Putting It All Together Pain Management Delirium Management of  Longterm  Anticoagulants Periop  Medication Management DVT...
CARDIAC  EVALUATION
PERIOPERATIVE  CARDIAC  COMPLICATION RATES Several ‘risk index’ tools are available to help quantify risk of cardiac compl...
Compared with the Goldman, Detsky, and Amer Society of Anesthesiology methods of preop risk assessment the newer Lee index...
Is EMERGENCY noncardiac surgery needed ? OPERATING ROOM Recurrent symptoms ? NO YES NO YES Has coronary angiography or str...
TABLE 1 :   Clinical Predictors of Increased Risk for Perioperative Cardiac Complications <ul><li>Major </li></ul><ul><li>...
Two or more of the following?   † 1. Intermediate clinical predictors 2. Poor functional capacity (less than 4 METS) 3. Hi...
PULMONARY
ASSESSMENT  of  PULMONARY  RISK <ul><li>Postoperative PULMONARY Complcations   Defined  as : PNEUMONIA,  ATELECTASIS, RESP...
PERIOPERATIVE  BETA  BLOCKERS
<ul><li>ELIGIBILITY CRITERIA for USE of PERIPERATIVE  B -BLOCKERS </li></ul><ul><li>MINOR CRITERIA </li></ul><ul><li>Aged ...
Identify Eligible Patients Risk Stratification Intermediate Risk Cardiac Event Rate  Without β-Blockade 2.2% to 6.6% Low R...
SBE PROPHYLAXIS
 
SOURCE : AHA JAMA 1977; 277:1794  Sanford guide 2003 NEGLIBLE RISK ( i.e. same as general population ) Atrial septal defec...
Table 4.  Prophylactic Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures   Table 5. Prophylactic Regi...
DVT  PROPHYLAXIS
Low risk surgical patients  —  Prophylaxis other than early ambulation usually is not recommended in low risk patients.How...
RISK FACTORS :  Advanced age : Prior DVT ; Obesity ; CHF ; Paralysis ; Hypercoagulable state (eg Protein C Defiency , Fact...
<ul><li>PRECAUTIONS  WITH  EPIDURAL CATHETERS  WHEN  USING  LMWH  </li></ul><ul><li>Therefore, the American Society of Reg...
<ul><li>STEPWISE  APPROACH  for  STARTING  PERI-OP  DVT  PROPHYLAXIS </li></ul><ul><li>What type of surgery is the patient...
 
Perioperative  Medication  Management
PERIOPERATIVE  MEDICATION  MANAGEMENT SOURCES:  Spell SO.  Stopping and Restarting medications in the perioperative period...
PERIOPERATIVE  MEDICATION  MANAGEMENT Liquids cleared from stomach within 2 hours of ingestion – no difference in volume o...
Perioperative   Management    of Patients on  Long - term Oral Anticoagulation
Perioperative Management of Patients on Long-term  Oral Anticoagulation Therapy  ( OAT ) LACK of RCT on which to base deci...
HIGH RISK : bridging advised  (1-yr risk of arterial embolism >10%  OR 1-month risk of  VTE  > 10%) Known hypercoagulable ...
INCLUSION  CRITERIA Age > 18 years, needing to undergo therapy with low-molecular-weight heparin Treating physician thinks...
<ul><li>PRECAUTIONS  WITH  EPIDURAL CATHETERS  WHEN  USING  LMWH  </li></ul><ul><li>Therefore, the American Society of Reg...
EPIDURAL ANESTHESIA or ANALGESIA: SPECIAL  CONSIDERATIONS FOR PATIENTS TAKING LONGTERM ANTIPLATELET or ANTICOAGULANT  MEDI...
DELIRIUM
Most common tool for  diagnosing  Delirium is the  CONFUSION ASSESSMENT METHOD   (sensitivity 94-100%; specficity 90-95%) ...
1)   FIRST -   ALWAYS   look for reversible causes  –  ie ELECTROLYTE abnormalities, hypoxemia, hypo/hyperglycemia, dehydr...
 Pain   Management 
   CHOICE of AGENTS :    MEPERIDINE     No  longer considered 1rst line agent    Metabolite= NORMEPERIDINE(NM) has ½ l...
<ul><li>H ISTORY-  MOST important component of Preop assessment.  Check  history of ANESTHESIA PROBLEMS, abnormal BLEEDING...
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Perop Manual

  1. 2. Putting It All Together Pain Management Delirium Management of Longterm Anticoagulants Periop Medication Management DVT Prophylaxis SBE Prophylaxis Periop Beta Blockers Pulmonary Evaluation Cardiac Evaluation CHAPTER
  2. 3. CARDIAC EVALUATION
  3. 4. PERIOPERATIVE CARDIAC COMPLICATION RATES Several ‘risk index’ tools are available to help quantify risk of cardiac complications preoperatively. The oldest of these is the GOLDMAN RISK INDEX which has been validated in other studies since it’s original introduction. The GOLDMAN INDEX may remain the most useful multivariate tool because of it’s ease of use and relative weighting of risk factors. It is useful in stratifying patients into high and low risk categories BUT a large intermediate risk category results. [ N Engl J Med 1977;297:845-850]. Risk of Death and Major Cardiac Complications Based on the Goldman Index Class GOLDMAN CARDIAC RISK INDEX Another useful RISK INDEX tool is the LEE INDEX shown on the next page. Risk Index: Class I = 0-5 points (low), Class II = 6-12 points (intermediate), Class III = 13-25 pts (high), Class IV  25 pts (very high)   4  · Emergency operation  3  · Intraperitoneal, intrathoracic or aortic operation  3  · PO2 <60 or PCO2 >50 mmHg; K<3.0 or HCO3 <20 mEq/L;    BUN >50 or Cr >3.0 mg/dl; abnormal AST, signs of chronic liver disease, or bedridden from noncardiac causes  7  · > 5 PVC / min documented at any time before operation  7  · Rhythm other than sinus or premature atrial contractions on last preoperative EKG  3  · Important aortic stenosis  11  · S3 gallop or jugular venous distention  10  · MI in previous six months  5  · Age > 70 years  POINTS  RISK FACTOR   56% CLASS IV 15.3% CLASS III 4.7% CLASS II 1.3% CLASS I
  4. 5. Compared with the Goldman, Detsky, and Amer Society of Anesthesiology methods of preop risk assessment the newer Lee index was statistically more accurate. <ul><li>ONE POINT FOR EACH of THE FOLLOWING : </li></ul><ul><li>High-risk surgery (intrathoracic, suprainguinal vascular, or intraperitoneal procedure) </li></ul><ul><li>History of ischemic heart disease </li></ul><ul><li>Congestive heart failure </li></ul><ul><li>Cerebrovascular disease </li></ul><ul><li>Insulin-dependent diabetes mellitus </li></ul><ul><li>Serum creatinine > 2.0 mg/dL </li></ul><ul><li>TOTAL POINTS COMPLICATION RATE * </li></ul><ul><li>0 0.4% </li></ul><ul><li>1 1% </li></ul><ul><li>2 7% </li></ul><ul><li>> 2 11% </li></ul><ul><li>* Acute MI, pulmonary edema, ventricular fibrillation or primary cardiac arrest, complete heart block. </li></ul>PERIOPERATIVE CARDIAC COMPLICATION RATES The LEE INDEX for ASSESSING PERIOPERATIVE CARDIOVASCULAR RISK DATA FROM LEE TH, MARCANTONIO ER, MANGIONE CM, ET AL. DERIVATION AND PROSPECTIVE VALIDATION OF A SIMPLE INDEX FOR PREDICTION OF CARDIAC RISK OF MAJOR NONCARDIAC SURGERY. CIRCULATION 1999; 100:1043–1049. Either of these RISK INDEX tools can be used to assess the risk of complications for a given patient. USE the ACC/AHA algorithm on the next page to determine if FURTHER PREOP CARDIAC EVALUATION IS INDICATED .
