CHAPTER Cardiac Evaluation

Pulmonary Evaluation

Periop Beta Blockers

SBE Prophylaxis

DVT Prophylaxis

Periop Medication Management

Management of Longterm Anticoagulants

Delirium

Pain Management

Putting It All Together

PERIOPERATIVE CARDIAC COMPLICATION RATES

Several ‘risk index’ tools are available to help quantify risk of cardiac complications preoperatively. The oldest of these is the GOLDMAN RISK INDEX which has been validated in other studies since it’s original introduction. The GOLDMAN INDEX may remain the most useful multivariate tool because of it’s ease of use and relative weighting of risk factors. It is useful in stratifying patients into high and low risk categories BUT a large intermediate risk category results.[N Engl J Med 1977;297:845-850].

RISK FACTOR  POINTS 

· Age > 70 years  5 

· MI in previous six months  10 

· S3 gallop or jugular venous distention  11 

· Important aortic stenosis  3 

· Rhythm other than sinus or premature atrial contractions on last preoperative EKG 

7 

· > 5 PVC / min documented at any time before operation  7 

· PO2 <60 or PCO2 >50 mmHg; K<3.0 or HCO3 <20 mEq/L;   BUN >50 or Cr >3.0 mg/dl; abnormal AST, signs of chronic liver disease, or bedridden from noncardiac causes 

3 

· Intraperitoneal, intrathoracic or aortic operation  3 

· Emergency operation  4 

Risk Index: Class I = 0-5 points (low), Class II = 6-12 points (intermediate), Class III = 13-25 pts (high), Class IV 25 pts (very high) 

Risk of Death and Major Cardiac

Complications Based on

the Goldman Index ClassCLASS I 1.3%

CLASS II 4.7%

CLASS III 15.3%

CLASS IV 56%

GOLDMAN CARDIAC RISK INDEX

Another useful RISK INDEX tool is the LEE INDEX shown on the next page.

Compared with the Goldman, Detsky, and Amer Society of Anesthesiology methods of preop risk assessment the newer Lee index was statistically more accurate.

ONE POINT FOR EACH of THE FOLLOWING :

• High-risk surgery (intrathoracic, suprainguinal vascular, or intraperitoneal procedure)

• History of ischemic heart disease

• Congestive heart failure

• Cerebrovascular disease

• Insulin-dependent diabetes mellitus

• Serum creatinine > 2.0 mg/dL

TOTAL POINTS COMPLICATION RATE *• 0 0.4%• 1 1%• 2 7%• > 2 11%

* Acute MI, pulmonary edema, ventricular fibrillation or primary cardiac arrest, complete heart block.

PERIOPERATIVE CARDIAC COMPLICATION RATES

The LEE INDEX for ASSESSING PERIOPERATIVE CARDIOVASCULAR RISK

DATA FROM LEE TH, MARCANTONIO ER, MANGIONE CM, ET AL. DERIVATION AND PROSPECTIVE VALIDATION OF A SIMPLE INDEX FOR PREDICTION OF CARDIAC RISK OF MAJOR NONCARDIAC SURGERY. CIRCULATION 1999; 100:1043–1049.

Either of these RISK INDEX tools can be used to assess the risk of complications for a given patient. USE the ACC/AHA algorithm on the next page to determine if FURTHER PREOP CARDIAC EVALUATION IS INDICATED.

Is EMERGENCY noncardiac surgery needed ? OPERATING ROOM

Recurrent symptoms ?

NO

YES

NOYES

Has coronary angiography or stress test been done in the last 2 years ?

Has coronary revascularization been done in the last 5 years ?

YESFavorable results ?

NO

Evaluate clinical predictors.º

INTERMEDIATE clinical predictors.ºMAJOR clinical predictors.º MINOR clinical predictors.º

Consider coronary angiography

Consider delay or cancel noncardiac surgery.

Poor functional capacity (<4METs)* OR HIGH risk procedure. **

Poor functional capacity (< 4 METs ) * AND HIGH risk procedure. **

Moderate or excellent functional capacity

(≥4 METs) * OR low / intermediate risk procedure. **

Moderate or excellent functional capacity (≥4 METs) * OR low / intermediate risk procedure. **

Consider coronary angiography

Consider coronary angiography

OPERATING ROOM

THE ACC/AHA STEPWISE APPROACH to PREOPERATIVE CARDIAC ASSESSMENT

NO

OPERATING ROOMNoninvasive Testing

Noninvasive Testing NEGATIVENEGATIVE POSITIVE

Subsequent care dictated by angiography findings

POSITIVE

NO

YES

Subsequent care dictated by angiography findings

Medical management and risk factor modification

Subsequent care dictated by findings and treatment results

º See table 1 *See table 2 **See table 3 Eagle KA, Berger PB, et al.J Am Coll Card 2002; 39: 542

TABLE 1 : Clinical Predictors of Increased Risk for Perioperative Cardiac Complications

MajorRecent MI (within 30 days)Unstable/ severe angina(Canadian class III or IV)*Decompensated CHFSignificant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias with underlying heart disease, supraventricular arrhythmias with uncontrolled rate)Severe valvular disease

IntermediateMild angina (Canadian class I or II)*

Prior MI by history or ECGCompensated or prior CHFDiabetes mellitusRenal insufficiency

MinorAdvanced ageAbnormal ECG (LVH, LBBB, ST-T-wave abnormalities)Rhythm other than sinus (eg a-fib) *Poor functional capacityHistory of strokeUncontrolled hypertension (e.g., diastolic BP >110 mm Hg)

*—Canadian Cardiovascular Society Classification of Angina: 0 = asymptomatic; I = angina with strenuous exercise; II = angina with moderate exertion; III = angina with walking one to two level blocks or climbing one flight of stairs or less at a normal pace; IV = inability to perform any physical activity without development of angina.

Excellent (>7 METs)SquashJogging (10-minute mile)Scrubbing floorsSingles tennis

Moderate (4 to 7 METs)CyclingClimbing a flight of stairsGolf (without cart)Walking 4 mphYardwork (e.g., rakingleaves, weeding, pushing a power mower)

Poor (<4 METs)VacuumingActivities of daily living(e.g., eating, dressing,bathing)Walking 2 mphWriting

TABLE 2 : Functional Status Assessment

TABLE 3 : CARDIAC EVENT RISK STRATIFICATION for NONCARDIAC SURGICAL PROCEDURES

HIGH RISK (reported cardiac risk often > 5%)

* Emergency major operation esp in elderly * Aortic & other major vascular surgery * Peripheral vascular surgery * Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss

INTERMEDIATE ( cardiac risk < 5%)

* Intraperitoneal and intrathoracic * Carotid endarterectomy * Head & neck surgery * Orthopedic surgery * Prostate surgery

LOW RISK( cardiac risk <1%)

* Endoscopic procedures * Superficial procedures * Cataract surgery * Breast surgery

COMBINED INCIDENCE of CARDIAC DEATH and NONFATAL MI

Two or more of the following? †1. Intermediate clinical predictors

2. Poor functional capacity(less than 4 METS)

3. High surgical risk

No further preoperative testing recommended

Indications for angiography ? (e.g. unstable angina

Preoperative angiography

Patient ambulatory and able to exercise ?

