Mayo Clinic

An Overview of
Perioperative Medicine 2013:

From Outpatient Preoperative Assessment to
Inpatient Postoperative Care
October 9-12, 2013

Grand Hyatt Seattle
Seattle, Washington
© Mayo Foundation for Medical Education and Research

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Table of Contents
CME Activity Description .......................................................................................................................... vii
CME Activity Objectives ............................................................................................................................ vii
Continuing Education Credit ...................................................................................................................... vii
CME Record of Attendance ....................................................................................................................... viii
CME Activity Evaluation .......................................................................................................................... viii
Syllabus and Internet Access ....................................................................................................................... ix
Recording Device Policy ............................................................................................................................. ix
Electronic Devices ....................................................................................................................................... ix
Faculty ......................................................................................................................................................... xi
Program Schedule ...................................................................................................................................... xiii
Presentations ................................................................................ See Program Schedule for Page Numbers
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CME Activity Description
An Overview of Perioperative Medicine 2013 has been a successful collaboration of Mayo Clinic and
Jefferson Medical College. This merger of two of the nation’s most comprehensive perioperative courses
features a collaborative faculty of multi-specialty experts in perioperative medicine from both Mayo
Clinic and Jefferson Medical College.
This course is intended to update general internists, internist-sub specialists, family medicine specialists,
and other health care providers on perioperative assessment and management. This course will focus on
the practical, clinical side of preoperative assessment and postoperative management.
CME Activity Objectives
Upon conclusion of this program, participants should be able to:
 Apply a systematic approach to guide preoperative assessment.

 Recommend appropriate perioperative cardiac testing using the current ACC / AHA guidelines and
risk calculators.
 Manage anticoagulants and antiplatelet agents in the perioperative setting.
 Discuss the management of the new oral anticoagulants in the perioperative setting.
 Assess risk factors for postoperative pulmonary complications and recommend measures most
effective in reducing perioperative pulmonary risk.
 Select appropriate prophylactic regimens for deep venous thrombosis in the perioperative setting based
on patient risk and current guidelines.
 Recommend the appropriate continuation and discontinuation of medications and nutraceuticals in the
perioperative setting.
 Assess the patient with chronic liver disease for surgery.
 Manage chronic kidney disease in the perioperative setting.
 Recognize and manage postoperative delirium.
 Identify risks and benefits of perioperative blood transfusion.
 Recommend appropriate bridging therapy in patients who are on chronic anticoagulation.
 Manage diabetes in the perioperative setting.
 Manage patients with obstructive sleep apnea in the perioperative setting.
Attendance at this Mayo Clinic activity does not indicate nor guarantee competence or proficiency in the
performance of any procedures which may be discussed or taught in this activity.
Continuing Education Credit
College of Medicine, Mayo Clinic, is accredited by the Accreditation Council for Continuing Medical
Education to provide continuing medical education for physicians.
College of Medicine, Mayo Clinic, designates this live activity for a maximum of 22.25 AMA PRA
Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their
participation in the activity.
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AAFP
This Live activity, Mayo Clinic's An Overview of Perioperative Medicine, with a beginning date of
10/09/2013, has been reviewed and is acceptable for up to 22.25 Prescribed credit(s) by the American
Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of
their participation in the activity.
Other Health Care Professionals

A record of attendance will be provided to other health care professionals for requesting credits in
accordance with state nursing boards, specialty societies, or other professional associations.
CME Record of Attendance
A Record of Attendance is provided to you during on-site registration. The Record of Attendance allows
attendees to calculate their own credits of participation in the educational activity.
The total number of credits participants can earn per day is noted on the Record of Attendance. Below
each day is a line to record the actual number of credits during which you participated in the educational
activity. It is recommended that you record your actual credits daily as you proceed through the CME
activity.
Upon conclusion of the CME activity, please total the number of credits you have recorded on the top half
of the form, sign it, and return it with your evaluation to the registration desk.
The bottom half of the form represents your Record of Attendance, which you must retain for your
records. Please make sure the number of credits claimed in both sections coincide. No other
documentation is provided to you after this CME activity. The Record of Attendance has replaced the
certificate.
The Record of Attendance can be used for requesting credits in accordance with state licensing boards,
specialty societies, or other professional associations.
CME Activity Evaluation
The overall CME activity evaluation will be emailed following the activity to the email address that was
provided when you registered. The CME activity evaluation is brief and will only take a few minutes to
complete.
Faculty evaluation forms were offered to a sampling of the registrants. Completed faculty evaluation
forms should be returned to the registration desk at the conclusion of the CME activity. If you wish to
participate in evaluating the faculty, please stop at the registration desk to inquire if extra evaluation
forms are available.
Your feedback is very important to us and will be used for planning future programs, as well as
identifying faculty strengths and opportunity for growth.
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Syllabus and Internet Access
An electronic syllabus will be provided to all attendees. Participants are invited to bring their laptops to
the meeting room(s). Due to copyright issues or revisions, some slides may be shown during a
presentation, but not provided within the syllabus.
Recording Device Policy
No recording devices, audio or visual, may be used during College of Medicine, Mayo Clinic CPD
activities. Duplication, distribution, or excerpting of this program, without the express written permission
of Mayo Clinic, is strictly prohibited.
All of the proceedings of this program, including the presentation of scientific papers, are intended for
limited publication only, and all property rights in the material presented, including common-law
copyright, are expressly reserved by the Faculty and/or Mayo Clinic. No statement of presentation made
is to be regarded as dedicated to the public domain. Any sound reproduction, transcript or other use of the
material presented at this CME activity without the permission of Mayo Clinic is prohibited to the full
extent of common-law copyright in such material.
Electronic Devices
Please turn all electronic devices (cellular telephones, pagers, etc.) to silent mode. As a courtesy to the
presenters and other participants, phone calls should be taken outside of the general session.
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Faculty
Course Directors
Karen F. Mauck, M.D., M.Sc. Margaret Beliveau, M.D.
Chair, Faculty Development Education Coordinator, Medical Consult Service
Assistant Professor of Medicine Assistant Professor of Medicine
Division of General Internal Medicine, Section Division of General Internal Medicine, Section
of Medical Education of Medical Education
College of Medicine, Mayo Clinic College of Medicine, Mayo Clinic
Geno J. Merli, M.D. Howard H. Weitz, M.D.

Professor of Medicine & Neurologic Surgery Professor of Medicine
Co-Director, Jefferson Vascular Center Vice-Chairman, Department of Medicine
Senior VP & CMO, Thomas Jefferson University Director, Jefferson Heart Institute
Hospital Jefferson Medical College of Thomas Jefferson
Jefferson Medical College of Thomas Jefferson University
University
Guest
James A. Fink, M.D. Stuart L. Gordon, M.D.
Associate Professor Division Chief: Hip and Knee Reconstruction
Bond University School of Medicine Service
Cooper University Hospital
Cooper Bone and Joint Institute
Brian F. Mandell, M.D. Marianne T. Ritchie, M.D.

Professor and Chairman of Academic Medicine Clinical Assistant Professor of Medicine
Department of Rheumatic Immunologic Diseases Jefferson Medical College
Cleveland Clinic
Mayo Clinic
John B. Bundrick, M.D. Richard A. Oeckler, M.D., Ph.D.
Paul R. Daniels, M.D. Eric J. Olson, M.D.
David R. Danielson, M.D. Rajiv K. Pruthi, MBBS
Molly A. Feely, M.D. William Sanchez, M.D.
Andrea N. Leep Hunderfund, M.D. Jennifer A. Whitaker, M.D.
Robert H. Lohr, M.D. Amy W. Williams, M.D.
Susan M. Moeschler, M.D.
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Program Schedule
An Overview of Perioperative Medicine 2013:
From Outpatient Preoperative Assessment to Inpatient Postoperative Care

WEDNESDAY, OCTOBER 9, 2013
6:00 a.m. Continental Breakfast and Registration
7:30 a.m. Welcome and Introductions
7:40 a.m. Role and Responsibility of the Medical Consultant ..................................................... 21

Margaret Beliveau, M.D.
 What are roles of the medical consultant?
 What are some key tips for successful consultation?
 What should a preoperative evaluation include?
8:00 a.m. Anesthesia 101 for the Non-Anesthesiologist ................................................................ 27

David R. Danielson, M.D.
 What are the basics of the anesthesia process?
 What hemodynamic and physiologic processes occur during anesthesia?
 Do we need to perform neck flexion and extension films for patients with RA or
Down Syndrome anymore?
 Which patients are appropriate for outpatient surgery?
 What are the current fasting guidelines?
8:30 a.m. Cardiac Risk Assessment:

Using Guidelines to Direct Practice
and Choosing the Appropriate Stress Test ................................................................... 47
Karen F. Mauck, M.D.
 How do I apply ACC/AHA guidelines to preoperative cardiac risk assessment?
 How do I use the Gupta cardiac risk calculator?
 How do I decide which stress test to order?
9:15 a.m. Cardiac Risk Reduction Strategies –

Medical and Interventional ............................................................................................ 59
Howard H. Weitz, M.D.
 How long after an MI is it recommended to wait before non-cardiac surgery?
 What are the risks of general vs spinal anesthesia with respect to cardiac outcomes?
 What is the evidence for perioperative beta-blocker, statin and alpha-2-agonist use?
 When is cardiac revascularization indicated prior to non-cardiac surgery?
 How long after revascularization is it recommended to wait before non-cardiac
surgery?
10:15 a.m. Question and Answer Session

Margaret Beliveau, M.D., David R. Danielson, M.D., Karen F. Mauck, M.D., and
10:30 a.m. Refreshment Break
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10:45 a.m. Perioperative Medication Management:
Prescription & Non-Prescription Medication .............................................................. 77
Moderator: Karen F. Mauck, M.D.
Panel: Geno J. Merli, M.D., Howard H. Weitz, M.D., Margaret Beliveau, M.D.,
and David R. Danielson, M.D.
 What issues need to be considered with perioperative medication management?
 What are the drugs that need to be held for surgery?
 What drugs need to be given before surgery?
 If certain medications are held preoperatively, how should they be restarted
postoperatively?
 What should I recommend to my patients regarding dietary supplements
perioperatively?
11:45 a.m. Preoperative Testing: What is Really Needed? ............................................................ 87

Robert H. Lohr, M.D.
 What standard preoperative screening laboratory testing is indicated?
 When are specific laboratory tests indicated preoperatively?
 Which patients need a preoperative ECG?
 Which patients need a preoperative CXR?
 When should pregnancy testing be done preoperatively?
12:15 p.m. Question and Answer Session

Robert H. Lohr, M.D., Geno J. Merli, M.D., Howard H. Weitz, M.D., and Margaret
Beliveau, M.D.
12:30 p.m. Lunch on your own
2:30 p.m. Management of Non-CAD Heart Disease in Non-Cardiac Surgery ........................... 97

 How do I manage a patient with valvular heart disease perioperatively?
 What issues need to be considered for a patient with heart failure preoperatively?
 What are the issues with preoperative hypertension?
 What are the preoperative issues for patients with chronic atrial fibrillation?
 What perioperative issues need to be considered in a patient with hypertrophic
cardiomyopathy?
 What perioperative issues need to be considered in a patient with pulmonary
hypertension?
 What are the indications for a temporary pacemaker in the perioperative period?
 How do I manage pacemakers and AICDs in the perioperative period?
3:30 p.m. Clinical Short: Urinalysis Prior to Joint Replacement .............................................. 117
Stuart L. Gordon, M.D.
 Do we need to perform preoperative urinalysis on patients scheduled to undergo joint
replacement surgery? What is the evidence?
3:45 p.m. Preoperative Pulmonary Risk Stratification and Risk

Reduction Strategies ..................................................................................................... 119
 Which factors contribute to pulmonary risk in non-cardiac surgery?
 How can I best estimate the risk of postoperative pulmonary complications—are
there good risk calculators available?
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 When is pulmonary testing recommended preoperatively?
 What measures can be employed to help minimize postoperative pulmonary
complications in at-risk patients?
 What are the basic tests to consider when evaluating a patient for lung resection
surgery?
 Which patients should be referred to a pulmonary specialist for preoperative
evaluation?

Howard H. Weitz, M.D., Stuart L. Gordon, M.D., and Margaret Beliveau, M.D.
4:45p.m. Complete Evaluation Forms / Adjourn
THURSDAY, OCTOBER 10, 2013
6:30 a.m. Continental Breakfast
7:55 a.m. Announcements
8:00 a.m. Managing Postoperative Cardiac Complications I and II ........................................ 131

 How do I manage hyper- and hypotension postoperatively?
 What are the precipitating factors for postoperative arrhythmias and conduction
disorders and how do I manage them?
 Which surgeries and patients have high risk for postoperative atrial fibrillation? Are
there ways to prevent postoperative atrial fibrillation? How do I manage
postoperative atrial fibrillation?
 Which patients should have ECG and/or troponin surveillance for postoperative MI?
 How do I diagnose and manage postoperative myocardial ischemia and infarction?
 What special perioperative management is needed for patients with heart failure
(systolic heart failure and heart failure with preserved ejection fraction)?
8:45 a.m. Management of Documented or Suspected Obstructive

Sleep Apnea in Patients Undergoing Non-Cardiac Surgery ..................................... 147
Eric J. Olson, M.D.
 What are the consequences of OSA in the perioperative period?
 What factors increase risk of postoperative complications in patients with OSA?
 How should patients be screened for OSA?
 Which patients at high risk need to be tested prior to surgery to decrease the risk of
potential complications?
 Which patients at high risk can be treated as “presumed” OSA and proceed with
surgery with additional precautions?
 Are there guidelines available to help guide management of patients with OSA in the
perioperative period?
 What postoperative monitoring is recommended for patients with suspected or
confirmed OSA?

Howard H. Weitz, M.D. and Eric J. Olson, M.D.
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10:00 a.m. DVT/PE Prophylaxis in the Surgical Patient I:

The ACCP Guidelines and the Internist’s Perspective.............................................. 157
Geno J. Merli, M.D.
 What are the patient- and surgery-related risk factors for perioperative DVT?
 What do the ACCP guidelines recommend for DVT prophylaxis in surgical patients?
 When is extended DVT prophylaxis indicated?
 How does renal function affect the management of DVT prophylaxis?
 What is new in the 2012 ACCP Guidelines?
 How do I use the Caprini Score and the Roger’s Score to determine DVT risk in
general and abdominal/ pelvic surgery?
10:45 a.m. DVT/PE Prophylaxis in the Surgical Patient II:

The AAOS Guidelines and the Orthopedist’s Perspective ........................................ 167
 What concerns do orthopedists have about DVT prophylaxis as recommended by the
AACP?
 What are the AAOS Guideline recommendations for DVT prophylaxis in orthopedic
surgical patients?
 When is extended DVT prophylaxis indicated and which agent is best?
11:15 a.m. Perioperative Management of Antiplatelet Agents .................................................... 173

 How do I manage patients with coronary artery disease who are taking antiplatelet
agents during the surgical period?
 How do I manage patients with cerebrovascular disease who are taking antiplatelet
agents?
 Do I manage aspirin therapy differently perioperatively based on whether it is taken
for primary or secondary prevention?
 How do I determine which patients need to have antiplatelet therapy stopped versus
those who need to have antiplatelet therapy continued in the perioperative period?
11:45 p.m. Clinical Short: How do I manage patients

who are DNR/DNI who are going to surgery? ........................................................... 185
Molly A. Feely, M.D.
 Do DNR orders need to be suspended prior to surgery?
 If they are suspended, when should DNR orders be reinstituted postoperatively?
12:00 p.m. Question and Answer

Geno J. Merli, M.D., Howard H. Weitz, M.D., Stuart L. Gordon, M.D., and Molly A.
Feely, M.D.
12:15 p.m. Lunch on your own
2:00 p.m. Perioperative Management of Anticoagulants:

To Bridge or Not to Bridge .......................................................................................... 189
Paul R. Daniels, M.D.
 Which patients with atrial fibrillation need bridging anticoagulation perioperatively?
 Which patients with mechanical heart valves need bridging anticoagulation
perioperatively?
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 Can you recommend an approach to anticoagulation dosing and the timing of
bridging?
 How and when should anticoagulation be restarted after surgery?
2:30 p.m. Perioperative Management of the New Oral Anticoagulants ................................... 199
Geno J. Merli, M.D.
 How long should I hold dabigatran, rivaroxaban or apixaban before surgery?
 When should the newer oral anticoagulants be restarted postoperatively?
 How do I manage prolonged DVT prophylaxis in patients who are also taking
dabigatran, rivaroxaban or apixaban?
 How should we reverse these agents if major bleeding occurs?
3:00 p.m. Perioperative Management of the Patient with Liver Disease .................................. 211
William Sanchez, M.D.
 How do I approach preoperative risk assessment in a patient with liver disease?
 Which patients with liver disease may not be good candidates for elective surgery
due to significant increase perioperative morbidity and mortality?
 What is the appropriate timing for transplant referral prior to surgery?
 What are the common postoperative management challenges for patients with
advanced liver disease?
3:30 p.m. Managing Patients with Neurologic Disease

in the Perioperative Period .......................................................................................... 219
Andrea N. Leep Hunderfund, M.D.
 How do I manage patients with seizure disorder in the perioperative period?
 How do I manage patients with Parkinson’s Disease perioperatively?
 What do I do if I find an asymptomatic carotid bruit during a preoperative
evaluation?
 How do I determine appropriate timing for elective surgery after ischemic stroke?
 What are the symptoms and risk factors for serotonin syndrome in the perioperative
setting?
4:00 p.m. Clinical Short: Preoperative Evaluation in Cancer Patients .................................... 231
Molly A. Feely, M.D.
 What chemotherapies are cardiotoxic?
 What additional preoperative testing should be considered in the cancer patient?

Paul R. Daniels, M.D., William Sanchez, M.D., Geno J. Merli, M.D., Andrea Leep
Hunderfund, M.D., and Molly A. Feely, M.D.
4:30 p.m. Complete Evaluation Forms / Adjourn
FRIDAY, OCTOBER 11, 2013
7:00 a.m. Meet the Professor Case Discussions: Informal Q & A with selected course faculty
at breakfast
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8:00 a.m. Understanding the Perioperative Stress Response/

Fluid Management ........................................................................................................ 235
John B. Bundrick, M.D.
 What is unique about fluid management perioperatively?
 Which is better-- liberal or restrictive fluid management?
 What is the physiologic effect of cytokine and catecholamine release in the
8:30 a.m. Managing the Diabetic Patient in the Perioperative Period...................................... 243
James A. Fink, M.D.
 Should I be screening for diabetes preoperatively in patients who are at risk?
 When would I recommend postponing an elective surgical procedure because of poor
diabetic control?
 How should I manage patients on insulin therapy in the perioperative period?
 How should I manage patients on oral hypoglycemics in the perioperative period?
 How should I manage patients on insulin pumps in the perioperative period?
 What is the optimal glycemic control in the postop setting?
9:15 a.m. Perioperative Management of the Patient with Kidney Disease ............................... 253
Amy W. Williams, M.D.
 What perioperative issues do I need to consider for a patient with advanced kidney
disease?
 How do I prevent acute kidney injury in the perioperative period?
 Who is at risk for contrast nephropathy and how can it be prevented?
10:00 a.m. Postoperative Delirium: Risk Factors, Diagnosis, and Management ....................... 265
 What are the risk factors of postoperative delirium?
 How do I diagnose postoperative delirium?
 What is the difference between hyperactive and hypoactive delirium?
 Are their preventive measures that have been shown to decrease the risk of
postoperative delirium?
 What diagnostic workup is recommended for patients with suspected postoperative
delirium?
 How is delirium managed in the postoperative setting?

John B. Bundrick, M.D., James A. Fink, M.D., Amy W. Williams, M.D., and Margaret
Beliveau, M.D.
11:00 a.m. Perioperative Management of Endocrine Issues:

Stress Dose Steroids, Adrenal Insufficiency, Thyroid Disease.................................. 277
James A. Fink, M.D.
 What issues do I need to consider in patients with hypothyroidism or
hyperthyroidism in the perioperative period?
 Who is at risk for adrenal insufficiency perioperatively?
 How do I determine the need for and the dose of stress dose steroids in the surgical
patient?
xviii
11:30 a.m. Perioperative Considerations in the Patient
with Rheumatologic Disease......................................................................................... 285
Brian F. Mandell, M.D.
 What special issues do I need to consider for patients with rheumatalogic disease who
are undergoing surgery?
 How should I manage antirheumatic drugs and biologic agents perioperatively?
 How do I diagnose and manage acute crystalline arthritis in the surgical patient?
12:00 p.m. Perioperative Infectious Disease Issues ....................................................................... 293

Jennifer A. Whitaker, M.D.
 How do I approach the postoperative patient with fever?
 Which patients need antibiotic prophylaxis perioperatively and for how long?
 How are patients with penicillin allergy managed in the perioperative period?
 How do I manage common postoperative infectious disease issues?
 What special management do I need to consider for a patient on HIV drugs
perioperatively?

James A. Fink, M.D., Brian F. Mandell, M.D., and Jennifer A. Whitaker, M.D.
12:45 p.m. Complete Evaluation Forms / Adjourn
SATURDAY, OCTOBER 12, 2013
7:00 a.m. Meet the Professor Case Discussions: Informal Q & A with selected course faculty
at breakfast
8:00 a.m. Common Hematology Issues in the Perioperative Period ......................................... 299
Rajiv K. Pruthi, MBBS
 Which patients should have hemostasis assessment preoperatively?
 Which transfusion strategy is best in the perioperative period—conservative or
liberal?
 What should trigger transfusion in the postop period?
 When is FFP indicated preoperatively?
 How do I diagnose and treat heparin induced thrombocytopenia in the perioperative
period?
 How do I manage patients with Von Willebrands disease perioperatively?
 How do I manage patients with sickle cell disease perioperatively?
8:45 a.m. Management of Postoperative Pulmonary Complications ........................................ 311

Richard A. Oeckler, M.D., PhD.
 What physiologic effects do anesthesia and surgery have on the respiratory system?
 What are the most common postoperative pulmonary complications and how are they
managed?
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9:30 a.m. Pain Management in the Perioperative Period .......................................................... 323
Susan M. Moeschler, M.D.
 What are the commonly used opioids in the postoperative setting and what issues
should I consider when prescribing these?
 What are the common PCA doses for postoperative pain control?
 How do I manage chronic pain patients who have uncontrolled postoperative pain?
 When should I consider adjunctive analgesic therapies to help with pain control?
 How should patients on multiple sedating medications postoperatively be monitored?
 For patients with epidural or spinal anesthesia, how should anticoagulant DVT
prophylaxis be managed?
10:15 a.m. Management of Postoperative Gastrointestinal Complications ............................... 331

Marianne T. Ritchie, M.D.
 How do I prevent and manage postoperative nausea and vomiting?
 How should I evaluate a patient with postoperative diarrhea?
 What agents are recommended to prevent stress related mucosal disease in the
surgical patient?
 How do I manage postoperative constipation and postoperative ileus?

Rajiv K. Pruthi, MBBS, Richard A. Oeckler, M.D., PhD., Susan M. Moeschler, M.D., and
11:00 a.m. Complete Evaluation Forms/Adjourn
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Disclosures
An Overview of
Roles and Responsibilities of the
• Nothing to disclose
Consultant
Mayo School of Continuous Professional Development

Margaret M. Beliveau MD
Mayo Clinic, Rochester, MN
©2011 MFMER | 3127551-1 ©2011 MFMER | 3127551-2
What is a Consultation? Potential Roles of the Medical Consultant

• A request to another physician for an opinion • Pure consultant (outpatient and inpatient)
regarding diagnosis or management. • Recommendations made and communicated
• Physicians should obtain consultation • Surgical team is primary and writes all orders
whenever they believe that it would be
medically indicated in the care of the patient or • Co-manager (inpatient)
when requested by the patient or the patient’s • Direct involvement of the consulting physician in
representative. (AMA Code of Ethics) implementing the management plan
• Consultations are primarily for the patient’s • Surgical team and medical consultant both manage
benefit. and write orders
©2011 MFMER | 3127551-3 ©2011 MFMER | 3127551-4
Ethical Principles- Surgical Co-

Surgical Co-management management
• The practice of allotting specific responsibilities • Co-management arrangements should ensure
of patient care to designated caregivers (AMA the highest quality care.
Code of Ethics)
• Responsibilities should be delineated according
to each physician’s scope of expertise.
• A single physician should be ultimately
responsible for ensuring that the care is
delivered in a coordinated and appropriate
manner.
©2011 MFMER | 3127551-5 ©2011 MFMER | 3127551-6
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Ethical Principles- Surgical Co- What is NOT a “Useful” Preoperative
management Consultation?
• The treating physicians are responsible for ensuring
• “Clearing” the patient for surgery
that the patient has consented not only to take part in • The decision to proceed with surgery is
the surgical co-management arrangement but also to based on the information included in the
the services that will be provided within the consultation
arrangement.
• Physicians should ensure that their surgical co- • Indicating the type of anesthesia to be used
management arrangements do not violate the ethical or • Recommending intraoperative monitoring
legal restrictions on self-referral.
• Referrals to another caregiver should be based only on • Qualitative advice (“Avoid hypotension and
that caregiver’s skill and ability to meet the patient’s tachycardia”)
needs and not on expected further referrals or other
self-serving bases
• Don’t tell the surgical and anesthesia teams
what they already know!
©2011 MFMER | 3127551-7 ©2011 MFMER | 3127551-8
What is in a “Useful” Preoperative What is in a “Useful” Preoperative

Consultation? Consultation?
• Information about the medical problems and • Guidelines for managing oral drug regimens
how bad they are. • Hold Lasix on the morning of surgery and restart
• Severe COPD, oxygen dependent POD#1
• Preoperative tests that will help optimize the • Pertinent anticoagulation recommendations
patient’s medical condition • Patient will require bridging anticoagulation because
• Known history of chronic kidney disease, check of recent DVT
electrolytes and creatinine • Details on coronary stents- when, where, type
• What can we do to prevent complications?
• SBE prophylaxis should be given, because of
prosthetic mitral valve
©2011 MFMER | 3127551-9 ©2011 MFMER | 3127551-10
What is in a “Useful” Preoperative Be Systematic to Avoid Omitting Important

Consultation Recommendations
• Information on implanted devices • Cardiac risk
• AICDs, pacemakers • Many people stop here!
• Recommendations about management of rare • Pulmonary risk
diseases, blood disorders, brittle diabetes
• DVT risk
• Information/explanation when
recommendations differ from guidelines • Delirium risk
• Perioperative medication management
• Other medical problems—perioperative
Lubasky D. Clev Clin Journal of Med. recommendations
Suppl 4. 2009.:S32-36.
©2011 MFMER | 3127551-11 ©2011 MFMER | 3127551-12
22
ACC/AHA Guidelines ACC/AHA Guidelines
• A critical role of the consultant is to determine • (the consultant should) provide a clinical risk
the stability of the patient’s cardiovascular profile that can be used in making treatment
status and whether the patient is in optimal decisions…
medical condition, within the context of the
surgical illness. The consultant may
recommend changes in medication, suggest
preoperative tests or procedures, or propose
higher levels of postoperative care.
©2011 MFMER | 3127551-13 ©2011 MFMER | 3127551-14
Ten Commandment of Effective V

Consultation (2006) Be Specific, Thorough, and Willing to Help
I VI • Express the perioperative plan concisely.
Provide contingency plans
Determine your customer
and discuss their execution • Give specific instructions.
ii VII • Don’t write: Give beta-blocker
Establish urgency Negotiate joint title to thy • Instead: Begin Metoprolol 50mg po BID starting tonight. Titrate
neighbor’s turf dose perioperatively to keep HR 55-65 as blood pressure
III tolerates.
Look for yourself VIII • Avoid leaving a laundry list of suggestions.
Teach with tact and pragmatism
IV • The higher the number of recommendations, the
Be as brief as appropriate IX less likely that all will be read
Talk is essential
V • Ask the requesting physician if they need help
Be specific, thorough and help
X with writing orders
Follow up daily
out
Salerno, S. M. et al. Arch Intern Med 2007;167:271-275 ©2011 MFMER | 3127551-16
VI
Provide Contingency Plans and Discuss IX
Their Execution Talk is Cheap, Effective…and Essential
• Patients are dynamic. Recommendations for • There is no substitute for direct personal
this morning may not be applicable this contact with the referring team.
afternoon.
• Recommendations are more likely to be
• Provide “if, then” statements. followed if they are verbally communicated.
• E.g. If the systolic BP is >150 after maximum beta blockade
(HR 55-65), then consider adding clonidine 0.1mg po Q 12 hrs. • Don’t document that the surgery should be
postponed or cancelled unless you have
• Be available if your help is needed. spoken with the surgeon first.
©2011 MFMER | 3127551-17 ©2011 MFMER | 3127551-18
23
What would you do? What would you do?
• You have been consulted for co-management • The surgeon insists that the antiplatelet agents
of a patient on the orthopedic service. The be stopped before the surgery. You discuss the
patient is a 75 year old man , who has suffered situation with the surgeon, and explain the risk
a right hip fracture after a fall. The patient has a of perioperative stent thrombosis if the
history of CAD. 2 months ago, he had an antiplatelet agents are discontinued. You
episode of severe chest pain with dyspnea, and provide the surgeon with a paper outlining the
was found to have a non-STEMI. He underwent high mortality associated with stent thrombosis.
cardiac catheterization, with drug eluting stents (Teach with tact)
placed in his LAD and obtuse marginal. He is
currently taking aspirin and clopidogrel. • The surgeon thanks you for your input and
discontinues the antiplatelet agents.
©2011 MFMER | 3127551-19 ©2011 MFMER | 3127551-20
What would you do? What would you do?

1. Immediately sign off the case. • The patient is admitted at 11PM and is
scheduled for surgery as the 3rd case the next
2. Write an order restarting the antiplatelet day. You see the patient on rounds in the
agents, since you have been asked to co- morning. He is quite concerned that he has not
manage been given his aspirin and clopidogrel, as he
3. Document your recommendations and agree paid close attention when he was told that
to disagree with the surgeon these should not be stopped for at least 1 year.
4. Call the legal department and see if you can
have the surgeon removed from the case
5. Transfer the patient to your service
©2011 MFMER | 3127551-21 ©2011 MFMER | 3127551-22
What would you do?

AMA Ethical Principles- Role of the
1. Avoid answering the question and have the Consultant
patient discuss this with the surgeon.
2. Tell the patient that you recommended that • One physician should be in charge, and the
these medications be continued, but that the attending physician has overall responsibility
surgeon stopped them. Explain the high risk for the patient’s care.
to him. • The consultant should not assume primary care
3. Tell the patient that you will immediately of the patient without consent of the referring
restart these medications, and write the order physician.
without telling the surgeon. • The consultation should be done in a timely
4. Obtain a cardiology consult to “break the tie”. manner. (Most hospitals have guidelines for
this: ASAP for urgent, 24 hours for routine)
5. Have a joint discussion with the patient and
the surgeon
©2011 MFMER | 3127551-23 ©2011 MFMER | 3127551-24
24
AMA Ethical Principles- Role of the
Consultant Remember…
• Discussions during the consultation should be • The decision to proceed with a surgical
with the referring physician and only with the procedure is ultimately between the patient, the
patient by prior consent of the referring surgeon and the anesthesiologist. The role of
physician. the consultant is to outline the risks and assist
with minimizing the risk.
• Conflicts of opinion should be resolved by a
second consultation or withdrawal of the
consultant. However, the consultant has the
right to give his or her opinion to the patient in
the presence of the referring physician.
©2011 MFMER | 3127551-25 ©2011 MFMER | 3127551-26
References References
• Ten Commandments for Effective • Principles of Effective Consultation: An Update
Consultations. Goldman L, et al. Arch Intern for the 21st Century Clinician. Salerno S. Arch
Med. 1983; 143: 1753-5 Int Med. 167: 271-275.
• Principles of Effective Consultation: An Update • Giving anesthesiologists what they want: How
for the 21st-Century Consultant. Salerno SM, et to write a useful preoperative consult.
al. Arch Intern Med. 2007; 167:271-5 Cleveland Clinic Journal of Medicine. 76: S32-
S36.
• Role of the Medical Consultant. Merli GJ and
Weitz HH. Clin in Chest Med. 1993; 14 (2):
205-10.
©2011 MFMER | 3127551-27 ©2011 MFMER | 3127551-28
Thank You!
• Beliveauficalora.margaret@mayo.edu
©2011 MFMER | 3127551-29
25
26
Anesthesia 101 for the
An Overview of
Non-Anesthesiologist
Perioperative Medicine 2013: October 9, 2013
From Outpatient Preoperative Assessment
to Inpatient Postoperative Care
Department of
Anesthesiology
Director, Pre-Operative
Evaluation
Mayo Clinic
David R. Danielson, M.D
Mayo Clinic Department of Anesthesiology.
October 9-12, 2013 Grand Hyatt Seattle Seattle, Washington
©2011 MFMER | 3127551-1 ©2011 MFMER | 3127551-2
Anesthesia 101 for the Non-Anesthesiologist Anesthesia 101 for the Non-Anesthesiologist
• DISCLAIMERS • Objectives: To Discover
• 1. No money from
anyone. • What’s happened in the OR since you
• 2. I have biases; they rotated there in medical school.
are obvious. • The physiologic changes that occur with the
• 3. I may mention modern anesthesia drugs.
brand names. They • Why anesthesiologists are so interested in
are not endorsements,
merely examples. systems and patient flow.
• 4. I may mention off- • A few pre-op pearls about odd things.
label use. You’re
smart enough to
beware.
©2011 MFMER | 3127551-3 ©2011 MFMER | 3127551-4
Anesthesia 101 for the Non-

Anesthesia 101 for the Non-Anesthesiologist Anesthesiologist
• Let’s start with • Propofol -
propofol. • Why are we (in
• “The Michael anesthesia) so
Jackson drug.” possessive?
• Pentothal is no • A dose large
longer enough to be
manufactured! effective may
produce APNEA
©2011 MFMER | 3127551-5 ©2011 MFMER | 3127551-6
27
Anesthesia 101 for the Non- Anesthesia 101 for the Non-
Anesthesiologist Anesthesiologist
• Alternatives for • Next is airway.
induction: • Face mask
• Inhalation • LMA
• Sevoflurane
• No paralysis
• Ketamine
• Etomidate
Glidescope
©2011 MFMER | 3127551-7 ©2011 MFMER | 3127551-8
• Definitive airway. • Why VIDEO
Laryngoscopy?
• Trach
• Neck stays neutral
• ETT • Less trauma
• VIDEO • Teeth
Laryngoscopy • Lips
• Tongue
• Easier!
• Teaching
Glidescope Glidescope
©2011 MFMER | 3127551-9 ©2011 MFMER | 3127551-10
• Because of VIDEO • But wait – that’s
Laryngoscopy and not all!
other advanced • Do not need
techniques -- flexion/extension
• Do NOT need films for
consults ahead of • Down’s
operative day • RA
solely for airway
issues • s/p trauma
Glidescope Olympus Bronchoscope Glidescope Olympus Bronchoscope
©2011 MFMER | 3127551-11 ©2011 MFMER | 3127551-12
28
• Maintainence • What do these drugs do?

• IV (TIVA) • Narcotics (bolus or drip)
• Narcotics (bolus or drip) • Lower BP & pulse, analgesia
• Propofol drip • Propofol drip
• Etc. • Lower BP (NO analgesia)
• Inhaled • Benzos
• Desflurane • Lower BP, wipe short-term memory
• Sevoflurane • Ketamine
• Isoflurane • Bronchodilator, analgesia, hallucinations
©2011 MFMER | 3127551-13 ©2011 MFMER | 3127551-14
• What do these drugs do? • What do I do about these drugs?

• Desflurane, Sevoflurane, Isoflurane • They all can cause  BP!!
  SVR → lowers BP • Wait for “Surgipress”
 Bronchodilators • Give α agonist (phenylephrine)
 Analgesia • Give Volume
 Amnesia • Trendelenburg position
• Have patient hold ACEI pre-op
©2011 MFMER | 3127551-15 ©2011 MFMER | 3127551-16
• What can you do about these drugs? • What happens upon emergence?
• They all can cause  BP!! • Stimulation
• Wait for “Surgipress” • Tachycardia
• Give α agonist (phenylephrine)
• Give Volume • Hypertension (What about that skipped
• Trendelenburg position ACEI pill?)
• Have patient hold ACEI pre-op • Need to balance analgesia with
respiratory drive
• Respiratory aids – CPAP machine
©2011 MFMER | 3127551-17 ©2011 MFMER | 3127551-18
29
• Machine is
different.
• All electronic
• No flowmeter
knobs
• No vaporizor dials
©2011 MFMER | 3127551-19
• What’s the
same?
• Breathing circuit
• CO2 absorber
• Ventilator
bellows
©2011 MFMER | 3127551-22
• What about • What about
monitors? brain monitors?
• ECG • EEG
• Pulse ox • Processed EEG
• BP • Do they work?
• Invasive lines
©2011 MFMER | 3127551-23 ©2011 MFMER | 3127551-24
30
• What about BIS? • BIS Monitor
• Aspect Medical Systems ,
now Covidien • Now 3 studies
• EEG processed • Prospective
via a proprietary • Non-industry
formula funded
• From frontal lead • Well-designed
only
• No different from
• Dimensionless # ETAG
• References at end
©2011 MFMER | 3127551-25 ©2011 MFMER | 3127551-26
What about Spinal and epidural

regional anesthesia have
fewer side effects and
anesthesia? risks than general
anesthesia (asleep
and pain-free).
IS IT SAFER TO Patients usually
HAVE A SPINAL? recover much faster
and can go home
sooner.
Medline Plus update 2011
Is this true? (side Is Spinal/Epidural safer than General?
effects)
Not if one uses modern
• Death, stroke, MI = NO
drugs/techniques. • DVT/PE, especially total joints = YES
• Fast on/Fast off
BUT strongest data pre-dates
• More TIVA
aggressive prophylaxis
• Multi-modal analgesia
• Desflurane helps
31
What about side effects? What does Spinal/Epidural do?
• GA • Dose dependent sensory block/motor
• PONV • Sympathetic blockade!!!
• Delerium – esp. elderly • Fore-warned is fore-armed
• SAB/Epi • Nothing to the airway
• Spinal headache – esp. young
• Hearing things
How to choose? When to choose?
The morning of
operation
It depends. . .
• Operation
So – helpful to introduce
• Co-morbidities both possibilities in
• Patient position selected cases
• Coagulation status
Can my patient have a Can my patient have a
spinal if s/he is on spinal if s/he is on
aspirin? clopidogrel or. . .?
See ASRA guidelines
Regional Anesthesia in the Patient Receiving
YES Antithrombotic or Thrombolytic Therapy:
American Society of Regional Anesthesia and
Pain Medicine Evidence-Based Guidelines
(Third Edition)
Regional Anesthesia and Pain Medicine:
• Horlocker TT, Wedel DJ, et al
January/February 2010 - Volume 35 - Issue 1 -
Anesth Analg. 1995;80(2):303.
pp 64-101
32
What about all those • The 3 O’s
other blocks?
• Operating Room Suite
Very effective for the • “Outfield”
right operation
• Office-based
Ultrasound has
boosted success
rates!!!
APSF Newsletter 2011
©2011 MFMER | 3127551-38
• Where is the “Outfield? • Is the Outfield more dangerous than
• GI Suite the Operating Room??
• Cardiac lab • Yes and No
• Emergency room • Look at ASA Closed Claims
• Radiology (MRI suite) database
APSF Newsletter 2011 APSF Newsletter 2011
©2011 MFMER | 3127551-39 ©2011 MFMER | 3127551-40
Anesthesia 101 for the Non- Anesthesia Risk in Remote Locations

Anesthesiologist From ASA Closed Claims Data Base
“Outfield”
• Look at ASA Closed Claims 60 OR
database
• Closed Malpractice Cases 40
• Mined for information, trends %

20
• Generates safety advice for the
specialty 0
Death Brain Nerve
Damage Damage
APSF Newsletter 2011 Adapted from APSF Newsletter, 2011
©2011 MFMER | 3127551-41 ©2011 MFMER | 3127551-42
33
• “Outfield” dangers • “Outfield” Pearls from Closed
• Older (20% ≥ 70) Claims
• Sicker (69% ASA 3-5) • O2 sat ≠ ventilation!!!!!!
• Emergent (36%) • O2 delivery may delay recognition
• Pt. expects “Totally asleep” • GETA may be safer than MAC!!!!
APSF Newsletter 2011 Adapted from APSF Newsletter 2011
©2011 MFMER | 3127551-43 ©2011 MFMER | 3127551-44
Anesthesia 101 for the Non-

Anesthesiologist “Outfield” (and Office) Anesthesia
• What are the needs for ??
• Remember the learning goal about systems
and patient flow? • anesthesia equipment •EXACTLY
• safety equipment
• Death in the GI Suite may only occur once in
your career, or my career. • pre-anesthesia
THE
• Multiply by how many GI docs or
anesthesiologist at your hospital
assessment
• MH drugs (dantrolene,
SAME
mannitol)
• ↑Safety from system change; not individual • resuscitation capabilities
practice change
• etc., etc.
Adapted from APSF Newsletter 2011
©2011 MFMER | 3127551-45
Who can’t be an outpatient at the U of

Who can’t be an outpatient? Chicago? (Historic list)
• Very young • Unstable ASA 3 or 4
• Very old • MH
• Severe pre-existing
disease • On MAOI
• High ASA physical status • Morbid Obesity (What BMI?)
• Acute substance abuse
• Psychosocial difficulties
34
Who can’t be an outpatient? Addendum
• Unstable ASA 3 or 4
• Remind your outpatients
• It’s NOT doing the
• MH case!!! • Bring someone along
• On MAOI • Leave valuables at home
• Morbid Obesity (What
BMI?) • It’s that we do NOT • Forget driving for 24 hrs.
have Level 1 Recovery
• Acute substance abuse facility and extra
• Psychosocial difficulties personnel
What keeps outpatients in hospital? What keeps outpatients in hospital?

• Pain • Pain
• Nausea and • Nausea and
vomiting vomiting
• Wound problems • Wound problems
• Change in surgical • Change in surgical
plan plan
Gadgets, Gizmos, Etc.

What keeps outpatients in hospital?
• Pain • 37 y/o female for
• Nausea and • Triple Whammy lap chole
vomiting
• Ondansetron • No meds
• Wound problems • Steroid
• Change in surgical • Droperidol • Never had
plan anesthesia
• Scopolamine patch
©2011 MFMER | 3127551-54
35
Gadgets, Gizmos, Etc. Gadgets, Gizmos, Etc.
• What is this? P6 Accupressure

100 ASA I & II for
• Sea Band laparoscopic operations
• P6 Acupuncture P6 acupressure band
site
vs.
• Hx of motion Sham = band without the
sickness bead
• Boat
• Plane White et al, Anesth Analg 2012; 115:31-37
• Car
©2011 MFMER | 3127551-55 ©2011 MFMER | 3127551-56
P6 Accupressure P6 Accupressure
PON→V @ 24 hrs NO difference in
10% vs. 26% (Sham) Hospital discharge
Time to normal activities
Return to work
Pt. satisfaction
84% vs. 66% (Sham)
White et al, Anesth Analg 2012; 115:31-37
White et al, Anesth Analg 2012; 115:31-37
©2011 MFMER | 3127551-57 ©2011 MFMER | 3127551-58
What to do? What to do?

1. Keep it in place 1. Keep it in place
2. Double the 2. Double the
droperidol dose droperidol dose
3. Acupuncture 3. Acupuncture
consult post-op consult post-op
4. Take it off 4. Take it off
©2011 MFMER | 3127551-59 ©2011 MFMER | 3127551-60
36
NPO Rules NPO Rules
• This is current rule (1999 ASA) • Clear Liquids 2 hrs ahead
•2 – 4 – 6 – 8 • Water
• 8 hours “heavy” meal • Juice (no pulp)
• 6 hours “light” meal
• 4 hours breast milk
• Coffee (no lightener)
• 2 hours clear liquids • Jello, popsicle, soda.
Anesth 90:896-905; 1999
NPO Rules Sports Drinks

• Gatorade Prime 01
• What about these?? contains 25 grams of
carbohydrates (100
• Newer sports drinks on the calories), 110 mg sodium,
35 mg potassium, and
market 10% Daily Value of the B
vitamins.
• Carbohydrates http://www.gatorade.com/
• Proteins
• Caffeine
Sports Drinks Sports Drinks

Gatorade Perform 02 A 16.9-oz. bottle of
contains water, 14 grams Gatorade Recover 03
of carbohydrates, 110 mg contains 16 g of [whey]
sodium, 30 mg protein to help promote
potassium, and coloring. muscle recovery, as well
as 14 g of carbohydrate
(130 calories), 250 mg of
sodium, and 95 mg of
http://www.gatorade.com/ potassium.
http://www.gatorade.com/default.aspx#product?s=recover
37
What about booze?
• Not the morning of • What is this?
surgery!
• E-cigarette
• Night before OK (in • Electronic cigarette
moderation)
• Less problem than a • Vapor cigarette
sleeping pill • E-cig
©2011 MFMER | 3127551-68
• What does it do? • What does the mist

contain in addition to
• Vaporizes. . . the diluent?
• Propylene glycol
• 1. Flavors, Nicotine
• Glycerine
• Polyethylene glycol • 2. Flavors
• . . . into a mist • 3. Nicotine
• 4. Who knows?
©2011 MFMER | 3127551-69 ©2011 MFMER | 3127551-70
• What does the mist • How does it work?

contain in addition to
the diluent? • The battery and
micro-circuitry
• 1. Flavors, Nicotine produce heat
• 2. Flavors • The heat atomizes the
liquid from the
• 3. Nicotine cartridge
• 4. Who knows? • The mist is inhaled
(and the end glows)
©2011 MFMER | 3127551-71 ©2011 MFMER | 3127551-72
38
• Is it safe? • Is it legal?
• Sort of. . . • Sort of . . .
• Safer than smoking • FDA must regulate it
like tobacco, not like a
• Dangerous if it gets drug.
you to start
• Varying doses of • States are lining up to
ban sales to minors.
nicotine
• (Think nicotine gum)
©2011 MFMER | 3127551-73 ©2011 MFMER | 3127551-74
• What do I tell my • LVAD

patient?
• Stop it at midnight • Always comes to OR
before surgery with technician
• Quit all tobacco
products
©2011 MFMER | 3127551-75 ©2011 MFMER | 3127551-76
• Pacemaker (CIED) • Pacemaker (CIED)

• What does it do? • What needs
• Speeds up things documentation
pre-op? (Within 6
• Runs on battery months)
• Programmable • Settings
• Battery level
• Dependency?
• Magnet effect
Anesth 114:247-61;2011 Anesth 114:247-61;2011

©2011 MFMER | 3127551-77 ©2011 MFMER | 3127551-78
39
Doesn’t have
• Pacemaker (CIED) • ICD (CIED)
to beneeds
• What on the
documentation
• What does it do?
• Senses bad rhythms
day of(Within 6
pre-op?
months) • Stops bad rhythms
operation!
• Settings • Always accompanied by
a pacemaker
• Battery level
• Dependency? • So, what does the
• Magnet effect magnet do?
Anesth 114:247-61;2011
©2011 MFMER | 3127551-79 ©2011 MFMER | 3127551-80
• ICD (CIED) • ICD (CIED)

• The magnet • The magnet
• 1. Turns off the shock • 1. Turns off the shock
mode; sets pacer to VOO mode; sets pacer to VOO
of 60 beats/min of 60 beats/min
mode; leaves pacer “as mode; leaves pacer “as
is” is”
mode; turns off the pacer mode; turns off the pacer
©2011 MFMER | 3127551-81 ©2011 MFMER | 3127551-82
• Circular magnet • What is it?

• Deep Brain Stimulator
• For Pacer • Generator in chest
• Sets to VOO or DOO • Battery pack
• Leads into the brain
• For ICD
• Turns off shock mode
• Leaves pacer as is
©2011 MFMER | 3127551-83 ©2011 MFMER | 3127551-84
40
• What does it do? • What do we need to do?

• Decreases movement • 1. Electrically shield it
• Parkinson’s
• 2. Turn it off
• Familial tremor
• Dystonias • 3. Call Neurosurgeon
• New uses • 4. Let someone else do

the case
• Epilepsy
• Depression • 5. Ignore it
• Etc.
©2011 MFMER | 3127551-85 ©2011 MFMER | 3127551-86
• What do we need to do? • Can think of it like a PM

• 1. Electrically shield it • Bi-polar cautery = OK
• 2. Turn it off • Any cautery below the
umbilicus = OK
• 3. Call Neurosurgeon
• Head, neck, chest case
• 4. Let someone else do = turn it off
the case
• 5. Ignore it
©2011 MFMER | 3127551-87 ©2011 MFMER | 3127551-88
• What else? • Recent media attention

• If Parkinson’s patient – • The issue is caffeine
take all meds up to the toxicity
last minute!
• How much is too much?
• Can it be fatal?
©2011 MFMER | 3127551-89
41
• 14 y/o Maryland female died • The teenager also is stated to

December, 2011 after drinking have had Ehlers-Danlos
poorly specified amount of October 22, 2012 syndrome October 22, 2012
Monster Energy drink
• Amount of Monster Energy?
• Mother is bringing suit because Monster Energy • 24 ounce can Monster Energy
coroner’s report implicates
“cardiac arrhythmia due to Drink Cited in • 240 mg caffeine Drink Cited in
caffeine toxicity” which • = 10 mg/oz.
Deaths Deaths
exacerbated an existing heart • Stated to have had 2 cans
problem. over 2 days

Energy Drinks
• Unknown from the article
• Vascular type of E-D? • TAURINE
• EtOH or other drugs? October 22, 2012
• GLUCURONOLACTONE
• Time frame between the 2nd
can of Energy and the Monster Energy • CAFFEINE (80 mg)
cardiac event •
Drink Cited in B-GROUP VITAMINS
Deaths • SUCROSE
• How to interpret this when • GLUCOSE
patients ask about it?
What about Pepsi? Energy Drinks
• A can of Pepsi (12 fl ounces)

has • Drip Coffee (8 oz.)
• 41 grams of carbohydrates • CAFFEINE (80- 120 mg)
• 30 mg of sodium
• 38 mg of caffeine and
• What about larger servings?
• 150 calories
42
Energy Drinks
• What to tell patients?

• Don’t worry, be
caffeinated.
Mpls Star Tribune 4-8-13
©2011 MFMER | 3127551-97
Headaches: Caffeine withdrawal?? Gadgets, Gizmos, Etc.
• What is this guy doing?

• 1. Vaping an e-cig
• 2. Applying lip gloss
• 3. Huffing crazy glue
• 4. Inhaling caffeine
• Mayo Clin Proc 1993;68:842-45

©2011 MFMER | 3127551-100
• What is this guy doing? A new fad – inhaled

caffeine
• 1. Vaping an e-cig
Is it really
• 2. Applying lip gloss inhaled???
• 3. Huffing crazy glue Shoots a fine
• 4. Inhaling caffeine powder into the
mouth, then one
swallows it.
©2011 MFMER | 3127551-101 ©2011 MFMER | 3127551-102
43
• FDA warning • “Air-based
March, 2012 Energy Shot”
• Marketing at • $2.99 Online
students price (Accessed
(minors) August, 2013)
• Not really
inhaled
©2011 MFMER | 3127551-103 ©2011 MFMER | 3127551-104
“Inhaled” caffeine “Inhaled” caffeine

What if my patient does this What if my patient does this
in the pre-op waiting area? in the pre-op waiting area?
1.Cancel the case 1.Cancel the case
2. Postpone the case 2 hours 2. Postpone the case 2 hours
3. Go ahead 3. Go ahead
4. Check ECG; then go 4. Check ECG; then go
ahead. ahead.
©2011 MFMER | 3127551-105 ©2011 MFMER | 3127551-106
Anesthesia 101 for the Non-Anesthesiologist

Big question from patients. . .
• What about risks? • Questions?

• Overall risk of death from GA • Want to start an e-mail conversation?
• Is it safer than riding home in my car?
• 1980 risk ~ 1/5000
• 2000 risk ~ 1/20,000
• 2004 risk (annual) MVA death ~ 1/19,000
• danielson.david@mayo.edu
• Annualized risk vs. single events
Multiple sources, including JAMA , NSC data, and several anesthesia textbooks
©2011 MFMER | 3127551-107
44
• The next three slides are the references for BIS Monitor vs.
The NEW ENGLAND
the measurement of ETAG = End-Tidal Anesthesia Gas
concentrations.
JOURNAL of MEDICINE
• All three studies showed ETAG to be equal or better at established in 1812 march 13, 2008 vol. 358 no. 11
predicting recall.
Anesthesia Awareness and the Bispectral
Index
• These three studies were NOT industry funded.
Michael S. Avidan, M.B., B.Ch., Lini Zhang, M.D., Beth A.
Burnside, B.A., Kevin J. Finkel, M.D., Adam C. Searleman, B.S.,
Jacqueline A. Selvidge, B.S., Leif Saager, M.D., Michelle S. Turner,
B.S., Srikar Rao, B.A., Michael Bottros, M.D., Charles Hantler, M.D.,
Eric Jacobsohn, M.B., Ch.B., and Alex S. Evers, M.D.
The NEW ENGLAND Next Round = Unselected patients

3 hospitals at U of Michigan
JOURNAL of MEDICINE 18,000 pts. BIS vs. ETAG
established in 1812 august 18, 2011 vol. 365 no. 7 Same results  ETAG ≅ BIS
Prevention of Intraoperative Awareness in a
High-Risk Surgical Population Mashour et al, Anesth 2012; 117:717-25
• Michael S. Avidan, M.B., B.Ch., Eric Jacobsohn, M.B., Ch.B., David Glick, M.D.,
M.B.A., Beth A. Burnside, B.A., Lini Zhang, M.D., Alex Villafranca, M.S., Leah Karl,
B.A., Saima Kamal, M.D., Brian Torres, B.S.N., Michael O’Connor, M.D., Alex S.
Evers, M.D., Stephen Gradwohl, B.S., Nan Lin, Ph.D., Ben J. Palanca, M.D., Ph.D
and George A. Mashour, M.D., Ph.D., for the BAG-RECALL Research Group.*
Anesthesia 101 for the Non-Anesthesiologist

Don’t forget about MULTIPLE end-users. . . Pre-op (NPO) Instructions
• Why might your pre-op consult need to be multi-
faceted? • Aspiration risk
• Multiple end-users may need different info! • 67:215,488 = 1:3,216
• The surgeon pre-op (changes in meds)
• ME (Pre-op, Intra-op, and Recovery Room) • Vent ≥ 6 hrs = 1:16,576
•
•
The surgeon post-op (continuing care of medical issues)
The Hospitalist (unique circumstances of this patient)
• 3 died = 1:71,829
• Warner,Warner,Weber.Anesth 1993;78:56-62
©2011 MFMER | 3127551-113
45
Pre-op (NPO) Instructions Pre-op (NPO) Instructions
• MI risk • Cardiac arrest (OR & PACU)
• Non-cardiac surgery • 1:2,324
• Within 30 days
• Hospital survival ≤ 50%
• 0.3% = 1:334 • Death is ~1:5,000
• Cardiac arrest (OR & PACU)
• Sprung et al. Anesth 2003; 99:259-69
• 1:2,324
• Sprung et al. Anesth 2003; 99:259-69
Pre-op (NPO) Instructions

• So, Which is riskier?
• Liberal NPO rules, OR
• Missing cardiac drugs
• Beta Blocker
• Statin
• Rhythm drug
46
Important Disclosures
Cardiac Risk Assessment:
Using Guidelines to Direct Practice and • No industry conflict of interest
Choosing the Appropriate Stress Test
• I will not advocate the off-label use of
FDA approved drugs

Karen F. Mauck, MD, MSc, FACP
Assistant Professor of Medicine
Consultant, Division of General Internal Medicine; Mayo Clinic, Rochester, MN
October 9-12  Seattle Washington
©2011 MFMER | 3135271-1 ©2011 MFMER | 3135271-2
Purpose of Preoperative Cardiac

Clinical Questions Evaluation
• How do I use the ACC/AHA guidelines for • Evaluate/assess/quantify cardiac risk for
preoperative cardiac risk assessment? both patient and surgeon
• How do I use the Gupta cardiac risk • Optimize appropriateness of testing and
calculator? intervention
• How do I decide which stress test to • Direct perioperative care in order to
order? decrease cardiac risk
©2011 MFMER | 3135271-3 ©2011 MFMER | 3135271-4
What Do We Need to Know for Cardiac

Risk Assessment? Clinical Risk Factors (RCRI*)
• History of ischemic heart disease

• Patient specific risk
• Clinical risk factors for CAD • History of compensated or prior HF
• Functional capacity • History of cerebrovascular disease
• Surgery specific risk • Diabetes
• Type or duration of surgery • Renal insufficiency
*Lee et al: Circulation 100:1043, 1999
©2011 MFMER | 3135271-5 ©2011 MFMER | 3135271-6
47
Lee Revised Risk Index
Independent Predictors of Perioperative Cardiac What Do We Need to Know for Cardiac
Events Risk Assessment?
OR (95% CI)
High-risk surgery 2.8 (1.6, 4.9)
History of CAD 2.4 (1.3, 4.2)

• Patient specific risk
History of CHF 1.9 (1.1, 3.5)
• Clinical risk factors for CAD
Diabetes on insulin 3.0 (1.3, 7.1)
• Functional capacity
Creatinine 2.0 mg/dL 3.0 (1.4, 6.8) • Surgery specific risk
History of CVA/TIA 3.2 (1.8, 6.0) • Type or duration of surgery
0 1 2 3 4 5 6 7 8
Derivation cohort (n=2,893); validation cohort (n=1,422)
Lee TH et al: Circulation 100:1043, 1999
Slide from W. Freeman, 2007
©2011 MFMER | 3135271-7 ©2011 MFMER | 3135271-8
Functional Capacity
Estimated Energy Requirements for Various What Do We Need to Know for Cardiac
Activities Risk Assessment?
1
Can you take care of yourself?
4
METs
Climb a flight of stairs or walk up a
hill? • Patient specific risk
MET Eat, dress, or use the toilet? Walk on level ground at 4 mph or 6.4
km per hr or run a short distance? • Clinical risk factors for CAD
Walk indoors around the
house? Do heavy work around the house like
scrubbing floors or lifting or moving
• Functional capacity
Walk a block or two on level heavy furniture?
ground at 2 to 3 mph or 3.2 to
4.8 km per h? Participate in moderate recreational
• Surgery specific risk
activities like golf, bowling, dancing?
3
METs
Do light work around the
house like dusting or washing Participate in strenuous sports like
• Type or duration of surgery
10+
dishes? swimming, singles tennis, football,
METs
basketball, or skiing?
©2011 MFMER | 3135271-9 ©2011 MFMER | 3135271-10
Surgical Risk Putting It All Together Using

Cardiac Risk* Stratification for Noncardiac Procedures a Stepwise Approach
Emergent major operations, particularly in
elderly
Aortic and major vascular surgery
High >5% Peripheral vascular surgery • ACC/AHA Guidelines on Perioperative
Prolonged surgery, large fluid shifts or blood Cardiovascular Evaluation and Care for
loss
Carotid endarterectomy
Noncardiac Surgery – 2007
Head and neck surgery
Intermediate Intraperitoneal or intrathoracic surgery
>1%, <5% Orthopedic surgery
Prostate surgery
Endoscopic procedures
Superficial procedures
Low <1% Cataract surgery
Breast surgery
*Combined incidence of cardiac death and nonfatal MI *Lee et al: Circulation 100:1043, 1999
©2011 MFMER | 3135271-11 ©2011 MFMER | 3135271-12
48
Overriding Theme Overriding Theme
• Surgical or percutaneous intervention is rarely
necessary simply to lower the risk of surgery • No testing should be performed unless it
unless the intervention is indicated irrespective is likely to influence patient treatment
of the preoperative context
• The ultimate decision regarding care of a
• The patient is not “cleared for surgery” rather, particular patient must be made by the
“the patient is medically optimized from a physician and patient in light of all the
cardiac standpoint and does not require
additional testing prior to planned surgical
specific clinical circumstances
procedure”
*Lee et al: Circulation 100:1043, 1999 *Lee et al: Circulation 100:1043, 1999
©2011 MFMER | 3135271-13 ©2011 MFMER | 3135271-14
Perioperative surveillance
Need for emergency Yes and postoperative risk
Step 1 (Class I, LOE C) Operating room stratification and risk
noncardiac surgery?
factor management
No
Step 2 Active cardiac

Yes
(Class I, LOE B)
Evaluate and treat
per ACC/AHA guidelines
Consider
operating room
Step 1
conditions*
No
Yes Proceed with

Step 1
Step 3 Low risk surgery (Class I, LOE B) planned surgery
No
Perioperative surveillance
Need for emergency Yes and postoperative risk
Good functional capacity (MET
Yes
Proceed with Operating room
Step 4 level 4) without symptoms†
(Class I, LOE B) planned surgery noncardiac surgery? stratification and risk
factor management
No
Step 5 No or unknown
Step 2
1 or 2 clinical
3 or more clinical risk factors
risk factors
No clinical
Intermediate risk risk factors
Vascular surgery
surgery
Intermediate risk
Vascular surgery
surgery Class I,
Class IIa, LOE B LOE B
Consider testing if it Proceed with planned surgery with HR control (Class IIa, LOE B) or Proceed with
will change management consider noninvasive testing (Class IIb, LOE B) if it will change management planned surgery
©2011 MFMER | 3135271-15 ©2011 MFMER | 3135271-16
Step 2 Step 3
Step 2 Step 3
Active cardiac Yes Evaluate and treat Consider Yes Proceed with
Low risk surgery
conditions per ACC/AHA guidelines operating room planned surgery
No No
Active cardiac conditions Low risk surgery
Step 3 • Unstable coronary syndromes Step 4
• Endoscopic procedures
• Unstable or severe angina • Superficial procedures
• Recent MI • Cataract surgery
• Decompensated HF
• Breast surgery
• Significant arrhythmias
• Severe valvular disease
©2011 MFMER | 3135271-17 ©2011 MFMER | 3135271-18
49
Step 4 Step 5
Step 4 Step 5
Good functional capacity Yes Proceed with