  5. 6. Is EMERGENCY noncardiac surgery needed ? OPERATING ROOM Recurrent symptoms ? NO YES NO YES Has coronary angiography or stress test been done in the last 2 years ? Has coronary revascularization been done in the last 5 years ? YES Favorable results ? NO Evaluate clinical predictors. º INTERMEDIATE clinical predictors. º MAJOR clinical predictors. º MINOR clinical predictors. º Consider coronary angiography Consider delay or cancel noncardiac surgery. Poor functional capacity (<4METs) * OR HIGH risk procedure. ** Poor functional capacity (< 4 METs ) * AND HIGH risk procedure. ** Moderate or excellent functional capacity ( ≥4 METs) * OR low / intermediate risk procedure. ** Moderate or excellent functional capacity ( ≥4 METs) * OR low / intermediate risk procedure. ** Consider coronary angiography Consider coronary angiography OPERATING ROOM THE ACC/AHA STEPWISE APPROACH to PREOPERATIVE CARDIAC ASSESSMENT NO OPERATING ROOM Noninvasive Testing Noninvasive Testing NEGATIVE NEGATIVE POSITIVE Subsequent care dictated by angiography findings POSITIVE NO YES Subsequent care dictated by angiography findings Medical management and risk factor modification Subsequent care dictated by findings and treatment results º See table 1 * See table 2 ** See table 3 Eagle KA, Berger PB, et al.J Am Coll Card 2002; 39: 542
  6. 7. TABLE 1 : Clinical Predictors of Increased Risk for Perioperative Cardiac Complications <ul><li>Major </li></ul><ul><li>Recent MI (within 30 days ) </li></ul><ul><li>Unstable/ severe angina (Canadian class III or IV) * </li></ul><ul><li>Decompensated CHF </li></ul><ul><li>Significant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias with underlying heart disease, supraventricular arrhythmias with uncontrolled rate) </li></ul><ul><li>Severe valvular disease </li></ul><ul><li>Intermediate </li></ul><ul><li>Mild angina (Canadian class I or II) * </li></ul><ul><li>Prior MI by history or ECG </li></ul><ul><li>Compensated or prior CHF </li></ul><ul><li>Diabetes mellitus </li></ul><ul><li>Renal insufficiency </li></ul><ul><li>Minor </li></ul><ul><li>Advanced age </li></ul><ul><li>Abnormal ECG (LVH, LBBB, ST-T-wave abnormalities) </li></ul><ul><li>Rhythm other than sinus (eg a-fib) * Poor functional capacity </li></ul><ul><li>History of stroke </li></ul><ul><li>Uncontrolled hypertension (e.g., diastolic BP >110 mm Hg) </li></ul>* —Canadian Cardiovascular Society Classification of Angina: 0 = asymptomatic; I = angina with strenuous exercise; II = angina with moderate exertion; III = angina with walking one to two level blocks or climbing one flight of stairs or less at a normal pace; IV = inability to perform any physical activity without development of angina. Excellent (>7 METs) Squash Jogging (10-minute mile) Scrubbing floors Singles tennis Moderate (4 to 7 METs) Cycling Climbing a flight of stairs Golf (without cart) Walking 4 mph Yardwork (e.g., raking leaves, weeding, pushing a power mower) Poor (<4 METs) Vacuuming Activities of daily living (e.g., eating, dressing, bathing) Walking 2 mph Writing TABLE 2 : Functional Status Assessment TABLE 3 : CARDIAC EVENT RISK STRATIFICATION for NONCARDIAC SURGICAL PROCEDURES HIGH RISK (reported cardiac risk often > 5%) * Emergency major operation esp in elderly * Aortic & other major vascular surgery * Peripheral vascular surgery * Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss I NTERMEDIATE ( cardiac risk < 5%) * Intraperitoneal and intrathoracic * Carotid endarterectomy * Head & neck surgery * Orthopedic surgery * Prostate surgery LOW RISK( cardiac risk <1%) * Endoscopic procedures * Superficial procedures * Cataract surgery * Breast surgery COMBINED INCIDENCE of CARDIAC DEATH and NONFATAL MI
  7. 8. Two or more of the following? † 1. Intermediate clinical predictors 2. Poor functional capacity (less than 4 METS) 3. High surgical risk No further preoperative testing recommended Indications for angiography ? (e.g. unstable angina Preoperative angiography Patient ambulatory and able to exercise ? Exercise echo or perfusion imaging . Bronchospasm? 2 nd degree AV block ? Theophyline dependent ? Valvular dysfunction ? Prior symptomatic arrhythmia (particularly ventricular tachycardia) ? Marked hypertension ? Pharmacologic stress imaging (nuclear or echo ) Prior symptomatic arrhythmia (particularly ventricular tachycardia) ? Marked hypertension ? Borderline or low blood pressure ? Marked hypertension ? Poor echo window ? Dobutamine stress echo or nuclear imaging Other (e.g. Holter monitor, angiography Dipyridamole or adenosine perfusion Resting ECG normal ? YES NO YES YES NO YES NO YES ECG ETT NO YES NO NO NO † See tables 1, 2, and 3 for clinical predictors, functional capacity, and surgical risk categories . SUPPLEMENTAL PREOPERATIVE EVALUATION - WHEN and WHICH TEST YES
  8. 9. PULMONARY
  9. 10. ASSESSMENT of PULMONARY RISK <ul><li>Postoperative PULMONARY Complcations Defined as : PNEUMONIA, ATELECTASIS, RESPIRATORY FAILURE, Need for MECHANICAL VENTILATION, BRONCHOSPASM, or EXACERBATION of underlying pulmonary disease. </li></ul><ul><li>MOST IMPORTANT PREDICTOR of PULMONARY RISK is SURGICAL SITE ! Risk increases as incision site approaches DIAPHRAGM . </li></ul><ul><li>MOST IMPORTANT MODIFIABLE RISK FACTOR…SMOKING … BUT risk of Post-op pulmonary complications declines ONLY after 8 weeks of preop cessation . </li></ul><ul><li>POOR FUNCTIONAL STATUS also increases risk of postop pulmonary complications. </li></ul><ul><li>COMBINATIONS of bronchodilators, physical therapy, antibiotics, smoking cessation, and corticosteroids reduce the risk of postop pulmonary complications. </li></ul><ul><li>AGE and OBESITY have NOT been shown to increase RIK of postop pulmonary complications. </li></ul><ul><li>ROUTINE pre-op PFT, ABG, and/or CXR NOT warranted & donot change Tx ORDER only if indicated BASED on H & P . </li></ul>RISK-REDUCTION STRATEGIES . PREOPERATIVE Encourage cessation of cigarette smoking for at least 8 wk Treat airflow obstruction in patients with COPD or asthma (Tx aggressively with inhalers, antibiotics, physical therapy, and steroids when indicated) Administer antibiotics and delay surgery if respiratory infection is present (i.e. COPD pts with active URI, bronchitis, or pneumonia) Begin patient education regarding lung-expansion maneuvers INTRAOPERATIVE Limit duration of surgery to less than 3 hr Use spinal or epidural anesthesia * Avoid use of pancuronium Use laparoscopic procedures when possible Substitute less ambitious procedure for upper abdominal or thoracic surgery when possible POSTOPERATIVE Use deep-breathing exercises or incentive spirometry Use continuous positive airway pressure Use epidural analgesia * Use intercostal nerve blocks * Sneatana GW. Current Concepts: preoperative pulmonary evaluation. NEJM 1999; 340:937-944 * This strategy is recommended, although variable efficacy has been reported in the literature.
  10. 11. PERIOPERATIVE BETA BLOCKERS
  11. 12. <ul><li>ELIGIBILITY CRITERIA for USE of PERIPERATIVE B -BLOCKERS </li></ul><ul><li>MINOR CRITERIA </li></ul><ul><li>Aged 65 years or older </li></ul><ul><li>Hypertension </li></ul><ul><li>Current smoker </li></ul><ul><li>Serum cholesterol at least 240mg/dl </li></ul><ul><li>Diabetes mellitus not requiring insulin </li></ul><ul><li>REVISED CARDIAC RISK INDEX CRITERIA </li></ul><ul><li>High-risk surgical procedure, defined as: intraperitoneal, intrathoracic, or suprainguinal vascular procedure </li></ul><ul><li>Ischemic heart disease, defined as following : History of MI History of OR current angina Use of sublingal TNG Positive exercise results Q waves on EKG </li></ul><ul><li>Patients have had transluminal coronary angioplasty or CABG and chest pain presumed to be of ischemic etiology </li></ul><ul><li>Cerebrovascular disease, defined as : History of TIA History of Stroke </li></ul><ul><li>Diabetes mellitus requiring insulin </li></ul><ul><li>Chronic renal insuff with creatinine >2.0mg/dl </li></ul><ul><li>PERIOPERATIVE β -BLOCKERS: AGENTS and REGIMENS </li></ul><ul><li>Prehospitalization (Outpatients) or Immediately Following Admission to Hospital </li></ul><ul><li>Not taking β-blockers long-term </li></ul><ul><li>Atenolol, 50-100 mg, periop qd or bisoprolol, 5-10 mg,qd </li></ul><ul><li>Begin as outpatient up to 30 days before surgery </li></ul><ul><li>Titrate to heart rate of ≤65/min </li></ul><ul><li>Taking β-blockers long-term </li></ul><ul><li>Continue long-term therapy </li></ul><ul><li>Titrate heart rate to ≤65/min, if needed </li></ul><ul><li>Immediate Postop Period (ie, in Preanesthesia Holding Area) </li></ul><ul><li>Atenolol, 5-10 mg, IV to reach target HR before introduction of anesthesia, if needed, whether β-blockers taken long-term or not </li></ul><ul><li>Immediate Postop Period and Transition to PO Meds (Whether β-Blockers Taken Long-term or not) </li></ul><ul><li>Patient not taking oral medications and hemodynamically stable </li></ul><ul><li>Atenolol, 5-10 mg, intravenously twice daily to target HR * Patient unstable, eg, high bleeding risk or in the intensive care unit </li></ul><ul><li>Esmolol, 500 μg/kg, intravenously for 1 minute and then infusion of 50-200 μg/kg per minute to target heart rate </li></ul><ul><li>Patient taking oral medications </li></ul><ul><li>Resume perioperative β-blocker use at previous dose; titrate as necessary to target heart rate </li></ul><ul><li>Overlap first oral dose with continued intravenous agents to maintain target heart rate, if necessary </li></ul>SUGGESTED EXCLUSION CRITERIA FOR PROPHYLACTIC BETA BLOCKERS * Known intolerance * Decompensated CHF or known severe LV dysfunction * Hx of Asthma or COPD with recent exacerbation or chronic severe * 2 nd or 3 rd degree heart block w/o pacer * Baseline HR < 60 or SBP < 110
  12. 13. Identify Eligible Patients Risk Stratification Intermediate Risk Cardiac Event Rate Without β-Blockade 2.2% to 6.6% Low Risk Cardiac Event Rate Without β-Blockade 0.4% to 1.0 % High Risk Cardiac Event Rate Without β-Blockade 3 - 4 Criteria: 9.2% to 18% ≥ 5 Criteria: 32% Assess Functional Status: Both (1) History of Angina or Peripheral Vascular Disease and (2) Poor (<4 NETS) or Indeterminate Functional Status? Additional Risk Stratification With Noninvasive Tests Good Functional Status Additional Risk Stratification With Noninvasive Tests Cardiac Event Rate With β-Blockade 0.8% to 1.6% Begin β Blockade Proceed With Surgery Consider Additional Therapies to Reduce Risk, eg, Coronary Revascularization Negative Noninvasive Test Results Positive Noninvasive Test Results Positive Noninvasive Test Results Negative Noninvasive Test Results ≥ 3 Revised Cardiac Risk Index Criteria 1-2 Revised Cardiac Risk Index Criteria Or Any 2 Minor Criteria No Revised Cardiac Risk Index And No Minor Criteria No YES No β Blockade Necessary Proceed With Surgery Begin β Blockade Proceed With Surgery Cardiac Event Rate With β-Blockade unknown Cardiac Event Rate With β-Blockade unknown Cardiac Event Rate With β-Blockade 6.5% to 16% Cardiac Event Rate With β-Blockade 0.4% Consider Additional Therapies to Reduce Risk, eg, Coronary Revascularization Begin β Blockade Proceed With Surgery Perioperative β-Blockers; Patient Selection and Preoperative Risk Stratification Examples of activities that expend about 4 METS (metabolic equivalent tasks) include climbing 1 flight of stairs, being able to walk on level ground at 4 mph, or being able to climb a short hill without difficulty. SOURCE : Auerbach ad, Goldman L. Beta-Blockers and reduction of cardiac events in noncardiac surgery:scientific review . JAMA 2002; 287:1435-44
  13. 14. SBE PROPHYLAXIS
  14. 16. SOURCE : AHA JAMA 1977; 277:1794 Sanford guide 2003 NEGLIBLE RISK ( i.e. same as general population ) Atrial septal defect or repaired ASD/VSD, or PDA (beyond 6 months) Previous CABG, mitral prolapse without MI Physiologic, functional, or innocent murmurs Previous Kawasaki or Rheumatic fever without valve dysfunction Cardiac pacemakers9all) and implanted defibrillators Cardiac conditions associated with endocarditis HIGH-RISK CONDITIONS: Prosthetic valves – both bioprosthetic and homograft Previous bacterial endocarditis Complex cyanotic congenital heart disease(CHD)e.g. single ventricle, transposition, tetrology of Fallot Surgically constructed systemic pulmonic shunts or conduits MODERATE_RISK CONDITIONS: Most other CHD; hypertrophic cardiomyopathy; mitral valve prolapse WITH regurgitation ENDOCARDITIS PROPHYLAXIS IS NO T RECOMMENDED ENDOCARDITIS PROPHYLAXIS RECOMMENDED
  15. 17. Table 4. Prophylactic Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures Table 5. Prophylactic Regimens for Genitourinary/Gastrointestinal (Excluding Esophageal) Procedures SOURCE : AHA JAMA 1977; 277:1794 Sanford guide 2003 Adults : 600 mg; Children: 20 mg/kg IV within 30 min before procedure Adults: 1.0 g; Children ; 25mg/kg IM or IV within 30 min before procdure Clindamycin OR Cefazolin † ALLERGIC to PCN and UNABLE to TAKE PO MEDS Adults: 600 mg; Children: 20 mg/kg orally 1 h before procedure Adults: 2.0 g; Children ; 50 mg/kg orally 1 h before procedure Adults : 500 mg; Children: 15 mg/kg orally 1 h before procedure Clindamycin OR Cephalexin † or cefadroxil † OR Azthromycin orclarithromycin ALLERGIC to PENICILLIN Adults: 2.0 g IM or IV ; Children: 50 mg/kg IM or IV within 30 min before procedure Ampicillin UNABLE to TAKE ORAL MEDS Adults: 2.0 g; Children: 50 mg/kg orally 1 h before procedure Amoxicillin STANDARD GENERAL PROPHYLAXIS REGIMEN AGENT SITUATION Adults: vancomycin 1.0 g IV over 1-2 h complete infusion within 30 min of starting procedure Children: vancomycin 20 mg/kg IV over 1-2 h; complete infusion within 30 min of starting procedure Vancomycin Moderate-risk patients allergic to ampicillin/amoxicillin Adults: amoxicillin 2.0 g orally 1 h before procedure, or ampicillin 2.0 g IM/IV within 30 min of starting procedure Children: amoxicillin 50 mg/kg orally 1 h before procedure, or ampicillin 50 mg/kg IM/IV within 30 min of starting procedure Amoxicillin or ampicillin Moderate-risk patients Adults: vancomycin 1.0 g IV over 1-2 h plus gentamicin 1.5 mg/kg IV/IM (not to exceed 120mg); complete infusion within 30 min. of starting procedure Children: vancomycin 20 mg/kg IV over 1-2 h plus gentamicin 1.5 mg/kg IV/IM; complete injection/infusion within 30 min of starting procedure Vancomycin plus Gentamicin High-risk patients allergic to ampicillin / amoxicillin Adults: ampicillin 2.0 g IM or IV plus gentamicin 1.5 mg/kg (not to exceed 120 mg) within 30 min of starting procedure; 6 h later, ampicillin 1 g IM/IV or amoxicillin 1 g orally Children: ampicillin 50 mg/kg IM or IV (not to exceed 2.0 g) plus gentamicin 1.5 mg/kg within 30 min of starting the procedure; 6 h later, ampicillin 25 mg/kg IM/IV or amoxicillin 25 mg/kg orally Ampicillin plus gentamicin High-risk patients REGIMEN AGENT SITUATION
  16. 18. DVT PROPHYLAXIS
  17. 19. Low risk surgical patients — Prophylaxis other than early ambulation usually is not recommended in low risk patients.However, prophylaxis may be used in certain circumstances. The custom in some countries to use graduated compression stockings ( ES), but this is not based on evidence from clinical trials. Moderate risk surgical patients — The following are recommendations for moderate risk patients: SQ low dose unfractionated heparin (LDUH) 5000 units q 8 or12 hours,or SQ (LMWH) is recommended for patients undergoing general abdominal, thoracic, or gynecologic surgery.The 2 types of heparin are equally effective, but in meta-analyses less bleeding has been seen with LMWH .Intermittent pneumatic compression (IPC) until the patient is ambulatory is an alternative for patients at high risk of bleeding. Pharmacologic methods may be combined with IPC or ES. High risk surgical patients — The following recommendations apply to high risk patients. They vary somewhat according to the clinical setting. High risk general surgery patients are typically treated with subcutaneous LMWH .Pharmacologic therapy may be combined with IPC in patients at highest risk. Adjusted dose heparin requires frequent monitoring and is seldom used.     Knee replacement — Following elective knee replacement, either LMWH (given once or twice daily), or adjusted dose oral anticoagulants can be used .Continue for at least seven to ten days. One trial found that LMWH started within 8hrs of TKR surgery significantly reduced the incidence of DVT when compared with adjusted dose warfarin _Prolonging therapy for additional 3-6 weeks does not appear to provide further benefit. IPC was found to be effective in earlier studies and is a useful alternative.    Hip replacement — Several approaches are effective for patients undergoing total hip replacement. Subcutaneous LMWH (given once or twice daily) or adjusted dose oral anticoagulation is effective and safe in patients undergoing hip replacement. As with knee replacement, prophylaxis should be continued for at least seven to ten days. _____In North America, LMWH has usually been started between 12 and 24 hours after surgery. One trial found that LMWH given within two hours preop, or 4-6 hours postop, significantly decreased both total and proximal DVT compared to warfarin . Timing of the first dose of LMWH following total hip replacement was further assessed in a meta-analysis of four trials . Early initiation of half-dose LMWH between two and six hours postoperatively was associated with decreased clot formation when compared with warfarin or LMWH treatment beginning 12 or more hours postoperatively . Risk of bleeding was similar in both groups. Randomized trials have shown that extended LMWH prophylaxis through postoperative day 27 to 35 significantly reduced the incidence of total DVT . Two separate meta-analyses showed a significant decrease in the incidence of DVT or PE versus placebo, without an increase in major bleeding episodes.    Hip fracture — DVT prophylaxis is becoming a routine aspect in care of the patient with hip fracture. However, questions remain, including choice of optimal agent and the timing and duration of prophylaxis . We recommend either one of two approaches for prophylaxis against DVT in patients with hip fractures : . 1) Oral anticoagulation with warfarin to an INR of 2.0 to 3.0 OR 2) fixed dose SQ LMWH started preoperatively. Use of EC with either approach may provide additional benefit in certain patients. DVT PROPHYLAXIS in the SURGICAL PATIENT Pineo GF. Prevention of Thromboembolic Disease. 2004 ; UpToDate online 12.1
  18. 20. RISK FACTORS : Advanced age : Prior DVT ; Obesity ; CHF ; Paralysis ; Hypercoagulable state (eg Protein C Defiency , Factor V Leiden etc.) REFERENCE : Geerts WH,et al . Sixth ACCP Consensus Conference on Antithrombotic Therapy . Chest 2001;119: 132S-175S DVT PROPHYLAXIS in SURGICAL PATIENTS TIP – CHECK PLATELET COUNT on DAYS 3 and 7 to R/O HEPARIN INDUCED THROMBOCYTOPENIA ! ENOXAPARIN 30mg SQ q12hr start 12-24hr post-op ENOXAPARIN 40mg SQ once daily starting 10-12 hr pre-op Start 5-10mg warfarin night before or immediately after surgery and adjust to INR 2-3 Prolonged prophylaxis ~4wksin THR others until fully ambulatory LMWH or warfarin May combine w/ ES or IPC ELECTIVE HIP REPLACEMENT ELECTIVE KNEE REPLACEMENT HIP FRACTURE SURGERY ENOXAPARIN 40mg SQ, 1-2hr pre-op and then once daily post-op LDUH or LMWH w/ ES or IPC GENERAL SURGERY-VERY HIGH RISK : Major surgery over age 40 plus RISK factors* HEPARIN 5000 units SQ q8-12 hrs start 1-2 hr before surgery ENOXAPARIN 40mg SQ, 1-2hr pre-op and then once daily post- op ENOXAPARIN 30mg SQ, q12hr start 8-12hr post-op LDUH, LMWH GENERAL SURGERY-HIGH RISK : nonmajor surgery over age 60 or age >40 with risks. Major surgery > 40 yr.* HEPARIN 5000 units SQ q8-12 hrs start 1-2 hr before surgery ENOXAPARIN 30 mg SQ, q12hr start 8-12hr post-op LDUH, LMWH, ES, or IPC GENERAL SURGERY-MODERATE RISK : minor procedure but with risk factor, nonmajor surgery age 40-60 with no risks, or major surgery <40 years with no risks* Early ambulation NONE GENERAL SURGERY-LOW RISK : minor procedures, <40 years, no risks* Dosage Recommended Prophylaxis Surgery / Condition
  19. 21. <ul><li>PRECAUTIONS WITH EPIDURAL CATHETERS WHEN USING LMWH </li></ul><ul><li>Therefore, the American Society of Regional Anesthesia recommends the following for patients receiving neuraxial blockade an d concurrent anticoagulant therapy or DVT prophylaxis </li></ul><ul><li>IF LMWH IS USED PREOPERATIVELY : </li></ul><ul><li>Co administration of antiplatelet or oral anticoagulant medication is contraindicated </li></ul><ul><li>Lumbar puncture should be delayed at least 12 hours after the last thromboprophylactic dose of LMWH (enoxaparin 40 mg), and at least 24 hours if treatment doses of LMWH being used (eg, enoxaparin 1 mg/kg every 12 hours or enoxaparin 1.5 mg/kg every 24 hours). </li></ul><ul><li>IF A LMWH IS USED POSTOPERATIVELY : </li></ul><ul><li>The first dose should be given no earlier than 24 hours after surgery if being given twice daily for prophylaxis or at treatment doses </li></ul><ul><li>Indwelling catheters may be safely maintained if low-molecular-weight heparins are given as a single daily thromboprophylactic dose </li></ul><ul><li>In general, the epidural catheter should be removed about 12 hours after the last prophylactic dose </li></ul><ul><li>The first dose of a low-molecular-weight heparin should be given no earlier than 2 hours after the catheter is removed </li></ul><ul><li>Concurrent use of a low-molecular-weight heparin and indwelling epidural catheter is generally not recommended </li></ul><ul><li>LMWH should be delayed for 24 hrs if the patient had excessive trauma to epidural space during attempted epidural or spinal anesthesia </li></ul>PARASPINAL HEMATOMA is a rare complication that can develop in patients that receive neuraxial blockade (spinal or epidural anesthesia or epidural analgesia) and concurrent anticoagulant therapy or DVT prophylaxis All patients should be monitored carefully and frequently for new onset of back pain and for symptoms or signs of cord compression ( eg , progression of lower extremity numbness or weakness , bowel or bladder dysfunction ).When Spinal hematoma is suspected, perform diagnostic imaging and definitive surgical therapy ASAP to reduce the risk of permanent paresis * Horlocker TT, Wedel DJ, Benzon H, et al . Regional anesthesia in the anticoagulated patient: defining the risks 2 nd ASRA Consensus Conf on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003; 28:172–197. * Horlocker TT . Thromboprophylaxis and neuraxial anesthesia . Orthopedics 2003; 26(suppl 2):243–249. Jaffer AK, Brotman DJ,Chukwumerue N . When patients on warfarin need surgery . ClevelandClinJnlMed 2003;70(11): 973-984 CAUTION ! ANTITHROMBOTIC DRUGS and REGIONAL ANESTHESIA
  20. 22. <ul><li>STEPWISE APPROACH for STARTING PERI-OP DVT PROPHYLAXIS </li></ul><ul><li>What type of surgery is the patient having ? </li></ul><ul><li>Are there any contraindications to DVT prophylaxis with anticoagulants ? </li></ul><ul><li>Will or has the patient had spinal or epidural anesthesia ? </li></ul><ul><li>Does the patient have a history of heparin induced thrombocytopenia ? </li></ul><ul><li>Choose DVT prophylaxis based on above answers. </li></ul><ul><li>Be sure to monitor PLATELETS ( check on day 3 & 7 ) and Hgb/Hct ! </li></ul>Risk of DVT/PE without Prophylaxis – Based on Surgical Risk Category 4-10% 4-7% 10-20% 40-80% VERY HIGH RISK 2-4% 1-5% 4-8% 20-40% HIGH RISK 1-2% 0.1-0.7% 2-4% 10-20% MODERATE RISK 0.2% <0.01% 0.4% < 2% LOW RISK Risk Risk Clinical PE FATAL PE Risk Proximal DVT Risk Calf DVT
  21. 24. Perioperative Medication Management
  22. 25. PERIOPERATIVE MEDICATION MANAGEMENT SOURCES: Spell SO. Stopping and Restarting medications in the perioperative period . Med Clinics of North Am 2001 Sept; 85(5):1117-1128 Paulman P, Paulman A. Perioperative Care . AAFP Home Study Monograph 2001; 263: 3-37 Kuwajerwala NK.Perioperative medication management. 2002: emedicine.com accessed 28 May 2004 Mercado DL, Petty BG.Perioperativ medication macnagement. MedClinics of NorthAm 2003 Jan;87(1): 41-58 Can resume when hemodynamically stable. Stop 2-3 days before surgery if possible to decrease risk of perioperative renal compromise. NSAID Resume when eating regular diet. Stop meds day before surgery. DRUG for DYSLIPIDEMIA (statins, niacin, etc. ) Resume when pt taking PO. D/C night before surgery. ( Has long ½ life ) AMIODARONE Transdermal clonidine or IV methyldopa while NPO Usual dose morning of surgery with sip water 2 hours before surgery. CENTRAL-ACTING SYMPATHOLYTICS Usual dose morning of surgery with sip water 2 hours before surgery. THYROXINE Restart when taking PO. Stop day before surgery. DIURETICS and KCL SUPPLEMENTS Continue IV dose until can take PO. Usual dose morning of surgery with sip water 2 hours before surgery. ACE INHIBITORS Continue IV dose until can take PO. Usual dose morning of surgery with sip water 2 hours before procedure. CALCIUM CHANNEL BLOCKERS Continue IV dose until can take PO. Usual dose morning of surgery with sip water 2 hours before procedure. BETA BLOCKERS Insulin until eating. D/C oral formulations night before surgery and convert to insulin either IV or SQ. Stop METFORMIIN 48 hrs before procedure. ORAL HYPOGLYCEMICS Resume warfarin- use LMWH ‘til INR therapeutic D/C 3-5 days before surgery patient may require bridging anticoagulation depending on condition. ANTICOAGULANTS Paste until taking PO. SL ok until anesthesia, convert to nitropaste during perioperative period NITRATES AFTER SURGERY PREOPERATIVE INSTRUCTIONS MEDICATION
  23. 26. PERIOPERATIVE MEDICATION MANAGEMENT Liquids cleared from stomach within 2 hours of ingestion – no difference in volume or pH of gastric contents versus taking clear liquids 9 hours before surgery. Therefore meds can be taken with sip of water up to 2 hours prior to anesthesia. If patient on ELDEPRYL it is a MOA – Discuss with anesthesologist BEFORE surg. Sinemet should be continued in periop period. Bromocriptine & pergolide DON”T give day of surgery. MOA can have FATAL interaction with DEMEROL ANTIPARKINSON MEDS Stop 7 – 10 days befor surgery. ASA – PLAVIX – TICLID - DIPYRIDAMOLE Continue IV dose until can take PO. Should be continued in perioperative period.If on med w/o IV form (i.e.Tegretol and Depakote) and long NPO time likely then convert to drug with IV form and load PREOP . ANTIEPILEPTICS Abrupt D/C may result in serious withdrawal syndromes. Both should be continued with minimal interruption in the periop period in pts that use chronically. BENZODAZEPINES and OPIOID ANALGESICS Should be continued through the perioperative period. ANTIPSYCHOTICS Some recommend cautious continuation through surgery . TCA Resume when renal function and electrolytes are stable. Some recommend stopping 2-3 days before MAJOR surgery. Others say OK to continue but monitor levels and lytes closely. LITHIUM Resume when taking PO. OK to take day of surgery wth sip of water ~ 2 hours before surgery. SSRI Resume when fully ambulatory. Most stop about 4 weeks before major surgery (if possible} due to increased DVT risk HRT Resume when fully ambulatory. No consensus- many recommend D/C ~4 weeks before MAJOR surgeries because of increased DVT risk. ORAL CONTRACEPTIVES Can use IV until taking PO. Monitor levels if renal/fluid status changes. Most recommend take day of surgery wth sip of water ~ 2 hours before surgery. DIGOXIN Resume after discharge Stop use 1-2 weeks before surgery is recommended HERBAL PRODUCTS AFTER SURGERY PREOPERATIVE INSTRUCTIONS MEDICATION
  24. 27. Perioperative Management of Patients on Long - term Oral Anticoagulation
