PREOPERATIVE ASSESSMENT & PERIOPERATIVE CARE: DVT, Delirium and More
Developed by UNMC Department of Anesthesia and Division of Geriatrics, Department of Internal Medicine
Tyler Hartley M4
Upon completion of this module, the learner will be able to:
- Describe DVT/PE prophylaxis strategies that are available, indications and medications used.
- Describe when to use mechanical methods versus anticoagulants in surgical patients.
- Describe deliriums influence on morbidity and mortality.
- Describe the management of delirium through modification of risk factors.
- Describe the effect of frailty on elderly surgical patient outcomes.
|Incidence and mortality of Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE) in surgical patients.|
|General Surgery||Other Surgeries*||All Surgeries|
|DVT||20-30% incidence||~ 40% incidence|
Up to 38% of postoperative deaths from pulmonary causes are due to pulmonary emboli.
- Prevention begins with entry of the patient into the hospital and involves all admitting orders. At the very least post-operative orders should address this issue for dosage and type of therapy.
- The most effective tool in prevention is DVT prophylaxis. This chart has been included on the pearl card to assist you in this management. The following paragraphs will explain the recommendations.
- DVT prophylaxis is critical and has been around for years. This is a current review of the recommendations that I will walk you through.
- Common errors in care are: not getting heparin started either preoperatively or immediately postoperatively, and if using Coumadin, to not getting to an INR goal of 2-3 and maintaining this until patient is active and out of the surgical induced risk area for thrombosis and DVT.
|DVT/PE Prophylaxis Strategies in Older Medical and Surgical Inpatients|
|DVT/PE Risk||Surgery Type or Medical Condition||Thromboprophylactic Options|
Healthy and mobile patients undergoing minor surgery
Aggressive early ambulation after procedure +/- intermittent pneumatic compression
Immobile (>72hr) patients
*Antithrombotic +/- intermittent pneumatic compression
See table below
* Note: Antithrombotics refer to antiplatelet, VK antagonists, heparin, LMWH, heparinoid, Factor Xa inhibitors, Direct thrombin inhibitors.
|Antithrombotic Medications for VTE Prophylaxis|
|Indication||Antiplatelet||VK Antagonist||Heparin||LMWH||Heparinoid||Factor Xa inhibitor||Direct Thrombin Inhibitor|
|Medical inpatients at moderate-high risk or VTE; patients with acute stroke of spinal cord injury||-----||-----||UFH*||Enoxaparin*
|Knee or hip replacement||ASA||Warfarin*||UFH||Enoxaparin*||Danaproid||Fondaparinux
|Nonorthopedic surgery patients at moderate-high risk of VTE||ASA||Warfarin*||UFH||Enoxaparin*
*Notes: First choice(s) in bold text; secondary or alternative choice(s) in regular text; LMWH = low-molecular weight heparin; UFH = unfractionated heparin; VK = vitamin K; VTE = venous thromboembolism (DVT/PE)
- 75-325mg/d for prophylaxis
- What about patients who are already on warfarin (Coumadin)?
- With NO history venous thromboembolism (VTE) for more than 12 mo. or atrial fibrillation (AF) without prior TIA/CVA
- Can be safely held for five days pre-op
- Restart evening after surgery at usual dose
- But if has had VTE within the last 12 mo. or has recurrent VTE, or active cancer or AF with multiple CVA risk factors or TIA/CVA within the last 3 mo. or has mech. cardiac valve
- Stop warfarin five days preop.
- Begin LMWH three days preop.
- Give last dose LMWH at ½ usual dose 24 hr preop.
- Start LMWH 24 hours after surgery
- This is THE traditional heparin. It is recommended to give 5000 U subcutaneous 2 hours pre-operatively (check with the surgeon first before giving) and q8 hours after that.
- Most regimes are continued until patient is fully ambulatory. This technique does not require laboratory monitoring.
- These products include: dalteparin (Fragmin) or enoxaparin (Lovenox)
- Enoxaparin – 30mg SC q12hrs or 40mg SC q24hrs
- Daltepain – 2500-5000 U SC Preop and Postop once daily (varies for procedure)
- Danaparoid (Orgaran)
- Hip Replacement, hip fracture surgery
- 750 anti-Xa U SC twice daily
- Rivaroxaban (Xarelto)
- 10mg/d po, begin 6-10 hrs after surgery
- Fondaparinux (Arixtra)
- 2.5 mg SC once daily beginning 6-8hrs postop
- Dagibatrin (Pradaxa)
- 150mg po q12hrs
- Desirudin (Iprivask)
- 15mg SC w 12hrs starting 5-15min before surgery
- Delirium has a significant impact on post-op morbidity and mortality.
- To prevent delirium the clinician must address:
- prolonged hospital stay
- increased incidence of nursing home placement
- loss of independence post surgery
- long term physical and cognitive effect
- Delirium: 1 month = 14% 6 months = 22%
- Controls: 1 months = 5% 6 months = 10%
- Delirium occurs in 15-50% of all surgeries performed.
|Total knee arthroplasty or hip surgery||61%|
Gani H, et el, The incidence of postoperative delirium in elderly patients after urologic surgery. 2013;67.
Steve M.M. de Castro, et el, Incidence and risk factors of delirium in the elderly general surgical patient, The American Journal of Surgery, Volume 208, Issue 1, July 2014, Pages 26-32
Pearl of Wisdom
- Forewarn the family that delirium will likely occur despite everyone's best efforts.
- Ask them to assist in prevention by being present as much as possible to "sit" with the patient and provide a "familiar face." This forewarning also prepares the family and reduces their anxiety when delirium occurs.
Insomnia Induced Delirium
- 3 potential causes
- Pain: Is the patient’s pain well controlled? If not readjust medications, avoiding narcotics if possible
- Alcohol or benzodiazepine withdrawal: Consider benzodiazepines (lorazepam 0.5-2mg IV q30-60min prn) and thiamine 100mg/d
- Other: Antipsychotics - consider haloperidol (0.5-1mg po or IV)and/or quetiapine (25-50mg q12hrs)
- Frailty is a measure of the older adult’s physiologic reserves and has been used to predict perioperative outcomes.
- Frail surgical patients have significantly longer length of hospital stay and increased risk of being discharged to a nursing home
Shrinking (weight loss)
>10 pound weight loss during previous year
Weakness (grip strength)
Lowest 20th percentile measured by hand-held dynamometer
Feeling "I can't get going" or "everything is an effort" 3 or more days per week
Kilocalorie expenditure less than 20th percentile for gender
Lowest 20th percentile walking 15 feet at normal pace
Each criteria is scored with a 0 or a 1. Intermediately frail was defined by meeting 2-3 criteria, while frail patients were defined by meeting 4-5 frailty criteria.
Frail patients (4-5 criteria) have a 2.54-times higher odds of complications when compared with nonfrail patients postoperatively.
- DVTs are best managed prophylactically.
- Always write orders for DVT prophylaxis on all elderly patients.
- Delirium has many risk factors and therefore many treatment options.
- Frailty can be measured and may be used as a predictor of surgical outcomes.