(METS 4) without symptoms planned surgery Clinical Risk Factors
No or • History of ischemic heart disease
unknown
• History of compensated or prior
Step 5 HF
• History of cerebrovascular
disease
• Diabetes
• Renal insufficiency
©2011 MFMER | 3135271-19 ©2011 MFMER | 3135271-20
Step 5 Case 1
• 78-year-old female scheduled for a modified
Step 5
radical mastectomy for breast cancer
Clinical Risk Factors
• DM II for 10 years
3 or more 1 or 2 None • Hx of CAD with NSTEMI 5 years ago, BMS
Vascular Intermediate placed in her RCA, asymptomatic
surgery risk surgery
• Functional capacity: <4 METS
Consider testing if
it will change
Vascular or
intermediate
Proceed with
• Exam: BP 125/65 P 70 BMI 29 ECG: NSR
planned surgery
management risk surgery
• Meds: lisinopril, metoprolol, asa, insulin and
metformin
Proceed with planned surgery with HR control or consider
noninvasive testing if it will change management • Labs: Cr 1.4
©2011 MFMER | 3135271-21 ©2011 MFMER | 3135271-22
What Would You Recommend With Respect

to Preoperative Cardiac Risk Assessment? Need for emergency
Step 1
noncardiac surgery? No
Active cardiac
Step 2
conditions? No
A. No additional cardiac testing, proceed
with planned surgery Step 3 Low risk surgery? Yes
B. Exercise stress test

Low risk surgery
C. Dobutamine stress Echo • Endoscopic procedures
• Superficial procedures
D. Cardiology consult • Cataract surgery
• Breast surgery
©2011 MFMER | 3135271-23 ©2011 MFMER | 3135271-24
50
Case 2 to Preoperative Cardiac Risk Assessment?
• 68-year-old female is scheduled for an
elective total hip arthroplasty A. No additional cardiac testing, proceed
• PMH: HTN, CRI with baseline Cr of 2.1, past with planned surgery
CVA with no residual deficits, no CAD B. Exercise stress test
• Functional capacity <4 METS
C. Dobutamine stress Echo
• Exam: BP 140/85; P 55; normal
D. Cardiology consult
• ECG: 1st degree AV block, normal
• Medications: lisinopril, metoprolol, lasix,
ASA, simvastatin, tramadol
©2011 MFMER | 3135271-25 ©2011 MFMER | 3135271-26
Need for emergency

Step 1
Active cardiac Step 5

Step 2
conditions? No
Step 3 Low risk surgery? No Clinical Risk Factors

Good functional
Step 4 capacity (METS 4) No • History of compensated or prior
without symptoms? HF
• History of cerebrovascular
disease
• Diabetes
©2011 MFMER | 3135271-27 ©2011 MFMER | 3135271-28
Case 3
• 71-year-old male scheduled for a R aorto-femoral
bypass for claudication
Step 5
• PMHx: hypertension, hyperlipidemia, diabetes, and
COPD – still smoking, no known CAD.
3 or more 1 or 2 None
• Functional capacity: <4 METS (dyspnea and
Vascular Intermediate
claudication)
• Exam: 140/75; P 82 regular; normal except
prolonged expiration phase with scattered rhonchi
Consider testing if
it will change
Vascular or
intermediate
Proceed with and diminished pulses distal RLE
planned surgery
management risk surgery
• ECG: Q waves in II, III, AVF (no old ECG available to
compare); Labs: NL
noninvasive testing if it will change management • Meds: pravastatin, insulin, metformin, lisinopril,
Ipratropium MDI, albuterol MDI
©2011 MFMER | 3135271-29 ©2011 MFMER | 3135271-30
51
to Preoperative Cardiac Risk Assessment? Need for emergency
Step 1
A. No additional cardiac testing, proceed with Active cardiac

Step 2 No
planned surgery; no beta blockade conditions?
because of COPD
Step 3 Low risk surgery? No
B. No additional cardiac testing, proceed with
planned surgery with beta blockade to Good functional
capacity (METS 4)
Step 4 No
keep heart rate 55-65 bpm without symptoms?
C. Dobutamine Stress Echo

D. Ask his profession: lawyer or cardiologist
–stress test; other – Beta Blocker and
proceed
©2011 MFMER | 3135271-31 ©2011 MFMER | 3135271-32
Step 5 Step 5
Clinical Risk Factors 3 or more 1 or 2 None
• History of ischemic heart disease Vascular Intermediate

• History of compensated or prior
HF
Consider testing if Vascular or
• History of cerebrovascular it will change intermediate
Proceed with
planned surgery
disease management risk surgery
• Diabetes
• Renal insufficiency noninvasive testing if it will change management
©2011 MFMER | 3135271-33 ©2011 MFMER | 3135271-34
Case 3
Take Home Message
• I would stress this patient prior to this
elective high risk surgery • Guidelines are not meant to be
• Aggressive beta blockade is not prescriptive
protective in patients with significant
ischemia who undergo high risk • Sound clinical judgment which considers
vascular surgery each patient’s specific clinical
circumstances should prevail
• This patient has not had prior
evaluation of his heart – and we have
found evidence on ECG of CAD
• I would evaluate his CAD regardless of
surgery
©2011 MFMER | 3135271-35 ©2011 MFMER | 3135271-36
52
Gupta Perioperative Cardiac Risk Calculator Development and Validation of a Risk
Calculator for Prediction of Cardiac Risk After
Surgery
Gupta PK et al. Circulation 2011; 124:281-7
• Historical cohort study

• Participants: 469,000 patients from the NSQIP
database undergoing variety of surgical
procedures 2007-2008
• Outcomes:
• 30-day Postop Intraoperative or
Postoperative MI or Cardiac Arrest
Gupta et. al. Circulation, 2011;124:382-7

©2012 MFMER | slide-37
Results: 5 factors contributed to risk of

Outcomes, continued.. MI and cardiac arrest
• Cardiac Arrest:
• absence of cardiac rhythm causing LOC and • Age
initiation of ACLS
• Creatinine
• ASA class
• Myocardial Infarction-- one of the following:
• ECG changes of acute MI • Procedure Type
• New elevation in troponin greater than 3 times • Dependent Functional Status
normal in the setting of suspected myocardial
ischemia
ASA Class
Results, continued..
N C-statistic
Gupta Derivation 211,410 0.88
Cohort
MI/CA 0.65%
Gupta Validation 257,385 0.87
Cohort
MI/CA 0.54%
RCRI Applied to 257,385 0.75
Validation Cohort
53
Perioperative Cardiac Risk Calculator
Compared to the Lee RCRI
Gupta Lee RCRI

YEAR 2011 1999
Cohort size 400,000 4315
C statistic 0.874 0.765
Surgery specific YES NO
Gupta et. al. Circulation, 2011;124:382-7

Take Home Points– Gupta Cardiac Risk

Where Can I Find the Calculator? Calculator
• Surgery specific
• Qx Calculate
• http://www.qxmd.com • Exact model based estimate of risk is provided
• Free app for phone in a smartphone app format or on the web
• Has not been externally validated and may
• http://www.surgicalriskcal underestimate risk because of how
culator.com postoperative MI was defined in the database
• Free download for • Has not been incorporated into updated
desktop
guidelines, so decisions on management based
• Request for password on risk is not defined
accepts anything
©2012 MFMER | slide-45 ©2012 MFMER | slide-46
Choosing the Best Stress Test Case 4

• 65-year-old male with known CAD is
• Cases to illustrate evaluated for preoperative cardiac risk
assessment
• For each case recommend the best
stress test • After review of the history, you have
decided that he needs to have a cardiac
stress test preoperatively to help you
further risk stratify him prior to AAA repair
• Medications
• Lisinopril 20 mg; ASA 81 mg; Pravastatin
40 mg; Metoprolol 50 mg BID
©2011 MFMER | 3135271-47 ©2011 MFMER | 3135271-48
54
Case 4 (cont)
• NSTEMI 3 yrs ago with 80% LAD lesion,
treated with bare metal stenting
• Echo 1 year ago: No wall motion
abnormalities; EF 65%
• Occasional mild angina with exertion since
the MI
• Functional capacity: < 4 METS by history
• BP: 140/80; pulse 60 regular
• ECG: shown
Left Bundle Branch Block
©2011 MFMER | 3135271-49 ©2011 MFMER | 3135271-50
Which Stress Test Would You Stress Testing in Left Bundle Branch
Recommend for this Patient? Block
A. Exercise ECG with no imaging • Tachycardia induced by exercise may

B. Exercise ECG with thallium result in reversible septal defects even in
the absence of LAD artery disease
C. Exercise ECG with sestamibi imaging
• Also reported with dobutamine*
D. Dobutamine stress Echo
E. Pharmacologic vasodilator stress
• Vasodilator stress with myocardial
perfusion studies recommended
(dipyridamole or adenosine) with
sestamibi imaging
*DSE can be used in LBBB, but may be less accurate in the setting of LAD disease
©2011 MFMER | 3135271-51 ©2011 MFMER | 3135271-52
Stress Testing in LBBB Case 5
Sensitivity Specificity • 64-year-old non-obese female needs

(rule out) (rule in) Accuracy
elective 9.5 cm AAA repair
Exercise
perfusion
imaging
75% 33% 36-60% • No history of CAD
Dobutamine
Stress Echo
91% 92% 92% • BP 180/95
(LAD DZ) (83%) (92%) (79%)
• No exercise limitations
Vasodilator
stress/with 98% 84% 88-92%
imaging
• No lung disease
• ECG
©2011 MFMER | 3135271-53 ©2011 MFMER | 3135271-54
55
Which Stress Test Would You
Case 5 (cont) Recommend for this Patient?
A. Exercise stress test with no imaging

B. Exercise stress test with thallium or
sestamibi imaging
C. Dobutamine stress Echo
D. No stress testing because of concern
for AAA rupture
LVH with strain pattern
©2011 MFMER | 3135271-55 ©2011 MFMER | 3135271-56
Issues to consider Case 6
• She can exercise • 72-year-old male with moderate COPD

scheduled for a lower extremity
• AAA not a contraindication to exercise revascularization for claudication
• Abnormal ECG • On exam you hear scattered wheezes
• LV hypertrophy with “strain” pattern, or and rhonchi
digitalis effect, stress with cardiac
imaging should be done because the • Patient taking multiple inhalers and
exercise ECG is non-diagnostic theophylline for his COPD
• Significant hypertension • BP 130/75

• Avoid dobutamine • METs <4 due to claudication
©2011 MFMER | 3135271-57 ©2011 MFMER | 3135271-58
Which Stress Test Would You

Recommend for this Patient? Issues to consider
A. Exercise stress echo • Patient cannot exercise

B. Dobutamine stress Echo
C. Exercise ECG with thallium or sestamibi • Avoid dipyridamole and adenosine in
imaging patients:
• On theophylline
D. Pharmacologic vasodilator stress
(dipyridamole or adenosine) with
• With significant bronchospasm
thallium or sestamibi imaging • With critical carotid stenosis
©2011 MFMER | 3135271-59 ©2011 MFMER | 3135271-60
56
Diagnostic Performance of Exercise Stress
Echo vs Nuclear Imaging Testing
Meta-Analyses: Coronary Angio Correlation
• Echo imaging • Nuclear perfusion imaging
• More specific • More sensitive – especially
for single vessel CAD Sensitivity Specificity
• Gives more extensive info involving the LCX
on cardiac anatomy and TMET ECG 68% 77%
function
• Quantifies extent of ischemia
• Costs less more reproducibly Stress Echo 85% 77%
• Superior to nuclear
perfusion in obese • More accurate in assessing Stress SPECT 87% 64%
patients – Echo travels ischemia when multiple
through adipose quite resting RWMA’s present Dob Echo 85% 84%
well
• Limited by poor Echo • More expensive Adeno SPECT 89% 79%
windows in some patients • Soft tissue attenuation of
nuclear trace in obese
• Technician dependent patients
Fleischman KE et al: JAMA 280:913, 1998
Gibbons RJ et al: JACC 41:159, 2003
©2011 MFMER | 3135271-61 ©2011 MFMER | 3135271-62
Don’t Forget Parting Pearls

• Surgical or percutaneous intervention is rarely
necessary simply to “get the patient through
• Standard exercise treadmill testing is a surgery”
viable option for preoperative cardiac risk
stratification for patients who: • Only test if it will change management
• Normal ECG • Patients with adequate functional capacity (4
METs) can usually go to surgery without
• No prior revascularization additional testing
• Not taking digoxin • Patients scheduled for low risk surgery usually
• Able to exercise at least 5 minutes on do not need additional testing
Bruce protocol • Choose your stress test based on the specific
clinical situation
©2011 MFMER | 3135271-63 ©2011 MFMER | 3135271-64
Reference
Fleisher LA, et al. ACC/AHA 2007 guidelines on
perioperative cardiovascular evaluation and care Thank You
for noncardiac surgery: a report of the American
College of Cardiology/American Heart
Association Task Force on Practice Guidelines. mauck.karen@mayo.edu
J Am Coll Cardiol 2007;50:e159 –242.
©2011 MFMER | 3135271-65 ©2011 MFMER | 3135271-66
57
58
The Plan
Cardiac Risk Reduction Strategies:
• Risk Reduction Strategies
Medical and Interventional – Timing of surgery
An Overview of Perioperative Medicine – Anesthesia
– Monitoring
October 2013 – Medications
– Interventions
Howard Weitz, M.D.
Jefferson Medical College
Thomas Jefferson University Hospitals
Timing of Surgery Post MI Timing of Surgery Post MI
Tarhan S, et al. JAMA 1972 Tarhan S, et al. JAMA 1972
Timing of Surgery Post MI Timing of Surgery Post MI
Hip surgery, cholecystectomy, AAA repair, colectomy, amputation
Tarhan S, et al. JAMA 1972

Annals of Surgery, May 2011
59
Timing of Surgery Post MI
Timing Dual Antiplatelet Rx post MI
• BMS: min 4 weeks, ideal 12 months

• DES: min 12 months
• Thrombolytic rx: up tp 12 months
• No reperfusion therapy: 9-12 months
Annals of Surgery, May 2011
Popular Science, October 1930
Anesthesia: General vs. Regional Role of spinal / epidural anesthesia
• No difference morbidity - mortality • Rogers et al, BMJ, December 2000

• ADVANTAGES of regional in the cardiac pt. • Meta analysis (141 trials, 9559 patients)
– Less myocardial, respiratory depression
– Avoid endotracheal intubation (autonomic • Trials with randomization to:
stimulation)
– Neuraxial blockade (spinal or epidural)
• DISADVANTAGES of regional:
– Anxiety catecholamine release MVO2
– General anesthesia
– Spinal vasodilation BP – Note: 43% of neuraxial blockade group also
received general anesthesia.
60
Rodgers Results Rodgers Results
Neuraxial blockade outcome Criticism
• 33% reduced mortality • Studies are heterogeneous – meta analysis

• 44% reduced DVT validity ?
• 55% reduced pulmonary embolus • Meta analysis overestimates “treatment
• 39% reduced pneumonia effect” (positive trial publication bias)
• 33% reduced MI
• Postop management has changed making
benefit of neuraxial anesthesia less important
• Is the benefit due to neuraxial blockade or to absence
of general anesthesia? • Many studies did not use Troponin as an MI
• Does neuraxial blockade alter stress response? marker – MI under diagnosed
2005 Evidence review

Rodgers Results
Criticism
• Large Multicenter retrospective studies

(2001, 2002) showed no mortality
benefit and only minimal morbidity
benefit from combined epidural/general Benefits of neuraxial anesthesia and analgesia
Less blood loss
anesthesia. Superior pain control
Decreased ileus
Fewer pulmonary complicatons
No Mortality benefit
No definite improvement in cardiac outcome
No fewer thromboembolic events when DVT prophylaxis used
2008 retrospective database review 2008 retrospective database review

Lancet 2008, 372:562 Lancet 2008, 372:562
61
Anesthesia for the Consultant: Summary
Perioperative Beta Blockers
What really is the evidence?
ACC / AHA Guideline 2007
62
High risk [
N Engl J Med 1999;341:1789-94
In the absence of major contraindications, therapeutic doses of beta- Perioperative Beta Blockers
adrenergic antagonists should be given to patients with an intermediate
or high risk of cardiac complications. Patients who are not already
receiving beta-blockers should be given one of these agents. Even if the What really is the evidence?
drug causes complications, such as fatigue or impotence, these side
effects can be tolerated during the perioperative period. Patients who are
already receiving a beta-blocker should be evaluated to ensure that
therapeutic serum concentrations have been achieved.
Lee, T.: Reducing Cardiac Risk in Noncardiac Surgery. N Engl J Med: 341:1838-40, 1999
Mangano, 1996
• “In hospital” post op adverse events not counted.

– “In hospital” atenolol group 4 deaths, control group 2 deaths.
If included the difference in death between the two groups
not significant
• Did beta blocker withdrawl favor the beta blocker group?
– 8 patients taken off beta blocker to enter placebo group
• 40% did not tolerate full dose atenolol, 15% did not tolerate
any atenolol
• Trend toward sicker patients (prior MI, angina,
diabetes,prior coronary revasc) in placebo group.
• Atenolol group trended toward more comprehensive
cardiac therapy (ie ACE inhibitors) at discharge
63
????
59 pts beta blocker

53 pts std care59 p
N Engl J Med 1999;341:1789-94
McCullough P. Failure of B-blockers in the reduction of

Perioperative events. Where did we go wrong? AHJ November 2006
Pre 2001
Post 2004
www.acc.org March 11, 2006
ACC / AHA 2006 Perioperative Beta Blocker Perioperative Beta Blockers

Update POISE Trial
• Most trials inadequately powered • PeriOperative ISchemic Evaluation
• Few randomized trials of medical therapy to prevent – Canadian Institutes of Health Research
perioperative cardiac complications – Noncardiac surgery
– Hx: cad, pvd, cva, chf within 3 yrs of surgery, or vascular surgery
• Few randomized trials examined therapy titration
– 30 days of controlled release metoprolol
• Few randomized trials re: role of periop beta blockers • Metoprolol CR 100 mg 2-4 hrs preop
• Studies lacking to determine role of beta blockers in • IV or po metoprolol 6 hrs postop (equiv metoprolol CR 100mg)
• Metoprolol CR 200 mg daily for 30 days
intermediate and low risk populations
– Outcomes: cardiovascular death; fatal MI; non-fatal MI
• No studies have addressed how, when, by whom – 190 centers, 23 countries
perioperative beta blockade should be implemented – Goal 10000 patients (final enrollment 8351)
or monitored
64
POISE POISE trial online release; Lancet May 13, 2008
Trial Design: POISE was a randomized trial of metoprolol (n = 4,174) or placebo (n = 4,177) in patients undergoing
noncardiac surgery. Study drug was given 2 to 4 hours prior to surgery and for the next 30 days. Primary endpoint was
major CV events (defined as CV death, MI, or cardiac arrest through 30 days.
CV Death, MI, or Total Mortality Results

Cardiac Arrest (HR 1.33, p = • Primary endpoint of CV death, MI, or cardiac arrest ↓
(HR 0.83, p = 0.04) 0.03) in metoprolol (Figure), driven by ↓ nonfatal MI (3.6% vs.
5.1%, HR 0.70, p = 0.0007)
• Total mortality ↑ in metoprolol group (Figure) as did
stroke (1.0% vs. 0.5%, HR 2.17, p = 0.005)
• Metoprolol group also had ↑ rates of significant
hypotension (15.0% vs. 9.7%, p < 0.0001) and
significant bradycardia (6.6% vs. 2.4%, p < 0.0001)
Conclusions
%
• Among patients undergoing noncardiac surgery,

treatment with beta-blocker metoprolol was associated
with reduction in primary endpoint of CV death, MI, or
stroke at 30 days compared with placebo, but total
mortality and stroke were increased with metoprolol
• Prior studies with prophylactic beta-blocker in patients
undergoing vascular surgery have shown mixed results
• While post-surgical CV event rate was high, given
increased risk of death, stroke, and severe
hypotension with metoprolol, routine
prophylactic therapy does not appear to be a
safe approach to reducing CV events in this
Metoprolol Placebo population
Presented at AHA
2007
POISE: Metoprolol sustained release

POISE 1000 patients
• Metoprolol prevented MI but increased risk of • PREVENT

stroke, death. – 15 MI
• Metoprolol decreased incidence Afib. – 3 Coronary revasc
• Metoprolol increased hypotension, – 7 Afib
bradycardia.
POISE: Metoprolol sustained release

1000 patients
• PREVENT • CAUSE Why didn’t the beta blocker decrease

– 15 MI – 8 Death mortality in POISE?
– 3 Coronary revasc – 5 Stroke
– 7 Afib – 53 sig hypotension
– 42 significant
bradycardia
65
POISE
• ? Started too soon before surgery to have a plaque

stabilizing effect.
– POBBLE and DIPOM both started beta blocker less than 24
hours preop and showed no protective beta blocker effect)
• High dose beta blocker
• Doses not titrated
• Beta blocker only stopped if systolic BP dropped
< 100 mm Hg
• Beta blocker related significant hypotension
contributed to 37% of deaths
• Beta blocker related significant hypotension was
most common prelude to stroke
Perioperative beta blockade Perioperative beta blockade

Class I recommendation (2009) Class IIa recommendation
(evidence / agreement that treatment is beneficial, useful, (evidence / opinion in favor of usefulnes, effective)
effective)
• Beta blockers when used should be titrated to heart
• Beta blockers should be continued for rate and blood pressure.
patients who are receiving them to treat • Beta blockers probably for vascular surgery when
high risk due to CAD or ischemia on preop testing.
angina, symptomatic arrhythmia,
• Beta blockers probably for vascular surgery in
hypertension, or other Class I guideline patients at high cardiac risk (defn:presence of > 1
indications. clinical risk factor).
• Beta blockers probably for patient with CAD or high
cardiac risk (defn >1 clinical risk factor) who is to
undergo intermediate-risk surgery.
Clinical risk factors: Ischemic heart disease; CHF; Cerebrovasc disease; DM; Renal insuf
Perioperative beta blockade Perioperative beta blockade

Class IIb recommendation Class III recommendation
(usefulnes, efficacy uncertain)
(treatment should not be administered)
• Intermediate-risk or vascular surgery with a single • Patient has absolute contraindication to beta blocker
clinical risk factor in the absence of CAD
• Vascular surgery with no clinical risk factors and who • Routine administration of high dose beta blockers in
are not currently taking beta blocker. the absence of dose titration is not useful and may be
harmful to patients not currently taking beta blockers
who are undergoing noncardiac surgery.
Clinical risk factors: Ischemic heart disease; CHF; Cerebrovasc disease;

DM; Renal insuf
66
When to start the beta blocker?
Flu et al.: JACC 2010, 56:1922
Our Approach 2013 Statins
• Continue beta blockers for those already receiving • Retrospective studies suggestive of benefit of
• Initiate beta blockers prior to surgery (cautiously) for postoperative statins:
patients who would otherwise need them – Poldermans et al.:Statins are associated with a
– Begin as early as possible- >1 week - not day of surgery reduced incidence of perioperative mortality in
– Titrate to heart rate (60-80) and BP patients undergoing major noncardiac surgery.
• Carefully follow those on beta blockers in the Circulation. 2003;107:1848-1851.
postoperative period – Lindenauer PK et al.: Lipid lowering therapy and in
– Hypotension hospital mortality in major non cardiac surgery.
– Bradycardia JAMA 2004;291(17):2092-9.
Fluvastatin 80 mg daily begun 37 days preop Fluvastatin 80 mg daily begun 37 days preop
N Engl J Med 2009 N Engl J Med 2009
67
2007 Guideline: Perioperative Statins
Noncardiac surgery 1236
DECREASE III, IV 1030
DECREASE VI in progress: preoperative NT-pro BNP for the identification of patients who
May benefit from additional preoperative testing prior to vascular surgery.
68
DECREASE VI in progress: preoperative NT-pro BNP for the identification of patients who
May benefit from additional preoperative testing prior to vascular surgery.
Am. J. Med. 2003;114:742-752
Beta blockers inhibit peripheral effect of catecholamines
Alpha-2 agonists inhibit catecholamine release
23 trials, 3395 patients

Cardiac, Vascular, Noncardiac surgery
Mortality effect in vascular surgery

Alpha-2 agonists
• Clonidine
– Single dose 2 to 6 ug/kg oral or iv preop
• Dexmedetomidine ( “Precedex” iv sedation in the ICU)
– 1-6 ug/kg iv bolus during or postop, then 0.2-0.7
ug/kg/hr for 48 hours
• Mivazerol
– 4ug/kg iv bolus preop, then 1.5 ug/kg/hr for 72
hours
69
Effect on myocardial infarction in
vascular surgery
Impression: Encouraging for vascular surgery risk reduction Initiated July 2010
Final data November 2013
Results November 2014
POISE – 2 Trial
ACE Inhibitors Other medications
• Hypotension risk under anesthesia • Nitrates

• Hypotension less frequent when ACE-I discontinued
day before OR • Calcium channel blockers
• ??? Discontinue day preop when ACE-I used to Rx • Aspirin cessation
hypertension
70
ASA withdrawl
assoc with 3- fold
higher risk of
major cardiac event
Meta-analysis of 41 studies
ASA increased risk of bleeding complications 1.5 fold
ASA withdrawl preceeded 10% of Acute Coronary Syndromes
Time interval from ASA withdrawl to ACS was 8.5 days
Conclusion: ASA should be discontinued only if low dose ASA may

cause bleeding risk with associated mortality
ACC/AHA Guideline - 2002 Maintenance of Normothermia

Philosophy Associated with reduced perioperative cardiac events.
• Preoperative intervention is rarely necessary • Frank, S.M., et al. JAMA 277 (14), 1997
to simply lower operative risk. – Randomized controlled trial
• Identify most appropriate testing and – 300 patients: abdominal, thoracic, vascular
treatment strategies to optimize patient care surgery
and assess short and long term risk. – Known CAD or high risk for CAD
– Outcome: Unstable angina, ischemia, MI,
• Avoid unnecessary testing in this era of cost
arrest, Ventricular tachycardia
containment.
71
Maintenance of Normothermia
Associated with reduced perioperative cardiac events.
Cardiac event Normothermic 1.4%

Hypothermic 6.3%
Vent tachycardia Normothermic 2.4%

Hypothermic 7.9%
1. Evidence
2. Consensus guideline
Coronary Artery Revascularization

Prophylaxis Trial (CARP)
• Elective vascular surgery
• Stable CAD, mean LVEF 54%
• Most with 1 or 2 vessel CAD
• Cardiac cath
• Randomized to coronary revasc vs. optimized medical
therapy
• Exclusions
– Left main
– LVEF < 20
– Unstable angina
– Critical AS
– Hx prior revasc without recurrent ischemia
– Urgent / emergent surgery
72
Coronary Artery Revascularization Coronary Artery Revascularization
Prophylaxis Trial (CARP) Prophylaxis Trial (CARP)
• Postoperative outcomes • Coronary revascularization prior to vascular

– Before vasc surg: 10 deaths revasc grp; surgery is not of benefit in the patient with
1 death No revasc grp
stable CAD if treated with beta blockers,
– 30 days post vasc surg: 7 deaths revasc grp; aspirin, statins in the absence of:
8 deaths No revasc grp
– unstable coronary disease
• 2.7 years post vascular surgery
– left main coronary disease
– 22% mortality Revasc Grp
– aortic stenosis
– 23% mortality No Revasc grp.
– severe left ventricular dysfunction
October 23, 2007
Elective vascular surgery in high risk patients.

101 patients
3 or more cardiac risk factors
All with extensive inducible ischemia by stress test
43% with LVEF < 35%
75% with Left main or 3-vd
All received beta blocker titrated to HR 60-65
Antiplatelet agents continued in perioperative period
No benefit of prophylactic coronary revascularization

400 new articles reviewed since 2002 guideline
Two patients died of ruptured AAA following CABG
ACC /AHA Preop Guideline Update, 2007: ACC /AHA Preop Guideline Update, 2007:
CABG prior to Non-cardiac surgery CABG prior to Non-cardiac surgery
Same Recommendation as 2002 Guideline
73
PTCA Prior to Noncardiac Surgery (planned)
“…PCI before noncardiac surgery is of no value in preventing

perioperative cardiac events, except in those patients in
whom PCI is independently indicated for an acute coronary
syndrome.”
ACC /AHA Preop Guideline Update, 2007:

PTCA prior to Non-cardiac surgery
PTCA Prior to Noncardiac Surgery (planned)
How about the patient who has

already received a stent and
requires noncardiac surgery ?
ACC /AHA CABG Guideline, 2011
Drug eluting stent related issues
• Stent thrombosis
– ASA + clopidogrel
• Hemorrhage
– ASA + clopidogrel
ASA 325 mg + Clopidogrel 75 mg daily / three months
74
Lancet, October 23, 2004
ASA 325 mg + Clopidogrel 75 mg daily / six months
September 14, 2006: FDA initial warning

December 7,8 2006: Circulatory Systems Device Advisory
Panel Hearings
January 4, 2007: FDA online announcement of package

insert revision.
Optimal duration of antiplatelet
therapy (especially clopidogrel) is
12 months for patients at low risk of
bleeding. On-line release January 24, 2007
Joint Advisory Recommendations and Joint Advisory Recommendations and

Noncardiac Surgery Noncardiac Surgery
• Consider bare metal stent if patient requires PCI and • Defer elective procedures for which there is bleeding
is likely to require invasive or surgical procedure risk until completion of antiplatelet course
within next 12 months. – 1 month bare metal stent
• Educate patient prior to discharge re: risk of – 12 months drug eluting stent
premature antiplatelet discontinuation. • For patient with drug eluting stent who are to undergo
– Instruct patient to contact treating cardiologist procedures that mandate discontinuation of
before antiplatelet discontinuation thienopyridine (eg, clopidogrel), continue aspirin if at
• Healthcare providers who perform surgical or all possible and restart thienopyridine as soon as
invasive procedures must be made aware of possible
catastrophic risks of premature antiplatelet • No evidence for “bridging therapy” with
discontinuation and should contact the treating antithrombins, warfarin, or glycoprotein IIb/IIIa agents
cardiologist to discuss optimal management strategy
75
Key Points
• Clearance. Perform evaluation and make
recommendations that will relate to perioperative and
long – term issues.
• Tests only if likely to influence treatment.
• Preoperative coronary revascularization if
independently indicated.
• Selective use of beta blockers. (beware bradycardia)
• Statins
• Beware of premature antiplatelet discontinuation in
the patient post PTCA stent.
• Continue beta blocker, aspirin, statins,
76
Perioperative Medication Management
Objectives
An Overview of
Perioperative Medicine 2013: • Understand the level of evidence for continuing
Perioperative Medication Management or discontinuing medications in the
perioperative period
• Review general principles
• Discussion of cases

Karen F. Mauck, M.D
Margaret Beliveau, M.D.,Geno Merli, M.D. Howard H. Weitz, M.D.,
October 9-12 Seattle, Washington
©2011 MFMER | 3127551-1 ©2011 MFMER | 3127551-2
Perioperative Medication Management

Disclosures Disclaimer
• Limited clinical trial outcome data in regards to
perioperative medication management
• Substantial variation in clinical practice
• The following recommendations are expert

opinion based on available evidence, clinical
experience, and theoretical considerations
©2011 MFMER | 3127551-3 ©2011 MFMER | 3127551-4
General Principals General Principals
• Accurate and complete medication history is • Individualize recommendations

essential—prescription meds, OTC meds, • Medical co-morbidities
supplements, ilicit drugs, alcohol • Type and extent of surgical procedure
• Indication for the medication
• Consider drug pharmacokinetics and the • Absorption, half-life, metabolism, elimination
and withdrawal risks for each medication
potential adverse effects in the perioperative
and the potential drug-drug interaction
setting
©2011 MFMER | 3127551-5 ©2011 MFMER | 3127551-6
77
Perioperative Physiological Changes
General Principals
• Surgical stress response
• Communication is key • Secretion of ACTH, growth hormone,
• Which medications should be held and for vasopressin, cortisol and aldosterone
how long prior to surgery
• Secretion of insulin and thyroxine
• Which medications should be taken on the
• Sympathetic activity
morning of surgery and which should not
• For medications that are held, indicate when • Gut response
they can be restarted • Gastric emptying
• Write it down • Absorption (decreased splanchnic blood
flow, edema, decreased mucosal transport)
• Motility (ileus)
Pass SE, 2004 Am J Health-Syst Pharm:61(9) pg:899 -912
©2011 MFMER | 3127551-7 ©2011 MFMER | 3127551-8
Bottom Line Cases to Consider

• Most medications are tolerated well through • Audience response
surgery and do not interfere with anesthetic
administration • Panel response/ discussion
• Therefore, continue most medications through
the morning of surgery unless totally • Purposefully omitting (covered later in course)
unnecessary or contraindicated • Anticoagulant/ antiplatelet drugs other than
ASA/ NSAIDs
• Anti-rheumatic agents/ Biologic agents
• Diabetic agents
• Parkinson’s meds/ Seizure meds
©2011 MFMER | 3127551-9 ©2011 MFMER | 3127551-10
Case 1 What do you recommend regarding his

• 68 year old male scheduled for an elective total medications on the morning of surgery?
hip replacement
• Hx of hypertension, controlled on HCTZ 1. Take all medications
25mg/d, lisinopril 20 mg/d, amlodipine 20 mg/d;
BPH on tamsulosin 0.4 mg/d 2. Take amlodipine, lisinopril and tamsulosin;
hold HCTZ
• No history of DM, CAD, CHF or CVA 3. Take amlodipine and tamsulosin; hold
• Exam: Pulse 68, reg; BP 165/95; Lungs clear, lisinopril and HCTZ
Heart RRR,no murmurs; Extremities with no
edema 4. Take amlodipine only; hold all others
• Labs: Cr 1.0 mg/dl; K 4.2 mg/dl 5. Hold all medications
©2011 MFMER | 3127551-11 ©2011 MFMER | 3127551-12
78
Panel—Take or Hold? Case 2
• Amlodipine • 73 year old female scheduled for a right

hemicolectomy for colon cancer
• Hydrochlorothiazide
• Lisinopril
• Hx of type 2 DM on insulin
• Tamsulosin
• Chronic renal insufficiency with baseline
creatinine 1.7 mg/dl
• Hx of CAD: s/p MI with DES to LAD 2 yrs ago,
no new sx
• NYHA class 2 CHF: EF 35% on last echo
©2011 MFMER | 3127551-13 ©2011 MFMER | 3127551-14
What do you recommend regarding her

Case 2 continued medications on the morning of surgery?
• Medications: Insulin, aspirin 150 mg/ d, 1. Take all medications
metoprolol 50 mg/dl; lisinopril 20 mg/dl;
furosemide 20 mg daily 2. Take metoprolol, lisinopril and aspirin; hold
furosemide
• Exam: P 70 bpm; BP 110/72 mmHg
3. Take metoprolol and lisinopril; hold aspirin
• Lungs and heart exam unremarkable, trace and furosemide
lower extremity edema
4. Take metoprolol and aspirin only; hold
lisinopril and furosemide
5. Hold all medications
©2011 MFMER | 3127551-15 ©2011 MFMER | 3127551-16
Summary Antihypertensive Agents

Panel—Take or Hold? Medication Preop Comments
Mgmt
• Metoprolol Alpha-2-Agonists
(Clonidine, Guanfacine,
Take • Central acting sympatholytic which may
improve postop cardiac outcomes
• Lisinopril Methyldopa) • Decreases stress response to surgery;
anxiolytic and analgesic effects
• Furosemide • Withdrawal associated with rebound
hypertension and tachycardia
• Aspirin • Convert clonidine patch to oral dosing
Alpha-1-Receptor Take • Cataract surgery; risk of intraoperative floppy
Antagonists iris syndrome; modification to surgical
(Alfuzosin, Doxazosin, technique may be necessary
Prazosin, Terazosin,
Tamsulosin)
Beta Blockers Take • Beta blockers reduce ischemia and may help
(Acebutolol, Atenolol, prevent or control arrhythmias
Bisoprolol, Metoprolol,
Nadolol, Nebivolol, • Increased risk of ischemia with withdrawal of
Propranolol, Sotalol) beta blockade
©2011 MFMER | 3127551-17

• Use judiciously in patients with SBP < 110
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79
Summary Antihypertensive Agents Summary Antihypertensive Agents
Medication Preop Comments
Medication Preop Comments Mgmt
Mgmt • Potential for volume depletion and electrolyte
Diuretics Hold
ACE Inhibitors Take/ • Consider holding if BP is low, renal function is (Chlorothiazide,
issues
(Captopril, Enalapril, impaired and/or large surgery with fluid shifts • For outpatient surgery or minor surgical
Ramipril, Quinapril, Hold Hydrochlorothiazide,
Perindopril, Lisinopril, • Holding preop can be associated with Indapamide, procedures, probably OK to take thiazide
significant, often refractory hypertension postop Metolazone, diuretics on the morning of surgery
Benazepril, Monopril)
Bumetanide,
Angiotensin Take/ • Consider holding if BP is low, renal function is Ethacrynic acid,
Receptor Blockers impaired and/or large surgery with fluid shifts Furosemide, Torsemide,
(Candesartan, Hold Amiloride, Eplerenone,
Eprosartan, Irbesartan, • Holding preop can be associated with Spironolactone,
Telmisartan, Valsartan, significant, often refractory hypertension postop Triamterene)
Losartan, Olmesartan)
Nitrates Take/ • Take if oral
Calcium Channel Take • Take unless preop blood pressure is low
Blockers (Amlodipine, (Isosorbide dinitrate, Hold • Hold nitropaste or nitropatch (transcutaneous
Diltiazem, Felodipine, Isosorbide mononitrate, absorption is unreliable intraoperatively)
Isradipine, Nicardipine, Nitroglycerin)
Nifedipine, Nisoldipine,
Verapamil) Vasodialators Take • Take unless preop blood pressure is low
(Hydralazine, Minoxidil)
©2011 MFMER | 3127551-19 ©2011 MFMER | 3127551-20
Case 3
Summary ASA
Patients on ASA
75-150 mg/d
• 55 year old male with long standing bipolar
disorder presents for preop eval prior to
planned partial bowel resection for colon
cancer
Secondary Prevention
Primary Prevention after MI, ACS, Stent,
Stroke, PAD
• Bipolar disorder well controlled on lithium 600
mg BID and aripiprazole 15 mg/day
Intracranial All Other • Anxiety treated with clonazepam 2 mg/day
Surgery Surgeries
• No history of significant medical problems other
than colon cancer and hypertension
Stop aspirin 7 days
Surgery under
continuous aspirin
• Creatinine is 1.5 mg/dl, electrolytes and TSH nl
before surgery
treatment • He is expected to be NPO for 2-4 days postop
©2011 MFMER | 3127551-21 ©2011 MFMER | 3127551-22
What do you recommend regarding his

psychiatric medications perioperatively? Panel—Take or Hold?
1. Take all medications on AM of surgery, continue • Lithium
periop with meds per NG if needed
• Aripiprazole
2. Take lithium on AM of surgery, hold aripiprazole
and clonazepam, resume when taking PO • Clonazepam
3. Hold lithium 2-3 days preop, take aripiprazole
and clonazepam on the morning of surgery and
resume via NG postop, resume lithium when
renal function and electrolytes stable postop
4. Hold all medications preop, resume when taking
PO
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80
What do you recommend regarding her
Case 4 psychiatric medications perioperatively?
• 75 year old female scheduled for lumbar 1. Take nortriptyline the evening before surgery and
decompression of L3-L4 tomorrow take both paroxetine and bupropion on the morning
of surgery, continue all throughout the periop period
• Past history includes depression—currently via NG if needed
treated with paroxetine 20 mg/d, bupropion 150
mg BID 2. Hold nortriptyline the evening before and take
paroxetine and bupropion on the morning of
• She also has a history of peripheral neuropathy surgery, resume all when taking PO
and is taking nortriptyline 50 mg/d (HS)
3. Take nortriptyline the evening before, hold
• Exam: unremarkable paroxetine and bupropion and resume all when
• ECG: normal; creatinine and electrolytes taking PO
normal 4. Hold all three medications preoperatively, resume
when taking PO
©2011 MFMER | 3127551-25 ©2011 MFMER | 3127551-26
Summary Psychiatric Agents

Panel—Take or Hold? Medication Preop Comments
Mgmt
• Paroxetine Antipsychotics Take/ • Withdrawal symptoms similar to
cholinergic rebound seen when
• Bupropion • Conventional Hold antipsychotics are stopped abruptly
(Prochlorperazine,
Haloperidol, Loxapine, • Use of conventional and atypical
• Nortriptyline Thioridazine, Molindone, antipsychotic agents associated with
Thithixene, Fluphenazine, arrhythmias and sudden death; monitor
Pimozide, for ECG changes
Trifluoperazine,
Chlorpromazine, • Consider holding preop for minor surgical
Perphenazine) procedures or outpatient surgery because
• Atypical of the risk of excessive sedation limiting
(Aripiprazole, Asenapine ability to safely discharge
Maleate, Clozapine, • Caution: Using multiple drugs with
Iloperidone, Lurasidone,
sedative properties is associated with
Olanzapine, Paliperidone,
Quetiapine, Risperidone, adverse postop outcomes; antipsychotic
Ziprasidone) agents can potentiate the effect of
narcotics
©2011 MFMER | 3127551-27 ©2011 MFMER | 3127551-28
Summary Psychiatric Agents Summary Psychiatric Agents

Medication Preop Comments Medication Preop Comments
Mgmt Mgmt
Benzodiazepines Take • Abrupt withdrawal from a patient on Lithium Take/ • May potentiate the effect of pancuronium and
succinylcholine
(Alprazolam, Chlordiazepoxide, chronic therapy can lead to excitatory Hold
Clonazepam, Clorazepate, state, including delirium and seizures • Clearance reduced and toxicity increased by
Diazepam, Estazolam, negative fluid balance, negative sodium balance,
Flurazepam, Halazepam, • Consider holding preop for minor
surgical procedures or outpatient and decreased glomerular filtration rate
Lorazepam, Midazolam,
Oxazepam, Prazepam, surgery because of the risk of excessive • Toxicity of lithium can be increased by drugs that
Quazepam, Temazepam, sedation limiting ability to safely reduce lithium excretion or increase reabsorption in
Triazolam, Zaleplon, Zolpidem) discharge the kidney; drugs such as NSAIDs, ACE-inhibitors,
• Caution: Using multiple drugs with thiazide diuretics, and metronidazole
sedative properties is associated with • Assess TSH, Na, K and Cr preop for any patient
adverse postop outcomes taking lithium
Cholinesterase Inhibitors Take • Cholinesterase inhibitors may interact • Hold 2-3 days before major surgery and resume
(Donepezil, Galantamine, with muscle relaxants given during
Rivastigmine)
when renal function and electrolyte levels are stable
general anesthesia postop
NMDA Receptor
Antagonists • For minor surgical procedures, OK to take on the
(Memantadine, Amantadine) morning of surgery
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81
Summary Psychiatric Agents Medication Preop Comments
Mgmt
Medication Preop Comments Tricyclic / Take/ • Abrupt withdrawal of tricyclic antidepressants
Mgmt Tetracyclic Hold can lead to insomnia, nausea, headache,
Antidepressants increased salivation, and sweating
SSRIs (Citalopram, Take • Withdrawal associated with dizziness,
Escitalopram, Fluvoxamine, GI complaints, palpitations, sleep (Amitriptyline, Amoxapine, • TCAs potentiate the circulatory effects of
Paroxetine, Fluoxetine, disturbance, anxiety, agitation Clomipramine, adrenaline and noradrenaline; risk for
Sertraline) Desipramine, Doxepin, hypertensive crisis related to the amine
• May increase transfusion with surgery Imipramine, Maprotiline, reuptake-blocking properties
SNRIs (Desvenlafaxine, due to platelet aggregation effect Nortriptyline, Protriptyline,
Duloxetine, Milnacipran,
• Continue perioperatively, but monitor for Trimipramine)
• Caution: TCAs lower seizure threshold, prolong
Nefazodone, Sibutramine, QT, increase the risk for arrhythmias in
Venlafaxine) drug-drug interactions combination with some volatile anesthetics or
Aminoketones (Bupropion) sympathomimetic agents
• Caution: Using multiple drugs with sedative
Other (Buspirone) properties is associated with adverse postop
outcomes
• For major surgery, it can be stopped, but needs
to be tapered over 2 weeks
• For outpatient or minor surgical procedures,
probably OK to take on the morning of surgery
©2011 MFMER | 3127551-31 ©2011 MFMER | 3127551-32

Mgmt Case 5
Monoamine Hold/ • Serotonergic risk and hemodynamic instability;
Oxidase Take Serotonergic risk can be minimized by avoiding
drugs that prevent presynaptic uptake of serotonin;
• 55 year old male is scheduled for an elective
Inhibitors
Hemodynamic instability risk is much less L2-L4 fusion
• Reversible controllable
MAOIs
(none in US) • MAOIs interact with other psychoactive substances • Past history includes hypertension, mixed
• Irreversible
in addition to tryptamines; effects of amphetamines,
general anaesthetics, sedatives, anti-histamines,
hyperlipidemia, CAD, paroxysmal atrial
MAOIs alcohol, potent analgesics and anticholinergic and fibrillation and DJD
(Phenelzine, antidepressant agents are prolonged and
Isocarboxazid,
Tranylcypromine)
intensified (particularly in patients taking
irreversible MAOIs)
• Lipid medications include atorvastatin 40 mg/d,
• Hold reversible MAOIs 24 hours before surgery;
fish oil 2000 mg BID, and cholestyramine 4 g
Hold irreversible MAOIs for 2 weeks preop (consult BID
psychiatry for assistance); resume both when
hemodynamically stable and taking po postop • He takes all of his medications in the morning
• For minor surgical procedures, OK to take on the
morning of surgery; just make anesthesiologist
aware
©2011 MFMER | 3127551-33 ©2011 MFMER | 3127551-34

lipid medications perioperatively? Panel—Take or Hold?
• Atorvastatin
1. Take all medications on the morning of
surgery • Fish Oil
2. Take atorvastatin and fish oil on the morning • Cholestyramine
of surgery; hold the cholestyramine
3. Take atorvastatin on the morning of surgery,
hold fish oil and cholestyramine
4. Hold all lipid medications on the morning of
surgery
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82
Summary Lipid Lowering Agents
Mgmt Case 7
Bile Sequestrant Drugs Hold • May interfere with bowel absorption of
(Cholestyramine, drugs • 72 year old male scheduled for bilateral
Colesevelam, Colestipol) inguinal hernia surgery
Ezetimibe Hold • Theoretic: rhabdomyolysis
Fibrates Hold • Theoretic: rhabdomyolysis • Past history significant for BPH for which he
(Clofibrate, Fenofibrate, takes finasteride and doxazosin
Gemfibrozil)
Fish Oil Take • May decrease risk of postop afib • Also takes oxybutynin for overactive bladder
• May be associated with increased bleeding
risk if given with other anticoagulants
Niacin Hold • Theoretic: rhabdomyolysis
Statins Take • May prevent vascular events through
(Atorvastatin, Fluvastatin, mechanisms other than cholesterol lowering
Lovastatin, Pitavastatin, (eg, plaque stabilization, reduction in
Pravastatin, Simvastatin, inflammation, decreased thrombogenesis)
Rosuvastatin) • Withdrawal may be associated with
increased risk of adverse cardiac outcomes
©2011 MFMER | 3127551-37 ©2011 MFMER | 3127551-38

urologic medications perioperatively? Panel—Take or Hold?
1. Take all medications on the morning of • Finasteride
surgery • Doxazosin
2. Take finasteride and doxazosin • Oxybutynin
preoperatively, but hold oxybutynin
3. Take oxybutynin, hold finasteride and
doxazosin
4. Take finasteride and oxybutynin but hold
doxazosin
©2011 MFMER | 3127551-39 ©2011 MFMER | 3127551-40
Summary Urologic Agents

Medication Preop Comments Case 9
Mgmt
Alpha-1-Receptor Take • Cataract surgery; risk of intraoperative floppy • A 45 year old male is seen for preop evaluation
Antagonists (Alfuzosin, iris syndrome; modification to surgical prior to a planned total hip arthroplasty
Doxazosin, Prazosin, technique may be necessary
Terazosin, Tamsulosin)
• History significant for hiatal hernia and
/ Hold • Increases anticholinergic side effects (urinary
Oxybutynin
retention, confusion, constipation, slowed gastroesophageal reflux treated with
Tolterodine
gastric emptying) omeprazole BID
• Increases sedative side effects of CNS
depressant during periop period • Has a history of Crohn's disease for which he
• Resume when these potential risks are no takes sulfasalazine—symptoms controlled
longer an issue postop
5-Alpha Reductase Take • Cataract surgery; case reports of increased • Uses Ibuprofen 800 TID for arthritis pain
Inhibitors (Finasteride, risk of intraoperative floppy iris syndrome
Dutasteride) • Electrolytes and creatinine normal
©2011 MFMER | 3127551-41 ©2011 MFMER | 3127551-42
83
GI medications perioperatively? Panel—Take or Hold?
1. Take omeprazole and sulfasalazine on the morning • Omeprazole

of surgery, hold the ibuprofen 3 days prior to surgery • Sulfasalazine
2. Take omeprazole, hold sulfasalazine on the morning • Ibuprofen
of surgery and ibuprofen 3 days prior to surgery
3. Take sulfasalazine, hold omeprazole on the morning
of surgery and ibuprofen 3 days prior to surgery
4. Hold all three medications on the morning of surgery
©2011 MFMER | 3127551-43 ©2011 MFMER | 3127551-44
Summary GI Agents Summary GI Agents

Mgmt Medication Preop Comments
Aminosalicylates Hold/ • Renally cleared Mgmt
Take
(Balsalazide, • Discontinue before surgery with resumption 3 Metoclopramide Take • Mild anticholinergic side effects
Mesalamine, Olsalazine, days after surgery
Sulfasalazine)
• Multiple drug-drug interactions
• For outpatient surgery or minor surgical Promethazine Hold • Increases anticholinergic side effects (urinary
procedures, OK to take on the morning of retention, confusion, constipation, slowed
surgery gastric emptying)
H2 Blockers Take • Cimetidine can alter the metabolism of several • Caution: Using multiple drugs with sedative
(Cimetidine, Famotidine, drugs properties is associated with adverse postop
Nizatidine, Ranitidine) outcomes
Hyoscyamine Hold • Increases anticholinergic side effects (urinary Proton Pump Take • GI protection
retention, confusion, constipation, slowed Inhibitors
gastric emptying) (Dexlansoprazole, • Decrease risk of chemical pneumonitis with
Esomeprazole, aspiration
• Resume when these potential risks are no Lansoprazole,
longer an issue postop Omeprazole,
Pantoprazole,
• Increases risk of regurgitation during induction Rabeprazole)
of anesthesia
©2011 MFMER | 3127551-45 ©2011 MFMER | 3127551-46
Summary NSAIDS/ Pain Medications Summary Opiates

Medication Preop Comments Mgmt
Mgmt Opiates Take • If chronic use (stable dose > 4 weeks), these should
NSAIDS Hold • Reversible inhibition of platelet cyclooxygenase (Buprenorphine, be continued periop
(Celecoxib, Diclofenac, (COX), diminished thromboxane A2 production, Codeine, • Will likely need higher opioid doses postop for
Diflunisal, Etodolac, diminished platelet aggregation, can increase Fentanyl, adequate pain control
Ibuprofen, Indomethacin, bleeding risk Hydrocodone,
Ketoprofen, Ketorolac, • Holding opiates in patients on chronic treatment
Meloxicam, • Can increase risk of acute kidney injury periop Hydromorphone, often results in difficult to control pain postoperatively
Nabumetone, Naproxen, Morphine,
• Hold NSAIDs 3 days before surgery, especially Oxycodone, • Withdrawal syndrome associated with GI symptoms,
Oxaprozin, Piroxicam, in surgical procedures at high risk for bleeding
Salsalate, Sulindac, Oxymorphone) diaphoresis, irritability, sleep disturbance and
Tolmetin) complications rhinorrhea
Tramadol/ Tapentadol Take • Lowers seizure threshold • Caution: For patients at high risk for pulmonary
complications, may consider reducing or holding
• If chronic use (stable dose > 4 weeks), these dose preop
should be continued perioperatively
• Caution: Using multiple drugs with sedative
• Caution: Using multiple drugs with sedative properties is associated with adverse postop
properties is associated with adverse postop outcomes
outcomes
Methadone Take • Get pain medicine involved for patients taking
methadone and undergoing surgery
©2011 MFMER | 3127551-47 ©2011 MFMER | 3127551-48
84
Case 13 What do you recommend regarding her
medications perioperatively?
• 54 year old postmenopausal female is
scheduled for a total abdominal hysterectomy 1. Take all medications on the morning of surgery
with bilateral salpingo-oophorectomy tomorrow
2. Take hormones, but hold allopurinol on the
• Past medical history significant for DJD and morning of surgery
gout
3. Take allopurinol, but hold hormones on the
• Medications include conjugated estrogen 0.3 morning of surgery
mg/ day and medroxyprogesterone acetate
2.5mg/ day for hot flashes and allopurinol 300 4. Hold all medications on the morning of surgery
mg/ day
©2011 MFMER | 3127551-49 ©2011 MFMER | 3127551-50
Summary Gout Agents

Panel—Take or Hold?
• Conjugated estrogen Mgmt
Allopurinol Take • Try to avoid interruption of treatment to prevent
• Medroxyprogesterone acetate gout flare
• If held, resume as soon as possible when
• Allopurinol taking po
Colchicine Take • Continue if patient is taking chronically, but
monitor liver and renal function and for
symptoms of toxicity
• Do not start this medication in the perioperative
setting
Febuxistat Take • Try to avoid interruption of treatment to prevent
gout flare
• If held, resume as soon as possible when
taking po
©2011 MFMER | 3127551-51 ©2011 MFMER | 3127551-52
Summary Hormonal Agents Summary Hormonal Agents

Medication Preop Comments Medication Preop Comments
Mgmt Mgmt
Estrogen Take/Hold • Modest increase in DVT risk GnRH Antagonists • Increased risk of thromboembolism
Replacement • If stopped to decrease risk of DVT, needs to be (Leuprolide, Goserelin, • Prolongation of the QT interval may occur
Therapy stopped for 4-6 wks preop; resume 2-4 weeks Buserelin, Degarelix) (Leuprolide)
postop
Oral Contraceptives Take • Modest increase in DVT risk Antiandrogens • Increased risk of thromboembolism
• Most often, these are just continued without (Flutamide, • Anemias, leukopenias, thrombocytopenias:
interruption perioperatively Bicalutamide, Nilutamide) check CBC
• If stopped to decrease risk of DVT, needs to be
stopped for 6 wks preop; resume 2-4 weeks postop
Selective Estrogen Take/Hold • Increased risk of DVT Aromatase Inhibitors • Increased risk of thromboembolism
Receptor Modifiers • If taken for osteoporosis or breast cancer prevention, (anastrazole, letrozole, • Anemias, pancytopenias, leukopenias: check
(SERMS) OK to hold (4 wks preop); resume 2-4 weeks postop exemestane) CBC
(Raloxifene, Tamoxifen, • If taken for breast cancer treatment consult with
Toremifene) oncologist
• Toremifene associated with prolonged QT and
Torsades.
• Monitor magnesium, potassium
©2011 MFMER | 3127551-53 ©2011 MFMER | 3127551-54
85
86
Disclosures
An Overview of
• No financial disclosures
• No discussion of “off label” use of drugs

Robert H. Lohr, MD
Pre-operative testing: What is really needed?
©2011 MFMER | 3127551-1
Objectives Today’s Outline
• Background
• To understand the rationale for evidence based
preoperative testing • Cases
• To understand when preoperative testing is not • Discussion/rationale
indicated…Most of the time!
• Back to our cases
• Questions
Why Should we Test?

Is Preoperative Testing a Problem • To identify or verify a condition which could affect
anesthetic care
• Yes, and a big one
• It wastes valuable resources • To help formulate or modify anesthetic care of the
• It exposes patients to needless blood work and patient
procedures • Can the identified risk be mitigated?
• It can creat anxiety for patients • Cardiac
• It is costly…$30 billion/year (1987 $) • Pulmonary
• It is still a problem- • Drugs
surgeons>anesthesiologists>preoperative directors • Bleeding, clotting, and bridging
• DM
• Katz, Anesth Analg 2011 • Other (liver, kidneys, endocrine)
• Roizen, Anesthesiol Clin North Am 1987 Anesthesiology 2012 (ASA Practice Advisory for Preanesthesia
Evaluation)
87
How Do You Decide? Case 1
• You are asked to see a 43 year old male for a
• My last case (that went south…) preoperative medical evaluation. He is
scheduled for an inguinal hernia repair next
• What my chief resident told me to do week
• EBM • His past medical history is notable only for
• Guidelines…which ones? obesity (BMI 32) and an uncomplicated ORIF of
a tib-fib fracture at age 14
• Hospital policies…who develops?
• He has never used tobacco and has 1-2 oz of
EtOH/week
Case 1 Case 1
• He does construction work and can easily • For preoperative testing you order:
exceed > 4 METS of activity • A) An ECG and CBC
• He takes only a men’s multivitamin daily • B) An ECG and creatinine
• His exam is noteworthy for his weight and an • C) A CBC and creatinine
easily reducible R inguinal hernia. • D) A CBC and INR
• E) No tests
Case 2 Case 2
• You are asked to see a 78 year old female for a • She has had a hysterectomy and carpel tunnel
preoperative medical evaluation. She is repair in the past without complication
scheduled for an elective R TKA tomorrow
• Her medications include lisinopril/HCTZ,
• Her past medical history is noteworthy for simvastatin, metoprolol, aspirin
hypertension, hyperlipidemia, obesity, DJD,
and coronary artery disease for which she • She is limited in her activity due to her knee,
received 2 drug eluting stents 4 years ago. but was able to do >4METS of activity within
the past several months
88
Case 2 Case 2
• Her exam reveals a BP of 143/80, P 60, BMI of • Preoperatively you order:
37, and a moderate effusion on the R knee. • A) An ECG, electrolytes, creatinine
Cardiovascular and pulmonary exams are
normal • B) Electrolytes, creatinine
• C) An ECG, electrolytes, creatinine, and INR
• You have an ECG available (NSR, non-specific • D) Electrolytes, creatinine, ECG, and a
lateral ST changes) from 3 months ago
dobutamine stress Echo
• You have no other laboratory data available • E) No testing
Case 3 Case 3
• You are asked to see a 58 year old male for a • His functional capacity is excellent, exceeding 4
preoperative medical evaluation. He is METS
scheduled for a R TSA next week
• His exam is normal except for a decreased
• His past medical history is significant for range of motion of his R shoulder
hepatitis C but no history of cirrhosis. He had
an inguinal hernia repaired as a child without
complication. He has had no recent follow up
regarding his liver.
• Medications include a multivitamin
Case 3 Case 4
• Preoperatively you order: • You are asked to do a pre-operative evaluation
• A) An ECG, electrolytes, creatinine for a 23 year old female college basketball
point guard for repair of a torn L ACL
• B) Electrolytes, LFT, creatinine
• C) LFT, INR, creatinine • She reports herself to be in excellent health, no
prior surgery, having irregular menstrual
• D) INR and aPTT periods felt secondary to her level of physical
• E) No studies activity
• She is taking no medicines and her physical
exam is normal except for her L knee
89
Case 4: You order pre-operatively Should we test?
• CBC
• EKG
• PT/PTT
• Pregnancy testing
• No testing
Preoperative testing: Should we do

anything? Should we Test?
• Narr et al. • Preoperative testing should be dictated by the
• Randomized 1044 patients who had NO patient’s clinical condition and abnormal
preoperative testing, age 0-95, median 21 findings on history or exam
• Deaths: 0.0% • Preoperative testing is NOT INDICATED unless
• 17 intraoperative lab tests; 3 abnormal there is a specific reason to perform the test
and the result will change management, or
• No testing done intraoperatively or mitigate perioperative risk
postoperatively changed management
• Narr. Mayo Clin Proc 1997;72:505-509
The Preoperative ECG Pre-op ECG

• No prospective, randomized clinical controlled • The prevalence of an abnormal ECG increases
trials with age with up to 75% of people older than 75
having an abnormal ECG
• No good, prospective outcome data for or against
• There is evidence suggesting poorer outcomes in
• Lots of retrospective reviews, case series, cohort patients with abnormal ECGs
studies
• RR 4.5 (3.3-6.0) of death
• Lots of complicated, conflicting consensus • However, absolute risk reduction only 0.5%
statements regarding pre-operative ECG with low and intermediate risk surgery
• Main cardiovascular risk assessment guidelines Noordzij. Am J Cardiol 97(7): 1103-1106
use ECG to risk stratify
90
ECGs? ECGs?
• Conflicting recommendations amongst ECG YES
consensus organizations
• ACC/AHA • CV symptoms/signs
• ASA • Known stable cardiac disease
• ICSI • Risk factors and intermediate or high risk
• ESC/ESA surgery
• RCRI ≥ 1
• CAD equivalent
Coagulation Studies?
ECGs?
• Coagulation studies only as indicated by H&P
ECG NO • What about high risk surgery e.g. neurosurgery:
“Patient history was as predictive as lab testing for
• Low risk surgery and low risk patient all outcomes (and had) higher sensitivity”
• Cataract surgery Seicean, J Neurosurg 2012
ECG MAYBE • Known h/o bleeding disorder or previous

bleeding complications
• Low risk patient and intermediate risk surgery • On current anticoagulation
• Risk factors and low risk surgery • H&P suggests bleeding or coagulation
problems
CBC? Electrolytes, Creatinine?

