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

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.

Perioperative Medicine Beyond Cardiac Clearance Management of anticoagulation Management of anticoagulation VTE prophylaxis VTE prophylaxis Stress dose steroids Stress dose steroids Postoperative fever Postoperative fever

Antiplatelet Therapy and Surgery

Anticoagulation and Surgery

To bridge or not bridge Bridge Dual prosthetic or old valve Dual prosthetic or old valve VTE w/in 3 months VTE w/in 3 months Pregnancy and PV Pregnancy and PV PV with embolism in past 6 months PV with embolism in past 6 months Afib with chad score ≥ 5 Afib with chad score ≥ 5 Bileaflet valve with additional risk factors 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

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

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

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

VTE Prophylaxis Special Circumstances  Warfarin vs. LMWH vs. fondaparinux  How long to treat?  Hips  Knees  Bariatric surgery  Renal insufficiency  HIT

Adrenal Physiology Baseline daily cortisol secretion 8-10mg Baseline daily cortisol secretion 8-10mg Surgical stress increases baseline secretion Surgical stress increases baseline secretion Exogenous steroids inhibit CRH and ACTH secretion Exogenous steroids inhibit CRH and ACTH secretion Adrenal atrophy may result and blunt normal response 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 Greater than 20mg/d prednisone for more than 3 weeks Clinically Cushingoid Clinically Cushingoid Assume No Suppression Any dose for less than 3 weeks Less than 5mg/d prednisone for any duration Alternate day regimen

Stress Dose Steroids Minor surgical stress Minor surgical stress Take usual morning dose Take usual morning dose Moderate surgical stress Moderate surgical stress Take usual morning dose plus 50mg IV HCT prior to surgery and 25mg IV q8hours for 3 doses Take usual morning dose plus 50mg IV HCT prior to surgery and 25mg IV q8hours for 3 doses Major surgical stress 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 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? Data limited by few RCTs and low sample sizes Data limited by few RCTs and low sample sizes 1-2% incidence of adrenal insufficiency when steroids completely withheld 1-2% incidence of adrenal insufficiency when steroids completely withheld No difference between stress dose and maintenance dose No difference between stress dose and maintenance dose Patients with adrenal crisis respond to “rescue” stress dose steroids Patients with adrenal crisis respond to “rescue” stress dose steroids

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

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

References Vinik R, et al. Periprocedural antithrombotic management:A review of the literature and practical approach for the hospitalist physician. J Hosp Med 4(9) November 2009 Vinik R, et al. Periprocedural antithrombotic management:A review of the literature and practical approach for the hospitalist physician. J Hosp Med 4(9) November 2009 Guyatt, G, et al. Antithrombotic Therapy and Prevention of Thombosis 9 th Ed: ACCP Guidelines. Chest November 2012 Issue 2 Supplement Guyatt, G, et al. Antithrombotic Therapy and Prevention of Thombosis 9 th 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): Badillo A, Sarani B, and S Evans. Optimizing Use of Blood Cultures in the Febrile Postoperative patient. J Am Coll Surg 194(4): Axelrod L. Perioperative Management of Patients treated with glucocorticoids. Endocrinol Metab Clin North Am. June 32(2)367: Axelrod L. Perioperative Management of Patients treated with glucocorticoids. Endocrinol Metab Clin North Am. June 32(2)367: