-
Mayo Clinic Proceedings Dec 2020Venous thromboembolism (VTE) is a preventable cause of postoperative morbidity and mortality; however, audits suggest that the use of thromboprophylaxis is underused. In... (Review)
Review
Venous thromboembolism (VTE) is a preventable cause of postoperative morbidity and mortality; however, audits suggest that the use of thromboprophylaxis is underused. In this review, we describe our approach to prevention of postoperative VTE and provide guidance on how to formulate an optimal VTE prophylaxis plan. We recommend that all patients undergo thrombosis- and bleeding-risk assessment as part of their preoperative evaluation. The risk of thrombosis can be estimated based on patient- and procedure-specific factors, using validated risk-assessment models such as the Caprini score. There are no validated models to predict perioperative bleeding; however, several risk factors have been proposed. Patients should ambulate early and frequently after surgery. We recommend no additional prophylaxis in patients at very low risk of VTE (Caprini score 0). Patients at low risk of VTE (Caprini 1 to 2) are recommended to receive either mechanical or pharmacological prophylaxis. Patients at moderate (Caprini 3 to 4) to high risk of VTE (Caprini ≥5) are recommended pharmacological prophylaxis either alone or combined with mechanical prophylaxis. Patients at high risk of bleeding should receive mechanical prophylaxis until their risk of bleeding is reduced and pharmacological prophylaxis can be reconsidered. Populations for which the Caprini score has not been validated (such as orthopedic surgery) are recommended prophylaxis based on individual and procedure-specific risk factors. Prophylaxis is typically continued until the patient is ambulatory or until hospital dismissal; however, longer durations can be considered in certain circumstances (high-risk patients undergoing malignant abdominopelvic operations, bariatric operations, and certain orthopedic operations).
Topics: Chemoprevention; Humans; Postoperative Complications; Preoperative Care; Risk Adjustment; Risk Assessment; Surgical Procedures, Operative; Venous Thromboembolism
PubMed: 33276846
DOI: 10.1016/j.mayocp.2020.06.015 -
Cardiology Clinics Feb 2021Valvular heart disease (VHD) is generally well tolerated during pregnancy; however, the dramatic changes in hemodynamics that occur during pregnancy can lead to clinical... (Review)
Review
Valvular heart disease (VHD) is generally well tolerated during pregnancy; however, the dramatic changes in hemodynamics that occur during pregnancy can lead to clinical decompensation in high-risk women. Women with VHD considering pregnancy should undergo preconception counseling with a high-risk obstetrician and cardiologist to review the maternal, fetal, and obstetric risks of pregnancy and delivery. Vaginal delivery is recommended for most women with VHD. Given the complexity of managing VHD during pregnancy, women should be managed by a multidisciplinary Pregnancy Heart Team during pregnancy, consisting of a high-risk obstetrician, cardiologist, and cardiac anesthesiologist.
Topics: Female; Heart Failure; Heart Valve Diseases; Hemodynamics; Humans; Pregnancy; Pregnancy Complications, Cardiovascular; Prognosis; Risk Adjustment; Risk Assessment
PubMed: 33222810
DOI: 10.1016/j.ccl.2020.09.010 -
Postgraduate Medical Journal Jul 2021Many drug therapies are associated with prolongation of the QT interval. This may increase the risk of Torsades de Pointes (TdP), a potentially life-threatening cardiac... (Review)
Review
Many drug therapies are associated with prolongation of the QT interval. This may increase the risk of Torsades de Pointes (TdP), a potentially life-threatening cardiac arrhythmia. As the QT interval varies with a change in heart rate, various formulae can adjust for this, producing a 'corrected QT' (QTc) value. Normal QTc intervals are typically <450 ms for men and <460 ms for women. For every 10 ms increase, there is a ~5% increase in the risk of arrhythmic events. When prescribing drugs associated with QT prolongation, three key factors should be considered: patient-related risk factors (eg, female sex, age >65 years, uncorrected electrolyte disturbances); the potential risk and degree of QT prolongation associated with the proposed drug; and co-prescribed medicines that could increase the risk of QT prolongation. To support clinicians, who are likely to prescribe such medicines in their daily practice, we developed a simple algorithm to help guide clinical management in patients who are at risk of QT prolongation/TdP, those exposed to QT-prolonging medication or have QT prolongation.