Exercise echo or perfusion imaging.

Bronchospasm? 2nd degree AV block ?

Theophyline dependent ? Valvular dysfunction ?

Prior symptomatic arrhythmia (particularly ventricular tachycardia) ? Marked hypertension ?

Pharmacologic stress imaging (nuclear or echo)

Prior symptomatic arrhythmia (particularly ventricular tachycardia) ? Marked hypertension ?

Borderline or low blood pressure ? Marked hypertension ?

Poor echo window ?

Dobutamine stress echo or nuclear imaging

Other (e.g. Holter monitor, angiography

Dipyridamole or adenosine perfusion

Resting ECG normal ?

YES

NO

YES

YES

NO

YES NO

YES

ECG ETT

NO

YES

NO

NO

NO

† See tables 1, 2, and 3 for clinical predictors, functional capacity, and surgical risk

categories.

SUPPLEMENTAL PREOPERATIVE EVALUATION - WHEN and WHICH TEST

YES

PULMONARY

ASSESSMENT of PULMONARY RISK Postoperative PULMONARY Complcations Defined as : PNEUMONIA, ATELECTASIS, RESPIRATORY FAILURE,

Need for MECHANICAL VENTILATION, BRONCHOSPASM, or EXACERBATION of underlying pulmonary disease. MOST IMPORTANT PREDICTOR of PULMONARY RISK is SURGICAL SITE ! Risk increases as incision site approaches

DIAPHRAGM . MOST IMPORTANT MODIFIABLE RISK FACTOR…SMOKING… BUT risk of Post-op pulmonary complications declines ONLY after

8 weeks of preop cessation . POOR FUNCTIONAL STATUS also increases risk of postop pulmonary complications.

COMBINATIONS of bronchodilators, physical therapy, antibiotics, smoking cessation, and corticosteroids reduce the risk

of postop pulmonary complications. AGE and OBESITY have NOT been shown to increase RIK of postop pulmonary complications. ROUTINE pre-op PFT, ABG, and/or CXR NOT warranted & donot change Tx ORDER only if indicated BASED on H & P.

RISK-REDUCTION STRATEGIES.PREOPERATIVEEncourage cessation of cigarette smoking for at least 8 wkTreat airflow obstruction in patients with COPD or asthma (Tx aggressively with inhalers, antibiotics, physical therapy, and steroids when indicated) Administer antibiotics and delay surgery if respiratory infection is present (i.e. COPD pts with active URI, bronchitis, or pneumonia)Begin patient education regarding lung-expansion maneuvers

INTRAOPERATIVELimit duration of surgery to less than 3 hrUse spinal or epidural anesthesia*Avoid use of pancuroniumUse laparoscopic procedures when possibleSubstitute less ambitious procedure for upper abdominal or thoracic surgery when possible

POSTOPERATIVEUse deep-breathing exercises or incentive spirometryUse continuous positive airway pressureUse epidural analgesia* Use intercostal nerve blocks*

Sneatana GW. Current Concepts: preoperative pulmonary evaluation. NEJM 1999; 340:937-944

*This strategy is recommended, although variable efficacy has been reported in the literature.

ELIGIBILITY CRITERIA for USE of PERIPERATIVE B-BLOCKERS

MINOR CRITERIA

Aged 65 years or older

Hypertension

Current smoker

Serum cholesterol at least 240mg/dl

Diabetes mellitus not requiring insulin

REVISED CARDIAC RISK INDEX CRITERIA

High-risk surgical procedure, defined as:

intraperitoneal, intrathoracic, or suprainguinal vascular procedure

Ischemic heart disease, defined as following:

History of MI History of OR current angina Use of sublingal TNG Positive exercise results Q waves on EKG

Patients have had transluminal coronary angioplasty or CABG and chest pain presumed to be of ischemic etiology

Cerebrovascular disease, defined as : History of TIA

History of Stroke

Diabetes mellitus requiring insulin

Chronic renal insuff with creatinine >2.0mg/dl

PERIOPERATIVE β -BLOCKERS: AGENTS and REGIMENS

Prehospitalization (Outpatients) or Immediately Following Admission to HospitalNot taking β-blockers long-term Atenolol, 50-100 mg, periop qd or bisoprolol, 5-10 mg,qd Begin as outpatient up to 30 days before surgery Titrate to heart rate of ≤65/minTaking β-blockers long-term Continue long-term therapy Titrate heart rate to ≤65/min, if needed

Immediate Postop Period (ie, in Preanesthesia Holding Area) Atenolol, 5-10 mg, IV to reach target HR before introduction of anesthesia, if needed, whether β-blockers taken long-term or not

Immediate Postop Period and Transition to PO Meds(Whether β-Blockers Taken Long-term or not)

Patient not taking oral medications and hemodynamically stable Atenolol, 5-10 mg, intravenously twice daily to target HR *Patient unstable, eg, high bleeding risk or in the intensive care unit Esmolol, 500 μg/kg, intravenously for 1 minute and then infusion of 50-200 μg/kg per minute to target heart ratePatient taking oral medications Resume perioperative β-blocker use at previous dose; titrate as necessary to target heart rate Overlap first oral dose with continued intravenous agents to maintain target heart rate, if necessary

SUGGESTED EXCLUSION CRITERIA FOR PROPHYLACTIC BETA BLOCKERS * Known intolerance * Decompensated CHF or known severe LV dysfunction * Hx of Asthma or COPD with recent exacerbation or chronic severe * 2nd or 3rd degree heart block w/o pacer * Baseline HR < 60 or SBP < 110

Identify Eligible Patients

Risk Stratification

Intermediate Risk

Cardiac Event Rate Without β-Blockade

2.2% to 6.6%

Low RiskCardiac Event Rate

Without β-Blockade

0.4% to 1.0%

High RiskCardiac Event Rate

Without β-Blockade

3- 4 Criteria: 9.2% to 18%

≥ 5 Criteria: 32%

Assess Functional Status:Both (1) History of Angina or Peripheral

Vascular Disease and (2) Poor (<4 NETS) or Indeterminate Functional Status?

