Perioperative Medicine Summit

SCOTTSDALE, ARIZ. – When it comes to holding or continuing with ACE inhibitors before surgery, all bets are off, a perioperative medicine consultant suggested.

Patients on angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARB) have about a 50% risk of developing hypotension during surgery, and a significant proportion of those episodes could be severe, said Dr. Paul Grant, of the University of Michigan Health System in Ann Arbor.

"I recommend having some sort of standard approach [to perioperative ACE inhibitor use] at your institution if that’s at all possible, either for a certain surgery type or across the board," he said at a meeting on perioperative medicine sponsored by the University of Miami.

Evidence from a small number of randomized trials and observational studies suggests that continuing ACE inhibitors during cardiac surgery may result in less cardiac enzyme release, less kidney injury, and a lower incidence of atrial fibrillation. In vascular surgery, evidence suggests that patients on ACE inhibitors who are undergoing surgery have less of a drop in cardiac output and may have improved creatinine clearance.

On the other hand, patients who remain on ACE inhibitors during surgery can experience a "profound" drop in blood pressure requiring immediate intervention, he said.

Data to support the continue vs. hold debate are sparse, but include a trial of 51 patients randomized to continue ACE inhibitors on the day of surgery or to have the drugs held for 12-24 hours before surgery. In all, 33 of the patients were on captopril (Capoten), and 18 were on enalapril (Vasotec).

The investigators found that among patients randomized to continue ACE inhibitor therapy, 7 of 7 on captopril and 9 of 14 on enalapril developed hypotension, defined as a systolic blood pressure (SBP) less than 90 mm Hg. In contrast, among patients assigned to the ACE-inhibitor hold protocol, only 2 of 11 on captopril and 4 of 19 on enalapril developed hypotension during surgery.

In a second randomized trial, investigators looked at 37 patients on an ARB who were randomly assigned to either discontinue ARB on the day before surgery (18 patients), or to receive their ARB 1 hour before anesthesia induction (19 patients).

The authors defined hypotension for their study as an SBP less than 80 mm Hg for more than 1 minute. They found that all 19 patients who continued on ARB had hypotension during surgery, compared with 12 of 18 who discontinued their ARB the day before. Patients who received their ARB on the day of surgery used significantly more vasoactive drugs. Despite the discontinuation of the ARB, there were no differences in hypertension between the groups in the recovery period. Postoperative cardiac complications occurred in 1 patient in each group.

In the final randomized study that Dr. Grant cited, 40 patients on an ACE inhibitor with good left-ventricular function were scheduled to undergo coronary artery bypass graft (CABG). They were randomly assigned to hold or continue on ACE inhibitors on the day of surgery.

Patients in whom the ACE inhibitors were held before CABG had higher mean blood pressures than patients who continued on the drugs, and they used less vasopressor during the surgery. In contrast, patients who continued on ACE inhibitors needed more vasodilators after CABG and in the recovery period. The authors of this trial did not study other clinical endpoints, Dr. Grant noted.

Evidence from two observational studies was more equivocal, however.

In a retrospective observational study, investigators studied the relationship between the timing of discontinuing ACE inhibitors and angiotensin II receptor subtype 1 antagonists (ARA) and the onset of hypotension in 267 patients scheduled for general surgery.

They found that patients exposed to an ACE inhibitor or ARA within 10 hours of anesthesia had an adjusted odds ratio of 1.74 for moderate hypotension (SBP 85 mm Hg or less; P = .04), but there was no difference in severe hypotension between these patients and those who discontinued the drugs more than 10 hours before surgery. There were no differences in either vasopressor use or postoperative complications, including unplanned intensive care unit stay, myocardial infarction, stroke, renal impairment, or death.

A second, smaller study compared 12 vascular surgery patients on ARB the day of surgery with matched cohorts of patients taking beta-blockers and/or calcium channel blockers the day of surgery, or ACE inhibitors held on the day of surgery.

Hypotension (SBP less than 90 mm Hg in this study) occurred in all of the patients on ARB but in only 60% (27 of 45) patients on the beta-blocker/calcium channel blockers, and in 67% (18 of 27) in the ACE-inhibitor hold cohort. The ARB patients were also less responsive to ephedrine and phenylephrine than other patients, and in some cases responded only to a vasopressin system agonist, Dr. Grant noted.

Finally, the authors of a random-effects meta-analysis of five studies with a total of 434 patients reported that patients receiving an immediate preoperative ACE inhibitor or ARA dose had a relative risk of 1.50 for developing hypotension requiring vasopressors at or shortly after induction of anesthesia, compared with patients who did not receive the drugs.

Dr. Grant noted that the American College of Physicians’ Smart Medicine guidelines on perioperative management of hypertensive patients recommend continuing ACE inhibitors "with caution," and they advise clinicians to avoid hypovolemia in patients maintained on ACE inhibitors during surgery. He said that in certain cases, it may be appropriate to continue surgical patients on ACE inhibitors or ARB, as in patients with hypertension that is difficult to control with multiple medications, or in those with severe heart disease who have adequate blood pressure.

Dr. Grant reported having no financial disclosures.

SCOTTSDALE, ARIZ. – When it comes to holding or continuing with ACE inhibitors before surgery, all bets are off, a perioperative medicine consultant suggested.

Patients on angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARB) have about a 50% risk of developing hypotension during surgery, and a significant proportion of those episodes could be severe, said Dr. Paul Grant, of the University of Michigan Health System in Ann Arbor.

"I recommend having some sort of standard approach [to perioperative ACE inhibitor use] at your institution if that’s at all possible, either for a certain surgery type or across the board," he said at a meeting on perioperative medicine sponsored by the University of Miami.

Evidence from a small number of randomized trials and observational studies suggests that continuing ACE inhibitors during cardiac surgery may result in less cardiac enzyme release, less kidney injury, and a lower incidence of atrial fibrillation. In vascular surgery, evidence suggests that patients on ACE inhibitors who are undergoing surgery have less of a drop in cardiac output and may have improved creatinine clearance.

On the other hand, patients who remain on ACE inhibitors during surgery can experience a "profound" drop in blood pressure requiring immediate intervention, he said.

Data to support the continue vs. hold debate are sparse, but include a trial of 51 patients randomized to continue ACE inhibitors on the day of surgery or to have the drugs held for 12-24 hours before surgery. In all, 33 of the patients were on captopril (Capoten), and 18 were on enalapril (Vasotec).

The investigators found that among patients randomized to continue ACE inhibitor therapy, 7 of 7 on captopril and 9 of 14 on enalapril developed hypotension, defined as a systolic blood pressure (SBP) less than 90 mm Hg. In contrast, among patients assigned to the ACE-inhibitor hold protocol, only 2 of 11 on captopril and 4 of 19 on enalapril developed hypotension during surgery.

In a second randomized trial, investigators looked at 37 patients on an ARB who were randomly assigned to either discontinue ARB on the day before surgery (18 patients), or to receive their ARB 1 hour before anesthesia induction (19 patients).

The authors defined hypotension for their study as an SBP less than 80 mm Hg for more than 1 minute. They found that all 19 patients who continued on ARB had hypotension during surgery, compared with 12 of 18 who discontinued their ARB the day before. Patients who received their ARB on the day of surgery used significantly more vasoactive drugs. Despite the discontinuation of the ARB, there were no differences in hypertension between the groups in the recovery period. Postoperative cardiac complications occurred in 1 patient in each group.

In the final randomized study that Dr. Grant cited, 40 patients on an ACE inhibitor with good left-ventricular function were scheduled to undergo coronary artery bypass graft (CABG). They were randomly assigned to hold or continue on ACE inhibitors on the day of surgery.