Topics: Humans; Long QT Syndrome; Patient Care Management; Practice Patterns, Physicians'; Risk Adjustment; Torsades de Pointes
PubMed: 33122341
DOI: 10.1136/postgradmedj-2020-138661 -
Mayo Clinic Proceedings Dec 2020Evaluation of endocrine issues is a sometimes overlooked yet important component of the preoperative medical evaluation. Patients with diabetes, thyroid disease, and... (Review)
Review
Evaluation of endocrine issues is a sometimes overlooked yet important component of the preoperative medical evaluation. Patients with diabetes, thyroid disease, and hypothalamic-pituitary-adrenal axis suppression are commonly encountered in the surgical setting and require unique consideration to optimize perioperative risk. For patients with diabetes, perioperative glycemic control has the strongest association with postsurgical outcomes. The preoperative evaluation should include recommendations for adjustment of insulin and noninsulin diabetic medications before surgery. Recommendations differ based on the type of diabetes, the type of insulin, and the patient's predisposition to hyperglycemia or hypoglycemia. Generally, patients with thyroid dysfunction can safely undergo operations unless they have untreated hyperthyroidism or severe hypothyroidism. Patients with known primary or secondary adrenal insufficiency require supplemental glucocorticoids to prevent adrenal crisis in the perioperative setting. Evidence supporting the use of high-dose supplemental corticosteroids for patients undergoing long-term glucocorticoid therapy is sparse. We discuss an approach to these patients based on the dose and duration of ongoing or recent corticosteroid therapy. As with other components of the preoperative medical evaluation, the primary objective is identification and assessment of the severity of endocrine issues before surgery so that the surgeons, anesthesiologists, and internal medicine professionals can optimize management accordingly.
Topics: Diagnostic Techniques, Endocrine; Endocrine System Diseases; Humans; Preoperative Care; Risk Adjustment; Surgical Procedures, Operative
PubMed: 33168157
DOI: 10.1016/j.mayocp.2020.05.004 -
Clinics in Geriatric Medicine Feb 2019As more patients live longer, it is probable that an increasing number of geriatric patients will require surgery. An organized, systematic, coordinated,... (Review)
Review
As more patients live longer, it is probable that an increasing number of geriatric patients will require surgery. An organized, systematic, coordinated, multidisciplinary approach to the perioperative management of these patients will result in fewer complications, improved outcomes, and reduced cost of care. Details are herein provided on the preoperative diagnostic evaluation and assessment as well as perioperative care provided to optimize outcomes. The diagnosis, workup, and treatment of osteoporosis and fragility fractures are presented. The article concludes with a review of the care of the geriatric orthopedic patient in the posthospital time period.
Topics: Aged; Geriatric Assessment; Hip Fractures; Humans; Orthopedics; Osteoporotic Fractures; Patient Care Team; Perioperative Care; Risk Adjustment
PubMed: 30390985
DOI: 10.1016/j.cger.2018.08.007 -
Obstetrics and Gynecology Clinics of... Dec 2017Induction of labor is a common procedure undertaken whenever the benefits of prompt delivery outweigh the risks of expectant management. Cervical assessment is essential... (Review)
Review
Induction of labor is a common procedure undertaken whenever the benefits of prompt delivery outweigh the risks of expectant management. Cervical assessment is essential to determine the optimal approach. Indication for induction, clinical presentation and history, safety, cost, and patient preference may factor into the selection of methods. For the unfavorable cervix, several pharmacologic and mechanical methods are available, each with associated advantages and disadvantages. In women with a favorable cervix, combined use of amniotomy and intravenous oxytocin is generally the most effective approach. The goal of labor induction is to ensure the best possible outcome for mother and newborn.