Additional Risk Stratification With Noninvasive Tests

Good Functional Status

Additional Risk Stratification With Noninvasive Tests

Cardiac Event Rate With β-Blockade

0.8% to 1.6%

Begin β Blockade

Proceed With Surgery

Consider Additional Therapies to Reduce Risk, eg, Coronary Revascularization

Negative Noninvasive Test

Results

Positive Noninvasive Test

Results

Positive Noninvasive Test

Results

Negative Noninvasive Test

Results

≥ 3 Revised Cardiac Risk Index Criteria

1-2 Revised Cardiac Risk Index CriteriaOr Any 2 Minor Criteria

No Revised Cardiac Risk IndexAnd No Minor Criteria

NoYES

No β Blockade Necessary

Proceed With Surgery

Begin β Blockade

Proceed With Surgery

Cardiac Event Rate With β-Blockade

unknown

Cardiac Event Rate With β-Blockade

unknown

Cardiac Event Rate With β-Blockade

6.5% to 16%

Cardiac Event Rate With β-Blockade

0.4%

Consider Additional Therapies to Reduce Risk, eg, Coronary Revascularization

Begin β Blockade

Proceed With Surgery

Perioperative β-Blockers; Patient Selection and Preoperative Risk Stratification

Examples of activities that expend about 4 METS (metabolic equivalent tasks) include climbing 1 flight of stairs, being able to walk on level ground at 4 mph, or being able to climb a short hill without difficulty.

SOURCE : Auerbach ad, Goldman L. Beta-Blockers and reduction of cardiac events in noncardiac surgery:scientific review. JAMA 2002; 287:1435-44

ENDOCARDITIS PROPHYLAXIS RECOMMENDED ENDOCARDITIS PROPHYLAXIS IS NOT RECOMMENDED

Cardiac conditions associated with endocarditis HIGH-RISK CONDITIONS: Prosthetic valves – both bioprosthetic and homograft Previous bacterial endocarditis Complex cyanotic congenital heart disease(CHD)e.g. single ventricle, transposition, tetrology of Fallot Surgically constructed systemic pulmonic shunts or conduitsMODERATE_RISK CONDITIONS: Most other CHD; hypertrophic cardiomyopathy; mitral valve prolapse WITH regurgitation

NEGLIBLE RISK ( i.e. same as general population) Atrial septal defect or repaired ASD/VSD, or PDA (beyond 6 months) Previous CABG, mitral prolapse without MI Physiologic, functional, or innocent murmurs Previous Kawasaki or Rheumatic fever without valve dysfunction Cardiac pacemakers9all) and implanted defibrillators SOURCE : AHA JAMA 1977; 277:1794

Sanford guide 2003

SITUATION AGENT REGIMEN

STANDARD GENERAL PROPHYLAXIS

Amoxicillin Adults: 2.0 g; Children: 50 mg/kg orally 1 h before procedure

UNABLE to TAKE ORAL MEDS

Ampicillin Adults: 2.0 g IM or IV; Children: 50 mg/kg IM or IV within 30 min before procedure

ALLERGIC to PENICILLIN

Clindamycin OR Cephalexin† or cefadroxil† OR Azthromycin orclarithromycin

Adults: 600 mg; Children: 20 mg/kg orally 1 h before procedure Adults: 2.0 g; Children; 50 mg/kg orally 1 h before procedureAdults: 500 mg; Children: 15 mg/kg orally 1 h before procedure

ALLERGIC to PCN and UNABLE to TAKE PO MEDS

Clindamycin OR Cefazolin †

Adults: 600 mg; Children: 20 mg/kg IV within 30 min before procedure Adults: 1.0 g; Children ; 25mg/kg IM or IV within 30 min before procdure

Table 4. Prophylactic Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures

SITUATION AGENT REGIMEN

High-risk patients Ampicillin plus gentamicin

Adults: ampicillin 2.0 g IM or IV plus gentamicin 1.5 mg/kg (not to exceed 120 mg) within 30 min of starting procedure; 6 h later, ampicillin 1 g IM/IV or amoxicillin 1 g orally Children: ampicillin 50 mg/kg IM or IV (not to exceed 2.0 g) plus gentamicin 1.5 mg/kg within 30 min of starting the procedure; 6 h later, ampicillin 25 mg/kg IM/IV or amoxicillin 25 mg/kg orally

High-risk patients allergic to ampicillin / amoxicillin

Vancomycin plus Gentamicin

Adults: vancomycin 1.0 g IV over 1-2 h plus gentamicin 1.5 mg/kg IV/IM (not to exceed 120mg); complete infusion within 30 min. of starting procedure Children: vancomycin 20 mg/kg IV over 1-2 h plus gentamicin 1.5 mg/kg IV/IM; complete injection/infusion within 30 min of starting procedure

Moderate-risk patients

Amoxicillin or ampicillin

Adults: amoxicillin 2.0 g orally 1 h before procedure, or ampicillin 2.0 g IM/IV within 30 min of starting procedure Children: amoxicillin 50 mg/kg orally 1 h before procedure, or ampicillin 50 mg/kg IM/IV within 30 min of starting procedure

Moderate-risk patients allergic to ampicillin/amoxicillin

Vancomycin Adults: vancomycin 1.0 g IV over 1-2 h complete infusion within 30 min of starting procedure Children:vancomycin 20 mg/kg IV over 1-2 h; complete infusion within 30 min of starting procedure

Table 5. Prophylactic Regimens for Genitourinary/Gastrointestinal (Excluding Esophageal) Procedures

