Nadia Mujahid MD

Co-Director Geriatric Fracture Program

Rhode Island Hospital

August 7th 2014

Grant through the Donald W Reynolds Foundation to disseminate Geriatric Education among sub specialists

Serve as a Geriatric Consultant with Depuy Synthes

Why is this topic worth discussing

Preoperative evaluation guidelines

Important consideration on beta blockers and

anticoagulation in the perioperative period

Strategies to reduce perioperative risk in

geriatric patients

US ~ 330000 hip fractures year

Expected to increase to 550000 by 2040

1-year mortality = 20 to 24

Many patients will lose their independence after hip fracture

The cost of caring for hip fractures was reported to be $17 billion in 1997 and it is estimated to grow to $62 billion by 2040

US Department of Health and Human Services The 2004Surgeon Generalrsquos report on bone health and osteoporosis

httpwwwsurgeongeneralgovlibrarybonehealthdocsOsteo

Agency for Healthcare Research and Quality 2005 HCUP Nationwide Inpatient Sample (NIS) Comparison Report Rockville MDUS Department of Health and Human Services 2008

Youm T Koval KJ Zuckerman JD The economic impact of geriatric hip fractures Am J Orthop 199928(7)423-428

Grant through the Donald W Reynolds Foundation to disseminate Geriatric Education among sub specialists

Serve as a Geriatric Consultant with Depuy Synthes

Why is this topic worth discussing

Preoperative evaluation guidelines

Important consideration on beta blockers and

anticoagulation in the perioperative period

Strategies to reduce perioperative risk in

geriatric patients

US ~ 330000 hip fractures year

Expected to increase to 550000 by 2040

1-year mortality = 20 to 24

Many patients will lose their independence after hip fracture

The cost of caring for hip fractures was reported to be $17 billion in 1997 and it is estimated to grow to $62 billion by 2040

US Department of Health and Human Services The 2004Surgeon Generalrsquos report on bone health and osteoporosis

httpwwwsurgeongeneralgovlibrarybonehealthdocsOsteo

Agency for Healthcare Research and Quality 2005 HCUP Nationwide Inpatient Sample (NIS) Comparison Report Rockville MDUS Department of Health and Human Services 2008

Youm T Koval KJ Zuckerman JD The economic impact of geriatric hip fractures Am J Orthop 199928(7)423-428

Why is this topic worth discussing

Preoperative evaluation guidelines

Important consideration on beta blockers and

anticoagulation in the perioperative period

Strategies to reduce perioperative risk in

geriatric patients

US ~ 330000 hip fractures year

Expected to increase to 550000 by 2040

1-year mortality = 20 to 24

Many patients will lose their independence after hip fracture

The cost of caring for hip fractures was reported to be $17 billion in 1997 and it is estimated to grow to $62 billion by 2040

US Department of Health and Human Services The 2004Surgeon Generalrsquos report on bone health and osteoporosis

httpwwwsurgeongeneralgovlibrarybonehealthdocsOsteo

Agency for Healthcare Research and Quality 2005 HCUP Nationwide Inpatient Sample (NIS) Comparison Report Rockville MDUS Department of Health and Human Services 2008

Youm T Koval KJ Zuckerman JD The economic impact of geriatric hip fractures Am J Orthop 199928(7)423-428

US ~ 330000 hip fractures year

Expected to increase to 550000 by 2040

1-year mortality = 20 to 24

Many patients will lose their independence after hip fracture

The cost of caring for hip fractures was reported to be $17 billion in 1997 and it is estimated to grow to $62 billion by 2040

US Department of Health and Human Services The 2004Surgeon Generalrsquos report on bone health and osteoporosis

httpwwwsurgeongeneralgovlibrarybonehealthdocsOsteo

Agency for Healthcare Research and Quality 2005 HCUP Nationwide Inpatient Sample (NIS) Comparison Report Rockville MDUS Department of Health and Human Services 2008

Youm T Koval KJ Zuckerman JD The economic impact of geriatric hip fractures Am J Orthop 199928(7)423-428

Cooper Am J Med 1997 103(2A)12s-19s

40

Unable to walk independently

30

Permanent disability

20

Death within one year

80

Unable to carry out at least one activity of daily living

Loss of function

50

Regained functional capacity

30

Mortality 20

Most patients benefit from surgical stabilization of their fractures

The sooner patients have surgery the less time they have to develop iatrogenic illness

Goal is to have surgery ideally within 24 hours - less decubitii ( 1)

- reduce major medical complications ( 2) - decreased preoperative pain ( 3)

- decreased average LOS by 2 days ( 3)

- earlier ambulation - reduced delirium (4)

a Grimes JP Am J Med 2002 112702-9 b Hoenig H Arch Int Med 1997 157513-20 c Orosz GM JAMA 2004291 1738-43 d Parker MJ J Bone Joint 5urg [Br] 199274203-5

93 yr old female admitted sp trip and fall accident at home around 2pm yesterday She was seen at a local hospital and transported to RIH for a right peri-prosthetic femur fracture

Available labs Hb 98mgdl Cr 098mgdl

EKG NSR rate of 85 bpm

No prior labsEKG in lifespan pt is a resident of Fall River MA

Per pt she recently had ldquocardiac surgeryrdquo and had angina 3 weeks ago

You are consulted by the Ortho trauma team to evaluate the patient for a possible second case this morning

Best done by the Revised Goldman Cardiac Risk Index (RCRI)

Most studied and Validated

Predictive value for cardiac complications and mortality significant in All types of non-cardiac surgery except AAA