• H&P findings suggestive of abnormality
• Known cytopenia
• Recent chemo • Lytes, creatinine
• h/o bleeding • Patients on diuretics
• pallor • Patients with known renal failure
• ? Patients on digoxin
• ? Anticipated large surgical blood loss
• ? Situation where even mild anemia could be
significant
91
CXR? Albumin?
• Frequent abnormalities --- 10-23.1% • Powerful predictor of perioperative
complications
• Rarely influence management --- < 0.1-3%
• Pulmonary complications increased
• Predictable from H&P • Infectious complications increased
• Who follows up on the abnormality? --- source • Wound healing issues
for missed opportunity, “falling through the • In some settings the strongest predictor of
cracks” morbidity and mortality
• Qaseen A et al. Ann Intern Med. 2006; 144: 575-580
Gibbs J et al. Arch Surg. 1999;134:36-42
Albumin? Glucose?
• Consider serum albumin • No good evidence for or against

• If modifiable risk factor present • Will it change my management?
• AND it would change your perioperative • Would I delay surgery if it was high?
management
• Would my perioperative management change?
Pregnancy Testing
LFTs? • 2056 women of child bearing age tested before
elective ambulatory surgery
• Play it again Sam…only if there is suspicion of
liver disease on the basis of history, exam, or • 7 had + pregnancy testing (0.3%)
previous liver function abnormality • Cost of pregnancy discovered: $2879
• www.nature.com/clinicalpractice/gasthep • All cancelled their surgery
• If there are indications to perform LFTs, include • 2558 women of child bearing age tested before
INR, bilirubin, creatinine in order to calculate elective orthopaedic surgery
MELD score which predicts post operative
mortality due to liver disease • 5 had + pregnancy testing (0.2%)
• Gastroenterology 2007;132:1261-1269 • Cost of discovered pregnancy: $3273
Anesthesiology 1995
Anesth Analg 2008
92
Pregnancy Testing Case 1
• “…the literature is inadequate to inform patients • You are asked to see a 43 year old male for a
or physicians on whether anesthesia causes preoperative medical evaluation. He is
harmful effects on early pregnancy. Pregnancy scheduled for an inguinal hernia repair next
testing may be offered to female patients of week
childbearing age and for whom the result would
alter the patient’s management.” • His past medical history is notable only for
obesity (BMI 32) and an uncomplicated ORIF of
a tib-fib fracture at age 14
Anesthesia 2012 (ASA Practice Advisory for Preanesthesia
Evaluation) • He has never used tobacco and has 1-2 oz of
EtOH/week
Case 1 Case 1
• He does construction work and can easily • For preoperative testing you order:
exceed > 4 METS of activity • A) An ECG and CBC
• He takes only a mens multivitamin daily • B) An ECG and creatinine
• His exam is note worthy for his weight and an • C) A CBC and creatinine
easily reducible R inguinal hernia. • D) A CBC and INR
• E) No tests
Case 2 Case 2
• You are asked to see a 78 year old female for a • She has had a hysterectomy and carpel tunnel
preoperative medical evaluation. She is repair in the past without complication
scheduled for an elective R TKA tomorrow
• Her medications include lisinopril/HCTZ,
• Her past medical history is note worthy for simvastatin, metoprolol, aspirin
hypertension, hyperlipidemia, obesity, DJD,
and coronary artery disease for which she • She is limited in her activity due to her knee,
received 2 drug eluting stents 4 years ago. but was able to do >4METS of activity within
the past several months
93
Case 2 Case 2
• Her exam reveals a BP of 143/80, P 60, BME • Preoperatively you order:
of 37, and a moderate effusion on the R knee. • A) An ECG, electrolytes, creatinine
Cardiovascular and pulmonary exams are
normal • B) Electrolytes, creatinine
• C) An ECG, electrolytes, creatinine, and INR
• You have an ECG available (NSR, non-specific • D) Electrolytes, creatine, and a dobutamine
lateral ST changes) from 3 months ago
stress Echo
• You have no other laboratory data available • E) No testing
Case 3 Case 3
• You are asked to see a 58 year old male for a • His functional capacity is excellent, exceeding 4
preoperative medical evaluation. He is METS
scheduled for a R TSA next week
• His exam is normal except for a decreased
• His past medical history is significant for range of motion of his R shoulder
hepatitis C but no history of cirrhosis. He had
an inguinal hernia repaired as a child without
complication. He has had no recent follow up
regarding his liver.
• Medications include a multivitamin
Case 3 Case 4
• Preoperatively you order: • You are asked to do a pre-operative evaluation
• A) An ECG, electrolytes, creatinine for a 23 year old female basketball guard for
repair of a torn L ACL
• B) Electrolytes, LFT, creatinine
• C) LFT, INR, creatinine • She reports herself to be in excellent health, no
prior surgery, having irregular menstrual
• D) INR and aPTT periods felt secondary to her level of physical
• E) No studies activity
• She is taking no medicines and her physical
exam is normal except for her L knee
94
Case 4: You order pre-operatively Take Home Points
• CBC
• EKG
• PT/PTT • ALL PREOPERATIVE TESTING SHOULD BE
• Pregnancy testing DICATATAED BY YOUR HISTORY AND EXAM
• No testing
Thank You
• QUESTIONS
95
96
Valvular Heart Disease
• Aortic stenosis
The Patient with Non – CAD Cardiac • Mitral regurgitation
– Beware of left ventricular dysfunction.
Disease • Aortic regurgitation
– Bradycardia may increase regurgitant flow.
An Overview of Perioperative Medicine 2013 • Mitral stenosis
October 2013 – Tachycardia will impair left ventricular filling.
Howard Weitz, M.D.

23 patients
17% risk major
Cardiac complication
RR 3.2
From Goldman, et al.: N Engl J Med, 1977
Vascular 46%
Moderate AS (mean gradient 25-49 or valve area 0.7 – 1.0): 11% complication
Orthopedics 21%
Abdominal 12%
Severe AS (mean gradient > 50 or valve area < 0.7): 31% complication
GU 7%
Head – Neck 2%
97
Aortic stenosis and Noncardiac Surgery
2013
• Increased short term mortality or postop

MI in patients with moderate or severe
AS
• Risk highest with:
– High risk surgery
– Severe symptomatic AS
– Coexisting mitral regurgitaton
– Preexisting CAD
ESC 2012
Mitral regurgitation Mitral stenosis
• When severe, LV function is the issue • Mitral annulus calcification in the elderly
Ejection fraction is key • Rheumatic
• Increased heart rate = decreased
diastolic filling time
• Atrial fibrillation
98
Chronic Severe Aortic Regurgitation
(ACC / AHA 2008 Valvular Heart Disease Guideline)
Aortic Regurgitation
• If severe know symptoms / LV function

• ?? Beta blocker issue
– Decreased heart rate = increased diastolic
filling time
Journal of the American Dental Association, November 2003

Antithrombotic Therapy in Patients with
Mechanical Valves who Require Interruption of
Warfarin Therapy for Noncardiac Surgery
• Continue antithrombotic therapy for procedures
where bleeding inconsequential:
– Skin
– Eye surgery
– Dental
• Cleaning
• Caries
– GI endoscopy
• Diagnostic (??? Mucosal biopsy)
• ERCP without sphincterotomy Review of clinical studies: anticoagulants and dental procedures
Warfarin and Low dose aspirin (100 mg/d)
Review of clinical studies: anticoagulants and dental procedures

Warfarin
Low dose aspirin (100 mg/d)
“The weight of evidence in the dental literature does not

1support the long-held belief that an oral anticoagulant regimen
must be altered or discontinued before most dental procedures,
including oral surgery.”
“Currently the INR does not require alteration of the therapy

regimen unless the INR value is greater than 4.0, provided
that local hemostatic measures are used.”
“Articles that document oral surgery experiences of patients

taking aspirin alone or in combination with clopidogrel have not
reported any cases of unusual intraoperative or postoperative
bleeding problems. This experience is anecdotal.”
99
Low risk of valve thrombosis
Bileaflet aortic valve

Normal LV function
Sinus rhythm
Stop warfarin 48-72 hours before procedure High risk of valve thrombosis:
Restart warfarin within 24 hours after mitral valve
tricuspid valve
Aortic valve AND

atrial fibrillation
prior thromboembolism
hypercoagulable
older generation valve
LVEF < 30%
a second mechanical valve
therapeutic unfractionated heparin

when INR < 2.0
Restart as soon as possible
Usefulness / efficacy less well established by evidence / opinion
LMWH
Mechanical valve: Bridge anticoag High Risk for thromboembolism

ACCP 9th ed Mitral prosthesis
Older aortic prosthesis
Recent TIA, stroke
Thromboembolic risk Bridge
Low None Moderate Risk for
thromboembolism
Moderate Maybe Bileaflet aortic valve AND
High Yes atrial fibrillation
prior stroke, TIA
Other CHADS2 risks
Low Risk for thromboembolism
Bileaflet aortic valve
100
Chronic hypertension
• Is chronic hypertension really a risk factor for

perioperative complication?
• Is elevated BP prior to surgery a risk?
• What evidence supports delaying elective surgery in
the patient with poorly controlled hypertension?
• How much BP control is needed and for how long
preop?
From: Chobanian A.. N Engl J Med 2009;361:878
Prys-Roberts et al.: Studies of anaesthesia in relation to

hypertension. Br J Anaesth 1971
• 34 patients elective anesthesia + surgery

– 15 “normotensive”
– 19 hypertensive (treated and untreated)
– Mean BP similar in both groups
• Untreated had greater decrease in BP at induction
• Untreated had more myocardial ischemia
• No adverse events in either group
• Implication: Defer surgery to treat hypertension
Meta analysis of 30 studies

No evidence that preoperative hypertension directly affects periop outcome
No perioperative risk No perioperative risk

Stage I BP (140-159 / 90-99 Stage I BP (140-159 / 90-99
Stage II BP (160-179 / 100-109) Stage II BP (160-179 / 100-109)
Control BP Preop Control BP Preop

Stage III BP (>180 / >110) Stage III BP (>180 / >110) NO Supportive evidence
101
No discussion of perioperative hypertension
JNC VI 1997 JNC VI 1997
JNC VII
JNC VII December 2003
ACC / AHA 2007 Preoperative Evaluation Guideline
ACC / AHA 2007 Guideline
102
Major issues of chronic hypertension
• Too aggressive control of BP a problem

• Increased periop hemodynamic lability
• More comorbidities
– CAD
– CHF
– CRF Anesth Analg 2005;100:636-44
•Retrospective
• Medication management •During first 30 minutes post induction moderate hypotension (syst BP < 85mm Hg)
– “perioperative continuation of medications” more likely if ACE or ARB taken during prior 10 hours
•No difference in postop complications
•Discontinuation of ACE / ARB at least 10 hrs pre induction associated with reduced
risk of immediate post induction hypotension
103
ACC / AHA 2007 Preoperative Evaluation Guideline
(ACC / AHA 2007 Guideline)
ACC / AHA 2007 Guideline
Chronic atrial fibrillation Chronic atrial fibrillation

Preoperative issues Preoperative issues
• Rhythm control (restoration of sinus rhythm) not • Rhythm control (restoration of sinus rhythm) not
superior to maintenance of afib with rate control in superior to maintenance of afib with rate control in
the asymptomatic patient. the asymptomatic patient.
• Patients with AF should receive antithrombotic • Patients with AF should receive antithrombotic
therapy (warfarin (INR 2-3)) unless they are at low therapy (warfarin (INR 2-3)) unless they are at low
risk of thromboembolism. risk of thromboembolism.
• Novel anticoagulants – Who is at low risk?
• Beta blockers commonly used to control rate. • Novel anticoagulants
• “Controlled” rate on no A-V nodal blockers suggests • Beta blockers commonly used to control rate.
A-V nodal conduction disease. • “Controlled” rate on no A-V nodal blockers suggests
A-V nodal conduction disease.
Who requires anticoagulation ? How do we determine stroke risk ?
• CHADS2 (Gage, et al.: JAMA 2001)

– Congestive heart failure - 1pt
– Hypertension - 1pt
– Age > 75 - 1 pt
– Diabetes - 1pt
– Stroke or TIA - 2 pts
– 0 points – low risk (1.2-3.0 strokes per 100 patient years)

– 1-2 points – moderate risk (2.8-4.0 strokes per 100 patient years)
– > 3 points – high risk (5.9-18.2 strokes per 100 patient years)
Annals of Internal Medicine, 2003:139;1009-1017
104
Lip Y, et al. Chest 2010, 137(2):263
Lip Y, et al. Chest 2010, 137(2):263
CHA2DS2-VASC
CHADS2 vs. CHA2DS2VASc
• CHADS2 score 0: 1.4% events

• CHA2DS2-VASc 0: 0 events
• CHA2DS2-VASc score 1: 0.6% events
• CHA2DS2-VASc score 2: 1.6% events

Our approach: anticoagulation when
Isch stroke risk > 0.9%/year
February 2012
105
Chronic atrial fibrillation Chronic atrial fibrillation
Preoperative issues Preoperative issues
Risk for embolization
• CHADS2 Score • Major bleeding rare while receiving warfarin:
– CHF (any hx) – 1 – Dental procedures
– Hypertension – 1 – Arthroscopy
– Age > 75 – 1 – Cataract surgery
– Diagnostic endoscopy
– Diabetes – 1
– Stroke or TIA – 2
Baker RI, et al.: Med J Australia 2004;18:492-7

0 low risk
1-2 Intermediate risk
> 3 High risk
Chronic atrial fibrillation

Preoperative issues
• Periop anticoagulation management
Mechanical valve: substitute heparin
Most patients: anticoag withdrawl for

up to 1 week
High risk: heparin
Multiple procedures: heparin
From Fuster et al. 2006 ACC/AHA/ESC 2006 Guideline for the Management of Patients with Atrial Fibrillation
April 15, 2010 Lenient

Hr < 110 bpm
Perioperative atrial fibrillation rate control Strict

Rest hr < 80
Mod exerc hr < 110
• Is there an “optimal” atrial fibrillation ventricular response

following surgery?
• Is there a benefit to “tight” control of atrial fibrillation

ventricular response?
106
Primary Outcomes
Cardiac death
CHF
Stroke
Systemic embolism
Major bleed
Syncope
Sust VT
Cardiac arrest
Life threat compl of antiarrhythmic
Pacemaker
Secondary Outcomes
Symptoms
Circulation Jan 4, 2011
ACCF / AHA / HRS 2011
Unexplained LVH
Source: Mayo Clinic
107
Hypertrophic Cardiomyopathy Hypertrophic Cardiomyopathy
• Symmetric vs. Asymmetric • Dynamic LV outflow gradient

– “small LV cavity worsens obstruction”
• Obstructive vs. Nonobstructive
• Avoid reduction of ventricular volume
– Tachycardia
– Hypovolemia
– Increased catecholamines – inotropes
– Increased intrathoracic pressure –
decreased venous return
Drawing credits: The Cardiomyopathy Assn. www.cardiomyopathy.org
Hypertrophic Cardiomyopathy Mr. H
• Approach to perioperative hypotension • 75 yo to undergo cystoscopy to eval painless

– Volume expansion hematuria
– Peripheral vasoconstrictors • COPD
• alpha sympathomimetics • Exam:
– BP 120/70, nsr
– Increased JVP
– II/VI holosystolic apical murmur
– II/VI midsystolic murmur LSB increases with
inspiration
• Ecg: sinus rhythm, no chamber hypertrophy
Mr. H Pulmonary Hypertension
• Echo report • Noncardiac surgery issues

– Normal LV size and function – Oxygenation
– Mild dilatation RV, normal RV function – Right ventricular failure
– Moderate MR, mild-mod TR
– PA systolic 54mmHg: Moderate pulmonary RA LA Hypoxia
hypertension Hypotension
RV LV
108
Pulmonary Hypertension
• Preoperative risk factors for 30 day M+M

– NYHA Functional class >II
– History pulmonary embolism
– History obstructive sleep apnea
– Intermediate or high risk surgery
– Anesthesia > 3 hours
• Preoperative warning “signs”
– RVH on ecg
– RVSP / SBP > 0.66
Adult with CHD
• Elective vs. emergency surgery

• Complicated
• Cyanotic CHD
– Increased RBC mass, hematocrit
– Hyperviscosity
• Worse with preop fasting
– Tpenia, platelet dysfunction, abnormal coags
Majority of patients with congenital heart disease lost to followup
– Pulmonary issues
96% regarded themselves as “health and fit”.
68% had no regular medical care.
ACC / AHA 2008 Adult Congenital Heart Disease Guideline

Adult with CHD
Even “routine” is complex
• History of “routine” ASD closure

– Residual pulmonary hypertension
– MR if primum ASD
– Increased incidence atrial arrhythmias
From: ACC / AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease, Dec 2008
109
Adult with CHD
• Noncardiac surgery
– Strongly recommend evaluation by cardiologist
experienced in the care of the patient’s disease
– Patients with high risk congenital heart disease
undergo surgery at centers with expertise
– Old records essential
– Emergency: consult with anesthesia, cardiac
anesthesia
– Arrange for post discharge cardiac followup
Earl Bakken
"Back at the garage, I dug out a back issue of Popular

Electronics magazine in which I recalled seeing a circuit for an
electronic, transistorized metronome. The circuit transmitted
clicks through a loudspeaker; the rate of the clicks could be
adjusted to fit the music. I simply modified that circuit and
placed it, without the loudspeaker, in a four-inch-square, inch-
and-thick metal box with terminals and switches on the outside -
and that, as they say, was that.”
C. Walton Lillehi
Earl Bakken
1997
110
Temporary Pacemaker: Indications Permanent Pacemaker
• Symptomatic sinus bradycardia
• Sinus pause > 3 seconds or causing • Pacemaker inhibition by electrocautery
– If pacemaker dependent reprogram to asynchronous mode (or put
symptoms magnet over the device)
• Symptomatic 20 A-V block (Mobitz I) • Rate adaptive unit may increase rate if
• Infranodal 20 A-V block (Mobitz II) respiratory rate increased or if mechanical
• New bifascicular block in acute MI stimulation of the generator.
• Complete heart block • No industry standard to response to
• LBBB in patient who is to undergo PA electromagnetic interference
catheter placement
• Interrogate pacemaker post op.
+ +
111
Radiation therapy for the patient with a pacemaker or AICD
Implantable Cardioverter Defibrillator
• Electrocautery
– May inhibit ICD
– May be sensed as malignant arrhythmia
– ICD shock function should be deactivated
preop if electrocautery planned
– If pacemaker dependent program pacing
function to asynchronous mode
– Response to magnet different than pmaker
• temporarily disables shock function
• Doesn’t affect pacing function
Radiation therapy for the patient with a pacemaker or AICD
October 4, 2011
125 MRI exams (109 patients)

No device resets
No device failures
No loss of capture
Popular Mechanics, June 1924

Online release ahead of print Sept 13, 2012
112
Ipod and Pacemaker Interference
Heart Rhythm Society, May 2007
Jay Thaker
High School Senior
100 pacemaker patients

IPod 2 inches from chest for 5-10 seconds
50% pacemaker interference (sensing)
1 case pacemaker inhibition
So who are you going to believe?
113
Heart failure admission or
> 3 outpt heart failure visits during prior 20 months
How about the RA ?
Tibor Farkas photographer. Image from History of Medicine, National Library of Medicine
114
Ann Rheum Dis, 2010 (69), p. 325-331
1. RA increases CV risk (AS, PsA ?)

a. Mortality 1.5X
b. Control disease activity to lower risk
2. Use local guidelines to decrease risk
No mention of perioperative risk evaluation
3. When selecting CV meds favor antiinflam
1. Statin, ACE
2. Minimal corticosteroid dose as possible
3. Smoking cessation
October 23, 2007

Step 5
Step 5

• History of compensated or prior HF
• History of cerebrovascular disease
• Diabetes
400 new articles reviewed since 2002 guideline • Renal insufficiency
??? Rheumatic disease
115
Non-CAD Cardiac Issues
• Valvular heart disease

• Chronic hypertension
• Chronic atrial fibrillation
• Hypertrophic cardiomyopathy
• Pulmonary hypertension
• Congenital heart disease
• Pacemaker
• ICD
• Chronic heart failure
• Rheumatologic disease
116
Urinalysis Prior to Joint Disclosures
Replacement:
Evidence Based or Expected Standard
Practice?
October 9-12, 2013
I have no disclosures to
make regarding this
presentation.

Chief of Hip and Knee Division
Camden, NJ
©2011 MFMER | 3127551-1
Rationale of Pre-op Screening Urinalysis Expected Standard Practice

• Detect unrecognized UTI or Renal Disease • Knee Society/Hip Society
which may increase risk of wound infection or
other complication after total joint replacement • American Academy of Orthopaedic Surgeons
• UTI -> Bacteriuria -> Prosthetic joint infection • American Association of Hip/Knee Surgeons
• Provide opportunity to reduce risk by executing • Practice Websites University/Community TJR

therapeutic strategy and avoid delaying Surgeons
planned surgery • (All support pre-op urinalysis
screening)
“I believe you should never order a U/A in Glynn 1984 David 2000
an asymptomatic patient with the Kovlouvaris (Hospital for
Ritter 1987
exception of patients undergoing GU or Special Surgery) 2009
GYN manipulation. Ordering a U/A before
TJR has been promoted in the orthopaedic
• No Correlation of Pre-op positive UTI with PJI
literature on the theoretical basis that (Prosthetic Joint Infection)
bacteria might somehow seed and
colonize the joint. Orthopaedic surgeons • Asymptomatic Bacteriuria (100,000 Colony Count)
like to do it (but I disregard their request • Did NOT cause seeding of joint
for it)” • No patient sample of untreated symptomatic
patients
-Steven L Cohn, M.D., B.A.
Cleveland Clinic Case Studies in Perioperative Management 2009
117
JBJS British 2012 Study Urinalysis Screening
• Possible correlation with UTI/PJI • No evidence-based support to screen patients
• Study included superficial wound swabs- who have no symptoms of bladder irritation
dubious criterion (cystitis), obstruction, or pyelonephritis
• 558 patients • Accepted as a practice standard
• 85% (+) dipstick bacteria
• 7% (+) Cultures
• UTI may be indicative of subset of sicker, more
debilitated patients rather than a discrete risk
factor for PJI
My University Practice
• All TJR patients have U/A and Cultures • Remove Foley Catheter within 24 hours after
surgery
• Nurse practitioner checks all results
• Asymptomatic UTI: Treat with appropriate • Mobilize patient early and often
antibiotics • Use multi-modal “comfort” protocol to
accelerate rehab process minimizing opiates
• DO NOT DELAY SURGERY!
• Symptomatic UTI: Treat with appropriate
antibiotics, treat until symptoms resolved
118
An Overview of Preoperative Pulmonary Risk Assessment
2 purposes:
Preoperative Assessment of the
Patient with Pulmonary Disease • Predict the risk of postoperative pulmonary
complications (PPC’s)
• Provide strategies to reduce the risk of PPC’s

Margaret Beliveau MD
©2011 MFMER | 3127551-1
Clinical Significance Why Don’t We Do This More Often?

• PPC’s are a major source of postoperative • We don’t know what the assessment can
morbidity and mortality predict
• 2-19% in non-cardiothoracic surgery • We don’t have guidelines for which tests we
should do in particular patients
• 8-35% in cardiothoracic surgery
• Similar incidence to postoperative cardiac • Shouldn’t we try to reduce the risk of PPC’s in
all patients?
complications
• Little good clinical data, so more uncertainty in
perioperative risk management
Postoperative Pulmonary Complications Postoperative Pulmonary Complications

General complications Specific cardiothoracic surgical complications
• Atelectasis • Exacerbation of
underlying chronic lung • Phrenic nerve injury
• Lung opacification w/ shift
of diaphragm or disease • Pleural effusion
mediastinum
• Respiratory failure • Bronchopleural fistula
• Respiratory infection • SaO2 < 90%, requiring
• Antibiotics, fever, X-ray oxygen • Sternal wound infection and empyema
changes, ↑WBC
• Pleural Effusion • Gastroesophageal anastomotic leak
• Bronchospasm • Pneumothorax • Postoperative arrhythmias
• New wheezing, treated
with bronchodilators • Aspiration pneumonia
119
The Literature… The Literature…
• Lawrence VA, Cornell JE, Smetana GW. • Qaseem A, Snow V, Fitterman N et al. Risk
Strategies to Reduce Postoperative Pulmonary Assessment and Strategies to Reduce
Complications after Noncardiothoracic Surgery: Perioperative Pulmonary Complications for
Systematic Review for the American College of Patients Undergoing Noncardiothoracic
Physicians. Ann Intern Med 2006: 144:596-608. Surgery: A Guideline from the American
College of Physicians. Ann Intern Med 2006;
144:575-580
The Literature… Perioperative Pulmonary Physiology

• Canet J, Gallart L et al. Prediction of • Reduction in lung volumes
Postoperative Pulmonary Complications in a
Population-based Surgical Cohort. • Thoracic and upper abdominal surgery:
Anesthesiology 2010; 113: 1338-50. • Vital capacity reduced 50-60%, may take up
to 1 week to return to normal
• FRC reduced about 30%
• Diaphragmatic dysfunction
• Residual effects of anesthesia and opiates may
suppress respiratory drive
©2011 MFMER | 3127551-9 ©2011 MFMER | 3127551-10
Case 1 Case 1
• A 39 yo obese woman (BMI 32) has a long- • What is the best strategy for preoperative
standing history of asthma. She is scheduled evaluation to prevent postoperative
for laparoscopic cholecystectomy for pulmonary complications?
symptomatic gallstones.
1. Chest X-ray
• On exam, her lungs are clear. 2. Spirometry and ABG
• Medications: Flovent inhaler 220 mcg BID;
albuterol inhaler prn, last used 2 months ago 3. Steroids for 5 days preoperatively
4. No further workup needed
120
Case 2 Case 2
• A 75 year old man with COPD, who smokes 1 • Which of the following should be ordered
PPD, scheduled for open prostatectomy for preoperatively?
prostate cancer
1. Spirometry and ABG
• Currently uses Spiriva inhaler
2. Spirometry without ABG
• Has failed multiple attempts at smoking 3. Send to surgery without further testing
cessation
• Chronic cough, but walks 2-3 miles daily 4. Delay surgery for 2 months until patient has
without symptoms stopped smoking
• Exam: Lungs clear 5. Pulmonary consult
Risk Assessment Patient Related Risk Factors

• Patient related factors • Age • Obesity
• Surgery related factors- often more important in • Smoking • Low serum albumin
predicting risk of PPC’s vs postoperative
cardiac complications • Chronic obstructive • Obstructive sleep
pulmonary disease apnea
• Functional status • Neurologic status
• Asthma • ASA classification
• Pulmonary
hypertension
Patient Related Risk Factors Age

• Asthma: no longer considered a risk factor for • Good evidence that advanced age is an
PPC’s important risk factor for PPC’s
• Patients should be at “personal best” before • Not a modifiable risk factor
elective surgery
• ? Influence of co-morbidities
• Tracheal intubation can trigger bronchospasm
in some patients
• ? Pretreat with steroids and β agonists
121
Smoking Smoking
• 44 million Americans smoke • Shouldn’t all patients stop smoking before
surgery?
• 1 in 5 deaths attributed to smoking
• Active smoking linked to increased risk of • Even brief preoperative smoking cessation can
reduce the risk of complications
perioperative cardiovascular, pulmonary and
wound healing complications • We should seize any opportunities to help
patients stop smoking.
• Smoking at the time of surgery associated with
inferior long-term surgical outcomes
Khullar D, Maa J. J Am Coll Surg; 2012: 215,

418-26.
Specialty Complications
Chronic Obstructive Pulmonary Disease
General surgery Superficial and deep wound infections, sepsis,
anastomotic leak, myocardial infarction,
pneumonia, prolonged intubation, stroke
• Major risk factor for PPC’s
Cardiac Pulmonary complications, sternal wound
infection, vein graft failure, prolonged ventilator
• Chronic respiratory muscle fatigue may be
support, ICU readmission exacerbated by the effects of surgery and
Plastic Increased scarring and asymmetry, delayed anesthesia
wound healing, reduced skin flap survival,
implant loss (breast reconstruction), lower
rates of successful digital replantation
• No incremental increase in risk with worsening
(microsurgery) airflow obstruction
Orthopedic Pneumonia, surgical site infections, impaired
bone healing, increased postoperative pain,
stroke
• Increased risk of postoperative arrhythmias in
Pediatric (parent smoking) Anesthesia-related respiratory complications
cardiothoracic surgery
Khullar D, Maa J. J Am Coll Surg; 2012: 215, 418-26.
©2011 MFMER | 3127551-21
Chronic Obstructive Pulmonary Disease Functional Status

• Preoperative history should focus on recent • Total dependence: inability to perform any
exacerbations, sputum production, presence of activities of daily living
dyspnea at rest
• Partial dependence: need for equipment and
• Physical exam should focus on signs of acute assistance of another person
exacerbation or pneumonia
• These patients are at almost twice the risk of
• Try to have patients at their “personal best” PPC’s
prior to elective surgery
• Not a modifiable risk factor
122
Obesity
• Postoperatively, decreased lung volume in most Obstructive Sleep Apnea (OSA)
patients
• Stay tuned for Dr. Olson
• Obese patients may have restrictive physiology
based on obesity
• Most studies found that obese patients, even
morbidly obese patients, did not have an
increased risk of PPC’s
• Potentially modifiable, but impractical in the
perioperative setting
• Should not impact decision to proceed with a
surgical procedure
Neurologic Status ASA Classification

• Impaired sensorium and previous stroke • I- A normally healthy patient (PPC’s 1.2%)
• Increased risk of both pneumonia and • II- A patient with mild systemic disease (PPC’s
respiratory failure 5.4%)
• Functional dependence • III- A patient with systemic disease which is not
• Aspiration risk incapacitating (PPC’s 11.4%)
• IV- A patient with an incapacitating disease
that is a constant threat to life (PPC’s 10.9%)
• V- A moribund patient not expected to survive
24 hours, with or without operation
ASA Classification Nutrition

• Higher ASA classification was associated with • Low serum albumin (as a marker for overall
increased risk of PPC’s nutritional status) is a risk factor for
postoperative respiratory failure
• 30 day mortality risk increases as albumin falls
below 4.0mg/dL
• Potentially a modifiable risk factor, but often not
feasible
123
Pulmonary Hypertension Pulmonary Hypertension
• Defined as RVSP >35mm Hg • Postoperative complications include:
• Increased risk of postoperative complications if • Respiratory failure
• NYHA functional status >2 • Congestive heart failure
• History of pulmonary embolism • Cardiac ischemic events
• OSA • Arrhythmias
• Hepatic dysfunction
• Most complications occur in the OR or within 48
hours after procedure • Renal dysfunction
• Need for inotropic or vasopressor support
Surgery Related Risk Factors

Pulmonary Hypertension
• High incidence of complications, even in • Surgical site
patients with mild-to-moderate PH
• Type (general vs regional) of anesthesia
• Risk increased if: • Duration of anesthesia
• Longer surgery
• Emergency and major procedures • Neuromuscular blockade (Pancuronium use)
• General anesthesia • Emergency surgery
• Patients with worse functional status have more
complications
©2011 MFMER | 3127551-33
Surgical Site Anesthesia

Increased risk of postoperative pneumonia and • Insufficient evidence in favor of neuraxial
respiratory failure: blockade vs general anesthesia
• Abdominal aortic aneurysm repair (highest risk) • Postoperative analgesia: PCA has advantage
over on request
• Thoracic
• Upper abdominal
• Neck
124
Assessment of Risk
• History and Physical exam
• Imaging
• Spirometry
• Special measures of lung function
• ABG
• Exercise testing
Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac
Surgery.
Arozullah, Ahsan; MD, MPH; Daley, Jennifer; Henderson, William; Khuri, Shukri
Annals of Surgery. 232(2):242‐253, August 2000.
Respiratory Failure Index

Class (score) Risk of respiratory
failure
1 (< 10) 0.5%
2 (11-19) 1.8%
3 (20-27) 4.2%
4 (28-40) 10.1%
5 (>40) 26.6%
Canet J, Gallart L. Anesthesiology; 2010 , 1338-50.

©2011 MFMER | 3127551-40
So what tests do we need to

Risk Assessment assess pulmonary risk?
• Low risk: < 26 points
• Intermediate risk: 26-44 points
• High risk: >44 points
©2011 MFMER | 3127551-41 ©2011 MFMER | 3127551-42
125
Spirometry Spirometry
• Good diagnostic tool for COPD • ACP Guidelines: Preoperative spirometry
should not be used routinely for predicting risk
• Has never been shown to be better than clinical of postoperative pulmonary complications
data (history and physical exam) for predicting
risk of PPC’s
• No absolute threshold of prohibitive risk
Spirometry Chest X-ray

Consider in: • Studies have looked at how CXR findings
changed perioperative management, not how
• Patients who are heavy smokers well they predicted PPC’s
• Patients complaining of inexplicable dyspnea or • Most studies show that a preoperative CXR
cough rarely (0.1%) changes perioperative
• Abnormal lung exam management
• Upper abdominal or aortic surgery • Abnormalities could often be predicted on the
basis of history and physical exam
• Lung resection or lung reduction surgery
Chest X-ray Case 3

• ACP Guidelines: Preoperative chest X-ray • 77 yo woman with “moderate” COPD,
should not be used routinely for predicting risk discovered to have a 6.1cm abdominal aortic
of postoperative pulmonary complications aneurysm on a community based screening
exam
• COPD diagnosed 3 years ago after admission
for an exacerbation; quit smoking at that time
126
Case 3 Case 3
• Currently on Spiriva inhaler, rare albuterol use Which of the following tests would be helpful
preoperatively to assess risk of PPC’s?
• Walks on a treadmill 3-4 times/week, weight
training, very physically active 1. Chest X-ray
• Rarely, some dyspnea on exertion 2. Spirometry
• Normal exam 3. Arterial blood gas

4. Serum albumin
5. Cardiopulmonary exercise testing
Case 4
How Do We Reduce the Risk of
Postoperative Pulmonary • A 70 yo man is being seen preoperatively for a left
nephrectomy for suspected renal cell cancer
Complications?
• He has a 60 pack-year smoking history, still
smokes ½ PPD
• Daily cough with production of sputum
• Last known FEV1 was 2 years ago= 1 L
Case 4
Which of the following will help
• Requires nocturnal oxygen decrease his risk of
• Currently on long-acting beta-agonist inhaler postoperative pulmonary
and steroid inhaler
• Last exacerbation was 6 months ago, currently
complications?
feels that he is at his baseline
• Exam: increased AP diameter, scattered
wheezes
• Surgery scheduled in 5 days
127
1. Smoking cessation Lung Expansion Modalities
2. Lung expansion modalities
• Incentive spirometry, chest physical therapy,
3. Pulmonary artery catheterization deep breathing exercises, cough, intermittent
positive-pressure breathing (IPPB), continuous
4. Pre- and postoperative total parenteral
positive-airway pressure (CPAP)
nutrition
5. Nasogastric tube decompression for 3 days
postoperatively
Lung Expansion Modalities Pulmonary Artery Catheterization

• For abdominal surgery, studies suggest that • No beneficial effect in reducing PPC’s
any type of lung expansion is better than no
attempt at prophylaxis
• Combining modalities may not increase efficacy
• Nasal CPAP in patient who are unable to
comply with other modalities
Nutrition Nasogastric Tube Decompression

• Studies of nutritional support have not shown a
benefit for TPN over enteral nutrition or no • Selective use: postoperative nausea and
intervention except possibly for patients with vomiting, severe abdominal distention
severe malnutrition
• Routine use: standard use after surgery until
gastrointestinal motility returns
• Selective use of NG tube decompression
probably beneficial in decreasing risk of PPC’s
128
Case 1- Asthma Case 2- COPD, Smoker
• What is the best strategy for preoperative • Which of the following should be ordered
evaluation to prevent postoperative preoperatively?
pulmonary complications?
1. Spirometry and ABG
1. Chest X-ray
2. Chest X-ray, spirometry and a 6 minute walk
2. Spirometry and ABG test
3. Steroids for 5 days preoperatively 3. Spirometry without ABG
4. No further workup needed 4. Send to surgery without further testing
5. Delay surgery for 2 months until patient has
stopped smoking
Case 3- COPD, AAA Case 4- Smoker, COPD

Which of the following tests would be helpful 1. Smoking cessation
preoperatively to assess risk of PPC’s?
2. Lung expansion modalities
1. Chest X-ray
3. Pulmonary artery catheterization
2. Spirometry
4. Pre- and postoperative total parenteral
3. Arterial blood gas nutrition
4. Serum albumin 5. Nasogastric tube decompression for 3 days
5. Cardiopulmonary exercise testing postoperatively
• Chung SA, Hongbo Y, Chung F. A Systematic Review • Khullar D, Maa J. The Impact of Smoking on
of Obstructive Sleep Apnea and Its Implications for Surgical Outcomes. J Am Coll Surgeons; 2012:
Anesthesiolgists. Anest Analg 2008; 107:1543-63. 215, 418-26.
• Bapoje SR et al. Preoperative Evaluation of the Patient
With Pulmonary Disease. Chest 2007; 132: 1637-1645. • Canet J, Gallart L et al. Prediction of
Postoperative Pulmonary Complications in a
• Practice Guidelines for the Perioperative Management Population-based Surgical Cohort.
of Patients with Obstructive Sleep Apnea.
Anesthesiology 2006; 104:1081-93. Anesthesiology; 2010: 113, 1338-50.
©2011 MFMER | 3127551-66
129
Questions?
• Thank you.
• Beliveauficalora.margaret@mayo.edu
©2011 MFMER | 3127551-67
130
Perioperative Cardiac Complications
in Perioperative Complications
Noncardiac Surgery
• Hypertension
I and II • Hypotension
An Overview of Perioperative Medicine • Arrhythmias
October, 2013 • Myocardial ischemia - infarction
• Heart failure
Howard Weitz, M.D.
Perioperative Hypertension Perioperative Hypertension

Occurrence
• Preop diastolic < 110 mm Hg not a risk
factor. • Laryngoscopy - induction
• ? Risk of preop systolic hypertension – Sympathetic stimulation
• No clear evidence perioperative
hypertension related to post op death. • Intraoperative
• Periop hypertension or hypotension – Sympathetic stimulation
occurs in 25% of hypertensive patients
who undergo surgery. – Visceral traction
• Carotid, abdominal aortic, vascular,
abdominal, thoracic.

Occurrence Occurrence
• Immediately post op
– Pain • 48 hours post op
– Hypothermia – Fluid mobilization
– Hypoxia – Medication withdrawal
– Volume overload
– Cessation of positive pressure ventilation
131
Treatment Treatment
• Prevention • Prevention
– Beware of medication withdrawal – Beware of medication withdrawal
• substitute with long acting agents • substitute with long acting agents
• parenteral agents • parenteral agents
• Is the BP “correct” ? • Is the BP “correct” ?

Treatment Treatment
• Are there precipitating factors? • First, do no harm !!!

– Pain
• Does the BP really require lowering and
– Cold how quickly ?
– Antihypertensive medication withdrawal
• Is there evidence to support urgent BP
– Cocaine
lowering?
– Alcohol withdrawal
Our Approach to Urgency of Perioperative

BP Control
From: Matthews J. The hypertensive patient in the emergency department. J Emerg Med
2000;19:379
132
Indications for Treatment Medical Rx
• Nitroprusside
• Myocardial ischemia, CHF, cerebral • Nicardipine
ischemia, aortic dissection
• Beta blockers
• ??MAP 20 mm Hg above baseline in
diabetic. • Enalapril
• “Significant” sustained elevation • Nitroglycerine
• AVOID too rapid control • Alpha methyldopa
– Goal: No more than 25% decrease in BP first • Diuretics
24 hrs. • NO Nifedipine
• Use the perioperative encounter to evaluate need
for long term BP Rx
Perioperative hypertension: medical

mgmt
Hypotension: Myocardial ischemia
• Clevidipine • Transient systolic 50%

– CCB • Systolic 33% > 10 minutes
– IV • MAP < 20 mm Hg in diabetic
– T1/2 3 minutes hypertensive 1 hour.
– No hepatic or renal metabolism
– Arterial vasodilator
– Cardioprotective
Perioperative Hypotension:
Perioperative Arrhythmias
Causes
• Acute
– Iatrogenic
• 84% incidence - 5% significant
– Vasodilation • Types
– Myocardial depression – wandering atrial pacemaker
– Volume depletion – isorhythmic A-V dissociation
– anesthesia (vasodilation/ myocardial
depression)
– nodal rhythm
• Delayed – sinus tachycardia / bradycardia
– Acute pulmonary embolism – Atrial premature contractions
– Sepsis – Ventricular premature contractions
133
Perioperative Arrhythmias
Supraventricular arrhythmia: Risk
Etiology
• Age > 70
• Altered autonomic tone
• Pre op rales
• Sympathetic stimulation • abdominal, thoracic, vascular
• Hypoxia surgery
• Hypercarbia • concurrent medical problems
• ?? Hypokalemia
4181 pts.major, nonemergent , NCS

317 perioperative SVA
SVA 33% increase length of stay
Polanczyk, et al.: Ann Intern Med. 1998;129:279-285

Polanczyk, et al.: Ann Intern Med. 1998;129:279-285
From Passman R, et al. Ann Thorac Surgery, 2005
134
2001
Supraventricular Arrhythmia: Rx
• Unstable vs. Stable

• PSVT
• Atrial flutter
• Atrial fibrillation
Prophylactic Beta blocker (Cardiac surg)
Rate control
Prophylaxis (cardiac surgery)
Restore sinus rhythm
Antiarrhythmics for recurrent / refractory
Antithrombotics
ACC / AHA / ESC 2006 Guidelines for the

Management of Patients With Atrial Fibrillation
Page e 214
Circulation and J Am Coll Cardiology August 15, 2006

Online www.acc.org
135
Cardiac surgery – prophylactic beta blocker
New onset periop afib
Postop afib rate control
• High risk procedures

Cardiac surgery- amiodarone prophylaxis – Thoracotomy ( > 65 years old)
– VATS (video assisted thoracoscopy) (> 80 years old)
Sinus rhythm restoration as for nonsurgical pts
• ?? Afib prophylaxis
– Beta blocker
Antiarrhythmics as for nonsurgical patients
– Calcium channel blocker ( diltiazem, verapamil)
– Amiodarone
Antithrombotics as for nonsurgical patients • Evidence in cardiac surgery
• No better than diltiazem in thoracic surgery
Cardiac surgery –prophylactic sotalol
Balser JR, et al.: Beta adrenergic blockade accelerates conversion of postoperative supraventricular
tachyarrhythmias. Anesthesiology 1998
80% of patients in afib
136
How do we determine stroke risk ? Perioperative atrial fibrillation: Rx
(Who requires anticoagulation to prevent stroke?)
• CHADS2 (Gage, et al.: JAMA 2001) • Atrial fibrillation

– Congestive heart failure - 1pt – Majority (85%) will spontaneously convert
– Hypertension - 1pt
• 98% in sinus rhythm 4-8 weeks postop
– Age > 75 - 1 pt
– Diabetes - 1pt – Rate control (beta blocker, Ca channel blocker)
– Stroke or TIA - 2 pts – Anticoagulation if > 48 hrs
• CHADS2
– 0 points – low risk (1.2-3.0 strokes per 100 patient years)
– Cardioversion (DC shock; ibutilide; TEE guided)
– 1-2 points – moderate risk (2.8-4.0 strokes per 100 patient years)
– > 3 points – high risk (5.9-18.2 strokes per 100 patient years)
Ventricular Arrhythmias Ventricular Arrhythmias

• Study Group: Men with known CAD or high
• Significance related to underlying heart CAD risk
disease.
• Rx: hemodynamically significant ectopy; • VPCs common
• Antiarrhythmic metabolism and excretion may – 44% had frequent or complex VPCs
be altered in perioperative period. • Preop 21%
• Intraop 16%
• Postop 31%
• No sustained Vtach or Vfib

O’Kelley, 1992
137
Retrospective
412 patients lobectomy or pneumonectomy
Continuous monitoring 72-96 hours
NSVT in 15%- no effect on 30 day outcome

Four patients perioperative MI: No VT
Am J Card 77, 1996
Plaque rupture
+
Thrombus Angiography avrg 6 days prior to vascular surgery.
1242 pts. Followed for subsequent MI or cardiac death postop. (21 pts)
(decreased Collateralized total occlusions and “nonobstructive lesions most common substrate.
myocardial blood
supply)
Were “inadequate collaterals” the cause (increased myocardial O2 demand) ?
138
Master et al.: 1938
3
MI
2
0
1 2 3 4 5 6 7 8 9 10
Master et al.: JAMA 110(18), 1939 Post operative day
Master, 1938
• Perioperative MI 1931-1937
• Shock 60%
• Mortality 66%
• Most without chest pain
139
Mangano, 1991
323 pts., Known ischemic heart disease
CK + Troponin bid day 1‐4, then daily
Ischemia most common first three postop days.
Ischemia clinically silent. From Badner et al.:Anesthesiology 1998;88:572‐8
Perioperative MI 2011 Perioperative MI 2011
Perioperative Myocardial infarction

• Autopsy
• Cardiac marker (+) and:
1. Symptoms
2. New Q waves
3. Ischemic ECG changes
4. Coronary intervention
5. Cardiac imaging c/w new MI
Perioperative MI 2011
Perioperative MI surveillance
• Cardiac troponins more specific than CPK-MB
(rise 3 hrs post injury).
Perioperative Myocardial Infarction • Surveillance for known CAD, high risk for CAD,
•30 days postop Intermediate-to-high risk for event:
•5% incidence periop MI
– ECG: baseline, immed post op, POD 1,2,3
•74% of MI first 48 hrs postop
•Asymptomatic 65% – Troponin:
•Mortality 11.6% • POD 1 and 4
•Majority NSTEMI
– Detects > 90% but ? Delayed detection
•Many not treated with meds to decrease
risk of recurrent MI • Evening post op and daily for 4 days
• Marker of risk for months post op
140
Perioperative MI 2012
Systematic review – 14 studies
Increased Tn postop
Increased 12 month mortality (OR 3.4)
Anesthesiology, April 2011
Perioperative MI 2012 Perioperative MI
• Randomized controlled data to guide

treatment:
Perioperative MI - ? Perioperative MI - ?
141
Perioperative MI - ? Perioperative MI - ?
Perioperative MI ‐ ? Perioperative MI : 0
Perioperative MI: 0 Treatment and prevention of postoperative myocardial ischemia and MI
Landesberg, G. et al. Circulation 2009;119:2936-2944
Copyright ©2009 American Heart Association
142
Perioperative Troponin Elevation Perioperative Troponin Elevation
• Myocardial necrosis (lab diagnosis; many causes) • Myocardial necrosis (lab diagnosis; many causes)
• Myocardial infarction (clinical diagnosis; few causes) – MI
– Infection
– Sepsis
– Pulmonary embolus
– Heart failure
– Renal failure
• Myocardial infarction (clinical diagnosis; few causes)
– MI
Is preoperative antiplatelet discontinuation a Is preoperative antiplatelet discontinuation a

risk for perioperative MI? risk for perioperative MI?
Burger et al 2005
• Retrospective meta-analysis Poor data

• Case reports re: ASA withdrawl – periop events
• Retrospective data ASA withdrawal – cardiovascular
events (stroke, acute coronary syndrome, limb ischemia)
– 10% of events followed aspirin discontinuation ( 8.5 days)
• Perioperative hemorrhagic fatalities on ASA
– Neurosurgery
Meta‐analysis of 41 studies
– Prostatectomy ASA increased risk of bleeding complications 1.5 fold
ASA withdrawal preceded 10% of Acute Coronary Syndromes
Time interval from ASA withdrawal to ACS was 8.5 days
143
ASA withdrawal
assoc with 3‐ fold
higher risk of
major cardiac event
JAMA Feb 5, 2008
Postoperative HF Perioperative Pulmonary Edema
• Systolic LV dysfunction • Predictors: diabetes, postop ischemia,

• HF with preserved ejection fraction (diastolic arrhythmia (Mangano,1990)
dysfunction • Occurrence
– 70% first hour post extubation.
– 24-48 hours post op
• Treatment
144
Perioperative Pulmonary Edema
• Predictors: diabetes, postop ischemia, arrhythmia

(Mangano,1990)
• Occurrence
– 70% first hour post extubation.
– 24-48 hours post op
• Treatment
– Control blood pressure
– Control afib ventricular response
– Diuretics (cautious if HR-PEF)
– Ischemia eval if no other cause
Negative pressure pulmonary edema

Postobstructive pulmonary edema
• Young
• Obese
• Difficult intubation
• Postop laryngospasm
• Pulmonary edema within 90 minutes
• Supportive care, diuretic
• Noncardiac
Operative and 30 day postoperative mortality:
Heart failure (admission during prior year): 11.7%
CAD (admission during prior year): 6.6%
Control: 6.2%
Perioperative cardiac arrest Sprung J, et al
• Noncardiac surgery (1990 – 2000)

• Cardiac arrest = chest compressions or open
cardiac massage
• After initiation of anesthesia – until – discharge
from recovery room or transfer of care to ICU
staff
145
Sprung J, et al Sprung J, et al
• 518294 anesthetics • 98 (44%) due to cardiac causes

• 223 cardiac arrests (4.3 per 10,000) • 78 (35%) due to bleeding
• 24 (11%) due to anesthesia (asystole most common rhythm)
– 13 (54%) medications
– 11 (46%) airway / ventilation
Sprung J, et al
Perioperative Complications
• 79% (19/24) of those whose arrests due to anesthesia
survived to be discharged. • Hypertension
• 29% (58/199) of those whose arrest not due to
anesthesia survived to discharge. • Hypotension
• Arrests due to loss of airway had worst outcome. • Arrhythmias
• Likelihood of survival greater if arrest occurred during
standard working hours.
• Myocardial ischemia - infarction
– ? more comprehensive response to arrest • Heart failure
146
Disclosures
Management of Documented or Suspected
Obstructive Sleep Apnea (OSA) in Patients
Undergoing Non-Cardiac Surgery
• No financial disclosures
• No discussion of “off label” use of drugs
Eric J. Olson, MD
Center for Sleep Medicine, Mayo Clinic Rochester
An Overview of Perioperative Medicine 2013
OSA: Increasingly Common in Peri-op Period Case

• Apnea-hypopnea index (AHI) > 15: ♂ 15% ♀ 9%1
• 58 M
• ↑ disease recognition, yet 70% still undiagnosed2
• DJD; seeking knee arthroplasty
• ↑ obesity prevalence
• Wife: witnessing loud snoring, apneas, gasping
2011 US Obesity Rates • Patient: no sleep concerns
• Hypertension
20%–<25%
25%–<30% • BMI: 46 kg/m2 BP: 152/92
30%–<35%
≥35%
• Neck: 18”
• OSA suspected; Sleep evaluation advised
• Pt resistant. “I just want my knee fixed!”
1Young T. N Engl J Med 1993; 328:1230
2Finkel KJ. Sleep Med 2009; 10:753
Peri-op Complications Attributed to OSA:

Initial Case Reports/Small Case Series
• What are the consequences of OSA in the peri-op • Difficult intubation and extubation
period? • Large blood pressure fluctuations
• Profound desaturation → myocardial ischemia, arrhythmias
• Delirium
• Postobstructive pulmonary edema (breathing efforts against
closed upper airway)
• Respiratory arrest
• Death
147
OSA Status and Complication Rates in Peri-op Complications Attributed to OSA:
Lower Extremity Joint Replacements Recent, Larger Series
• Complication rates 2-7x ↑ in OSA
• Serious complication rates 14-24%
• ↑ risk in OSA for:
• Unplanned ICU stays
• Reintubation
• Aspiration pneumonia
• Venous thromboembolism in ortho patients
• Longer length of stay
Gupta RM. Mayo Clin Proc 2001; 76:897 Kaw R. Chest 2012; 141:436. Memtsoudis S. Anesth Analg 2011; 112:113. Liao P. Can J Anesth 2009; 56:819
Factors that ↑ Post-op Risk in OSA

• What factors ↑ risk of post-op complications in Hypoxemia
OSA patients? Difficult Hypercapnia Associated ↑ Risk
airway + + =
Intrathoracic co-morbidities
control
pressure swings
Arousals
Obesity
Depressant effects of anesthetics/analgesics/sedatives
CHF
Upper airway narrowing due to post-intubation edema,
nasal packings, appliances, hematomas Hypertension (systemic; pulmonary)
Forced supine positioning Stroke
Intense REM rebound CAD
Temporary suspension of CPAP DM2
Pre-op Considerations
• How should patients be screened for OSA? • OSA is highly prevalent
• Most cases undiagnosed All pre-op evals
should look for OSA!
• Potentially devastating
complications if untreated
• History
• Physical exam
• Clinical screening tool to sieve out high risk pts
148
Berlin Questionnaire for OSA: Category 1 Berlin Questionnaire for OSA: Category 2
1.Do you snore? 4. Has your snoring ever bothered other people?
6. How often do you feel tired or fatigued after
Yes (1) Yes (1) your sleep? 8. Have you ever nodded off or fallen asleep
while driving a vehicle?
No No Almost every day (1)
Don’t know 3-4 times per week (1) Yes (2)
Don’t know
1-2 times per week No
5. Has anyone noticed that you stop breathing 1-2 times per month
2. Your snoring is: during your sleep?
Rarely or never
Slightly louder than breathing Almost every day
As loud as talking 3-4 times per week (2) Score: “+” if ≥ 2
7. During your waking time, do you feel tired,
1-2 times per week (2) fatigued or not up to par?
Louder than talking (1)
1-2 times per month Almost every day (1)
Very loud-can be heard in other rooms (1) Rarely or never 3-4 times per week (1)
1-2 times per week
3. How often do you snore? 1-2 times per month
Almost every day (1) Rarely or never
3-4 times per week (1)
1-2 times per week Score: “+” if ≥ 2
1-2 times per month
Rarely
Netzer N. Ann Intern Med 1999; 131:485 Netzer N. Ann Intern Med 1999; 131:485
Berlin Questionnaire for OSA: Category 3 and Interpretation

STOP-BANG
10. Do you have high blood pressure? Snoring: Do you snore loudly (heard through closed doors)? Y N
Yes (1)
No Tired: Do you often feel tired, fatigued, or sleepy during day? Y N
Observed: Has anyone observed you stop breathing? Y N
11. BMI “High risk” for OSA:  2 categories “+”
> 30 (1) “Low risk” for OSA: < 2 categories “+” Pressure: Do you have or are you being treated for
< 30 high blood pressure? Y N
BMI: > 35? Y N
Score: “+” if either Age: > 50? Y N
hypertension or obesity
Neck circumference: > 40 cm? Y N
Gender: Male? Y N
“High risk” for OSA: ≥ 3 questions “yes”

“Low risk” for OSA: < 3 questions “yes”
Netzer N. Ann Intern Med 1999; 131:485 Chung F. Anesthesiology 2008; 108:812
Sleep Apnea Clinical Score

For Patients with Moderate-Severe OSA Prediction of OSA
(AHI > 15): (Circle the patient's score.)
Historical features Sleep Apnea Clinical Score (SACS)
1. Habitual snoring
2. Partner witnessed gasping, Not Hypertensive Hypertensive
choking, or snorting
Historical Features* Historical Features*
Berlin STOP-BANG Neck Circ (cm) None One Both None One Both
<30 0 0 1 0 1 2
Sensitivity 79% 93% 30/31 0 0 1 1 2 4
32/33 0 1 2 1 3 5
Specificity 51% 43% 34/35 1 2 3 2 4 8
36/37 1 3 5 4 6 11
PPV 51% 52% 38/39 2 4 7 5 9 16

40/41 3 6 10 8 13 22
NPV 78% 90% 42/43 5 8 14 11 18 30

44/45 7 12 20 15 25 42
46/47 10 16 28 21 35 58
Sensitivity favored at expense of specificity; “Low risk” 48/49 14 23 38 29 48 80

>49 19 32 53 40 66 110
patients may proceed to surgery with usual peri-op care
Chung F. Anesthesiology 2008; 108:822

Flemons WW. Am J Respir Crit Care Med 1994; 150:1279
Chung F. Anesthesiology 2008; 108:812
149
Prediction Formulas: Which is Best? Pearls for Pre-op OSA Detection
• Seek bed partner input
• “No clinical model is recommended for use to • Consider overnight oximetry if no collateral history
predict severity of sleep apnea”
AASM. Sleep 2005; 28:499 • History of difficult intubation predicts OSA and vice versa
• ↑ Mallampati predicts ↑ OSA risk

• Screening tool decision lies with clinicians and
their institutional experience
• ↑ serum bicarb + BMI ≥ 30 → possible obesity hypoventilation
Back to our Patient…

Prediction of OSA
(Circle the patient's score.)
Historical features Sleep Apnea Clinical Score (SACS)
Question
1. Habitual snoring
2. Partner witnessed gasping, Not Hypertensive Hypertensive
choking, or snorting
Historical Features* Historical Features* What would you advise?
Neck Circ (cm) None One Both None One Both
<30 0 0 1 0 1 2
30/31 0 0 1 1 2 4
32/33 0 1 2 1 3 5 A. Proceed to surgery
34/35 1 2 3 2 4 8
36/37 1 3 5 4 6 11 B. Screening overnight oximetry
38/39 2 4 7 5 9 16
40/41 3 6 10 8 13 22
C. Referral to Sleep for polysomnogram
42/43 5 8 14 11 18 30
44/45
46/47
7
10
12
16
20
28
15
21
25
35
42
58
D. Surgery now with empiric auto-CPAP post-op
48/49 14 23 38 29 48 80
>49 19 32 53 40 66 110
Flemons WW. Am J Respir Crit Care Med 1994; 150:1279
Pre-op Sleep Testing vs Presumptive

Treatment of “High Risk for OSA” Patients
• Which patients with suspected OSA need sleep • Case-by-case decision with all stakeholders
testing before surgery?
• Consider:
• Urgency of surgery
• Invasiveness of surgery
• Type of anesthesia
• Post-op opioid needs
• Suspected severity of OSA
• Co-morbidity burden
• Likely use of PAP by Rx-naïve patient
150
Back to our Patient…
• Sleep evaluation advised: • If presumptive management: peri-op care
• Elective surgery should be same as for known mod-severe OSA
• Strong suspicion for OSA (oxi unlikely to change this)
• General anesthesia
• Post-op IV opioids likely • If pre-op tested and OSA confirmed → CPAP
• Hypertension not tightly controlled
• Face validity, yet impact on post-op
complications not well defined
• Polysomnogram: severe OSA
• AHI: 49 events/hr • Optimal pre-op use unclear; suggest 1 week
• Lowest SpO2: 70% • Non-PAP options not well studied
• % time SpO2 < 90%: 18%
Pre op Evaluation: Known OSA

• How about the pre-op assessment of patients •  OSA severity   risk
with known OSA?
• Instruct to bring treatment modality to hospital!
• Referral to sleep center if:

• Symptomatic despite CPAP
• CPAP non-compliance
• > 10% weight change since CPAP titration
• No recent Sleep f/u
• Reassessment of non-CPAP options
Seet E. Can J Anesth 2010; 57:849
Publications on Peri-op OSA Management

• Are there guidelines for management of OSA in • AASM: Sleep 2003; 26:1060
peri-op period?
• ASA: Anesthesiology 2006; 104:1081
• CAS: Can J Anesth 2010; 57:849
• Review: Chest 2010; 138:1489
151
ASA Checklist: An Aid to Assess Risk
• A. Severity of sleep apnea based on sleep study or clinical indicators:
• Inpatient or outpatient surgery? • None
• Mild
(0)
(1)
• Moderate (2)
• Severe (3)
• B. Invasiveness of surgery and anesthesia
• Superficial surgery w/o sedation (0)
• Superficial surgery w sedation or GA (1)
• Peripheral surgery with spinal/epidural (1)
• Peripheral surgery with GA (2)
• Airway surgery, moderate sedation (2)
• Major surgery, GA (3)
• Airway surgery, GA (3)
• C. Post-operative opioid requirements
• None (0)
• Low-dose opioids (1)
• High-dose oral opioids, parenteral, or neuraxial (3)
• D. Estimation of peri-operative risk: A + (B or C [whichever higher])
• High risk: 5-6 6
Anesthesiology 2006; 104:1081
Intra-op Considerations for Known or

Surgery Location: General Principles1,2 Suspected Mod-Severe OSA
• Case-by-case decision • Avoid sedating pre-meds
• If no intubation:
• Ambulatory surgery center considered: • Provide pt’s usual OSA treatment
• Any OSA status: procedures with NO post-op IV • If moderate sedation:
narcotics anticipated • Administration by properly trained personnel
• Continuous SpO2, CO2 monitoring
• Mild OSA or low-risk for OSA: procedures with only
post-op ORAL narcotics anticipated
• If intubated:
• ASA Difficult Airway Guideline1
• Hospital-based surgery:
• All procedures with post-op IV narcotics anticipated • Anesthesia:
• Poorly studied
• Known OSA (any severity) or high-risk for OSA: • Local, regional options, if possible
upper airway surgery and lap upper abdominal • Ideal GA not known; short-acting agents preferable
surgery
1Bolden N. J Clin Anesth 2009; 21:286
1Anesthesiology 2003; 98:1269
2Anesthesiology 2006; 104:1081
Extubation
• Airway resources immediately available • Which known or suspected OSA patients
require closer monitoring?
• Ensure sufficient patient wakefulness, cooperation
• Verify reversal of neuromuscular blockade
• Maximal head of bed elevation
• Prompt initiation of PAP
152
2-Step Process for Identifying Patients at
Risk for Post-op Complications from OSA
1. Calculate pre-op Sleep Apnea Clinical Score

2. Monitor for recurrent events in PACU
Gali B. Anesthesiology 2009; 110:869 Gali B. Anesthesiology 2009; 110:869
2-Step Process for Identifying Patients at

Risk for Post-op Complications from OSA
OR for post-op resp

complications:
High SACS: 3.5
↑ PACU events: 21
Gali B. Anesthesiology 2009; 110:869 Gali B. Anesthesiology 2009; 110:869
Post-op Setting for High-Risk Patients Other Post-op Considerations