Patients in whom the ACE inhibitors were held before CABG had higher mean blood pressures than patients who continued on the drugs, and they used less vasopressor during the surgery. In contrast, patients who continued on ACE inhibitors needed more vasodilators after CABG and in the recovery period. The authors of this trial did not study other clinical endpoints, Dr. Grant noted.

Evidence from two observational studies was more equivocal, however.

In a retrospective observational study, investigators studied the relationship between the timing of discontinuing ACE inhibitors and angiotensin II receptor subtype 1 antagonists (ARA) and the onset of hypotension in 267 patients scheduled for general surgery.

They found that patients exposed to an ACE inhibitor or ARA within 10 hours of anesthesia had an adjusted odds ratio of 1.74 for moderate hypotension (SBP 85 mm Hg or less; P = .04), but there was no difference in severe hypotension between these patients and those who discontinued the drugs more than 10 hours before surgery. There were no differences in either vasopressor use or postoperative complications, including unplanned intensive care unit stay, myocardial infarction, stroke, renal impairment, or death.

A second, smaller study compared 12 vascular surgery patients on ARB the day of surgery with matched cohorts of patients taking beta-blockers and/or calcium channel blockers the day of surgery, or ACE inhibitors held on the day of surgery.

Hypotension (SBP less than 90 mm Hg in this study) occurred in all of the patients on ARB but in only 60% (27 of 45) patients on the beta-blocker/calcium channel blockers, and in 67% (18 of 27) in the ACE-inhibitor hold cohort. The ARB patients were also less responsive to ephedrine and phenylephrine than other patients, and in some cases responded only to a vasopressin system agonist, Dr. Grant noted.

Finally, the authors of a random-effects meta-analysis of five studies with a total of 434 patients reported that patients receiving an immediate preoperative ACE inhibitor or ARA dose had a relative risk of 1.50 for developing hypotension requiring vasopressors at or shortly after induction of anesthesia, compared with patients who did not receive the drugs.

Dr. Grant noted that the American College of Physicians’ Smart Medicine guidelines on perioperative management of hypertensive patients recommend continuing ACE inhibitors "with caution," and they advise clinicians to avoid hypovolemia in patients maintained on ACE inhibitors during surgery. He said that in certain cases, it may be appropriate to continue surgical patients on ACE inhibitors or ARB, as in patients with hypertension that is difficult to control with multiple medications, or in those with severe heart disease who have adequate blood pressure.

Dr. Grant reported having no financial disclosures.

SCOTTSDALE, ARIZ. – When it comes to holding or continuing with ACE inhibitors before surgery, all bets are off, a perioperative medicine consultant suggested.

Patients on angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARB) have about a 50% risk of developing hypotension during surgery, and a significant proportion of those episodes could be severe, said Dr. Paul Grant, of the University of Michigan Health System in Ann Arbor.

"I recommend having some sort of standard approach [to perioperative ACE inhibitor use] at your institution if that’s at all possible, either for a certain surgery type or across the board," he said at a meeting on perioperative medicine sponsored by the University of Miami.

Evidence from a small number of randomized trials and observational studies suggests that continuing ACE inhibitors during cardiac surgery may result in less cardiac enzyme release, less kidney injury, and a lower incidence of atrial fibrillation. In vascular surgery, evidence suggests that patients on ACE inhibitors who are undergoing surgery have less of a drop in cardiac output and may have improved creatinine clearance.

On the other hand, patients who remain on ACE inhibitors during surgery can experience a "profound" drop in blood pressure requiring immediate intervention, he said.

Data to support the continue vs. hold debate are sparse, but include a trial of 51 patients randomized to continue ACE inhibitors on the day of surgery or to have the drugs held for 12-24 hours before surgery. In all, 33 of the patients were on captopril (Capoten), and 18 were on enalapril (Vasotec).

The investigators found that among patients randomized to continue ACE inhibitor therapy, 7 of 7 on captopril and 9 of 14 on enalapril developed hypotension, defined as a systolic blood pressure (SBP) less than 90 mm Hg. In contrast, among patients assigned to the ACE-inhibitor hold protocol, only 2 of 11 on captopril and 4 of 19 on enalapril developed hypotension during surgery.

In a second randomized trial, investigators looked at 37 patients on an ARB who were randomly assigned to either discontinue ARB on the day before surgery (18 patients), or to receive their ARB 1 hour before anesthesia induction (19 patients).

The authors defined hypotension for their study as an SBP less than 80 mm Hg for more than 1 minute. They found that all 19 patients who continued on ARB had hypotension during surgery, compared with 12 of 18 who discontinued their ARB the day before. Patients who received their ARB on the day of surgery used significantly more vasoactive drugs. Despite the discontinuation of the ARB, there were no differences in hypertension between the groups in the recovery period. Postoperative cardiac complications occurred in 1 patient in each group.

In the final randomized study that Dr. Grant cited, 40 patients on an ACE inhibitor with good left-ventricular function were scheduled to undergo coronary artery bypass graft (CABG). They were randomly assigned to hold or continue on ACE inhibitors on the day of surgery.

Patients in whom the ACE inhibitors were held before CABG had higher mean blood pressures than patients who continued on the drugs, and they used less vasopressor during the surgery. In contrast, patients who continued on ACE inhibitors needed more vasodilators after CABG and in the recovery period. The authors of this trial did not study other clinical endpoints, Dr. Grant noted.

Evidence from two observational studies was more equivocal, however.

In a retrospective observational study, investigators studied the relationship between the timing of discontinuing ACE inhibitors and angiotensin II receptor subtype 1 antagonists (ARA) and the onset of hypotension in 267 patients scheduled for general surgery.

They found that patients exposed to an ACE inhibitor or ARA within 10 hours of anesthesia had an adjusted odds ratio of 1.74 for moderate hypotension (SBP 85 mm Hg or less; P = .04), but there was no difference in severe hypotension between these patients and those who discontinued the drugs more than 10 hours before surgery. There were no differences in either vasopressor use or postoperative complications, including unplanned intensive care unit stay, myocardial infarction, stroke, renal impairment, or death.

A second, smaller study compared 12 vascular surgery patients on ARB the day of surgery with matched cohorts of patients taking beta-blockers and/or calcium channel blockers the day of surgery, or ACE inhibitors held on the day of surgery.

Hypotension (SBP less than 90 mm Hg in this study) occurred in all of the patients on ARB but in only 60% (27 of 45) patients on the beta-blocker/calcium channel blockers, and in 67% (18 of 27) in the ACE-inhibitor hold cohort. The ARB patients were also less responsive to ephedrine and phenylephrine than other patients, and in some cases responded only to a vasopressin system agonist, Dr. Grant noted.

Finally, the authors of a random-effects meta-analysis of five studies with a total of 434 patients reported that patients receiving an immediate preoperative ACE inhibitor or ARA dose had a relative risk of 1.50 for developing hypotension requiring vasopressors at or shortly after induction of anesthesia, compared with patients who did not receive the drugs.

Dr. Grant noted that the American College of Physicians’ Smart Medicine guidelines on perioperative management of hypertensive patients recommend continuing ACE inhibitors "with caution," and they advise clinicians to avoid hypovolemia in patients maintained on ACE inhibitors during surgery. He said that in certain cases, it may be appropriate to continue surgical patients on ACE inhibitors or ARB, as in patients with hypertension that is difficult to control with multiple medications, or in those with severe heart disease who have adequate blood pressure.

Dr. Grant reported having no financial disclosures.

SCOTTSDALE, ARIZ. – When patients on immunosuppressive therapies need surgery, the risks of disease flare and compromised postoperative recovery and rehabilitation must be weighed against the risk of increased infections and impaired wound healing.