Does Not Capture all-cause Mortality

1 point for each risk factor

1 High risk surgery (peritoneal thoracic supra inguinal vascular)

2 Hx of CAD

3 Hx of CHF

4 Hx of CVA

5 Hx of DM insulin dependent

6 Pre op Cr gt20mgdl

Lee et all circulation 1999 Auerbach circulation 2006

Risk Factors Rate 95 CI

No Risk Factors 04 01 ndash 08

One Risk Factor 10 05 ndash 14

Two Risk Factors 24 13 ndash 35

Three Risk Factors 54 28 ndash 79

Devereaux PJ Goldman L Cook DJ et al CMAJ 2005 173627

Risk Factors Rate Rate with Beta Blockers

None 04 ndash 10 lt 1

One to Two 22 ndash 66 08 ndash 16

Three or More gt 9 gt 3

Auerbach A Goldman L Circulation 2006 1131361

of risk factors determine the risk of major cardiac complication

A major cardiac complication is described as cardiac death and nonfatal MI cardiac arrest or ventricular fibrillation pulmonary edema and or complete heart block

Risk reduces with the use of BB

DELAY SURGERY

Unstable Coronary syndrome

Decompensated heart failure

Significant arrhythmia

Severe valvular heart disease

Sepsis

NO NEED TO DELAY SURGERY

Stable CAD

Ch Compensated left ventricular failure

Ch Kidney disease

UTI without sepsis

Delirium

Pre operative cardiac testing (echo stress testing) is unlikely to improve outcomes or change management for almost all geriatric fracture patients

Preoperative subspecialty consultation (eg cardiology) is rarely needed

Timely surgery and avoidance should be the primary goals

Relevant class 1 recommendation

Emergent surgery should proceed to OR focus on risk reduction perioperative surveillance and treatment

Active cardiac conditions should be treated and surgery still considered when stable

-ACS decompensated heart failure severe valvular disease and arrhythmias

Relevant class IIb guidelines

Noninvasive testing might be considered ldquoif it will change managementrdquo in patients with poor functional capacity (lt4 METs) and multiple risk factors undergoing intermediate risk surgery

Remember

Many frail geriatric fracture patients fall in this category

Echocardiography and or stress testing or angiography is very unlikely to change management This will only delay surgery and pt recovery

Continue if on BB at home

Start if pt is high risk (3 or more risk factors)

No need to start if pt is low risk (lt2 risk factors) as they may cause more harm then benefit

Use with holding parameters

AHA guidelines revised (2009)

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Loss of function

50

Regained functional capacity

30

Mortality 20

Most patients benefit from surgical stabilization of their fractures

The sooner patients have surgery the less time they have to develop iatrogenic illness

Goal is to have surgery ideally within 24 hours - less decubitii ( 1)

- reduce major medical complications ( 2) - decreased preoperative pain ( 3)

- decreased average LOS by 2 days ( 3)

- earlier ambulation - reduced delirium (4)

a Grimes JP Am J Med 2002 112702-9 b Hoenig H Arch Int Med 1997 157513-20 c Orosz GM JAMA 2004291 1738-43 d Parker MJ J Bone Joint 5urg [Br] 199274203-5

93 yr old female admitted sp trip and fall accident at home around 2pm yesterday She was seen at a local hospital and transported to RIH for a right peri-prosthetic femur fracture

Available labs Hb 98mgdl Cr 098mgdl

EKG NSR rate of 85 bpm

No prior labsEKG in lifespan pt is a resident of Fall River MA

Per pt she recently had ldquocardiac surgeryrdquo and had angina 3 weeks ago

You are consulted by the Ortho trauma team to evaluate the patient for a possible second case this morning

Best done by the Revised Goldman Cardiac Risk Index (RCRI)

Most studied and Validated

Predictive value for cardiac complications and mortality significant in All types of non-cardiac surgery except AAA

Does Not Capture all-cause Mortality

1 point for each risk factor

1 High risk surgery (peritoneal thoracic supra inguinal vascular)

2 Hx of CAD

3 Hx of CHF

4 Hx of CVA

5 Hx of DM insulin dependent

6 Pre op Cr gt20mgdl

Lee et all circulation 1999 Auerbach circulation 2006

Risk Factors Rate 95 CI

No Risk Factors 04 01 ndash 08

One Risk Factor 10 05 ndash 14

Two Risk Factors 24 13 ndash 35

Three Risk Factors 54 28 ndash 79

Devereaux PJ Goldman L Cook DJ et al CMAJ 2005 173627

Risk Factors Rate Rate with Beta Blockers

None 04 ndash 10 lt 1

One to Two 22 ndash 66 08 ndash 16

Three or More gt 9 gt 3

Auerbach A Goldman L Circulation 2006 1131361

of risk factors determine the risk of major cardiac complication

A major cardiac complication is described as cardiac death and nonfatal MI cardiac arrest or ventricular fibrillation pulmonary edema and or complete heart block

Risk reduces with the use of BB

DELAY SURGERY

Unstable Coronary syndrome

Decompensated heart failure

Significant arrhythmia

Severe valvular heart disease

Sepsis

NO NEED TO DELAY SURGERY

Stable CAD

Ch Compensated left ventricular failure

Ch Kidney disease

UTI without sepsis

Delirium

Pre operative cardiac testing (echo stress testing) is unlikely to improve outcomes or change management for almost all geriatric fracture patients

Preoperative subspecialty consultation (eg cardiology) is rarely needed

Timely surgery and avoidance should be the primary goals

Relevant class 1 recommendation

Emergent surgery should proceed to OR focus on risk reduction perioperative surveillance and treatment

Active cardiac conditions should be treated and surgery still considered when stable

