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.