"I’m not sure that there is necessarily a right answer, but I think most people would stop biologic [agents] beforehand," Dr. Paul Grant said at a meeting on perioperative medicine sponsored by the University of Miami.

The decision whether to suspend a disease-modifying antirheumatic drug before surgery may depend on the individual drug and on the patient, said Dr. Grant, director of perioperative and consultative medicine at the University of Michigan Health System in Ann Arbor.

For example, it appears to be safe for patients on methotrexate to continue on therapy during elective orthopedic surgery. Evidence for this comes from a randomized clinical trial in which patients with rheumatoid arthritis (RA) were assigned to either continue on methotrexate (MTX) or suspend taking it for 2 weeks before and 2 weeks after surgery. The study also contained a control of patients with RA who were not on MTX (Ann. Rheum. Dis. 2001;60:214-7).

The investigators found that there were no significant differences in early complication rates or in complications up to 1 year of follow-up between patients who suspended or remained on MTX. Patients who stayed on the drug had significantly lower rates of RA flare.

Additionally, two systematic reviews, one looking at eight studies echoes the findings of the aforementioned randomized trial, and the other looking at four studies, in which the reviewer concluded that "continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares (Clin. Exp. Rheumatol. 2009;27:856-62) (Clin. Rheumatol. 2008;27:1217-20).None of the examined papers addresses the issue of safety in connection with comorbidities, age, or high doses of methotrexate."

"The bottom line here is that methotrexate should be continued for most surgeries. I think it might be reasonable to hold it in certain situations, for example if the patient has pretty bad kidney or liver disease, or if it’s surgery to treat a major infection," Dr. Grant said.

TNF-alpha antagonists

In contrast, the data on tumor necrosis factor–alpha (TNF-alpha) antagonists are fuzzier, with limited and conflicting information on perioperative use of these agents (etanercept, infliximab, adalimumab, certolizumab, golimumab).

"The major concern with these drugs is infection," Dr. Grant said. He pointed to a meta-analysis published in JAMA in 2006, which showed that taking the drugs doubled the risk of serious infections in general. The study did not specifically look at perioperative use of TNF-alpha antagonists (JAMA 2006;295:2275-85).

A retrospective cohort studyof 127 patients with RA who were undergoing various orthopedic procedures found that there were no differences in surgical site infections but more cases of wound dehiscence in patients who continued on the drugs, compared with those who interrupted their use perioperatively (Clin. Exp. Rheumatol. 2007;25:430-6).

A second, prospective study in 31 patients with RA undergoing foot/ankle surgery found that there were no significant differences in infection or healing between patients who interrupted therapy and those who did not (Foot Ankle Clin. 2007;12:509-24).

Other studies and systematic reviews in patients with RA or Crohn’s disease generally found no significant differences in serious infection rates, but they did detect a higher incidence of skin and soft-tissue infections among patients on anti-TNF-alpha agents vs. other disease-modifying antirheumatic drugs.

The risk of infections tends to be highest at the start of therapy with a TNF-alpha antagonist and stopping therapy is more likely to result in RA flares among patients with established disease, compared with those in the early stages of RA. Therefore, TNF blocker therapy should be restarted as soon as possible after surgery to prevent flare, Dr. Grant said.

The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks. These agents should also be held for 10-14 days after surgery or until wound healing is satisfactory.

"It’s probably safe to continue these medications for minor surgeries," Dr. Grant said.

Other agents

The anti-CD20 agent rituximab (Rituxan) – currently used to treat RA, vasculitis, hematologic malignancies, and other conditions – has a lower risk for bacterial infections than does TNF-alpha antagonists and has been shown to be safe in patients with a history of recurrent bacterial infections.

"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.

There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.

There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.

Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.

"Stress dose steroids are not routinely needed as long as the patients continue their normal dose. That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.

Dr. Grant reported having no financial disclosures.

SCOTTSDALE, ARIZ. – When patients on immunosuppressive therapies need surgery, the risks of disease flare and compromised postoperative recovery and rehabilitation must be weighed against the risk of increased infections and impaired wound healing.

"I’m not sure that there is necessarily a right answer, but I think most people would stop biologic [agents] beforehand," Dr. Paul Grant said at a meeting on perioperative medicine sponsored by the University of Miami.

The decision whether to suspend a disease-modifying antirheumatic drug before surgery may depend on the individual drug and on the patient, said Dr. Grant, director of perioperative and consultative medicine at the University of Michigan Health System in Ann Arbor.

For example, it appears to be safe for patients on methotrexate to continue on therapy during elective orthopedic surgery. Evidence for this comes from a randomized clinical trial in which patients with rheumatoid arthritis (RA) were assigned to either continue on methotrexate (MTX) or suspend taking it for 2 weeks before and 2 weeks after surgery. The study also contained a control of patients with RA who were not on MTX (Ann. Rheum. Dis. 2001;60:214-7).

The investigators found that there were no significant differences in early complication rates or in complications up to 1 year of follow-up between patients who suspended or remained on MTX. Patients who stayed on the drug had significantly lower rates of RA flare.

Additionally, two systematic reviews, one looking at eight studies echoes the findings of the aforementioned randomized trial, and the other looking at four studies, in which the reviewer concluded that "continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares (Clin. Exp. Rheumatol. 2009;27:856-62) (Clin. Rheumatol. 2008;27:1217-20).None of the examined papers addresses the issue of safety in connection with comorbidities, age, or high doses of methotrexate."

"The bottom line here is that methotrexate should be continued for most surgeries. I think it might be reasonable to hold it in certain situations, for example if the patient has pretty bad kidney or liver disease, or if it’s surgery to treat a major infection," Dr. Grant said.

TNF-alpha antagonists

In contrast, the data on tumor necrosis factor–alpha (TNF-alpha) antagonists are fuzzier, with limited and conflicting information on perioperative use of these agents (etanercept, infliximab, adalimumab, certolizumab, golimumab).

"The major concern with these drugs is infection," Dr. Grant said. He pointed to a meta-analysis published in JAMA in 2006, which showed that taking the drugs doubled the risk of serious infections in general. The study did not specifically look at perioperative use of TNF-alpha antagonists (JAMA 2006;295:2275-85).

A retrospective cohort studyof 127 patients with RA who were undergoing various orthopedic procedures found that there were no differences in surgical site infections but more cases of wound dehiscence in patients who continued on the drugs, compared with those who interrupted their use perioperatively (Clin. Exp. Rheumatol. 2007;25:430-6).

A second, prospective study in 31 patients with RA undergoing foot/ankle surgery found that there were no significant differences in infection or healing between patients who interrupted therapy and those who did not (Foot Ankle Clin. 2007;12:509-24).

Other studies and systematic reviews in patients with RA or Crohn’s disease generally found no significant differences in serious infection rates, but they did detect a higher incidence of skin and soft-tissue infections among patients on anti-TNF-alpha agents vs. other disease-modifying antirheumatic drugs.

The risk of infections tends to be highest at the start of therapy with a TNF-alpha antagonist and stopping therapy is more likely to result in RA flares among patients with established disease, compared with those in the early stages of RA. Therefore, TNF blocker therapy should be restarted as soon as possible after surgery to prevent flare, Dr. Grant said.

The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks. These agents should also be held for 10-14 days after surgery or until wound healing is satisfactory.

"It’s probably safe to continue these medications for minor surgeries," Dr. Grant said.

Other agents

The anti-CD20 agent rituximab (Rituxan) – currently used to treat RA, vasculitis, hematologic malignancies, and other conditions – has a lower risk for bacterial infections than does TNF-alpha antagonists and has been shown to be safe in patients with a history of recurrent bacterial infections.