-ACS decompensated heart failure severe valvular disease and arrhythmias

Relevant class IIb guidelines

Noninvasive testing might be considered ldquoif it will change managementrdquo in patients with poor functional capacity (lt4 METs) and multiple risk factors undergoing intermediate risk surgery

Remember

Many frail geriatric fracture patients fall in this category

Echocardiography and or stress testing or angiography is very unlikely to change management This will only delay surgery and pt recovery

Continue if on BB at home

Start if pt is high risk (3 or more risk factors)

No need to start if pt is low risk (lt2 risk factors) as they may cause more harm then benefit

Use with holding parameters

AHA guidelines revised (2009)

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Most patients benefit from surgical stabilization of their fractures

The sooner patients have surgery the less time they have to develop iatrogenic illness

Goal is to have surgery ideally within 24 hours - less decubitii ( 1)

- reduce major medical complications ( 2) - decreased preoperative pain ( 3)

- decreased average LOS by 2 days ( 3)

- earlier ambulation - reduced delirium (4)

a Grimes JP Am J Med 2002 112702-9 b Hoenig H Arch Int Med 1997 157513-20 c Orosz GM JAMA 2004291 1738-43 d Parker MJ J Bone Joint 5urg [Br] 199274203-5

93 yr old female admitted sp trip and fall accident at home around 2pm yesterday She was seen at a local hospital and transported to RIH for a right peri-prosthetic femur fracture

Available labs Hb 98mgdl Cr 098mgdl

EKG NSR rate of 85 bpm

No prior labsEKG in lifespan pt is a resident of Fall River MA

Per pt she recently had ldquocardiac surgeryrdquo and had angina 3 weeks ago

You are consulted by the Ortho trauma team to evaluate the patient for a possible second case this morning

Best done by the Revised Goldman Cardiac Risk Index (RCRI)

Most studied and Validated

Predictive value for cardiac complications and mortality significant in All types of non-cardiac surgery except AAA

Does Not Capture all-cause Mortality

1 point for each risk factor

1 High risk surgery (peritoneal thoracic supra inguinal vascular)

2 Hx of CAD

3 Hx of CHF

4 Hx of CVA

5 Hx of DM insulin dependent

6 Pre op Cr gt20mgdl

Lee et all circulation 1999 Auerbach circulation 2006

Risk Factors Rate 95 CI

No Risk Factors 04 01 ndash 08

One Risk Factor 10 05 ndash 14

Two Risk Factors 24 13 ndash 35

Three Risk Factors 54 28 ndash 79

Devereaux PJ Goldman L Cook DJ et al CMAJ 2005 173627

Risk Factors Rate Rate with Beta Blockers

None 04 ndash 10 lt 1

One to Two 22 ndash 66 08 ndash 16

Three or More gt 9 gt 3

Auerbach A Goldman L Circulation 2006 1131361

of risk factors determine the risk of major cardiac complication

A major cardiac complication is described as cardiac death and nonfatal MI cardiac arrest or ventricular fibrillation pulmonary edema and or complete heart block

Risk reduces with the use of BB

DELAY SURGERY

Unstable Coronary syndrome

Decompensated heart failure

Significant arrhythmia

Severe valvular heart disease

Sepsis

NO NEED TO DELAY SURGERY

Stable CAD

Ch Compensated left ventricular failure

Ch Kidney disease

UTI without sepsis

Delirium

Pre operative cardiac testing (echo stress testing) is unlikely to improve outcomes or change management for almost all geriatric fracture patients

Preoperative subspecialty consultation (eg cardiology) is rarely needed

Timely surgery and avoidance should be the primary goals

Relevant class 1 recommendation

Emergent surgery should proceed to OR focus on risk reduction perioperative surveillance and treatment

Active cardiac conditions should be treated and surgery still considered when stable

-ACS decompensated heart failure severe valvular disease and arrhythmias

Relevant class IIb guidelines

Noninvasive testing might be considered ldquoif it will change managementrdquo in patients with poor functional capacity (lt4 METs) and multiple risk factors undergoing intermediate risk surgery

Remember

Many frail geriatric fracture patients fall in this category

Echocardiography and or stress testing or angiography is very unlikely to change management This will only delay surgery and pt recovery

Continue if on BB at home

Start if pt is high risk (3 or more risk factors)

No need to start if pt is low risk (lt2 risk factors) as they may cause more harm then benefit

Use with holding parameters

AHA guidelines revised (2009)

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

93 yr old female admitted sp trip and fall accident at home around 2pm yesterday She was seen at a local hospital and transported to RIH for a right peri-prosthetic femur fracture

Available labs Hb 98mgdl Cr 098mgdl

EKG NSR rate of 85 bpm

No prior labsEKG in lifespan pt is a resident of Fall River MA

Per pt she recently had ldquocardiac surgeryrdquo and had angina 3 weeks ago

You are consulted by the Ortho trauma team to evaluate the patient for a possible second case this morning

Best done by the Revised Goldman Cardiac Risk Index (RCRI)

Most studied and Validated

Predictive value for cardiac complications and mortality significant in All types of non-cardiac surgery except AAA