SOURCE : AHA JAMA 1977; 277:1794 Sanford guide 2003

Low risk surgical patients — Prophylaxis other than early ambulation usually is not recommended in low risk patients.However, prophylaxis may be used in certain circumstances. The custom in some countries to use graduated compression stockings ( ES), but this is not based on evidence from clinical trials.Moderate risk surgical patients — The following are recommendations for moderate risk patients: SQ low dose unfractionated heparin (LDUH) 5000 units q 8 or12 hours,or SQ (LMWH) is recommended for patients undergoing general abdominal, thoracic, or gynecologic surgery.The 2 types of heparin are equally effective, but in meta-analyses less bleeding has been seen with LMWH.Intermittent pneumatic compression (IPC) until the patient is ambulatory is an alternative for patients at high risk of bleeding. Pharmacologic methods may be combined with IPC or ES. High risk surgical patients — The following recommendations apply to high risk patients. They vary somewhat according to the clinical setting. High risk general surgery patients are typically treated with subcutaneous LMWH.Pharmacologic therapy may be combined with IPC in patients at highest risk. Adjusted dose heparin requires frequent monitoring and is seldom used.  Knee replacement — Following elective knee replacement, either LMWH (given once or twice daily), or adjusted dose oral anticoagulants can be used.Continue for at least seven to ten days. One trial found that LMWH started within 8hrs of TKR surgery significantly reduced the incidence of DVT when compared with adjusted dose warfarin _Prolonging therapy for additional 3-6 weeks does not appear to provide further benefit. IPC was found to be effective in earlier studies and is a useful alternative.  Hip replacement — Several approaches are effective for patients undergoing total hip replacement. Subcutaneous LMWH (given once or twice daily) or adjusted dose oral anticoagulation is effective and safe in patients undergoing hip replacement. As with knee replacement, prophylaxis should be continued for at least seven to ten days. _____In North America, LMWH has usually been started between 12 and 24 hours after surgery. One trial found that LMWH given within two hours preop, or 4-6 hours postop, significantly decreased both total and proximal DVT compared to warfarin. Timing of the first dose of LMWH following total hip replacement was further assessed in a meta-analysis of four trials . Early initiation of half-dose LMWH between two and six hours postoperatively was associated with decreased clot formation when compared with warfarin or LMWH treatment beginning 12 or more hours postoperatively . Risk of bleeding was similar in both groups. Randomized trials have shown that extended LMWH prophylaxis through postoperative day 27 to 35 significantly reduced the incidence of total DVT . Two separate meta-analyses showed a significant decrease in the incidence of DVT or PE versus placebo, without an increase in major bleeding episodes.  Hip fracture —DVT prophylaxis is becoming a routine aspect in care of the patient with hip fracture. However, questions remain, including choice of optimal agent and the timing and duration of prophylaxis . We recommend either one of two approaches for prophylaxis against DVT in patients with hip fractures: . 1) Oral anticoagulation with warfarin to an INR of 2.0 to 3.0 OR 2) fixed dose SQ LMWH started preoperatively. Use of EC with either approach may provide additional benefit in certain patients.

Pineo GF. Prevention of Thromboembolic Disease. 2004 ; UpToDate online 12.1

Surgery / Condition Recommended Prophylaxis

Dosage

GENERAL SURGERY-LOW RISK: minor procedures, <40 years, no risks*

NONE Early ambulation

GENERAL SURGERY-MODERATE RISK: minor procedure but with risk factor, nonmajor surgery age 40-60 with no risks, or major surgery <40 years with no risks*

LDUH, LMWH, ES, or IPC

HEPARIN 5000 units SQ q8-12 hrs start 1-2 hr before surgeryENOXAPARIN 30 mg SQ, q12hr start 8-12hr post-op

GENERAL SURGERY-HIGH RISK: nonmajor surgery over age 60 or age >40 with risks. Major surgery > 40 yr.*

LDUH, LMWH

HEPARIN 5000 units SQ q8-12 hrs start 1-2 hr before surgery ENOXAPARIN 40mg SQ, 1-2hr pre-op and then once daily post-op ENOXAPARIN 30mg SQ, q12hr start 8-12hr post-op

GENERAL SURGERY-VERY HIGH RISK: Major surgery over age 40 plus RISK factors*

LDUH or LMWH w/ ES or IPC

ENOXAPARIN 40mg SQ, 1-2hr pre-op and then once daily post-op

ELECTIVE HIP REPLACEMENT ELECTIVE KNEE REPLACEMENT HIP FRACTURE SURGERY

LMWH or warfarin May combine w/ ES or IPC

ENOXAPARIN 30mg SQ q12hr start 12-24hr post-op ENOXAPARIN 40mg SQ once daily starting 10-12 hr pre-opStart 5-10mg warfarin night before or immediately after surgery and adjust to INR 2-3 Prolonged prophylaxis ~4wksin THR others until fully ambulatory

RISK FACTORS : Advanced age : Prior DVT ; Obesity ; CHF ; Paralysis ; Hypercoagulable state (eg Protein C Defiency , Factor V Leiden etc.)

REFERENCE: Geerts WH,et al. Sixth ACCP Consensus Conference on Antithrombotic Therapy. Chest 2001;119: 132S-175S

TIP – CHECK PLATELET COUNT on DAYS 3 and 7 to R/O HEPARIN INDUCED THROMBOCYTOPENIA !

PRECAUTIONS WITH EPIDURAL CATHETERS WHEN USING LMWH Therefore, the American Society of Regional Anesthesia recommends the following for patients receiving neuraxial blockade and concurrent anticoagulant therapy or DVT prophylaxis IF LMWH IS USED PREOPERATIVELY : Co administration of antiplatelet or oral anticoagulant medication is contraindicated Lumbar puncture should be delayed at least 12 hours after the last thromboprophylactic dose of LMWH (enoxaparin 40 mg), and at least 24 hours if treatment doses of LMWH being used (eg, enoxaparin 1 mg/kg every 12 hours or enoxaparin 1.5 mg/kg every 24 hours).

IF A LMWH IS USED POSTOPERATIVELY: The first dose should be given no earlier than 24 hours after surgery if being given twice daily for prophylaxis or at treatment doses Indwelling catheters may be safely maintained if low-molecular-weight heparins are given as a single daily thromboprophylactic dose In general, the epidural catheter should be removed about 12 hours after the last prophylactic dose The first dose of a low-molecular-weight heparin should be given no earlier than 2 hours after the catheter is removed Concurrent use of a low-molecular-weight heparin and indwelling epidural catheter is generally not recommended LMWH should be delayed for 24 hrs if the patient had excessive trauma to epidural space during attempted epidural or spinal anesthesia

PARASPINAL HEMATOMA is a rare complication that can develop in patients that receive neuraxial blockade (spinal or epidural anesthesia or epidural analgesia) and concurrent anticoagulant therapy or DVT prophylaxis

All patients should be monitored carefully and frequently for new onset of back pain and for symptoms or signs of cord compression (eg, progression of lower extremity numbness or weakness ,bowel or bladder dysfunction).When Spinal hematoma is suspected, perform diagnostic imaging and definitive surgical therapy ASAP to reduce the risk of permanent paresis

* Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks 2nd ASRA Consensus Conf on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003; 28:172–197.* Horlocker TT. Thromboprophylaxis and neuraxial anesthesia. Orthopedics 2003; 26(suppl 2):243–249. Jaffer AK, Brotman DJ,Chukwumerue N. When patients on warfarin need surgery. ClevelandClinJnlMed 2003;70(11): 973-984

STEPWISE APPROACH for STARTING PERI-OP DVT PROPHYLAXIS

• What type of surgery is the patient having ?