• Monitored bed • Inconsistent post-op CPAP use in known OSA
• Auto-CPAP may be an option
• Continuous pulse oximetry with local and
remote monitoring via telemetry • Breakthrough snoring on PAP means obstruction occurring
• Early nursing intervention possible • Caution with PCA
C • ICU • Monitoring must be in place
o • Consider eliminating basal infusion
n
c
• Step-down unit
e
• Bed close to RN station on ward • Regional, multimodality analgesia to minimize opioids
r
n
• Minimize sedative/hypnotics
• Lateral or up-right positioning preferred, if possible
153
Back to our Patient… Post-op Desaturations Despite CPAP
• Extubated in PACU; immediate CPAP initiation • Inadequate pressure
• Consider if breakthrough snoring
• Post-op nausea → nasogastric tube • Empiric  pressure; auto-CPAP;  meds
• You are called for desaturations during sleep
despite CPAP • Interface issues due to tubes, packings
• Full face mask
• Central sleep apnea from opioids

•  meds
• Other post-op pulmonary complications
Pre-op patient
w/o known OSA OSA very common!
• Putting it all together…
Berlin
Hx, PE,
STOP-BANG
OSA screening tool
SACS
Oximetry
High-risk of OSA Low risk of OSA
Go to next slide
Modified from: Seet E. Can J Anesth 2010; 57:849
High-risk of OSA Low risk of OSA

BMI > 35 Pre-op patient
CHF with known OSA
HTN
Major elective surgery, Stroke
post-op opioids, or Arrhythmias
major co-morbidities? Routine cares
CAD
DM2
Moderate-severe OSA Mild OSA
No Yes (AHI > 15; hypoventilation) (AHI 5-15)
Consider
Proceed to pre-op sleep Stakeholder
surgery with evaluation discussion
peri-op OSA
precautions
CPAP Go to next slide
154
Moderate -severe OSA Mild OSA Peri-op Precautions for Known or
Persistent symptoms Suspected Moderate-Severe OSA
PAP non use • Hospital-based surgery if post-op opioids (IV or PO) anticipated
Changes in Weight change
OSA status? Lost to Sleep Routine cares
Assess non-PAP options • Prepare for difficult intubation
No Yes
• Anesthesia: regional, short-acting GA agents
Don’t ignore! Pt to
bring OSA Rx to
hospital; may need • Extubate only in safe location when patient awake, in non-supine
closer monitoring if position, and neuromuscular blockade reversed
Proceed to PACU events
surgery with Pre-op sleep
peri-op OSA evaluation • Analgesia: multimodality; minimize opioids
precautions
• Early reinitiation of PAP
PACU
Assessment
Known Suspected Thanks for your attention

OSA OSA
• olson.eric@mayo.edu
Severe OSA (AHI > 30)
Non-Compliant with PAP Recurrent PACU Events*
Recurrent PACU Events*
Upper Airway Surgery
No Yes
No Yes
Mod OSA (AHI 16-30)
Post-op IV opioids  Monitored
care needs bed
No Yes
DC home if Post-op care

minor surg on surg ward
*SpO2 < 90 [≥ 3 episodes]; Bradypnea [< 8 respirations/min X ≥ 3;
Apnea [≥ 10 sec X ≥ 1]; Pain-sedation mismatch
155
156
Disclosure
Financial Relationships
Update VTE Prophylaxis 2013  Geno J. Merli, MD, MACP, FHM, FSVM
 Bayer: Research, Scientific Advisory
Surgical Patient  Bristol-Meyer Squibb: Research, Scientific
Advisory
 Sanofi-Aventis: Research
Geno J Merli, MD, MACP, FHM, FSVM  Portola: Research
Professor of Medicine & Surgery
Co-Director Jefferson Center for Vascular Diseases
Chief Medical Officer
Current Recommendations
Managing Surgical Patients
At-Risk Surgical Patients
Continuum of Care
HOSPITAL
NON-HOSPITAL
Medical Institutions
Surgical Procedure
Rehab Centers Long Term Care
2012
Skilled Nursing Facility
VTE
Prophylaxis Transition of Care
HOME
2013
Gould M, et al Chest 2012;141:227S-277S International Consensus, Inter Angiology 2013;32:111

Acute VTE Px Extended VTE Px
Surgical Patient
Procedure
VTE Risk Assessment Tools

VTE Risk Assessment Exclusion Model
vs
Bleeding Risk Assessment Risk Assessment Models
Surgery & Pharmacologic Px
Select VTE Prophylaxis
157
Risk Factors VTE
VTE Levels of Risk
 Surgery  Selective estrogen receptor
 Trauma modulators
 Immobility, lower extremity  Erythropoiesis-stimulating Level of Risk Approximate DVT Risk without
paresis agents Prophylaxis %
 Cancer (active or occult)  Acute medical illness Low Risk < 10 %
 Cancer therapy (hormonal,  Inflammatory bowel disease Minor surgery, Mobile Patient
chemotherapy, angiogenesis,  Nephrotic Syndrome
inhibitors, radiotherapy)  Myeloproliferative disorders
Moderate Risk 10% to 40%
 Venous compression (tumor,  Paroxysmal nocturnal
Most general surgery, open GYN or
hematoma, arterial abnormality) Urologic procedures
hemoglobinuria
 Previous VTE  Obesity
 Increasing age  Central venous catheter High Risk 40% to 80%
 Pregnancy and the postpartum  Inherited or acquired Hip or Knee Arthroplasty, HFS,
period thrombophilia Major Trauma, SCI, Cancer
 Estrogen-containing oral
contraceptives or hormone
replacement therapy
Geerts, et al. CHEST 2008;133:381S-453S. Geerts, et al. CHEST 2008;133:381S-453S.
Caprini Risk Index

Caprini Score & Risk
Total Score Risk Level Incidence DVT
0-1 Low Risk 2%
2 Moderate Risk 10% - 20%
3-4 High Risk 20% - 40%
5 or more Highest Risk 40 – 80%
Rogers
Risk Assessment Rogers VTE Risk Assessment
 Operation other than  ASA Physical Status
endocrine Class
 Resp & hemic [9]  3, 4 or 5 [2]
 Thoracoabdominal  2 [1]
aneurysm, embolectomy
/thromboectomy, venous
 Female Gender [1]
reconstruction,  Work RVU
endovascular repair [ 7]  > 17 [3]
 Aneurysm [4]  10-17 [2]
 Mouth palate [4]
 Stomach, intestines [4]
 Integument [3]
 Hernia [2]
Rogers S, et al J Am Coll Surg 2007;204:1211-1221

Rogers S, et al J Am Coll Surg 2007;204:1211-1221
158
Rogers VTE Risk Assessment Rogers VTE Risk Assessment
 Two Points for each  One Point for each of  Zero points for each of
of these conditions these conditions these conditions
 Disseminated cancer  Wound class  ASA physical status
 Chemotherapy for (clean/contaminated) Class I
malignancy with 30  Preop Hematocrit  Work RVU < 10
days of surgery
 Preoperative Na >
< 38%  Male gender
145 mmol/L
 Preop Bilirubin
> 1 mg/dL
 Transfusion > 4U  Dyspnea
PRBCs in 72 hrs
prior to surgery  Albumin < 3.5 mg/dL
 Ventilator Dependent  Emergency
Rogers S, et al J Am Coll Surg 2007;204:1211-1221 Rogers S, et al J Am Coll Surg 2007;204:1211-1221
Rogers VTE Risk Assessment Rogers VTE Risk Assessment

Risk Score No Pts Predicted Actual
Level VTE % VTE %
Low <7 26,289 0.099 0.110
Moderate 7-10 37,569 0.502 0.474
High > 10 27,450 1.374 1.315
Rogers S, et al J Am Coll Surg 2007;204:1211-1221 Rogers S, et al J Am Coll Surg 2007;204:1211-1221
Caprini vs Rogers Risk Assessment Models

Actual VTE Rate Caprini & Rogers
 Populations studied varied or excluded
Risk Level Caprini Rogers groups
Low 0% 0.110 %  Did not differentiate Asymptomatic vs
Symptomatic VTE
Moderate 0.7% 0.474%
 Rogers not externally validated
High 0.97% 1.315%
 Implementation barriers
Highest 1.94% N/A
159
General Bleeding Risk Factors
 Active Bleeding
 Previous Major Bleeding
 Known or Untreated Bleeding Disorder
 Severe Renal or Hepatic Failure
Bleeding Risk  Thrombocytopenia
 Acute Stroke
 Uncontrolled Systemic Hypertension
 Lumbar Puncture, Epidural, Spinal Anesthesia
(previous 4 hrs or next 12 hrs)
 Concomitant use of anticoagulants, antiplatelet
agents, thrombolytics
Gould M, et al Chest 2012;141:227S-277S
Procedure Related Risk Factors Procedure Related Risk Factors

 Abdominal Surgery  Cardiac Surgery
 Male sex, preop Hgb < 13 g/dL, malignancy,  Use of ASA, Clopidogrel within 3 days of surgery
complex surgery defined as 2 or more
procedures, difficult dissection, more than one  BMI > 25 kg/m2, non-elective surgery, placement
anastomosis of 5 or my grafts, older age
 Pancreaticoduodenectomy  Older age, renal insufficiency, operation other
 Sepsis, pancreatic leak, sentinel bleed than CABG, longer bypass time
 Hepatic Resection  Thoracic Surgery

 Number of segments, concomitant extra hepatic  Pneumonectomy or extended resection
organ resection, primary liver malignancy, lower
preoperative hemoglobin level, low platelets
Gould M, et al Chest 2012;141:227S-277S Gould M, et al Chest 2012;141:227S-277S
Procedure Related
Severe Consequences of Bleeding
Jefferson Approach
 ACCP VTE Risk Guideline (Exclusion Model)
 Craniotomy  Low
 Spinal Surgery  Moderate
 Spinal Trauma  High
 Reconstructive procedures involving  Assess Bleeding Risk (ACCP Model)
free flaps
 CPOE System that requires all patients to be
risk assessed and VTE prophylaxis ordered
before remainder of order set can be
completed
160
Aspirin
7th ACCP Recommendation
For all patients we do not recommend
ASA for prophylaxis, because other
measures are more efficacious (1A)
Frequently Asked Questions 8th ACCP Recommendation

Recommend against the use of ASA as
prophylaxis against VTE in any patient
group (1A)
9th ACCP Recommendation

Recommend use of ASA as prophylaxis in
Orthopedic surgery. Better than NO Px
Mechanical Thromboprophylaxis
High-Risk surgery patients with multiple risk
factors, pharmacologic method combined with
mechanical method (2C)
High Bleeding Risk (1A), when bleeding risk

decreases substitute or add pharmacological
thromboprophylaxis (2C)
Mobile Mechanical Compression Mechanical DVT Prophylaxis

Total Hip Arthroplasty Medical Patients
Group No Pts DVT/PE Major Bleed  Advantages
 No bleeding risk 100 N=227
Mobile: IPC 199 pts 10 (5%) 0  Disadvantages 90
8 DVTs P=0.0004  Supportive data in 80
78
medical patients lacking
Compliance (%)
2 PEs (only ~200 studied) 70

Enoxaparin 196 10 (5%) 11 (6%)  Continuous application 60
48
necessary 50
8 DVTs
2 PEs
 Compliance problematic 40
30
Treatment Phase 14 days 20
Endpoint: 10-12 days Bilateral Lower Extremity US 10
Lovenox 30mg, Q12hrs until discharge then 40 mg Qday 0
Mobile: IPC 20 hrs per day with 60% receiving 81 mg ASA
ICU Floor
Colwell C, et al JBJS 2010;9:527-535 Comerota AJ, et al. Am J Surg. 1992;164:265-268.
161
IPC Use Intermittent Pneumatic Compression
Thomas Jefferson University Hospitals Use at TJUHs
No Yes
80
IPC Device on Patient Number Percent (%) 70
Percentage Use
No 250 73.75 % 60
All Patients Three shift x 4 days
50
Yes 89 26.25 % 40 74%
Total 339 100 % 30
20
26%
10
0
% Pts
All patients 7 th floor day and night shift x 4 days Gardiner D, Kelly B, Hosp Pract 2013
Combination VTE Prophylaxis

Jefferson Reason IPC Non-Use General Surgery
Reason Non-Use Number Percent %
Patient in Chair 17 6.77 % VTE Incidence Up to Day 10 9

Combined Modalities
8
No IPC devices in room 97 36.65 %
7 RR 0.31, 95% CI 0.12 - 0.69
Other reasons 2 0.80 % 6 P = 0.004
22/418
(%)
5
Patient out of room 9 3.59%
4
5.3%
Unknown 125 49.8 % 3 7/424
Patient refused 0 0 2
1 1.7%
Total 250 100 %
0
Fondaparinux Placebo
Major Bleeding
+ IPC + IPC
All patients 7th floor day and night shift x 4 days
Fond 1.6% vs Placebo 0.2%
Proximal DVT 0.2% vs 1.7% Turpie AG, et al. J Thromb Haemost. 2007;5:1854-1861
VTE Incidence
No Px & Surveillance
Surgery No Studies No Pts VTE 95% CI
Gen Surgery 54 4310 1084 (25%) 24%-26%

VTE Prophylaxis
Non-Orthopedic Surgery GYN Malignant 6 400 90 (22.5%) 19%-27%
GYN Benign 4 460 63 (14%) 11%-17%
Urology 11 469 159 (33%) 29%-38%
International Consensus, Intern Angiology 2013;32: 111-258
162
Guidelines 2102-2013 Guidelines 2102-2013
General Abdominal-Pelvic Surgery Px General Abdominal-Pelvic Surgery Px
High VTE Risk Moderate VTE Risk
Low BR High BR Low BR High BR
UFH LMWH IPC UFH LMWH IPC

[1B] [1B] Plus IPC [2B] [2B] [2C] IPC
[2C] [2C] [2C]
UFH LMWH

International Consensus, Inter Angiology 2013;32: 111-258 International Consensus, Inter Angiology 2013;32: 111-258
Guidelines 2102-2013 Guidelines 2012-2013

General Abdominal-Pelvic Surgery Px General Abdominal-Pelvic Surgery Px
Low VTE Risk Extended VTE Prophylaxis
IPC LBR HBR

[2C]
LMWH IPC or GES

[2B]

International Consensus, Inter Angiology 2013;32: 111-258 International Consensus, Inter Angiology 2013;32: 111-258
Extended VTE Prophylaxis

High-Risk Abdominal Surgery
Placebo Prophylaxis
18 16.3 RRR 55%
RRR 60%
16
Extended VTE 14
12
12
VTE (%)
Prophylaxis Cancer Surgery 10

7.3
8
6 4.8
4
2
0
ENOXACAN II (N=332) FAME (N=427)
Enoxaparin 40mg, Q24hrs x 30 days Dalteparin 5000 u, Q24hrs x 30 days
Bergqvist D, et al. N Engl J Med. 2002;346:975-980.

Rasmussen MS, et al. J Thromb Haemost. 2006;4:2384-2390.
163
CANBESURE Study
Abdominal & Pelvic Cancer Surgery
The @RISTOS Project
Clinical Outcomes After Cancer Surgery
4.0
Group No Pt VTE+Death RRR (95% CI)
3.5
Bemiparin 248 21 (8.5%) 36.5
VTE incidence (%)

3.0 2.83
(-6.9 – 62.3) 2.5

2.00
Placebo 240 32 (13.3%) 2.0
1.5
Major Bleeding Bemiparin 2 (0.6%) 1.0 0.87
Placebo 2 (0.6%)
0.5
0
General Gynecologic Urologic
surgery surgery surgery
Kakkar VV, et al J Thromb Haemost 2010;8:1223-1229 Agnelli G, et al. Ann Surg. 2006;243:89-95.
Surgical Cancer Patients Risk Factors for VTE in Cancer Surgery

@RISTOS Project
40% occur after discharge
12
@RISTOS Risk Factors VTE Odds Ratio 95% CI
10
Prospective Cohort Age >60 years 2.63 1.27-5.71
Previous VTE 5.98 2.13-16.80
Incidence of VTE
8
N = 2373
Advanced Cancer 2.68 1.37-5.24
6 Symptomatic VTE 2.1%
Anesthesia >2 hours 4.50 1.06-19.04
Overall Mortality 1.7%
4
Bed Rest >3 days 4.37 2.45-7.78
2
The Odds Ratio were the same for late VTE
0 46% due
1–5 5–10 11–15 16–20 21–25 25–30 >30
to fatal PE
Days post surgery
Agnelli G, et al Ann Surg 2006;243:89-95
Agnelli G, et al. Ann Surg. 2006;243:89-95.
Relative Risk From Time of Surgery VTE Following Surgery

Million Women Study Million Women Study
Weeks since Surgery

Sweetland et al, BMJ 2009;339:b4583 Sweetland et al, BMJ 2009;339:b4583
164
ACCP Guidelines 2008 Extended VTE Prophylaxis
Extended VTE Px Cancer Surgery Abdominal-Pelvic Cancer Surgery
 In Selected High-Risk General Surgery patients including those
who have undergone major cancer surgery, suggested post-
 High Risk patient undergoing abdominal or
hospital discharge prophylaxis with LWMH [2A] pelvic surgery for cancer who are not high
 Enoxaparin 40mg, SC, Q24hrs risk for major bleeding [1B]
 Dalteparin 5,000 IU, SC, Q24hrs
 Patients undergoing Gynecologic Cancer Surgery and who are  Extended prophylaxis 4 weeks with LMWH
>60 years of age or have previously experienced a VTE  Dalteparin 5,000 U, Q24 hrs
recommend continuing prophylaxis for 2 to 4 weeks [2C]  Enoxaparin 40 mg, Q24 hrs
 Enoxaparin 40mg every 24 hours
 Dalteparin 5000 IU every 24 hours

Geerts W, et al Chest 2008;133:381S-453S. International Consensus, Inter Angiology 2013;32: 111-258
VTE Incidence Guidelines 2012-2013

Neurosurgery, Multiple Trauma, Acute SCI
Surgery No No Pts VTE 95% CI
Neurosurgery
Studies
Neurosurg 6 330 77 (23%) 19%-28%

Non-Malignancy Malignancy
Multiple 4 536 270 (50%) 46%-55%

Trauma UFH LMWH IPC IPC Plus
[2C] [2C] [2C]
Spinal Cord Injury 9 458 160 (35%) 31%-39% UFH LMWH

[2C] [2C]

International Consensus, Inter Angiology 2013;32: 111-258
Guidelines 2102-2013
Trauma & Spinal Cord Injury
Moderate VTE Risk High VTE Risk #
Low BR High BR Low BR High BR
Plus IPC
UFH LMWH IPC IPC IPC
[2B] [2B] [2C] [2C] UFH LMWH [2C]
[2C] [2C]

International Consensus, Inter Angiology 2013;32: 111-258
165
166
DVT/PE Prophylaxis in the Surgical Disclosures
Patient II: The AAOS Guidelines and
the Orthopedist's Perspective
October 9-12, 2013
make regarding this
presentation.

Chief of Hip and Knee Division
Camden, NJ
©2011 MFMER | 3127551-1
DVT Facts 101

• 775,000 total joint replacements performed in • Historical data: 40-60% lower extremity total
U.S. yearly joint replacements will develop DVT (Venogram
• Revision cases are increasing in an Positive) or PE without chemoprophylaxis
accelerated pace • Without prophylaxis but with early mobilization
• Over 65 population projected to double from 35 and modern TJR surgical techniques, risk of
million to 72 million by 2030 symptomatic DVT reduced to 4.3%
• Hospitalist/Joint surgeons are in high demand • With chemoprophylaxis added, rate reduced
0.7-1.5% within 35 days of TJR
• Need for dedicated orthopaedic hospitalist
• Fatal PE risk equals 0.1-0.5% regardless of
drug agent used
Mechanical Agents for DVT

Prophylaxis
Agents Used for Chemoprophylaxis
• Dextran • TEDS compression stockings below knee
• Adjusted dosed Heparin • Calf/foot pumps: sequential, graded
compression
• Aspirin (81mg/325mg) BID
• Sterile compression pumps on operated limb
• Coumadin (WARFarin)
• Ankle dorsiflexion exercises in bed
• Low molecular weight Heparins
• Early mobilization post-op day 1
• Factor Xa inhibitors
• Leg elevation
• Oral rivaroxaban (Xarelto)
• Avoidance of prolonged sitting
167
Bleeding Risk
• Joint replacement involves aggressive

reaming, cutting, and drilling of
vascular bone and soft tissues
• Any significant manipulation of
coagulation pathways may create
wound or GI bleeding events
Effects on TJR with Excessive

Wound Bleeding/Hematoma
• Risk of Infection (Human Petri Dish)
• Decrease in range of motion
• Pain
• Increase in Transfusion Risk
• Decrease Patient Satisfaction (bleeding trail in
bed/room/hall)
• Delays patient discharge
Balance Evolution of Clinical Practice

Guidelines (CPG)
Efficacy vs Safety • SCIP (Surgical Care Improvement Project) 2006
DVT Risk Minimize • “DVT prophylaxis ordered according to current
guidelines and given within 24 hours after
bleeding risk surgery”
• Clinical Practice Guidelines
• AAOS 2007
• risk stratification to prevent SYMPTOMATIC
PE and wound bleeding
• Graded recommendations presented with
aspirin included as a sole agent
• Strategies to reduce bleeding risk
emphasized
168
Evolution of Clinical Practice Evolution of Clinical Practice
Guidelines (CPG) Guidelines (CPG)
“The Grand Merger”
• AACP 2004, 2008
• Focus on choosing best prophylactic agent • AAOS 2011/AACP 2012
in preventing ASYMPTOMATIC DVT, ASA • Both guidelines emphasize balancing efficacy and
safety for the selection of DVT prophylactic agents
not included
• AAOS emphasis on prevention of symptomatic
• No consideration for bleeding risk DVT
• Recommendations based on randomized • AACP 2012 CPG includes aspirin and some newer
drug trials (mostly pharmaceutical funded) agents, but unlike the 2008 CPG, does not offer
specific dosage protocol
Evolution of Clinical Practice

Guidelines (CPG) The Battle of the Mighty Aspirin Tablet
• CMS (Center for Medicare and Medicaid • Joint Surgeon/Hospitalist vs “The Quality
Services) 2006 Measures Committee”
• Mandated quality measures for hospital care
with SCIP guidelines, ASA not included
• Present SCIP measure based on outdated
2004, 2008 AACP guideline, ASA not
indicated for quality measure
• January 2014 – projected updated SCIP
guidelines to include aspirin as sole agent
(finally!)
“Note to self…” AAOS Guideline 2011

• “…there is a high risk • Use drug agent and/or mechanical agent;
of bleeding however no specific recommendations are given
associated with this for “best drug” or duration of use
TJR surgery and I
have chosen aspirin • Assess patient for known bleeding disorder or
as the DVT active liver disease
prophylactic agent” • No need for routine use of post-op duplex
ultrasound screening for DVT
• Mobilize patient early and often
169
AAOS Guideline 2011 AAOS 2011 Clinical Practice Guideline
• Use neuraxial anesthesia: decreases blood • Balance risk of bleeding with symptomatic DVT
loss prophylaxis
• Questions use of IVC filters • Encourage orthopaedic surgeons to engage in
• Discontinue anti-platelet agents perioperatively discussion of DVT strategy with patient,
(aspirin/plavix) hospitalist, internist, cardiologist, and
hematologist
• For patients with high risk of bleeding use
mechanical compression devices, drug agents?
• Patient with prior DVT, use drug agent and
mechanical compression device
How I Manage DVT/Bleeding Risk

How I Manage DVT/Bleeding Risk
• Pre-op risk assessment with office consultation
questionnaire given by nurse/student and • Office consultation (Continued)
personally reviewed by surgeon • Estrogen replacement
• “Have you or any blood relative ever had a • Smoking history and suggest smoking cessation
DVT/PE?” program
• Explain if the event was provoked or • Morbid/super-morbid obesity (ability for post-op
rehab?)
otherwise? recurrent? IVC filter? • Lymphedema/pretibial edema (vascular consult,
• Thrombophilic disorder? compression stockings, and diuretics)
• Anemia – correct if present • Bleeding disorders (von Willebrand Disease, ITP,
Thrombocytopenia, Liver Disease, Hepatitis C, HIV)
• Diabetes – Obtain A1c Hemoglobin • Coronary Artery Disease/Stents
• History of Lupus/AVN • Baby aspirin through surgery, stop Plavix 10
days pre-op
Day of Surgery
Drug Agents • Holding area
• Aspirin 325 mg po bid (90% of my practice) • Apply below knee stockings
• OR
• Lovenox (renal dosed)
• Regional block (not indwelling epidural pain catheter)
• Xarelto (rivaroxaban) • Foot mechanical pumps – sterile compression boot with
sterile tubing
• Coumadin
• Measure twice, cut once!
• Lovenox bridged with Coumadin
• Limit TKR tourniquet time/limit leg rotation during THR to
• Aspirin, add Plavix with baby aspirin 10 days avoid kinking of the femoral vein
post-op • IV toradol with aspirin DVT prophylaxis
• Do not use IV toradol with Lovenox/Coumadin/Factor Xa
Inhibitors because risk of bleeding
170
No Toradol for you! PACU
“Your bed is your exercise mat!”
• Patient instructed to do quad sets and ankle

pumps in the recovery room
Lovenox, Coumadin, DVT prophylaxis
Floor to Discharge Post-Discharge Regimen

All hospital patients receive multi-modal
• Comfortable compression stockings below
knee comfort protocol (celebrex/IV toradol (if on
aspirin)/IV acetaminophen, TKR-FNB x2 days
• Leg elevation with anesthesia head pillow or Liposomal bupivacaine
• Bed exercises posted on foot of bed • If aspirin: 325 mg EC bid x4-6 weeks
• Foot mechanical pumps continuous in bed and • If lovenox: renal dosing, start morning after
sitting on side of bed surgery q 12 hours or once daily for 2-3
• No sitting more than 45 minutes out of bed or hospital days, then 10-12 days home/SNIF,
on side of bed then aspirin 325 mg EC x2-4 weeks
Post-Discharge Regimen Things That Go Bump in the Night

• Anesthesia/Hospitalist/Non-Joint Team
• If rivaroxaban: 10 mg po daily, start 6AM Member gives Toradol/NSAID other than
POD#1 through hospital stay, then 10-12 days Celebrex
at home/SNIF, then aspirin x2-4 weeks • COMMUNICATE!!
• If coumadin: 5 mg 9PM night of surgery, titrate • Medical Team adds ASA for coronary risk to
to INR of 2.0-2.3. Lovenox bridge with renal Coumadin/Lovenox regimen
dosing started 6AM morning after surgery. • Failure to anticoagulate within 24 hours of
Stop lovenox when INR reaches 1.6 surgical event
• Failure to plan rational, safe AAOS guidelines
• EMR medication hold errors – computer glitch
©2011 MFMER | 3127551-29
171
Things That Go Bump in the Night
• Post-op TJR specific order set not employed
• Surgeon/Nursing/Medicine Service overlooks
(missing) anticoagulation order
• Voluminous discharge instructions for home or
SNIF unit
• “Was I supposed to be taking aspirin after I
left the hospital?”
Thank you!
©2011 MFMER | 3127551-31
172
Ask: Why receiving antiplatelet agents???
• Primary prevention
Perioperative Management of Antiplatelet
Agents in Cardiac Patients • Secondary prevention: with or without
revascularization
An Overview of Perioperative Medicine • Aspirin, Clopidogrel, Ticagrelor, Prasugrel
October 2013 • Post stent
• Post CVA
Howard Weitz, M.D.
Case 1 Case 1
• 65 year old man for dental extraction. • You advise:

• Inferior wall MI 5 years ago. Underwent coronary
angiography and found to have occluded RCA. No A. stop aspirin 2 weeks prior to dental extraction
intervention done.
B. stop aspirin 1 week prior to dental extraction
• Hypertension, hyperlipidemia
C. stop aspirin 5 days prior to dental extraction
• Meds: beta blocker, ace-I, aspirin 81 mg daily
D. do not stop aspirin prior to dental extraction
• Dentist wishes to stop aspirin 2 weeks prior to dental
extraction.
Case 1
• You advise:
A. stop aspirin 2 weeks prior to dental extraction

B. stop aspirin 1 week prior to dental extraction
C. stop aspirin 5 days prior to dental extraction
D. do not stop aspirin prior to dental extraction

Warfarin and Low dose aspirin (100 mg/d
173

Warfarin
Low dose aspirin (100 mg/d)
“The weight of evidence in the dental literature does not

1support the long-held belief that an oral anticoagulant regimen
must be altered or discontinued before most dental procedures,
including oral surgery.”
“Currently the INR does not require alteration of the therapy

regimen unless the INR value is greater than 4.0, provided
that local hemostatic measures are used.”
ASA withdrawl
“Articles that document oral surgery experiences of patients assoc with 3- fold
taking aspirin alone or in combination with clopidogrel have not higher risk of
major cardiac event
reported any cases of unusual intraoperative or postoperative
bleeding problems. This experience is anecdotal.”
Perioperative aspirin use
• Minimal evidence re: bleeding

• Minimal evidence re: safety
• Surgery site specific issues (neurosurgery, prostate)
• Primary prevention: no evidence that asa cessation a
problem (stop 5-7 days pre-op)
• Secondary prevention: continue aspirin if possible

85 year old man

Cardiac cath post NSTEMI 11 months ago
left colectomy
• NSTEMI 11 months ago
• Diabetes (insulin), Cr 2.1
• Hgb 10.8 at time of NSTEMI
• Cath
– 95% proximal LAD stenosis
– No other significant cad
– PTCA of LAD: Drug eluting stent
174
85 year old man
PTCA post NSTEMI 11 months ago
left colectomy
• Presents now with fatigue
• Stool heme (+)
• Hgb 9.2, Hgb A1C 12, Cr 2.1
• Colonoscopy without biopsy reveals
fungating mass left colon
What is best approach at this time?
We have been requested to assess him for • A. Stop asa + clopidogrel and perform
surgery. colonoscopic biopsy
Our concerns relate to: • B. Consult with GI and see if they can perform
colonoscopic bx on asa + clop
a. Management of his antiplatelet therapy in
• C. Consult with GI and see if they can perform
the peri-colonoscopy period biopsy on asa
b.Management of his antiplatelet therapy in
• D. Consult with surgery and see if they can
perform colectomy on asa
the perioperative period
• E. Wait 1 month, then approach off asa-
clopidogrel
The Problem: Balancing the risk of hemorrhage vs.

stent thrombosis
September 14, 2006: FDA initial warning

December 7,8 2006: Circulatory Systems Device Advisory
Panel Hearings
January 4, 2007: FDA online announcement of package

insert revision.
Optimal duration of antiplatelet
therapy (especially clopidogrel) is
12 months for patients at low risk of
bleeding.
175
Society for Cardiovascular Angiography Clinical Alert, Jan 2007
Society for Cardiovascular Angiography Clinical Alert, Jan 2007
Joint Advisory Recommendations and Joint Advisory Recommendations and

Noncardiac Surgery Noncardiac Surgery
 Consider bare metal stent if patient requires PCI and is  Defer elective procedures for which there is bleeding risk
likely to require invasive or surgical procedure within until completion of antiplatelet course
next 12 months.  1 month bare metal stent (risk increased for up to 90 days)
 Educate patient prior to discharge re: risk of premature  12 months drug eluting stent
antiplatelet discontinuation.  For patient with drug eluting stent who are to undergo
 Instruct patient to contact treating cardiologist before procedures that mandate discontinuation of
antiplatelet discontinuation thienopyridine (eg, clopidogrel), continue aspirin if at all
 Healthcare providers who perform surgical or invasive possible and restart thienopyridine as soon as possible
procedures must be made aware of catastrophic risks of  No evidence for “bridging therapy” with antithrombins,
premature antiplatelet discontinuation and should warfarin, or glycoprotein IIb/IIIa agents
contact the treating cardiologist to discuss optimal
management strategy
Figure. Flow chart to determine the risk of stent thrombosis.
Risk Factors for Stent Thrombosis
• Advanced age
• Diabetes mellitus
• Multivessel cad
• Stent placed in setting of acute coronary syndrome
• Stent
– Bifurcation lesion
– Stent placed to treat in-stent restenosis
– Multiple stents
– Small stent dia
– Stent malposition or underexpansion
– LAD
Riddell J W et al. Circulation 2007;116:e378-e382
Copyright © American Heart Association
176
Risk Factors for Stent Thrombosis
• *Advanced age
• *Diabetes mellitus
• *Renal insufficiency
• Multivessel cad
• *Stent placed in setting of acute coronary syndrome
• Stent
– Bifurcation lesion
– Stent placed to treat in-stent restenosis
– Multiple stents
– Small stent dia
– Stent malposition or underexpansion
– *LAD
JACC White Paper
• Retrospective evidence that aspirin does not

increase post polypectomy bleeding
• No evidence to aid in estimation of risk of
endoscopic biopsy bleeding on clopidogrel or
aspirin + clopidogrel
J Gastro Endos 2002
2002 Guideline on the Management of

anticoagulation and antiplatelet therapy for
endoscopic procedures
• In the absence of pre-existing bleeding

disorders endoscopic procedures may be
performed on patients taking aspirin and
NSAIDs in standard doses.
• Colonoscopy with biopsy is a low risk

procedure
J Gastro Endos 2005
177
J Gastrointest Endos 2009
J Gastrointest Endos, 2009
178
Can we get by with short term antiplatelet
discontinuation?
• Eisenberg , MJ Circ 2009:119:1634-42
J Gastro Endos 2009
Eisenberg MJ, Circulation 2009 Our patient
Time to stent • Multiple risks for stent thrombosis

thrombosis
• High risk of hemorrhage colonoscopic biopsy
Stop ASA, stop thienopyridine Median 7 d
Continue ASA, stop thienopyridine Median 122 d

(6% within 10 d)
What happened Case
• Biopsy done 12 months post stent Resection of a large symptomatic meningioma

– Clopidogrel discontinued 5 days prior
– Aspirin continued because of multiple risks for stent thrombosis 80 years old
– Adenocarcinoma multivessel coronary artery disease
1989: triple vessel coronary artery bypass as treatment
of refractory angina.
– Partial colectomy
– Aspirin continued
– No bleeding
179
Case Case
Recurrent angina last year led to repeat Following cath his medical antianginal regimen was
catheterization. Cath revealed: maximized.
1. left internal mammary artery bypass that was anastomosed He feels well and only has angina if he over exerts.
to the left anterior descending was patent but the distal lad was He can predict this and for 6 months has been able to
diffusely diseased and not thought amenable to intervention.
take prophylactic nitroglycerine to prevent episodes.
Episodes have been infrequent and he has been
2. vein graft to the right coronary artery was occluded and
the right coronary artery was diffusely diseased and not stable. He is unable to climb one flight of stairs due
amenable to intervention. to severe degenerative joint disease.
3. Vein graft to the circumflex was occluded and the

circumflex diffusly disease and not amenable to intervention.
Case Case
He has chronic renal insufficiency (analgesic related ) Cr. 2.2 He is going to neurosurgery. Regarding his
aspirin you recommend
Medications: metoprolol 100 mg po twice daily, lisinopril 20
mg daily, aspirin 325 mg daily, nitroglycerine
Bp 105/70 HR 58
A. Continue aspirin in the perioperative period
Exam unremarkable. B. Discontinue aspirin in the perioperative period
C. Discuss with the neurosurgeon and recommend
ECG: Normal sinus rhythm. Old diaphragmatic infarct.
Unchanged from prior ecg that aspirin be continued if at all possible
D. Pharmacologic stress test
E. None of the above
Will results of stress test change management?

Case
(Would a positive stress test change management?)
He is going to neurosurgery. Regarding his • He has diffuse coronary artery disease felt not amenable
aspirin you recommend to repeat revascularization 1 year ago
• He has chronic stable angina

B. Discontinue aspirin in the perioperative period
• Surgery is not elective
that aspirin be continued if at all possible
180
How about his aspirin in the perioperative How about his aspirin ?
period ?
1236 ACS admissions
51 within 1 month after

ASA withdrawl
10 BMS thrombosis
28 related to procedures
ACS 10 days post ASA

475 previously stable pts admitted with MI
11 had discontinued ASA 9.5 days prior to MI
How about his aspirin ?

What would the neurosurgeon say? Bleeding Risk Associated With Different Surgical Procedures With
Regard to Antiplatelet Therapies
Majority of neurosurgeons
require ASA stopped
7.3 days preop
O'Riordan, J. M. et al. Arch Surg 2009;144:69-76.
Copyright restrictions may apply.
181
Chassot PG, et al. Br J Anaesth 2007;99:316-28 Chassot PG, et al. Br J Anaesth 2007;99:316-28
182
Post MI Antiplatelet Rx
• BMS: min 4 weeks, ideal 12 months

• DES: min 12 months
• Thrombolytic rx: up tp 12 months

• No reperfusion -or- intervention:
– Prior to 2011: ASA
– 2011: ASA + second antiplatelet (ticagrelor or prasugrel
rather than clopidogrel)
– 2012 ASA + (clopidogrel or ticagrelor)
Antiplatelet agents in cardiac patients in the

perioperative period
• Balancing risk of hemorrhage vs. thrombosis vs. delay

surgery
• Minimal data re: surgery specific bleeding risk
• Small amount of blood in a closed space is bad
• All stent situations are not alike. What is the patient’s
risk for stent thrombosis
• Stented patient: Perform surgery on at least aspirin if at
all possible
• BMS patient probably at increased risk of stent
thrombosis for up to 90 days (ESC and Cardiac Society of
Australia and New Zealand Guideline)
• Very late DES thrombosis does occur
• Its not just stents
183
Case
He is going to surgery. Regarding his

aspirin you recommend

B. Discontinue aspirin in the perioperative period
that aspirin be continued if at all possible
184
Disclosure
Relevant Financial Relationships
None
Clinical Short: How do I manage
patients who are DNR going to Off-Label/Investigational Uses
None
surgery?
Molly Feely MD
Learning Objectives Mrs. L

• Patient is a 97 y.o. female with multiple medical
comorbidities
• Clarify the ethics of DNR in the
perioperative setting • ESRD on HD thrice weekly
• HTN, hypothyroidism, DJD
• Define the dilemma that of managing
DNR patients perioperatively • Functional status is impaired
• Lives in assisted living
• Propose a framework for • Family present daily to assist in ADL’s
preparedness planning • Family or MOW provides all meals
• Ambulatory with a walker
Which of the following statements is true? Which of the following statements is true?
A. An institutional policy requiring full code status A. An institutional policy requiring full code status
for surgery is ethically sound for surgery is ethically sound
B. Medical personnel may ethically rescind her B. Medical personnel may ethically rescind her
DNR status for emergency surgery DNR status for emergency surgery
C. It makes no ethical sense to be DNR and C. It makes no ethical sense to be DNR and
have surgery have surgery
D. All available guidelines recommend a D. All available guidelines recommend a
discussion with the patient or surrogate re- discussion with the patient or surrogate re-
examining wishes regarding resuscitation in examining wishes regarding resuscitation in
the perioperative period the perioperative period
185
The ethics
The Dilemma
• Patient autonomy
• Dying of disease or dying of iatrogenic
• Patient right to self-determination intervention?
• Patient right to refuse • Resuscitation is more successful in the OR
• DNR does not mean “do not treat” • Patients who are DNR have increased mortality
• Ethics vs morality post-operatively
• “failure to rescue”
• Reflected in all guidelines
• what is the definition of “success”
• ACS
• ASA
• AORN
Preparedness Planning
• Attempts to define “success” and “failure”
• Aligns expectations
• Establishing goals of care for a specific intervention
• “What are you hoping this surgery will do for
So, what should we do with patients you?”
who are DNR and need surgery? • “What would you want us to know if things didn’t
go as well as we hope?”
• “What’s the worst thing that could happen from
this surgery?”
• “XXX is a likely complication from this surgery.
How should we address XXX if it happens to
you?”
Preparedness Planning Back to Mrs. L

• Once goals of care are established, the rest • Patient is a 97 y.o. female with multiple medical
flows easily comorbidities
• Able to negotiate care decisions that align • ESRD on HD thrice weekly
with goals • HTN, hypothyroidism, DJD
• Make recommendations • Functional status is impaired
• May avoid the smorgasbord of options • Lives in assisted living
• Family present daily to assist in ADL’s
• Family or MOW provides all meals
• Ambulatory with a walker
186
Mrs. L Take Home Points
• Presents to ER with abdominal pain • It is ethically permissible to be DNR in the OR
• CT shows ruptured AAA • Preparedness planning is a way to align
expectations going forward
• Patient is DNR
• Negotiate care decisions based on goals of
care
187
188
Disclosures
• Relevant Financial Relationships
Perioperative Management of Warfarin • NONE
• Off Label Usage

• Low molecular weight heparins for bridging
therapy

Paul Daniels, M.D., FACP
daniels.paul@mayo.edu
Assistant Professor of Medicine
Mayo Thrombophilia Center
©2011 MFMER | 3127551-2
Objectives
Goal 1. Recognize when bridging therapy is

recommended
2. Estimate post-procedure bleeding risk
Provide a framework for managing a patient’s when anticoagulation used
warfarin anticoagulation around the time of an 3. Demonstrate an approach to
invasive procedure anticoagulation dosing and timing in
bridging situations
©2011 MFMER | 3127551-3 ©2011 MFMER | 3127551-4
INR
Heparin Bridge
3.0
Definition of Bridging Therapy

2.0 (2.5)
• Substitution of another anticoagulant (typically

heparin) when warfarin is interrupted for an 1.0
invasive procedure
Warfarin Stop Warfarin Restart

TIME
PROCEDURE
©2011 MFMER | 3127551-5 ©2011 MFMER | 3127551-6
189
Warfarin Interruption for Invasive Approach to Bridging Therapy:
Procedures Three Key Questions
• IF NO BRIDGING GIVEN:
• There will be 7 – 10 day window of time without
therapeutic anticoagulation 1. Need to stop warfarin?
• Bridging therapy minimizes the window 2. Need bridging therapy?
• Thrombotic risk related to underlying indication for 3. How and when to restart anticoagulation after
anticoagulation and the “prothrombotic” surgical state
a procedure?
• Thromboembolism in 1%
• Preoperative management is the easy part
• Bridging therapy can contribute to risk of perioperative
bleeding complications
• Bleeding rates about 2 – 3X thrombosis rates
©2011 MFMER | 3127551-7 ©2011 MFMER | 3127551-8
QUESTION 1: QUESTION 2:
Need to Stop Warfarin? Need to Give Bridging Therapy?
• Some procedures can be done without • American College of Chest Physicians (ACCP)
stopping or with INR at low end of target range 2012 Guidelines on Antithrombotic and
• Examples: Thrombolytic Therapy
• EMG, Cataract surgery, Dental surgery • Guidelines for atrial fibrillation, mechanical
heart valves, and venous thromboembolism
• QI opportunity
• Establish what level INR acceptable for • Risk strata with annual thrombosis risk
different procedures and standardize • Low: < 5%
• Moderate: 5 – 10%
• High: > 10%
Chest 2012; 141(2) (Suppl):e326S – e350S

©2011 MFMER | 3127551-9 ©2011 MFMER | 3127551-10
The CHADS2 Score:

71 year old woman taking warfarin due to atrial fibrillation has Risk of Stroke in Atrial Fibrillation Without
hypertension and type 2 diabetes mellitus; she had a stroke 8 Anticoagulation
years ago.
Adjusted Stroke Rate
Score N (per 100 patient-years)
She has no history of congestive heart failure or rheumatic heart
disease. • One point each 0 120 1.9
•CHF
She has been diagnosed with breast cancer and will undergo a •HTN 1 463 2.8
mastectomy. 2 523 4.0
•Age > 75
Would you give this patient bridging therapy? •DM 3 337 5.9
• Two points 4 220 8.5
1. YES •Stroke 5 65 12.5
2. NO 6 5 18.2
Gage et al, JAMA. 2001;285:2864-2870

©2011 MFMER | 3127551-11 ©2011 MFMER | 3127551-12
190
ACCP Risk Stratification 2012:
Bridging Therapy for Atrial Fibrillation Mayo Clinic Thrombophilia:
Bridging Therapy for Atrial Fibrillation
Bridging
Risk level Characteristics
therapy? Risk Bridging
Characteristics
level therapy?
Any one of the following:
Any one of the following:
• CHADS score 5 or 6
High YES • CHADS score 4 - 6
• Recent (within 3 months) stroke or TIA
• Rheumatic valvular heart disease High • Previous cardioembolic stroke or TIA YES
• Intracardiac thrombus
Moderate CHADS 3 or 4 YES • Rheumatic valvular heart disease
CHADS score 0 – 3
CHADS 0 – 2 Low NO
Low NO (and no history of cardioembolic stroke/TIA)
(no history of stroke or TIA)
Chest 2012; 141(2) (Suppl):e326S – e350S Wysokinski et al. Mayo Clinic Proc. June 2008;83(6): 639-645
©2011 MFMER | 3127551-14
Influence of the Perioperative State on

Back to the patient Stroke Risk
• If average stroke incidence in non-valvular atrial
• CHF = 0 fibrillation = 4.5 per 100 person-years
• Hypertension = 1 • Estimated risk in one week off warfarin = 0.1%
• Age > 75 = 0 Stroke rate – within 30 days of procedure
Adjusted
• Diabetes mellitus = 1 Chronic AFib NO AFib
Odds Ratio
• Stroke history = 2 (N= 69,202) (N= 2,470,649)
(95% CI)
• CHADS2 Score = 4 YES TO BRIDGING 2.1
All Cases 1.8 % 0.6 %
(2.0-2.3)
Cardiovascular and Neurosurgery procedures highest risk
Kaatz et al. J Thromb Haemost. 2010;8: 884-890

©2011 MFMER | 3127551-15 ©2011 MFMER | 3127551-16
ACCP Risk Stratification 2012:

Bridging Therapy for Venous Thromboembolism
66 year old man taking warfarin for a history of deep vein Bridging
heparin?
thrombosis and pulmonary embolism ten years ago that was
“unprovoked”; he has not had any recurrent thrombotic events. One of the following:
High •Recent (within 3 months) VTE YES
He now has rectal adenocarcinoma and is scheduled for
rectosigmoid colon resection. •“Severe” thrombophilia
One of the following:
Would you give this patient bridging therapy? •VTE within past 3 to 12 months
Moderate
•“Nonsevere” thrombophilia (Factor V Leiden OR YES
prothrombin gene heterozygote)
1. YES •Recurrent VTE
2. NO •Active cancer (treated in last 6 months or palliative)
Single VTE > 12 months ago and no additional risk
Low NO
factors
Chest 2012; 141(2) (Suppl):e326S – e350S

©2011 MFMER | 3127551-17
191
Mayo Clinic Thrombophilia:
Bridging Therapy for Venous
“Severe” Thrombophilia – a la ACCP
Thromboembolism (VTE)
Risk Bridging
level
Characteristics
therapy? • Protein C or S deficiency
One of the following:

• Antithrombin deficiency
• Recent (within 6 months) VTE • Anti-phospholipid antibodies
High YES
• “Severe” thrombophilia • Multiple defects or homozygous Factor V Leiden
• Active cancer or cancer treatment or Prothrombin 20210 gene mutation
Last VTE event > 6 months ago and no

Low NO
additional risk factors
McBane et al. Arterioscler Thromb Vasc Biol. June 2010;30: 442-448 Chest June 2008 133:6 suppl 299S – 339S
©2011 MFMER | 3127551-19 ©2011 MFMER | 3127551-20
Back to the patient

• Recent VTE? NO
• Thrombophilia? Unknown
• Recurrent VTE? NO
• Active cancer? YES
• Risk of thromboembolism = moderate – high

• YES TO BRIDGING
©2011 MFMER | 3127551-21
Thrombosis Risk of Mechanical Heart Valves

72 year old man with a bileaflet mechanical aortic valve due to
Without Anticoagulation calcific aortic stenosis.
CHARACTERISTIC LOWER RISK HIGHER RISK He has atrial fibrillation but no prior thromboembolism,
rheumatic heart disease or congestive heart failure.
Number of Valves Single Multiple He is scheduled for a total hip arthroplasty for degenerative joint
disease.
Position of Valve Aortic Mitral
Would you give this patient bridging therapy?
Type of Valve Bi-leaflet Tilting disk & Caged-ball

1. YES
Atrial fibrillation, low 2. NO
Other - ejection fraction, prior
embolism
Cannegieter SC et al. Circulation. 1994;89:635-641

©2011 MFMER | 3127551-23 ©2011 MFMER | 3127551-24
192
ACCP Risk Stratification 2012: Mayo Clinic Thrombophilia:
Bridging Therapy for Mechanical Heart Valves
Bridging Therapy for Mechanical Heart Valves
Bridging (MHV)
heparin?
Risk Bridging
•Any mitral MHV Characteristics
level therapy?
High •Caged-ball or tilting disk aortic MHV YES
• Any mitral MHV
•Recent (within 6 months) stroke or TIA
• Older (caged-ball or tilting disk) aortic
MHV
Aortic bileaflet MHV and any one of the following: High YES
Moderate YES
• History of cardioembolic stroke or TIA
•Atrial fibrillation, Prior stroke or TIA, HTN, DM,
Age > 75 yrs • Aortic bileaflet AND atrial fibrillation or
CHF
Low
Aortic bileaflet MHV without AFib and no additional
NO Aortic bileaflet MHV without atrial fibrillation
risk factors Low NO
or CHF
Daniels et al. Thrombosis Research. 2009;124: 300-305
©2011 MFMER | 3127551-26
PRE PROCEDURE MANAGEMENT

Back to the patient For those requiring warfarin interruption
• Number of MHV = 1
• WARFARIN:
• Position of MHV = Aortic
• stop 5 days before procedure
• Type of MHV = Bileaflet
• BRIDGING THERAPY (If given):
• Other conditions = Atrial fibrillation • Start Heparin when INR below goal range
• Discontinue unfractionated heparin (UFH) 4 to
6 hours before procedure
• Risk of thromboembolism = moderate
• Last dose of low molecular weight heparin
• YES TO BRIDGING (LMWH) given 24 hours before procedure
Chest 2012; 141(2) (Suppl):e326S – e350S

©2011 MFMER | 3127551-27 ©2011 MFMER | 3127551-28
QUESTION 3:
Pre-Procedure Low Molecular Weight How and when to restart anticoagulation
Heparin (LMWH) Dosing for Bridging after a procedure?
• Start LMWH when INR below goal range • Balance:

• Thrombosis risk of patient/procedure
• Dalteparin 200 IU / kg every 24 hrs
• VERSUS bleeding risk related to procedure and patient
• Enoxaparin 1 mg / kg SC every 12 hrs characteristics
• Last dose of LMWH 24 hours prior to procedure
• Dalteparin 100 IU / kg SC • Utility of moderate vs high thrombosis risk distinction
• Guides how “aggressively” you will give anticoagulation
• Enoxaparin 1 mg / kg SC postprocedure
©2011 MFMER | 3127551-29 ©2011 MFMER | 3127551-30
193
Risk of Post-Procedure Bleeding: Risk of Post-Procedure Bleeding:
PROSPECT Study Experience With Bridging PROSPECT Study Experience With Bridging
• 260 patients with AF or VTE Major Bleeding while on
Procedure (N)
Enoxaparin + 24 hrs (%)
• Warfarin stopped for:
• invasive procedure Invasive procedure
0.7
• minor surgery (148)
• or major surgery (≥ 1 hour duration) Minor Surgery
0.0
• Resumed warfarin night of procedure (72)
• Enoxaparin started 12-24 hours post-procedure Major Surgery
20.0
(dose = 1.5 mg/kg SC daily) – given until (40)
therapeutic on warfarin
Dunn et al. J Thromb Haemost 2007;5: 2211-2218 Dunn et al. J Thromb Haemost 2007;5: 2211-2218
©2011 MFMER | 3127551-31 ©2011 MFMER | 3127551-32
Study of a Stratified Approach to Post-Procedure

Bridging
How to Assess Post-Procedure Bleeding
Risk? • EXCLUSION CRITERIA
• INCLUSION CRITERIA
• Adults (≥ 18) • Creatinine > 2.0 mg/dL
Procedure related factors • Previous HIT
• Taking warfarin
• MHV, AF, Stroke/TIA • Pregnant
Patient related factors (embolic) • Treated with AC other than
• Undergoing invasive LMWH
procedure • Minor dental procedure
• Urgent/emergent surgery
• Indwelling epidural catheter
after spinal anesthesia
Douketis et al. Arch Intern Med. 2004;164:1319-1326
©2011 MFMER | 3127551-33 ©2011 MFMER | 3127551-34
Treatment Strategy
Classifying Bleeding Risk Of Procedures Bleeding Risk of
Procedure
Pre-Procedure Post-Procedure
1. Cardiovascular surgery
• Valve replacement, CABG, AAA Dalteparin
repair High No Dalteparin
100 IU/kg SC BID
2. Cancer surgery
High Risk • Neurosurgery, Urology, ENT, Breast Dalteparin Dalteparin
3. Intra-abdominal surgery Non-High
100 IU/kg SC BID 100 IU/kg SC BID
4. Other
• Bilateral TKA, laminectomy, TURP, • Coumadin
kidney biopsy • Stopped 5-6 days pre-procedure
• Started back when patient could take oral medication
Non-High Risk All others
• Outcomes (assessed within 14 days):
• thromboembolism, major bleeding, wound related blood loss
Douketis et al. Arch Intern Med. 2004;164:1319-1326 Douketis et al. Arch Intern Med. 2004;164:1319-1326
©2011 MFMER | 3127551-35 ©2011 MFMER | 3127551-36
194
% with outcome in each group Predictors of major bleeding in peri-
Non-High High procedural anticoagulation management
Outcome Bleeding Bleeding
Risk Risk All • Mayo Thrombophilia Center Registry
(N = 542) (N = 108) • Retrospective cohort from 1997 – 2007
Thromboembolism • 2182 patients seen for anticoagulation
0.37 1.85 0.62 management recommendations for 2484
(including possible) procedures
Major Bleeds 0.74 1.85 0.92
• 1496 patients given bridging therapy
• Major bleeding rates
Increased Wound
5.9 NA NA • 3% of bridged patients
Blood Loss
• 1% of those not bridged
Douketis et al. Arch Intern Med. 2004;164:1319-1326 Tafur et al. J Thromb Haemost 2012;10:261-7.
©2011 MFMER | 3127551-37 ©2011 MFMER | 3127551-38
Predictors of major bleeding in peri- Strategy for Post-Procedure Management

procedural anticoagulation management WHEN BLEEDING RISK IS LOW
Resume
Risk factor Hazard ratio
Warfarin
Heparin given within 24 hours post 1.9
procedure (among those bridged) when safe
Previous bleeding history 2.6
Mitral mechanical valve 2.2
Active cancer 1.8

Full Dose Bridging:
Wait 24 hours before
Platelet count < 150,000 2.3
starting
Tafur et al. J Thromb Haemost 2012;10:261-7. Chest June 2008 133:6 suppl 299S – 339S
©2011 MFMER | 3127551-39 ©2011 MFMER | 3127551-40
Possible Strategies for Post-Procedure

Management Low Dose Versus Full Dose Bridging
WHEN BLEEDING RISK IS HIGH Heparin
Resume • “Low dose”
Warfarin • Thromboprophylaxis dosing of LMWH or UFH
when safe
• Example: Dalteparin 5000 units SC daily OR
Enoxaparin 40 mg SC daily
Low Dose • Not specifically studied
Full Dose
No Bridging Bridging
Bridging • “Full dose”
(prophylaxis dose)
• “Therapeutic” bridging – treatment doses
• Dalteparin 200 IU / kg every 24 hrs
• Enoxaparin 1 mg / kg SC every 12 hrs
Starting 24 hours Wait 48-72 hours
after procedure before starting
Chest June 2008 133:6 suppl 299S – 339S

©2011 MFMER | 3127551-41 ©2011 MFMER | 3127551-42
195
71 year old woman taking warfarin due to atrial Bleeding risk assessment
fibrillation has a CHADS score = 4.
• Type of surgery: Cancer surgery, general surgery
By ACCP – MODERATE Thrombosis Risk
• Mechanical mitral valve: NA
Want to give bridging. • Active cancer: Present
Patient will undergo a mastectomy. • Thrombocytopenia: No
Assess post-operative bleeding risk and recommend a • TWO BLEEDING RISK FACTORS PRESENT
strategy for anticoagulation management.
©2011 MFMER | 3127551-43 ©2011 MFMER | 3127551-44
Possible Strategies for Post-Procedure

Management Comparing UFH and LMWH for Bridging:
WHEN BLEEDING RISK IS HIGH The REGIMEN Registry
Resume
Warfarin • Multicenter observational study
when safe
• All on oral anticoagulation for ≥ 3 months;
needing interruption for procedure
Low Dose
Full Dose • Patients with MHV, AFib, and VTE
No Bridging Bridging
Bridging
(prophylaxis dose) • Heparin bridging used Pre and/or Post
Procedure for at least 2 days
• Compared safety and efficacy of UFH vs
Starting 24 hours Wait 48-72 hours LMWH as bridging anticoagulants
after procedure before starting
Chest June 2008 133:6 suppl 299S – 339S Spyropoulos et al. J Thromb Haemost 2006;4: 1246-1252.
©2011 MFMER | 3127551-45 ©2011 MFMER | 3127551-46
N (%) with outcome in each group

OUTCOME UFH LMWH Low Molecular Weight Heparin:
Dosing According to Renal Function
(N = 164) (N = 668)
Arterial
4 (2.4) 4 (0.6) Calculated creatinine
Thromboembolism Dose adjustment
clearance (mL / minute)
Venous
0 (0.0) 2 (0.3)
Thromboembolism
> 30 None
Major bleed 9 (5.5) 22 (3.3)
Minor bleed 15 (9.1) 80 (12.0)
20 – 30 Decrease by 50%
Death 2 (1.2) 4 (0.6)
Length of Stay (d) 10.3 4.6 Avoid LMWH
< 20
Use unfractionated heparin
Days of heparin 6.8 8.6
Spyropoulos et al. J Thromb Haemost 2006;4: 1246-1252. Nutescu et al. Ann Pharamcother 2009;43: 1064-1083.
©2011 MFMER | 3127551-47 ©2011 MFMER | 3127551-48
196
Putting it Together:
Post Procedure Warfarin Dosing Identify the patients who do not require bridging
•CHADS = 0 - 3
• We often resume at the dose patient was stable on Atrial fibrillation •AND no stroke/TIA history, intra-
pre-procedure cardiac thrombus or rheumatic heart
disease
• CAUTION: •Last event > 6 months ago
• patients may be more sensitive to warfarin after a Venous
thromboembolism •AND no cancer or “severe”
procedure (e.g. NPO, antibiotics) so may need a thrombophilia
lower dose at re-initiation – do require close
•Aortic position only, bileaflet
monitoring of INR Mechanical heart
valve •AND no history of thromboembolism
or atrial fibrillation
©2011 MFMER | 3127551-49 ©2011 MFMER | 3127551-50
Putting it Together:
Post-Procedure Management
Thrombosis
Warfarin Heparins
Risk Level
When
LOW Not used – No Bridging
safe
Low Bleeding Risk:
•Full bridging 24 hrs post
When High Bleeding Risk:
HIGH
safe •Full bridging 48 – 72 hrs post
•OR low dose bridging
•OR no bridging
©2011 MFMER | 3127551-51
197
198
Disclosure
Financial Relationships
Geno J. Merli, MD, MACP, FHM, FSVM
Perioperative Management
 Bayer: Research, Scientific Advisory
 Bristol-Meyer Squibb: Research, Scientific
New Oral Anticoagulants Advisory
Geno J Merli, MD, MACP, FHM, FSVM
 Sanofi-Aventis: Research, Scientific
Professor Medicine & Surgery Advisory
Co-Director Jefferson Vascular Center
Chief Medical Officer  Portola: Research
geno.merli@jefferson.edu
Common Pathway
New Oral Agents

Apixaban Xa
Xa
Rivaroxaban Blocker
New Agents Oral Anticoagulants Dabigatran
Prothrombin Thrombin
Clot
Fibrinogen Fibrin
Key Points Laboratory Testing New Oral Agents

New Oral Anticoagulants
Lab
Useful Dabigatran Rivaroxaban Apixaban
Key Points Dabigatran Rivaroxaban Apixaban Lab Test
Tests
Target IIa Xa Xa
Strong ECT Chromogenic Chromogenic
anti-Xa Anti -Xa
Half-Life 12-17 hrs 7-11 hrs 12 hrs
TT aPTT, PT
Clearance 80% renal 60% Renal 25% Renal
33% Liver 75% Liver
Protein 35% > 90% 87% aPTT
Binding
Dialyzable Yes No No
Weak PT / INR
Chromogenic Assay not yet available

Erikkson BI, et al. Clin Pharmacokinet 2009;48:1-22.
Galanis T et al Thromb Thrombolysis 2011;31:310-320 Jefferson assessing HEMOCLOT
Palladino M et al A J Hem 2012;87 Suppl:S127-S132
199
Dabigatran Rivaroxaban
Pre-procedural Management Pre-Procedural Management
Stable CrCl T1/2 D/C time D/C time
(ml/min) (range, hrs) before minor before major Stable CrCl Rivaroxaban D/C Time D/C Time
procedure procedure or (ml/min) t1/2 before before
epidural (hours) minor major
procedure procedure
> 80 13 (11-22) 36 hours 4 days or epidural
> 50 8 24 hours 48 hours
50 -79 15 (13 – 24) 48 hours 4 days
30 - 49 16 (13 – 23) 3 days 5 days 15 - 49 9 - 10 48 hours 48 – 72
hours
< 30 27 (22 – 35) At least 5 days prior
*Check PTT
TJUH Guidelines for use 2012. TJUH Guidelines for use 2012.
Apixaban
Pre-Procedural Management
Minor Procedure* Major Procedure*

24 hrs 48 hrs
1. Not studied in severe renal (CrCl < 15 ml/min) or hepatic impairment.