Topics: Female; Humans; Labor, Induced; Pregnancy; Risk Adjustment; Safety Management; Trial of Labor
PubMed: 29078939
DOI: 10.1016/j.ogc.2017.08.011 -
The Canadian Journal of Cardiology Dec 2020The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as...
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
Topics: Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Canada; Cardiovascular Diseases; Catheter Ablation; Female; Heart Disease Risk Factors; Hemorrhage; Humans; Male; Middle Aged; Patient Care Management; Prevalence; Risk Adjustment; Societies, Medical; Stroke
PubMed: 33191198
DOI: 10.1016/j.cjca.2020.09.001 -
Expert Review of Pharmacoeconomics &... 2015By 2018, Medicare payments will be tied to quality of care. The Centers for Medicare and Medicaid Services currently use quality-based metric for some reimbursements...
By 2018, Medicare payments will be tied to quality of care. The Centers for Medicare and Medicaid Services currently use quality-based metric for some reimbursements through their different programs. Existing and future quality metrics will rely on risk adjustment to avoid unfairly punishing those who see the sickest, highest-risk patients. Despite the limitations of the data used for risk adjustment, there are potential solutions to improve the accuracy of these codes by calibrating data by merging databases and compiling information collected for multiple reporting programs to improve accuracy. In addition, healthcare staff should be informed about the importance of risk adjustment for quality of care assessment and reimbursement. As the number of encounters tied to value-based reimbursements increases in inpatient and outpatient care, coupled with accurate data collection and utilization, the methods used for risk adjustment could be expanded to better account for differences in the care delivered in diverse settings.
Topics: Centers for Medicare and Medicaid Services, U.S.; Data Collection; Delivery of Health Care; Humans; Medicare; Quality of Health Care; Reimbursement Mechanisms; Risk Adjustment; United States
PubMed: 26313120
DOI: 10.1586/14737167.2015.1083864 -
Heart (British Cardiac Society) Sep 2018
Review
Topics: Anticoagulants; Blood Loss, Surgical; Humans; Medication Therapy Management; Perioperative Care; Postoperative Hemorrhage; Risk Adjustment; Surgical Procedures, Operative
PubMed: 29217632
DOI: 10.1136/heartjnl-2016-310581 -
American Family Physician Jul 2020Millions of units of blood products are transfused annually to patients in the United States. Red blood cells are transfused to improve oxygen-carrying capacity in...
Millions of units of blood products are transfused annually to patients in the United States. Red blood cells are transfused to improve oxygen-carrying capacity in patients with or at high risk of developing symptomatic anemia. Restrictive transfusion thresholds with lower hemoglobin levels are typically clinically equivalent to more liberal thresholds. Transfusion of plasma corrects clinically significant coagulopathy in patients with or at high risk of bleeding. Mildly abnormal laboratory coagulation values are not predictive of clinical bleeding and should not be corrected with plasma. Transfused platelets prevent or treat bleeding in patients with thrombocytopenia or platelet dysfunction. Cryoprecipitate is transfused to treat hypofibrinogenemia. Many adverse reactions can occur during or after blood product transfusion. Transfusion-associated circulatory overload (i.e., volume overload) is the most common cause of mortality associated with blood products. Modifications to blood products can prevent or decrease the risks of transfusion-related adverse reactions. It is critical to quickly recognize when a reaction is occurring, stop the transfusion, assess, and support the patient. Reporting a reaction to the blood bank is part of ensuring patient safety and supporting hemovigilance efforts.
Topics: Blood Component Transfusion; Hematologic Diseases; Humans; Patient Safety; Practice Guidelines as Topic; Risk Adjustment; Risk Assessment; Transfusion Reaction
PubMed: 32603068
DOI: No ID Found