• Are there any contraindications to DVT prophylaxis with anticoagulants ?

• Will or has the patient had spinal or epidural anesthesia ?

• Does the patient have a history of heparin induced thrombocytopenia ?

• Choose DVT prophylaxis based on above answers.

• Be sure to monitor PLATELETS (check on day 3 & 7) and Hgb/Hct !Risk of DVT/PE without Prophylaxis – Based on Surgical Risk Category

Risk Calf DVT

Risk Proximal DVT

Risk Risk Clinical PE FATAL PE

LOW RISK < 2% 0.4% 0.2% <0.01%

MODERATE RISK 10-20% 2-4% 1-2% 0.1-0.7%

HIGH RISK 20-40% 4-8% 2-4% 1-5%

VERY HIGH RISK 40-80% 10-20% 4-10% 4-7%

Perioperative Medication

Management

MEDICATION PREOPERATIVE INSTRUCTIONS AFTER SURGERY

NITRATES SL ok until anesthesia, convert to nitropaste during perioperative period

Paste until taking PO.

ANTICOAGULANTS D/C 3-5 days before surgery patient may require bridging anticoagulation depending on condition.

Resume warfarin- use LMWH ‘til INR therapeutic

ORAL HYPOGLYCEMICS D/C oral formulations night before surgery and convert to insulin either IV or SQ. Stop METFORMIIN 48 hrs before procedure.

Insulin until eating.

BETA BLOCKERS Usual dose morning of surgery with sip water 2 hours before procedure.

Continue IV dose until can take PO.

NSAID Stop 2-3 days before surgery if possible to decrease risk of perioperative renal compromise.

Can resume when hemodynamically stable.

CALCIUM CHANNEL BLOCKERS Usual dose morning of surgery with sip water 2 hours before procedure.

Continue IV dose until can take PO.

ACE INHIBITORS Usual dose morning of surgery with sip water 2 hours before surgery.

Continue IV dose until can take PO.

DIURETICS and KCL SUPPLEMENTS

Stop day before surgery. Restart when taking PO.

THYROXINE Usual dose morning of surgery with sip water 2 hours before surgery.

CENTRAL-ACTING SYMPATHOLYTICS

Usual dose morning of surgery with sip water 2 hours before surgery.

Transdermal clonidine or IV methyldopa while NPO

AMIODARONE D/C night before surgery. ( Has long ½ life ) Resume when pt taking PO.

DRUG for DYSLIPIDEMIA (statins, niacin, etc. )

Stop meds day before surgery. Resume when eating regular diet.

PERIOPERATIVE MEDICATION MANAGEMENT

SOURCES: Spell SO. Stopping and Restarting medications in the perioperative period. Med Clinics of North Am 2001 Sept; 85(5):1117-1128 Paulman P, Paulman A. Perioperative Care. AAFP Home Study Monograph 2001; 263: 3-37 Kuwajerwala NK.Perioperative medication management. 2002: emedicine.com accessed 28 May 2004 Mercado DL, Petty BG.Perioperativ medication macnagement. MedClinics of NorthAm 2003 Jan;87(1): 41-58

MEDICATION PREOPERATIVE INSTRUCTIONS AFTER SURGERY

DIGOXIN Most recommend take day of surgery wth sip of water ~ 2 hours before surgery.

Can use IV until taking PO. Monitor levels if renal/fluid status changes.

HERBAL PRODUCTS Stop use 1-2 weeks before surgery is recommended Resume after discharge

ORAL CONTRACEPTIVES

No consensus- many recommend D/C ~4 weeks before MAJOR surgeries because of increased DVT risk.

Resume when fully ambulatory.

HRT Most stop about 4 weeks before major surgery (if possible} due to increased DVT risk

Resume when fully ambulatory.

SSRI OK to take day of surgery wth sip of water ~ 2 hours before surgery.

Resume when taking PO.

TCA Some recommend cautious continuation through surgery.

LITHIUM Some recommend stopping 2-3 days before MAJOR surgery. Others say OK to continue but monitor levels and lytes closely.

Resume when renal function and electrolytes are stable.

ANTIPSYCHOTICS Should be continued through the perioperative period.

BENZODAZEPINES and OPIOID ANALGESICS

Both should be continued with minimal interruption in the periop period in pts that use chronically.

Abrupt D/C may result in serious withdrawal syndromes.

ANTIEPILEPTICS Should be continued in perioperative period.If on med w/o IV form (i.e.Tegretol and Depakote) and long NPO time likely then convert to drug with IV form and load PREOP.

Continue IV dose until can take PO.

ANTIPARKINSON MEDS Sinemet should be continued in periop period. Bromocriptine & pergolide DON”T give day of surgery. MOA can have FATAL interaction with DEMEROL

If patient on ELDEPRYL it is a MOA – Discuss with anesthesologist BEFORE surg.

ASA – PLAVIX – TICLID - DIPYRIDAMOLE

Stop 7 – 10 days befor surgery.

PERIOPERATIVE MEDICATION MANAGEMENT

Liquids cleared from stomach within 2 hours of ingestion – no difference in volume or pH of gastric contents versus taking clear liquids 9 hours before surgery. Therefore meds can be taken with sip of water up to 2 hours prior to anesthesia.

Perioperative Management

of Patients on Long-term Oral Anticoagulation

Perioperative Management of Patients on Long-term Oral Anticoagulation Therapy (OAT)

LACK of RCT on which to base decisions – recommendations based on General Consensus

THREE MANAGEMENT OPTIONS for PATIENT on OAT THAT NEEDS SURGERY :

1) STOP OAT 4-5 days before SURGERY- Operate when INR ≤ 1.5 (≤ 1.2 if NEUROSURGERY)- restart OAT after surgery with DVT prophylaxis

2) CONTINUE OAT but keep INR on low end of THERAPEUTIC range and proceed with SURGERY

3) STOP OAT 4-5 days BEFORE surgery – use LMWH or UFH as ‘BRIDGING THERAPY’ (see protocol)

CHOICE of which option is appropriate depends on RISK of BLEEDING WITH anticoagulation VS. RISK of THROMBOEMBOLISM (TE) WITHOUT anticoagulation (see TABLE 1 and see below)