"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.

There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.

There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.

Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.

"Stress dose steroids are not routinely needed as long as the patients continue their normal dose. That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.

Dr. Grant reported having no financial disclosures.

SCOTTSDALE, ARIZ. – When patients on immunosuppressive therapies need surgery, the risks of disease flare and compromised postoperative recovery and rehabilitation must be weighed against the risk of increased infections and impaired wound healing.

"I’m not sure that there is necessarily a right answer, but I think most people would stop biologic [agents] beforehand," Dr. Paul Grant said at a meeting on perioperative medicine sponsored by the University of Miami.

The decision whether to suspend a disease-modifying antirheumatic drug before surgery may depend on the individual drug and on the patient, said Dr. Grant, director of perioperative and consultative medicine at the University of Michigan Health System in Ann Arbor.

For example, it appears to be safe for patients on methotrexate to continue on therapy during elective orthopedic surgery. Evidence for this comes from a randomized clinical trial in which patients with rheumatoid arthritis (RA) were assigned to either continue on methotrexate (MTX) or suspend taking it for 2 weeks before and 2 weeks after surgery. The study also contained a control of patients with RA who were not on MTX (Ann. Rheum. Dis. 2001;60:214-7).

The investigators found that there were no significant differences in early complication rates or in complications up to 1 year of follow-up between patients who suspended or remained on MTX. Patients who stayed on the drug had significantly lower rates of RA flare.

Additionally, two systematic reviews, one looking at eight studies echoes the findings of the aforementioned randomized trial, and the other looking at four studies, in which the reviewer concluded that "continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares (Clin. Exp. Rheumatol. 2009;27:856-62) (Clin. Rheumatol. 2008;27:1217-20).None of the examined papers addresses the issue of safety in connection with comorbidities, age, or high doses of methotrexate."

"The bottom line here is that methotrexate should be continued for most surgeries. I think it might be reasonable to hold it in certain situations, for example if the patient has pretty bad kidney or liver disease, or if it’s surgery to treat a major infection," Dr. Grant said.

TNF-alpha antagonists

In contrast, the data on tumor necrosis factor–alpha (TNF-alpha) antagonists are fuzzier, with limited and conflicting information on perioperative use of these agents (etanercept, infliximab, adalimumab, certolizumab, golimumab).

"The major concern with these drugs is infection," Dr. Grant said. He pointed to a meta-analysis published in JAMA in 2006, which showed that taking the drugs doubled the risk of serious infections in general. The study did not specifically look at perioperative use of TNF-alpha antagonists (JAMA 2006;295:2275-85).

A retrospective cohort studyof 127 patients with RA who were undergoing various orthopedic procedures found that there were no differences in surgical site infections but more cases of wound dehiscence in patients who continued on the drugs, compared with those who interrupted their use perioperatively (Clin. Exp. Rheumatol. 2007;25:430-6).

A second, prospective study in 31 patients with RA undergoing foot/ankle surgery found that there were no significant differences in infection or healing between patients who interrupted therapy and those who did not (Foot Ankle Clin. 2007;12:509-24).

Other studies and systematic reviews in patients with RA or Crohn’s disease generally found no significant differences in serious infection rates, but they did detect a higher incidence of skin and soft-tissue infections among patients on anti-TNF-alpha agents vs. other disease-modifying antirheumatic drugs.

The risk of infections tends to be highest at the start of therapy with a TNF-alpha antagonist and stopping therapy is more likely to result in RA flares among patients with established disease, compared with those in the early stages of RA. Therefore, TNF blocker therapy should be restarted as soon as possible after surgery to prevent flare, Dr. Grant said.

The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks. These agents should also be held for 10-14 days after surgery or until wound healing is satisfactory.

"It’s probably safe to continue these medications for minor surgeries," Dr. Grant said.

Other agents

The anti-CD20 agent rituximab (Rituxan) – currently used to treat RA, vasculitis, hematologic malignancies, and other conditions – has a lower risk for bacterial infections than does TNF-alpha antagonists and has been shown to be safe in patients with a history of recurrent bacterial infections.

"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.

There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.

There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.

Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.

"Stress dose steroids are not routinely needed as long as the patients continue their normal dose. That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.

Dr. Grant reported having no financial disclosures.

SCOTTSDALE, ARIZ. – When patients on immunosuppressive therapies need surgery, the risks of disease flare and compromised postoperative recovery and rehabilitation must be weighed against the risk of increased infections and impaired wound healing.

"I’m not sure that there is necessarily a right answer, but I think most people would stop biologic [agents] beforehand," Dr. Paul Grant said at a meeting on perioperative medicine sponsored by the University of Miami.

The decision whether to suspend a disease-modifying antirheumatic drug before surgery may depend on the individual drug and on the patient, said Dr. Grant, director of perioperative and consultative medicine at the University of Michigan Health System in Ann Arbor.

'If someone's taking prednisone every day, make sure they take at least that dose on the day of surgery.'

For example, it appears to be safe for patients on methotrexate to continue on therapy during elective orthopedic surgery. Evidence for this comes from a randomized clinical trial in which patients with rheumatoid arthritis (RA) were assigned to either continue on methotrexate (MTX) or suspend taking it for 2 weeks before and 2 weeks after surgery. The study also contained a control of patients with RA who were not on MTX (Ann. Rheum. Dis. 2001;60:214-7).

The investigators found that there were no significant differences in early complication rates or in complications up to 1 year of follow-up between patients who suspended or remained on MTX. Patients who stayed on the drug had significantly lower rates of RA flare.

Two systematic reviews also looked at the question. One review of eight studies echoes the findings of the aforementioned randomized trial (Clin. Exp. Rheumatol. 2009; 27:856-62), while the other review of four studies concluded that "continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares" (Clin. Rheumatol. 2008; 27:1217-20). None of the examined papers addressed the issue of safety in connection with comorbidities, age, or high doses of methotrexate.

"The bottom line here is that methotrexate should be continued for most surgeries. I think it might be reasonable to hold it in certain situations, for example if the patient has pretty bad kidney or liver disease, or if it’s surgery to treat a major infection," Dr. Grant said.

TNF-alpha antagonists

In contrast, the data on tumor necrosis factor–alpha (TNF-alpha) antagonists are fuzzier, with limited and conflicting information on perioperative use of these agents (etanercept, infliximab, adalimumab, certolizumab, golimumab).

"The major concern with these drugs is infection," Dr. Grant said. He pointed to a meta-analysis published in JAMA in 2006, which showed that taking the drugs doubled the risk of serious infections in general. The study did not specifically look at perioperative use of TNF-alpha antagonists (JAMA 2006;295:2275-85).

A retrospective cohort study of 127 patients with RA who were undergoing various orthopedic procedures found that there were no differences in surgical site infections but more cases of wound dehiscence in patients who continued on the drugs, compared with those who interrupted their use perioperatively (Clin. Exp. Rheumatol. 2007;25:430-6).

A second, prospective study in 31 patients with RA undergoing foot/ankle surgery found that there were no significant differences in infection or healing between patients who interrupted therapy and those who did not (Foot Ankle Clin. 2007;12:509-24).

Other studies and systematic reviews in patients with RA or Crohn’s disease generally found no significant differences in serious infection rates, but they did detect a higher incidence of skin and soft-tissue infections among patients on anti-TNF-alpha agents vs. other disease-modifying antirheumatic drugs.

The risk of infections tends to be highest at the start of therapy with a TNF-alpha antagonist, and stopping therapy is more likely to result in RA flares among patients with established disease, compared with those in the early stages of RA. Therefore, TNF-blocker therapy should be restarted as soon as possible after surgery to prevent flare, Dr. Grant said.

