprophylaxis • Highly efficacious in prevention of DVT • Highly efficacious in prevention of symptomatic DVT and fatal PE • DVT prevention prevents PE • Cost effectiveness has been demonstrated

26. Absolute Risk of DVT in Hospitalized Patients

27. Thromboprophylaxis Reduces DVT Events Pulmonary Embolus is the most common preventable cause of hospital death

28. Surgery Trauma Immobility, paresis Malignancy Cancer therapy Previous VTE Increasing age Pregnancy and postpartum Estrogen-containing oral contraception or HRT Selective estrogen receptor modulators Acute medical illness Heart or respiratory failure Inflammatory bowel disease Nephrotic syndrome Myeloproliferative disorders Paroxysmal nocturnal hemoglobinuria Obesity Smoking Varicose veins Central venous catheterization Inherited or acquired thrombophilia Risk Factors for DVT

29. Methodsof Prophylaxis • Mechanical Methods • Graduated Compression Stockings • Intermittent Pneumatic Compression device • Venous foot pump • Studies • Not blinded • High rate of false negative scans • Compliance in true practice – poor • Acceptable option • High risk for bleeding • Adjunct to anticoagulant prophylaxis • Improves efficacy when used in combination with anticoagulant prophylaxis

30. Anticoagulants • Most widely used and studied prophylaxis • Before 1987, only heparin and warfarin were available • Now, 4 low molecular weight heparins 1 Factor Xa inhibitor 3 direct thrombin inhibitors 1 coumarin derivative

31. Unfractionated Heparin Potentiates inactivation of activated enzymes of clotting cascade, via binding to antithrombin III Effective in preventing DVT in low and moderate risk patients Does not increase risk of hemorrhage

32. Low Molecular Weight Heparin Higher bioavailability; stable and predictable antithrombotic activity Can be administered once-daily Lower risk of thrombocytopenia More effective for high risk prophylaxis than heparin

33. General Surgery • 46 RCT Low Dose Unfractionated Heparin v. placebo or no proph. • Reduced • DVT 22 to 9% • Symptomatic PE 2 to 1.3% • Fatal PE 3 to .8% • Meta-analysis • No increase in wound hematoma or bleeding

34. General Surgery • LMWH (Lovenox) • Meta-analysis (Douketis Arch Intern Med 2002) • 70 % reduction DVT v. no prophylaxis • Nine meta-analysis and systematic reviews • No difference in DVT LMWH and UFH • Some trials fewer hematomas and bleeding complications with LMWH • No difference in total mortality, fatal PE between LDUH 5000 units TID and LMWH

35. General Surgery • Low Risk • Minor Surgery (hernia repair, outpatient surgery) • < 40 years of age • No additional risk factors • Risk • DVT Calf – 2% Proximal – 0.4% • PE Clinical – 0.2% Fatal - <0.01% • Prevention Strategies • No specific prophylaxis; early mobilization

36. General Surgery • Moderate Risk • Minor Surgery with additional risk factors • Age 40-60 with no risk factors • Major surgery, < 40 with no risk factors • Risk • DVT Calf - 10-20% Proximal - 2-4% • PE Clinical - 1-2% Fatal - 0.1-0.4 % • Prevention Strategies • LDUH (5,000 units q 12 hours, start 1-2 hrs pre-op) • LMWH ( 30mg daily) • Graduated Compression Stockings • Intermittent Pneumatic Compression Devices

37. General Surgery • High Risk • Non-major surgery in age > 60 yr. or have additional risk factors • Major Surgery > 40 or have additional risk factors • Risks • DVT Calf – 20-40% Proximal – 4-8% • PE Clinical – 2-4 % Fatal – 0.4-1.0% • Prevention Strategies • LDUH (5,000 U q 8 hours) • LMWH ( 30mg q 12h)

38. General Surgery • Highest Risk • Surgery in patients with multiple risk factors • Risk • DVT Calf – 40-80% Proximal – 10-20% • PE Clinical – 4-10% Fatal - 0.2 - 5% • Prevention Strategies • LDUH ( 5,000 q 8 hours) or • LMWH ( 30mg q12h)with • GCS and/or IPC

39. General Surgery • Special Considerations High Risk of Bleeding Properly fitted GCS and/or IPC Major Cancer Surgery Post hospital discharge prophylaxis with LMWH for 2-3 weeks Prolonged prophylaxis in abdominal and pelvic cancer reduced DVT 12 to 5% Bergqvist NEJM 2002

40. Vascular Surgery • Risk • Aortic Surgery - DVT – 0.9 - 12 % No prophylaxis – 41% • Femorodistal – DVT – 0.7 – 9% No prophylaxis – 18% • No routine prophylaxis in patients without risk factors • LDUH or LMWH in patients with risk factors

41. Recommendations in Laparoscopy • European Association for Endoscopic Surgery • Intraoperative IPC for all prolonged laparoscopic procedures • SAGES • Same thromboprophylaxis options with laparoscopic procedures as for the equivalent open surgical procedures • ACCP • No risk factors – aggressive early mobilization With risk factors – LDUH, LMWH, IPC or GCS

42. Major Trauma • Highest Risk of all Hospitalized Patients • Risk – without Rx exceeds 50% • DVT Calf – 40-80% Proximal – 10-20% • PE Clinical – 4-10% Fatal - 0.2 - 5% • Risk with routine thromboprophylaxis • DVT Calf – 27% Proximal – 7% • Increased Risk Factors • Spinal Cord injury, lower extremity or pelvic Fx, need for surgery, increasing age, femoral venous line insertion or major venous repair, prolonged immobility, prolonged ventilatory support and longer duration of hospital stay, +/- ISS

43. Trauma Recommendations • All patients with at least one risk factor receive thromboprophylaxis • LMWH as soon as considered ‘safe’ • If LMWH delayed – Boots • Continued thromboprophylaxis until mobility adequate • Duplex ultrasound screening – high risk and suboptimal prophylaxis or no prophylaxis

45. Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

46. “Pain is whatever the experiencing person says it is and exists whenever he/she says it does.”

47. Classes of drugs • Opioid analgesics • Nonsteroidal anti-inflammatory drugs (NSAIDS) (Aspirin, Motrin, Toradol)

48. Opioid Analgesics

49. Schedules of Controlled Narcotics • Schedule I: Unacceptable potential for abuse: Heroin, Cocaine, LSD • Schedule II: High potential for abuse and dependence: opioids, amphetamines • Schedule III:Intermediate potential for abuse: codeine+ acetaminophen, hydrocodone + acetaminophen

50. Schedules of Controlled Narcotics • Schedule IV: Less abuse potential than schedule III, minimal dependence: lorazepam alprazolam, diazepam • Schedule V: minimal abuse potential: codiene cough syrup, lomotil