MOST patients will NEED to follow OPTION 1

PROCEDURES THAT DO NOT REQUIRE STOPPING‡ “OAT” PRIOR TO SURGERY

CATARACT EXTRACTION

TRABECULECTOMIES

ROUTINE DENTAL SURGERIES *

Restorations Peridontal Endodontics Dental hygeine Uncomplicated extractions DERMATOLOGICAL PROCEDURES

SOFT TISSUE and JOINT INJECTIONS

‡ GOAL IS TO HAVE INR IN LOWER END OF THERAPEUTIC RANGE i.e. TARGET INR around 2.0

* TRANEXAMIC ACID MOUYHWASH HELPS DECREASE BLEEDING AFTER DENTAL SURGERY WHILE ON `OAT’

Kaboli p, Henderson MC, White RH. DVT prophylaxis and anticoagulation in the surgical patient.MedClinN Am 2003;87(1):77-110 Spandorfer J. The management of anticoagulation before and after procedures. MedClinN Am 2001; 85(5):1109-1116

HIGH RISK : bridging advised (1-yr risk of arterial embolism >10% OR 1-month risk of VTE > 10%)Known hypercoagulable state as documented by a thromboembolic event and one of the following: Protein C deficiency Protein S deficiency Antithrombin III deficiency Homozygous factor V Leiden mutation Antiphospholipid-antibody syndromeHypercoagulable state suggested by recurrent ( ≥two ) arterial or idiopathic venous thromboembolic events (not _ including primary atherosclerotic events, such as stroke or MI due to intrinsic cerebrovascular or CAD )Venous or arterial thromboembolism within the preceding 1–3 monthsRheumatic atrial fibrillationAcute intracardiac thrombus visualized by echocardiogramAtrial fibrillation plus mechanical heart valve in any positionOlder mechanical valve model (single-disk or ball-in-cage) in mitral positionRecently placed mechanical valve (< 3 months)Atrial fibrillation with history of cardioembolism

HIGH RISK : bridging case-by-case basis ( 1-year risk of arterial embolism 5-10%, or 1-month risk of VTE 2-10% )Cerebrovascular disease with multiple ( ≥two ) strokes or TIAs without risk factors for cardiac embolismNewer mechanical valve model (eg, St. Jude) in mitral positionOlder mechanical valve model in aortic positionAtrial fibrillation without a history of cardiac embolism but with multiple risks for cardiac embolism(eg, EF < 40%, DM,HTN, nonrheumatic valvular heartdisease, transmural MI within preceding month)Venous thromboembolism > 3–6 months ago*

LOW RISK: bridging not advised ( 1-year risk of arterial embolism less than 5%, or 1-month of VTE < 2% )One remote venous thromboembolism (> 6 months ago)*Intrinsic cerebrovascular disease (such as carotid atherosclerosis) without recurrent strokes or TIAsAtrial fibrillation without multiple risks for cardiac embolismNewer-model prosthetic valve in aortic position

* For pts with a history of venous thromboembolism (VTE) undergoing major surgery, consideration can be given to postoperative bridging therapy only (without preoperative bridging)

Jaffer AK, Brotman DJ,Chukwumerue N. When patients on warfarin need surgery. ClevelandClinJnlMed 2003;70(11): 973-984

WHICH PATIENTS on WARFARIN SHOULD RECEIVE HEPARIN BRIDGING BEFORE SURGERY ?

INCLUSION CRITERIA Age > 18 years, needing to undergo therapy with low-molecular-weight heparin Treating physician thinks patient needs bridging therapy (see TABLE 1) Medically and hemodynamically stable Scheduled for elective procedure or surgeryEXCLUSION CRITERIA Allergy to unfractionated heparin or low-molecular-weight heparin Weight > 150 kg Pregnant woman with a mechanical valve History of bleeding disorder or intracranial hemorrhage Creatinine clearance < 30 mL/minute Gastrointestinal bleeding within the last 10 days Major trauma or stroke within the past 2 weeks History of heparin-induced thrombocytopenia or severe thrombocytopenia Severe liver diseaseBEFORE SURGERY If preoperative INR is 2.0–3.0, stop warfarin 5 days before surgery (ie, hold four doses) If preoperative INR is 3–4.5, stop warfarin 6 days before surgery (hold five doses) Start low-molecular-weight heparin 36 hours after last warfarin dose, ie: Enoxaparin 1 mg/kg SQ q 12 hours, ORr Enoxaparin 1.5 mg/kg SQ every 24 hours Give last dose of LMWH approximately 24 hours before procedure Educate patient in self-injection and provide with written instructions Discuss plan with surgeon and anesthesiologist Check INR AM of surgery to ensure that it is <1.5, or in some cases (eg,neurologic surgery) <1.2AFTER SURGERY Restart LMWH ~24 hrs after procedure or consider thromboprophylactic dose of LMWH on first postoperative day if patient is at high risk for bleeding Discuss above with surgeon Start warfarin at patient’s preop dose on postop day 1 Daily PT and INR until patient discharged and periodically thereafter until INR in therapeutic range Daily phone follow-up with patient Complete CBC with platelets on day 3 and day 7 Discontinue LMWH when INR is 2–3 for 2 consecutive days

Cleveland Clinic PROTOCOL FOR LMWH AS A BRIDGE TO SURGERY IN PATIENTS WARFARIN

Jaffer AK, Brotman DJ,Chukwumerue N. When patients on warfarin need surgery. ClevelandClinJnlMed 2003;70(11): 973-984

PRECAUTIONS WITH EPIDURAL CATHETERS WHEN USING LMWH Therefore, the American Society of Regional Anesthesia recommends the following for patients receiving neuraxial blockade and concurrent anticoagulant therapy or DVT prophylaxis IF LMWH IS USED PREOPERATIVELY : Co administration of antiplatelet or oral anticoagulant medication is contraindicated Lumbar puncture should be delayed at least 12 hours after the last thromboprophylactic dose of LMWH (enoxaparin 40 mg), and at least 24 hours if treatment doses of LMWH being used (eg, enoxaparin 1 mg/kg every 12 hours or enoxaparin 1.5 mg/kg every 24 hours).

