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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Pamela Pride MD
July 31, 2012
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
Guidelines on bridging anticoagulation and surgery suggest case by case decision.
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.
Management of anticoagulation
Stress dose steroids
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
VTE >12 months ago
Afib with chad score ≤ 2 and no hx of cva/tiaTo bridge or not bridge
Hx of VTE
ThrombophiliaVenous Thromboembolism ProphylaxisVTE Risk Factors
IVC filterModes Of Prophylaxis
Recommend LMWH unless risk of bleeding is high, then use mechanical prophylaxis
Greater than 20mg/d prednisone for more than 3 weeks
Assume No Suppression
Any dose for less than 3 weeks
Less than 5mg/d prednisone for any duration
Alternate day regimenWho is at risk for HPA suppression?
Common, related to cytokines
History and physical exam only recommended for first 48 hours postop