Does Not Capture all-cause Mortality

1 point for each risk factor

1 High risk surgery (peritoneal thoracic supra inguinal vascular)

2 Hx of CAD

3 Hx of CHF

4 Hx of CVA

5 Hx of DM insulin dependent

6 Pre op Cr gt20mgdl

Lee et all circulation 1999 Auerbach circulation 2006

Risk Factors Rate 95 CI

No Risk Factors 04 01 ndash 08

One Risk Factor 10 05 ndash 14

Two Risk Factors 24 13 ndash 35

Three Risk Factors 54 28 ndash 79

Devereaux PJ Goldman L Cook DJ et al CMAJ 2005 173627

Risk Factors Rate Rate with Beta Blockers

None 04 ndash 10 lt 1

One to Two 22 ndash 66 08 ndash 16

Three or More gt 9 gt 3

Auerbach A Goldman L Circulation 2006 1131361

of risk factors determine the risk of major cardiac complication

A major cardiac complication is described as cardiac death and nonfatal MI cardiac arrest or ventricular fibrillation pulmonary edema and or complete heart block

Risk reduces with the use of BB

DELAY SURGERY

Unstable Coronary syndrome

Decompensated heart failure

Significant arrhythmia

Severe valvular heart disease

Sepsis

NO NEED TO DELAY SURGERY

Stable CAD

Ch Compensated left ventricular failure

Ch Kidney disease

UTI without sepsis

Delirium

Pre operative cardiac testing (echo stress testing) is unlikely to improve outcomes or change management for almost all geriatric fracture patients

Preoperative subspecialty consultation (eg cardiology) is rarely needed

Timely surgery and avoidance should be the primary goals

Relevant class 1 recommendation

Emergent surgery should proceed to OR focus on risk reduction perioperative surveillance and treatment

Active cardiac conditions should be treated and surgery still considered when stable

-ACS decompensated heart failure severe valvular disease and arrhythmias

Relevant class IIb guidelines

Noninvasive testing might be considered ldquoif it will change managementrdquo in patients with poor functional capacity (lt4 METs) and multiple risk factors undergoing intermediate risk surgery

Remember

Many frail geriatric fracture patients fall in this category

Echocardiography and or stress testing or angiography is very unlikely to change management This will only delay surgery and pt recovery

Continue if on BB at home

Start if pt is high risk (3 or more risk factors)

No need to start if pt is low risk (lt2 risk factors) as they may cause more harm then benefit

Use with holding parameters

AHA guidelines revised (2009)

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

You are consulted by the Ortho trauma team to evaluate the patient for a possible second case this morning

Best done by the Revised Goldman Cardiac Risk Index (RCRI)

Most studied and Validated

Predictive value for cardiac complications and mortality significant in All types of non-cardiac surgery except AAA

Does Not Capture all-cause Mortality

1 point for each risk factor

1 High risk surgery (peritoneal thoracic supra inguinal vascular)

2 Hx of CAD

3 Hx of CHF

4 Hx of CVA

5 Hx of DM insulin dependent

6 Pre op Cr gt20mgdl

Lee et all circulation 1999 Auerbach circulation 2006

Risk Factors Rate 95 CI

No Risk Factors 04 01 ndash 08

One Risk Factor 10 05 ndash 14

Two Risk Factors 24 13 ndash 35

Three Risk Factors 54 28 ndash 79

Devereaux PJ Goldman L Cook DJ et al CMAJ 2005 173627

Risk Factors Rate Rate with Beta Blockers

None 04 ndash 10 lt 1

One to Two 22 ndash 66 08 ndash 16

Three or More gt 9 gt 3

Auerbach A Goldman L Circulation 2006 1131361

of risk factors determine the risk of major cardiac complication

A major cardiac complication is described as cardiac death and nonfatal MI cardiac arrest or ventricular fibrillation pulmonary edema and or complete heart block

Risk reduces with the use of BB

DELAY SURGERY

Unstable Coronary syndrome

Decompensated heart failure

Significant arrhythmia

Severe valvular heart disease

Sepsis

NO NEED TO DELAY SURGERY

Stable CAD

Ch Compensated left ventricular failure

Ch Kidney disease

UTI without sepsis

Delirium

Pre operative cardiac testing (echo stress testing) is unlikely to improve outcomes or change management for almost all geriatric fracture patients

Preoperative subspecialty consultation (eg cardiology) is rarely needed

Timely surgery and avoidance should be the primary goals

Relevant class 1 recommendation

Emergent surgery should proceed to OR focus on risk reduction perioperative surveillance and treatment

Active cardiac conditions should be treated and surgery still considered when stable

-ACS decompensated heart failure severe valvular disease and arrhythmias

Relevant class IIb guidelines

Noninvasive testing might be considered ldquoif it will change managementrdquo in patients with poor functional capacity (lt4 METs) and multiple risk factors undergoing intermediate risk surgery

Remember

Many frail geriatric fracture patients fall in this category

Echocardiography and or stress testing or angiography is very unlikely to change management This will only delay surgery and pt recovery

Continue if on BB at home

Start if pt is high risk (3 or more risk factors)

No need to start if pt is low risk (lt2 risk factors) as they may cause more harm then benefit

Use with holding parameters

AHA guidelines revised (2009)

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Best done by the Revised Goldman Cardiac Risk Index (RCRI)

Most studied and Validated

Predictive value for cardiac complications and mortality significant in All types of non-cardiac surgery except AAA

Does Not Capture all-cause Mortality

1 point for each risk factor

1 High risk surgery (peritoneal thoracic supra inguinal vascular)

2 Hx of CAD

3 Hx of CHF

4 Hx of CVA

5 Hx of DM insulin dependent

6 Pre op Cr gt20mgdl

Lee et all circulation 1999 Auerbach circulation 2006

Risk Factors Rate 95 CI

No Risk Factors 04 01 ndash 08

One Risk Factor 10 05 ndash 14

Two Risk Factors 24 13 ndash 35

Three Risk Factors 54 28 ndash 79

Devereaux PJ Goldman L Cook DJ et al CMAJ 2005 173627

Risk Factors Rate Rate with Beta Blockers

None 04 ndash 10 lt 1

One to Two 22 ndash 66 08 ndash 16

Three or More gt 9 gt 3

Auerbach A Goldman L Circulation 2006 1131361

of risk factors determine the risk of major cardiac complication

A major cardiac complication is described as cardiac death and nonfatal MI cardiac arrest or ventricular fibrillation pulmonary edema and or complete heart block