The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks. These agents should also be held for 10-14 days after surgery or until wound healing is satisfactory.

"It’s probably safe to continue these medications for minor surgeries," Dr. Grant said.

Other agents

The anti-CD20 agent rituximab (Rituxan) – currently used to treat RA, vasculitis, hematologic malignancies, and other conditions – has a lower risk for bacterial infections than do TNF-alpha antagonists and has been shown to be safe in patients with a history of recurrent bacterial infections.

"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.

There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.

There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.

Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.

"Stress dose steroids are not routinely needed as long as the patients continue their normal dose.

"That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.

Dr. Lary Robinson, FCCP, comments: Surgeons are rightfully concerned about the preoperative use of any medicines that might increase the risk of bleeding, infections or wound healing. The topic of immunomodulating drugs was explored by evaluating the published evidence about their safety in the perioperative period. These agents, used in patients with autoimmune/inflammatory diseases such as rheumatoid arthritis and Crohn's disease, are generally safe to continue although most authorities generally recommend holding the TNF-alpha antagonists prior to and after major surgery due to potential wound healing and infectious problems.

SCOTTSDALE, ARIZ. – When patients on immunosuppressive therapies need surgery, the risks of disease flare and compromised postoperative recovery and rehabilitation must be weighed against the risk of increased infections and impaired wound healing.

"I’m not sure that there is necessarily a right answer, but I think most people would stop biologic [agents] beforehand," Dr. Paul Grant said at a meeting on perioperative medicine sponsored by the University of Miami.

The decision whether to suspend a disease-modifying antirheumatic drug before surgery may depend on the individual drug and on the patient, said Dr. Grant, director of perioperative and consultative medicine at the University of Michigan Health System in Ann Arbor.

'If someone's taking prednisone every day, make sure they take at least that dose on the day of surgery.'

For example, it appears to be safe for patients on methotrexate to continue on therapy during elective orthopedic surgery. Evidence for this comes from a randomized clinical trial in which patients with rheumatoid arthritis (RA) were assigned to either continue on methotrexate (MTX) or suspend taking it for 2 weeks before and 2 weeks after surgery. The study also contained a control of patients with RA who were not on MTX (Ann. Rheum. Dis. 2001;60:214-7).

The investigators found that there were no significant differences in early complication rates or in complications up to 1 year of follow-up between patients who suspended or remained on MTX. Patients who stayed on the drug had significantly lower rates of RA flare.

Two systematic reviews also looked at the question. One review of eight studies echoes the findings of the aforementioned randomized trial (Clin. Exp. Rheumatol. 2009; 27:856-62), while the other review of four studies concluded that "continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares" (Clin. Rheumatol. 2008; 27:1217-20). None of the examined papers addressed the issue of safety in connection with comorbidities, age, or high doses of methotrexate.

"The bottom line here is that methotrexate should be continued for most surgeries. I think it might be reasonable to hold it in certain situations, for example if the patient has pretty bad kidney or liver disease, or if it’s surgery to treat a major infection," Dr. Grant said.

TNF-alpha antagonists

In contrast, the data on tumor necrosis factor–alpha (TNF-alpha) antagonists are fuzzier, with limited and conflicting information on perioperative use of these agents (etanercept, infliximab, adalimumab, certolizumab, golimumab).

"The major concern with these drugs is infection," Dr. Grant said. He pointed to a meta-analysis published in JAMA in 2006, which showed that taking the drugs doubled the risk of serious infections in general. The study did not specifically look at perioperative use of TNF-alpha antagonists (JAMA 2006;295:2275-85).

A retrospective cohort study of 127 patients with RA who were undergoing various orthopedic procedures found that there were no differences in surgical site infections but more cases of wound dehiscence in patients who continued on the drugs, compared with those who interrupted their use perioperatively (Clin. Exp. Rheumatol. 2007;25:430-6).

A second, prospective study in 31 patients with RA undergoing foot/ankle surgery found that there were no significant differences in infection or healing between patients who interrupted therapy and those who did not (Foot Ankle Clin. 2007;12:509-24).

Other studies and systematic reviews in patients with RA or Crohn’s disease generally found no significant differences in serious infection rates, but they did detect a higher incidence of skin and soft-tissue infections among patients on anti-TNF-alpha agents vs. other disease-modifying antirheumatic drugs.

The risk of infections tends to be highest at the start of therapy with a TNF-alpha antagonist, and stopping therapy is more likely to result in RA flares among patients with established disease, compared with those in the early stages of RA. Therefore, TNF-blocker therapy should be restarted as soon as possible after surgery to prevent flare, Dr. Grant said.

The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks. These agents should also be held for 10-14 days after surgery or until wound healing is satisfactory.

"It’s probably safe to continue these medications for minor surgeries," Dr. Grant said.

Other agents

The anti-CD20 agent rituximab (Rituxan) – currently used to treat RA, vasculitis, hematologic malignancies, and other conditions – has a lower risk for bacterial infections than do TNF-alpha antagonists and has been shown to be safe in patients with a history of recurrent bacterial infections.

"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.

There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.

There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.

Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.

"Stress dose steroids are not routinely needed as long as the patients continue their normal dose.

"That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.

Dr. Lary Robinson, FCCP, comments: Surgeons are rightfully concerned about the preoperative use of any medicines that might increase the risk of bleeding, infections or wound healing. The topic of immunomodulating drugs was explored by evaluating the published evidence about their safety in the perioperative period. These agents, used in patients with autoimmune/inflammatory diseases such as rheumatoid arthritis and Crohn's disease, are generally safe to continue although most authorities generally recommend holding the TNF-alpha antagonists prior to and after major surgery due to potential wound healing and infectious problems.

SCOTTSDALE, ARIZ. – When patients on immunosuppressive therapies need surgery, the risks of disease flare and compromised postoperative recovery and rehabilitation must be weighed against the risk of increased infections and impaired wound healing.

"I’m not sure that there is necessarily a right answer, but I think most people would stop biologic [agents] beforehand," Dr. Paul Grant said at a meeting on perioperative medicine sponsored by the University of Miami.

The decision whether to suspend a disease-modifying antirheumatic drug before surgery may depend on the individual drug and on the patient, said Dr. Grant, director of perioperative and consultative medicine at the University of Michigan Health System in Ann Arbor.

'If someone's taking prednisone every day, make sure they take at least that dose on the day of surgery.'

For example, it appears to be safe for patients on methotrexate to continue on therapy during elective orthopedic surgery. Evidence for this comes from a randomized clinical trial in which patients with rheumatoid arthritis (RA) were assigned to either continue on methotrexate (MTX) or suspend taking it for 2 weeks before and 2 weeks after surgery. The study also contained a control of patients with RA who were not on MTX (Ann. Rheum. Dis. 2001;60:214-7).

The investigators found that there were no significant differences in early complication rates or in complications up to 1 year of follow-up between patients who suspended or remained on MTX. Patients who stayed on the drug had significantly lower rates of RA flare.

Two systematic reviews also looked at the question. One review of eight studies echoes the findings of the aforementioned randomized trial (Clin. Exp. Rheumatol. 2009; 27:856-62), while the other review of four studies concluded that "continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares" (Clin. Rheumatol. 2008; 27:1217-20). None of the examined papers addressed the issue of safety in connection with comorbidities, age, or high doses of methotrexate.

"The bottom line here is that methotrexate should be continued for most surgeries. I think it might be reasonable to hold it in certain situations, for example if the patient has pretty bad kidney or liver disease, or if it’s surgery to treat a major infection," Dr. Grant said.