Cases
2. Elimination may be slower in elderly patients (>80 yr), weight (< 60 kg) or
Scr > 1.5 mg/dl.
3. Consider stopping earlier in patients with one or more of these
characteristics undergoing procedures associated with a high rate of
bleeding
4. Half-life 12 hrs
TJUH Guidelines for use 2012.
Case 1 Case 1
 68 year old woman is scheduled with non-valvular  When should dabigatran be
atrial fibrillation on dabigatran is scheduled for
hysterectomy for maligancy in 1 week. discontinued prior to the elective
 PMHx: Non-Valvular Afib, HBP, HL, No Stroke or TIA,
hysterectomy ?
No HF
 Meds: Dabigatran 150mg, BID, atorvastatin 20mg,
HCTZ 12.5mg, atenolol 50mg
 PE: BP 122/78, P 78, R 12, BMI 27
 68 yr old, well nourished, hispanic, female
 S1 and S2 normal, irregular-irregular rate 78
 Remainder examination normal
 Labs: CrCl 60 ml/min, Hgb 12.2, HCT 37, Plt 200k, INR
1, PTT 32s
200
CHADS2 CHADS2
CHF, HBP, Age, DM, Stroke, TIA CHF, HBP, Age, DM, Stroke, TIA
CHADS2 Stroke Risk NRAF Stroke Treatment
Medical Condition Assigned Score Rate (per 1.2 yrs)
Points 0 Low 1.9 Option ASA
History of stroke or TIA 2 1 Low 2.8 ASA-W-D-R
Hypertension 1 2 Moderate 4.0 W-D-R
3 Moderate 5.9 W-D-R
Diabetes Mellitus 1
4 High 8.5 W-D-R
Presence of congestive heart failure 1
5 High 12.5 W-D-R
Age 75 years or older 1
6 High 18.2 W-D-R
Our Patient HBP = 1 point

W = warfarin
D = dabigatran Gage BF et al. JAMA 2001;285:2864-2870
Gage BF et al. JAMA 2001;285:2864-2870
R = Rivaroxaban You J et al, Chest 2012;141(2):e531S-e575S
Discontinuation Dabigatran
ACCP Guidelines 2012 CrCl & Half-life
 In patients with atrial fibrillation at low CrCL Dabigatran t ½ D/C Minor D/C Major
risk for thromboembolism, suggest NO hrs Procedure Procedure,
epidural, spinal
Bridging [2C] > 80 13 (11-22) 1.5 days 4 days
> 50 to < 80 15 (13-24) 2 days 4 days
>30 to < 50 18 (13-23) 3 days 5 days
< 30 27 (22-35) 4 days 5 days
CrCl 60 ml/min = Dabigatran ½ life 15 hrs, Major procedure

Stop 4 days prior to procedure
Douketis J, et al Chest 2012;141:e326S-e350S
Case 1
Discontinuation Rivaroxaban
Surgery
CrCl & Half-life
Hysterectomy
Stable CrCl Rivaroxaban Discontinuation time

t ½ Hrs before major
Dabigatran VTE Px
procedure/epidural 4 days 1. LMWH
> 50 mL/min 8 hrs 2 days 2. UFH
3. IPC + above
15 – 49 9-10 hrs 3 days
mL/min
CrCl 60 ml/min = Rivaroxaban ½ life 8 hrs,
Major procedure Restart
Assess renal function to plan dosing
Dabigatran 150mg, BID 1st post discharge day
201
Case 1
ACCP Guidelines 2012
Surgery Dabigatran at Afib dose
Hysterectomy Most likely effective VTE
Extended Px
 In patients with atrial fibrillation at low
risk for thromboembolism, suggest NO
Bridging [2C]
Dabigatran VTE Px  Patients requiring VTE prophylaxis
4 days 1. LMWH other than dabigatran, start UFH,
2. UFH
3. IPC + above LMWH, plus-minus IPCs for duration of
prophylaxis then resume these agents
post discharge day one. [Jefferson
Approach]
Restart
Assess renal function to plan dosing
Dabigatran 150mg, BID 1st post discharge day Douketis J, et al Chest 2012;141:e326S-e350S
Case 2 Case 2
 75 yr old woman scheduled for right TKA in  PE: BP 120/80, P 74, R 12, Wt 80 kg
two weeks. The patient has non-valvular  72 yr old overweight, white, female
atrial fibrillation being treated with atenolol  Heart Irregular-Irregular, no murmurs
and rivaroxaban.
 Abdomen: No organ enlargement
 Meds: atenolol 25 mg, rivaroxaban 20mg,  Right knee: + knee effusion, pain ROM
furosemide 40mg, Insulin
 PMHx: HBP, Afib, Hx TIA 5yrs ago, HF NY II  Labs: Cr 1.2, CrCl 62 ml/min
(compensated EF 35%), Diabetes (insulin)
Case 1
 How would you manage rivaroxaban in
the perioperative period in patient
undergoing right TKA ?
Step 1
202
CHADS2 CHADS2
CHF, HBP, Age, DM, Stroke, TIA CHF, HBP, Age, DM, Stroke, TIA
Medical Condition Assigned Score Rate (per 1.2 yrs)
Points 0 Low 1.9 Option ASA
History of stroke or TIA 2 1 Low 2.8 ASA-W-D-R-A
Hypertension 1 2 Moderate 4.0 W-D-R-A
3 Moderate 5.9 W-D-R-A
Diabetes Mellitus 1
4 High 8.5 W-D-R-A
5 High 12.5 W-D-R-A
6 High 18.2 W-D-R-A
Pt = TIA, HBP, DM, HF, Age 75 [6 points]
Gage BF et al. JAMA 2001;285:2864-2870 Gage BF et al. JAMA 2001;285:2864-2870

You J et al, Chest 2012;141(2):e531S-e575S
ACCP Guidelines 2012 Discontinuation Rivaroxaban

CrCl & Half-life
 In patients with Atrial Fibrillation at High Risk
for thromboembolism, suggest Bridging
Anticoagulation during interruption of Stable CrCl Rivaroxaban Discontinuation time
warfarin therapy [2C] t ½ Hrs before major
 Jefferson Approach: substitute rivaroxaban procedure/epidural
and follow the Bridging Anticoagulation > 50 mL/min 8 hrs 2 days
protocol 15 – 49 9-10 hrs 3 days
mL/min
CrCl 62 ml/min = Rivaroxaban ½ life 8 hrs,
Major procedure
Case 2 Case 2
Surgery Surgery
Right TKA Right TKA
Preop Day 3 2 1 Preop Day 3 2 1
Stop Stop
Rivaroxaban VTE Prophylaxis Rivaroxaban VTE Prophylaxis
1. Warfarin 1. LMWH
Enoxaparin Enoxaparin
2. IPC + above 2. UFH
80 mg, Q12hrs 80 mg, Q12hrs
3. IPC + above
Start 1800 hrs Start 1800 hrs
Stop Stop
Enoxaparin after Warfarin Enoxaparin after Stop LMWH, UFH
Morning Dose Continue dosing to target Morning Dose after AM dose day prior
INR of 2 to 3 for 4-6 wks, to discharge then
Then convert to Rivaroxaban start Rivaroxaban that
evening prior to D/C
203
Case 2
Surgery ACCP Guidelines 2012
Right TKA
 In patients receiving Bridging
Preop Day 3 2 1
Anticoagulation with therapeutic LMWH and
undergoing a high-bleeding risk surgery,
Stop
Rivaroxaban
suggest resuming therapeutic-dose LMWH
VTE Prophylaxis
1. Rivaroxaban 10mg 48 to 72 hr after surgery instead of resuming
Enoxaparin
80 mg, Q12hrs
4. IPC + above within 24 hrs postop. [2C]
Start 1800 hrs
 If the patient cannot restart full dose LMWH
Stop because of bleeding risk then continue VTE
Enoxaparin after Rivaroxaban prophylaxis and reassess patient. [Jefferson
Morning Dose Continue 10 mg dosing,
Post discharge day 1
Approach]
Change dose to 20 mg
Case 3 Case
 Pt is a 64 yr old man undergoing right TKA. His  How should rivaroxaban be managed
orthopedic surgeon would like to use rivaroxaban for
VTE prophylaxis because of the patient’s PMHx of with spinal anesthesia in the
DVT after a femoral fracture in skiing accident. postoperative period?
 PMHx: HBP, HL
 Meds: Atenolol 50mg, HCTZ 12.5 mg, atorvastatin
20mg, Qday
 PE: BP132/82, P 66, R 12, BMI 29
 Lungs clear without crackles
 Heart regular rhythm, S1 and S2 normal
 Right knee effusion, decrease ROM
 Labs: normal
Black Box Warning Black Box Warning

Rivaroxaban Rivaroxaban
 Epidural or Spinal Hematoma
 Use of epidural catheter
 Concomitant use of NSAID, Anti-platelet
 Traumatic or repeated spinal puncture
 History of spinal deformity
204
Dosing Rivaroxaban
Epidural Catheters Case 4
Remove
Epidural  Patient is a 62 yr old woman admitted with small
> 18 hrs from bowel obstruction. The patient is on rivaroxaban for
Surgery 10 AM Last dose
Riva
stroke prevention for non-valvular atrial fibrillation.
8AM Leave PACU
Medical consultation is requested for managing the
patient’s anticoagulation.
 PMHx: A-Fib, HBP
Epidural
Placed Riva 10 mg Start Riva  ROS: no HF, no Stroke/TIA, no DM
6-8 hrs postop
4 PM – 6 PM
6 hrs after
Epidural
 Meds: Rivaroxaban 20 mg, Qday, amlodipine 5 mg,
Removed NKA medications
Half-Life 7 – 11 hrs
Case 4 Case 4
 PE: BP 134/78, P 78, R 12, Wt 68 kg
 Patient is a 62 year old, well nourished, white, female.
 Is there any withdrawal risk for stroke
 Lungs clear after stopping rivaroxaban abruptly?
 Heart irregular, irregular rate 78, no murmurs
 Abdomen distended, absent bowel sounds, no rebound, N/G
tube in place
 Labs: CrCl 68 ml/min, WBC 12 K, no shift, Plts 200K,
INR 0.9, Ptt 32 sec, H& H normal, Obstruction Series
Positive small bowel obstruction
Black Box Warning CHADS2

Rivaroxaban CHF, HBP, Age, DM, Stroke, TIA
Medical Condition Assigned

Points
History of stroke or TIA 2
Hypertension 1
Diabetes Mellitus 1
Our Pt = HBP [1 points]
Gage BF et al. JAMA 2001;285:2864-2870
205
CHADS2 ROCKET AF
CHF, HBP, Age, DM, Stroke, TIA
Score Rate (per 1.2 yrs)
0 Low 1.9 Option ASA
1 Low 2.8 ASA-W-D-R
4 High 8.5 W-D-R-A
5 High 12.5 W-D-R-A Black Box Warning
6 High 18.2 W-D-R-A 1. Discontinuing Rivaroxaban increases thrombotic
events
2. After Discontinuing Rivaroxaban start alternative
anticoagulant
Gage BF et al. JAMA 2001;285:2864-2870
You J et al, Chest 2012;141(2):e531S-e575S Patel M et al, NEJM 2011;365:883-891
Rocket AF Study
Group Riva Warfarin HR P value
Temporary 6.2 (9) 5.05 (8) 1.28 0.62

Interruption 0.49-3.31
Permanent 25.6 (42) 23.28 (36) 1.10 0.66

Discontinuation 0.71-1.72
After end of study 6.42 (22) 1.73 (6) 3.72 0.004

1.51-9.16
All 11.2 (73) 7.57 (50) 1.5 0.026

Discontinuation + 1.05-2.15
End of study
Patel M, et al JACC 2013;61:651-658 Patel M, et al JACC 2013;61:651-658
Rocket AF Study
Case 4
Warfarin 81%
 Patient has low CHADS2 Score [1]
Cumulative Proportion with INR > 2
 No Bridging will be needed

 Because of low CHADS2 Score, would
49% discuss with orthopedic surgery using
Rivaroxaban
rivaroxaban 10 mg as VTE prophylaxis then
increase the dose back to 20 mg after 2
weeks.
Days after Last Dose at End of Study
Patel M, et al JACC 2013;61:651-658
206
Case 5 Case 5
 Patient is a 68 yr old man scheduled for  Are patients using dabigatran at risk for
left total hip replacement surgery. acute coronary syndrome with atrial
fibrillation in the post joint replacement
surgery period ?
Dabigatran compared to control

(warfarin, enoxaparin, placebo)
1. Increased absolute risk of MI or ACS 0.27%

7 Clinical Trials Evaluated 2. Increased relative risk of MI or ACS 33%
2 Stroke Prophylaxis in Atrial Fibrillation
1 Acute Venous Thromboembolism
1 Acute Coronary Syndrome
3 VTE Prophylaxis Joint Replacement Surgery
Uchino K, et al Arch Intern Med 2012;172:397-402 Uchino K, et al Arch Intern Med 2012;172:397-402
Dabigatran & ACS Events

Orthopedic Surgery
ACS Events Dabi 150 mg Dabi 220 mg Enoxaparin

Adjudicated (2665) (2611) (2639)
MI 1 1 5
Unstable 1 0 0
Angina
Cardiac Death 0 0 3
Total Definite 2 (0.8) 1 (0.04) 7 (0.27)

ACS
Conclusion: No ACS signal identified
Eriksson B, et al Thromb Res 2012;130:396-402 Eriksson B, et al Thromb Res 2012;130:396-402
207
Case 6 Case 6
 The patient is an 66 yr old man  Pt was discharged on rivaroxaban for
 PMHx: HBP, DM, HL VTE prophylaxis for 30 days.
 Meds: rivaroxaban 10mg, Qday, amlodipine,  On the 16 day postop day the patient
glucophage complained of dizziness and near
 PE: BP 128/88, P 80, R 12, BMI 28 syncope.
 Labs: PT 11 sec, INR 0.9, PTT 28 sec, Plts  At PCP orthostatic, stool heme +,
271K, Cr 1.2, CrCl 72 ml/min testing then sent to ED
 CBC: Hgb 5.8, HCT 17.3
 PT/INR: 23 sec/2.16
Case 6 Laboratory Testing New Oral Agents
 How would you manage the prolonged Lab

Useful Dabigatran Rivaroxaban Apixaban
PT/INR ? Tests Lab Test
Strong ECT Chromogenic Chromogenic
anti-Xa Anti -Xa
TT aPTT, PT
aPTT
Weak PT / INR
Palladino M et al A J Hem 2012;87 Suppl:S127-S132
Prothrombin Time
Placebo
PCC
COFACT (Prothrombin Complex Concentrate)

1. Non-activated PCC
2. Factor II, VII, IX, X
3. Protein C, S, ATIII Rivaroxaban PCC or Placebo
20 mg BID
4. 50 IU PCC/kg dosing
Eerenberg E, et al Circulation 2011;124:1573-1579 Eerenberg E, et al Circulation 2011;124:1573-1579
208
GI Bleed
Four Factor vs Three Factor PCC Rivaroxaban
PTT
Rivaroxaban Reversal PT/INR
Abnormal
Agent Reduction PT (sec)

Normal Hemodynamic Status Impaired Hemodynamic Status
Beriplex (50 IU/kg) 2.5 sec – 3.5 sec

Transfuse Transfuse
Profilnine (50 IU/kg) 0.6 – 1.0 sec PCC
50 IU/kg PCC PCC PRBC
over 5-10 minutes
Rivaroxaban 20mg, BID x 4 days
30 minute following infusion effect noted
Recheck: CBC, PT/INR & PTT Recheck: CBC, PT/INR & PTT
Re-Evaluate Re-Evaluate
Levi M, et al Abstract ISTH July 2013
209
210
Disclosure
Perioperative Management of the

• Esai Pharmaceuticals, Philips –
Investigator/Grant Support
Patient with Liver Disease
• Off-label Drug Usage – none

William Sanchez, MD
Division of Gastroenterology and Hepatology, Mayo Clinic
©2011 MFMER | 3127551-1 ©2011 MFMER | 3127551-2
Learning Objectives Background

• Review the pre-operative assessment of • Incidence and prevalence rates of chronic liver disease
patients with chronic liver disease (CLD) continue to climb
• 3 Million HCV-infected patients in the USA with a
• Identify patients with liver disease who are at growing proportion developing cirrhosis
high risk for post-operative morbidity and • Prevalence of NASH continues to increase with the
mortality following surgery obesity epidemic
• Review the appropriate timing of referral for • An increasing proportion of cirrhotics will not be
transplant evaluation candidates for LT and will need to be managed in the
community setting
• Identify common pitfalls in the post-operative • Patients with CLD utilize significant health care
management of cirrhotic patients resources (largely hospital care)
©2011 MFMER | 3127551-3 ©2011 MFMER | 3127551-4
Preoperative Assessment
of the Patient with Chronic Liver Disease Case #1
• History and Physical exam are critical You are asked to see a 46 year old female with autoimmune
hepatitis who is scheduled for excision of a indeterminant breast
• Detailed alcohol use history lump. She is not currently on therapy for her hepatitis.
• CBC (platelets > 50K) Pre-op labs: ALT 540 U/L, AST 428 U/L. INR, Bilirubin and
Albumin are normal. No ascites on exam.
• Thrombocytopenia suggests portal HTN When would you recommend surgery?
• Liver labs (includes bilirubin and albumin) A.Right away
• Prothrombin time (< 1.5 INR) B.ALT and AST <5X ULN
C.ALT and AST <2X ULN
• Creatinine, electrolytes
D.After 8 weeks of prednisone therapy
• Abdominal US E.Not a surgical candidate
©2011 MFMER | 3127551-5 ©2011 MFMER | 3127551-6
211
Acute Acute
Acute Injury
Case #1 Bronchitis Hepatitis
You are asked to see a 46 year old female with autoimmune

hepatitis who is scheduled for excision of a suspicious breast Chronic Injury Chronic Chronic
lump. She is not currently on therapy for hepatitis. (Reversible) Bronchitis Hepatitis
Pre-op labs: ALT 340 U/L, AST 228 U/L. INR, Bilirubin and
Albumin are normal. No ascites on exam.
When would you recommend surgery? Chronic Injury
Cirrhosis
(Irreversible) Emphysema
A.Right away (Compensated)
B.ALT and AST <5X ULN
C.ALT and AST <2X ULN Organ Failure O2 Dependent Decompensated
D.After 8 weeks of prednisone therapy (End Stage) Emphysema Cirrhosis*
E.Not a surgical candidate

* Any of the following: Jaundice, Ascites, Encephalopathy, Variceal Bleeding
©2011 MFMER | 3127551-7 ©2011 MFMER | 3127551-8
Acute & Chronic Hepatitis and Surgery Viral Hepatitis

• When possible, the underlying cause of hepatitis should • Hepatitis A is usually severe but self limiting
be treated prior to elective surgery
• Postpone elective surgery until resolved
• Ability to treat depends on underlying disorder
• Increased mortality for patients with acute hepatitis who • Hepatitis B (with active hepatitis)
undergo surgery (10-30%) • Start rapid acting oral antivirals (e.g.,
• Severe hepatitis (patient jaundiced) should be tenofovir)
considered a contraindication to elective surgery • Postpone elective surgery until AST/ALT <
• In general, postpone elective surgery until AST/ALT < 2x ULN
2x ULN, INR & Bilirubin normal • Chronic inactive carriers (normal LFTs): not
a contraindication to surgery
©2011 MFMER | 3127551-9 ©2011 MFMER | 3127551-10
Viral Hepatitis (cont) Autoimmune Hepatitis

• Hepatitis C • Patients with active disease (untreated or acute
• Common disease: over 3 million chronically flare) should be treated with immuno-
infected persons in the USA suppressive Rx prior to elective surgery
• HCV Rx duration 6-12 months • Usually rapid response (days to few weeks)
to steroid Rx
• Not reasonable to postpone even the
most elective surgery • Postpone elective surgery until AST/ALT <
2x
• Proceed with surgery irrespective of
AST/ALT (unless decompensated cirrhosis) • No contraindication to surgery for inactive or
controlled disease (unless decompensated
cirrhosis)
©2011 MFMER | 3127551-11 ©2011 MFMER | 3127551-12
212
Alcoholic Hepatitis Non-Alcoholic Fatty Liver Disease
• Very high mortality rate from illness and very • Increasingly common
high peri-operative mortality rate (> 30%) • Ranges from simple steatosis to steatohepatitis with
• Important to distinguish between alcoholic cirrhosis
hepatitis (sick) and alcoholic steatosis (not • Unsuspected cirrhosis in 4%
sick) • PO risk from obesity, diabetes and CV disease
• Recommend abstinence > 12 weeks prior to • Need to identify cirrhotics due to further increase in
elective surgery risk
• Resolution of jaundice required • No effective Rx besides control of metabolic syndrome

• Proceed with surgery irrespective of AST/ALT (unless
• Watch-out for AWS! decompensated cirrhosis)
©2011 MFMER | 3127551-13 ©2011 MFMER | 3127551-14
Case #2 Case #2
69 year old female with obesity, diabetes and 69 year old female with obesity, diabetes and
cirrhosis due to NASH has symptomatic DJD cirrhosis due to NASH has symptomatic DJD
and wants knee replacement. CTP score is 6, and wants knee replacement. CTP score is 6,
MELD 7. What do you recommend? MELD 7. What do you recommend?
A.Proceed with surgery A.Proceed with surgery
B.Surgical risk prohibitive B.Surgical risk prohibitive
C.Transjugular portosystemic shunt (TIPS) C.Transjugular portosystemic shunt (TIPS)
prior to surgery prior to surgery
D.Liver transplant evaluation D.Liver transplant evaluation
©2011 MFMER | 3127551-15 ©2011 MFMER | 3127551-16
Case #3 Case #3
60 year old male with NASH cirrhosis, diabetes 60 year old male with NASH cirrhosis, diabetes
has severe aortic valve stenosis. Dyspnea with has severe aortic valve stenosis. Dyspnea with
minimal exertion, no CHF. Moderate ascites minimal exertion, no CHF. Moderate ascites
present. CTP score is 8, MELD 17. What do present. CTP score is 8, MELD 17. What do
you recommend? you recommend?
A.Proceed with surgery A.Proceed with surgery
B.Surgical risk prohibitive B.Surgical risk prohibitive
C.Transjugular portosystemic shunt (TIPS) prior to C.Transjugular portosystemic shunt (TIPS) prior to
surgery surgery
D.Liver transplant evaluation D.Liver transplant evaluation
©2011 MFMER | 3127551-17 ©2011 MFMER | 3127551-18
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Cirrhosis and Surgery: CTP Classification Child-Turcotte-Pugh Classification
Parameter 1 2 3
Encephalopathy None Stage 1-2 Stage 3-4
Ascites Nil Slight-Mod Mod-Severe
Operative Mortality (%)
76%
80 Bilirubin
70
-Cholestatic <4 4-10 >10
60
50 -Non-Cholestatic <2 2-3 >3
40 Albumin >3.5 2.8-3.5 <2.8
30
31%
INR <1.7 1.7-2.3 >2.3
20
10
10%
0
Score CTP Class
Child's A Child's B Child's C
5-7 A
8-10 B
11-15 C
From Garrison, et al. Ann Surg 1984; 199:648-55.

©2011 MFMER | 3127551-19 ©2011 MFMER | 3127551-20
MELD Related Post-Operative Survival What is the MELD Score?

0-5
100 6-10 • (Mayo) Model for End-Stage Liver Disease
11-15
80 16-20 • Reliably predicts short-term (3 month) liver-
Survival (%)
21-25
related mortality
26-30
60
P<0.001
• Because of this now used for allocating
40
donor organs
• Complex equation but incorporates simple
20
laboratory values
0 • INR, total bilirubin and creatinine
0 1 2 3 4 5 6 7 8 9 10
Time after surgery or diagnosis (yr)
CP1216495-4
Teh SH, et al. Gastro 2007;132(4)

©2011 MFMER | 3127551-21 ©2011 MFMER | 3127551-22
Postoperative Mortality (%) in Relation to

Web-based MELD Calculator MELD Score
MELD 7 Day 30 Day 90 Day
0-5 (n=163) 0.6% 3.2% 7.1%
6-10 (N=392) 2.8% 8.6% 13.9%
11-15 (N=159) 7.2% 21.9% 30.6%
16-20 (N=35) 14.6% 44.0% 55.8%
21-25 (N=10) 22.2% 55.6% 66.7%
≥26 (N=8) 25.0% 87.5% 87.5%
Mortality is independent of type of procedure (GI, hepatobiliary,

orthopedic or cardiac), or whether the procedure is emergency
once ASA, MELD, and age are factored in.
http://www.mayoclinic.org/meld/mayomodel6.html
Teh SH, et al. Gastro 2007;132(4)
©2011 MFMER | 3127551-23 ©2011 MFMER | 3127551-24
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Caput Medusae, Umbilical Hernia, Ascites
Decompensated Cirrhotics Have a
Prohibitively High Perioperative Mortality
Rate
Defer All Non-emergent Surgery Until

Consultation with Hepatology
©2011 MFMER | 3127551-25 ©2011 MFMER | 3127551-26
©2011 MFMER | 3127551-27 ©2011 MFMER | 3127551-28
©2011 MFMER | 3127551-29 ©2011 MFMER | 3127551-30
215
In Decompensated Cirrhosis Open
Abdominal Surgery is Fraught with
Complications
Consult with Hepatology and Pursue

Minimally Invasive Procedures When
Possible
©2011 MFMER | 3127551-31 ©2011 MFMER | 3127551-32
Role of TIPS prior to surgery Transplant Referral

• Not recommended by AASLD-NIH consensus, • Patients with decompensated liver disease
AASLD practice guideline should be referred for transplant evaluation
prior to elective surgery
• Case reports of usefulness in abdominal
surgery, renal transplantation • Salvage transplant in patients who
decompensate following elective surgery
• Esophageal varices may resolve in 3 months
• Difficult if not impossible if patient has not
• Gastric varices seldom resolve been evaluated as LT candidate beforehand
• No data to support perioperative use • Defer elective surgery in decompensated
patients
©2011 MFMER | 3127551-33 ©2011 MFMER | 3127551-34
Case #4
55 year old alcoholic male is S/P emergent repair of
Patients with Advanced Liver Disease* ruptured umbilical hernia. Intraoperative course
Should Be Evaluated For Transplantation notable for hemorrhage. You are asked to see
persistent regarding worsening ascites output,
PRIOR to Elective Surgery encephalopathy and jaundice. You recommend:
A.TIPS
B.Steroids for alcoholic hepatitis
C.EGD to screen for esophageal varices
D.Discontinue ketorolac
*in the absence of major comorbidities
that would preclude LT (eg, metastatic
carcinoma)
©2011 MFMER | 3127551-35 ©2011 MFMER | 3127551-36
216
Cirrhosis and Surgery
Case #4 Postoperative Problems
55 year old alcoholic male is S/P emergent repair of • Mortality • Sepsis
ruptured umbilical hernia. Intraoperative course
notable for hemorrhage. You are asked to see • Liver failure • Ascites
persistent regarding worsening ascites output,
encephalopathy and jaundice. You recommend: • Hepatic • Wound dehiscence
encephalopathy
A.TIPS • Hypoxemia
B.Steroids for alcoholic hepatitis • Renal failure
• ? Hypoglycemia or
C.EGD to screen for esophageal varices • Coagulopathy hyperglycemia
D.Discontinue ketorolac
• Cholestasis
©2011 MFMER | 3127551-37 ©2011 MFMER | 3127551-38
Cirrhosis and Surgery Cirrhosis and Surgery

Postoperative Problems Common Management Pitfalls
• Organ failure
SEPSIS! • Often driven by infection – screen aggressively
• This means tapping ascites to look for SBP
• Ascites
• Sodium restriction often overlooked, be aware of IV
saline
• Albumin preferred volume expander
• Hepatic Encephalopathy
Multi-Organ Failure • Delayed clearance of sedative/hypnotics and
narcotic analgesics
• Aggravated by narcotic induced constipation
©2011 MFMER | 3127551-39 ©2011 MFMER | 3127551-40
Cirrhosis and Surgery

Common Management Pitfalls Take Home Points
• Cholestasis • Surgery in patients with liver disease requires a
• Often multifactorial (infection, antibiotics, TPN) major team effort
• TPN is a frequent contributing factor
• Surgery most safe if MELD < 8
• Transition to enteral feeds ASAP
• Renal Failure
• Consider completing transplant evaluation before
surgery in patients with MELD 12-20+
• Impaired renal function sensitive to NSAIDS
• Ketorolac (Toradol) often used as an analgesic • Avoid surgery in patients with decompensated
cirrhosis – involve hepatology (the earlier the
• Coagulopathy better)
• Often aggravated by broad-spectrum antibiotics and
vitamin K deficiency • Watch the patient like a hawk post-operatively –
the surgeon needs you!
• Replace Vitamin K parenterally (SQ)
©2011 MFMER | 3127551-41 ©2011 MFMER | 3127551-42
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References (1) References (2)
• Sen S, et al. The pathophysiological basis of acute-on- • Northrup PG, et al. MELD predicts non-transplant
chronic liver failure. Liver 2002;22(Suppl 2). surgical mortality in patients with cirrhosis. Ann Surg
2005;42(3).
• Teh SH, et al. Risk factors for mortality after surgery in
patients with cirrhosis. Gastro 2007;132(4). • Befeler AS, et al. The safety of intra-abdominal surgery
in patients with cirrhosis: MELD score is superior to
• Perkins L, et al. Utility of preoperative scores for CTP score in predicting outcome. Arch Surg
predicting morbidity after cholecystectomy in patients 2005;140(7).
with cirrhosis. Clin Gastro Hep 2004;2(8).
• Suman a, et al. Predicting outcome after cardiac
• Teh SH, et al. Hepatic resection of hepatocellular surgery in patients with cirrhosis: a comparison of
carcinoma in patients with cirrhosis: MELD score Child-Pugh and MELD scores. Clin Gastro Hep
predicts perioperative mortality. J Gastrointest Surg 2004;2(8).
2005;9(9).
©2011 MFMER | 3127551-43 ©2011 MFMER | 3127551-44
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Disclosures
Managing Patients with Neurologic • None
Disease in the Perioperative Period

Andrea N. Leep, M.D. Assistant Professor of Neurology
October 9-12, 2013  Grand Hyatt Seattle Seattle, Washington
Disclosures
©2011 MFMER | 3127551-1 ©2011 MFMER | 3127551-2
What is the approximate risk of perioperative

Case seizure in an adult patient with epilepsy?
• A 32 year old man with a history of epilepsy 1. <1%
injures his ACL playing soccer.
2. 3%
• He is scheduled for knee surgery under general 3. 5%
anesthesia and expresses the following
concern: 4. 10%
• “Could the anesthesia make me have a 5. 20%

seizure?”
ACL = anterior cruciate ligament
©2011 MFMER | 3127551-3 ©2011 MFMER | 3127551-4
Perioperative Seizure Risk Perioperative Seizure Risk

• Niesen et al, 2010 • Niesen et al, 2010
• Retrospective review of epilepsy patients • Risk not influenced by:
receiving any type of anesthetic (intracranial • Type of surgical procedure (intracranial
surgery excluded) surgeries excluded)
• Lower risk in adults: • Type of anesthesia (general vs. regional)
• 16 of 568 (2.8%) • Higher risk if:
• Higher risk in children: • Frequent seizures at baseline
• 6 of 73 (8.2%) • Recent seizure activity
Niesen el al, 2010 Niesen el al, 2010
©2011 MFMER | 3127551-5 ©2011 MFMER | 3127551-6
219
• Benish et al, 2010 • Risk likely driven more by the:
• Retrospective review of epilepsy patients • Severity of the patient’s underlying epilepsy
undergoing a procedure under general
and
anesthesia (excluding neurosurgery)
• Baseline seizure frequency
• Lower risk in adults
• 1 out of 104 (<1%) • …than by the type of surgery (apart from
intracranial surgery, which has a higher risk) or
• Higher risk in children: type of anesthesia
• 5 out of 132 (3.8%)
Benish SM, et al 2010 Benish SM, et al 2010
©2011 MFMER | 3127551-7 ©2011 MFMER | 3127551-8

• Perioperative factors that could increase risk • New seizures in the post-operative patient
without a prior history of epilepsy should not
• Withdrawal of antiepileptic drugs while patient simply be blamed on general anesthesia!
NPO prior to surgery
• Sleep deprivation
• Need to consider other causes…
• Use of pro-convulsant medications
• Altered GI absorption or inability to take pills • Drug or alcohol withdrawal
• Metabolic derangements
• Altered timing of medication administration • Hypoglycemia
• Electrolyte disturbances • Posterior reversible encephalopathy syndrome (PRES)
• Many others…
Niesen el al, 2010 Voss LJ, et al. 2008

NPO = non per os or “nothing by mouth”
©2011 MFMER | 3127551-9 ©2011 MFMER | 3127551-10
Case Case
• A 25 year old man with developmental delay • His medications are continued up through the
and longstanding refractory epilepsy is seeing morning of surgery, which goes well.
you prior to an upcoming surgery
• After surgery, however, he develops a
• His antiepileptic regimen includes prolonged ileus with severe nausea and
• Valproic acid (Depakote) vomiting.
• Levetiracetam (Keppra) • He is unable to keep down any pills.
• Lamotrigine (Lamictal)
• Clonazepam (Klonopin)
©2011 MFMER | 3127551-11 ©2011 MFMER | 3127551-12
220
General Principles Intravenous Anti-Epileptics
• Continue anti-epileptics before surgery and Drug Oral to IV conversion Typical loading dose
resume as quickly as possible after surgery Phenytoin 1:1 oral phenytoin to IV 20 mg/kg IV
(Dilantin) or IM fos-phenytoin*
Should achieve total blood level
of 20 mcg/mL
• Consider alternative delivery routes
Therapeutic range 10-20
• Intravenous Valproic acid 1:1 oral valproic acid to 15-25 mg/kg IV
• Liquid or orally dissolving (Depakote) IV valproate
Should achieve total blood level
• Others (rectal, intramuscular, etc.) of 100-150 mcg/mL
Therapeutic range 40-100
Levetiracetam 1:1 oral to IV 1000 to 4000 mg IV
• If switching antiepileptics, give loading dose of (Keppra) levetiracetam
the new drug Can also load orally (1500 mg)*
*Koubeissi MZ, et al 2008
©2011 MFMER | 3127551-13 ©2011 MFMER | 3127551-14
Intravenous Anti-Epileptics Other Formulations

Drug Alternative Formulation
• IV fos-phenytoin requires continuous ECG
Carbamazepine Suspension
monitoring (IM does not)
Clonazepam Orally disintegrating tablet
• Cardiac conduction delay / asystole
Lamotrigine Orally disintegrating tablet
• Hypotension
Levetiracetam Solution
• Phenobarbital and Lacosamide are also Oxcarbazepine Suspension
available IV
Phenobarbital Solution
• Typically used when patient is already on
these medications as part of their outpatient Phenytoin Suspension
therapy Valproic acid Syrup or Sprinkles
MciroMEDEX
©2011 MFMER | 3127551-15 ©2011 MFMER | 3127551-16
Which anti-epileptic medication is LEAST

likely to cause drug-drug interactions? A mnemonic…
• These medications have higher potential for
1. Levetiracetam (Keppra) drug-drug interactions, so…
2. Phenobarbital
• “PPrescribe Very Carefully!”
3. Phenytoin (Dilantin)
4. Valproic acid (Depakote)
• P = phenytoin
• P = phenobarbital
5. Carbamazepine (Tegretol)
• V = valproic acid
• C = carbamazepine
©2011 MFMER | 3127551-17 ©2011 MFMER | 3127551-18
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When a Seizure Happens… Acute Treatment for Seizures
• Goal of treatment is to • Lorazepam 1-2 mg IV every 5 minutes to as
high as 0.1 mg/kg
• Stop seizure(s) quickly
• Need to consider airway at higher doses…
• Prevent recurrent seizures
• Identify and treat underlying cause • If no IV access…
• Prevent injury and complications • Rectal diazepam (0.2-0.5 mg/kg)
• Midazolam via subcutaneous, nasal,
intramuscular, rectal, or buccal routes
(0.15-0.3 mg/kg)
MciroMEDEX
©2011 MFMER | 3127551-19 ©2011 MFMER | 3127551-20
RAMPART Trial Case

• “Rapid Anticonvulsant Medications Prior to • A 74 year old man with advanced Parkinson’s
Arrival Trial” disease will be undergoing a hernia repair
• Compared 4 mg IV lorazepam to 10 mg IM • His medications include

midazolam as initial treatment for seizures
by EMTs (hence, patients without an IV) • Carbidopa / levodopa (Sinemet) 25/100 mg
• Doses halved for children < 40 kg 3 tablets every 4 hours
• Entacapone (Comtan) 200 mg with each
• More patients seizure free upon arrival to the dose of carbidopa / levodopa
hospital with IM midazolam (73% vs. 63%)
Silbergleit R et al, 2012
©2011 MFMER | 3127551-21 ©2011 MFMER | 3127551-22
How long does it take for the effects of

Case carbidopa / levodopa to completely wear off?
• He is listed as the first surgical case of the day 1. 4 to 6 hours
• You advise him to stop taking his Parkinson’s 2. 12 to 24 hours
medications the night before 3. 1 to 2 days
4. 3 to 5 days
5. 7 to 10 days
©2011 MFMER | 3127551-23 ©2011 MFMER | 3127551-24
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Carbidopa / Levodopa: Duration of Effect Case
• Carbidopa/levodopa has both a short duration • Surgery goes well, and the patient’s
(onset over ~30 minutes, lasts hours) and a medications are resumed shortly thereafter.
long duration response (builds over 7-10 days)
• On hospital day 2, however, he develops a
• With a missed dose… severe post-operative delirium and appears to
• Short-term response lost right away be hallucinating.
• Long-term response declines over several
days • The patient’s family is very upset and confused
by the situation.
• Hence, consequences of missed doses
increase over time!
©2011 MFMER | 3127551-25 ©2011 MFMER | 3127551-26
If absolutely necessary, which is the best anti-

Post-Operative Delirium / Hallucinations psychotic to use in this situation?
• Parkinson’s patient are predisposed to this
(discuss pre-operatively!) 1. Haloperidol (Haldol)
2. Risperidone (Risperdal)
• Dopamine agonists are 3x more likely to
provoke hallucinations* 3. Olanzapine (Zyprexa)
4. Quetiapine (Seroquel)
• Adjunctive medications also increase risk
• Entacapone 5. Ziprasidone (Geodon)
• Levodopa least likely offender!

*Rascol O, et al 2000
©2011 MFMER | 3127551-27 ©2011 MFMER | 3127551-28
Case Other Options

• Despite the best efforts of his care providers, Drug Alternative Formulation
the patient refuses to swallow pills due to his
Carbidopa / levodopa Crushed in water
delirium. (immediate release)
Orally dissolving tablet
Rotigotine Transdermal patch
(taken off the market in US)
Apomorphine Intravenous (requires

monitoring for orthostasis)
Inhaled formulation in the
works?*
*Grosset KA (abstract) 2011
©2011 MFMER | 3127551-29 ©2011 MFMER | 3127551-30
223
Perioperative Parkinson’s Disease Nausea
• Delirium
• Avoid anti-emetics that are anti-dopaminergic
• Swallowing • Prochlorperazine (Compazine)
• Nausea
• Metoclopramide (Reglan)
• Post-operative pain • Odansetron (Zofran) acceptable
• Orthostatic hypotension / syncope
• Rare for a patient who previously tolerated
• Loss of parkinsonism control levodopa to then develop nausea (consider
other causes)
©2011 MFMER | 3127551-31 ©2011 MFMER | 3127551-32
Post-Operative Pain Orthostatic Hypotension / Syncope

• Levodopa off-states associated with reduced • Parkinson’s disease itself can cause
pain thresholds* orthostatic hypotension
• Optimize levodopa to better manage post-op • Levodopa can also lower standing blood
pain pressure for 3-4 hours after each dose
• Monitor standing blood pressure

• Should be > 90 mm Hg
*Gerdelat-Mas A, et al 2008
©2011 MFMER | 3127551-33 ©2011 MFMER | 3127551-34
Loss of parkinsonism control Other Issue to Consider

• Formulation mix-up • Severe tremor or dyskinesias can interfere with
• Need 30-50% more continuous release some types of surgery and procedures where
carbidopa/levodopa for given dose of patient is awake and it’s important to hold still
immediate-release formulation • Dental work
• Giving with meals • Cataract surgery
• Inappropriate dose timing • MRI scans
• Time levodopa dosing to response duration
• There is no cumulative toxicity from adding
doses!!!
Yeh 1989; Ahlskog 1988
©2011 MFMER | 3127551-35 ©2011 MFMER | 3127551-36
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Case Which of the following is true?
• You are seeing a 60 year old man for a PAME 1. A carotid bruit is highly predictive of an
prior to prostate surgery. underlying severe stenosis (70-99%)
2. Patients with an asymptomatic carotid bruit
• You note a right carotid bruit. have a higher risk of ischemic stroke
• He denies any prior history of stroke or 3. Patients with an asymptomatic carotid bruit
transient neurologic symptoms including vision have a higher risk of perioperative stroke
loss. 4. All patients over age 65 should undergo
carotid ultrasonography prior to surgery
regardless of the presence of a bruit
PAME = pre-anesthesia medical examination
©2011 MFMER | 3127551-37 ©2011 MFMER | 3127551-38
Asymptomatic Carotid Bruit Case

• Only 30-40% of patients with a carotid bruit have • After leaving the room, your resident asks,
an underlying severe carotid stenosis “But what if he really did have a severe carotid
stenosis?”
• Risk of stroke associated with an asymptomatic
carotid bruit is 1.5-2.0% per year*
• No evidence that general surgery increases risk**

• Hence, patient could be screened at some point,
but does not need to be done before surgery
*Wiebers 1990; Chambers & Norris 1986; **Ropper et al 1982 PAME = pre-anesthesia medical examination
©2011 MFMER | 3127551-39 ©2011 MFMER | 3127551-40
Situation Perioperative Risk

Adults undergoing non-vascular ~0.5% Case
surgery under general anesthesia (stroke)
Carotid stenosis of 50 - 99% with ~3.6% • Your next patient is a 71 year old man seeing
bruit or prior symptoms (stroke) you prior to upcoming coronary artery bypass
undergoing general surgery* grafting.
Carotid endarterectomy done for 2.7%
asymptomatic carotid stenosis of (stroke or death) • He also has a carotid bruit.
60 - 99%**
Carotid stenting*** 4.1% (stroke)

• Would your answer to the resident be different?
Surgery following prior carotid “Not likely to be less
endarterectomy than that of the
general population”*
*Evans & Wijdicks 2001; **ACAS (Asymptomatic Carotid Artery Stenosis) Trial 1995; PAME = pre-anesthesia medical examination
***CREST trial 2010
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225
Does the Type of Surgery Matter? But the issue is tricky…
• For asymptomatic carotid stenosis, the risk of • Main mechanisms of stroke associated with
perioperative stroke is not high enough to CABG are hypoperfusion or embolism from the
justify the risks of endarterectomy for general aortic arch
surgery. • Neither preventable by carotid endarterectomy!
• The same might not be true for cardiac surgery, • Example: 239 patients with >50% carotid stenosis
including coronary artery bypass grafting • 18 perioperative strokes (7.5%) with CABG
(CABG). • Only 4 of these strokes referable to a carotid
artery, of which 3 were occluded & hence not
amenable to surgery
PAME = pre-anesthesia medical examination Li et al, 2009
©2011 MFMER | 3127551-43 ©2011 MFMER | 3127551-44
Coronary Artery Bypass Grafting Coronary Artery Bypass Grafting

Situation Perioperative Risk • ACC/AHA Guidelines 2011
(selected examples)
Overall CABG 1.4-3.0% Carotid revascularization may be considered
CABG + unilateral >50% stenosis 3.0% in patients scheduled to undergo CABG if…
2004
CABG + unilateral >80% stenosis 3.4% • Bilateral severe (70-99%) stenoses
2011
CABG + bilateral >50% stenosis 5% • Unilateral severe stenosis with a
contralateral occlusion
CABG + stenosis >50% + occlusion 7-11%
• Symptomatic stenosis (50-99%)
CABG + symptomatic stenosis 5-8.5%
ACC/AHA Guidelines 2011; Mahmoudi 2011; Naylor 2002; Schwartz 1995; Blacker 2004 CABG = coronary artery bypass grafting; ACC = American College of Cardiology;
AHA – American Heart Association, ACC/AHA Guidelines 2011
©2011 MFMER | 3127551-45 ©2011 MFMER | 3127551-46
Why not unilateral severe stenosis? Coronary Artery Bypass Grafting

• 2011 study by Mahmoudi, et al • ACC/AHA Guidelines 2011
Asymptomatic ≥75% stenosis <75% stenosis
patients with… Screening is reasonable in selected patients
(n=117) (n=761) with high risk features such as:
Risk of in-hospital 3.4% 3.6%
stroke • Age > 65 years* • Diabetes
Risk of in-hospital 3.4% 4.2% • Left main coronary stenosis • Hypertension
mortality • Peripheral arterial disease • Prior TIA/stroke*
• Smoking • Carotid bruit*
Conclusion: “Severe carotid artery stenosis alone is not a
risk factor for stroke or mortality in pts undergoing CABG”
Mahmoudi et al, 2011 ACC/AHA Guidelines 2011
©2011 MFMER | 3127551-47 ©2011 MFMER | 3127551-48
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Case Case
• A 62 year old woman is scheduled to have a • Two days before surgery, she develops sudden
lumbar spine surgery for severe spinal stenosis onset left facial droop and left hand weakness.
and disabling pseudoclaudication.
• When the symptoms are still present the next
• She has chronic rate-controlled atrial fibrillation morning, she goes to the local ED.
on warfarin anticoagulation.
• Initial head CT and carotid ultrasounds are
• Her warfarin (Coumadin) is stopped in negative, but an MRI shows an acute infarct
anticipation of surgery. corresponding to the anterior division of the
right middle cerebral artery.
PAME = pre-anesthesia medical examination
©2011 MFMER | 3127551-49 ©2011 MFMER | 3127551-50
How long should you tell her to wait before

having her back surgery?
1. Don’t wait, proceed as planned

2. 1 week
3. 2 weeks
4. 4 weeks
5. 6 weeks
Chen M, Front Neurol, 2010
©2011 MFMER | 3127551-51 ©2011 MFMER | 3127551-52
Where does the concern come from? Where does the concern come from?
• Brain may be more • Risk of hemorrhagic

susceptible to infarction conversion
during the first few weeks
after an ischemic stroke • Procedures involving
thrombolytics,
• Hemodynamic stressors anticoagulation, or
of surgery / anesthesia antiplatelet agents
• Impaired cerebral • Reperfusion injury
autoregulation
Thank you to Joseph Parisi, MD for sharing gross brain photo Thank you to Joseph Parisi, MD for sharing gross brain photo
©2011 MFMER | 3127551-53 ©2011 MFMER | 3127551-54
227
General Recommendations General Recommendations
• Promptly evaluate all stroke patients • If possible, advise patient to wait at least 1
month before undergoing non-urgent / elective
• Defer non-essential surgery until this evaluation surgery
is complete
• Especially for larger strokes (greater than
• Optimize medical management 1/3rd of the middle cerebral artery territory)
• Promptly address symptomatic carotid stenosis

before patient undergoes surgery
Blacker et al 2004 Blacker et al 2004
©2011 MFMER | 3127551-55 ©2011 MFMER | 3127551-56
Does the Evidence Support This? ACC / AHA Guidelines 2011

• Rerkasem 2009 systematic review • “When revascularization is indicated for
patients with TIA or stroke and there are no
Timing of Carotid Surgery Perioperative Risk of Stroke or Death
(cut off for early vs. late) contraindications to early revascularization,
Before After
intervention within 2 weeks of the index event is
1 day 4.2% 1.9% reasonable rather than delaying surgery.”
1 week 6.8% 6.3%
2 weeks 6.7% 6.3% • Class IIa
3 weeks 6.3% 4.3% • Level of Evidence B
4 weeks 5.3% 4.8%
6 weeks 4.1% 1.8%
Rerkasem et al 2009
©2011 MFMER | 3127551-57 ©2011 MFMER | 3127551-58
Factors to Consider Case

Ischemia-related variables Surgery related variables • A 78 year old woman is admitted following a
severe right hip fracture requiring surgical
• Stage of ischemia • Type of surgery repair
• Size of stroke • Urgency of surgery • A fentanyl PCA is started for post-operative
• Underlying cause • Timing of surgery pain control with prochlorperazine available as
needed for nausea.
• Several hours later you are called to see the
What else is going on? patient because she is “somnolent, rigid, and
posturing”
• Medical management / Other comorbidities
©2011 MFMER | 3127551-59 ©2011 MFMER | 3127551-60
228
Case What is going on?
• Examination reveals: 1. Acute delirium
• Somnolent patient that can be aroused with 2. Alcohol withdrawal
strong stimuli but cannot follow commands
3. Neuroleptic malignant syndrome
• Sinus tachycardia on monitor 4. Opioid-induced seizure
• Increased tone in all extremities with 5. Serotonin syndrome
frequent myoclonic jerks
• Brisk reflexes throughout with upgoing toes
and four beats of clonus at each ankle
©2011 MFMER | 3127551-61 ©2011 MFMER | 3127551-62
Serotonin Syndrome Serotonin Syndrome

• Caused by increased serotonergic activity in • Core clinical features*
the central nervous system
• Mental status changes
• A clinical diagnosis that sometimes requires a • Autonomic hyperactivity
high index of suspicion • Hypertension, hyperthermia, tachycardia,
sweating, diarrhea
• Broad spectrum of manifestations that range • Neuromuscular hyperactivity
from mild to life threatening • Tremor, rigidity, clonus, myoclonus, and
hyperreflexia (most prominent in legs)
*Mason PJ, et al. 2000
©2011 MFMER | 3127551-63 ©2011 MFMER | 3127551-64
Serotonin Syndrome Fentanyl does which of the following?

• Requires exposure to a serotonergic medication 1. Increases serotonin formation
• Most cases of serotonin syndrome present 2. Increases serotonin release
within 6 hours of a change or initiation of a
serotonergic drug* 3. Impairs reuptake of serotonin
4. Inhibits serotonin metabolism
5. Acts as direct serotonin agonist
6. Increases sensitivity of serotonin receptor
*Mason PJ, et al. 2000
©2011 MFMER | 3127551-65 ©2011 MFMER | 3127551-66
229
Back to the patient Summary
• Patient’s daughter reported that the nurse was • Risk of perioperative seizure
pushing the fentanyl PCA button frequently • Perioperative management of anti-epileptic
(even after the patient became somnolent) in medications
order to “stay on top of the pain”
• Perioperative issues in Parkinson’s disease
• Fentanyl was discontinued and with supportive • Asymptomatic carotid bruit
cares the patient returned to baseline over the
next 24 hours • Timing of surgery after ischemic stroke
• Serotonin syndrome
©2011 MFMER | 3127551-67 ©2011 MFMER | 3127551-68
References
Thank You to…
• Niesen AD, et al. Perioperative seizures in patients with a history of a seizure disorder.
Anesthesia-Analgesia 2010 111(3):729-735
• Content experts who reviewed this talk • Benish SM, et al. Effect of general anesthesia in patients with epilepsy: a population-based
study. Epilepsy & Behavior, 2010;17:87-89.
• Voss LJ, Sleigh JW, Barnard JP, Kirsch HE. The howling cortex: seizures and general
• Eric Ahlskog, MD, PhD (Parkinson’s disease) •
anesthetic drugs. Anesth Analg 2008:107(5):1689-1703.
Koubeissi MZ, et al. Tolerability and efficacy of oral loading of levetiracetam. Neurology
2008;70:2166-2170.
• Jeffrey Britton, MD (Epilepsy) • Silbergleit R, et al. Intramuscular vs. intravenous therapy for prehospital status epilepticus.
NEJM 2012;366(7):591-600.
•
• Alejandro Rabinstein, MD (Stroke) Rascol O, et al. A five-year study of the incidence of dyskinesia in patients with early
Parkinson’s disease who were treated with ropinirole or levodopa. NEJM 2000;342:1484-1491.
• Grosset KA, et al. Inhaled apomorphine (VR040) for “off” periods in Parkinson’s disease.
Abstract 385 at The Movement Disorder Society’s 15th International Congress of Parkinson’s
Disease and Movement Disorders in Toronto, ON, Canada; June 5-9, 2011.
• Gerdelat-Mas A, et al. Levodopa raises objective pain threshold in Parkinson’s disease: a RIII
reflex study. J Neurol Neurosurg Psychiatry 2008:78(10):1140-1142
• Yeh KC, et al. Pharmokinetics and bioavailability of Sinemet CR: a summary of human studies.
Neurology 1989;39(11 Suppl 2):25-38.
• Ahlskog JE, et al. Controlled-release Sinemet (CR-4): a double-blind crossover study in patients
with fluctuating Parkinson’s disease. Mayo Clin Proc 1988;63(9):876-886.
©2011 MFMER | 3127551-69 ©2011 MFMER | 3127551-70
References, continued References, continued

• Wiebers DO, et al. Prospective comparison of a cohort with asymptomatic carotid bruit and a • Schwartz LB, et al. Asymptomatic carotid artery stenosis and stroke in patients undergoing
population-based cohort without carotid bruit. Stroke 1990;21:984-988. cardiopulmonary bypass. J Vasc Surg 1995;21:146
• Chambers BR, Norris JW. Outcome in patients with asymptomatic neck bruits. NEJM • Blacker DJ et al. The perioperative cerebrovascular consultation: common cerebrovascular
1986;315(14):860-865. questions before general or cardiac surgery. Mayo Clin Proc 2004:79:223-229.
• Ropper AH, Wechsler LR, Wilson LS. Carotid bruit and the risk of stroke in elective surgery. • Chen M. Mechanical recanalization of acute carotid terminus occlusion from traumatic arterial
dissection. Front Neurol 2010;1:123
NEJM 1982;307:1388-1390.
• Rerkasem K, Rothwell PM. Systematic review of the operative risks of carotid endarterectomy
• Evans BA and Wijdicks EFM. High-grade carotid stenosis detected before general surgery: Is for recently symptomatic stenosis in relation to the timing of surgery. Stroke 2009;40:e564-e572.
endarterectomy indicated? Neurology 2001;57(5):1328-1330.
• Brott, et al. Pocket guideline on the management of patients with extracranial carotid and
• Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the vertebral artery disease. ACC/AHA 2011.
Asymptomatic Carotid Atherosclerosis Study. JAMA 1995;273(18):1421-1428 • Mason PJ, et al. Serotonin syndrome. Presentation of 2 cases and review of the literature.
• Brott, et al CREST investigators. Stenting vs. endarterectomy for treatment of carotid artery Medicine 2000;79(4):201.
stenosis. NEJM 2010;363:11-23.
• ACC/AHA 2004 Guideline update for coronary artery bypass grafting
(http://circ.ahajournals.org/content/124/23/e652; accessed August 30, 2012)
• Li Y, et al. Strokes after cardiac surgery and relationship to carotid stenosis. Arch Neurol
2009;66(9):1091.
• Mahmoudi, et al. Patients with severe asymptomatic carotid artery stenosis do not have a
higher risk of stroke and mortality after coronary artery bypass surgery. Stroke 2011;4
• Naylor et al. Carotid artery disease and stroke during coronary artery bypass: a critical review of
the literature. J Vasc Endovasc Surg 2002:23(4):283-294.
©2011 MFMER | 3127551-71 ©2011 MFMER | 3127551-72
230
Disclosure
Relevant Financial Relationships

Clinical Short: Preoperative None
Evaluation in Cancer Patients

Molly Feely MD
Off-Label/Investigational Uses
None
Learning Objectives Ms. V

• 49 y.o. ♀ presents for preoperative evaluation in
anticipation of bilateral breast reconstruction.
• Identify who should have a
preoperative ECG • Breast cancer history
• Abnormal mammogram
• Clarify perioperative VTE
prophylaxis for patients with CNS • Ductal carcinoma, triple +, node +
tumor • Bilateral mastectomy
• Systemic chemotherapy with doxorubicin,
• Address preoperative pain cyclophosphamide and 5-FU followed by
medication management trastuzumab (Herceptin)
Which of the following factors increases

Ms. V’s perioperative cardiac risk Perioperative Cardiac Risk in Cancer
A. Doxorubicin chemotherapy Risk due to cancer Risk due to treatment
B. Cyclophosphamide chemotherapy • Pericardial disease • Cardiotoxic chemotherapy
C. Trastuzumab chemotherapy • Pericardial
effusion/tamponade
• Cardiomyopathy/CHF
• Hypercoagulability
D. All of the above • Pericardial mets • Pericardial disease
• SVC syndrome • CAD
• Hypercoagulability of • XRT to the chest

malignancy • Premature CAD
• Valvular heart disease
• Constrictive pericarditis
• Restrictive cardiomyopathy
231
Cardiotoxic Chemotherapy Ms. V
Cardiomyopathy HTN CAD Dysrhythmia Hypercoagulable

• PMH None
Anthracyclines
Doxorubicin
Bevacizu Capecitabine Anthracycline Bevacizumab • Functional Status
mab 5-FU paclitaxel Thalidomide
Daunorubicin
Epirubicin sunitinib Bevacizumab docetaxel lenalidomide • Fatigued, generally weak and mildly
Idarubicin
Cyclophosphamide
sorafenib Capecitabine dyspneic with activity. Household
vatalanib paclitaxel 5-FU
Trastuzumab Pazopanib docetaxel gemcitabine ambulation
Sunitinib motesanib trastuzumab
Sorafenib axitinib sorafenib cetuximab • Medications
aflibercept sunitinib arsenic
trioxide • Levothyroxine
Vincristine
Vinblastine
thalidomide
interleukin-2
• Colace
• Tamoxifen
Adão, R et. Al. Rev Port Cardiol. 2013;32:395-409.
In addition to a thorough H&P, what testing Preop cardiac assessment in Cancer

should Ms. V have preoperatively? Patients
A. None • THOROUGH History
B. ECG • Dyspnea, orthopnea, edema, chest pain,
syncope
C. Echocardiogram
• THOROUGH Physical Exam
D. Stress test • JVD, rales, PMI, S3, S4, tamponade
E. All of the above physiology, edema
• ECG
• If equivocal functional status, risk factors and
no recent testing
TAKE HOME POINTS Mr. N

• Cancer and its treatment can increase cardiac • 37 y.o. male with known widely metastatic
morbidity even in young patients multiple myeloma
• H&P still the most important screening tool • Brain and liver mets
• Stable disease on treatment
• Consider pre-op ECG if functional status
equivocal • Admitted after MVA with right femoral neck
fracture
• Planned hemiarthroplasty in the am
232
Known CNS
Which of the following statements is correct Malignancy
regarding VTE prophylaxis Perioperative

VTE Treatment
VTE Prophylaxis
A. Because of the high risk of hemorrhage
melanoma brain mets, he should only receive Contraindications
Plts < 50K High Risk Tumor:
pneumatic compression devices Active bleeding Melanoma, thyroid,
Coagulopathy renal, choriocarcinoma
B. Because of the high risk of hemorrhage in Recent CNS surgery
melanoma brain mets, he should receive a
prophylactic IVC filter YES NO NO YES
C. Because of the high risk of VTE due to

malignancy, he should receive pharmacologic
VTE prophylaxis SCD
IVC
LMWH Filter
Lyman G, et al. J Clin Oncol 25:5490-5505
TAKE HOME POINTS Ms. B

• Patients with CNS tumors should receive the • Ms. B is a 40 y.o. female with metastatic
same perioperative VTE prophylaxis as those ovarian cancer and malignant small bowel
without CNS disease obstruction
• Chronic cancer related pain well managed on
stable regimen prior to current illness
• Plan is for exploratory lap tomorrow
In addition to recommending post-op

consultation with pain medicine, how would
Ms. B
you manage her pain meds pre-op
• MEDS
• Gabapentin 900mg po tid A. Take her pain medication as usual the
morning of surgery
• MS Contin 200mg po tid
• Morphine 75mg po q4h prn pain B. Stop her MS Contin the night before surgery
C. Switch her to a fentanyl patch pre-op
D. Cut her MS Contin in half the day before
surgery
233
Opiate tolerance and perioperative period TAKE HOME POINT
• Inadequate pain control increases morbidity • Don’t mess with the pain meds pre-op!
• Inadequate pain control increases length of stay
• Inadequate pain control in unnecessary
• Tolerance ≠ addiction
RECAP
• Consider pre-op ECG for cancer patients with
equivocal functional status, risk factors and no
recent evaluation
• Patients with CNS tumors should receive the
same perioperative VTE prophylaxis as those feely.molly@mayo.edu
without CNS disease
• Don’t mess with the pain meds pre-op!
234
Disclosures:
Understanding the Perioperative

• None
Stress Response

John B. Bundrick, MD FACP
Consultant, Division of General Internal Medicine
Mayo Clinic Rochester
October 2013 Seattle
©2011 MFMER | 3127551-1 ©2011 MFMER | 3127551-2
Road Map Road Map

• Perioperative fluid shifts (major focus) Not covered in this talk (will be in others):
Briefly noted: • Beta blockers
• Catecholamines • Thrombogenic effect of surgery
• Corticosteroid stress dosing
• Postoperative fever
Case 1 Case 1
• 72 yo male is 12 hrs post ORIF R hip fx and • Blood loss with surgery = 420 cc
you are called by his nurse to assess for
possible hypovolemia. • Fluids with surgery = 3.8 L crystalloid (Lactated
Ringers).
• Urine output for past four hours has averaged
20 cc/hr and the urine appears concentrated. • Wt is 72.9 kg, up 2.9 kg from pre-op
Type the footnote/source in this space
©2011 MFMER | 3127551-5 ©2011 MFMER | 3127551-6
235
Case 1 Case 1
• PMH: • Exam: BP 125/72 P 76/reg R 14
• HTN, controlled with amlodipine 5 mg/d • Alert and oriented
• No other meds • Heart normal, lungs clear, oxysat 92% RA
• Tongue moist
• 3 mm pitting edema R mid tib; 1 mm L
• JVP 2 cm > clavicle at 30 degrees
©2011 MFMER | 3127551-7 ©2011 MFMER | 3127551-8
Case 1
Labs: Case 1
Current Preop How would you manage this patient?
Hgb 11.2 13.5
1. 500 cc IV bolus of 0.9 saline
Na+ 133 137
2. 25 grams of IV albumin
K+ 4.1 4.6
3. 20 mg of IV furosemide
Creatinine 1.0 1.0
4. Recheck creatinine in 12 hours
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Perioperative fluids and the stress Perioperative fluids and the stress
response response
• Normal distribution of body fluids: • Normal distribution of body fluids:
• 50% (women) to 60% (men) of lean body wt • 50% (women) to 60% (men) of lean body wt
= total body water (TBW) = total body water (TBW)
• 2/3 of TBW is intracellular
• 1/3 of TBW is extracellular (ECV)
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response response
• Normal distribution of body fluids: • 1/5 of ECV is plasma volume (1/15 or 7% of
• 50% (women) to 60% (men) of lean body wt TBW)  except in the acute postop
= total body water (TBW) setting…where the plasma volume is
significantly less
• 2/3 of TBW is intracellular
• 1/3 of TBW is extracellular (ECV)
• 1/5 of ECV is plasma volume (1/15 or 7%
of TBW)
©2011 MFMER | 3127551-13 ©2011 MFMER | 3127551-14
Perioperative fluids and the stress Perioperative fluids and the stress response
response Time Course
• 1/5 of ECV is intravascular volume (1/15 or • Several stress hormones act to conserve fluid:
7% of TBW)  except in the acute postop • ACTH, cortisol, plasma renin-aldosterone
setting…where the plasma volume by are all fairly short-lived, <24 hrs peak effect
proportion is significantly less
• Primarily related to capillary leak from IL-6

and other pro-inflammatory cytokines
©2011 MFMER | 3127551-15 ©2011 MFMER | 3127551-16
response response
Time Course Clinical Response
• Several stress hormones act to conserve fluid: • Oliguria with concentrated urine is very
• ACTH, cortisol, plasma renin-aldosterone common in the first 12-24 hours
are all fairly short-lived, <24 hrs peak effect • No correlation with postop renal failure in this
• ADH and IL-6 are potently stimulated by context
surgical stress and may linger for 3 days or
longer
Type the footnote/source in this space Alpert RA, Roizen MF, Hamilton WK, et al. Surgery. 1984;95(6):707-711.
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237
response response
Clinical Response Therapeutic Implications
• Oliguria with concentrated urine is very • It is generally best to avoid diuretics in the first
common in the first 12-24 hours 24-48 hrs postop
• No correlation with postop renal failure in this
context
• Generally by 48-72 hours the patient will begin

to auto-diurese
Type the footnote/source in this space Type the footnote/source in this space
©2011 MFMER | 3127551-19 ©2011 MFMER | 3127551-20
response response
Clinical Studies of Intraoperative Fluids Clinical Studies of Intraoperative Fluids
• Some fluid is good: • Too much fluid may not be so good:
• RCT in lap choley shows 3 L of Ringer’s lactate • Literature is complex and results somewhat
are better than 1 L in terms of: mixed…
• Exercise capacity
• Subjective outcomes (fatigue, nausea)
• Lower aldosterone and ADH
©2011 MFMER | 3127551-21 ©2011 MFMER | 3127551-22
response response
• Too much fluid may not be so good: • Too much fluid may not be so good:
• Literature is complex and results somewhat • Literature is complex and results somewhat
mixed… mixed…
• However, “liberal” (~5L) vs “restrictive”(~2L): • However, “liberal” (~5L) vs “restrictive”(~2L):
• More cardiopulmonary complications • More cardiopulmonary complications
• Tissue healing complications • Tissue healing complications
• Prolonged post-op ileus • Prolonged post-op ileus
• It takes an average of 7 days to resolve 6L
excess
Type the footnote/source in this space Holte K. Dan Med Bull. 2010;57(7):B4156.
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238
response response
• Goal-directed management seems optimal • Goal-directed management seems optimal
• This usually involves transesoph Doppler in • This usually involves transesoph Doppler in
most studies – fluid boluses are given until most studies – fluid boluses are given until
cardiac output hits the flat part of Starling curve cardiac output hits the flat part of Starling curve
• …but this is not practical at the bedside…so
what’s a clinician to do?
©2011 MFMER | 3127551-25 ©2011 MFMER | 3127551-26
response response
Postoperative management Postoperative management
• Some things are easy: • Some things are not so easy:

• Hypotension • Hypotension and tachycardia insensitive
(especially in supine position)
• Tachycardia • Oliguria in first 12-24 hours nonspecific
• Blood loss, severe anemia • JVP is a helpful indicator of CVP, though
more for IV volume excess (and may not
always be clearly visible)
Type the footnote/source in this space McGee S. JAMA 1999;281:1022-1029.
©2011 MFMER | 3127551-27 ©2011 MFMER | 3127551-28
response response
Back to the bedside basics: • Timing is everything:

• Fluid balance – (periop fluid, weight) • In first 24-48 hrs, bias should (paradoxically)
generally be towards avoiding BOTH:
• Comorbidities – (esp CHF) • Further excess of total fluid AND
• Physical exam – (oxysat, JVP) (After 1st day --- • IV volume depletion (no Lasix unless forced)
tongue moisture)
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239
response response
• Timing is everything: • Timing is everything:
• In first 24-48 hrs, bias should (paradoxically) • After 48 hrs, similar principles apply but to
generally be towards avoiding BOTH: lesser degree:
• Further excess of fluid AND • Fluid should still be minimized, though may
• IV volume depletion (no Lasix unless forced) be required for orthostatic tolerance
• Lasix should still generally be avoided
• Generally this means giving maintenance IV unless necessary (or patient on it preop), as
fluids only, until auto-diuresis commences at auto-diuresis should help
48-72 hours.
©2011 MFMER | 3127551-31 ©2011 MFMER | 3127551-32
response response
Which fluid? Which fluid?
• Ringer’s Lactate is often used in intraop setting, • Ringer’s Lactate is often used in intraop setting,
due to concern for hyperchloremic acidosis with due to concern for hyperchloremic acidosis with
large infusions of saline large infusions of saline
• This is thought to not be clinically significant for • This is thought to not be clinically significant for
volumes <5L. volumes <5L.
• RCTs of colloid vs crystalloid are not conclusive

in favor of either.
©2011 MFMER | 3127551-33 ©2011 MFMER | 3127551-34
Case 2 – Catecholamine control Perioperative Clonidine

• 55 yo asthmatic with CAD undergoing lap • Ideal for patients who would otherwise be
choley for symptomatic gallstones. candidates for beta blocker, but have significant
reactive airways disease
• Regimen:
• Has had moderately severe bronchospasm with
beta blockers in the past. • place 0.2 mg patch night prior to surgery,
along with a 0.2 mg oral dose
• repeat oral dose in AM; remove patch on
• Are there other options for managing the day four
catecholamine cardiac stress?
240
Perioperative Clonidine Perioperative Clonidine
• RCT of 190 pts with CAD (or at risk) • A meta-analysis of randomized trials of alpha-2
agonists in over 3000 patients undergoing
• Major vascular and intraabd surgeries surgery confirmed similar results, with a 36%
• Postop myocardial ischemia: 14% rx vs 31% relative risk reduction in mortality.
for placebo
• Postop mortality to two years: 15% rx vs 29%
for placebo
• More bradycardia in rx group (12% vs 2%)
Wallace AW, Galindez D, et al. Anesthesiology 2004; 101:284-93.