Risk reduces with the use of BB

DELAY SURGERY

Unstable Coronary syndrome

Decompensated heart failure

Significant arrhythmia

Severe valvular heart disease

Sepsis

NO NEED TO DELAY SURGERY

Stable CAD

Ch Compensated left ventricular failure

Ch Kidney disease

UTI without sepsis

Delirium

Pre operative cardiac testing (echo stress testing) is unlikely to improve outcomes or change management for almost all geriatric fracture patients

Preoperative subspecialty consultation (eg cardiology) is rarely needed

Timely surgery and avoidance should be the primary goals

Relevant class 1 recommendation

Emergent surgery should proceed to OR focus on risk reduction perioperative surveillance and treatment

Active cardiac conditions should be treated and surgery still considered when stable

-ACS decompensated heart failure severe valvular disease and arrhythmias

Relevant class IIb guidelines

Noninvasive testing might be considered ldquoif it will change managementrdquo in patients with poor functional capacity (lt4 METs) and multiple risk factors undergoing intermediate risk surgery

Remember

Many frail geriatric fracture patients fall in this category

Echocardiography and or stress testing or angiography is very unlikely to change management This will only delay surgery and pt recovery

Continue if on BB at home

Start if pt is high risk (3 or more risk factors)

No need to start if pt is low risk (lt2 risk factors) as they may cause more harm then benefit

Use with holding parameters

AHA guidelines revised (2009)

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

1 point for each risk factor

1 High risk surgery (peritoneal thoracic supra inguinal vascular)

2 Hx of CAD

3 Hx of CHF

4 Hx of CVA

5 Hx of DM insulin dependent

6 Pre op Cr gt20mgdl

Lee et all circulation 1999 Auerbach circulation 2006

Risk Factors Rate 95 CI

No Risk Factors 04 01 ndash 08

One Risk Factor 10 05 ndash 14

Two Risk Factors 24 13 ndash 35

Three Risk Factors 54 28 ndash 79

Devereaux PJ Goldman L Cook DJ et al CMAJ 2005 173627

Risk Factors Rate Rate with Beta Blockers

None 04 ndash 10 lt 1

One to Two 22 ndash 66 08 ndash 16

Three or More gt 9 gt 3

Auerbach A Goldman L Circulation 2006 1131361

of risk factors determine the risk of major cardiac complication

A major cardiac complication is described as cardiac death and nonfatal MI cardiac arrest or ventricular fibrillation pulmonary edema and or complete heart block

Risk reduces with the use of BB

DELAY SURGERY

Unstable Coronary syndrome

Decompensated heart failure

Significant arrhythmia

Severe valvular heart disease

Sepsis

NO NEED TO DELAY SURGERY

Stable CAD

Ch Compensated left ventricular failure

Ch Kidney disease

UTI without sepsis

Delirium

Pre operative cardiac testing (echo stress testing) is unlikely to improve outcomes or change management for almost all geriatric fracture patients

Preoperative subspecialty consultation (eg cardiology) is rarely needed

Timely surgery and avoidance should be the primary goals

Relevant class 1 recommendation

Emergent surgery should proceed to OR focus on risk reduction perioperative surveillance and treatment

Active cardiac conditions should be treated and surgery still considered when stable

-ACS decompensated heart failure severe valvular disease and arrhythmias

Relevant class IIb guidelines

Noninvasive testing might be considered ldquoif it will change managementrdquo in patients with poor functional capacity (lt4 METs) and multiple risk factors undergoing intermediate risk surgery

Remember

Many frail geriatric fracture patients fall in this category

Echocardiography and or stress testing or angiography is very unlikely to change management This will only delay surgery and pt recovery

Continue if on BB at home

Start if pt is high risk (3 or more risk factors)

No need to start if pt is low risk (lt2 risk factors) as they may cause more harm then benefit

Use with holding parameters

AHA guidelines revised (2009)

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Risk Factors Rate 95 CI

No Risk Factors 04 01 ndash 08

One Risk Factor 10 05 ndash 14

Two Risk Factors 24 13 ndash 35

Three Risk Factors 54 28 ndash 79

Devereaux PJ Goldman L Cook DJ et al CMAJ 2005 173627

Risk Factors Rate Rate with Beta Blockers

None 04 ndash 10 lt 1

One to Two 22 ndash 66 08 ndash 16

Three or More gt 9 gt 3

Auerbach A Goldman L Circulation 2006 1131361

of risk factors determine the risk of major cardiac complication

A major cardiac complication is described as cardiac death and nonfatal MI cardiac arrest or ventricular fibrillation pulmonary edema and or complete heart block

Risk reduces with the use of BB

DELAY SURGERY

Unstable Coronary syndrome

Decompensated heart failure

Significant arrhythmia

Severe valvular heart disease

Sepsis

NO NEED TO DELAY SURGERY

Stable CAD

Ch Compensated left ventricular failure

Ch Kidney disease

UTI without sepsis

Delirium

Pre operative cardiac testing (echo stress testing) is unlikely to improve outcomes or change management for almost all geriatric fracture patients