TNF-alpha antagonists

In contrast, the data on tumor necrosis factor–alpha (TNF-alpha) antagonists are fuzzier, with limited and conflicting information on perioperative use of these agents (etanercept, infliximab, adalimumab, certolizumab, golimumab).

"The major concern with these drugs is infection," Dr. Grant said. He pointed to a meta-analysis published in JAMA in 2006, which showed that taking the drugs doubled the risk of serious infections in general. The study did not specifically look at perioperative use of TNF-alpha antagonists (JAMA 2006;295:2275-85).

A retrospective cohort study of 127 patients with RA who were undergoing various orthopedic procedures found that there were no differences in surgical site infections but more cases of wound dehiscence in patients who continued on the drugs, compared with those who interrupted their use perioperatively (Clin. Exp. Rheumatol. 2007;25:430-6).

A second, prospective study in 31 patients with RA undergoing foot/ankle surgery found that there were no significant differences in infection or healing between patients who interrupted therapy and those who did not (Foot Ankle Clin. 2007;12:509-24).

Other studies and systematic reviews in patients with RA or Crohn’s disease generally found no significant differences in serious infection rates, but they did detect a higher incidence of skin and soft-tissue infections among patients on anti-TNF-alpha agents vs. other disease-modifying antirheumatic drugs.

The risk of infections tends to be highest at the start of therapy with a TNF-alpha antagonist, and stopping therapy is more likely to result in RA flares among patients with established disease, compared with those in the early stages of RA. Therefore, TNF-blocker therapy should be restarted as soon as possible after surgery to prevent flare, Dr. Grant said.

The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks. These agents should also be held for 10-14 days after surgery or until wound healing is satisfactory.

"It’s probably safe to continue these medications for minor surgeries," Dr. Grant said.

Other agents

The anti-CD20 agent rituximab (Rituxan) – currently used to treat RA, vasculitis, hematologic malignancies, and other conditions – has a lower risk for bacterial infections than do TNF-alpha antagonists and has been shown to be safe in patients with a history of recurrent bacterial infections.

"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.

There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.

There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.

Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.

"Stress dose steroids are not routinely needed as long as the patients continue their normal dose.

"That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.

Dr. Lary Robinson, FCCP, comments: Surgeons are rightfully concerned about the preoperative use of any medicines that might increase the risk of bleeding, infections or wound healing. The topic of immunomodulating drugs was explored by evaluating the published evidence about their safety in the perioperative period. These agents, used in patients with autoimmune/inflammatory diseases such as rheumatoid arthritis and Crohn's disease, are generally safe to continue although most authorities generally recommend holding the TNF-alpha antagonists prior to and after major surgery due to potential wound healing and infectious problems.

SCOTTSDALE, ARIZ. – When it comes to holding or continuing with ACE inhibitors before surgery, all bets are off, a perioperative medicine consultant suggested.

Patients on angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARB) have about a 50% risk of developing hypotension during surgery, and a significant proportion of those episodes could be severe, said Dr. Paul Grant, of the University of Michigan Health System in Ann Arbor.

"I recommend having some sort of standard approach [to perioperative ACE inhibitor use] at your institution if that’s at all possible, either for a certain surgery type or across the board," he said at a meeting on perioperative medicine sponsored by the University of Miami.

Evidence from a small number of randomized trials and observational studies suggests that continuing ACE inhibitors during cardiac surgery may result in less cardiac enzyme release, less kidney injury, and a lower incidence of atrial fibrillation. In vascular surgery, evidence suggests that patients on ACE inhibitors who are undergoing surgery have less of a drop in cardiac output and may have improved creatinine clearance.

On the other hand, patients who remain on ACE inhibitors during surgery can experience a "profound" drop in blood pressure requiring immediate intervention, he said.

Data to support the continue vs. hold debate are sparse, but include a trial of 51 patients randomized to continue ACE inhibitors on the day of surgery or to have the drugs held for 12-24 hours before surgery. In all, 33 of the patients were on captopril (Capoten), and 18 were on enalapril (Vasotec).

The investigators found that among patients randomized to continue ACE inhibitor therapy, 7 of 7 on captopril and 9 of 14 on enalapril developed hypotension, defined as a systolic blood pressure (SBP) less than 90 mm Hg. In contrast, among patients assigned to the ACE-inhibitor hold protocol, only 2 of 11 on captopril and 4 of 19 on enalapril developed hypotension during surgery.

In a second randomized trial, investigators looked at 37 patients on an ARB who were randomly assigned to either discontinue ARB on the day before surgery (18 patients), or to receive their ARB 1 hour before anesthesia induction (19 patients).

The authors defined hypotension for their study as an SBP less than 80 mm Hg for more than 1 minute. They found that all 19 patients who continued on ARB had hypotension during surgery, compared with 12 of 18 who discontinued their ARB the day before. Patients who received their ARB on the day of surgery used significantly more vasoactive drugs. Despite the discontinuation of the ARB, there were no differences in hypertension between the groups in the recovery period. Postoperative cardiac complications occurred in 1 patient in each group.

In the final randomized study that Dr. Grant cited, 40 patients on an ACE inhibitor with good left-ventricular function were scheduled to undergo coronary artery bypass graft (CABG). They were randomly assigned to hold or continue on ACE inhibitors on the day of surgery.

Patients in whom the ACE inhibitors were held before CABG had higher mean blood pressures than patients who continued on the drugs, and they used less vasopressor during the surgery. In contrast, patients who continued on ACE inhibitors needed more vasodilators after CABG and in the recovery period. The authors of this trial did not study other clinical endpoints, Dr. Grant noted.

Evidence from two observational studies was more equivocal, however.

In a retrospective observational study, investigators studied the relationship between the timing of discontinuing ACE inhibitors and angiotensin II receptor subtype 1 antagonists (ARA) and the onset of hypotension in 267 patients scheduled for general surgery.

They found that patients exposed to an ACE inhibitor or ARA within 10 hours of anesthesia had an adjusted odds ratio of 1.74 for moderate hypotension (SBP 85 mm Hg or less; P = .04), but there was no difference in severe hypotension between these patients and those who discontinued the drugs more than 10 hours before surgery. There were no differences in either vasopressor use or postoperative complications, including unplanned intensive care unit stay, myocardial infarction, stroke, renal impairment, or death.

A second, smaller study compared 12 vascular surgery patients on ARB the day of surgery with matched cohorts of patients taking beta-blockers and/or calcium channel blockers the day of surgery, or ACE inhibitors held on the day of surgery.

Hypotension (SBP less than 90 mm Hg in this study) occurred in all of the patients on ARB but in only 60% (27 of 45) patients on the beta-blocker/calcium channel blockers, and in 67% (18 of 27) in the ACE-inhibitor hold cohort. The ARB patients were also less responsive to ephedrine and phenylephrine than other patients, and in some cases responded only to a vasopressin system agonist, Dr. Grant noted.

Finally, the authors of a random-effects meta-analysis of five studies with a total of 434 patients reported that patients receiving an immediate preoperative ACE inhibitor or ARA dose had a relative risk of 1.50 for developing hypotension requiring vasopressors at or shortly after induction of anesthesia, compared with patients who did not receive the drugs.

Dr. Grant noted that the American College of Physicians’ Smart Medicine guidelines on perioperative management of hypertensive patients recommend continuing ACE inhibitors "with caution," and they advise clinicians to avoid hypovolemia in patients maintained on ACE inhibitors during surgery. He said that in certain cases, it may be appropriate to continue surgical patients on ACE inhibitors or ARB, as in patients with hypertension that is difficult to control with multiple medications, or in those with severe heart disease who have adequate blood pressure.

