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Perioperative Medicine Beyond Cardiac Clearance

Perioperative Medicine Beyond Cardiac Clearance. Pamela Pride MD July 31, 2012 MUSC. Objectives. 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.

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Perioperative Medicine Beyond Cardiac Clearance

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  1. Perioperative MedicineBeyond Cardiac Clearance Pamela Pride MD July 31, 2012 MUSC

  2. Objectives 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

  3. Key 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.

  4. Perioperative MedicineBeyond Cardiac Clearance Management of anticoagulation VTE prophylaxis Stress dose steroids Postoperative fever

  5. Antiplatelet Therapy and Surgery

  6. Anticoagulation and Surgery

  7. Bridge Dual prosthetic or old valve VTE w/in 3 months Pregnancy and PV PV with embolism in past 6 months Afib with chad score ≥ 5 Bileaflet valve with additional risk factors Don’t Bridge Bileaflet AV VTE >12 months ago Afib with chad score ≤ 2 and no hx of cva/tia To bridge or not bridge

  8. Surgery Trauma Immobility Malignancy Hx of VTE Advanced age Pregnancy/HRT Organ failure IBD Nephrotic syndrome Myeolproliferative d/o PNH Obesity Tobacco abuse Varicose veins CV catheters Thrombophilia Venous Thromboembolism ProphylaxisVTE Risk Factors

  9. LDUH LMWH ASA Coumadin GCS Foot pumpers Fondaparinux Early mobilization IPC IVC filter Modes Of Prophylaxis

  10. VTE Prophylaxis Made Easy“KISS” Recommend LMWH unless risk of bleeding is high, then use mechanical prophylaxis However…………….

  11. VTE ProphylaxisSpecial Circumstances • Warfarin vs. LMWH vs. fondaparinux • How long to treat? • Hips • Knees • Bariatric surgery • Renal insufficiency • HIT

  12. Adrenal Physiology • Baseline daily cortisol secretion 8-10mg • Surgical stress increases baseline secretion • Exogenous steroids inhibit CRH and ACTH secretion • Adrenal atrophy may result and blunt normal response

  13. Assume suppression Greater than 20mg/d prednisone for more than 3 weeks Clinically Cushingoid Assume No Suppression Any dose for less than 3 weeks Less than 5mg/d prednisone for any duration Alternate day regimen Who is at risk for HPA suppression?

  14. Stress Dose Steroids • Minor surgical stress • Take usual morning dose • Moderate surgical stress • Take usual morning dose plus 50mg IV HCT prior to surgery and 25mg IV q8hours for 3 doses • Major surgical stress • Take usual am dose plus 100mg IV HCT prior to surgery and 50mg IV q8 for 3 doses, then taper by 50% each day

  15. What does the data show? • Data limited by few RCTs and low sample sizes • 1-2% incidence of adrenal insufficiency when steroids completely withheld • No difference between stress dose and maintenance dose • Patients with adrenal crisis respond to “rescue” stress dose steroids

  16. Surgical Patients on Chronic Steroids-Summary • Post op adrenal insufficiency is a rare but serious complication • With holding steroids completely leads to higher rates of crisis • Data suggests that maintenance dosing with close post-op monitoring is advisable • If decision is made to give stress dose steroids, follow previous listed recs

  17. Postoperative Fever Common, related to cytokines History and physical exam only recommended for first 48 hours postop

  18. References Vinik R, et al. Periproceduralantithrombotic 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 CollSurg194(4):4772002 Axelrod L. Perioperative Management of Patients treated with glucocorticoids. EndocrinolMetabClin North Am. June 32(2)367:-83 2003.

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