IF A LMWH IS USED POSTOPERATIVELY: The first dose should be given no earlier than 24 hours after surgery if being given twice daily for prophylaxis or at treatment doses Indwelling catheters may be safely maintained if low-molecular-weight heparins are given as a single daily thromboprophylactic dose In general, the epidural catheter should be removed about 12 hours after the last prophylactic dose The first dose of a low-molecular-weight heparin should be given no earlier than 2 hours after the catheter is removed Concurrent use of a low-molecular-weight heparin and indwelling epidural catheter is generally not recommended LMWH should be delayed for 24 hrs if the patient had excessive trauma to epidural space during attempted epidural or spinal anesthesia

PARASPINAL HEMATOMA is a rare complication that can develop in patients that receive neuraxial blockade (spinal or epidural anesthesia or epidural analgesia) and concurrent anticoagulant therapy or DVT prophylaxis

All patients should be monitored carefully and frequently for new onset of back pain and for symptoms or signs of cord compression (eg, progression of lower extremity numbness or weakness ,bowel or bladder dysfunction).When Spinal hematoma is suspected, perform diagnostic imaging and definitive surgical therapy ASAP to reduce the risk of permanent paresis

* Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks 2nd ASRA Consensus Conf on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003; 28:172–197.* Horlocker TT. Thromboprophylaxis and neuraxial anesthesia. Orthopedics 2003; 26(suppl 2):243–249. Jaffer AK, Brotman DJ,Chukwumerue N. When patients on warfarin need surgery. ClevelandClinJnlMed 2003;70(11): 973-984

MEDICATION RISK of EPIDURAL HEMATOMA with MEDICATION

SUGGESTED TIME INTERVAL BEFORE

REMOVAL of EPIDURAL CATHETER

LAB TESTS NECESSARY PRIOR TO d/cOF EPIDURAL CATHETER

INTERVAL BEFORE RESUME MEDS AFTER EPIDURAL

CATHETER

Heparin (standard) (IV or SQ route) Therapeutic aPTT 1.5 x control

High 4–6 hours after stopping heparin aPTT should be within normal limits prior to catheter removal

aPTT At least 2 hours after epidural catheter removal, providing clinical monitoring checks are within normal limits, including no apparent bleeding

Heparin (minidose-prophylaxis)

Low 12 hours after the last dose None Immediately

Low molecular-weight Heparins

High 12–24 hours after last dose None 12-24 hours

Fibrinolytic and thrombolytic drugs

High At least 12 hours after the last dose of the thrombolytic drug

None At least 24 hours after catheter removal

Warfarin (Therapeutic INR  >  2.0)

Moderat-High

Prothrombin time (PT) INR <1.5 prior to removal of the epidural catheter

PT Immediately

Warfarin (Low dose-Prophylaxis)

Low-Moderate

Prothrombin time (PT) INR <1.5 prior to removal of the epidural catheter

PT Immediately

Aspirin Low No Restriction None Immediately

Dipyridamole Low No Restriction None Immediately

Ticlopidine Low No Restriction None Immediately

Clopidogrel Low No Restriction None Immediately

NSAIDs Low No Restriction None Immediately

EPIDURAL ANESTHESIA or ANALGESIA: SPECIAL CONSIDERATIONS FOR PATIENTS TAKING LONGTERM ANTIPLATELET or ANTICOAGULANT MEDICATIONS

Mercado DL, Petty BG. Perioperativ medication macnagement. MedClinics of NorthAm 2003 Jan; 87(1): 41-58

Most common tool for diagnosing Delirium is the CONFUSION ASSESSMENT METHOD (sensitivity 94-100%; specficity 90-95%)

Feature 1 : ACUTE ONSET and FLUCTUATING COURSE. This feature usually obtained from family or nurse-shown by positive response to following questions: Is ther evidence of an acute change in mental status from the patient’s baseline?Did the (abnormal) behavior fluctuate during the day (i.e. tend to come and go, or increase and decrease in severity)?

Feature 2 : INATTENTION. Shown by a positive response to : Did the patient have difficulty focusing attention (being easily distractible or having difficulty keeping track of what is being said)?

Feature 3 : DISORGANIZED THINKING. Shown by positive response to following question: Was the patient’s thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?

Feature 4 : ALTERED LEVEL of CONSCIOUSNESS. Shown by any answer other alert to the question: Overall, how would you rate this patient’s level of consciousness?

**Diagnosis of delirium by the CAM requires presence of features 1 and 2 and either 3 or 4 .**

IMPORTANT POINTS ABOUT POST OPERATIVE DELIRIUM

Associated with higher mortality, longer length of stay, and higher risk of institutionalization

DELIRIUM very common after surgery – especially in ELDERLY. Incidence may be as high as 61% after hip fracture

Majority of cases had no single clear etiology – most are actually MULTIFACTORIAL .

VERY IMPORTANT TO WARN and EDUCATE FAMILIES ABOUT POSSIBILITY OF DELIRIUM DEVELOPING POSTOPERATIVELY !!! DELIRIUM in a loved one can be VERY FRIGHTENING to the family that is UNPREPARED !!!!

1) FIRST - ALWAYS look for reversible causes – ie ELECTROLYTE abnormalities, hypoxemia, hypo/hyperglycemia, dehydration, acidosis/alkalosis, acute renal failure, pneumonia, UTI, or other infections, Myocardial ischemia (EKG & enzymes), hepatic dysfunction, physical restraints, foley catheter, new STROKE (order CT if there are new neuro findings BUT DON’T ORDER ROUTINELY ON ALL POSTOP PATIENTS WITH DELIRIUM !)

2) REVIEW all meds - ELIMINATE NON-ESSENTIAL MEDS

3) R/O ETOH & BENZODIAZIPINE WITHDRAWAL SYNDROMES

4) INSTITUTE SUPPORTIVE MEASURES:

5) HALDOL is the preferred (and most commonly used) agent for treatment of delirium.

TRADITIONAL REGIMEN START with 1-2mg IV/IM for initial dose and adjust q 1-2hr if needed THEN 1-5mg q 4-6 hrs. Once delirium controlled can give regularly scheduled doses (IV, IM, or PO) q4-6hr for a few days then taper over several days. MONITOR for ECG CHANGES ie QT prolongation and/or ARRHYTHMIAS.

6) AVOID use of DEMEROL ESPECIALLY IN THE ELDERLY ( Morphine low risk for Delirium )

4) AVOID BENZODIAZEPINES these are drugs of choice for ETOH & sedative withdrawal syndromes and as adjunct to neuroleptics to reduce EPS. NOT first line for DELIRIUM.

5) AVOID drugs with ANTICHOLINERGIC effects ie Benadryl & Vistaril.