Dr. Grant reported having no financial disclosures.

SCOTTSDALE, ARIZ. – When it comes to holding or continuing with ACE inhibitors before surgery, all bets are off, a perioperative medicine consultant suggested.

Patients on angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARB) have about a 50% risk of developing hypotension during surgery, and a significant proportion of those episodes could be severe, said Dr. Paul Grant, of the University of Michigan Health System in Ann Arbor.

"I recommend having some sort of standard approach [to perioperative ACE inhibitor use] at your institution if that’s at all possible, either for a certain surgery type or across the board," he said at a meeting on perioperative medicine sponsored by the University of Miami.

Evidence from a small number of randomized trials and observational studies suggests that continuing ACE inhibitors during cardiac surgery may result in less cardiac enzyme release, less kidney injury, and a lower incidence of atrial fibrillation. In vascular surgery, evidence suggests that patients on ACE inhibitors who are undergoing surgery have less of a drop in cardiac output and may have improved creatinine clearance.

On the other hand, patients who remain on ACE inhibitors during surgery can experience a "profound" drop in blood pressure requiring immediate intervention, he said.

Data to support the continue vs. hold debate are sparse, but include a trial of 51 patients randomized to continue ACE inhibitors on the day of surgery or to have the drugs held for 12-24 hours before surgery. In all, 33 of the patients were on captopril (Capoten), and 18 were on enalapril (Vasotec).

The investigators found that among patients randomized to continue ACE inhibitor therapy, 7 of 7 on captopril and 9 of 14 on enalapril developed hypotension, defined as a systolic blood pressure (SBP) less than 90 mm Hg. In contrast, among patients assigned to the ACE-inhibitor hold protocol, only 2 of 11 on captopril and 4 of 19 on enalapril developed hypotension during surgery.

In a second randomized trial, investigators looked at 37 patients on an ARB who were randomly assigned to either discontinue ARB on the day before surgery (18 patients), or to receive their ARB 1 hour before anesthesia induction (19 patients).

The authors defined hypotension for their study as an SBP less than 80 mm Hg for more than 1 minute. They found that all 19 patients who continued on ARB had hypotension during surgery, compared with 12 of 18 who discontinued their ARB the day before. Patients who received their ARB on the day of surgery used significantly more vasoactive drugs. Despite the discontinuation of the ARB, there were no differences in hypertension between the groups in the recovery period. Postoperative cardiac complications occurred in 1 patient in each group.

In the final randomized study that Dr. Grant cited, 40 patients on an ACE inhibitor with good left-ventricular function were scheduled to undergo coronary artery bypass graft (CABG). They were randomly assigned to hold or continue on ACE inhibitors on the day of surgery.

Patients in whom the ACE inhibitors were held before CABG had higher mean blood pressures than patients who continued on the drugs, and they used less vasopressor during the surgery. In contrast, patients who continued on ACE inhibitors needed more vasodilators after CABG and in the recovery period. The authors of this trial did not study other clinical endpoints, Dr. Grant noted.

Evidence from two observational studies was more equivocal, however.

In a retrospective observational study, investigators studied the relationship between the timing of discontinuing ACE inhibitors and angiotensin II receptor subtype 1 antagonists (ARA) and the onset of hypotension in 267 patients scheduled for general surgery.

They found that patients exposed to an ACE inhibitor or ARA within 10 hours of anesthesia had an adjusted odds ratio of 1.74 for moderate hypotension (SBP 85 mm Hg or less; P = .04), but there was no difference in severe hypotension between these patients and those who discontinued the drugs more than 10 hours before surgery. There were no differences in either vasopressor use or postoperative complications, including unplanned intensive care unit stay, myocardial infarction, stroke, renal impairment, or death.

A second, smaller study compared 12 vascular surgery patients on ARB the day of surgery with matched cohorts of patients taking beta-blockers and/or calcium channel blockers the day of surgery, or ACE inhibitors held on the day of surgery.

Hypotension (SBP less than 90 mm Hg in this study) occurred in all of the patients on ARB but in only 60% (27 of 45) patients on the beta-blocker/calcium channel blockers, and in 67% (18 of 27) in the ACE-inhibitor hold cohort. The ARB patients were also less responsive to ephedrine and phenylephrine than other patients, and in some cases responded only to a vasopressin system agonist, Dr. Grant noted.

Finally, the authors of a random-effects meta-analysis of five studies with a total of 434 patients reported that patients receiving an immediate preoperative ACE inhibitor or ARA dose had a relative risk of 1.50 for developing hypotension requiring vasopressors at or shortly after induction of anesthesia, compared with patients who did not receive the drugs.

Dr. Grant noted that the American College of Physicians’ Smart Medicine guidelines on perioperative management of hypertensive patients recommend continuing ACE inhibitors "with caution," and they advise clinicians to avoid hypovolemia in patients maintained on ACE inhibitors during surgery. He said that in certain cases, it may be appropriate to continue surgical patients on ACE inhibitors or ARB, as in patients with hypertension that is difficult to control with multiple medications, or in those with severe heart disease who have adequate blood pressure.

Dr. Grant reported having no financial disclosures.

SCOTTSDALE, ARIZ. – When it comes to holding or continuing with ACE inhibitors before surgery, all bets are off, a perioperative medicine consultant suggested.

Patients on angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARB) have about a 50% risk of developing hypotension during surgery, and a significant proportion of those episodes could be severe, said Dr. Paul Grant, of the University of Michigan Health System in Ann Arbor.

"I recommend having some sort of standard approach [to perioperative ACE inhibitor use] at your institution if that’s at all possible, either for a certain surgery type or across the board," he said at a meeting on perioperative medicine sponsored by the University of Miami.

Evidence from a small number of randomized trials and observational studies suggests that continuing ACE inhibitors during cardiac surgery may result in less cardiac enzyme release, less kidney injury, and a lower incidence of atrial fibrillation. In vascular surgery, evidence suggests that patients on ACE inhibitors who are undergoing surgery have less of a drop in cardiac output and may have improved creatinine clearance.

On the other hand, patients who remain on ACE inhibitors during surgery can experience a "profound" drop in blood pressure requiring immediate intervention, he said.

Data to support the continue vs. hold debate are sparse, but include a trial of 51 patients randomized to continue ACE inhibitors on the day of surgery or to have the drugs held for 12-24 hours before surgery. In all, 33 of the patients were on captopril (Capoten), and 18 were on enalapril (Vasotec).

The investigators found that among patients randomized to continue ACE inhibitor therapy, 7 of 7 on captopril and 9 of 14 on enalapril developed hypotension, defined as a systolic blood pressure (SBP) less than 90 mm Hg. In contrast, among patients assigned to the ACE-inhibitor hold protocol, only 2 of 11 on captopril and 4 of 19 on enalapril developed hypotension during surgery.

In a second randomized trial, investigators looked at 37 patients on an ARB who were randomly assigned to either discontinue ARB on the day before surgery (18 patients), or to receive their ARB 1 hour before anesthesia induction (19 patients).

The authors defined hypotension for their study as an SBP less than 80 mm Hg for more than 1 minute. They found that all 19 patients who continued on ARB had hypotension during surgery, compared with 12 of 18 who discontinued their ARB the day before. Patients who received their ARB on the day of surgery used significantly more vasoactive drugs. Despite the discontinuation of the ARB, there were no differences in hypertension between the groups in the recovery period. Postoperative cardiac complications occurred in 1 patient in each group.

In the final randomized study that Dr. Grant cited, 40 patients on an ACE inhibitor with good left-ventricular function were scheduled to undergo coronary artery bypass graft (CABG). They were randomly assigned to hold or continue on ACE inhibitors on the day of surgery.