  25. 28. Perioperative Management of Patients on Long-term Oral Anticoagulation Therapy ( OAT ) LACK of RCT on which to base decisions – recommendations based on General Consensus THREE MANAGEMENT OPTIONS for PATIENT on OAT THAT NEEDS SURGERY : 1) STOP OAT 4-5 days before SURGERY- Operate when INR ≤ 1.5 (≤ 1.2 if NEUROSURGERY)- restart OAT after surgery with DVT prophylaxis 2) CONTINUE OAT but keep INR on low end of THERAPEUTIC range and proceed with SURGERY 3) STOP OAT 4-5 days BEFORE surgery – use LMWH or UFH as ‘BRIDGING THERAPY’ ( see protocol ) CHOICE of which option is appropriate depends on RISK of BLEEDING WITH anticoagulation VS. RISK of THROMBOEMBOLISM (TE) WITHOUT anticoagulation (see TABLE 1 and see below) MOST patients will NEED to follow OPTION 1 PROCEDURES THAT DO NOT REQUIRE STOPPING ‡ “OAT” PRIOR TO SURGERY  CATARACT EXTRACTION  TRABECULECTOMIES  ROUTINE DENTAL SURGERIES * Restorations Peridontal Endodontics Dental hygeine Uncomplicated extractions  DERMATOLOGICAL PROCEDURES  SOFT TISSUE and JOINT INJECTIONS ‡ GOAL IS TO HAVE INR IN LOWER END OF THERAPEUTIC RANGE i.e. TARGET INR around 2.0 * TRANEXAMIC ACID MOUYHWASH HELPS DECREASE BLEEDING AFTER DENTAL SURGERY WHILE ON `OAT’   Kaboli p, Henderson MC, White RH. DVT prophylaxis and anticoagulation in the surgical patient.MedClinN Am 2003;87(1):77-110 Spandorfer J. The management of anticoagulation before and after procedures. MedClinN Am 2001; 85(5):1109-1116
  26. 29. HIGH RISK : bridging advised (1-yr risk of arterial embolism >10% OR 1-month risk of VTE > 10%) Known hypercoagulable state as documented by a thromboembolic event and one of the following: Protein C deficiency Protein S deficiency Antithrombin III deficiency Homozygous factor V Leiden mutation Antiphospholipid-antibody syndrome Hypercoagulable state suggested by recurrent ( ≥two ) arterial or idiopathic venous thromboembolic events (not _ including primary atherosclerotic events, such as stroke or MI due to intrinsic cerebrovascular or CAD ) Venous or arterial thromboembolism within the preceding 1–3 months Rheumatic atrial fibrillation Acute intracardiac thrombus visualized by echocardiogram Atrial fibrillation plus mechanical heart valve in any position Older mechanical valve model (single-disk or ball-in-cage) in mitral position Recently placed mechanical valve (< 3 months) Atrial fibrillation with history of cardioembolism HIGH RISK : bridging case-by-case basis ( 1-year risk of arterial embolism 5-10%, or 1-month risk of VTE 2-10% ) Cerebrovascular disease with multiple ( ≥ two ) strokes or TIAs without risk factors for cardiac embolism Newer mechanical valve model (eg, St. Jude) in mitral position Older mechanical valve model in aortic position Atrial fibrillation without a history of cardiac embolism but with multiple risks for cardiac embolism(eg, EF < 40%, DM,HTN, nonrheumatic valvular heartdisease, transmural MI within preceding month) Venous thromboembolism > 3–6 months ago * LOW RISK: bridging not advised ( 1-year risk of arterial embolism less than 5%, or 1-month of VTE < 2% ) One remote venous thromboembolism (> 6 months ago) * Intrinsic cerebrovascular disease (such as carotid atherosclerosis) without recurrent strokes or TIAs Atrial fibrillation without multiple risks for cardiac embolism Newer-model prosthetic valve in aortic position * For pts with a history of venous thromboembolism (VTE) undergoing major surgery, consideration can be given to postoperative bridging therapy only (without preoperative bridging) Jaffer AK, Brotman DJ,Chukwumerue N . When patients on warfarin need surgery . ClevelandClinJnlMed 2003;70(11): 973-984 WHICH PATIENTS on WARFARIN SHOULD RECEIVE HEPARIN BRIDGING BEFORE SURGERY ?
  27. 30. INCLUSION CRITERIA Age > 18 years, needing to undergo therapy with low-molecular-weight heparin Treating physician thinks patient needs bridging therapy (see TABLE 1) Medically and hemodynamically stable Scheduled for elective procedure or surgery EXCLUSION CRITERIA Allergy to unfractionated heparin or low-molecular-weight heparin Weight > 150 kg Pregnant woman with a mechanical valve History of bleeding disorder or intracranial hemorrhage Creatinine clearance < 30 mL/minute Gastrointestinal bleeding within the last 10 days Major trauma or stroke within the past 2 weeks History of heparin-induced thrombocytopenia or severe thrombocytopenia Severe liver disease BEFORE SURGERY If preoperative INR is 2.0–3.0, stop warfarin 5 days before surgery (ie, hold four doses) If preoperative INR is 3–4.5, stop warfarin 6 days before surgery (hold five doses) Start low-molecular-weight heparin 36 hours after last warfarin dose, ie: Enoxaparin 1 mg/kg SQ q 12 hours, ORr Enoxaparin 1.5 mg/kg SQ every 24 hours Give last dose of LMWH approximately 24 hours before procedure Educate patient in self-injection and provide with written instructions Discuss plan with surgeon and anesthesiologist Check INR AM of surgery to ensure that it is <1.5, or in some cases (eg,neurologic surgery) <1.2 AFTER SURGERY Restart LMWH ~24 hrs after procedure or consider thromboprophylactic dose of LMWH on first postoperative day if patient is at high risk for bleeding Discuss above with surgeon Start warfarin at patient’s preop dose on postop day 1 Daily PT and INR until patient discharged and periodically thereafter until INR in therapeutic range Daily phone follow-up with patient Complete CBC with platelets on day 3 and day 7 Discontinue LMWH when INR is 2–3 for 2 consecutive days Cleveland Clinic PROTOCOL FOR LMWH AS A BRIDGE TO SURGERY IN PATIENTS WARFARIN Jaffer AK, Brotman DJ,Chukwumerue N . When patients on warfarin need surgery . ClevelandClinJnlMed 2003;70(11): 973-984
  28. 31. <ul><li>PRECAUTIONS WITH EPIDURAL CATHETERS WHEN USING LMWH </li></ul><ul><li>Therefore, the American Society of Regional Anesthesia recommends the following for patients receiving neuraxial blockade an d concurrent anticoagulant therapy or DVT prophylaxis </li></ul><ul><li>IF LMWH IS USED PREOPERATIVELY : </li></ul><ul><li>Co administration of antiplatelet or oral anticoagulant medication is contraindicated </li></ul><ul><li>Lumbar puncture should be delayed at least 12 hours after the last thromboprophylactic dose of LMWH (enoxaparin 40 mg), and at least 24 hours if treatment doses of LMWH being used (eg, enoxaparin 1 mg/kg every 12 hours or enoxaparin 1.5 mg/kg every 24 hours). </li></ul><ul><li>IF A LMWH IS USED POSTOPERATIVELY : </li></ul><ul><li>The first dose should be given no earlier than 24 hours after surgery if being given twice daily for prophylaxis or at treatment doses </li></ul><ul><li>Indwelling catheters may be safely maintained if low-molecular-weight heparins are given as a single daily thromboprophylactic dose </li></ul><ul><li>In general, the epidural catheter should be removed about 12 hours after the last prophylactic dose </li></ul><ul><li>The first dose of a low-molecular-weight heparin should be given no earlier than 2 hours after the catheter is