Wijeysundera DN, Naik JS, Beattie S. Am J Med 2003; 114:742-752.
The Perioperative Stress Response The Perioperative Stress Response

Summary Summary
• Surgery induces significant fluid shifts which • Surgery induces significant fluid shifts which
tend to increase ECV and decrease plasma tend to increase ECV and decrease plasma
volume. volume.
• ADH is potently stimulated by surgical trauma
and may remain elevated for 3 days or longer.
©2011 MFMER | 3127551-39 ©2011 MFMER | 3127551-40

Summary Summary
• Surgery induces significant fluid shifts which • Loop diuretics should generally be avoided in
tend to increase ECV and decrease plasma the first 12-24 hours postop.
volume.
• ADH is potently stimulated by surgical trauma
and may remain elevated for 3 days or longer.
• Oliguria is common in the early postop period
and is not necessarily indicative of renal
insufficiency in that context.
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241
Summary Summary
• Loop diuretics should generally be avoided in • Loop diuretics should generally be avoided in
the first 12-24 hours postop. the first 12-24 hours postop.
• Autodiuresis generally begins with waning of • Autodiuresis generally begins with waning of
ADH levels (48-72 hours). ADH levels (48-72 hours).
©2011 MFMER | 3127551-43 ©2011 MFMER | 3127551-44
The Perioperative Stress Response

Summary Thank you!
• In patients for whom beta blockers are • Bundrick.john@mayo.edu
indicated for reduction of perioperative CV risk,
yet who cannot tolerate them due to risk of
bronchospasm, clonidine may be a useful
option.
©2011 MFMER | 3127551-45
• Holte K. Pathophysiology and clinical implications of • McGee S. Is This Patient Hypovolemic? JAMA.
perioperative fluid management in elective surgery. 1999;281:1022-1029.
Dan Med Bull. 2010;57(7):B4156.
• Wallace AW, Galindez D, et al. Effect of clonidine on
• Desborough JP. The stress response to trauma and cardiovascular morbidity and mortality after noncardiac
surgery. Br J Anaesth. 2000;85(1):109-117. surgery. Anesthesiology 2004; 101:284-93.
• Alpert RA, Roizen MF, Hamilton WK, et al. • Wijeysundera DN, Naik JS, Beattie S. Alpha-2
Intraoperative urinary output does not predict adrenergic agonists to prevent perioperative
postoperative renal function in patients undergoing cardiovascular complications: a meta-analysis. Am J
abdominal aortic revascularization. Surgery. Med 2003; 114:742-752.
1984;95(6):707-711.
242
An Overview of
to Inpatient Postoperative Care Perioperative Management of Diabetes

James Fink, MD, MPH
October 9 - 12, 2013  Grand Hyatt  Seattle, Washington
©2011 MFMER | 3127551-1 ©2011 MFMER | 3127551-2
Literature Updates 2013:

Disclosures
• None
©2011 MFMER | 3127551-3 ©2011 MFMER | 3127551-4
Diabetes
Perspective Diabetes and Surgery:
• most common endocrinopathy in western society Scenario 1 - Outpatient:
Elective  Surgical outpts  pre-op assessment  Hospital admission  OR & recovery
• 15-20 million Americans: 7-8 % of US pop.
 post-op care  discharge
• 20+ % of US surgical patients

Scenario 2 - Inpatient:
• Greater perioperative risks of:
• stroke Hospital
• MI Urgent Admission
• renal insufficiency   OR & recovery  post-op care  discharge
• wound complications/infection Emergent Pre-op
assessment
Diabet. Med. 29, 420–433 (2012)

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243
Based on your extensive knowledge of the
Question 1. evidence, you advise you colleague to target?
• A colleague calls (knows you’re interested in perioperative
medicine) asking about a diabetic patient going for 1) < 6%
elective surgery
2) < 7%
• A diabetic patient on oral hypoglycemics is due

for an elective TKR. HbA1c is 7.5% and steady 3) < 9%
• This colleague wants to know what pre-op 4) < 12%

HbA1c is recommended for elective surgery
©2011 MFMER | 3127551-7 ©2011 MFMER | 3127551-8
Answer: History
1) < 6% • Medication management

• Insulin vs. oral/others
• Compliance/Adherence
2) < 7%
3) < 9%
? • Hypoglycemia awareness
• Other DM related co-morbidities

• Gastroparesis/Autonomic dysfunction
4) < 12%
• Prior surgery – issues/complications
©2011 MFMER | 3127551-9 ©2011 MFMER | 3127551-10
“Prayer Sign” - Cheiroarthropathy Pre-op Investigations

• Preoperative resting 12-lead ECG
may be reasonable in patients with at least 1
clinical risk factor who are undergoing
intermediate-risk operative procedures. (Level of
Evidence: B)
• Consider ‘silent’ CAD in patients with autonomic

Predictor of complications associated with “stiff joint” syndrome neuropathic sx
• (may include further risk stratification for CAD)
Increasing Interphalangeal gap  difficult laryngoscopy
Sens 50’s – 86%, Sens 50’s – 75%, PPV 90.5%, NPV 67%
http://emedicine.medscape.com/article/284451-overview Connery, LE & Coursin, DB. Assessment and therapy of selected endocrine disorders. Anesthesia Clin N AM. 2004; 22:93-123
J Anaesth Clin Pharmacol 2005;21(3):261-264 ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary
©2011 MFMER | 3127551-11 ©2011 MFMER | 3127551-12
244
Pre-op HbA1c Pre-op BSL / HbA1c – targets?
• Guidelines: • Dr Google:
• Elective surgery goal < 6%
• Check in patients presenting with hyperglycemia
• “Involve diabetes team” > 8.5 - 9%
• Known DM without record of HbA1c in last 2-3 months
• “Consideration should be given to improving control
prior to surgery” > 12%
JCEM 2012
ADA 2010 ©2011 MFMER | 3127551-13 ©2011 MFMER | 3127551-14
Evidence linking elevated pre-op BSL or

HbA1c with post-op complications Utility of pre-op HbA1c
• Arch Surg 2006;141:375-380
• HbA1c <7% decreased surgical infections
• J Thorac Cardiovasc Surg 2008;136:631-640
• HbA1c > 8.6% associated with a 4 fold increase in mortality in
patients undergoing CABG
• Can J Anaes 2010;57:565-572
• HbA1c >6% in non-diabetics increased mortality in cardiac surgery • Determine post-op and
discharge management
• Ann Surg 2011;253:158-165
• Preoperative random BSL and HbA1c not associated with
postoperative infection
• Euro J Cardo-Thoracic Surg 2012;41:102-107
• Decreased incidence of post-CABG Atrial fib with increasing HbA1c
http://www.ehospitalistnews.com/
©2011 MFMER | 3127551-15 ©2011 MFMER | 3127551-16
Pre-op BSL targets/evidence

Take Home: Pre-op BSL / HbA1c
• Insufficient data to specifically recommend

preoperative fasting BSL or HbA1c above
which elective ambulatory surgery patients
should be postponed
Reasons for elevated pre-op BSL • Surgery should be postponed if significant

• Inadequate long-term glycemic control complications of hyperglycemia are present
• Inappropriate discontinuation of preoperative antidiabetic therapy • Severe dehydration, ketoacidosis, hyperosmolar nonketosis
• Preoperative stress response
• May be caused by the illness for which the patient needs surgery!
Alexanian, S et. al. Anesthesiology Research and Practice 2011 Anesth Analg 2010;111:1378-87
Review Article: Creating a Perioperative Glycemic Control Program AACE Diabetes Mellitus Guidelines, Endocr Pract. 2007;13(Suppl 1) 2007 63
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245
Pre-op summary Case #2
• History • 42yo female planned elective cholecystectomy after an episode
• control/adherence of acute cholecystitis 1 mo ago
• complications
• hypoglycemia awareness • Type II DM
• Exam • Meds:
• neuropathies • 30units BD 70/30 insulin
• cardiovascular abnormalities (micro/macrovascular) • Metformin 1000mg BD
• Lisinopril 5mg daily
• Investigations
• BSL • Sees Dr regularly, no known complications, reportedly good
control
• HbA1c
• ECG • First on the OR list in 7 days time
©2011 MFMER | 3127551-19 ©2011 MFMER | 3127551-20
How do you manage her diabetic Answer:

medications on the morning of surgery?
1) Half the dose of 70/30 and metformin the AM of surg
1) Half the dose of 70/30 and metformin the AM of surg
2) Hold metformin, continue 70/30 insulin without change

2) Hold metformin, continue 70/30 insulin without change
3) Hold both, check BSL’s post –op

3) Hold both, check BSL’s post –op
4) Withold metformin, give 1/2 of the intermediate (NPH)

4) Withold metformin, give 1/2 of the intermediate (NPH) component of the 70/30 insulin
component of the 70/30 insulin
©2011 MFMER | 3127551-21 ©2011 MFMER | 3127551-22
Perioperative Diabetes
Oral Hypoglycemics/Others
Bottom Line
• sulfonylureas - Glipizide, Glyburide, Chlorpropramide
• short acting insulin secretagogues - Nateglinide(starlix)Repaglinide(prandin)
• Hold all oral hypoglycemics/newer agents
• biguanides – Metformin on the AM of surgery
• thiazolinediones - Pioglitazone
• carbohydrase inhibitors - Acarbose, Miglitol • resume only when taking adequate PO
• DPP4 inhibitor - Sitagliptin (Januvia)
• GLP1 agonists – Exenatide (Byetta)
• SGLT2 inhibitors – Canagliflozin
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Management of Oral Hypoglycemics
metformin (cont)
• contraindication rigidly defined (in U.S.):
• Serum creatinine > 1.5 ♂, > 1.4 ♀
• Creatinine clearance < 60 mL/min
• CHF, hypoperfusion, old age (>80), chronic
pulmonary disease
• HOLD:
• 48 hrs prior to radiocontrast; 24 hrs prior to OR
• RESTART:
• 24-48 hrs post procedure if renal function OK
Metformin Drug Information

The Cochrane Collaboration 2010
Arch Intern Med 2002;162:434-437
©2011 MFMER | 3127551-25 ©2011 MFMER | 3127551-26
Perioperative Diabetes Oral Hypoglycemics: Management
Management of Oral Hypoglycemics
sulfonylureas
“…Recent evidence continues to indicate that lactic • HOLD:
acidosis is a rare complication despite the relative • Glipizide/Glyburide - night before or morning of procedure
frequency of risk factors. However, in the hospital,
where the risk of hypoxia, hypotension and renal • Nateglinide/Repaglinide - (short acting) morning of
procedure
insufficiency is increased, it is prudent to avoid the
use of metformin in most patients...”
• RESTART:
• when taking adequate PO
Clement, S et al. Diabetes Care 2004:27(2):553-591
©2011 MFMER | 3127551-27 ©2011 MFMER | 3127551-28
Perioperative Diabetes Perioperative Diabetes

Management of Oral Hypoglycemics Newer Agents
thiazolinediones:
• Sitagliptin (Januvia) – DPP4 Inhibitors
• slow onset and long duration of action
• Exenatide (Byetta) – GLP1 agonists
• HOLD/RESTART:
• can be continued morning of, and throughout
periop period
• No formal guidelines, hold both perioperatively!
• Caution: Hemodynamic changes/CHF or hepatic
dysfunction
Med Clin N Am 2009;93:1031-1047

Clement, S et al. Diabetes Care 2004:27(2):553-591
CCJM 2009;76(supp4):s53-s59
Marks, JB. AAFP 2003;67(1):93-100
©2011 MFMER | 3127551-29 Personal communication, K. Furlong 1/2010 ©2011 MFMER | 3127551-30
247
Hold ‘em Perioperative Diabetes
Glycemic control considerations
• Duration of procedure
• Pre-op diabetes control
• Post-op complications and/or expected LOS
©2011 MFMER | 3127551-31 ©2011 MFMER | 3127551-32
Preop Insulin Management
Case #2
• basal insulin (Lantus/Glargine)
• continued without dose change • Given 20 units NPH on AM of surgery
• consider decrease by 50% in type 2 DM • Metformin held AM
• intermediate acting insulin (NPH) • Post – op day #0 - receives an additional 20 units of

NPH in evening – resumes fluids
• 1/2 to 2/3 of the usual dose the evening
before and morning of surgery
• Post - op day #1 – resume 70/30 insulin
• fast acting/immediate (regular/Lispro) • continue to hold vs. restarting metformin (check creatinine,
dehydration status)
• not given the morning of surgery
CCJM 2006;73(s1):s95-s99
Anesthesia Clin N Am. 2004; 22:93-123
©2011 MFMER | 3127551-33 ©2011 MFMER | 3127551-34
Case #3 Case #3
• 55yo male sent to ER by local free medical clinic due
to concerns about his infected foot
• Admitted for surgical debridement
• Hx of poorly managed DM, CAD, HTN…
• Medicine consult – HELP!
• Meds ?
• SH: + tobacco, + alcohol
©2011 MFMER | 3127551-35 ©2011 MFMER | 3127551-36
248
Case #3 Question
Case #3 How should we manage this patients diabetes
perioperatively?
• Exam:
1) Sliding Scale Insulin
• T: 98, P:100, BP: 170/95
• BSL – 305mg/dl 2) NPH or Lantus insulin + bolus correction
3) Continuous insulin infusion (CII) with a target BSL

between 140 – 180 mg/dl
4) CII with a target insulin < 110mg/dl (< 6.2mmol/L)
©2011 MFMER | 3127551-37 ©2011 MFMER | 3127551-38
Answer:
Considerations
1) Sliding Scale Insulin
• Multiple risks – including presumed CKD

2) NPH or Lantus insulin + bolus correction
• Poor control pre-op
3) Continuous insulin infusion (CII) with a target
BSL between 140 – 180 mg/dl
• Neuropathies – peripheral, autonomic/gastroparesis
4) CII with a target insulin < 110mg/dl (<
6.2mmol/L)
©2011 MFMER | 3127551-39 ©2011 MFMER | 3127551-40
Perioperative glycemic control Hyperglycemia/Insulin Management

Continuous Insulin Infusion (CII):
• Start insulin infusion • best way to maintain glycemic control in perioperative

• Suspect poor control period
• Oral hypoglycemics inadequate +

unpredictable hospital LOS, fasting… • start 2 hours prior to surgery
• Easiest to adjust to proper BSL targets
• frequent glucose monitoring Q1-2 hrs and as needed
• What are our targets? • monitor electrolytes
©2011 MFMER | 3127551-41 ©2011 MFMER | 3127551-42
249
Phagocyte Dysfunction
Increased infections
Immune function
Impairs Ischemic Preconditioning

Increased infarct size
Cardiovascular Reduced coronary collateral blood flow
Catecholamine elevations
Thrombosis Increased platelet activation

Reduced fibrinolytic activity
Hyperglycemia
Inflammation Increased IL-6
Increased TNF
Endothelial Cell
Inactivation of NO
Dysfunction
Increased permeability
The Brain Enhanced neuronal damage

Increased lactate
Diabetes Care 2004:27(2):553-591 Cell and tissue injury

Oxidative Stress
Reactive oxygen species
©2011 MFMER | 3127551-43 ©2011 MFMER | 3127551-44
Intensive Insulin
Not so Intensive Insulin
NEJM 2010;363(15):1410 - 18
©2011 MFMER | 3127551-45 ©2011 MFMER | 3127551-46
Insulin Therapy in Hospitalized Patients

Sample Insulin Infusion
• Critically Ill:
• initial target < 180 mg/dl (10 mmol/l)
• 140 – 180 mg/dl on IV insulin therapy
• “somewhat lower in some patients”
• < 110 mg/dl (6.2 mmol/l) not recommended
• Noncritically Ill:
• Premeal < 140mg/dl (7.8 mmol/l)
• Random < 180 mg/dl
Diabetes Care 2010;33(s1):s11-s61
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Insulin Sliding Scale
• “corrective” insulin
Perioperative Diabetes • avoid as only means of glucose control

Odds & Ends + Special situations
• useful adjunct to long acting regimens
• Basal / Bolus / Boost!
©2011 MFMER | 3127551-49 ©2011 MFMER | 3127551-50
Rabbit II Surgery Results:
Decreased composite complications in G & g group
Increased hypoglycemic episodes

SSI 4x / day
Prospective trial
Type 2 DM
Pre-op antidiabetic meds discontinued
SSI vs. Glargine / glulysine
0.5 U/kg/day divided into G & g
Glargine & glulysine
Diabetes Care 34:256–261, 2011

©2011 MFMER | 3127551-51 ©2011 MFMER | 3127551-52
Insulin Pump Management
• Limited data, no trials specific for pump management
• Management dependent on:

• type of surgery
• duration
• anesthesiology familiarity/comfort
• Communication essential
• Generally:
• discontinue insulin pump preoperatively and start
continuous insulin infusion IV
• restart insulin pump when patient is alert & awake
and taking adequate PO
“Perioperative Management of Endocrine Disorders” in

Medical Management of the Surgical Patient 2008 Current Pharmaceutical Design 2012:18;6204-6214
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251
Hyperglycemia with TPN Hyperglycemia with TF
• Total Parenteral Nutrition (TPN)
• Majority of patients require insulin • Tube Feeding (TF) - complicated by regimen
• higher insulin requirements than enteral (lack of GLP -1) • Start with Continuous insulin infusion
• Consider cutting insulin dose by 1/2 when changing
from TPN to enteral • Bolus TF
• can use basal/bolus regimen
• Start IV infusion with TPN x 24hrs
• overnight or continuous TF
• 70/30 insulin one time vs Q8H with regular insulin coverage Q4H
• Add 60-80% of 24 hour total to TPN bag then correct every • Q6H regular insulin + sliding scale for continuous TF
4-6hrs with fast or rapid acting insulin
CCJM 2006;73(S1):S95-S99
CCJM 2006;73(S1):S95-S99
Medical Management of the Surgical Patient 2008 “Perioperative Management of Endocrine Disorders” in
©2011 MFMER | 3127551-55 Medical Management of the Surgical Patient 2008 ©2011 MFMER | 3127551-56
Perioperative Diabetes Perioperative Diabetes
Steroid Induced Hyperglycemia Steroid Induced Hyperglycemia

• Common & complicated • Insulin is drug of choice
• dose of steroid, duration, patient’s understanding, degree of • Prandial insulin with short acting agents
hyperglycemia • Glargine – if longer acting steroid, (dexamethasone)
• NPH – if using prednisone; maximize AM dose,
• Pathogenesis minimize PM dose
• hepatic gluconeogenesis • 50:50 Basal:Bolus - normal insulin therapy
• peripheral insulin resistance
• 30:70 Basal:Bolus - steroid induced hyperglycemia
• Often manifests as post-prandial hyperglycemia
• Other Literature Recommendations - Oral agents
• 2-3 fold increase in total daily insulin dose may be • Repaglinide (prandin) with meals
required with high dose steroid therapy
• Glipizide in AM
Diabetes Care 2004:27(2):553-591 “Perioperative Management of Endocrine Disorders” in Medical Management of the Surgical Patient 2008
Personal communication, K. Furlong 1/2010 J Hosp Med 2007;2(s1):23-32
©2011 MFMER | 3127551-57 ©2011 MFMER | 3127551-58
COPD exacerbations on Prednisone with

Continuous Glucose Monitoring (CGM)
NPH
J Clin Endocrinol Metab 96: 1789–1796, 2011

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252
An Overview of
Perioperative Medicine 2013: Perioperative Nephrology
to Inpatient Postoperative Care Issues
Mayo School of Continuous Professional Development Mayo School of Continuous Professional Development
Amy W. Williams, MD
October 9-12, 2013 Grand Hyatt Seattle Seattle, Washington Amy W. Williams MD
Division of Nephrology and Hypertension
©2011 MFMER | 3127551-1 ©2011 MFMER | 3127551-2
Case #1
85 year old women on hemodialysis three times a
• Disclosures week via a left arm AV fistula. Her left arm is
massively swollen due to a proximal stenosis.
None to report
She has now developed a nonhealing ulcer on
her left hand.
She is scheduled for ligation of the left AV fistula
and creation of a right arm AV fistula under
general anesthetic
She refuses to have general anesthetic as
someone told her never to have it because she
would die
©2011 MFMER | 3127551-3 ©2011 MFMER | 3127551-4
Case #1 Case #1
Significant medical history What do you tell her ?
• Atrial fibrillation since 2007, not currently on 1. Her risk of perioperative death is < 10%.
warfarin due to fall risk.
2. Her risk of perioperative death is 45%.
• S/P permanent pacemaker placement for sick
sinus syndrome (2007) which was subsequently 3. Her risk of perioperative death is high and there
removed 7/2008 due to endocarditis. is nothing that can be done to improve it.
• S/P lumbar osteomyelitis 4. Dialysis right after surgery will improve her risk.
5. Transfusions to get her Hemoglobin to a normal
level will decrease her perioperative risk of
death
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Perioperative Nephrology Issues Why is this important?
• > 300,000 people in the US on dialysis
ESRD patients
• > 26 million people in the US have CKD
increased surgical mortality
• 11 million have stage 3 CKD
• Elective general surgery 4% mortality (GFR<60mL/min/1.73m2)
• Cardiac surgery 10% mortality • 6.6 million age >60 years have stage 3 CKD
• Emergency surgery 45% mortality
• 10-16% of the world population has CKD
• Causes: Sepsis & CVD
©2011 MFMER | 3127551-7 ©2011 MFMER | slide-8
Stages of Chronic Kidney Disease & Recommended

ESRD patients undergoing surgery Clinical Action
have
Risks canincrease morbidity
be present in CKD Stage Description GFR Action
ml/min/1.73m2
50% morbidity At Increased risk >90 with Screening
0 CKD risk CKD risk reduction
factors
Causes of perioperative morbidity 1 Kidney damage with
normal or  GFR  90
Dx & Rx of common conditions
Slow progression, CVD risk 
Kidney damage with
• Decreased ability to: • Anemia 2 Mild  GFR 60 - 89 Estimating progression
• Regulate sodium and • Platelet dysfunction – 3 Moderate  GFR
volume bleeding 30 - 59 Evaluating and treating complications
Preparation for renal
• Handle acid loads 4 Severe  GFR 15 - 29 replacement therapy
• Arrhythmias
• Excrete potassium 5 <15 or
Kidney failure dialysis Replacement if uremia present
• Excrete medications • Infections NKF, Am J Kidney Dis.2002;39(suppl 1):S 1-S266
• CVD
©2011 MFMER | slide-9 ©2011 MFMER | 3127551-10
Stages of Chronic Kidney Disease & Recommended Increased surgical risk: Advanced CKD &
Clinical Action
ESRD multi-system involvement
Stage Description GFR Action
ml/min/1.73m2
Increased Risk for • Co-morbid illnesses • Malnutrition
At Increased risk >90 with Screening
0 Cardiovascular & • Diabetes Mellitus
CKD risk
Cerebrovascular
factors disease
CKD risk reduction • Multiple medications
• HTN
1 Kidney damage with
normal or  GFR  90
Dx & Rx of common conditions
Slow progression, CVD risk 
• Altered volume status
• CAD/heart disease
2 Kidney damage with
Mild  GFR 60 - 89 Estimating progression • PVD • Electrolyte /acid-base
imbalances
3 Moderate  GFR 30 - 59 Evaluating and treating complications
• Autonomic dysfunction
Preparation for renal • Cerebral VD • Abnormal coagulation
4 Severe  GFR 15 - 29 replacement therapy
<15 or
• Pulmonary disease
5 Kidney failure dialysis Replacement if uremia present • Immune mediated
NKF, Am J Kidney Dis.2002;39(suppl 1):S 1-S266
diseases
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Major Adverse Cardiac & Cerebrovascular Events after
Non-Cardiac Surgery –
Can you predict who is at risk? Independent Predictors of MACCE
3387 patients: 4.3% had at least one MACCE • History of CAD
• Arrhythmia • History of CHF
• 13.7% died from a
• CHF MACCE • CKD
• Angina • History of Cerebrovascular disease
• Stroke • Abnormal ECG
• MI • Intraoperative Hypotension
• Non-fatal cardiac arrest • RBC Transfusions
S. Sabate, et al. British Journal of Anesthesia. 107 (6):879-90. 2011
CKD5 is a major risk factor in patients

undergoing elective vascular surgery.
Independent Predictors of MACCE James C. Iannuzzi, MD, University of Rochester, NY
• History of CAD 47,704 patients

• History of CHF 1324 (2.8%) with CKD5
• CKD
CKD Morality CKD5 - 8% vs. 2%; P < .001
• History of Cerebrovascular disease • 2.92 adjusted odds ratio for mortality
• Abnormal ECG • 3-fold increased risk for cardiac complications
• 50% greater risk for major complications (39% vs. 21%,
• Intraoperative Hypotension P < .001)
• RBC Transfusions • Hospital stay was approximately twice as long
American College of Surgeons (ACS) 98th Annual Clinical Congress:
Abstract NP2012-23767. Presented October 3, 2012.
Predictors of major postoperative

complications with CKD5 Perioperative goals for patients
• Functional status Predictors of mortality in CKD5
multivariate analysis
• Race - Black
• Wound class
• older than 75 years • Euvolemic • Normokalemic
• • transfer status. • Not anemic
Diabetes • Normotensive
• Pulmonary co morbidities • Normonatremic • Normal platelet
• Cardiac co morbidities function/coagulation
profile
• Anemia.
American College of Surgeons (ACS) 98th Annual Clinical Congress:
Abstract NP2012-23767. Presented October 3, 2012.
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Pre-op Laboratory Evaluation
Preparing the ESRD & Advanced CKD Patient Emergent Attention/Risk Assessment
for Surgery 1. Anemia Hgb
• Lab evaluation • Correction of bleeding 2. Bleeding diathesis BUN, Hgb
• Nutritional status diathesis 3. Metabolic Acidosis Bicarbonate
• Anemia • Antibiotic administration 4. Sodium abnormalities Sodium
• Fluid and electrolyte • IV access 5. Hyperkalemia Potassium
balance
• Glucose metabolism • Anesthetic considerations 6. Metabolic bone disease Calcium, phosphorus, magnesium
• Blood pressure control • ESRD -Dialysis dose/method 7. Uremia Creatinine, BUN
• CVD risk evaluation and • CKD - Prevention of ARF & 8. Nutrition Albumin
need for renal replacement
management 9. Diabetes Glucose
©2011 MFMER | 3127551-19 ©2011 MFMER | 3127551-20
Preoperative Management: Uremic Bleeding Diathesis

ESRD/CKD
Anemia • Decreased platelet adhesiveness
Goal: Hct 25% - 30% • Abnormal factor VIII activity
Treatment: When to treat?
• Increase erythropoietin pre-op • High BUN or evidence of uremia
• Intra- and postoperative excessive bleeding
• need time for results ESRD - best to Treatment
• RBC Transfusion transfuse on dialysis
• Transfuse - HCT 30%
Improves platelet-vessel wall interaction normalizing • Dialysis
bleeding time
• Cryoprecipitate (10 bags)
Large K load: check K pre & post transfusion
• l-desamino-8-arginine vasopressin (DDAVP)
Significant volume: check volume status pre & post
0.3 ug/kg IV or 3.0 ug/kg intranasal
each unit
©2011 MFMER | 3127551-21 ©2011 MFMER | 3127551-22
Case #1 continued Preparing the ESRD patient for surgery

The patient normally dialyzes M-W-F. Her surgery is
on a Thursday. Based on this, you schedule her
dialysis to • Anemia
1. occur two consecutive days prior to surgery
2. to be longer the day before surgery • Metabolic acidosis
3. to occur as usual (no change) • Hyperkalemia Treatment is

4. occur the AM of surgery • Fluid overload Dialysis
5. occur as usual on Wednesday but without • Uremia
heparin
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ESRD Preoperative Management: ESRD Preoperative Management:
Dialysis Dialysis
• Timing before surgery
• Corrects electrolyte imbalances
• Immediately post dialysis – hypokalemia, • Elective surgery - dialyze the day before
hypercalcemia, metabolic alkalosis • Emergent surgery - can dialyze pre-op
• Removes excess fluid with
• If hypovolemic, anesthesia-induced systemic • Dialysate prescription to avoid hypokalemia
vasodilatation can lead to profound hypotension
• Careful fluid removal
• Can transfuse if needed • Discuss goals for peri-op volume status
• Involves heparin use with surgeon and anesthesiologist
• No heparin
©2011 MFMER | 3127551-25 ©2011 MFMER | 3127551-26
Fluid & Electrolyte Balance

Fluid & Electrolyte Balance Postoperative Management
ESRD Perioperative Management ESRD Rx: Dialysis
Intra- & Post- operative Abnormalities Pre-dialysis Post-dialysis

Metabolic acidosis Metabolic Alkalosis
Metabolic acidosis
Hyperkalemia Hypokalemia
Hypervolemia Hypovolemia
Hyperkalemia
Hyperphosphatemia Hypophosphatemia
Hypovolemia or Hypervolemia
Hemodynamic instability
©2011 MFMER | 3127551-27 ©2011 MFMER | 3127551-28
Fluid & Electrolyte Balance

Postoperative Management Perioperative Management
ESRD Rx: Dialysis ESRD & CKD
1. Daily hemodialysis Hyperkalemia
2. Continuous renal replacement therapy If EKG changes – Rx emergently
 Less electrolyte and osmolality changes
 Allows for achieving a more true dry weight 1. Calcium gluconate
ESRD 2. Insulin/glucose
 Improved hemodynamic stability Most
effective 3. B-adrenergic agonists
3. Best to wait 12-24 hours postop for daily or 4. Bicarbonate
intermittent dialysis ESRD
Effective only with severe
4. Peritoneal dialysis – continuous Metabolic acidosis
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Perioperative Management
ESRD & CKD Case #2
52 year old ESRD patient develops an acutely
Hyperkalemia incarcerated abdominal wall hernia and needs
emergent surgery. He is in extreme pain.
If EKG changes – Rx emergently
He dialyzes M-W-F and it is now Sunday at 9PM
To remove K
ESRD - dialysis Exchange Resins He is 2L above his dry weight, but lungs are clear
and he has no edema.
CKD Caution
If urine output - Intestinal Necrosis Labs: Na 132 mmol/L K 5.9 mmol/L
Loop diuretic and Risks: Creatinine 5.9 mg/dL BUN 58mg/dL
Decreased motility
IV fluid replacement
Hypertonic sorbitol
Cation exchange resin
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Case #2 Hyperkalemia and Emergency Surgery

The surgeon feels the patient needs emergent
surgery and asks you if anything further needs ECG first
to be done prior to going to the OR.
You recommend: • ECG changes result from
1. Emergent dialysis • Changes in transcellular K gradient
• Not absolute value
2. Kayexalate PO
3. Perioperative LR solution at 100cc’s hour
• Chronic dialysis patients – tolerance
4. Emergent ECG
• ECG changes may not occur until K >6.0
5. Patient go directly to the OR
©2011 MFMER | 3127551-33 ©2011 MFMER | 3127551-34
ESRD, Hyperkalemia & Emergency Surgery Peri-operative fluid management

K > 5.5
ECG Changes ? ESRD CKD
YES NO
• replace losses
• 3rd spacing + Urine output
Time for pre-operative dialysis ? • GI losses
• Insensible losses (including wound)
NO YES
Dialysis
• No need for maintenance fluids if anuric
Medical therapy Check K
•IV Ca gluconate • Standard solution: Normal Saline
•Glucose & insulin • Avoid Lactated Ringers, or other K containing
Surgery Dialysis solutions
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Perioperative Hypertension
ESRD and CKD Postoperative Hypertension
ESRD and CKD
Pre and Post -Op
 If NPO
Post-op and taking PO
• IV analaprilat Caution with advanced CKD
• Hydralazine (with B-Blocker) 1. ARF

2. Hyperkalemia  Careful, graduated reinstitution of
• labetalol normal antihypertensive regimen
• diltiazem  Fluid removal – gently
• Nitroprusside ( cyanide poisoning) • ESRD – dialysis, CKD - loop diuretic
 Fluid removal: gently ESRD – dialysis, CKD - loop

diuretic
©2011 MFMER | 3127551-37 ©2011 MFMER | 3127551-38
Perioperative Hypotension Postoperative

Causes in ESRD & advanced CKD Inter and Intra-dialytic Hypotension
1. Dialysis 4. Sympathetic dysfunction • Too much or too rapid fluid pull on dialysis
due to • Third spacing
• Fluid removal
• Diabetic neuropathy
• Electrolyte, and • Increased insensible loss or unrecognized GI losses and
osmolality changes • Acquired dystonia of drainages
recumbency
2. Left ventricular • Sympatholytic • Myocardial dysfunction
dysfunction medications • Antihypertension medications (are all the preop BP meds
3. Vasodilation – meds 5. Pericardial tamponade needed ?)
• Opiod analgesics • Infection
• Anti-anxiety meds
• Pain medication
• Exaggerated peripheral vasodilatation (worsened by anemia)
©2011 MFMER | 3127551-39 ©2011 MFMER | 3127551-40
Evaluation of Cardiac Risk Evaluation of Cardiac Risk

ESRD and CKD ESRD & CKD (with CV risks)
Myocardial Function Assessment
High risk for CVD Mortality from CVD
 Left ventricular dysfunction increases surgical morbidity and
 Inflammatory state ESRD = 10 X Non-ESRD mortality
 Hypertension ESRD + DM = 44 X Non-ESRD
• Evaluate with Echocardiogram
 Coronary Artery Disease • Identifies patients at higher risk
 Impaired Cardiac Function (CHF, LVH) • Guides perioperative management
 Hyperlipidemia • Fluid management –dialysis management and timing

• Guide medical management of cardiac function
 Anemia
• Indicate need for intra- and peri-operative monitoring
 Hyperphosphatemia, decreased Vit D
 Proteinuria
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259
Case 4: At this point, which test to you recommend
ESRD to further evaluate.
62 year old women on hemodialysis presents to
the emergency room with abdominal pain. Her A. CT with contrast
exam is consistent with a small bowel
obstruction. She is afebrile and her WBCs is B. CT without contrast
normal. An abdominal film is also consistent C. MRI with gadolinium
with a small bowel obstruction.
D. CT with contrast with hemodialysis
BP 160/82 P 76 immediately after
1+ LE edema E. Bolus with IV fluids
Lungs: Free bibasilar crackles F. NSAIDs to control the pain
Gadolinium Gadolinium
Nephrogenic Systemic Fibrosis (NSF) Nephrogenic Systemic Fibrosis (NSF)
Risk Factors Risk Factors
• Proinflammatory • Metabolic • Proinflammatory • Metabolic

states abnormalities states abnormalities
• Infection • Hyperphosphatemia • Infection • Hyperphosphatemia
• Connective tissue • Hypercalcemia • Connective tissue • Hypercalcemia
disease • Acidosis disease • Acidosis
• Major surgery • Iron overload • Major surgery
CKD stage • risk
Iron overload
• Hypercoagulable • Therapeutic agents 1-3

• Hypercoagulable low agents
• Therapeutic
state • High dose ESA state 4 moderate
• High dose ESA
• IV iron 5 • IV iron
HIGH
• Liver failure • Liver failure
• Hepatorenal syndrome • Hepatorenal syndrome
• Liver transplant • Liver transplant
Do you need to worry about Nephrotoxins

NSF once on dialysis?
Prevention • Residual renal function is important with ESRD
• Use only macrocyclic gadolinium • Improves survival
• Use lowest dose possible • Improves fluid and electrolyte balance
• Avoid IV iron and ESA before and after • Allows adequate total clearance with less
gadolinium dialysis
• Avoid nephrotoxins to preserve residual
• Optimize calcium, phosphorus, acid/base status renal function (contrast dye, NSAIDs)
prior to exposure
• Dialysis on any kind will not protect against
• HD post gadolinium exposure contrast nephropathy
260
Case #3 Case #3
78 year old man with squamous cell CA of the
tongue is scheduled for extensive ENT surgery. You discuss the case with the surgeon and
He has stage 4 CKD (GFR 28ml/min, Cr recommend which measure(s) to prevent AKI:
1.8mg/dL) due to a nephrotic glomerular 1. No real caution needed, this degree of CKD is not a risk for
disease. He never wants to go on dialysis. acute kidney injury (AKI)
2. In the perioperative period maintain strict BP control
3. If urine output decreases to < 35cc/hour give IV loop
diuretics.
4. There is no increase in mortality until the creatinine doubles.
5. Hypotension is the insult most likely to cause AKI.
©2011 MFMER | 3127551-49 ©2011 MFMER | 3127551-50
Stages of Chronic Kidney Disease & Recommended

Clinical Action AKI in the Hospital
Stage Description GFR
ml/min/1.73m2
Action • occurs in 4-7.2% of all hospitalized patients
0 At Increased risk >90 with Screening • 0.3 increase in creatinine = increased mortality
CKD risk CKD risk reduction
CKD is a risk factor for Acute Kidney Injuryfactors • >0.5 increase in creatinine = 6.5 x increase in odds
1 Kidney damage with Dx & Rx of common conditions of death Cherrow GM. et al. J Am Soc Nephrol 2005;16:3365-70
normal or  GFR  90 Slow progression, CVD risk 
Kidney damage with
2 Mild  GFR 60 - 89 Estimating progression • most common etiologies of AKI
3 • Decreased renal perfusion
Moderate  GFR 30 - 59 Evaluating and treating complications
Preparation for renal
• Medications
4 Severe  GFR 15 - 29 replacement therapy • IV contrast
5 <15 or • Post-op status
Kidney failure dialysis Replacement if uremia present
NKF, Am J Kidney Dis.2002;39(suppl 1):S 1-S266
• Sepsis
Nash K. et al. J Am Soc Nephrol 2002;39:930-6
©2011 MFMER | 3127551-51 ©2011 MFMER | 3127551-52
CKD - Prevent AKI & the need for renal Contrast Nephropathy
replacement Who Is At Risk?
• Maintain renal blood flow • Creatinines < 2mg/dl - Diabetics
• Cautiously use ACE/ARB
• Avoid pre-renal azotemia
• Creatinines > 2mg/dl
• Avoid NSAID • Volume depletion
• Avoid renotoxic medications • CHF
• aminoglycoside • NSAID, Cyclosporin, meds that decrease RBF (ARB,
ACE)
• Avoid electrolyte disturbances
• Hyperkalemia • Advanced age > 80 years
• Metabolic acidosis • ? Multiple myeloma (nephrotic syndrome)
• Hypo- & hypernatremia
• Repeated exposure within 72 hours
• Avoid contrast dye
• Multiple risk factors are additive
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Strategies to Prevent Contrast Nephropathy Strategies to Prevent Contrast Nephropathy
What has not been proven to work: What has been proven to work:
• HemoDialysis/hemofiltration post contrast

• Hydration IV .9NS or Oral
• Fenoldopam
• Avoid high osmolality contrast
• Sodium Bicarbonate infusion
• Avoid repeated exposures
• N-Acetylcysteine ? Higher doses Pannu N. JAMA. 2006
Marenzi G, Curr Opin Crit Care. 2004
From AM,. (Abstract) American Society of Nephrology, 2006
©2011 MFMER | 3127551-55 ©2011 MFMER | 3127551-56
Case # 4
Which of the following will most negatively
58 year old man is s/p mitral and aortic valve replacement impact his survival on long term dialysis?
due to severe endocarditis which destroyed both valves.
His is in respiratory failure - ventilator dependent, on 1. His respiratory failure requiring ventilator
multiple pressors due to a systemic inflammatory support
response and has developed anuric acute kidney injury
requiring continuous renal replacement therapy. 2. His multisystem failure
Exam: he is intubated, ventilated, sedated 3. Requiring continuous renal replacement
He has a temporary dialysis catheter in the L IJ, an art therapy
line in his R arm and a PICC (triple lumen) in the L arm
and a feeding tube in place
4. His PICC line
BP 89/48 p 68 5. His need for a feeding tube
4+ edema
©2011 MFMER | 3127551-57 ©2011 MFMER | 3127551-58
Hemodialysis access
Arteriovenous fistula is the best AVF vs Graft or Central Venous Catheter
• Lack of an AVF is associated with • AVF - better patency rates
• Increased hospitalizations • AVF - fewer complications
• Infections
• Inadequate dialysis • AVF – lower mortality
• Increased mortality • AVF – improved dialysis adequacy
• Previous Peripherally inserted central venous
catheter (PICC)
• 46-100% incidence of stenosis after subclavian vein • CVC – 5x risk of bacteremia
puncture
• unrelated to duration or size of the catheter
262
ABIM Foundation/Consumer Reports Preserve UE veins!
Choosing Wisely Campaign • PICCS and Central Venous Complications
ASN recommendation #4: • 38%Allenincidence of central vein thrombosis
AW, et al. J Vasc Interv Radiol 2000
“Do not place peripherally inserted • 42% incidence of central vein stenosis
Gonsalves CF, et al.Cardiovasc Intervent Radiol 2003
central venous catheters (PICC) in
stage 3-5 patients without consulting • 46-100% incidence of subclavian stenosis
Nephrology” after subclavian puncture
Barrett N, et al. Nephrol Dial Transplant 1988, Schwab SJ, et al.Kidney Int 1988
Spinowitz BS, et al. Arch Intern Med 1987
• Prior PICC is a strong, independent

predictor of a lack of a functioning AVF
ABIM Foundation. Choosing Wisely. http://choosingwisely.org/. Philadelphia, PA. April 4, 2012 El Ters M, et al. Am J Kidney Dis 2012
Perioperative Recommendations for

Patients with ESRD & CKD
Recommendations to preserve Veins in CKD
• Document renal function pre-op and monitor for changes in GFR
• Avoid PICC and subclavian punctures • Adjust medication doses for GFR
No aluminum containing medications
• Protect the non-dominant arm from blood •
draws and IV cannulations • Monitor electrolytes, Mg, Phos

• Avoid K containing IV maintenance fluids
• Use only the dorsum of the hand if needed • Careful monitoring and management of blood glucose
• Educate patients and health care professionals • Closely monitor and optimize intravascular volume
• Avoid nephrotoxins (NSAID, contrast)
• Avoid gadolinium when GFR is ≤ 20
• Avoid upper extremity IV access/PICC lines
• Preserve veins for AVF
Perioperative Management of Patients with References

ESRD & CKD
1. Craig R.G., Hunter J.M.. Recent developments in the perioperative management of
adult patients with chronic kidney disease. Br J. Anaesth 2008; 101: 286-310
Multi-disciplinary team approach 2. Marenzi G., et al. Contrast volume during primary percutaneous coronary intervention
and subsequent contrast-induced nephropathy and mortality. Ann Intern Med 2009;
150: 170-177
3. Marathias K.P., et al. Preoperative intravenous hydration confers renoprotection in
Surgeon General Internist patients with chronic kidney disease undergoing cardiac surgery. Artifical organs
2006;30(8):615-621
Primary Physician 4. Fishbane S.. Cardiovascular risk evaluation before kidney transplantation. J Am Soc
Nephrol 2005;16: 843-845
5. Heher E.C., et. al. Adverse Renal and Metabolic Effects Associated with Oral Sodium
Anesthesiologist Phosphate Bowel Preparation. Clin J Am Soc Nephrol 2008; 3: 1494-1503
Patient 6. Ishani A., et. al. Acute Kidney Injury Increases Risk of ESRD among Elderly. J Am
Soc Nephrol 2009; 20;223-228
Nurse 7. Palevsky P. M. Perioperative management of patients with chronic kidney disease or
Allied Health ESRD. Best Practice & Research, Clinical Anesthesiology 2004; 18(1); 129-144
8. Eilers H., et al. Chronic Kidney Disease: implications for the perioperative period.
Nephrologist Minerva Anestesiologica. 2010;76;725-736
Pharmacist
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264
Disclosures
An Overview of
• No relevant financial disclosures
Delirium in the Surgical Patient • I have a second job which generates $0
• My 15 year old son is the reason that all my
hair turned grey!

Margaret M. Beliveau MD
Division of General Internal Medicine
©2011 MFMER | 3127551-1 ©2011 MFMER | 3127551-2
Objectives Delirium
• Discuss the incidence, impact and • An acute change in mental status
pathogenesis of postoperative delirium
• Inattention
• Review the risk factors for postoperative • Fluctuating course
delirium
• Understand diagnosis and management of • Disorganized thinking
postoperative delirium
• Review persistent delirium and postoperative
cognitive dysfunction
©2011 MFMER | 3127551-3 ©2011 MFMER | 3127551-4
Delirium Emergence Delirium

• Cognitive deficits • Occurs during the transition from anesthesia to
wakefulness
• Perceptual disturbances
• Psychomotor changes
• Characterized by agitation and hyperactivity
• Altered sleep wake cycle
• Generally short- lived
• Emotional disturbances
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265
Impact Impact
• Increased mortality • Common cause of postoperative morbidity and
mortality
• Increased length of stay
• Increased rate of discharge to long term care • 50% of all surgeries in the US are done on
people over age 65
facilities
• Increased risk of major medical complications • Depending on surgery, approximately 10% will
develop delirium
• MI
• Pulmonary edema • Highest risk in patients having hip fracture
surgery and CABG
• Respiratory failure
• pneumonia
©2011 MFMER | 3127551-7 ©2011 MFMER | 3127551-8
Impact Pathophysiology
• Patients who developed delirium had 62% • Not well understood
greater risk of mortality within 1 year after
discharge and lived an average of 274 days vs • EEG- diffuse slowing of cortical background
321 days for those without delirium (Leslie DL. • Neuroimaging-generalized disruption of higher
Arch Int Med 2005) cortical function
• Total direct healthcare costs attributable to
delirium about $143 billion annually (Leslie DL.
JAGS 2011)
©2011 MFMER | 3127551-9 ©2011 MFMER | 3127551-10
Pathophysiology Pathophysiology
Neurotransmission Inflammation
• Cholinergic deficiency • Increased proinflammatory cytokines increased
in delirium
• Anticholinergic drugs
• Physostigmine and cholinesterase inhibitors • Cytokines may alter blood-brain barrier and
neurotransmission
• ? perivascular edema> hypoxia>
• decreased synthesis of acetylcholine
Hala M. Med Hypotheses 2007
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Case 1 Case 1
• A 76 year old woman undergoes a right L5 • Postoperatively, she has some mild
foraminotomy and L5-S1 fusion. Past history hypoxemia, thought to be due to narcotics.
significant for “Mixed Connective Tissue
Disease”. Medications preoperatively: • POD #0- no sleep
Prednisone, Plaquenil, Celebrex, Nortriptyline, • AM rounds: easily startled, irritable, restless
Coumadin and Ultram
©2011 MFMER | 3127551-13 ©2011 MFMER | 3127551-14
What is the best way to determine if this What is the best way to determine if this
patient has delirium? patient has delirium?
1. Request a psychiatry evaluation 1. Request a psychiatry evaluation
2. CAM (Confusion Assessment Method) 2. CAM (Confusion Assessment Method)
3. Folstein mini-mental status exam 3. Folstein mini-mental status exam
4. MRI of her brain 4. MRI of her brain
5. MMPI 5. MMPI
©2011 MFMER | 3127551-15 ©2011 MFMER | 3127551-16
Diagnosis Diagnosis
Diagnostic tools for delirium: • Confusion Assessment Method (CAM)
• Folstein MMSE • More useful in diagnosing delirium
• Most helpful if baseline MMSE done • Input from caregivers and family
previously • Studied mostly in the assessment of
• Very good at predicting cognitive impairment postoperative delirium
• Cannot easily distinguish between delirium • 94-100% sensitive
and dementia • 90-95% specific
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Diagnosis Diagnosis
• Recent JAMA study: CAM is the most reliable 1. Acute onset and fluctuating course
instrument for the evaluation of delirium
2. Inattention
• Takes about 5 minutes to administer 3. Disorganized thinking
4. Altered level of consciousness
Diagnosis of delirium requires the presence of
both 1 and 2 and either 3 or 4
Wong et al JAMA 2010;304(7):779-786
©2011 MFMER | 3127551-19 ©2011 MFMER | 3127551-20
Confusion Assessment Method Confusion Assessment Method

• Have we met before? • Have you had any problems with confusion or
disorientation since the operation?
• What surgery have you had done?
• What surgeon did the procedure?
• Have you seen or heard things that aren’t really
there?
• How long ago was the procedure? • How much pain are you having on a scale of 1-
• How are things going today? 10?
• Please count backwards from 20-1
Marcantonio JAMA 1994;271:134
©2011 MFMER | 3127551-21 ©2011 MFMER | 3127551-22
Confusion Assessment Method Confusion Assessment Method

• Feature 1: Acute onset and fluctuating course • Feature 3: Disorganized thinking
• Acute change in mental status? • Speech disorganized or incoherent?
• Has the behavior fluctuated in the past 24 • Illogical flow of ideas?
hours?
• Feature 4: Altered level of consciousness
• Feature 2: Inattention • Vigilant
• Difficulty focusing attention? • Lethargic
• Distractible? • Stupor
• Difficulty keeping track of conversation? • Coma
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Case 2 Case 2
• 66 year old woman with multiple medical • Medications: Lisinopril, digoxin
problems is admitted for repair of a right hip • BMI=46
fracture.
• Unknown functional status
• Medical issues include: • Possible history of bipolar disorder, and bizarre
• Hypertension behavior
• Untreated OSA • On admission, appeared to be oriented, answered most
• Atrial fibrillation, history of RVR questions appropriately
• CAD • Normal vital signs, heart rate 60, atrial fibrillation
• CHF
• Labs normal, except UA showed 20-50 WBC’s
• History of previous perioperative DVT
©2011 MFMER | 3127551-25 ©2011 MFMER | 3127551-26
Which of the following puts her at Which of the following puts her at
increased risk for postoperative delirium? increased risk for postoperative delirium?
1. Morbid obesity 1. Morbid obesity
2. Digoxin use 2. Digoxin use
3. Multiple co-morbidities 3. Multiple co-morbidities
4. Atrial fibrillation 4. Atrial fibrillation
5. Family history of Alzheimer’s disease 5. Family history off Alzheimer’s disease
©2011 MFMER | 3127551-27 ©2011 MFMER | 3127551-28
Risk Factors Predisposing Factors-Established

• Predisposing factors- increase a patient’s • Age • Decreased functional
vulnerability to delirium status
• Cognitive impairment
• Comorbid medical illness
• Precipitating factors- initiate the delirium • Lower education level
• Malnutrition
• Vulnerable patients are at increased risk when • Sensory impairment
exposed to precipitating factors • Depression
Bagri et al Clin Geriatr Med 24 (2008)
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Box 1: Risk factors for delirium after noncardiac surgery* 11,12.
Predisposing Factors- Controversial

• History of prior delirium • Apolipoprotein E4 gene
carrier status
• Gender
• Alcohol use or abuse
• Tobacco use
Holroyd-Leduc J M et al. CMAJ 2010;182:465-470
©2010 by Canadian Medical Association

©2011 MFMER | 3127551-31
Precipitating Factors- Established Precipitating Factors- Established

• Orthopedic, vascular, • Hypoxemia • Immobility • ? Longer operations
cardiac surgery
• Electrolyte disturbance • Poorly controlled pain
• Emergency procedure
• Transfusion requirement • Polypharmacy
• Delayed repair after hip • Sleep deprivation • Benzodiazepines
fracture
• Preoperative • Urinary catheter • Anticholinergics
hemodynamic instability • Meperidine
©2011 MFMER | 3127551-33 ©2011 MFMER | 3127551-34
Precipitating Factors- No Effect Case 2

• General vs regional anesthesia • 66 year old woman with multiple medical
problems is admitted for repair of a right hip
• Route of postoperative analgesia fracture.
• Type of opioid • Medical issues include:
• Hypertension
• Untreated OSA
• Atrial fibrillation, history of RVR
• CAD
• CHF
• History of previous perioperative DVT
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What is the most appropriate strategy to
Case 2 determine the cause of her delirium?
• The patient undergoes surgery without any 1. Administer a dose of Narcan
intraoperative complications.
2. Obtain a CT of her head
• She is extubated in the PACU. 3. Obtain an ABG
• About 30 minutes after extubation, she 4. Obtain an EEG
becomes confused and combative, requiring
multiple doses of haloperidol for agitation. 5. Obtain a psychiatry consultation
©2011 MFMER | 3127551-37 ©2011 MFMER | 3127551-38
Workup Workup
Physical exam:
The search for an underlying cause: • Vital signs
• History- Patient may be unreliable, family and • Oxygenation
caregivers very important
• Hydration
• Prior history of delirium
• Trauma
• Infection
• Neurologic exam
©2011 MFMER | 3127551-39 ©2011 MFMER | 3127551-40
Workup
Workup
• Review of all medications
Organ system evaluation:
• ?Potential for withdrawal syndrome
• CHF, MI
• All have potential, some more common
• Acute renal failure
• Liver disease
• Stroke
• COPD, respiratory failure, pulmonary embolism
• Constipation
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Drugs Commonly Associated with Delirium Workup
• NSAIDs • H-2 receptor blockers
Diagnostic workup:
• Opioids • St. John’s wort
• Fluoroquinolones • Benzodiazepines
• Based on results of history and physical exam
• Cephalosporins • SSRIs • CBC, electrolytes, renal and liver function, blood
sugar, urinalysis
• Atropine • Tricyclic antidepressants
• Diphenhydramine • Clonidine • Drug levels when appropriate
• Levodopa • Digoxin • EKG, cardiac enzymes
• Cultures when infection suspected
©2011 MFMER | 3127551-43 ©2011 MFMER | 3127551-44
Workup Workup
Neuroimaging should not be part of

