Peri-operative Assessments, Pain, Fever, Oliguria and DVT Prophylaxis

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Peri-operative Assessments, Pain, Fever, Oliguria
and DVT Prophylaxis

• Peter E. Rice, MD
• Surgical Fundamentals Session 4

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Question
What are the specific pre-operative laboratory
tests and/or evaluations that should be performed
to confirm or to rule out medical conditions that
are likely to impact a patients perioperative
course?
gt 3 billion dollars are spent each year on pre-op
lab evaluations- and gt 60 of these are
unnecessary
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From the Anesthesiologists Point of View.
Class Physical Status 48 hr mortality
I No systemic disease 0.07
II Mild systemic disease no functional limitation (obese, smoker, HTN) 0.24
III Severe, not incapacitating systemic disease (CAD, CHF, COPD) 1.4
IV Incapacitating disease that is a constant threat to life 7.5
V Moribund pt. not expected to survive 24 hrs regardless of surgery 8.1
E Suffix added to class (emergency) Doubles risk
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Lab Tests lt35 days acceptable w/o change in
condition CXR lt6 months EKG lt2 months Urine
pregnancy on day of surgery
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ASA III
CBC SMA-12 U/A CXR EKG Upreg Consult from an
appropriate physician
Tests as indicated by the patients specific
disease state
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Tests as Indicated by the Disease State..
CNS
Seizure/stroke
Pulmonary
PFTs, ABG, Bronchodilators, Steroids
GI
Liver dz
Systems Assessment
Renal
CBC, Lytes
Heme/Onc
CBC,INR,PT,PTT
Medications
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Tests as indicated by the patients specific
disease state
And the risk of the planned procedure
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The History and Physical will uncover the
clinical risk of the patient
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A Special Case.
Low risk procedure
OR
Hx/PE ?Cardiac Disease-CAD,CHF,Arrhythmia,CVA,
PVD
Estimate Clinical Risk
High risk procedure
Exercise Stress Dobutamine w/ Echo Persantine
Thallium
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One Additional Note
Perioperative Beta-Blocker Therapy

• Patients who are receiving beta-blockers to treat
  angina, arrhythmias, or hypertension
• Patients undergoing vascular surgery who are at
  high cardiac risk
• Patients who are at increased cardiovascular risk
• advanced age
• diabetes mellitus
• renal insufficiency

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Fever is a common event but cannot be
ignored Two temperature elevations gt38.5 in a
24-hour period
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Postoperative Fever Tgt38.5
Late gt48 hours
Early lt48 hours
Both evaluations begin with History and Physical
Exam

• The cause of most postoperative fevers will be
  elucidated by the history and physical
• Check the comorbidities- transfusion, meds,
  malignancy, FB, diabetes
• Always check the operative site

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Early lt48 hours
Physical exam
Wind Wound Water Walk Wonder Drugs
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cellulitis
Wound
drainage
Respiratory
CXR
?AIE
IV sites
?infected
Physical Examination
Late gt48 hours
GU
UA /CX
Intra-abdominal
CT Scan
Extremity swelling
Duplex
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Oliguria
Acute oliguria is the excretion of lt400cc of
urine per day, and is often the earliest sign of
impaired renal function
Oliguria
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68yo male s/p LAR with loop ileostomy T 37 P 110
BP 110/75 R12 UO 14cc in the last hour
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Fe NA Urine Na / Plasma Na
Urine Cr / Plasma Na
x100
FeNa lt 1 prerenal FeNa gt 2 renal (ATN)
Urinary sodium (meqL) lt20 prerenal
gt40 renal
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Venous Thromboembolism
DVT
Pulmonary Embolus
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National Body Position Statements

• Leapfrog1
• PE is the most common preventable cause of
  hospital
• death in the United States
• Agency for Healthcare Research and Quality
  (AHRQ)2
• Thromboprophylaxis is the number 1 patient
  safety practice
• American Public Health Association (APHA)3
• The disconnect between evidence and execution
  as it
• relates to DVT prevention amounts to a public
  health crisis.

