Perioperative Medicine
Beyond Cardiac Clearance
Pamela Pride MD
July 31, 2012
MUSC
Objectives
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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
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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
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Management of anticoagulation
VTE prophylaxis
Stress dose steroids
Postoperative fever
Antiplatelet Therapy and Surgery
Anticoagulation and Surgery
To bridge or not bridge
Don’t Bridge
Bridge
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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
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Bileaflet AV
VTE >12 months ago
Afib with chad score ≤ 2 and no
hx of cva/tia
Venous Thromboembolism Prophylaxis
VTE Risk Factors
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Surgery
Trauma
Immobility
Malignancy
Hx of VTE
Advanced age
Pregnancy/HRT
Organ failure
IBD
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Nephrotic syndrome
Myeolproliferative d/o
PNH
Obesity
Tobacco abuse
Varicose veins
CV catheters
Thrombophilia
Modes Of Prophylaxis
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LDUH
LMWH
ASA
Coumadin
GCS
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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
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Warfarin vs. LMWH vs. fondaparinux
How long to treat?
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Hips
Knees
Bariatric surgery
Renal insufficiency
HIT
Adrenal Physiology
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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
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Greater than 20mg/d
prednisone for more
than 3 weeks
Clinically Cushingoid
Assume No
Suppression
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Any dose for less than 3
weeks
Less than 5mg/d
prednisone for any
duration
Alternate day regimen
Stress Dose Steroids
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Minor surgical stress
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Moderate surgical stress
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Take usual morning dose
Take usual morning dose plus 50mg IV HCT prior to surgery
and 25mg IV q8hours for 3 doses
Major surgical stress
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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?
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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
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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
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Common, related to cytokines
History and physical exam only recommended
for first 48 hours postop
References
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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.