Post Trauma Pharmaceutical Care – Clinical Pearls

1. Post Trauma Pharmaceutical Care – Clinical Pearls Erik Feltz, Pharm.D. Clinical Pharmacist, Emergency Services Meriter Hospital Madison, WI

2. Objectives • Understand importance of and appropriate therapy for venous thromboembolism prophylaxis in the post-surgical trauma patient • Differentiate common IV anti-hypertensive agents and their role in the inpatient setting • Recognize differences amongst available insulin therapies for blood glucose control in NPO patients

3. Venous Thromboembolism (VTE) Prophylaxis

4. Case • 55 y.o. male s/p fall from ladder presents with hip fracture and left tibia + ankle fractures requiring surgery. Pt remains intubated post-operatively • Vitals (on arrival): • Ht: 6’1”, Wt: 140kg • BP 170/95, HR 115 • SCr1.2 mg/dL • Na 140, K+ 3.9, Mg 2.1 • H/H 12/35 • Platelets 270 • Temp 98.5 F • BG 210

5. Case • PMH: • HTN • MI • Diabetes • Hyperlipidemia • Medications PTA: • aspirin 81mg once daily • metoprolol XL 50 mg once daily • hydrochlorothiazide 25mg PO every morning • lisinopril 10mg PO every morning • metformin 850mg PO twice daily • glyburide 10mg PO BID with meals • simvastatin 20mg once daily at bedtime

6. Choosing the right therapy… • Risk stratification • Ambulatory status • Renal function • Body Weight • History of Heparin Induced Thrombocytopenia (HIT)/allergies • Contraindications

7. VTE Risk Virchow’s Triad Major orthopedic surgeries confer some of the highest risk of VTE amongst all surgical procedures

9. Contraindications to VTE prophylaxis

10. Atherothrombosis: Clopidogrel Prasugrel Ticagrelor Rivaroxaban, Apixaban AT III + Dabigatran Bivalirudin Heparin Enoxaparin Fondaparinux Thrombolytic Abciximab Eptifibatide Adaptedfrom Falk E, et al. Circulation. 1995;92:657-671.

12. VTE prophylaxis in Orthopedic Surgery • Patients Undergoing Major Orthopedic Surgery: (HFS) • In patients undergoing HFS, we recommend use of one of the following rather than no antithrombotic prophylaxis for a minimum of 10 to 14 days: LMWH, fondaparinux, LDUH, adjusted-dose VKA, aspirin (all Grade 1B) , or an IPCD (Grade 1C) .  • For patients undergoing major orthopedic surgery, we suggest extending thromboprophylaxis in the outpatient period for up to 35 days from the day of surgery rather than for only 10 to 14 days (Grade 2B) • In patients undergoing HFS, irrespective of the concomitant use of an IPCD or length of treatment, we suggest the use of LMWH in preference to the other agents we have recommended as alternatives: fondaparinux, LDUH (Grade 2B), adjusted-dose VKA, or aspirin (all Grade 2C). • For patients in whom surgery is likely to be delayed, we suggest that LMWH be initiated during the time between hospital admission and surgery but suggest administering LMWH at least 12 hours before surgery Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in Orthopedic Surgery Patients Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.CHEST 2012;141(2)(Suppl):e278S–e325S

13. Hypertension Management

14. Case • 55 y.o. male s/p fall from ladder presents with hip fracture and left tibia + ankle fractures requiring surgery. Pt remains intubated post-operatively • Vitals (Day 1 s/p ORIF + DHS): • Ht: 6’1”, Wt: 140kg • BP 215/105, HR 95 • SCr 1.3 mg/dL • Na 140, K+ 3.9, Mg 2.1 • H/H 12/35 • Platelets 270 • Temp 98.5 F • BG 270

15. Case • PMH: • HTN • MI • Diabetes • Hyperlipidemia • Medications PTA: • aspirin 81mg once daily • metoprolol XL 50 mg once daily • hydrochlorothiazide 25mg PO every morning • lisinopril 10mg PO every morning • metformin 850mg PO twice daily • glyburide 10mg PO BID with meals • simvastatin 20mg once daily at bedtime

16. Management Issues • Variable PO absorption/NPO • Acute BP control essential to prevent cardiovascular complications • Hypertension due to other causes (anxiety/pain/withdrawal) • IV medications available to supplement oral therapy in NPO patients • Resume PTA medications ASAP/as able

17. Acute Hypertension Management

18. Acute Hypertension Management

19. IVPB for maintenance therapy

20. Post Operative Hyperglycemia

21. Case • 55 y.o. male s/p fall from ladder presents with hip fracture and left tibia + ankle fractures requiring surgery. Pt remains intubated post-operatively and tube feeding has been initiated which patient is tolerating well. • Vitals ( Day 2 s/p ORIF + DHS): • Ht: 6’1”, Wt: 140kg • BP 158/82, HR 72 • SCr 1.3 mg/dL • Na 140, K+ 3.9, Mg 2.1 • H/H 12/35 • Platelets 270 • Temp 98.5 F • BG 295

22. Case • PMH: • HTN • MI • Diabetes • Hyperlipidemia • Medications PTA: • aspirin 81mg once daily • metoprolol XL 50 mg once daily • hydrochlorothiazide 25mg PO every morning • lisinopril 10mg PO every morning • metformin 850mg PO twice daily • glyburide 10mg PO BID with meals • simvastatin 20mg once daily at bedtime

23. Factors associated with Post operative Hyperglycemia • Stress response induced by surgical procedure • Type of anesthesia used • Individual patient factors: • Type 1 vs. Type 2 DM • infection/sepsis • nutritional status • Steroids • Accurate PTA medication list • PTA medications ≠ Inpatient medications

24. Restarting Oral Antihyperglycemics • metformin – use contraindicated in the presence of renal dysfunction. (SCr≥ 1.4 mg/dL in males and 1.5 in females), or within 48hrs of IV contrast dye • sulfonylureas – stimulate insulin release and may cause hypoglycemia in patients with inadequate PO intake. (glipizide, glyburide, glimepiride, etc) • thiazolidinediones – avoid in patients with CHF, or elevated LFTs (pioglitazone, rosiglitazone)

25. Insulin Comparison

26. Insulin Comparison http://www.endotext.org/diabetes/diabetes17/diabetesframe17.htm

27. THANK YOU!

28. References • Gould MK, Garcia DA, Wren SM, et al.Prevention of VTE in Nonorthopedic Surgical Patients Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012; 141(2)(Suppl):e227S–e277S • Guyatt GH, Akl EA, Crowther M, et al. Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9thed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141;7S-47S • Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in Orthopedic Surgery Patients Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.CHEST 2012;141(2)(Suppl):e278S–e325S • Dasta JF, Boucher BA, Brophy GM, et al. Intravenous to Oral Conversion of Antihypertensives: A Toolkit for Guideline Development. Ann Pharmacother 2010;44: 1430-47. • Qaseem A, Humphrey LL, Chou R, et al. Use of Intensive Insulin Therapy for the Management of Glycemic Control in Hospitalized Patients: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2011;154:260-7.