1. The Leapfrog Group Hospital Quality and Safety
   Survey. Available at www.leapfrog.medstat.com/pdf
   /Final/doc
2. Shojania KG, et al. Making Healthcare Safer A
   Critical Analysis of Patient Safety Practices.
   AHRQ, 2001. Available at www.ahrq.gov/clinic/ptsa
   fety/
3. White Paper. Deep-vein thrombosis Advancing
   awareness to protect patient lives. 2003.
   Available at www.alpha.org/ppp/DVT_White_Paper.pd
   f

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Rationale for DVT Prophylaxis

• High Prevalence of DVT
• Adverse Consequences of DVT
• Efficacy and effectiveness of thromboprophylaxis
• Highly efficacious in prevention of DVT
• Highly efficacious in prevention of symptomatic
  DVT and fatal PE
• DVT prevention prevents PE
• Cost effectiveness has been demonstrated

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Absolute Risk of DVT in Hospitalized Patients
Patient Group DVT Prevalence,
Medical patients 10-20
General surgery 15-40
Major GYN surgery 15-40
Major GU surgery 15-40
Neurosurgery 15-40
Stroke 20-50
Hip or Knee surgery 40-60
Major Trauma 40-80
Spinal Cord Injury 60-80
Critical Care patients 10-80
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Thromboprophylaxis Reduces DVT Events

• Pulmonary Embolus is the most common preventable
  cause of hospital death

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Risk Factors for DVT

• Surgery
• Trauma
• Immobility, paresis
• Malignancy
• Cancer therapy
• Previous VTE
• Increasing age
• Pregnancy and postpartum
• Estrogen-containing oral contraception or HRT
• Selective estrogen receptor modulators
• Acute medical illness

• Heart or respiratory failure
• Inflammatory bowel disease
• Nephrotic syndrome
• Myeloproliferative disorders
• Paroxysmal nocturnal hemoglobinuria
• Obesity
• Smoking
• Varicose veins
• Central venous catheterization
• Inherited or acquired thrombophilia

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Methods of Prophylaxis

• Mechanical Methods
• Graduated Compression Stockings
• Intermittent Pneumatic Compression device
• Venous foot pump
• Studies
• Not blinded
• High rate of false negative scans
• Compliance in true practice poor
• Acceptable option
• High risk for bleeding
• Adjunct to anticoagulant prophylaxis
• Improves efficacy when used in combination with
  anticoagulant prophylaxis

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Anticoagulants

• Most widely used and studied prophylaxis
• Before 1987, only heparin and warfarin were
  available
• Now,
• 4 low molecular weight heparins
• 1 Factor Xa inhibitor
• 3 direct thrombin inhibitors
• 1 coumarin derivative

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Unfractionated Heparin

• Potentiates inactivation of activated enzymes of
  clotting cascade, via binding to antithrombin III
• Effective in preventing DVT in low and moderate
  risk patients
• Does not increase risk of hemorrhage

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Low Molecular Weight Heparin
Higher bioavailability stable and predictable
antithrombotic activity Can be administered
once-daily Lower risk of thrombocytopenia More
effective for high risk prophylaxis than heparin
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General Surgery

• 46 RCT Low Dose Unfractionated Heparin v. placebo
  or no proph.
• Reduced
• DVT 22 to 9
• Symptomatic PE 2 to 1.3
• Fatal PE 3 to .8
• Meta-analysis
• No increase in wound hematoma or bleeding

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General Surgery

• LMWH (Lovenox)
• Meta-analysis (Douketis Arch Intern Med 2002)
• 70 reduction DVT v. no prophylaxis
• Nine meta-analysis and systematic reviews
• No difference in DVT LMWH and UFH
• Some trials fewer hematomas and bleeding
  complications with LMWH
• No difference in total mortality, fatal PE
  between LDUH 5000 units TID and LMWH

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General Surgery

• Low Risk
• Minor Surgery (hernia repair, outpatient surgery)
• lt 40 years of age
• No additional risk factors
• Risk
• DVT Calf 2 Proximal 0.4
• PE Clinical 0.2 Fatal - lt0.01
• Prevention Strategies
• No specific prophylaxis early mobilization

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General Surgery

• Moderate Risk
• Minor Surgery with additional risk factors
• Age 40-60 with no risk factors
• Major surgery, lt 40 with no risk factors
• Risk
• DVT Calf - 10-20 Proximal - 2-4
• PE Clinical - 1-2 Fatal - 0.1-0.4
• Prevention Strategies
• LDUH (5,000 units q 12 hours, start 1-2 hrs
  pre-op)
• LMWH ( 30mg daily)
• Graduated Compression Stockings
• Intermittent Pneumatic Compression Devices

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General Surgery

• High Risk
• Non-major surgery in age gt 60 yr. or have
  additional risk factors
• Major Surgery gt 40 or have additional risk
  factors
• Risks
• DVT Calf 20-40 Proximal 4-8
• PE Clinical 2-4 Fatal 0.4-1.0
• Prevention Strategies
• LDUH (5,000 U q 8 hours)
• LMWH ( 30mg q 12h)