removed </li></ul><ul><li>Concurrent use of a low-molecular-weight heparin and indwelling epidural catheter is generally not recommended </li></ul><ul><li>LMWH should be delayed for 24 hrs if the patient had excessive trauma to epidural space during attempted epidural or spinal anesthesia </li></ul>PARASPINAL HEMATOMA is a rare complication that can develop in patients that receive neuraxial blockade (spinal or epidural anesthesia or epidural analgesia) and concurrent anticoagulant therapy or DVT prophylaxis All patients should be monitored carefully and frequently for new onset of back pain and for symptoms or signs of cord compression ( eg , progression of lower extremity numbness or weakness , bowel or bladder dysfunction ).When Spinal hematoma is suspected, perform diagnostic imaging and definitive surgical therapy ASAP to reduce the risk of permanent paresis * Horlocker TT, Wedel DJ, Benzon H, et al . Regional anesthesia in the anticoagulated patient: defining the risks 2 nd ASRA Consensus Conf on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003; 28:172–197. * Horlocker TT . Thromboprophylaxis and neuraxial anesthesia . Orthopedics 2003; 26(suppl 2):243–249. Jaffer AK, Brotman DJ,Chukwumerue N . When patients on warfarin need surgery . ClevelandClinJnlMed 2003;70(11): 973-984 CAUTION ! ANTITHROMBOTIC DRUGS and REGIONAL ANESTHESIA
  29. 32. EPIDURAL ANESTHESIA or ANALGESIA: SPECIAL CONSIDERATIONS FOR PATIENTS TAKING LONGTERM ANTIPLATELET or ANTICOAGULANT MEDICATIONS Mercado DL, Petty BG. Perioperativ medication macnagement . MedClinics of NorthAm 2003 Jan; 87(1): 41-58 Immediately None No Restriction Low NSAIDs Immediately None No Restriction Low Clopidogrel Immediately None No Restriction Low Ticlopidine Immediately None No Restriction Low Dipyridamole Immediately None No Restriction Low Aspirin Immediately PT Prothrombin time (PT) INR <1.5 prior to removal of the epidural catheter Low-Moderate Warfarin (Low dose-Prophylaxis) Immediately PT Prothrombin time (PT) INR <1.5 prior to removal of the epidural catheter Moderat-High Warfarin (Therapeutic INR  >  2.0) At least 24 hours after catheter removal None At least 12 hours after the last dose of the thrombolytic drug High Fibrinolytic and thrombolytic drugs 12-24 hours None 12–24 hours after last dose High Low molecular-weight Heparins Immediately None 12 hours after the last dose Low Heparin (minidose-prophylaxis) At least 2 hours after epidural catheter removal, providing clinical monitoring checks are within normal limits, including no apparent bleeding aPTT 4–6 hours after stopping heparin aPTT should be within normal limits prior to catheter removal High Heparin (standard) (IV or SQ route) Therapeutic aPTT 1.5 x control INTERVAL BEFORE RESUME MEDS AFTER EPIDURAL CATHETER LAB TESTS NECESSARY PRIOR TO d/c OF EPIDURAL CATHETER SUGGESTED TIME INTERVAL BEFORE REMOVAL of EPIDURAL CATHETER RISK of EPIDURAL HEMATOMA with MEDICATION MEDICATION
  30. 33. DELIRIUM
  31. 34. Most common tool for diagnosing Delirium is the CONFUSION ASSESSMENT METHOD (sensitivity 94-100%; specficity 90-95%) Feature 1 : ACUTE ONSET and FLUCTUATING COURSE. This feature usually obtained from family or nurse- shown by positive response to following questions: Is ther evidence of an acute change in mental status from the patient’s baseline?Did the (abnormal) behavior fluctuate during the day (i.e. tend to come and go, or increase and decrease in severity)? Feature 2 : INATTENTION. Shown by a positive response to : Did the patient have difficulty focusing attention (being easily distractible or having difficulty keeping track of what is being said)? Feature 3 : DISORGANIZED THINKING. Shown by positive response to following question: Was the patient’s thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)? Feature 4 : ALTERED LEVEL of CONSCIOUSNESS. Shown by any answer other alert to the question: Overall, how would you rate this patient’s level of consciousness? ** Diagnosis of delirium by the CAM requires presence of features 1 and 2 and either 3 or 4 . ** IMPORTANT POINTS ABOUT POST OPERATIVE DELIRIUM Associated with higher mortality, longer length of stay, and higher risk of institutionalization DELIRIUM very common after surgery – especially in ELDERLY. Incidence may be as high as 61% after hip fracture Majority of cases had no single clear etiology – most are actually MULTIFACTORIAL . VERY IMPORTANT TO WARN and EDUCATE FAMILIES ABOUT POSSIBILITY OF DELIRIUM DEVELOPING POSTOPERATIVELY !!! DELIRIUM in a loved one can be VERY FRIGHTENING to the family that is UNPREPARED !!!!
  32. 35. 1) FIRST - ALWAYS look for reversible causes – ie ELECTROLYTE abnormalities, hypoxemia, hypo/hyperglycemia, dehydration, acidosis/alkalosis, acute renal failure, pneumonia, UTI, or other infections, Myocardial ischemia (EKG & enzymes), hepatic dysfunction, physical restraints, foley catheter, new STROKE (order CT if there are new neuro findings BUT DON’T ORDER ROUTINELY ON ALL POSTOP PATIENTS WITH DELIRIUM !) 2) REVIEW all meds - ELIMINATE NON-ESSENTIAL MEDS 3) R/O ETOH & BENZODIAZIPINE WITHDRAWAL SYNDROMES 4) INSTITUTE SUPPORTIVE MEASURES: 5) HALDOL is the preferred (and most commonly used) agent for treatment of delirium. TRADITIONAL REGIMEN START  with 1-2mg IV/IM for initial dose and adjust q 1-2hr if needed THEN 1-5mg q 4-6 hrs. Once delirium controlled can give regularly scheduled doses (IV, IM, or PO) q4-6hr for a few days then taper over several days . MONITOR for ECG CHANGES ie QT prolongation and/or ARRHYTHMIAS. 6) AVOID use of DEMEROL ESPECIALLY IN THE ELDERLY ( Morphine low risk for Delirium ) 4) AVOID BENZODIAZEPINES these are drugs of choice for ETOH & sedative withdrawal syndromes and as adjunct to neuroleptics to reduce EPS. NOT first line for DELIRIUM. 5) AVOID drugs with ANTICHOLINERGIC effects ie Benadryl & Vistaril. 6) CONSIDER consulting Pharmacy regarding possible medication etiologies ● Maintain hydration ● Mobilize patient ● Quiet environment & avoid extraneous stimulation ● Bedside sitters ● Reserve restraints for patients at high risk for self-harm ● Remove FOLEY ASAP ● Frequent re-orientation and reassurance ASSESSMENT and MANAGEMENT of ACUTE DELIRIUM  Jacobi J,Fraser GL, et al. Clinical practice guidelines for the sustained use of sedatives and anagesics in the critically ill adult . CritCareMed 2002;30(1): 119-141 Morrison RS,Siu AL. Medical consultation for patients with hip fracture . 2004;UpToDate online 12.1 accessed 20May 2004 Winawer N. Postoperative delirium . MedClinicsNorthAm 2001 Sept;85(5):1229-1239  This source recommends Loading dose 2-10 mg IVP q 20-30 min (can start with 2 mg and double q 20-30 min) until agitation controlled THEN 25% of loading dose every 6 hours. GEODON is another option – less EPS side effects than HALDOL – some say works faster . DOSING : 10mg IM q 2hr, OR 20mg q 4hr. Once controlled can use 10mg IM q 6hr. MAX DOSE 40mg per day. NO IV FORM AVAILABLE.