• Chest X-ray baseline workup
• ABG • New neurologic deficits
• Diagnostic tests for pulmonary embolism • History of head trauma
if suspected EEG:
• Not part of baseline workup
• Subclinical seizures
©2011 MFMER | 3127551-45 ©2011 MFMER | 3127551-46
Case 2 Case 2
• 66 year old woman with multiple medical • Since her episode of agitation in the PACU,
problems is admitted for repair of a right hip she remained confused and combative.
fracture.
• She was noted to be hypercapnic and was
• Medical issues include: started on non-invasive ventilation, with
• Hypertension normalization of her pCO2.
• Untreated OSA
• Atrial fibrillation, history of RVR
• Urine culture grew E. coli, which was treated
with ciprofloxacin
• CAD
• CHF • Electrolytes, creatinine and ECG were all
• History of previous perioperative DVT normal or unchanged
©2011 MFMER | 3127551-47 ©2011 MFMER | 3127551-48
272
How should her agitation and How should her agitation and
combativeness be managed? combativeness be managed?
1. Reorient her frequently and use a sleep 1. Reorient her frequently and use a sleep
enhancement protocol enhancement protocol
2. Start benzodiazepines and continue to titrate 2. Start benzodiazepines and continue to titrate
the dose until she is sedated the dose until she is sedated
3. Use vest restraints and give haloperidol until 3. Use vest restraints and give haloperidol until
she is sedated she is sedated
4. Transfer her to the ICU 4. Discontinue all medications
5. Start her on donepezil 5. Start her on donepezil
©2011 MFMER | 3127551-49 ©2011 MFMER | 3127551-50
Management
Management
Supportive care:
Management of delirium: • Simplify the environment • Enlist family members
• Find and treat the underlying cause • Adequate but not • Familiar objects, pictures
excessive lighting • Frequent orientation
• Supportive measures
• Room temperature • Clocks and calendars
• Pharmacologic measures for symptom control and • Glasses, dentures,
safety • Early mobilization
hearing aids
• Prevention • Adequate nutrition,
hydration and
oxygenation
©2011 MFMER | 3127551-51 ©2011 MFMER | 3127551-52
Management
Management
• Sleep disruption may be a key contributing factor
• Remove urinary catheters as soon as to delirium
possible
• Sleep enhancement may help prevent delirium
• Encourage participation in self-care • Delirium and sleep deprivation share many clinical
• Avoid use of restraints except when and physiological features
absolutely necessary • Inattention
• Fluctuating mental status
• Impaired cognition, especially executive
function
• Cholinergic deficiency, dopaminergic excess
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273
Management
• Always try non-pharmacologic strategies first!
©2011 MFMER | 3127551-55 ©2011 MFMER | 3127551-56
Management Management
Medications for symptom control: • Cochrane Review 2007:
• Antipsychotics • No convincing studies that newer
antipsychotics are any better than
• Haloperidol haloperidol
• Risperidone or olanzapine • Prophylactic low dose haloperidol in hip
• Quetiapine fracture patients did not decrease the risk of
delirium, but did reduce the duration and
• APA (American Psychiatric Association) severity
recommends low dose haloperidol as the
first line agent for episodes of delirium. • No difference in adverse drug effects
between low-dose haloperidol and atypical
antipsychotics
©2011 MFMER | 3127551-57 ©2011 MFMER | 3127551-58
• Benzodiazepines only for use in alcohol or • Some recent studies looking at the use of
sedative withdrawal cholinesterase inhibitors for management of
delirium
• ? nicotine replacement in smokers
• No good evidence • Cochrane Database Review: No evidence that
these are effective
• May be some adverse effects on bone
grafts
• Some studies suggest that melatonin may be
useful in treating postoperative delirium
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274
• Prevention seems to be a matter of excellent
• Few intervention studies which demonstrate medical care
success • Fluids, electrolytes, nutrition
• Most successful interventions involve identifying • No unnecessary medications
patients at risk and taking steps to minimize the • Sleep enhancement
risk = Prevention! • Early mobilization and rehabilitation
• Management of the environment
©2011 MFMER | 3127551-61 ©2011 MFMER | 3127551-62
Management Postoperative Cognitive Dysfunction

(POCD)
• Importance of pain management
• Occurs weeks to months after surgery
• Significant postoperative pain or increased pain
in patients with preoperative pain highly • Affects memory, information processing and
associated with delirium executive function
• Optimal method of treating postoperative pain • Patients often discover new difficulties with
controversial normal activities at home or work
• PCA probably better than “on-demand” • Attention impaired, but consciousness normal
• Oral may be better than parenteral • Diagnosis with neuropsychiatric testing
• ? Scheduled oral
©2011 MFMER | 3127551-63 ©2011 MFMER | 3127551-64
Postoperative Cognitive Dysfunction

(POCD) Persistent Delirium
Risk factors • Patients with persistent delirium were 3x more
likely to die in the first year of followup
• Extensive surgical trauma compared to patients whose delirium resolved.
• Increasing age • 1 year cumulative mortality of 39%
• Sleep deprivation • At risk for long term nursing home placement
• Postoperative pain • Poor quality of life
• Systemic inflammation • Greater healthcare expenditures
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275
Persistent Delirium Predicts Greater
Mortality Take Home Points
• Postoperative delirium is a medical emergency
• Development of postoperative delirium is
associated with increased morbidity and
mortality
• The pathogenesis is unknown, but cholinergic
deficiency is thought to play a role
• CAM is the most reliable tool for diagnosing
delirium
Journal of the American Geriatrics Society

Volume 57, Issue 1, pages 55-61, 11 DEC 2008
DOI: 10.1111/j.1532-5415.2008.02092.x
©2011 MFMER | 3127551-67 ©2011 MFMER | 3127551-68
Take Home Points References

• Proactive strategies can be used for at-risk • Inouye SK. Delirium in hospitalized older patients:
patients Recognition and risk factors. J Geriatr Psychiatry
Neurol 1998;11:118–125; discussion 157–158.
• There are pharmacologic and non- • Leslie D, Marcantonio ER, Zhang Y et al. One-year
pharmacologic interventions for management of health care costs associated with delirium in the elderly.
delirium Arch Intern Med 2008;168:27–32.
• Delirium makes it difficult to obtain informed • Krenk L, Rasmussen LS. Postoperative delirium and
consent and to involve patients in their own postoperative cognitive dysfunction in the elderly - what
are the differences? Minerva Anestesiol. 2011
care July;77(7):742–749.
©2011 MFMER | 3127551-69 ©2011 MFMER | 3127551-70
References
• Marcantonio ER, Flacker JM, Wright RJ, Resnick NM . Thank You!
Reducing delirium after hip fracture: a randomized trial.
J Am Geriatr Soc 2001;49:516–22 • Beliveauficalora.margaret@mayo.edu
• Lonergan E, Britton AM, Luxenberg J, Wyller T.
Antipsychotics for delirium. Cochrane Database Syst
Rev 2007
• Overshott R, Karim S, Burns A. Cholinesterase
inhibitors for delirium. Cochrane Database Syst Rev
2008
• Flinn DR, Diehl KM, Seyfried LS, Malani PN.
Prevention, diagnosis, and management of
postoperative delirium in older adults. J Am Coll Surg
2009; 209(2): 261-8.
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276
An Overview of
From Outpatient Preoperative Assessment Perioperative Management of
to Inpatient Postoperative Care Endocrine Issues:
Stress Dose Steroids, Adrenal Insufficiency, Thyroid Disease

James Fink MD, MPH
October 9 - 12, 2013  Grand Hyatt  Seattle, Washington
©2011 MFMER | 3127551-1 ©2011 MFMER | 3127551-2
Take Home
Disclosures
• Adrenal Insufficiency/Steroids
• “Stress Dose” steroids appropriate in certain patients
• None • Adjust dose to pre-op condition & surgery
• Keep it brief!
• Thyroid Disease
• Don’t test pre-operatively unless clinically indicated
• Thyroxine T1/2 = 6-7 days
• Be aware Thyroid Storm
©2011 MFMER | 3127551-3 ©2011 MFMER | 3127551-4
FYI Case # 1
• 37 yo male with a history of Addison’s and

Hypothyroidism
• For elective Back Surgery – lumbosacral and

sacroiliac fusion
• Medications
• Hydrocortisone 20mg/10mg AM/PM
• Levothyroxine 150 mcg daily
Med Clin N Am 2009;93:1031-1047

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277
Case # 2
What is the best management for his Addison’s Answer:
disease perioperatively?
1) Cease patients regular steroids and give 200mg IV
1) Cease patients regular steroids and give 200mg IV hydrocortisone x 1 pre-op
hydrocortisone x 1 pre-op
2) Continue patients usual steroids and give 200mg IV
2) Continue patients usual steroids and give 200mg IV hydrocortisone x 1 pre-op
hydrocortisone x 1 pre-op
3) Continue patients usual steroids and give 25mg of
3) Continue patients usual steroids and give 25mg of hydrocortisone pre and post-op
hydrocortisone pre and post-op
4) Continue patients usual steroids and give 50 – 100mg of
4) Continue patients usual steroids and give 50 – 100mg hydrocortisone pre-op and Q8H post-op for 24 -48hrs
of hydrocortisone pre-op and Q8H post-op for 24 -48hrs
©2011 MFMER | 3127551-7 ©2011 MFMER | 3127551-8
Steroid Supplementation / Stress Dose Steroids
JAMA 1952;149:1542-1543
Ann Intern Med 1953;39:116-125
©2011 MFMER | 3127551-9 ©2011 MFMER | 3127551-10
Periop Steroid Replacement 1953

I. For patients receiving cortisone: II. For patients receiving ACTH:
A. Preoperative program: A. Preoperative program:
1. ACTH in doses of 20 to 30 units intramuscularly every six 1. Cortisone intramuscularly, 100 mg. daily for two days before
hours for five days before surgery. surgery and again preoperatively on the day of surgery
or 2. Continue usual ACTH dosage uninterruptedly.
ACTH in doses of 20 units, by slow intravenous drip (in
1,000ml 5 per cent glucose in water) over periods of 12 to 24
hours daily for three days before surgery. B. Postoperative program
2. Cortisone intramuscularly, 100mg daily for two days before 1. Normal saline, 1,000 ml. intravenously ( or fluids as indicated by
surgery and again preoperatively on the day of surgery electrolyte and hematologic studies).
2. Cortisone intramuscularly, 25mg. Every six hours for two days,
then every eight hours for two days. If oral medication is
B. Postoperative program possible at the end of a few days, continue with 25 mg. every 12
hours for two days, then 25 mg. daily for two days. Otherwise,
1. Normal saline, 1,000 ml. intravenously (or fluids as indicated follow the same dosage schedule by intramuscular route.
by electrolyte and hematologic studies).
3. Continue usual (preoperative) ACTH dosage uninterruptedly.
2. Cortisone intramuscularly, 25 mg. every six hours for three
days or equivalent amount orally; then resume preoperative
oral dosage. III. For emergency surgery when above preoperative preparation is
3. ACTH in doses of 20 units intramuscularly every four to six impossible, continue usual dosage of hormone and give 300 mg.
hours for two days, then 15 units every six hours for two cortisone intramuscularly. Also give 30 to 50 ml. of aqueous
days, 10 units twice daily for two days, 5 units twice daily adrenal cortical extract intravenously during surgery, repeated is
for one day (or modified schedule of gradually diminishing necessary. Postoperatively, give both ACTH by intravenous
dosage). route and cortisone intramuscularly. The dosage required under
these circumstances cannot be estimated accurately, but effective
amounts should be used and electrolyte balance should be
closely supervised.
Ann Intern Med 1953;39:116-125

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Adrenal Insufficiency Perioperative Adrenal Insufficiency
Risk Factors
• Primary:
• adrenal gland dysfunction • Patients with known HPA disease
• loss of mineralocorticoid and glucocorticoid
• patients taking steroids for > 3 weeks in the past year
• Secondary:
• ACTH dependent (adrenal gland intact) • examples:
• usually intact mineralocorticoid function - transplant recipients - chronic lung disease
- rheumatologic disease - IBD
• Tertiary: - collagen vascular disease - neurosurgery
• hypothylamic/pituitary suppression - dermatologic conditions
• most common
JAMA 2002;287(2):236-240
Uptodate – The surgical patient taking glucocorticoids
©2011 MFMER | 3127551-13 http://www.eric.vcu.edu/home/resources/consults/PreOp_Steroids.pdf ©2011 MFMER | 3127551-14
Steroid Supplementation: Steroid Supplementation:

Agreement Agreement – HPA dysfunction 1
• all patients on chronic steroids require their normal daily • supplementation individualized according to
corticosteroid therapy
age, procedure, weight, use of concurrent
medications (phenytoin, rifampin, barbiturates)
• patients receiving < 5mg Prednisone/day or alternate
day therapy usually DO NOT require supplemental
therapy • typical dose:
• Hydrocortisone - can be multiple divided doses
• Patients with HPA insufficiency (1°, 2°) require stress
dose supplementation • alternative
• continue pre-procedure therapy and add 0.5mg
dexamethasone or 5mg Prednisone/day – (longer T 1/2)
• no benefit to excessive supplementation or prolonged
treatment !
JAMA 2002;287(2):236-240
http://www.eric.vcu.edu/home/resources/consults/PreOp_Steroids.pdf
Med Clin N Am 2009;93:1031-1047
©2011 MFMER | 3127551-15 ©2011 MFMER | 3127551-16
Steroid Supplementation:
Agreement – HPA dysfunction 2
• all HPA patients:

• superficial procedure [<1hr in duration under local
anesthesia (dental work, skin bx, minor ortho)]
• requires only the normal daily replacement dose of

corticosteroids
• ** production of cortisol normalizes 24 - 48hrs post

surgery (taper accordingly)
Med Clin N Am 2009;93:1031-1047 J Clin Endocrinol Metab 1987:64;986-994

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279
Perioperative Adrenal Insufficiency
Steroid Supplementation: Risk Stratification
Controversy
• Applies to patients at risk of iatrogenic (3°) adrenal • Low Risk:
insufficiency • Patients taking glucocorticoids < 5mg/day or alternate day
therapy
• Inhaled, topical or regional steroids
• Issues/Questions:
• Intermediate Risk:
• To cosyntropin test or not? • Patients taking 5 – 20 mg glucocorticoids day > 3 weeks in the
past year
• Dosage of supplementation?
• High Risk:
• Patients taking > 20mg/day, > 3 weeks in past year or
• Duration of supplementation? • Patients with Cushing features
Uptodate – The surgical patient taking glucocorticoids

http://www.eric.vcu.edu/home/resources/consults/PreOp_Steroids.pdf
Med Clin N Am 2009;93:1031-1047
©2011 MFMER | 3127551-19 ©2011 MFMER | 3127551-20

Risk Management Risk Management Cont’d
• Intermediate risk:
• Low Risk
• no further testing, continue standard dose, no • Emergent surgery:
supplementation • no further testing, continue daily dose + supplemental
dose
• Urgent/Elective:
• High Risk
• Cosyntropin stimulation testing of HPA
• no further testing, continue daily dose + • Subnormal response – daily dose + supplementation
supplementation • Normal response – daily dose steroid
©2011 MFMER | 3127551-21 ©2011 MFMER | 3127551-22
Patient Risk
Steroid Management
Maintenance dose +
INTERMEDIATE
LOW Cosyntropin normal Cosyntropin subnormal
HIGH
Procedure Risk
No supplementation No supplementation
or or
Emergent 25mg IV 25mg IV
Minor
Hydrocortisone x 1 Hydrocortisone x 1 25 – 50 mg IV
Hydrocortisone x 1 Too Complicated !
Urgent/Elective No supplementation No supplementation
Emergent no supplementation no supplementation

or or
Moderate 50mg IV 50mg IV 100 mg IV Hydrocortisone
Urgent/Elective Hydrocortisone x 1 Hydrocortisone x 1 x 1 or 50 mg Q12H for
then Q8h x 24 – then Q8h x 24 – 24hrs
48hrs 48hrs
no supplementation no supplementation
Emergent or or
100 mg IV Hydrocortisone
Major 100 mg IV 100 mg IV x 1 and 100 mg IV Q8H x
Hydrocortisone x 1 Hydrocortisone x 1 24 hrs then taper 50%/day
Urgent/Elective then 50 – 100mg then 50 – 100mg to baseline
Q8h x 24 – 48hrs Q8h x 24 – 48hrs
©2011 MFMER | 3127551-23 ©2011 MFMER | 3127551-24
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Periop Steriod Recs 1994
Minor Surgical Stress (inguinal hernia)

Target 25mg hydrocortisone equivalent
Pt taking 5mg Pred every other day for asthma
Give 5 mg prednisone day of procedure
Moderate Surgical stress (joint replacement,

hysterectomy)
50 – 75mg/day of hydrocortisone equivalent for 1- 2 days
Pt taking 10mg pred/day for SLE
10mg pred pre-op, 50mg hydrocortisone intraop, then 20mg
hydrocortisone x 3 POD #1, return to pre-op doses on POD
#2
Major Surgical Stress (total colectomy, CABG)

100 – 150 mg hydrocortisone equivalent/day for 2- 3 days
Pt receiving 5 mg prednisone/day for years
5mg pred preoperatively, 25mg hydrocortisone
intraoperatively, then 25mg hydrocortisone Q8H for 48 – 72
hrs, then return to normal daily coverage
Cochrane Database of Systematic Reviews, Issue 4, 2009
Ann Surg 1994;219(4):416-425
©2011 MFMER | 3127551-25

JAMA
©2011 MFMER | 3127551-26
2002;287(2):236-
Therefore: 40 mg of prednisone x 1 is
likely to be more than adequate for most
patients/procedures if you have concerns
for peri-op adrenal insufficiency.
JAMA 2002;287(2):236-240
©2011 MFMER | 3127551-27 ©2011 MFMER | 3127551-28
Case # 2 How do we manage this patients thyroid

medication in this setting?
• 37yo male with Addison’s and Hypothyroidism for 1) Continue to withhold thyroxine until taking PO.
back surgery
2) Give 75mcg thyroxine IV daily
• Hydrocortisone and levothyroxine 150mcg/day
• Some mild adrenal insufficiency findings have
occurred post op and the patient remains
intubated/NPO 5 days post-OR 4) Give 300mcg of thyroxine IV daily
©2011 MFMER | 3127551-29 ©2011 MFMER | 3127551-30
281
Hypothyroidism
Answer: Perspective
• prevalence 1%, F > M, increased incidence with age
1) Continue to withhold thyroxine until taking PO.
• Multisystem complications
2) Give 75mcg thyroxine IV daily • decreased cardiac output
• anemia
• hypoventilation/reduced pulmonary responses
• constipation
• increase total body water
4) Give 300mcg of thyroxine IV daily • hyponatremia
• myxedema coma
©2011 MFMER | 3127551-31 ©2011 MFMER | 3127551-32
Perioperative Thyroid Disease

Hypothyroidism (cont’d) Preop Hypothyroidism
Pharmacologic Management
• Who’s at risk?
• Treated Hyperthyroidism • Mild to moderate – symptomatic!
• Other hypothalamic/pituitary disorders
• Lithium • If young otherwise healthy
• Rx thyroxine 1.7ug/kg
• Amiodarone
• Iron
• Older patients or cardiopulmonary disease
• Cholestyramine • start 25-50ug/day and titrate up every 2-6 weeks
Up to Date: Nonthyroid surgery in the patient with thyroid disease

Med Clin N Am 2009;93:1031-1047
©2011 MFMER | 3127551-33 ©2011 MFMER | 3127551-34

Periop Hypothyroidism
Myxedema
• Levothyroxine
• Continued perioperatively • clues to diagnosis include:
• pericardial effusion, CHF, hypothermia, hyponatremia
• T1/2 ~ 6-7 days
• therapy
• if pt is NPO for > 5-7 days: consider IV replacement • 200-500 mcg thyroxine IV +
• IV 100% bioavailable; PO 50-80% bioavailable
• Cut dose in half PO  IV
• Steroids for occult AI
• newly diagnosed hypothyroidism does not need treatment unless • increase in total body water but decreased intravascular
symptomatic volume
Anes Clin N America 22:2004;93-123

Med Clin N Am 2009;93:1031-1047 ©2011 MFMER | 3127551-35 ©2011 MFMER | 3127551-36
282
Hyperthyroidism Perioperative Thyroid Disease
Perspective Preop Hyperthyroidism

• Decreased TSH on treatment not necessarily contraindication to
• prevalence 1%, F > M, increased incidence with age surgery if normal T3, free T4
• TSH can take months to normalize
• Multiple systemic effects –
• Cardiovascular -  ionotropic/chronotropic • pharmacologic management:
 renin/angiotensin system
 cardiac output • Elective surg: antithyroid agents
• Chronic stimulation diminishes ability to respond to stress • Urgent/Emergent: (goal – reduce risk of thyroid storm)
• Beta blockers
• Thoinamides - Methimazole, PTU
• Overt • SSKI or Lugol’s iodine
• Subclinical
• increased nocturnal pulse, increased gut motility, premature atrial • take medications on morning of surgery
contractions, increased peripheral vascular resistance
Medical Management of the Surgical Patient 2008
©2011 MFMER | 3127551-37 Med Clin N Am 2009;93:1031-1047 ©2011 MFMER | 3127551-38

Periop Thyrotoxicosis
Preop Hyperthyroidism (cont’d)
Issue: Thyroid Storm Management
• Thyrotoxic crisis (“storm”)
• Beta Blocker (adrenergic sx, inhibit T4  T3)
• rare • Methimazole or PTU (PO/PR no IV)

• Give 1 hour prior to…
• often discovered intraoperatively to 48hrs post-op
• Iodine solution (block thyroid hormone release = Wolff-Chaikoff effect)
• Others:
• if discovered Pre-op
• Iodinated radiocontrast agent (inhibit T4-T3)
• procedure should be postponed
• mortality rate 10 - 75% • Glucocorticoids (reduce T4-T3, Rx autoimmune process)
Anes Clin N America 22:2004;93-123

Med Clin N Am 2009;93:1031-1047 ©2011 MFMER | 3127551-39 ©2011 MFMER | 3127551-40

Euthyroid Sick Syndrome
• Low T4, T3, TSH
• Increased reverse T3
• Treatment of little benefit - ? Harm Our patient, October 1954 – New York
• In critically ill pts - TSH alone is inadequate for

assessment of thyroid function
• TFT’s should not be assessed in critically ill pts

unless pretest probability is high

Medical Management of the Surgical Patient 2008
©2011 MFMER | 3127551-41 ©2011 MFMER | 3127551-42
283
Daily Management
150mg desoxycorticosterone pellets Q3Months
25mg cortisone daily
Pre-op
24 and 12 hrs - 100mg cortisone IM
Intra-op
100mg cortisone in 1000ml NS
2000cc blood
Post-op
UTI, Transfusion reaction, Angioedema
JAMA Arch Surg 1955;71:737-42 JAMA Arch Surg 1955;71:737-42

©2011 MFMER | 3127551-43 ©2011 MFMER | 3127551-44
Corticosteroid Comparison
Biologic ½ HPA axis
Equivalent Mineralocorticoid life
Drug suppression
dose (mg) potency
(hrs) (mg)2
Hydrocortisone 20 2+ 8-12 20-30
Cortisone 25 2+ 8-12 25-35
Prednisone 5 1+ 24-36 7.5
Methylpred 4 0-0.5+ 24-36 7.5
Dexamathasone 0.75 0 36-54 1-1.5
Mineralocorticoid: Fludrocortisone 0.05 – 0.20mg /day
www.vhpharmsci.com/VHFormulary/Tools/Systemic-corticosteroid-comparison.htm
©2011 MFMER | 3127551-45
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PATIENTS with RHEUMATIC DISEASE Goals for the Pre-operative Visit
selected perioperative challenges
• Be your patient’s advocate
Brian F Mandell md phd • Are there disease associated issues: Is disease controlled?
• Think about rehab in the setting of joint, muscle or neurologic disease
Professor and Chairman of Academic Medicine
Department of Rheumatic and Immunologic Diseases • Document concisely the RELEVANT history (prior postop
Center for Vasculitis Care and Research flares?) , lab abnormalities, and baseline physical examination,
Cleveland Clinic especially pulses and neurologic
• Try to recognize potential perioperative problems
• Consider disease specific perioperative risks / complications
• Review medications
• DVT and infection prophylaxis - “inflammation” = higher risk
No relevant conflicts of interest to disclose
PERIOPERATIVE ISSUES PERIOPERATIVE ISSUES

Myositis Scleroderma
• RESPIRATORY MUSCLE FUNCTION • Venous access available ?
• ASPIRATION RISK • Severe Raynauds
• WEANING – POSITIONING • Caution w/ arterial punctures/lines
• CONSIDER NON-INVASIVE VENTILATION » Absent ulnar artery
• CARDIOPULMONARY STATUS • Digital O2 monitoring
• Avoid over-cooling in OR and recovery
• CONDUCTION DISEASE
• Dx OF PERIOP MI – baseline labs abnormal ? • Reflux – aspiration
• ILD • Malabsorption and slowed GI motility
• REHABILITATION POTENTIAL
• POSTOPERATIVE DVT and FALLS • Occult pulmonary hypertension
• OCCULT MALIGNANCY
Mix and Match

 26 yo woman with dx of SLE (+ANA, hx
thrombocytopenia, rash and pleurisy) in
Preoperative Lab Testing in remission.
Patients with Rheumatic Disease  Preop assessment for THR for AVN.
 SLE: inactive
 Adopted; no other medical or surgical hx
 Meds: plaquenil (hydroxychloroquine)
 Creatinine 0.8, WBC 2600, Hgb 12.9, Plat 143
285
PREOPERATIVE TESTING
Lab tests: Would you order 3131 ASYMPTOMATIC PATIENTS
PT, PTT ?
No data to support In asymptomatic
getting “routine” patients…
preop tests
20
ABNL
1. YES 15
2. NO % 10
INFLUENCED
SURGERY
5
0
CXR ECG Hgb Plt PT PTT Gluc Creat ANY
Perez et al Br J Anesth 74:250-56, 1995
Mix and Match: Mixing test normalizes the prolonged

PTT
26 yo woman with dx of SLE
A. Proceed with surgery using LMW heparin
and compression stockings
B. Proceed with surgery using ASA, LMW
 PT is normal; PTT is prolonged by 6 heparin and mechanical compression
seconds (confirmed on retest).
C. Delay surgery to do a platelet neutralization
test to confirm “lupus” anticoagulant
 Mixing test normalizes the PTT D. Delay surgery to look for a factor deficiency
E. Delay surgery and repeat PTT after stopping
Now what? hydroxychloroquine
Mix and Match

Mix and Match
Prolonged PTT
Although PT/PTT are NOT necessary
 Factor deficiency – may bleed preop tests; when prolonged, they
require evaluation – CANNOT
 Antibody to factor – may bleed ASSUME A LAC – even with SLE.
PL Prolonged PTT Mixing Study
 Lupus anticoagulant – NOT likely Dependent Does NOT Correct with
Normal plasma
Corrects with
to bleed, may be hypercoagulable Inhibitor? Normal plasma
Anti-factor Ab or LAC R/O Factor Inhibitor R/O Factor Deficiency

(bleeds) (clots)
286
Choose elective pre-op lab testing based on
ANTIPHOSPHOLIPID SYNDROME DISEASE AND MEDICATIONS
PERIOPERATIVE MANAGEMENT
• w/ HISTORY, @ HIGH RISK FOR THROMBOSIS
•DISEASE:
• SAME as FOR PATIENTS with PROSTHETIC HEART VALVES • Lupus – creatinine, cbc, pt, ptt, UA, + CK
• THROMBOCYTOPENIA /HEMOLYSIS • RA / spondylitis – Hgb
• ROUTINE MONITORING of PTT • Scleroderma – none
or ACT MAY NOT be RELIABLE* • Vasculitis – creatinine, UA, CBC (medication related changes)
• DOSE LMW HEPARIN BY ALGORITHM • Myositis – CK with MB, troponin
• THROMBIN TIME
• Xa ACTIVITY
• Medications
• HEPARIN LEVEL • MTX / Leflunomide / Tofacitinib – CBC, AST
• ALTERNATIVE AGENT (little data)
• Anti TNFs, Abatacept, Tocalizumab, - none
• Rituximab, Azathioprine, Cyclophosphamide - CBC
Bartholomew: Clin Rheum 4:307-11, 1998,
Erkan in Mandell BF(ed). Perioperative management of the patient with rheumatic disease. Springer 2012
Cervical Spine Imaging?

RA Preop Assessment
58 yo F with longstanding RA with planned bilateral TKRs. Initially hard to
control with early nodulosis and hand deformities. Currently without AM Regarding the cervical spine, YOU:
stiffness. Mild fatigue(stable) but limited for many months to using a
wheelchair or cane due to knee pain..
S/p uneventful C section, TAH/BSO, cholecystectomy. No cardiovascular, GI, 1. Note that cervical films 2 years ago were normal. No need to
Pulmonary Sx. repeat X-RAYS.
NKDA, + smoker.
MEDS: ASA, alendronate 70 qw, Ca/Vit D, HCTZ 25, Enalapril 20, Metformin 500
bid, Atorvastatin 20, MTX 25 qw sq, Folic acid, Adalimumab qow, Pred 5qd and 2. Order cervical spine films with flex and extension views
Celecoxib 200 bid.
Labs: Hgb 10.1, Creat 1.2, ESR 18, AST/ALT normal, glucose 108 fbs
3. 1 or 2 and suggest fiberoptic intubation
PE: 126/78, HR 82. Skin clear, no thrush, no scleritis, gait not tested, DTRs: 3+=
biceps with +Hoffmans and 1+ = knees, 3+ ankles normal Babinski test, neck
motion painless, good jaw opening, lungs clear, no murmur/gallop, -HJR, 1+ 4. Alert the anesthesiologist to the RA
bilat edema,nl pulses no bruits.
+ ulnar drift bilat with PIP nodulosis, swan neck changes but good grip, no CTS,
hips nl, knees valgus with prolif changes and crepitus, valgus ankle changes 5. Delay surgery to obtain C spine MRI with flex/extension views
with pes planus.
RHEUMATOID ARTHRITIS THE CERVICAL

SPINE.
RADIOGRAPHIC EVIDENCE OF BUT… look for and do not ignore physical

RHEUMATOID CERVICAL SUBLUXATION findings
IS FAR MORE COMMON THAN CLINICAL
SYMPTOMS or FINDINGS.
287
58 yo F with longstanding RA with planned bilateral TKRs. Initially hard to
control with early nodulosis and hand deformities. Currently without AM
RHEUMATOID CERVICAL
stiffness. Mild fatigue(stable) but limited for many months to using a
wheelchair or cane due to knee pain. Cannot walk steps.
SPINE
S/p uneventful C section, TAH/BSO and cholecystectomy, tonsillectomy. No
cardiovascular, GI, Pulmonary Sx. THE PREOP QUESTION:
NKDA, + smoker. • DAMAGE in C-SPINE
(PATHOPHYSIOLOGY is
MEDS: ASA, alendronate 70 qw, Ca/Vit D, HCTZ 25, Enalapril 20, Metformin 500 SIMILAR to EXTREMITY
bid, Atorvastatin 20, MTX 25 qw sq, Folic acid, Adalimumab qow, Pred 5qd and WILL BONE, LIGAMENT, DAMAGE)
Celecoxib 200 bid. or PANNUS IMPINGE on
Labs: Hgb 10.1, Creat 1.2, ESR 18, AST/ALT normal, glucose 108 fbs CERVICAL CORD WITH LAXITY OF CAPSULE
POSITIONING OF THE NECK?
DTRs: 3+
PE: 126/78, HR 82. Skin clear, no thrush, no scleritis, gait not tested,
LAXITY OF
biceps with +Hoffmans and 1+ = knees, 3+ ankles normal SUPPORTING
Babinski test, neck motion painless, good jaw opening, lungs clear, no
murmur/gallop, -HJR, 1+ bilat edema,nl pulses no bruits. LIGAMENTS
hips nl, knees valgus with prolif changes and crepitus, valgus ankle changes
with pes planus. PANNUS
ANKYLOSIS
RHEUMATOID CERVICAL RHEUMATOID CERVICAL SPINE

SPINE PRE-OP ASSESSMENT
• CERVICAL • PAIN • Have Prior Films Reviewed if They Exist
SUBLUXATION - UP TO • STIFFNESS
80% OF PRE-OP
PATIENTS (>50% are • HEADACHE
“SILENT”) • NECK CLUNK • Asymptomatic; Recent or Mild Disease:
• IMPINGEMENT Normal Exam; No Films Necessary
3
1. ATLANTO-AXIAL • RADICULOPATHY Alert anesthesiologist
1
• MYELOPATHY • Proliferative / Erosive Disease
2
2. SUBAXIAL HYPER-REFLEXIA
• “SYMPTOMATIC” NEUROSURG. CONSULT
CLUMSINESS or Abnl Exam RADIOGRAPHS/CT/MRI
3. “CRANIAL SETTLING” TINGLING • ASYMPTOMATIC FLEX / EXTENSION VIEWs (?)
L’ HERMITTES
CAREFUL NEUROL. EXAM
Real World impact

C Spine imaging in RA
Cle Clinic Survey Data
• 176 pts with RA had surgery with general anesthesia
at MD Anderson cancer center
• 52% had c spine imaging within 2 years (20% of these had C-
spine abnormalities)
•Intubation
No neuroMethod
or vascular complications in any of the 176
NO association between
direct
laryngo method of intubation and
prior C spine films
fiber optic
mask
Lopez-Olivo et al J Clin Rheum 18:61-66, 2012
288
58 yo F with longstanding RA with planned bilateral TKRs. Had early nodulosis and
hand deformities. Currently no AM stiffness. Mild fatigue(stable); but limited for
RHEUMATOID CERVICAL SPINE PRE-OP ASSESSMENT many months to using a wheelchair or cane due to knee pain. Cannot walk steps.
S/p uneventful C section, TAH/BSO and cholecystectomy, tonsillectomy. No
Bottom Line: cardiovascular, GI, Pulmonary Sx.
NKDA, + smoker.
MEDS: ASA, alendronate 70 qw, Ca/Vit D, HCTZ 25,
Enalapril 20, Metformin 500 bid, Atorvastatin 20,
MTX 25 qw sq, Folic acid, Adalimumab qow, Pred
Communicate 5qd and Celecoxib 200 bid.
Labs: Hgb 10.1, Creat 1.2, ESR 18, AST/ALT normal, glucose 108
PE: 126/78, HR 82. Skin clear, no thrush, no scleritis, gait not tested, DTRs: 3+
biceps with +Hoffmans and 1+ knees, 3+ ankles, normal Babinski test, neck
motion painless, good jaw opening, lungs clear, no murmur/gallop, -HJR, 1+
bilat edema, nl pulses no bruits.
hips nl, knees valgus with contractures and prolif changes and crepitus, valgus
ankle changes with pes planus.
Meds: would you hold Celecoxib

NSAIDs and SURGERY
pre-arthroplasty ?
• PROLONGATION OF BLEEDING TIME
• ASPIRIN - IRREVERSIBLE
• SALICYLATE - MINIMAL IF ANY EFFECT
• NABUMETONE: + EFFECT / NO EFFECT ON WARFARIN
• OTHERS - VARIABLE PROLONGATION, INCREASE INR
1. YES
• COX 2 SELECTIVE DRUGS: CELECOXIB
2. NO » NO ANTI-PLATELET EFFECT
• OUTCOME DATA – NON-SELECTIVE NSAIDs
• ASA and CORONARY BYPASS SURGERY
• ASA PLUS HEPARIN IN HIP FRACTURE
• ABDOMINAL GYN PROCEDURES
• EYE / NEUROSURGICAL PROCEDURES
• TONSILLECTOMY - PRE Tx KETOROLAC BLEEDING
COX-2 SELECTIVE NSAIDS NSAIDs AND SURGERY
• EFFECTIVE ANALGESIA •Hold for 4-5 half lives of the drug

• NARCOTIC SPARING – maybe…
preoperatively NO SAFETY ADVANTAGE
• +/- GASTRIC SAFER (no periop data) • 5 days is usually sufficient with
• NO RENAL SAFETY ADVANTAGE • Hold piroxicam 10 days preop. PARENTERAL NSAID
THERAPY!
• NO ANTI-PLATELET EFFECT •Hold aspirin 10-14 days preop
• LESS CONCERN OVER POST- OP BLEEDING •Unless ASA need (ie coronary stent, dvt prophylaxis)
• Little interaction heparin / warfarin
•No documented need to hold Cox-2 selective
?? ANY PRO-THROMBOTIC EFFECT ?? NSAID (celecoxib)
289
RA and RISK of
POSTOPERATIVE INFECTION: METHOTREXATE AND
TOTAL ARTHROPLASTY POSTOPERATIVE COMPLICATIONS
Which has/have been shown to be associated with an increased
risk of periop prosthetic joint infection:
THERE ARE NO CONSISTENT
A. Methotrexate >15mg/wk within 2 weeks of surgery DATA THAT PERIOPERATIVE
B. RA as the diagnosis vs. Osteoarthritis USE OF METHOTREXATE CAUSES
C. Anti-TNF therapy INCREASED WOUND
D. Smoking INFECTIONS OR DECREASED
E. A, B, and C HEALING
F. B, C and D
G. All
Dosing Biologics Periop PERIOPERATIVE MEDICATIONS

CORTICOSTEROIDS*
DRUG - Dose interval
Etanercept q 1 week** • CONCERN of ADRENAL INSUFFICIENCY
• ABNORMAL ADRENAL “RESERVE”
Adalimumab q 2 week**
• BUT…. DO WE NEED TO BE CONCERNED?
Infliximab q 6-8 week**
Golimumab q 4 week**
THE PROBLEMS WITH BEING
Abatacept $ q 1 week (sq)**
OVERCONCERNED
Rituximab$ 20 days (prolonged drug effect)
q 4 week**
• PROLONGED POSTOPERATIVE USE
Tocilizumab$
• WOUND HEALING (?) / INFECTION
Anakinra$ q day • ANTIPYRETIC
• LEUKOCYTOSIS
• HYPERGLYCEMIA
** Consider holding > 1 dose interval
$ Particularly little periop data * see Coursin and Wood JAMA 287:236-40, 2002
The Decision…
How to manage perioperative How often is a diagnostic arthrocentesis
gout performed to confirm gout (r/o infection)?
Inpatients: 19%*, 25% (by med); 52% (by rheum) **

*J Rheum 34:1566-68, 2007
200 ** 36: 1699-04,2009
180
160
140
120
100 distinguishing
80 septic from gouty joint
60
40 Fever ~ 30-50% in both
20
0
ESR CRP WBC SF WBC
>50000
CRYSTAL SEPTIC
290
Its so obvious…
54yo m renal transplant pt adm. 12/2012 with disseminated “I want to go home”
cryptococcal infection; on fluoconazole therapy for > 2 weeks.
Previously clinically diagnosed with gout, had been on ULT • 48 yo man with hypertensive cardiomyopathy, atrial fibrillation,
Developed acutely swollen right / painful elbow and wrist. creatinine 3.8 with chronic edema, type 2 DM recovering from bout of
Creat acute increase to 5 (had been <2) post-op (lap partial colectomy) pulmonary edema. New recurrent
flare in gout (tophacious with current SUA 6.1 mg/dL), 5 days postop.
Meds incl: mycophenolate 500 bid, tacrolimus 2 bid, pred 5.
Last attack of arthritis ~ year ago knee. • Meds: warfarin, losartan, furosemide (now 120 mg q12h), nifedipine,
minoxidil, metformin, allopurinol (400 mg).
Elbow aspiration: 4cc
(cultures negative) • Acutely swollen, tender bilat midfeet, l ankle, l knee, r wrist. Chronic
SUA venous stasis changes, edema, forearm tophi. Bilateral crackles and
summation gallop. Unable to bear weight to walk to bathroom.
CPPD
Treating Acute Attacks

Treatment option you choose: Choose therapy based on patient’s co-morbidities
1. Morphine IV (or other narcotic) for pain control as needed • NSAID – any in high dose will work; indomethacin 50mg tid the gold
2. Colchicine 1.2 mg followed by 0.6 mg po an hour later standard – treat few days past resolution..
3. Celecoxib 200 mg bid 3 days • Colchicine 1.2mg followed by 0.6 in an hour – efficacious at
reducing pain with early treatment – outpatient trial demonstrated
4. Methylprednisolone 60 mg IV single dose; repeat if needed effect; did not demonstrate resolution.
5. Anakinra 100mg sq ; repeat daily for 3 days as needed • 38% got 50% relief by 24hrs (31% used rescue med)
6. ACTH 40mg IM; repeat in 24 hrs if needed • Steroid - efficacious – use enough for long enough
• IL1 antagonist – comorbidities or resistant attack – anakinra
• $$; no metabolic side effects
• OFF LABEL USE
• Narcotics - variable efficacy !!
Treatment of acute gouty arthritis in complex hospitalized Gout

patients with anakinra
Perioperative Pearls
15/26 Pts withCKD
5/26 GFR< 30 • Try to avoid any discontinuation of hypouricemic
therapy
7 perioperative • Try to continue (start?) prophylactic anti-

4 immunosuppressed inflammatory therapy e.g. 0.6 colchicine daily
3 had infections (responded to Abx)
• Peak postoperative gout ~ 4 days
7 Pts multiple courses • Postoperative gout can cause fever
15/26 had failed steroid therapy • Postoperative gout often polyarticular
Significant response: move w/o pain

& weight bear • Aspiration for Dx and local steroid therapy as Tx
should not be avoided
Ghosh et al Arth Care Res 65:1381-84, 2013
291
292
Disclosures
An Overview of • Pfizer
Perioperative Infectious Disease Issues • Pfizer Independent Grants for Learning &
Change
• No off-label use of medications will be

discussed

Jennifer Whitaker, MD, MS
©2011 MFMER | 3127551-1 ©2011 MFMER | 3127551-2
Objectives Objective #1
• Understand how to approach a patient with • Understand how to approach a patient with
postoperative fever. postoperative fever.
• Review management of common postoperative • Review management of common postoperative
infectious disease issues. infectious disease issues.
• Understand the indications for and the duration of
perioperative antibiotic prophylaxis.
• Review the approach to patients with penicillin
allergy.
• Review perioperative management of patients on
antiretroviral therapy for HIV.
©2011 MFMER | 3127551-3 ©2011 MFMER | 3127551-4
Postoperative Fever Case 1:

General Considerations
You are called to evaluate a 50 yo female who
was readmitted with fever 6 days after
• Temperature ≥ 38 C or 100.4 F uncomplicated open cholecystectomy surgery.
She has been having fever for the past 48 hours.
• Broad differential of infectious & non-infectious Her medications include ranitidine (new) and
etiologies HCTZ.
• Timing after surgery and duration are important • Temp=38.6 C, HR 100, BP 100/60, RR 22
clues • Physical exam reveals slight bibasilar crackles,
tachycardia with no murmur, mild abdominal
• Type of surgery is key consideration tenderness and erythema around surgical site,
and 1+ bilateral lower extremity edema. There is
no urinary catheter in place.
©2011 MFMER | 3127551-5 ©2011 MFMER | 3127551-6
293
Case 1: Case 1:
All of the following conditions should be in All of the following conditions should be in
your differential diagnosis for etiology of your differential diagnosis for etiology of
postoperative fever in this patient, except: postoperative fever in this patient, except:
A. Urinary tract infection A. Urinary tract infection

B. Atelectasis B. Atelectasis
C. DVT C. DVT
D. Surgical site infection D. Surgical site infection
E. Drug fever E. Drug fever
©2011 MFMER | 3127551-7 ©2011 MFMER | 3127551-8
Modification to the 5 W’s you might have Postoperative Fever

learned in medical school… Timing & Differential
• Wind---pneumonia, atelectasis • Immediate fever-in OR or within few hours of surgery
• Medications
• Water---urinary tract infection, IV sites • Transfusion reactions
(thrombophlebitis, CLABSI) • Infection present before surgery
• Malignant hyperthermia
• Wound---wound infections • Early postoperative fever
• Most commonly due to inflammatory response
• Wonder drugs---drug fever • Cytokine response (IL-6) related to trauma
• Usually resolves spontaneously (within 1-3 days)
• Walking---thromboembolism • May last up to weeks if head trauma
Engoren M, et al. Chest. 1995;107(1):81.
Mavros MN, et al. Chest. 2011;140(2):418-24.
©2011 MFMER | 3127551-9 ©2011 MFMER | 3127551-10
Immediate/Early Postoperative Fever

Management Postoperative Fever: Timing & Differential
• Review OR record. Consider drug reactions & • Acute fever- onset within first week of surgery
transfusion reactions Infectious Non-infectious
• Review records prior to surgery, was infection Nosocomial infections Vascular
present before surgery? UTI DVT, PE, thrombophlebitis
Central line associated fat embolism, MI
• Malignant hyperthermia-most likely to be seen in bloodstream infection Drug Fever
OR—high CO2, rigidity, tachycardia, tachypnea, (CLABSI) Surgical site inflammation
Pneumonia & VAP hematoma, seroma
fever may come later Other inflammatory
Meningitis after neurosurgery
• Rx: dantrolene Surgical site infection (SSI) gout, pseudogout
Community acquired infections pancreatitis
• Fever in first 48 hours, does patient appear well? (may have been present before) parotitis
Check PE and history. If no signs of infection and Acalculous cholecystitis Endocrine
vitals are stable, observe. Addisonian crisis, thyroid storm
©2011 MFMER | 3127551-11 ©2011 MFMER | 3127551-12
294
Management of Postoperative Fever within
1 Week of Surgery Postoperative Fever: Timing & Differential
• History: make sure to review all medications, determine Subacute fever- onset 1-4 weeks after surgery
new medications
Infectious Non-infectious
• Physical: make sure to include current and former IV UTI, CLABSI Thromboembolism
sites, joints, surgical site, back Pneumonia Drug Fever
• If outside of expected time for fever due to surgery (inflammatory Meningitis after CNS surgery Central fever, in cases of
process) itself, patient appears ill, or vitals abnormal: C. difficile colitis neurosurgery/head trauma
Sinusitis Post-pericardiectomy syndrome
• CBC, UA with micro, urine culture, blood cultures, CXR, if
abdominal pain, consider liver enzymes, lipase Skin/soft tissue infection (SSI)
• Consider workup for thromboembolism based on risk factors, Acalculous cholecystitis
history, PE Specific to surgery type
Device related infections
• If patient is hemodynamically unstable, start broad spectrum Mediastinitis
antibiotics. You can always de-escalate if no infection is found after Deep Abscess
48 hours.
Septic thrombophlebitis
©2011 MFMER | 3127551-13 ©2011 MFMER | 3127551-14
Subacute Postoperative Fever Postoperative Fever: Timing & Differential

Management
• Similar to approach for fever within 1 week of surgery Delayed fever- onset ≥ 4 weeks after surgery
• Make sure to ask about diarrhea, consider C. difficile • SSI due to indolent microorganisms
infection
• Infective Endocarditis
• Must consider site of surgery, presence of prosthetic • Medication Reaction
material
• Consider deeper sources of infection & order • Consider type of surgery
appropriate tests • Postpericardiotomy syndrome
• Imaging to evaluate for abscess • Device related infection
• Appropriate evaluation of cardiac device, prosthetic • Deep abscess
joints • Infected prosthesis
• Transplant (wide differential)
Surgical Site Infections Objective #2

Surgical site infection (SSI) • Understand the indications for and the duration of
• infection related to an operative procedure that perioperative antibiotic prophylaxis.
occurs at or near the surgical incision within 30 days • Review the approach to patients with penicillin
of the procedure allergy.
• or within 90 days if prosthetic material is implanted
at surgery
• In recent study, SSIs accounted for 31% of all hospital
acquired infections (HAI)
• National Healthcare Safety Network data for 2006-2008
showed an overall SSI rate of 1.9%.
Magill SS, et al. Infect Control Hospital Epidemiol 2012;33(3):283-91.

Yi M, et al. Infect Control Hosp Epidemiol 2011; 2(10):970-986.
©2011 MFMER | 3127551-17 ©2011 MFMER | 3127551-18
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Why is Perioperative Antibiotic Prophylaxis What Are the Indications for Perioperative
Given? Antimicrobial Prophylaxis?
• Prevent Surgical Site Infections • Patients undergoing procedures with high rate
• Antimicrobial prophylaxis is primarily to decrease of infection (not clean surgical site) –
microbial burden at site of surgery abdominal/gynecologic surgery
• Prevent Bacteruria/Bacteremia with Urologic • Implantation of prosthetic material
Procedures
• Ideally urine should be sterilized prior to urologic • Infection potentially catastrophic –
surgery neurosurgery, cardiac surgery
• Prevent endocarditis • Procedures where prophylaxis has been
• Treat Infection present at time of surgery proven to improve outcomes –surgery for
breast cancer
©2011 MFMER | 3127551-19 ©2011 MFMER | 3127551-20
Optimization of Antimicrobial Prophylaxis Timing of Antimicrobial Prophylaxis

• Select active against the most likely pathogens to • Generally about 30-60 minutes prior to surgery
contaminate the surgical site
• Exception: vancomycin and fluoroquinolones
• Administer agent in an appropriate dose and at 120 minutes prior to surgery
appropriate time to ensure adequate serum and tissue
concentrations during the period of potential • If prolonged procedures or significant blood
contamination loss, repeat antibiotic every 1-2 half-lives of
• Administer agent for the shortest effective period to drug if renal function is normal
minimize adverse effects, emergence of resistance, • cefazolin q 2-5 hrs, vancomycin q 6-12 hrs
and cost
• Repeat dosing with short procedures or after
wound closure in not necessary
©2011 MFMER | 3127551-21 ©2011 MFMER | 3127551-22
Which Agent? Vancomycin

• For most procedures cefazolin drug of choice • No consensus on preoperative MRSA screening for
• Active against streptococci, methicillin-susceptible colonization prior to surgery
staphylococci, and some gram-negative organisms • Vancomycin can be considered in the following cases:
• Has a long half-life, good safety profile • A cluster of SSIs due to MRSA or methicillin-resistant
• For penicillin allergy, vancomycin/clindamycin are coagulase-negative staphylococci has been detected at an
institution
acceptable alternatives
• A patient is known to be colonized with MRSA
• Bowel procedures • A patient is at high risk for MRSA colonization
• Additional anaerobic and gram negative coverage • In such cases, a beta-lactam antibiotic (first or second
generation cephalosporin) should be added for activity against
• Cefoxitin or cefotetan generally used gram-negative organisms
• Elective colorectal surgery: oral neomycin and • alternatives for patients allergic to cephalosporins include
erythromycin + parenteral antibiotic gentamicin, fluoroquinolones, or aztreonam
Bratzler DW; American Society of Health-System Pharmacists; Infectious Disease Society of America; Surgical Infection Society; Society for
Healthcare Epidemiology of America. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm.
2013 Feb 1;70(3):195-283.
©2011 MFMER | 3127551-23 ©2011 MFMER | 3127551-24
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Case 2: Case 2:
• A 35 yo female reports documented penicillin • A 35 yo female reports documented penicillin
allergy resulting in anaphylaxis 10 years ago. allergy resulting in anaphylaxis 10 years ago.
She is scheduled for an elective vaginal She is scheduled for an elective vaginal
hysterectomy. What do you recommend for hysterectomy. What do you recommend for
antimicrobial prophylaxis? antimicrobial prophylaxis?
• A. Meropenem • A. Meropenem
• B. Vancomycin • B. Vancomycin
• C. Perform penicillin skin testing prior to making • C. Perform penicillin skin testing prior to making
recommendations recommendations
• D. Clindamycin + levofloxacin • D. Clindamycin + levofloxacin
• E. No antimicrobial prophylaxis is required • E. No antimicrobial prophylaxis is required
©2011 MFMER | 3127551-25 ©2011 MFMER | 3127551-26
Penicillin Allergy Penicillin Skin Testing Caveats

• If questionable allergy reported or unknown
reaction/remote history, (not anaphylaxis or
exfoliative rash), consider penicillin allergy skin • Patients with history of anaphylaxis to penicillin
testing should not undergo skin testing without careful
weighing of the risk/benefit and only under
• Penicillin skin testing can be used to: supervision of an allergist
• Optimize antibiotic choice • Non-IGE mediated reactions can not be tested
• Decrease use of more expensive antibiotics by skin testing, patients with history of
• Decrease chance of antibiotic resistance exfoliative skin reactions should not undergo
skin testing
©2011 MFMER | 3127551-27 ©2011 MFMER | 3127551-28
Case 3:
A 30 yo male with HIV/hepatitis B coinfection, CD4 150,
Objective #3 viral load undetectable, on tenofovir, emtricitabine,
atazanavir/ritonavir & trimethoprim/sulfamethoxazle is
• Review perioperative management of patients scheduled for bioprosthetic vale replacement for infective
on antiretroviral therapy for HIV. endocarditis & perivalvular abscess. What are your
perioperative recommendations?
A. Proceed with surgery. Hold all ARVs through the perioperative
period until patient is reliably taking po. Give TMP/SMX IV for OI
prophylaxis.
B. Delay surgery until CD4 is >200. Continue ARVs and OI
prophylaxis.
C. Proceed with surgery. Continue ARVs and OI prophylaxis
through perioperative period (give through NG if necessary).
D. Continue tenofovir to cover for hepatitis B infection & prevent
flare, discontinue other ARVs, continue OI prophylaxis.
©2011 MFMER | 3127551-29 ©2011 MFMER | 3127551-30
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Case 3:
A 30 yo male with HIV/hepatitis B coinfection, CD4 150, Preoperative Evaluation
viral load undetectable, on tenofovir, emtricitabine,
atazanavir/ritonavir & trimethoprim/sulfamethoxazle is • Same as for patients not infected with HIV
scheduled for bioprosthetic vale replacement for infective
endocarditis & perivalvular abscess. What are your • With addition of evaluation of:
perioperative recommendations?
• Immunologic status: CD4 count/percentage
A. Proceed with surgery. Hold all ARVs through the perioperative • HIV control: viral load
period until patient is reliably taking po. Give TMP/SMX IV for OI
prophylaxis. • Review current antiretrovirals (ARVs), ARV history,
B. Delay surgery until CD4 is >200. Continue ARVs and OI history of opportunistic infections (OI), OI
prophylaxis. prophylactic medications
C. Proceed with surgery. Continue ARVs and OI prophylaxis • If elective surgery, and patient does not have
through perioperative period (give through NG if necessary).
optimal control of HIV (viral load is not
D. Continue tenofovir to cover for hepatitis B infection & prevent suppressed or patient is not on ARVs), consider
flare, discontinue other ARVs. Continue OI prophylaxis.
delay of surgery.
©2011 MFMER | 3127551-31 ©2011 MFMER | 3127551-32
Antiretroviral Therapy Postoperative Fever in Patients with HIV

• 2012 DHHS HIV Treatment Guidelines recommend all • Same differential diagnoses as patients without
HIV-infected persons be on antiretroviral treatment HIV
• Carefully review ARV drug-drug interactions prior to • If CD4 <200, then you may also need to
anesthesia/surgery. Monitor addition of new
medications after surgery.
consider opportunistic infections, if patient has
not been on appropriate prophylaxis
• Ideally continue all antiretrovirals and medications for • PCP CD4 <200
prophylaxis through the operative period. • Toxoplasmosis CD4 <100
• Exceptions would be inability to tolerate NG • Mycobacterium avium complex CD4 <50
medications/feeds, high pressor requirements. • CMV CD4 <50
• If not able to take one antiretroviral, hold all ARVs. • FUO, consideration of lymphoma
• Consult HIV expert if patient is expected to be NPO or • In patients with CD4 <50, also consider adrenal
have issues with absorption for an extended time. insufficiency in appropriate clinical scenario
Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and
Human Services. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf
Accessed: August 18, 2013. ©2011 MFMER | 3127551-33 ©2011 MFMER | 3127551-34
Summary Summary
• Postoperative fever evaluation depends on • In general, ARVs should be continued through
timing of fever and type of surgery performed. the perioperative period unless prolonged
• Atelectasis is generally not considered a period of inability to take oral/NG medications is
cause of fever. suspected.
• Remember to carefully check for drug
• Perioperative antimicrobial prophylaxis usually interactions between new medications and
consists of cefazolin (with additional gram- ARVs.
negative & anaerobic coverage for bowel
surgery).
• Penicillin skin testing can be helpful in
clarifying validity of penicillin allergy.
©2011 MFMER | 3127551-35 ©2011 MFMER | 3127551-36
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Disclosures
Financial
None
Peri-operative Medicine
Hematology Issues Off label use
None
Rajiv K. Pruthi, M.B.B.S
Special Coagulation Laboratory &
Comprehensive Hemophilia Center
Division of Hematology/Internal Medicine
Dept of Laboratory Medicine & Pathology Did I change my slides?
Mayo Clinic
Peri-operative Medicine, Seattle 2013 You betcha!
pruthi.rajiv@mayo.edu
©2011 MFMER | 3142030-1 ©2011 MFMER | 3142030-2
Objectives Objectives
• Pre-operative hemostatic assessment: Who • Pre-operative hemostatic assessment: Who
and What and What
• Perioperative transfusion strategy: • Perioperative transfusion strategy:
conservative or liberal? conservative or liberal?
• Post-operative transfusion triggers. • Post-operative transfusion triggers.
• How do I diagnose and treat heparin • How do I diagnose and treat heparin
induced thrombocytopenia in the induced thrombocytopenia in the
perioperative period? perioperative period?
• Perioperative management of Von • Perioperative management of Von
Willebrand’s disease Willebrand’s disease
• Perioperative management of sickle cell • Perioperative management of sickle cell
disease. ©2011 MFMER | 3142030-3
disease. ©2011 MFMER | 3142030-4
Pre-operative hemostatic Preoperative Screening for Hemostasis

assessment: Screening Hemostatic History (patient/family)
• Who? • Detect underlying congenital and acquired
• All patients….but bleeding disorders
• Not everyone needs a laboratory test • For a positive history:
• Consider additional laboratory testing
• What?
• Preoperative clinical suspicion of a • Medication history
hemostatic abnormality • Detect antiplatelet and anticoagulant
• How do you determine this medicaments
• The patient personal and family • Herbal preparations
hemostatic history • Undetected antiplatelet agents
• Bleeding scores assessment
©2011 MFMER | 3142030-5 ©2011 MFMER | 3142030-6
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Bleeding Questionnaire
Outcomes of condensed bleeding score
• Normal controls: -3.2 to +3.6
• Abnormal cut off: >4 Bowman et al JTH 2008;6:2062
• Prospective study for VWD diagnosis
• Sensitivity100%
• Positive predictive value: 20%
• Negative predictive value: 100%
• Abnormal cut off: >3 Tosetto et al JTH 2011;9:1143
• Positive predictive value: 71%

• Negative predictive value: 99.6%
Bowman et al JTH 2008;6:2062
©2011 MFMER | 3142030-7 ©2011 MFMER | 3142030-8
Conclusion
• Best haemostatic screening test
• Patient and family history
• Limitation
• Children may not have been exposed to Pre-operative hemostatic
trauma, previous surgery assessment: What tests?
• Circumcision related bleeding: not an
optimal history (improvements in surgical
techniques)
• Family history will be important
©2011 MFMER | 3142030-9 ©2011 MFMER | 3142030-10
vWD: 1%:
aPTT order VWF PT
assays
Approx Intrinsic Extrinsic Approx
frequency
XII frequency
XI
0 to 4.3% VII 1:500,000
IX
1/30,000
Tests of hemostasis VIII
>150 cases
PT and aPTT: What is the point? 1/5,000
V
Incidence:
1/million
X >30 cases
II >20 cases
Fibrinogen >150 cases
©2011 MFMER | 3142030-11 ©2011 MFMER | 3142030-12
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Outcomes of Routine Preoperative Outcomes of Routine Preoperative
Prothrombin Time Partial Thromboplastin Time
• Incidence of abnormalities: 0-4.8% • Incidence of abnormalities: 0-15.6%
• Significantly abnormal: 0% • Significantly abnormal: 0%
• Change in management: 0% • Change in management: 0-0.7%
Munro J et al: Health Technology Assessment Vol 1: No.12, 1997 Munro J et al: Health Technology Assessment Vol 1: No.12, 1997
©2011 MFMER | 3142030-13 ©2011 MFMER | 3142030-14
Conclusion Why are the PT/APTT not good predictors

PT/aPTT of surgical hemorrhage?
• No association between an abnormal • Majority of surgical hemorrhage is due to
PT/aPTT and postoperative bleeding technical reasons (‘silk deficiency’)
• Low positive predictive value in the • PT/APTT designed to detect static changes in
asymptomatic patient hemostasis, dynamic changes in hemostatic
• Useful for patients with bleeding system in surgery/trauma etc
symptoms • Intraoperative DIC, fibrinolysis etc cannot be
• Diagnosis and altered management predicted by pre-operative testing
• Remember, surgical technique is a variable • Most patients with hereditary bleeding

in risk of bleeding disorders have been diagnosed in childhood
©2011 MFMER | 3142030-15 ©2011 MFMER | 3142030-16
Platelet function analyzer-100

(PFA-100)
©2011 MFMER | 3142030-17 ©2011 MFMER | 3142030-18
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Role of PFA-100
• Evaluation of bleeding symptoms
• As an adjunct to hemostatic history and
Special Coagulation testing including platelet
aggregation
• Not useful for predicting surgical hemorrhage
• Less than 100% sensitive for residual ASA
effect
• Only 68% ASA users had prolonged CT
Ortel et al Thromb Haemost 2000;84:94
©2011 MFMER | 3142030-19 ©2011 MFMER | 3142030-20
Outcomes of Patients with no

Preoperative Laboratory Tests Types of Procedures
• Study period 1994 (56,000 50
surgical/diagnostic procedures)
40
35
• 5,120 patients with no laboratory tests
30
25
• Analyzed 1,000 patients (87 pt/month) %
20
10 10
10 6 5 5 5
n=366 n=260 n=107 n=100 n=59 n=54 n=51 n=51
0
Orthopedic ENT Gen surg Ophthal Dental Urologic Gynecol Other
Narr et al Mayo Cl Proc 72:505, 1997 Narr et al Mayo Cl Proc 72:505, 1997
©2011 MFMER | 3142030-21 ©2011 MFMER | 3142030-22
Results Results
• Deaths 0 (0%) • Based on H&P if no preoperative indication
for laboratory tests determined
• Transfusions 0 (0%)
• Safe to proceed with anesthesia/surgery
• Excess bleeding 1 (0.1%)
• Laboratory evaluation
• Sinus surgery; no transfusions
• based medical and anaesthesia
• No role of obtaining routine preoperative perioperative indications
tests
• Clinical assessment is essential with
additional testing if indicated
Narr et al Mayo Cl Proc 72:505, 1997 Narr et al Mayo Cl Proc 72:505, 1997
©2011 MFMER | 3142030-23 ©2011 MFMER | 3142030-24
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Objectives Transfusion thresholds: AABB Guidelines
• Pre-operative hemostatic assessment: Who
and What • Hospitalized hemodynamically stable
• Perioperative transfusion strategy: patients (HHSP)
conservative or liberal? • 1) No other co-morbidity
• Post-operative transfusion triggers. • 2) with preexisting CV disease
• How do I diagnose and treat heparin • 3) with acute coronary syndrome
induced thrombocytopenia in the • 4) Transfusion criteria: symptoms vs
perioperative period? hemoglobin
• Perioperative management of Von
Willebrand’s disease
• Perioperative management of sickle cell Carson JL et al Annals Int Med 2012: 157:49-58
disease. ©2011 MFMER | 3142030-25 ©2011 MFMER | 3142030-26
HHSP: no comorbidity
Restrictive vs Liberal
• Restrictive strategy
• Trend towards • Based on statistical
• Adult/pediatric ICU patients: <7 g/dL decreased mortality analysis, unlikely to
• Post-operative surgical patient: • No evidence of harm
decrease mortality
• <8 g/dL OR
• Symptomatic patient
• Chest pain, orthostatic
hypotension/tachycardia unresponsive to
fluid resuscitation
• Congestive heart failure
• Quality of evidence: high
• Strength of recommendation: strong
Carson JL et al Annals Int Med 2012: 157:49-58 Carson JL et al Annals Int Med 2012: 157:49-58
©2011 MFMER | 3142030-27 ©2011 MFMER | 3142030-28
HHSP: with preexisting CV disease