Preoperative subspecialty consultation (eg cardiology) is rarely needed

Timely surgery and avoidance should be the primary goals

Relevant class 1 recommendation

Emergent surgery should proceed to OR focus on risk reduction perioperative surveillance and treatment

Active cardiac conditions should be treated and surgery still considered when stable

-ACS decompensated heart failure severe valvular disease and arrhythmias

Relevant class IIb guidelines

Noninvasive testing might be considered ldquoif it will change managementrdquo in patients with poor functional capacity (lt4 METs) and multiple risk factors undergoing intermediate risk surgery

Remember

Many frail geriatric fracture patients fall in this category

Echocardiography and or stress testing or angiography is very unlikely to change management This will only delay surgery and pt recovery

Continue if on BB at home

Start if pt is high risk (3 or more risk factors)

No need to start if pt is low risk (lt2 risk factors) as they may cause more harm then benefit

Use with holding parameters

AHA guidelines revised (2009)

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Risk Factors Rate Rate with Beta Blockers

None 04 ndash 10 lt 1

One to Two 22 ndash 66 08 ndash 16

Three or More gt 9 gt 3

Auerbach A Goldman L Circulation 2006 1131361

of risk factors determine the risk of major cardiac complication

A major cardiac complication is described as cardiac death and nonfatal MI cardiac arrest or ventricular fibrillation pulmonary edema and or complete heart block

Risk reduces with the use of BB

DELAY SURGERY

Unstable Coronary syndrome

Decompensated heart failure

Significant arrhythmia

Severe valvular heart disease

Sepsis

NO NEED TO DELAY SURGERY

Stable CAD

Ch Compensated left ventricular failure

Ch Kidney disease

UTI without sepsis

Delirium

Pre operative cardiac testing (echo stress testing) is unlikely to improve outcomes or change management for almost all geriatric fracture patients

Preoperative subspecialty consultation (eg cardiology) is rarely needed

Timely surgery and avoidance should be the primary goals

Relevant class 1 recommendation

Emergent surgery should proceed to OR focus on risk reduction perioperative surveillance and treatment

Active cardiac conditions should be treated and surgery still considered when stable

-ACS decompensated heart failure severe valvular disease and arrhythmias

Relevant class IIb guidelines

Noninvasive testing might be considered ldquoif it will change managementrdquo in patients with poor functional capacity (lt4 METs) and multiple risk factors undergoing intermediate risk surgery

Remember

Many frail geriatric fracture patients fall in this category

Echocardiography and or stress testing or angiography is very unlikely to change management This will only delay surgery and pt recovery

Continue if on BB at home

Start if pt is high risk (3 or more risk factors)

No need to start if pt is low risk (lt2 risk factors) as they may cause more harm then benefit

Use with holding parameters

AHA guidelines revised (2009)

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

of risk factors determine the risk of major cardiac complication

A major cardiac complication is described as cardiac death and nonfatal MI cardiac arrest or ventricular fibrillation pulmonary edema and or complete heart block

Risk reduces with the use of BB

DELAY SURGERY

Unstable Coronary syndrome

Decompensated heart failure

Significant arrhythmia

Severe valvular heart disease

Sepsis

NO NEED TO DELAY SURGERY

Stable CAD

Ch Compensated left ventricular failure

Ch Kidney disease

UTI without sepsis

Delirium

Pre operative cardiac testing (echo stress testing) is unlikely to improve outcomes or change management for almost all geriatric fracture patients

Preoperative subspecialty consultation (eg cardiology) is rarely needed

Timely surgery and avoidance should be the primary goals

Relevant class 1 recommendation

Emergent surgery should proceed to OR focus on risk reduction perioperative surveillance and treatment

Active cardiac conditions should be treated and surgery still considered when stable

-ACS decompensated heart failure severe valvular disease and arrhythmias

Relevant class IIb guidelines

Noninvasive testing might be considered ldquoif it will change managementrdquo in patients with poor functional capacity (lt4 METs) and multiple risk factors undergoing intermediate risk surgery

Remember

Many frail geriatric fracture patients fall in this category

Echocardiography and or stress testing or angiography is very unlikely to change management This will only delay surgery and pt recovery

Continue if on BB at home

Start if pt is high risk (3 or more risk factors)

No need to start if pt is low risk (lt2 risk factors) as they may cause more harm then benefit

Use with holding parameters

AHA guidelines revised (2009)

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

DELAY SURGERY

Unstable Coronary syndrome

Decompensated heart failure

Significant arrhythmia

Severe valvular heart disease

Sepsis

NO NEED TO DELAY SURGERY

Stable CAD

Ch Compensated left ventricular failure

Ch Kidney disease

UTI without sepsis

Delirium

Pre operative cardiac testing (echo stress testing) is unlikely to improve outcomes or change management for almost all geriatric fracture patients

Preoperative subspecialty consultation (eg cardiology) is rarely needed

Timely surgery and avoidance should be the primary goals

Relevant class 1 recommendation

Emergent surgery should proceed to OR focus on risk reduction perioperative surveillance and treatment

Active cardiac conditions should be treated and surgery still considered when stable

-ACS decompensated heart failure severe valvular disease and arrhythmias

Relevant class IIb guidelines

Noninvasive testing might be considered ldquoif it will change managementrdquo in patients with poor functional capacity (lt4 METs) and multiple risk factors undergoing intermediate risk surgery

Remember

Many frail geriatric fracture patients fall in this category

Echocardiography and or stress testing or angiography is very unlikely to change management This will only delay surgery and pt recovery

Continue if on BB at home

Start if pt is high risk (3 or more risk factors)

No need to start if pt is low risk (lt2 risk factors) as they may cause more harm then benefit