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General Surgery

• Highest Risk
• Surgery in patients with multiple risk factors
• Risk
• DVT Calf 40-80 Proximal 10-20
• PE Clinical 4-10 Fatal - 0.2 - 5
• Prevention Strategies
• LDUH ( 5,000 q 8 hours) or
• LMWH ( 30mg q12h) with
• GCS and/or IPC

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General Surgery

• Special Considerations
• High Risk of Bleeding
• Properly fitted GCS and/or IPC
• Major Cancer Surgery
• Post hospital discharge prophylaxis with LMWH
  for 2-3 weeks

Prolonged prophylaxis in abdominal and pelvic
cancer reduced DVT 12 to 5 Bergqvist NEJM
2002
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Vascular Surgery

• Risk
• Aortic Surgery - DVT 0.9 - 12 No prophylaxis
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• Femorodistal DVT 0.7 9 No prophylaxis
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• No routine prophylaxis in patients without risk
  factors
• LDUH or LMWH in patients with risk factors

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Recommendations in Laparoscopy

• European Association for Endoscopic Surgery
• Intraoperative IPC for all prolonged laparoscopic
  procedures
• SAGES
• Same thromboprophylaxis options with laparoscopic
  procedures as for the equivalent open surgical
  procedures
• ACCP
• No risk factors aggressive early mobilization
  With risk factors LDUH, LMWH, IPC or GCS

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Major Trauma

• Highest Risk of all Hospitalized Patients
• Risk without Rx exceeds 50
• DVT Calf 40-80 Proximal 10-20
• PE Clinical 4-10 Fatal - 0.2 - 5
• Risk with routine thromboprophylaxis
• DVT Calf 27 Proximal 7
• Increased Risk Factors
• Spinal Cord injury, lower extremity or pelvic Fx,
  need for surgery, increasing age, femoral venous
  line insertion or major venous repair, prolonged
  immobility, prolonged ventilatory support and
  longer duration of hospital stay, /- ISS

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Trauma Recommendations

• All patients with at least one risk factor
  receive thromboprophylaxis
• LMWH as soon as considered safe
• If LMWH delayed Boots
• Continued thromboprophylaxis until mobility
  adequate
• Duplex ultrasound screening high risk and
  suboptimal prophylaxis or no prophylaxis

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Pain

• An unpleasant sensory and emotional experience
  associated with actual or potential tissue
  damage, or described in terms of such damage.

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Pain is whatever the experiencing person says it
is and exists whenever he/she says it does.
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Classes of drugs

• Opioid analgesics
• Nonsteroidal anti-inflammatory drugs (NSAIDS)
  (Aspirin, Motrin, Toradol)

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Opioid Analgesics
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Schedules of Controlled Narcotics

• Schedule I Unacceptable potential for abuse
  Heroin, Cocaine, LSD
• Schedule II High potential for abuse and
  dependence opioids, amphetamines
• Schedule III Intermediate potential for abuse
  codeine acetaminophen, hydrocodone
  acetaminophen

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Schedules of Controlled Narcotics

• Schedule IV Less abuse potential than schedule
  III, minimal dependence lorazepam alprazolam,
  diazepam
• Schedule V minimal abuse potential codiene
  cough syrup, lomotil

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Action

• Binds to opiate receptors in the central nervous
  system.
• Alters the perception of and response to painful
  stimuli
• Produces generalized CNS depression

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CNS side effects of opioids

• Respiratory depression
• Hypotension, orthostatic hypotension
• Constipation, nausea,vomiting
• Urinary retention
• Confusion
• Rash

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Contraindications Precautions

• Contraindications
• Hypersensitivity
• Precautions
• Elderly
• Respiratory diseases
• Head trauma
• Liver or kidney disease
• Opioid addiction

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Morphine

• Prototype opioid analgesic
• Equianalgesic doses of opioids
• Indications
• Severe pain
• Pulmonary edema
• Pain associated with myocardial infarction.

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Morphine administration routes

• Many preparations routes
• Oral tablets, extended release (MS Contin)
• elixir (Roxanol)
• Sublingual tablets 10 mg, rapidly absorbed
• IM
• IV, PCA
• Epidural

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Postoperative pain

• Regular frequent dosing intervals in early
  postop period, then PRN
• PCA, Epidural, IV
• Opioid NSAID
• Switch to oral dosing when taking po
• Medicate prior to anticipated pain
• Ambulation physical therapy
• Dressing changes

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PCA patient controlled analgesia

• Self-administration of IV analgesic
• Very effective
• Prevents delays
• Reduces patient anxiety

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PCA dosing

• Example
• Morphine PCA 30mg/30ml
• Basal rate 1 mg/hr
• Demand dose 1-2 mg
• Lockout 6-8 minutes
• 4 Hour Max

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QUESTIONS ?