Restrictive vs Liberal Strategy
• Restrictive strategy
• Increase vs decreased incidence of myocardial
• Adult/pediatric ICU patients: <7 g/dL infarction
• Post-operative surgical patient: • Conflicting results in the two large trials
• <8 g/dL OR • (TRICC and FOCUS)
• Symptomatic patient
• Chest pain, orthostatic • Overall results (all trials):
hypotension/tachycardia unresponsive to
fluid resuscitation • no statistically significant increase in
• Congestive heart failure • Mortality
• Quality of evidence: moderate • Myocardial infarction
• Strength of recommendation: weak
©2011 MFMER | 3142030-29 ©2011 MFMER | 3142030-30
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HHSP transfusion criteria: symptoms vs
HHSP: with acute coronary syndrome
hemoglobin
• Restrictive strategy vs liberal: no data • Both

• Quality of evidence: very low • Quality of evidence: low
• Strength of recommendation: uncertain • Strength of recommendation: weak
©2011 MFMER | 3142030-31 ©2011 MFMER | 3142030-32
Objectives
• Pre-operative hemostatic assessment: Who Type II: Immune HIT
and What • Isolated HIT or HIT with thrombosis (HITTS)
• Perioperative transfusion strategy: • Based on timing:
conservative or liberal? • Classical HIT (day 5 to 14)
• Post-operative transfusion triggers. • Rapid onset HIT (<day 5)
• How do I diagnose and treat heparin • Delayed HIT (>day 14 to ~4 weeks)
induced thrombocytopenia in the • Atypical HIT
• Skin necrosis
• Perioperative management of Von • Systemic reactions to UFH infusion
• HIT-like syndrome
• Perioperative management of sickle cell
Risk of Thrombosis in Isolated HIT HIT Pre-Test Probability Scoring

Warkentin
Wallis et al, and Kelton, Lewis et al
Study 1999 1996 2003
Design Retrospective Retrospective Prospective
Therapy D/C heparin, D/C heparin D/C heparin
21/113 received or substitute and/or sub-
other Rx warfarin stitute warfarin
New 21/113 (18%) 32/62 (52%) 32/139 (23%)
thrombosis
• Patients with isolated HIT have high risk of thrombosis

• Prophylactic therapy with a DTI should be considered
CP1219740-42 Warkentin TE: Sem Thromb Haemost 30(4):273, 2004 CP1218590-49

©2011 MFMER | 3142030-35 ©2011 MFMER | 3142030-36
304
Emerging Clinical Diagnostic Approach:HIT Expert Probability
Clinical feature
1. Magnitude of fall in platelet count (measured from peak platelet count to nadir platelet count Score
since heparin
1. Magnitude of fall inexposure)
platelet count (measured from peak platelet count to nadir platelet count
a. <30%
since heparin exposure)
a.b.<30%
30%-50%
b.c. 30%-50%
>50%
c. >50%
-1
1
3
-1
1
3
Role of emerging clinical predictors
2.
2. Timing
Timing of fall in platelet
of fall count –count
in platelet for patients
– forinpatients
whom typical onset HIT
in whom is suspected
typical onset HIT is suspected
a.a. Fall
Fall
Fall
d.c. Fall
Fall
begins
begins
begins
begins
begins
begins
<4 days
5-104days
5-10
11-14
after heparin
<4 days
days after
daysdays
exposure exposure
after heparin
b. Fall begins 4 days after heparin exposure
c.b.Fall after heparin
heparin
after heparin
after heparin
exposure
exposure
exposureexposure
-2
2
3
2
-2
2
3
• HEP Score:
• Requires prospective clinical validation prior
e.d. Fall
Fallbegins
begins>14 11-14
days after
daysheparin
afterexposure
heparin exposure -1 2
For
e. patients with previous
Fall begins >14 days heparin exposure
after heparinin last 100 days in whom rapid onset HIT is suspected
exposure -1
f. Fall begins <48 h after heparin re-exposure
g.ForFallpatients
begins >48 with previous
h after heparinheparin exposure in last 100 days in whom rapid onset HIT is
re-exposure suspected
2
-1 Cut off 2:
f. Fall begins <48 h after heparin re-exposure 2
3. Nadir platelet
g. Fall beginscount
a. <20 x 109 L-1
>48
h after heparin re-exposure
-2
-1 to routine use
b. >20 x 109 L-1 2
Sens:100%
4. Thrombosis (Select no more than one)
For patients in whom typically onset HIT is suspected
a. New VTE or ATE 4 days after heparin exposure 3
Spec: 60%
b. Progression of pre-existing VTE or ATE while receiving heparin 2
For patients in whom rapid onset HIT is suspected PPV: 30%
c. New VTE or ATE after heparin exposure 3
d. Progression of pre-existing VTE or ATE while receiving heparin 2 NPV: 100%
5. Skin necrosis
a. Skin necrosis at subcuteaneous heparin injection sites 3
6. Acute systemic reaction
a. Acute systemic reaction after intravenous heparin bolus 2
7. Bleeding
a. Skin necrosis at subcuteaneous heparin injection sites 3
8. Other
8. Other causes
causes of thrombocytopenia
of thrombocytopenia (select all(select all that apply)
that apply)
a.a.Presence
Presence of a of
chronic thrombocytopenic
a chronic disorder disorder
thrombocytopenic -1 -1
b. Newly initiated non-heparin medication known to cause thrombocytopenia -2
c.b.Severe
Newlyinfection
initiated non-heparin medication known to cause thrombocytopenia -2 -2
d.c. Severe
SevereDICinfection
(defined as fibrogen <100 mg/dL-1 and D-dimer >5.0 g mL-1) -2 -2
e.d.Indwelling
Severe intra-arterial
DIC (defined as(e.g.
device fibrogen mg/dL-1 and D-dimer >5.0 g mL-1)
<100ECMO)
IABP, VAD, -2 -2
f.e.Cardiopulmonary bypass withindevice
Indwelling intra-arterial previous(e.g.
96 h IABP, VAD, ECMO) -1 -2
g. No other apparent cause 3
f. Cardiopulmonary bypass within previous 96 h -1
VTE,g.venous
No other apparent cause
thromboembolism; ATE, arterial thromboembolism; DIC, disseninated intravascular coagulation; IABP, intra-aortic balloon 3
pump; VAD, ventricular assist device, ECMO, extracorporporeal membrane oxgenation
Cucker A et al JTH 2010;8:2642
©2011 MFMER | 3142030-38
Post CABG Thrombocytopenia

HIT Laboratory assays
Variables Clinical scenario Points Category Sensitivity Specificity
(b) Lillo-Le Louët model
1. Platelet count time
course Pattern A (Platelet 2
count begins to recover Immunologic Polytypic >95% 50-89%
after CPB, but then
begins to fall again >4 IgG-specific
days after CPB)
2. Time from CPB to 5 days 2 PGIA
index date <5 days 0
3. CPB duration 118 min 1

>118 min 0 Functional SRA >90% >90%
Total score of 2 points, high probability of HIT; <2 points, low probability HIPA
of HIT
Cucker A Curr Op Hem 2011;epub
©2011 MFMER | 3142030-39 ©2011 MFMER | 3142030-40
HIT: “Dos and don'ts”

Treatment Goals in HIT
• Don’t • Do
Interrupt the immune response • Increase dose of • Stop ALL heparin
heparin
• Discontinue heparin • Switch to low molecular
• Consider risks benefits
of direct thrombin
weight heparin inhibitors (DTI)
Inhibit thrombin generation • Start warfarin alone • Start DTI especially if
there is documented
• Treat existing thrombosis • “Load” the patient with
warfarin
thrombosis
• Prevent new thrombosis • Let patient “cool off”
before starting warfarin
©2011 MFMER | 3142030-41 ©2011 MFMER | 3142030-42
305
Frequency of a Positive Test for
Heparin-Dependent Antibodies
Objectives
100 • Pre-operative hemostatic assessment: Who
and What
80 Antigen assay
• Perioperative transfusion strategy:
60 conservative or liberal?
40
• Post-operative transfusion triggers.
Activation assay
• How do I diagnose and treat heparin
20
induced thrombocytopenia in the
0
0 25 50 75
Days to negative assay result
100 125 • Perioperative management of Von
No. at risk
Antigen assay 93 36 17 8 6
Activation assay 144 53 23 10 3
• Perioperative management of sickle cell
Warkentin TE 2004
©2011 MFMER | 3142030-43
disease. ©2011 MFMER | 3142030-44
von Willebrand disease Platelet Adhesion

• Deficiency of von Willebrand factor
• The most common congenital bleeding disorder
• Function of vWF
• mediates platelet adhesion (aggregation) to
injured vessel wall
• carrier for factor VIII
©2011 MFMER | 3142030-45 ©2011 MFMER | 3142030-46
von Willebrand disease

• Testing for vWD:
• Patient history (family history)
• Functional assay: VWF activity/Ristocetin cofactor
Low
• Antigenic assay: vWF antigen Low
• FVIII activity
• Multimer pattern: Distribution
• APTT Typically normal (rarely prolonged)
©2011 MFMER | 3142030-47 ©2011 MFMER | 3142030-48
306
von Willebrand disease: Perioperative
management Postoperative management
• Factor replacement options: • Type 1 (mild)
• Desmopressin (DDAVP) • DDAVP once preop
• Plasma derived VWF concentrate • Typically switch to VWF concentrate
• General principles • Types 2 and 3
• Preop: Infuse and measure a post infusion • Plasma derived VWF concentrates
level (lasts 8 to 12 hours)
• Check daily AM levels for ongoing dosing
• Intraop: depending on length of surgery • Requires quick turn around time of VWF
additional doses may be needed
assays
• Do not dose without checking daily levels
©2011 MFMER | 3142030-49 ©2011 MFMER | 3142030-50
Objectives Pathophysiology: Viscosity, %HbS and

• Pre-operative hemostatic assessment: Who hematocrit
and What • At a fixed %HbS:
• Perioperative transfusion strategy: • Viscosity increases with hematocrit
conservative or liberal?
• At a fixed hematocrit:
• Post-operative transfusion triggers. • Viscosity increases with %HbS
• How do I diagnose and treat heparin • Simple Transfusions: raise hematocrit and
induced thrombocytopenia in the viscosity
• Reduces oxygen delivery
• Perioperative management of Von
Willebrand’s disease • Exchange transfusion: raise hematocrit and
reduce %HbS
• Perioperative management of sickle cell • Reduces viscosity
Transfusion in Sickle Cell Disease and

surgery: Randomized Trial
• Aggressive regimen (group 1):
• Target Hb 10 g/dL(9 to 11) AND
• HbS level of <30%
• Conservative regimen (Group 2):
The main perioperative question • Target Hb 10 g/dL (9 to 11)
Simple transfusion vs exchange transfusion • regardless of the HbS level
Vichinsky et al NEJM 1995;333: 206-213

©2011 MFMER | 3142030-53 ©2011 MFMER | 3142030-54
307
Types of Surgeries Complication Rate
Group 1 Group 2 Group 1 Group 2
Variable (n=303) (n=301) Complications (n=303) (n=301)
Operations (%) Operations (%)
Types of surgery Before, during, or after surgery
Cholecystectomy 36 41 Miscellaneous intraoperative 19 20
event
Ear, nose, and throat 25 26
procedure Acute chest syndrome 11 10
Orthopedic procedure 11 13 Fever or infection 7 7
Orthopedic procedure 11 13 Miscellaneous postoperative 6 5
event
Splenectomy 6 4
Painful crisis 5 7
Herniorrhaphy 5 5
Neurologic event 1 1
Genitourinary procedure 3 2
Renal complication 1 <1
Obstetrical or gynecologic 3 2
procedure Death 1 0
Skin procedure 3 2 Any complication 31 35
Gastrointestinal procedure 2 2 After surgery
Eye procedure <1 2 Acute chest syndrome 10 10
Vascular-access procedure 2 1 Fever or infection 7 5
Soft-tissue biopsy 2 <1 Miscellaneous postoperative 6 5
event
Craniotomy <1 0
Painful crisis 4 7
Arteriography <1 <1
Neurologic event 1 <1
Other <1 0
Renal complication 1 <1
Surgical-risk category†
Death 1 0
1 26 23
Any complication 21 22
2 73 77
*Complications associated with transufions, which are shown in Table 5, are excluded here.
3 1 0 The group numbers refer to operations.
Vichinsky et al NEJM 1995;333: 206-213 Vichinsky et al NEJM 1995;333: 206-213

©2011 MFMER | 3142030-55 ©2011 MFMER | 3142030-56
Perioperative management Predictors of complications

• Preoperative: • Acute chest syndrome (10%):
• Hydration for 8 hours • Higher surgical risk category
• Intraoperative monitoring: • History of pulmonary disease
• Temperature • Painful crises (5%)
• Blood pressure • Older age
• ECG • Frequent hospitalizations
• Oxygenation
• Postoperative:
• Hydration, oxygen, etc
Vichinsky et al NEJM 1995;333: 206-213 Vichinsky et al NEJM 1995;333: 206-213
©2011 MFMER | 3142030-57 ©2011 MFMER | 3142030-58
Complications: Alloimmunization Rate

The bottom line:
• Aggressive transfusion strategy provided no
advantage over simple transfusion for surgery
• Caveats:
• None of the studied patients underwent
CABG
Vichinsky et al NEJM 1995;333: 206-213

©2011 MFMER | 3142030-59 ©2011 MFMER | 3142030-60
308
Lancet 2013;381:930 Lancet 2013;381:930
©2011 MFMER | 3142030-61 ©2011 MFMER | 3142030-62
Take home messages Take home messages

• NHLBI Guidelines • SCD-SS and SCD-S βo-thalassemia
• All sickle cell patients: (regardless of genotype) • simple transfusion: Hb ~10 g/dL
• Rigorous pre/intra/postoperative monitoring: • all but the lowest risk procedures
• I/O hematocrit, hydration, peripheral • SCD-SC:
perfusion, oxygenation status, blood • exchange transfusions avoidance of
pressure, cardiac rhythm and rate, hyperviscosity complications
respiratory therapy.
• Extended antigen-matched blood
• Team awareness
• K, C, E, S, Fy, and Jk antigens
©2011 MFMER | 3142030-63 ©2011 MFMER | 3142030-64
309
310
Learning objectives
An Overview of
Perioperative Medicine 2013: • Brief review of pulmonary (patho)physiology
From Outpatient Preoperative Assessment most relevant to the perioperative period
• Describe the most common post-operative
pulmonary complications
• Discuss best practice to minimize or treat
pulmonary complications in the postoperative
period

Management of Post-operative Pulmonary Complications
Richard A. Oeckler, M.D., Ph.D.
©2011 MFMER | 3127551-1 ©2011 MFMER | 3127551-2
Question 1 Independent predictors of PPCs

• The most important risk factor for the • Surgical site (Intrathoracic) Highest Risk
development of a post-operative pulmonary
complication is: • Pre-op SaO2 ≤90%
a) Smoking history • Surgical duration >3 hours
b) General anesthesia • Respiratory infection in last month
c) Surgical site • Age >80
d) Recent pneumonia • Functional status

• Emergency procedure Lower Risk
Adapted from Canet et al. Anesthesiology 2010; 113:1338 –50
©2011 MFMER | 3127551-3 ©2011 MFMER | 3127551-4
Independent predictors of PPCs Incidence by surgical procedure/site

• Surgical site (Intrathoracic) • Non-cardiothoracic ~2-7%
• Pre-op SaO2 ≤90% • Cardiothoracic ~30-40%
• Surgical duration >3 hours
• Respiratory infection in last month
• Age >80
• Functional status
• Emergency procedure
Qaseem et al. Ann Intern Med. 2006;144:575-580. Canet et al. Anesthesiology 2010; 113:1338 –50
©2011 MFMER | 3127551-5 ©2011 MFMER | 3127551-6
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Stable incidence despite best practice PPCs increase LOS, mortality
N Engl J Med 1937; 216:973-976June 3, 1937DOI: 10.1056/NEJM193706032162203 Canet et al. Anesthesiology 2010; 113:1338 –50
©2011 MFMER | 3127551-7 ©2011 MFMER | 3127551-8
PPCs increase LOS, mortality Causes of post-op respiratory failure
Canet et al. Anesthesiology 2010; 113:1338 –50 Borzecki et al. doi:10.1016j.jamcollsurg.2010.09.034
©2011 MFMER | 3127551-9 ©2011 MFMER | 3127551-10
Case #1
• 52F with COPD, DM2 undergoes uneventful
RUL pulm nodule wedge resection. Develops
low-grade fever evening POD #1, and
tachypnea (no wheeze), tachycardia, increased
secretions, SaO2 90% (preop baseline 96-
99%) on POD #2. The most likely diagnosis is:
a) HCAP
b) Bronchospasm
c) Atelectasis
d) VTE
Annals of Surgery, August 1941
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Anesthesia and the lung:
Set-up for atelectasis Induction and the benefit of preoxygenation
No Preoxygenation With Preoxygenation
British Journal of Anaesthesia 91 (1): 61-72 (2003) British Journal of Anaesthesia 91 (1): 61-72 (2003)
DOI: 10.1093/bja/aeg085 DOI: 10.1093/bja/aeg085
©2011 MFMER | 3127551-13 ©2011 MFMER | 3127551-14
Absorption atelectasis: Compression atelectasis:

Negative consequences of high FiO2 Pulmonary mechanics under anesthesia
• Loss of muscle tone
• Altered diaphragm motion
• Cephalad displacement
Goran Hedenstierna1 and Hans Ulrich Rothen2 Compr Physiol 2011. Hedenstierna G. Acta Anaesthesiol Scand 2012; 56: 675–685
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Inhalational anesthetics inhibit hypoxic

Anesthetics and ventilatory drive vasoconstriction
• Ventilatory drive affected by state of arousal, • Exacerbates pre-exisiting V/Q mismatching
O2/CO2/acid-base status
• Compounds shunting due to atelectasis
• Blunted ventilatory response to both hypoxemia
and hypercarbia
• Depression of peripheral chemoreceptors
• Response to O2
• Depression of central chemoreceptors
• Response to PaCO2
Goran Hedenstierna1 and Hans Ulrich Rothen2 Compr Physiol 2011. Goran Hedenstierna1 and Hans Ulrich Rothen2 Compr Physiol 2011.
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Obesity: A further mechanical disadvantage The role of postoperative pain in PPCs
Effects of pain Effects of its treatment
• Poor inspiratory effort • Decreased VE
• Shallow breathing • Decreased muscle tone
• Few deep breaths / sigh
maneuvers • Opioids and bronchospasm
• Reduced ability to recruit
• Decreased mental status,
• Ineffectual cough and increased risk of aspiration
mucus clearance
• Retained secretions
British Journal of Anaesthesia 91 (1): 61-72 (2003)

DOI: 10.1093/bja/aeg085
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Pneumonitis (Aspiration) Pneumonitis (Aspiration): Prevention

• Chemical injury to the lung, NOT infectious • Pre-procedural fasting (several hours)
• Clinical history • Metoclopramide to enhance gastric emptying
• Witnessed aspiration • H2 or PPI to increase gastric contents pH
• Decreased consciousness = unprotected • Selective use of nasogastric (NG) tubes
airway
• Anesthesia (Up to 4.5%, general anesthesia) • In symptomatic or with abdominal distension
• Pain, sedative medications • Routine use apears to increase aspiration
risk (OR=1.45; 1.08-1.93 v. selective use)
• Unprotected airway + vomitus = aspiration
pneumonitis, potential evolution to PNA?
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Approach to the treatment of atelectasis

Excessive Secretions No secretions
• Frequent suctioning • Trial CPAP*
• Bronch for mucus plugging • Decreased re-intubation
• 1% v. 10%
• Chest physiotherapy
• Decreased pneumonia
• Up and ambulate • 2-3% v. 10%
• Decreased sepsis
• No evidence for N-AC • 2% v. 9%
• CPAP contraindicated • Up and ambulate
Incentive spirometry?
*Squadrone et al. JAMA. 2005;293(5):589. Annals of Surgery, August 1941
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Lung expansion techniques to prevent or
treat atelectasis Question #2
• Incentive spirometry • Atelectactic regions of the lung are associated
with all of the following except:
• Chest physical therapy
• including deep breathing exercises, a) Surfactant dysfunction
percussion and vibration b) Increased inflammatory signaling
• Cough c) Ventilator-induced lung injury
• Postural drainage d) An increased V/Q
• Ambulation e) Low tidal volume lung ventilation
• PAP (CPAP, BIPAP)
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The biophysics of atelectasis Atelectrauma

• Pathological changes at the functional Interfacial stress injury
respiratory unit (respiratory bronchiole and •Cyclical opening and closing
alveoli) as a result of atelectasis: of alveoli leads to resident
• Barotrauma cell injury
• Biotrauma •May lead to paradoxical
• Surfactant loss overdistension of open units
• Interdependence mechanisms •Barrier property changes,
fluid shifting
•Inflammatory response
Carney D, et al Crit Care Med 33:S122-128, 2005.
©2011 MFMER | 3127551-27 28
Overdistension Edema / Foam

• Resident cell injury • Airway flooding, “functional atelectasis”
• Basement membrane disruption, loss of • Lower Pcrit, need more force to reopen
compartmentalization, alveolar flooding
• Pressure-gradient injury1
• Immune and inflammatory response
• Liquid-bridge rupture injury2
Hotchkiss et al. Crit Care Med 2002;30:2368–2370. 1) Oeckler et al. Am J Physiol Lung Cell Mol Physiol. 2010 Dec;299(6):L826-33.
2) Huh et al. PNAS. 2007 Nov;104(48):18886-18891.
29 30
315
The biophysics of atelectasis
Key players:
• Pathological changes at the functional Neutrophil and
macrophage
respiratory unit (respiratory bronchiole and • TNF-alpha
alveoli) as a result of atelectasis: • TGF-beta
• IL-1,6,8,10
• Barotrauma
• Biotrauma Compartmental
loss = potential
• Surfactant loss systemic effect
• Interdependence mechanisms
©2011 MFMER | 3127551-31 Ware & Matthay, NEJM, 2000. 32
The biophysics of atelectasis Consequences of surfactant loss

• Pathological changes at the functional ↑ Surface tension
respiratory unit (respiratory bronchiole and ↑ Work of breathing
alveoli) as a result of atelectasis: ↑ Fluid from capillaries to
• Barotrauma alveolar space (Pulmonary
edema)
• Biotrauma
• Surfactant loss ↓ Innate immunity
SP-A and SP-D carbohydrate
• Interdependence mechanisms recognition domains coat
Pediatric Research (2001) 49, 38–44.
foreign particles, promote
macrophage phagocytosis =
decreased bacterial clearance
34
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The biophysics of atelectasis Interdependence

• Pathological changes at the functional
respiratory unit (respiratory bronchiole and • Biophysics of networked Normal
alveoli) as a result of atelectasis: structures

• Barotrauma • Shear stress between
neighboring units with
• Biotrauma different volumes,
• Surfactant loss transmural pressures,
mechanical composition
• Interdependence mechanisms Atelectatic
• Stress concentrations
• Setup for lung cell and
basement membrane
failure
36
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Case #2 Case #2:
• 75M smoker with moderate COPD, CAD, and • His blood gas on FiO2 0.5 and SaO2 90% is:
systolic CHF underwent resection of RUL pulm
nodule. Post-op he was extubated but unable • PaO2 65
to wean off O2. Despite diuresis he has an • PaCO2 55
increasing O2 requirement and is reintubated • pH 7.35
on POD#3.
• HCO3 30
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Acute Lung Injury & the Acute Respiratory

Case #2 Distress Syndrome
Based on the provided information, the diagnosis • Definition
most consistent with the patient’s current
respiratory condition is: • Acute onset (<1 week)
• B/L pulmonary infiltrates
a) Procedural related volume overload / acute
exacerbation of CHF • Not primarily due to
volume overload / acute
b) Acute exacerbation of COPD exacerbation of CHF
(PCWP <18 mmHg)
c) Acute respiratory distress syndrome • PaO2:FiO2 <300 with
d) Pneumonia PEEP of at least 5 cmH2O
From: Bernard GR et al. Am J Resp Crit Care Med. 1994. 149:818-824.

©2011 MFMER | 3127551-39 40
Acute Lung Injury & the Acute Respiratory Acute lung injury
Distress Syndrome • Ventilator-induced (VILI/VALI)
• Severity Grading • Exposure to mechanical ventilation
• Based on PaO2:FiO2
• Barotrauma
• Mild 200-300 Our patient’s P/F ratio • Biotrauma
• Moderate 100-200
=PaO2/FiO2 • O2/ROS/RNS toxicity
=65/0.5
• Severe <100 =130 • Transfusion-related (TRALI)
= Moderate ALI • Immune response to
blood products
• Preventable, “Hospital-acquired” conditions ?
From: Bernard GR et al. Am J Resp Crit Care Med. 1994. 149:818-824.

41 ©2011 MFMER | 3127551-42
317
Question #3
Which of the following interventions has been
shown to reduce mortality in patients with acute
lung injury?
a) Increasing PEEP from 5 to 10 cm H2O
b) Lowering tidal volume from 10 to 6 cc/kg
c) High frequency oscillatory ventilation
d) All of the above
e) None of the above
ARDSNET, 2000
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Low VT: Minimizing overdistension Low VT for everyone?
Upper Pflex
Lower Pflex
VT
http://www.scielo.br/img/revistas/jped/v83n2s0/en_a12f04.gif
JAMA, October 24/31, 2012—Vol 308, No. 16 1651
46
Low VT in the OR
 PNA
 ARF
 Sepsis/Septic shock
 Mortality
…in low VT group at 30 days
JAMA, October 24/31, 2012—Vol 308, No. 16 1651 Futier et al. N Engl J Med 2013;369:428-37.
DOI: 10.1056/NEJMoa1301082
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Lung opening and collapse during a
PEEP: Minimizing atelectasis & atelectrauma respiratory cycle
Upper Pflex Upper Pflex
Lower Pflex
PEEP
http://www.scielo.br/img/revistas/jped/v83n2s0/en_a12f04.gif
49 50
Choosing PEEP:
Actuarial Medicine?
Hager et al. Am. J. Respir. Crit. Care Med. 2005. 172 (10): 1241.
51 52
Etiology of Pulmonary Infiltrates Postoperative pneumonia

• Usually occurs by POD#5
Aspiration
• Fever
• Leukocytosis
Pneumonia • Infiltrate
ALI
• Dyspnea, tachypnea
• ± hypoxemia, hypercapnia
Pulmonary • Non-distinct from HAP/VAP in presentation
Edema
Singh et al. Chest. 1998;114(4):1129
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Postop PNA: Diagnosis Therapy
• High level of suspicion • Broad spectrum empiric coverage
• Fever, purulent sputum, WBC, • <50% culture positive
WOB/increasing hypoxia • GNB (Pseudomonas, Kleb, Acinetobacter)
• CXR and Staph aureus most common
• Microbiologic sample • ~30% polymicrobial (Enterobacter + Staph
or Strep)
• Trach secretions
• BAL • Adjust based on culture results and course
• Procalcitonin to de-escalate?
• Biomarkers?
©2011 MFMER | 3127551-55 ©2011 MFMER | 3127551-56
Case #3
Role for procalcitonin?
• 67M with DM2 and moderate COPD s/p
uncomplicated upper abdominal procedure.
POD #2 he develops tachypnea, increased
WOB, and wheezes throughout all lung fields.
All of the following may be a cause of this
condition except:
a) Aspiration
b) Pneumothorax
c) Acute exacerbation of underlying COPD
d) Opioid pain medications
Scheutz et al. Chest 2012;141;1063-1073
DOI 10.1378/chest.11-2430
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Bronchospasm: Common causes Bronchospasm: Treatment

• Aspiration • “Treat the underlying cause”
• Reflex SM constriction • Stop meds
• Tracheal stimulation, secretions, suctioning • Secretion management
• Medications (histamine release) • Short-acting B2 agonist
• Opiates, atracurium • May add anticholinergic for synergy
• Allergic response • For COPDers, asthmatics, manage as you
would an exacerbation of the underlying dz
• Exacerbation of underlying disease
• COPD, asthma
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Case #4 Case #4
• 44M obese smoker s/p Ivor-Lewis You immediately recommend:
esophagectomy for adenoCA is POD#4 and on
the general care floor. Despite resting after a) He remain supine without HOB elevation to
ambulation during his PT session he continues help with presyncope and orthostasis
to be lightheaded and dizzy. His therapist is b) Increase supplemental O2 to maintain
concerned that this may be due to the PRN saturation >92%
dose of oxycodone he took prior to their
session. He denies pain or dyspnea, although c) Obtain CT-PE protocol to rule out VTE
he is tachypneic and tachycardic. His SpO2 is d) Administer 0.4 mg naloxone for presumed
91% on 4L NC. BP 95/65 HR 115 RR 26. opioid overdose
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VTE/Pulmonary embolism Pulmonary embolism and pain medications

• Narcotics may blunt, mask or confound:
• Classical symptoms of discomfort
• Feelings of dyspnea
• Findings of hypotension, presyncopal, or
syncopal events
• Acid-base and ABG due to respiratory
depression
F. van Lier et al. / Thrombosis Research 129 (2012) e14–e17
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A quick note about pleural effusions in the

Pulmonary embolism and pain medications post-operative period
• Maintain a high level of suspicion • Up to 50% of abdominal, cardiac surgeries
• Low threshold for investigation • Majority benign, resolve spontaneously in 3-5
days
• Prophylaxis in all without contraindication
• SCDs* • In clinical context, don’t forget association with:
• Pharmacologic • Pulmonary embolus
• Dressler’s (Postpericardiotomy) syndrome
• Workup persistent effusion, or with other
concerning findings (infiltrate, fever, WBC)
• Thoracentesis
*Ho & Tan. Circulation 2013
DOI: 10.1161/CIRCULATIONAHA.113.002690
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Exacerbation of OSA Take home points: PPCs
• Apneas, hypopneas • Pulmonary physiology is your key to predicting,
• Loss of upper airway patency during sleep preventing, and treating PPCs. Learn it well!
• Episodic awakenings, desaturations • Recommend West or Munis (see refs)
• Worsened postoperatively • Atelectasis is bad. Prevent it, and you will
prevent many PPCs!
• Anesthesia, opioids, sedatives
• Compounding effects of obesity, OSA, high
• Muscle relaxation FiO2
• Depression of central, peripheral
respiratory centers
• Supine position post-op may contribute
©2011 MFMER | 3127551-67 ©2011 MFMER | 3127551-68
Take home points: PPCs References/Suggested Reading

• Over-treating pain is at least as bad as under- • PPC risk calculator:
treating pain! http://www.surgicalriskcalculator.com/prf-risk-
• Undertreat and its too painful to breath or calculator
clear secretions • West JB, Respiratory Physiology: The
• Overtreat and they don’t feel the need to Essentials, Eighth Ed. Lippincott Williams
breath or cough (and they aspirate!) Wilkins, 2011.
• Have a high index of suspicion based on timing • West’s online lectures in resp physiology:
and differentiate based upon key positive & http://meded.ucsd.edu/ifp/jwest/resp_phys/
negative symptoms • Munis JR, Just Enough Physiology, Mayo Clinic
• Atelectasis v. PNA v. overload v. PE Scientific Press, 2012.
©2011 MFMER | 3127551-69 ©2011 MFMER | 3127551-70
Questions?

Contact information:
Richard Oeckler, M.D., Ph.D.
(507) 284-2158
oeckler.richard@mayo.edu
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Goals and Objectives
Peri-operative pain management What are the commonly used opioids in the
postoperative setting and what issues should I consider
Susan M. Moeschler, MD when prescribing these?
October12, 2013
What are the common PCA doses for postoperative
pain control?
How do I manage chronic pain patients who have
uncontrolled postoperative pain?
When should I consider adjunctive analgesic therapies
to help with pain control?
How should patients on multiple sedating medications
postoperatively be monitored?
For patients with epidural or spinal anesthesia, how
should anticoagulant DVT prophylaxis be managed?
Q1. What does JCAHO require from a

pain management standpoint?
A) Patients have a right to be pain-free

B) Patients have a right to have their pain reduced to
4/10 on the pain numeric rating scale
C) Opioid therapy is required for any pain > 4/10
D) Patients are required to try non-opioid analgesics
prior to initiating opioid therapy
E) Pain must be assessed and managed reasonably
with periodic reassessments and education
Taken from http://www.jointcommission.org/assets/1/18/Pain_Management.pdf
©2011 MFMER | 3127551-3 ©2011 MFMER | 3127551-4
41 y.o. Male s/p Lumbar Lami/fusion Oral Morphine Equivalents (OME)

Conversions
• Chronic low back and leg pain x 10
years • Oxycodone SR 40mg
BID
• Baseline pain with medications “8/10” • Morphine 1:1
• OXYCODONE, • Oxycodone IR 15mg
• BMI 40 with sleep apnea, using CPAP MORPHINE IR,
q4h prn pain
• DM2 with normal renal function (CrCl • Percocet, lortab,

70 mL/min) vicodin
• 40 x 2 = 80
• Depression/Anxiety • Hydromorphone 1:5
• 15 mg x 6 = 90
• Opioids x 6 years • Oxymorphone 1:10
• 80 + 90 = 170 OME
• Oxycodone SR 40mg BID
• Oxycodone IR 15mg q4h prn pain
• Gabapentin 1200mg TID
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What are our pain issues?
A tumultuous course… • Chronic pain “8/10” with opioid tolerance
• Different pain generators
• While in PACU, “10/10” pain requiring significant amounts • Incisional pain
of IV fentanyl, hydromorphone, midazolam, ketamine • Myofascial spasm
• Sedated, wakes up only to mumble “10/10” • Neuropathic pain (radiculopathy)
• Localizes pain to lumbar spine and legs • Anxiety
• Lumbar incisional pain • Sedation
• Back muscle spasms • General Anesthetic
• Burning, tingling pain down both legs (similar to baseline) • PACU medications
• P.Ox 90% on 2L O2 NC, CPAP initiated • Reduced renal function
• Family is upset • OSA requiring CPAP
• “the doctor needs to do something about his pain…”
EMOTIONAL SENSORY
©2011 MFMER | 3127551-7 ©2011 MFMER | 3127551-8
What tools are available to treat this patient’s pain? Patient found in room in
• MEDICATIONS Increase dose cardiorespiratory arrest, cold and blue
• Opioid Analgesics
• Non-opioid Analgesics • For anxiety…
• NSAIDs
Change Med • lorazepam 1mg IV q8h PRN
Add Med
• Anticonvulsants
• Topical agents
• For spasms…
• Antidepressants • valium 5-10mg PO TID
• Antipsychotic Medications Decrease dose • baclofen 10mg PO TID
• PHYSICAL THERAPY “Think both vertically and laterally” • For insomnia…
• PSYCHOLOGIC THERAPIES • zolpidem 10mg PO QHS
• COMPLIMENTARY AND INTEGRATIVE MEDICINE • For nausea/vomiting…
TECHNIQUES • phenergan 6.25mg IV q6h PRN
• REGIONAL ANESTHESIA
• ADVANCED INTERVENTIONAL PAIN THERAPIES Watch out for polypharmacy
©2011 MFMER | 3127551-9 ©2011 MFMER | 3127551-10
Q4. When is the most likely time period Complex Pharmacology: First 24 hours
for postoperative respiratory
depression/arrest to occur? Polypharmacy/resolving anesthesia:
Opioids
A) In the immediate preoperative period
Residual Anesthetic
Benzodiazepines
B) 0-24 hours postoperatively Barbiturate
Muscle relaxants
C) 24-48 hours postoperatively Volatile anesthetic
Antiemetics
D) 48-72 hours postoperatively
E) Immediately post-dismissal from the hospital PACU Floor
Time
Assess: “Sedation Allowance”
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How do you take care of chronic pain Case #2
patients that always report “10/10” pain?
• Document patient’s “baseline” pain rating • 82 y/o female: “Aches and Pains”
• Reassure patient that you are treating the pain • 10/10 left leg pain- to undergo total hip arthroplasty
• Set realistic patient expectations
• Neurontin and Tramadol for pain
• Consider using alternate pain measurement scale
(“better or worse”, “tolerable or intolerable”) rather than • Post-operative Plan?
NRS • Oxycodone?
• Try to assess physical pain vs. emotional suffering • Hydromorphone?
• Maintain pre-hospital medications if possible, especially • Morphine?
antipsychotics, antidepressants and anxiolytics
• Put in the face time
->acetaminophen
What is an appropriate peri-operative pain
regimen? perception
• What was her pre-operative pain scale? ->TCA:chronic pain

Anti
Epileptic
• What analgesics was she using? Drugs
What is an appropriate post-operative pain

modulation
regimen?
• Is she adequately controlled at this time?
• Is she on other sedating medications?
transmission
• Is she nauseated? Taking orals?
• What adjuvants are reasonable for this patient? transduction
->topical cold
Kehlet H, Dahl JB. Anesth Analg 1993;77:1049.
Tools in the “toolbox”

Opioid Requirements
• Opioids
• NSAIDs
• Education • Pre-existing pain
• Local Anesthetics conditions
• Gender/Age
• Adjuvant meds • Actual Pain Problem
• Culture
-antiepileptic • Renal/Hepatic function
-antidepressants • Psychological
• Depression/Affective • Attitude of patient
-NMDA antagonists (ketamine) disorder
-alpha 2 agonists (clonidine) • Anxiety disorder
• Genetic predisposition
• Non-pharmacologic treatments • Drug/EtOH abuse (may

not admit)
325
Opioid Metabolism Excretion Active Pearl
Metabolite
Morphine Liver Renal Morphine-6 GL Poor choice in
P450-UGT2B7 Morphine-3 GL Renal failure Opioid Therapy: Routes of Administration
Hydrocodone Liver Renal Hydro- Screen will show
#1 drug P450-CYP2D6 morphone hydro-
prescribed morphone • Oral and transdermal - preferred – if patient
Oxycodone Liver Renal Oxymorphone Screen will show has/can use gut then use it
P450- Oxymorphone
CYP2D6/3A4 • Parenteral – (SQ) and IV preferred for acute post-
Oxymorphone Liver Renal 3-glucuronide, Reduce op and (long-term - hospice) therapy
6-hydroxy Dose if
(both active) CrCl <50ml/min • Oral transmucosal - fentanyl – cancer
Hydro- Liver Renal NONE Active Better choice if • Rectal route – peds/ acetaminophen
morphone P450- renal insuff.
Fentanyl Liver Renal None Caution w
• Epidural – peri-op/hospice
P450-CYP3A4 (redistribution CYP3A4 inhibitor • Intrathecal – peri-operative/ ITP for oncology/
to fat) drugs
hospice/ rarely non-malignant pain
Codeine Liver Renal Morphine Ultrafast or
CYP-2D6 Ultraslow
metabolizers
Patient case #3
**OME conversions**
• 43 y/o otherwise healthy female (60 kg) comes for an
abdominal TAH/BSO; her main concern is pain
during and after surgery. What is your plan for peri-
operative pain management? Oral Intravenous Epidural Intrathecal
• Intra-operative opioids:
• Intrathecal hydromorphone 100 mcg
100 mcg = 0.1 mg 30 10 1 0.1
Assume same opioid/concentration
Pain Consult: 43 y/o writhing in pain, with Standard PCA Parameters for Opioid
nausea and vomiting Naïve Adult Patients
Patient has received oxycodone 5-10 mg 6 hours- Increased Morphine Hydromorphone Fentanyl
pain?  20 mg q 4 hours and patient is vomiting-
help! 1X (single strength) 1 mg/ml 0.2 mg/ml 10 mcg/ml
Bolus (optional) 1-3 mg 0.4 mg 25-50 mcg
Plan? PCA Dose 2 mg 0.2 mg 10 mcg

0.4 mg 20 mcg
Anti-emetics: Zofran, droperidol, Phenergan Lockout 10 min 10 min 10 min
Pain Control?: Total Dose (4 hours) 40 mg 4 mg 200 mcg

8 mg 400 mcg
IV: PCA
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Case #4
P.atient C.ontrolled A.nalgesia
• 59 y/o male with metastatic colorectal cancer:
• Fentanyl: s/p subtotal colectomy, POD #1
• 10/10/200 mcg • Limit Basal Rates
• PCA: fentanyl 20/20/400 mcg
• 20/10/400 • Continuous Pulse Oximetry-
“with remote monitoring” • He used 1200 mcg/ 24 hours: falls asleep once
• Hydromorphone • Review med list for other comfortable but wakes up in pain- what are the
• 0.2/10/4 mg potentially sedating agents options?
• Assume that no one has
• 0.4/10/8 canceled other pain med
• Basal Rate vs Patch
• Morphine: orders, ie. Post-op tramadol • 1200 mcg/24 hours ~
• 2/10/40 mg • 50 mcg/hour=> 25 mcg patch
Switching Opioids
Fentanyl
• IV = Transdermal • Plan for incomplete cross-tolerance
• 50 mcg patch= ??? Dose/hour? • 25-50% typical (+/- based on clinical scenario)
• Patch x 2.5 = OME • Opioid calculators- estimates, at best
• OME/3 = Patch • Formulas based on opioid naïve, white,
cancer dx
• Fentanyl difficult
Underdose- can always increase
Case #5 What is the patient’s Daily Oral Morphine

• Mrs. Smith 61 y/o with chronic low back pain is going to Equivalents (DOME)?
surgery in 7 days for lumbar spine revision
• Methadone: ~ 30 X 10 = 300 OME
• Out-Patient pain meds:
• Methadone 10 mg TID • Hydromorphone:
• Hydromorphone 8 mg q 4 hours prn • 8 tabs x 8 mg x 5 (convert to morphine)=
What are your recommendations going into 320 OME
surgery?
A. Stop opioids for more optimal post-op pain control • Post-operatively: The patient will require
B. Stop the methadone, continue the hydromorphone their baseline DOME + more
C. Stop the hydromorphone, continue the methadone • Continue Methadone + hydromorphone PCA
D. Continue the methadone and hydromorphone
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Opioid Therapy: Drug Selection
Methadone Methadone
• Useful loooong-acting drug with mu-agonist and
NMDA-antagonist activity
• 1:3 to 1:20 (when converting to methadone) • Potency greater than expected based on single-dose
studies
• > 1000 OME use 1:20 and decrease by 30 % • When used for pain: twice a day or three times a
for cross tolerance.
day
• PO:IV  2:1 • Do not change doses < q 3 days
• Patient admitted on methadone continue same dose
• Long acting: Methadone via pharmacokinetics
• NOT a “prn” medication
• Order ECG to monitor QTc- when changing dose
24 y/o on suboxone admitted for fevers and

“not feeling well”- bacteremic- s/p dental
extraction.
Butrans
• Pain control? Acetaminophen and NSAIDS
(buprenorphine transdermal)
• Mitral valve replacement in 7 days? Now what?
• Options regarding agonists/antagonists:
1- Discontinue 7 days prior to surgery
(POE)
2- Provide “short-acting” opioids
Con’t butrans and add short acting
opioids
5 mcg/hr 10 mcg/hr 20 mcg/hr
3-Transition Butrans to methadone
Worn for 7 days
Opioids are great, but,

Buprenorphine side effects
• Mixed agonist (mu) – antagonist (kappa) • Nausea: stimulation of dopamine receptors in
chemoreceptor zone of 4th ventricle
• High affinity binding
• Withdrawal symptoms less • Tx: Kytril, droperidrol, phenergan
• slow disassociation from receptors • Constipation: methylnaltrexone 12 mg SQ
• Safer? • (confirm no bowel obstruction)
• Less abuse potential • Pruritis: mu receptor- nalbuphine/naloxone
• Less risk of respiratory depression • Respiratory depression/apnea:Tx?
• NOT for acute pain Naloxone 40 mcg
328
Serotonin Syndrome
42 y/o female undergoing ACL repair Mild
tachycardia
• PMHx: depression, chronic headaches mydriasis
diaphoresis
• Medications: tramadol prn, ibuprofen, paroxetine
myoclonus
• Uncomplicated operative case- hyperreflexia/clonus
Classic Triad of Symptoms
• recovering in 23 hour observation unit Moderate •Altered Mental Status
Hypertension •Neuromuscular abnormality
Hyperthermia (40 C) •Autonomic Dysfunction
• Page: Patient was confused- seizure activity
• Tx: benzodiazepine Severe
Agitated Delerium
• Cause? Patient had received fentanyl in PACU + Severe HTN/Hyperthermia
tramadol and paroxetine @ home Shock
Tramadol 72 y/o male undergoing left THA

• Chemically unrelated to opioids
• Mr. Jones has been taking
• Racemic mixture (+ and – enantiomers) 2-3 percocet/day for hip
• (+) 4X more potent mu agonist pain
• (-) responsible for NE/5HT reuptake inhibitor • Plan: Epidural for post-
• treat pain, anxiety, & depression operative pain control and
general anesthesia
• (Mild) NMDA antagonism
• What DVT prophylaxis
• Drug Interaction significance should Mr. Jones receive?
• serotonin syndrome when used with SSRIs
Neuraxial procedures and DVT prophylaxis Black Box Warning

Epidural or spinal hematomas may occur in patients who are anticoagulated with
low molecular weight heparins (LMWH) or heparinoids and are receiving neuraxial
• The Danger is catheter anesthesia or undergoing spinal puncture. These hematomas may result in long-
movement- term or permanent paralysis. Consider these risks when scheduling patients for
spinal procedures.
ie:Placement and removal
Factors that can increase the risk of developing epidural or spinal hematomas in
these patients include:
• Use of indwelling epidural catheters
• Concomitant use of other drugs that affect hemostasis, such as non-
• ASA is ok steroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors, other
anticoagulants.
• UFH- BID • A history of traumatic or repeated epidural or spinal punctures
• A history of spinal deformity or spinal surgery
• LMWH- Qday-
Consider the benefits and risks before neuraxial intervention in patients
• Prophylaxis only anticoagulated or to be anticoagulated for thromboprophylaxis
329
American Society of Regional Anesthesia
• Epidural analgesia can be maintained when

patient taking prophylaxis doses of
unfractionated heparin (UH) BID or single daily
dosing of low molecular weight heparin
(LMWH)
Moeschler.Susan@mayo.edu
• Patients should not receive TID dosing of

subcutaneous UFH or BID dosing of LMWH THANK YOU
while the epidural catheter is maintained
Horlocker TT, et al. Regional Anesthesia & Pain Medicine: 2010: 35;
64-101
330
Disclosures
Management of Postoperative
Gastrointestinal Complications:
An Overview of Postoperative Medicine 2013
October 12, 2013
make regarding this
presentation.

Clinical Assistant Professor
Philadelphia, PA
©2011 MFMER | 3127551-1
A 45 year old woman is seen prior to

Perioperative GI Issues laparoscopic myomectomy for preoperative
consultation. Which element of her history
• Post operative nausea and vomiting puts her at higher than normal risk for post
operative nausea and vomiting?
• Postoperative ileus, pseudo-
obstruction A. Anxiety disorder
B. Female gender
• Postoperative diarrhea C. Increased BMI
• Stress-related mucosal injury D. Tobacco use
E. Use of total intravenous anesthesia
Question 1
Risk factors for PONV Risk factors for PONV

Strong evidence Good evidence
Conflicting results Poor data or
Female gender Young age disproved
Hx motion sickness Nitrous oxide Site of surgery Pain
Hx PONV Muscle relaxants Menstrual cycle Movement
General anesthesia Experience of Anxiety or personality
Volatile anesthetics anesthetist
Non-smoking status NG tube during surgery BMI
Duration of anesthesia
Postoperative opioids Kranke P, et al. Expert Opin Pharmacother. 2007;8:3217-35.
Question 1 Kranke P, et al. Expert Opin Pharmacother. 2007;8:3217-35. Question 1
331
Predicting risk of PONV Despite receiving balanced anesthesia and
perioperative prophylactic ondansetron (4 mg IV),
100 the patient experiences nausea and vomiting in
79
80
the PACU. Which treatment is most likely to be
Risk 61 effective in ameliorating her symptoms?
Factors Risk of PONV (%) 60
Female
39 A. Dexamethasone
40
Non-smoker 10
21 B. Metoclopramide
20
Hx of PONV 0
C. Propofol
Perioperative 0 1 2 3 4
D. Propranolol
Number of Risk Factors
Opioids E. Tropisetron
Kranke P, et al. Expert Opin Pharmacother. 2007;8:3217-35.
Question 1 Question 2
Treatment of PONV Treatment of PONV
Apfel CC, et al. N Engl J Med. 2004;350:2441-51. Apfel CC, et al. N Engl J Med. 2004;350:2441-51.
Aprepitant (neurokinin-1 receptor antagonist)

Aprepitant 40mg Aprepitant 125mg Ondansetron 4mg
100 *
*
*
% Patients without N/V
80 *
60
40
20
0
0-24h 0-48h
*p < 0.05 vs. ondansetron
Gan TJ, et al. Anesth Analg 2007;104:1082-1089. www.pressureright.com
332
P6 Acupressure for PONV PONV
90
80
84
• Incidence as high as 30%
P6
70 acupressure 66 • Common patient complaint and cause of
60 dissatisfaction
% 50
40
• Prolongs recovery room time, length of stay
30 26
30 and overall costs
20
10 12
• Treatment dependent on pre-op risk
10 assessment
0
POVN 24hrs PONV 72hrs Pt satisfaction • Multiple modality approach most efficacious
White PF, et al. Anesth Analg 2012 Apr 13 [Epub ahead of print]
A 73 year old man is scheduled for elective Prevention of Post-Op Ileus

surgery for recurrent bouts of diverticulitis.
Which postoperative recommendation will most
likely decrease his chance of prolonged
postoperative ileus?
A. Amitriptyline
B. Epidural anesthesia
C. Nasogastric intubation
D. Nifedipine for BP control
E. PCA pump
Story SK, et al. Dig Surg 2009;26:265-75.
Peripherally-acting mu-opioid antagonists Alvimopam for post-operative ileus

(PAM-OR) Time to recovery
• Methylnaltrexone Alvimopa Alvimopa Placebo

• Approved for opioid-induced constipation in m 6 mg m 12 mg
patients with advanced illness (n = 155) (n = 165) (n = 149)
• Under investigation for POI Hazard Ratio 1.28 1.54 
• Alvimopan p value 0.046 < 0.001 
• Approved for accelerating recovery from bowel Mean hours 105 98 120
resection with primary anastomosis  vs. (-15) (-22) 
placebo
Viscusi ER, et al. Anesth Analg 2009;108:1811-22 Leslie JB. Ann Pharmacother 2005;39:1502-10
333
Chewing Gum – Time to Flatus
Chewing Gum – Time to BM
Fitzgerald JEF, et al. World J Surg 2009;33:2557-66

Fitzgerald JEF, et al. World J Surg 2009;33:2557-66
Despite reduction in opiate analgesia, correction

of electrolyte abnormalities, avoidance of
anticholinergic drugs, increased mobilization of
the patient and nasogastric/rectal intubation, the
patient becomes more distended. [Radiograph]
Which is the most appropriate treatment?
A. Barium enema
B. Endoscopic decompression
C. Exploratory laparotomy
D. Metoclopramide
E. Neostigmine
www.radiology.co.uk/srs-x/cases/103/b.jpg
Acute colonic pseudo-obstruction

[Ogilvie Syndrome]
• Gross dilatation of cecum and right colon
without mechanical obstruction
• ~35% cases are post-surgical
• Risk of ischemia, perforation, and death
• Conservative therapy: bowel rest, body
positioning, treatment of underlying cause
• Pharmacologic therapy for non-response
Sir Heneage Ogilvie Maj-Gen KBE, MD, MCh, FRCS, 1887- 1971 Elsner JL, et al. Ann Pharmacother 2012;46:430-5
334
Neostigmine for acute colonic pseudo-
obstruction
Contraindications for neostigmine
neostigmine placebo neostigmine placebo
• Bradycardia
10 7
6 • Severe cardiac disease
# of patients
# of patients
8
5
6 4 • Hypotension
4 3
2
• Active bronchospasm
2
0
1
0
clinical treatment decreased decreased
response failures cecum girth • Pregnancy
Saunders MD, Kimmey MB. Aliment Pharmacol Ther 2005;22:917-25.
A 55 year old woman is seen 3 days following ORL

surgery for loose stool, approximately 5-6 times per Medications that can cause diarrhea
day. There is no nausea, nor has there been blood • Antibiotics
in the stool. Medications include cefazolin, • Almost all
furosemide and amlodipine. On exam she has a • Antineoplastics
nasoenteric feeding tube and hyperactive bowel • Doxorubicin, 5FU, interferon, MTX
sounds. Which is the most likely cause of her
diarrhea? • CNS Agents
• Alprazolam, fluoxetine, lithium, valproate
A. Clostridium difficile infection
• Cardiovascular
B. Enteral support formula • ACE-I, β-blockers, digoxin, hydralazine, quinidine
C. Irritable bowel syndrome • Other
D. Ischemic colitis • Loop diuretics, colchicine, glipizide, magnesium, misoprostil,
thyroxine
E. Medications
The patient is given a regular diet; antibiotics

and loop diuretics are discontinued, but the
diarrhea progresses to 10-12 episodes of
watery stool, now with progressive nausea.
[endoscopic photo] Which is the most
appropriate treatment?
A. Bacterial enemas
B. Metronidazole IV
C. Metronidazole PO
D. Vancomycin IV
E. Vancomycin PO
335
Clostridium difficile in the US Annual occurrence of C. Difficile by region
1
0.9
0.8
0.7
Northeast
0.6
Midwest
0.5
National
0.4 South
0.3 West
0.2
0.1
0
1999 2000 2001 2002 2003
Polgreen PM, et al. Infect Control Hosp Epidemiol 2010;31:382-7. Zerey M, et al. Surg Infect 2007;8:557-66.
PPI and Risk of C. diff

Cost of Postsurgical C. difficile
estimate OR 95% CI p
LOS 16.0 NA 15.6- <0.0001
16.4
Charges $77,483 NA 75K-80K <0.0001
Death 3.37 3.2-3.77 <0.0001
Estimated annual cost ~$1 billion

Deshpande A, et al. Clin Gastro Hepatol 2012;10:225-33.
Zerey M, et al. Surg Infect 2007;8:557-66.
Risk factors for postsurgical C. difficile Risk factors for postsurgical C.

• Patient factors difficile
• Older • Highest risk
• Female • Colectomy
• Medicare • Small bowel resection
• Hospital factors • Gastric resection
• Northeast • Lowest risk
• Large • Cholecystectomy
• Urban • Appendectomy
• Teaching
336
A 46 year old man is seen in the ICU prior
to surgery. He is mechanically ventilated,
but hemodynamically stable. Which is the
most appropriate recommendation
regarding peptic ulcer prophylaxis?
A. Antacids
B. H2-receptor antagonist
C. No prophylaxis indicated
D. Proton pump inhibitor
E. Sucralfate
Risk for Stress Ulcer

Risk for Stress Ulcers Risk Factor Simple Multiple
Regression Regression
• Neurosurgery OR p OR p
• Burns Respiratory failure 25.5 <0.001 15.6 <0.001
Coagulopathy 9.5 <0.001 4.3 <0.001
• Sepsis Hypotension 5.0 0.03 3.7 0.08
• Mechanical Ventilation Sepsis 7.5 <0.001 2.0 0.17
Hepatic failure 6.5 <0.001 1.6 0.27
• Coagulopathy Renal failure 4.6 <0.001 1.6 0.26
• Multiple organ failure Enteral feeding 3.8 <0.001 1.0 0.99
Steroids 3.7 <0.001 1.5 0.26
Transplant 3.6 0.006 1.5 0.45
Anticoagulation 3.3 0.004 1.1 0.88
Pisegna JR, Martindale RG. J Clin Gastroenterol 2005;39:10-16.
Question 7 Question 7 Cook DJ, et al. N Engl J Med 1994;330:377-81.
References
ICU stress ulcer prophylaxis • Apfel CC, Korttila K, Abdalla M, et al. A factorial trial of six
interventions for the prevention of postoperative nausea and vomiting.
N Engl J Med. 2004;350:2441-51.
• Recommended by many professional
organizations • Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal
bleeding in critically ill patients. N Engl J Med. 1994;330:377-81.
• Joint Commission “core quality measure” • Deshpande A, Pant C, Pasupuleti V, et al. Association between
proton pump inhibitor therapy and Clostridium difficile infection in a
meta-analysis. Clin Gastroenterol Hepatol. 2012;10:225-33.
• Data is for H2RA, but PPI are equivalent by • Elsner JL, Smith JM, Ensor CR. Intravenous neostigmine for
meta-analysis postoperative acute colonic pseudo-obstruction. Ann Pharmacother
2012;46:430-5.
• Increase risk of C. diff, pneumonia • Fitzgerald JE, Ahmed I. Systematic review and meta-analysis of
chewing-gum therapy in the reduction of postoperative paralytic ileus
• May not be necessary with early enteral following gastrointestinal surgery. World J Surg 2009;33:2557-66.
feeding (in fact, may worsen outcome) • Kranke P, Schuster F, Eberhart LH. Recent advances, trends and
economic considerations in the risk assessment, prevention and
treatment of postoperative nausea and vomiting. Expert Opin
Pharmacother. 2007;8:3217-35.
Question 7 Marik P, et al. Crit Care Med 2010;38:2222-8
337
References
• Marik PE, Vasu T, Hirani A, Pachinburavan M. Stress ulcer prophylaxis in the
new millennium: a systematic review and meta-analysis. Crit Care Med
2010;38:2222-8.
• Pisegna JR, Martindale RG. Acid suppression in the perioperative period. J Question Answer
Clin Gastroenterol. 2005;39:10-6.
• Polgreen PM, Yang M, Bohnett LC, Cavanaugh JE. A time-series analysis of 1 A
clostridium difficile and its seasonal association with influenza. Infect Control
Hosp Epidemiol 2010;31:382-7. 2 A
• Saunders MD, Kimmey MB. Systematic review: acute colonic pseudo- 3 B
obstruction. Aliment Pharmacol Ther. 2005;22:917-25.
• Story SK, Chamberlain RS. A comprehensive review of evidence-based
strategies to prevent and treat postoperative ileus. Dig Surg 2009;26:265-75.
4 E
• Viscusi ER, Gan TJ, Leslie JB, et al. Peripherally acting mu-opioid receptor 5 B
antagonists and postoperative ileus: mechanisms of action and clinical
applicability. Anesth Analg 2009;108:1811-22. 6 C
• White PF, Zhao M, Tang J, et al. Use of a disposable acupressure device as
part of a multimodal antiemetic strategy for reducing postoperative nausea and 7 D
vomiting. Anesth Analg 2012 Apr 13.
338

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An Overview of

Perioperative Medicine 2013:

October 9-12, 2013

© Mayo Foundation for Medical Education and Research

Procedures, products or instrumentation systems used, discussed and/or demonstrated may be

CME Activity Description .......................................................................................................................... vii

CME Activity Objectives ............................................................................................................................ vii

Continuing Education Credit ...................................................................................................................... vii

CME Record of Attendance ....................................................................................................................... viii

CME Activity Evaluation .......................................................................................................................... viii

Syllabus and Internet Access ....................................................................................................................... ix

Recording Device Policy ............................................................................................................................. ix

Electronic Devices ....................................................................................................................................... ix

Program Schedule ...................................................................................................................................... xiii

Presentations ................................................................................ See Program Schedule for Page Numbers

CME Activity Objectives

Upon conclusion of this program, participants should be able to:

 Apply a systematic approach to guide preoperative assessment.

Continuing Education Credit

Other Health Care Professionals

CME Record of Attendance

CME Activity Evaluation

Recording Device Policy

Geno J. Merli, M.D. Howard H. Weitz, M.D.

Brian F. Mandell, M.D. Marianne T. Ritchie, M.D.

Paul R. Daniels, M.D. Eric J. Olson, M.D.

David R. Danielson, M.D. Rajiv K. Pruthi, MBBS

Molly A. Feely, M.D. William Sanchez, M.D.

Andrea N. Leep Hunderfund, M.D. Jennifer A. Whitaker, M.D.

Robert H. Lohr, M.D. Amy W. Williams, M.D.

Susan M. Moeschler, M.D.

6:00 a.m. Continental Breakfast and Registration

7:30 a.m. Welcome and Introductions

7:40 a.m. Role and Responsibility of the Medical Consultant ..................................................... 21

8:00 a.m. Anesthesia 101 for the Non-Anesthesiologist ................................................................ 27

8:30 a.m. Cardiac Risk Assessment:

9:15 a.m. Cardiac Risk Reduction Strategies –

10:15 a.m. Question and Answer Session

10:30 a.m. Refreshment Break

11:45 a.m. Preoperative Testing: What is Really Needed? ............................................................ 87

12:15 p.m. Question and Answer Session

12:30 p.m. Lunch on your own

2:30 p.m. Management of Non-CAD Heart Disease in Non-Cardiac Surgery ........................... 97

3:45 p.m. Preoperative Pulmonary Risk Stratification and Risk

4:30 p.m. Question and Answer Session

4:45p.m. Complete Evaluation Forms / Adjourn

THURSDAY, OCTOBER 10, 2013

6:30 a.m. Continental Breakfast

7:55 a.m. Announcements

8:00 a.m. Managing Postoperative Cardiac Complications I and II ........................................ 131

8:45 a.m. Management of Documented or Suspected Obstructive

9:30 a.m. Question and Answer Session

10:00 a.m. DVT/PE Prophylaxis in the Surgical Patient I:

10:45 a.m. DVT/PE Prophylaxis in the Surgical Patient II:

11:15 a.m. Perioperative Management of Antiplatelet Agents .................................................... 173

11:45 p.m. Clinical Short: How do I manage patients

12:00 p.m. Question and Answer