Use with holding parameters

AHA guidelines revised (2009)

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Pre operative cardiac testing (echo stress testing) is unlikely to improve outcomes or change management for almost all geriatric fracture patients

Preoperative subspecialty consultation (eg cardiology) is rarely needed

Timely surgery and avoidance should be the primary goals

Relevant class 1 recommendation

Emergent surgery should proceed to OR focus on risk reduction perioperative surveillance and treatment

Active cardiac conditions should be treated and surgery still considered when stable

-ACS decompensated heart failure severe valvular disease and arrhythmias

Relevant class IIb guidelines

Noninvasive testing might be considered ldquoif it will change managementrdquo in patients with poor functional capacity (lt4 METs) and multiple risk factors undergoing intermediate risk surgery

Remember

Many frail geriatric fracture patients fall in this category

Echocardiography and or stress testing or angiography is very unlikely to change management This will only delay surgery and pt recovery

Continue if on BB at home

Start if pt is high risk (3 or more risk factors)

No need to start if pt is low risk (lt2 risk factors) as they may cause more harm then benefit

Use with holding parameters

AHA guidelines revised (2009)

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Relevant class 1 recommendation

Emergent surgery should proceed to OR focus on risk reduction perioperative surveillance and treatment

Active cardiac conditions should be treated and surgery still considered when stable

-ACS decompensated heart failure severe valvular disease and arrhythmias

Relevant class IIb guidelines

Noninvasive testing might be considered ldquoif it will change managementrdquo in patients with poor functional capacity (lt4 METs) and multiple risk factors undergoing intermediate risk surgery

Remember

Many frail geriatric fracture patients fall in this category

Echocardiography and or stress testing or angiography is very unlikely to change management This will only delay surgery and pt recovery

Continue if on BB at home

Start if pt is high risk (3 or more risk factors)

No need to start if pt is low risk (lt2 risk factors) as they may cause more harm then benefit

Use with holding parameters

AHA guidelines revised (2009)

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Relevant class IIb guidelines

Noninvasive testing might be considered ldquoif it will change managementrdquo in patients with poor functional capacity (lt4 METs) and multiple risk factors undergoing intermediate risk surgery

Remember

Many frail geriatric fracture patients fall in this category

Echocardiography and or stress testing or angiography is very unlikely to change management This will only delay surgery and pt recovery

Continue if on BB at home

Start if pt is high risk (3 or more risk factors)

No need to start if pt is low risk (lt2 risk factors) as they may cause more harm then benefit

Use with holding parameters

AHA guidelines revised (2009)

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Continue if on BB at home

Start if pt is high risk (3 or more risk factors)

No need to start if pt is low risk (lt2 risk factors) as they may cause more harm then benefit

Use with holding parameters

AHA guidelines revised (2009)

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Perioperative beta blockers reduced cardiovascular events but caused more strokes and higher mortality (POISE trail -2008)

Very high doses of BB were started in the pts not titrated up stopped only if systolic BP lt100 mm HG or HR lt50 bpm

Less aggressive titrated beta blockade may help reduce MI (DECREASE trial -2009)

Bisoprolol 25 mgs started 30 days prior to surgery

Non fatal MI decreased in BB group

No difference in strokes and overall mortality

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Aggressive intravascular volume restoration

Avoid medications that promote hypotension

Pain control

Rapid identification of any acute medical problems that may require pre operative treatment

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Intra operative hypotension is common

-anesthesia blood loss poor cardiovascular reserve

Intra operative hypotension is dangerous for elderly patients

-Can result in stroke MI AKI

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

-Keep preoperative Hb gt10mgdl

-IV hydration with isotonic fluids (saline ringer lactate)

-Fractures bleed a lot so assess vascular status

-Too much is better than too little

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Avoid most medications that promote hypotension

Routinely stop all blood pressure meds like ACE-I ARBS and diuretics

Stop oral hypoglycemic agents use ISS

If pt on insulin reduce dose to 13rd to prevent hypoglycemia

Stop clopidogrelwarfarin

Continue BP meds that are important for heart rate control like BB and CCB

Continue aspirin

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Pre operative pain control is essential

Pain causes tremendous adrenergic stress on elderly patients and can promote arrhythmias delirium and drain energy reserves

Strategies for optimization

IV acetaminophen (three doses can be ordered)

IV opiates (morphine 2-4 mgs IV or hydromorphone 05 mg IV)

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Warfarin is a vitamin K antagonist with a long

half life

Common uses

-Cardiac arrhythmias valvular heart disease

thrombus MI

-Cerebrovascular stroke TIA

-Thromboembolic disease DVTPE

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Goal for surgery INR lt15

Treatment options

- Vitamin K oralIVSub Q

- Fresh Frozen Plasma IV

- Waiting

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Route of administration reaching target in 24 hrs

placebo 20

Sub Q 31

IV 77

PO 82

Dezze KJ et al Arch Internal Medicine 2006 166391

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

10-15 mlKg

1 unit= 190 ndash 240 ml

Lasts only for 6 hours

EG a 70 Kg person needs between 700-1050 ml of FFPs which comes to about 4 units of FFP

Use in pts who have active thromboembolism in which INR reversal is contraindicated

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Is not an option

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Restart 12- 24 hrs after surgery

INR goal (ACCP) 2-3

Takes 3-4 days to reach target levels

Bridge based on individual cases

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Typical goal INR is between 25 and 35

High risk of thrombosis with Mitral heart valves

Typically bridge with heparin drip

Preferred over therapeutic LVX

Hold drip usually 4-6 hours pre-operatively

Recommended to restart heparin drip after hemostasis achieved (12 ndash 24 hrs)