  33. 36.  Pain Management 
  34. 37.  CHOICE of AGENTS :  MEPERIDINE  No longer considered 1rst line agent  Metabolite= NORMEPERIDINE(NM) has ½ life 15-40 hrs; NM has TWICE CNS stimulation & ½ analgesia of MEPERIDINE  Adverse SE limit usefulness i.e. Agitation, myoclonus, DELIRIUM, seizures ;INCREASED risk if Renal impairment  NOT RECOMMENDED if RENAL or LIVER impaired; in CNS disorders; if pt on SSRI; AND ESPECIALLY in ELDERLY   ABSOLUTELY CONTRAINDICATED if patient is on MAOI ( example = ELDEPRYL used in tx of PARKINSONS) MORPHINE – HYDROMORPHONE– FENTANYL ACCORDING to SOCIETY of CRITICAL CARE MEDICINE(SCCM): 1) ” If IV doses of an Opioid analgesic are required, fentanyl, hydromorphone, and morphine are the recommended agents.” 2) Fentanyl and hydromorphone are preferred for patients with hemodynamic instability or renal insufficiency. EQUIANALGESIC DOSE (iv) : Fentanyl 200 ug - Hydromorphone (HM) 1.5 mg - Morphine (MS) 10 mg - Demerol 75-100 mg And increased SE POSTOPERATIVE PAIN MANAGEMENT HOW TO SET UP PATIENT CONTROLLED ANESTHESIA 1) SPECIFY CHOICE OF OPIOID - usually Morphine (MS), fentanyl, hydromorphone (MS by far MOST COMMONLY USED) 2) INITIAL LOADING / BOLUS DOSE – purpose PCA is to MAINTAIN analgesia NOT ESTABLISH IT that is GOAL of initial loading bolus TYPICAL INITIAL LOADING DOSE: MS 2-6mg or HM 0.2-0.4mg 3) INTERMITTENT BOLUS (aka On-Demand dose) = Dose patient gets EACH TIME pushes button AVG. HOURLY MORPHINE DOSE calculated (for pts 20-70 yrs old) by formula mg/hr = (100 – age )/ 24 (Because of pt. variability may take up to 2X this value to provide adequate analgesia) TOTAL DAILY MS DOSE would be BETWEEN 1 to 2X (100 - AGE ) 4) LOCKOUT INTERVAL = minimal allowable time between between consecutive intermittent (on-demand) bolus doses TYPICAL INTERVAL 10 – 15 minutes . 5) CONTINOUS (aka ‘background’) INFUSION - NOT RECOMMENDED in postop patients. Majority studies show increased opioid consumption, increased SE(including SEDATION and RESPIRATORY DEPRESSION) without improved analgesia 6) MAXIMUM DOSE LIMITS- sets limits on amount of med pt gets in 1or 4 hours segments; safeguards against programming errors and acts to alert the practitioner to the unsatisfied needs of the patient. Probably THERAPY of CHOICE in postop patients with moderate to severe pain Jacobi J,, et al. Clinical practice guidelines for the sustained use of sedatives and anagesics in the critically ill adult . CritCareMed 2002;30(1): 119-141 Etches RC.Patient controlled analgesia. SurgClinN Am 1999; 79(2):297-312
  35. 38. <ul><li>H ISTORY- MOST important component of Preop assessment. Check history of ANESTHESIA PROBLEMS, abnormal BLEEDING, DOE, cough, fever,activity level, and LMP(r/o PG). Review PMH, PSH, HABITS and MED ALLERGIES. </li></ul><ul><li>P HYSICAL - Self explanatory. </li></ul><ul><li>M EDICATIONS - Review of chronic meds and how to manage during periop period (e.g. METFORMIN & anticoagulants ETC.) </li></ul><ul><li>S TUDIES -Review lab, x-rays, and EKGs for abnormalities that may effect surgery. Are additional studies indicated? </li></ul><ul><li>C ARDIAC RISK – Determine cardiac risk and develop risk reduction strategy. Determine if additional studies indicated. </li></ul><ul><li>P ULMONARY EVALUATION - Evaluate risk for postop pulmonary complications. Develop plan to minimize risk. </li></ul><ul><li>S BE PROPHYLAXIS - Determine if a condition requiring SBE PROPHYLAXIS is present ? </li></ul><ul><li>B ETA BLOCKERS – Determine if perioperative beta-blockers are indicated. </li></ul><ul><li>D IABETES MANAGEMENT – aggressive control improves morbidity and mortality – use insulin infusion if necessary. </li></ul><ul><li>D VT PROPHYLAXIS – Determine appropriate PROPHYLAXIS regimen .DID PATIENT HAVE NEUROAXIAL ANESTHESIA? </li></ul><ul><li>P AIN CONTROL – Develop a plan for providing adequate analgesia. Reassess adequacy frequently and adjust as needed. </li></ul><ul><li>F OLEY CATHETER – Remove ASAP–dangerous source of infection, delays ambulation, and increases risk of delirium. </li></ul><ul><li>D IABETES MANAGEMENT POSTOP- TIGHT control associated with improved outcome. Avoid tx with SSI only. Monitor daily. </li></ul><ul><li>N UTRITION – Adequate nutrition essential. Review status daily. Determine if TPN required ? </li></ul><ul><li>A CTIVITY – Monitor activity daily. Consult PT EARLY if patient is debilitated. EARLY ambulation decreases morbidity. </li></ul><ul><li>D ELIRIUM(‘ C razy’) – Anticipate in elderly and critically ill. FOREWARN families BEFORE surgery of likelihood of postop delirium. </li></ul>S YSTEMATIC A PPROACH F OR E VALUATION Use the “ SAFE “ method for comprehensive Perioperative management.It is a TOOL to help recall all the areas of importance when evaluating a patient preoperatively and taking care of the patient during thr postop period.Most of the categories are covered in more depth in this manual USE THE MNEMONIC BELOW AS AN AID TO REMEMBER ALL THE CATEGORIES TO COVER ! PUTTING IT ALL TOGETHER PUTTING IT ALL TOGETHER H aving P rocedures M ay S ometimes C ause P atients S ome B asic D oubts D ue P artly F rom D octors N ot A dequately C ounselling
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