6) CONSIDER consulting Pharmacy regarding possible medication etiologies

● Maintain hydration ● Mobilize patient ● Quiet environment & avoid extraneous stimulation ● Bedside sitters ● Reserve restraints for patients at high risk for self-harm ● Remove FOLEY ASAP ● Frequent re-orientation and reassurance

ASSESSMENT and MANAGEMENT of ACUTE DELIRIUM

Jacobi J,Fraser GL, et al. Clinical practice guidelines for the sustained use of sedatives and anagesics in the critically ill adult. CritCareMed 2002;30(1): 119-141 Morrison RS,Siu AL. Medical consultation for patients with hip fracture. 2004;UpToDate online 12.1 accessed 20May 2004 Winawer N. Postoperative delirium. MedClinicsNorthAm 2001 Sept;85(5):1229-1239

This source recommends Loading dose 2-10 mg IVP q 20-30 min (can start with 2 mg and double q 20-30 min) until agitation controlled THEN 25% of loading dose every 6 hours.

GEODON is another option – less EPS side effects than HALDOL – some say works faster . DOSING : 10mg IM q 2hr, OR 20mg q 4hr. Once controlled can use 10mg IM q 6hr. MAX DOSE 40mg per day. NO IV FORM AVAILABLE.

Pain Management

CHOICE of AGENTS : MEPERIDINE No longer considered 1rst line agent

Metabolite= NORMEPERIDINE(NM) has ½ life 15-40 hrs; NM has TWICE CNS stimulation & ½ analgesia of MEPERIDINE

Adverse SE limit usefulness i.e. Agitation, myoclonus, DELIRIUM, seizures ;INCREASED risk if Renal impairment

NOT RECOMMENDED if RENAL or LIVER impaired; in CNS disorders; if pt on SSRI; AND ESPECIALLY

in ELDERLY ABSOLUTELY CONTRAINDICATED if patient is on MAOI ( example = ELDEPRYL used in tx of PARKINSONS)

MORPHINE – HYDROMORPHONE– FENTANYL ACCORDING to SOCIETY of CRITICAL CARE MEDICINE(SCCM): 1) ” If IV doses of an Opioid analgesic are required, fentanyl, hydromorphone, and morphine are the recommended agents.” 2) Fentanyl and hydromorphone are preferred for patients with hemodynamic instability or renal insufficiency.

EQUIANALGESIC DOSE (iv) : Fentanyl 200ug - Hydromorphone(HM) 1.5mg - Morphine(MS) 10mg - Demerol 75-100mg

And increased SE POSTOPERATIVE PAIN MANAGEMENT

HOW TO SET UP PATIENT CONTROLLED ANESTHESIA

1) SPECIFY CHOICE OF OPIOID - usually Morphine (MS), fentanyl, hydromorphone (MS by far MOST COMMONLY USED) 2) INITIAL LOADING / BOLUS DOSE – purpose PCA is to MAINTAIN analgesia NOT ESTABLISH IT that is GOAL of initial loading bolusTYPICAL INITIAL LOADING DOSE: MS 2-6mg or HM 0.2-0.4mg 3) INTERMITTENT BOLUS (aka On-Demand dose) = Dose patient gets EACH TIME pushes button AVG. HOURLY MORPHINE DOSE calculated (for pts 20-70 yrs old) by formula mg/hr = (100 – age )/ 24 (Because of pt. variability may take up to 2X this value to provide adequate analgesia) TOTAL DAILY MS DOSE would be BETWEEN 1 to 2X (100 - AGE ) 4) LOCKOUT INTERVAL = minimal allowable time between between consecutive intermittent (on-demand) bolus doses TYPICAL INTERVAL 10 – 15 minutes . 5) CONTINOUS (aka ‘background’) INFUSION - NOT RECOMMENDED in postop patients. Majority studies show increased opioid consumption, increased SE(including SEDATION and RESPIRATORY DEPRESSION) without improved analgesia 6) MAXIMUM DOSE LIMITS- sets limits on amount of med pt gets in 1or 4 hours segments; safeguards against programming errors and acts to alert the practitioner to the unsatisfied needs of the patient.

Probably THERAPY of CHOICE in postop patients with moderate to severe pain

Jacobi J,, et al. Clinical practice guidelines for the sustained use of sedatives and anagesics in the critically ill adult. CritCareMed 2002;30(1): 119-141 Etches RC.Patient controlled analgesia. SurgClinN Am 1999; 79(2):297-312

1) HISTORY- MOST important component of Preop assessment. Check history of ANESTHESIA PROBLEMS, abnormal

BLEEDING, DOE, cough, fever,activity level, and LMP(r/o PG). Review PMH, PSH, HABITS and MED ALLERGIES.

2) PHYSICAL - Self explanatory.

3) MEDICATIONS - Review of chronic meds and how to manage during periop period (e.g. METFORMIN & anticoagulants ETC.)

4) STUDIES -Review lab, x-rays, and EKGs for abnormalities that may effect surgery. Are additional studies indicated?

5) CARDIAC RISK – Determine cardiac risk and develop risk reduction strategy. Determine if additional studies indicated.

6) PULMONARY EVALUATION - Evaluate risk for postop pulmonary complications. Develop plan to minimize risk.

7) SBE PROPHYLAXIS - Determine if a condition requiring SBE PROPHYLAXIS is present ?

8) BETA BLOCKERS – Determine if perioperative beta-blockers are indicated.

9) DIABETES MANAGEMENT – aggressive control improves morbidity and mortality – use insulin infusion if necessary.

10) DVT PROPHYLAXIS – Determine appropriate PROPHYLAXIS regimen.DID PATIENT HAVE NEUROAXIAL ANESTHESIA?

11) PAIN CONTROL – Develop a plan for providing adequate analgesia. Reassess adequacy frequently and adjust as needed.

12) FOLEY CATHETER – Remove ASAP–dangerous source of infection, delays ambulation, and increases risk of delirium.

13) DIABETES MANAGEMENT POSTOP-TIGHT control associated with improved outcome. Avoid tx with SSI only. Monitor daily.

14) NUTRITION – Adequate nutrition essential. Review status daily. Determine if TPN required ?

15) ACTIVITY – Monitor activity daily. Consult PT EARLY if patient is debilitated. EARLY ambulation decreases morbidity.

16) DELIRIUM(‘Crazy’) – Anticipate in elderly and critically ill. FOREWARN families BEFORE surgery of likelihood of postop delirium.

SYSTEMATIC APPROACH FOR

EVALUATION Use the “ SAFE “ method for comprehensive Perioperative management.It is a TOOL to help recall all the areas of importance when evaluating a patient preoperatively and taking care of the patient during thr postop period.Most of the categories are covered in more depth in this manual USE THE MNEMONIC BELOW AS AN AID TO REMEMBER ALL THE CATEGORIES TO COVER !

PUTTING IT ALL TOGETHER

PUTTING IT ALL TOGETHER

Having Procedures May Sometimes Cause Patients Some Basic Doubts Due Partly From Doctors Not Adequately Counselling