Can consult cardiology if have additional questions

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

68 yr old male admitted directly from the airport after a trip and fall accident on a road in St Martin where he was vacationing

Past Hx DCM AFIB now sp cardio version severe MR sp St Jude valve replacement HTN HLD PTSD GERD neuropathy

PAST SURGICAL HX MVR in 1995 Biventricular ICD placement 2012

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Labs on admission 128 Na 133 Cr 19 BUN 113342 HbHCT 34 INR

EKG atrial sensed- ventricular paced rhythm

You are consulted by Ortho to ldquoclearrdquo the patient for surgery hellip

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

For anticoagulation

Reversal of AC in this patient

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Pt received Vitamin K 10 mg PO x 1

Repeat INR in 8 hours was 34

Pt received another dose of Vitamin K 10 mg

Repeat INR was 22

Started on IV heparin and taken for surgery the next day with FFPs to help control intra operative bleeding

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

-Antiplatelet irreversibly binds to ADP receptors inhibiting platelet activation and aggregation

-No treatment options (no reversal)

-Shall we delay surgery

-For how long

PrasugrelEffient -Shall we delay surgery

-For how long

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

The ACCP 2012 guidelines state that LMWH Coumadin Fundoparinox UFH and Aspirin may be used for VTE prophylaxis

LMWH is preferred (lovenox)

Cr Cl lt30 mlmin Lovenox 30 mg sc daily (instead of standard dosing (30mg BID)

If ASA is used it should be dosed 325mg twice daily versus once daily

Indications for ASA are contraindications to LVX and heparin

Not just meds prompt surgery early weight bearing avoiding restraints delirium prevention and treating pain

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

Statins reduce perioperative adverse cardiovascular events NNT 131 2

Do not stop them abruptly as it increases risk of cardiovascular events 3 4

i Schouten (2009) N Engl J Med 361(10) 980-89

ii Poldermans (2003) Circulation 1071848-51

iii Le Manach (2007) Anesth Analg 104(6) 1326-33

iv Schouten (2007) Am J Cardiol 100(2) 316-20

68 across all non cardiac surgeries

14-15 in pts gt 65 yrs of age

Most common risk factors

Age gt 60 yrs frail pts with + weight loss

COPD OSA current smokers ASA class II

Functional dependence etc

Prevention Aggressive Intensive Spirometry in pre amp post operative period OOB status deep breathing exercises adequate pain control

Adequate preoperative hydration is essential

Rate control and thoughtful beta blockade

Review and adjust pre op meds

Avoid perioperative hypotension

Tolerate a risk for pulmonary edema more manageable than hypotension and its consequences

Tolerate preoperative hypertension

Avoid over testing and over consultation

ER calls you at 11 pm for evaluation of a 93 yr old female sp fall at home She is transferred from an OSH for Rt periprosthetic femur fracture

Available labs Hb 98 Cr 098mgdl

EKG NSR rate of 85 bpm

AVSS

No prior labsEKG for comparison in lifespan as pt is from Fall River MA

Per pt she had ldquocardiac surgeryrdquo a few months ago

You are the on call Ortho resident and have to admit this patient

Which medications from her home meds will you continue

Atenolol 125 mg po bid

Furosemide 40 mg po bid

Simvastatin 20 mg po qhs

Aspirin 81 mgs po daily

Plavix 75 mg po daily

Quetiaprine 75 mg po qhs

Adequate preoperative hydration is essential

Rate control and thoughtful beta blockade

Review and adjust pre op meds

Avoid perioperative hypotension

Tolerate a risk for pulmonary edema more manageable than hypotension and its consequences

Tolerate preoperative hypertension

Avoid over testing and over consultation

ER calls you at 11 pm for evaluation of a 93 yr old female sp fall at home She is transferred from an OSH for Rt periprosthetic femur fracture

Available labs Hb 98 Cr 098mgdl

EKG NSR rate of 85 bpm

AVSS

No prior labsEKG for comparison in lifespan as pt is from Fall River MA

Per pt she had ldquocardiac surgeryrdquo a few months ago

You are the on call Ortho resident and have to admit this patient

Which medications from her home meds will you continue

Atenolol 125 mg po bid

Furosemide 40 mg po bid

Simvastatin 20 mg po qhs

Aspirin 81 mgs po daily

Plavix 75 mg po daily

Quetiaprine 75 mg po qhs

ER calls you at 11 pm for evaluation of a 93 yr old female sp fall at home She is transferred from an OSH for Rt periprosthetic femur fracture

Available labs Hb 98 Cr 098mgdl

EKG NSR rate of 85 bpm

AVSS

No prior labsEKG for comparison in lifespan as pt is from Fall River MA

Per pt she had ldquocardiac surgeryrdquo a few months ago

You are the on call Ortho resident and have to admit this patient

Which medications from her home meds will you continue

Atenolol 125 mg po bid

Furosemide 40 mg po bid

Simvastatin 20 mg po qhs

Aspirin 81 mgs po daily

Plavix 75 mg po daily

Quetiaprine 75 mg po qhs

You are the on call Ortho resident and have to admit this patient

Which medications from her home meds will you continue

Atenolol 125 mg po bid

Furosemide 40 mg po bid

Simvastatin 20 mg po qhs

Aspirin 81 mgs po daily

Plavix 75 mg po daily

Quetiaprine 75 mg po qhs

Atenolol 125 mg po bid

Furosemide 40 mg po bid

Simvastatin 20 mg po qhs

Aspirin 81 mgs po daily

Plavix 75 mg po daily

Quetiaprine 75 mg po qhs