Perioperative medicine beyond cardiac clearance
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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
Perioperative MedicineBeyond Cardiac Clearance

Pamela Pride MD

July 31, 2012

MUSC


Objectives
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


Key messages
Key Messages

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.


Perioperative medicine beyond cardiac clearance1
Perioperative MedicineBeyond Cardiac Clearance

Management of anticoagulation

VTE prophylaxis

Stress dose steroids

Postoperative fever




To bridge or not bridge

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


Venous thromboembolism prophylaxis vte risk factors

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


Modes of prophylaxis

LDUH

LMWH

ASA

Coumadin

GCS

Foot pumpers

Fondaparinux

Early mobilization

IPC

IVC filter

Modes Of Prophylaxis


Vte prophylaxis made easy kiss
VTE Prophylaxis Made Easy“KISS”

Recommend LMWH unless risk of bleeding is high, then use mechanical prophylaxis

However…………….


Vte prophylaxis special circumstances
VTE ProphylaxisSpecial Circumstances

  • Warfarin vs. LMWH vs. fondaparinux

  • How long to treat?

    • Hips

    • Knees

  • Bariatric surgery

  • Renal insufficiency

  • HIT


Adrenal physiology
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


Who is at risk for hpa suppression

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?


Stress dose steroids
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


What does the data show
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


Surgical patients on chronic steroids summary
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


Postoperative fever
Postoperative Fever

Common, related to cytokines

History and physical exam only recommended for first 48 hours postop