Patients in whom the ACE inhibitors were held before CABG had higher mean blood pressures than patients who continued on the drugs, and they used less vasopressor during the surgery. In contrast, patients who continued on ACE inhibitors needed more vasodilators after CABG and in the recovery period. The authors of this trial did not study other clinical endpoints, Dr. Grant noted.

Evidence from two observational studies was more equivocal, however.

In a retrospective observational study, investigators studied the relationship between the timing of discontinuing ACE inhibitors and angiotensin II receptor subtype 1 antagonists (ARA) and the onset of hypotension in 267 patients scheduled for general surgery.

They found that patients exposed to an ACE inhibitor or ARA within 10 hours of anesthesia had an adjusted odds ratio of 1.74 for moderate hypotension (SBP 85 mm Hg or less; P = .04), but there was no difference in severe hypotension between these patients and those who discontinued the drugs more than 10 hours before surgery. There were no differences in either vasopressor use or postoperative complications, including unplanned intensive care unit stay, myocardial infarction, stroke, renal impairment, or death.

A second, smaller study compared 12 vascular surgery patients on ARB the day of surgery with matched cohorts of patients taking beta-blockers and/or calcium channel blockers the day of surgery, or ACE inhibitors held on the day of surgery.

Hypotension (SBP less than 90 mm Hg in this study) occurred in all of the patients on ARB but in only 60% (27 of 45) patients on the beta-blocker/calcium channel blockers, and in 67% (18 of 27) in the ACE-inhibitor hold cohort. The ARB patients were also less responsive to ephedrine and phenylephrine than other patients, and in some cases responded only to a vasopressin system agonist, Dr. Grant noted.

Finally, the authors of a random-effects meta-analysis of five studies with a total of 434 patients reported that patients receiving an immediate preoperative ACE inhibitor or ARA dose had a relative risk of 1.50 for developing hypotension requiring vasopressors at or shortly after induction of anesthesia, compared with patients who did not receive the drugs.

Dr. Grant noted that the American College of Physicians’ Smart Medicine guidelines on perioperative management of hypertensive patients recommend continuing ACE inhibitors "with caution," and they advise clinicians to avoid hypovolemia in patients maintained on ACE inhibitors during surgery. He said that in certain cases, it may be appropriate to continue surgical patients on ACE inhibitors or ARB, as in patients with hypertension that is difficult to control with multiple medications, or in those with severe heart disease who have adequate blood pressure.

Dr. Grant reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Optimal management of patients with chronic kidney disease involves knowing what can be modified, understanding that much is uncertain, and having the wisdom to know the difference, suggested an anesthesiologist at a meeting on perioperative medicine sponsored by the University of Miami.

"There is a lot to be done in terms of evaluation of chronic kidney disease and also defining interventions," said Dr. Claus U. Niemann, professor of anesthesia and surgery at the University of California, San Francisco.

Kidney disease is identified either by markers of function such as glomerular filtration rate (GFR), markers of damage such as proteinuria, and markers of volume sense, such as edema, ascites, and urinary sodium excretion.

None of these measures is particularly accurate at measuring disease, however. For example, GFR is not observed directly but estimated from creatinine clearance, which is produced by the body in varying amounts daily and which depends on muscle mass, so that values for a young, muscular man will be higher than those of a small, older woman, Dr. Niemann noted.

In addition, even in people without kidney disease, GFR declines gradually with age, from about 116 mL/min per 1.73 m² for people in their 20s, to about 75 mL/min per 1.73 m² in those aged 70 years and older.

In 2002, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) developed a five-stage classification for chronic kidney disease (CKD), based on GFR, with CKD defined as either a GFR of less than 60 mL/min per 1.73 m² for more than 3 months or evidence of kidney damage for more than 3 months, based on the presence of abnormalities such as proteinuria. The classification notes that a combination of GFR less than 60 mL/min per 1.73 m² and proteinuria is prognostic.

The classification includes moderately and severely reduced GFR, with respective rates of 30-59 and 15-29 mL/min per 1.73 m², respectively, and end-stage renal disease, with a GFR less than 15 mL/min per 1.73 m² or a need for dialysis,

The most common cause of CKD is diabetic nephropathy or hypertensive nephrosclerosis, which account for 67% of all cases. About 1 in 5 or 1 in 6 Americans has some form of CKD, and the problem can be lifelong, Dr. Niemann said.

Risk stratification

The goal of perioperative management of patients with CKD is to prevent further renal impairment from acute kidney injury, a rapid reduction in kidney function as measured by a significant rise in serum creatinine levels or reduction in urine output within 48 hours of exposure.

Approximately 5%-7% of all hospitalized patients experience some degree of acute kidney injury and changes in serum creatinine of only 0.3 mg/dL have been associated with greater length of stay and increased morbidity and mortality, Dr. Niemann said.

"What is really necessary is that we do perioperative risk stratification. We want to identify the subset of patients who are at risk, we can do tests potentially, and we want to understand what the procedure is, put it in the context of the patient and his renal disease, and then hopefully define a plan and get him to surgery," Dr. Niemann said.

Defining perioperative renal risk involves determining as best as possible the extent of renal insufficiency or CKD, the etiology of the kidney disease (including severity and complications), and the risk of loss of kidney function from the planned or urgent/emergent surgery. The preop clinical team should also know where the patient will be discharged after surgery (home, ICU, floor).

Risk factors for in-hospital acute renal failure include baseline risks, such as age, diabetes, heart or liver failure, and male sex; acute clinical conditions, such as sepsis, hypotension, shock, volume depletion, or rhabdomyolysis; and use of nephrotoxic agents, such as contrast media, aminoglycosides, chemotherapy drugs, or NSAIDs.

Mixed results

Dr. Niemann noted that in a systematic review of possible interventions for protecting renal function in the perioperative period found little in the way of solid evidence to support the use of various interventions, including dopamine agonists or analogs, loop diuretics, mannitol, calcium inhibitors, angiotensin-converting enzyme (ACE) inhibitors, N-acetylcysteine in contrast studies or surgery, or sodium bicarbonate (Cochrane Database of Syst. Rev. 2013;9:CD003590 [doi:10.1002/14651858.CD003590.pub]).

"The long and the short of it is that no interventions have definitely been shown to make a big difference in randomized trials," he said.

Nonetheless, to prevent further loss of renal function in at-risk patients, clinicians should optimize modifiable variables, such as blood pressure, and discontinue nephrotoxic medications, such as NSAIDs.

In addition, the perioperative team should strive to better control acidosis, anemia, and hyperphosphatemia.

"I think what is really important is that you counsel the patient in the preop clinic," Dr. Niemann said.

Preoperative clinic staff should review the procedure and risks based on the presence and severity of the patient’s CKD and outline possible outcomes based on the best available evidence.

"We do it for the heart, but we don’t do it for the kidney," he commented.

During surgery, the team should be aware of the risks of a potential "second hit" – that is, an acute injury on top of chronic disease, and after surgery, clinicians should monitor for the known risk factors, such as sepsis and infection, he said.

Dr. Niemann reported no relevant conflicts.

SCOTTSDALE, ARIZ. – Optimal management of patients with chronic kidney disease involves knowing what can be modified, understanding that much is uncertain, and having the wisdom to know the difference, suggested an anesthesiologist at a meeting on perioperative medicine sponsored by the University of Miami.

"There is a lot to be done in terms of evaluation of chronic kidney disease and also defining interventions," said Dr. Claus U. Niemann, professor of anesthesia and surgery at the University of California, San Francisco.

Kidney disease is identified either by markers of function such as glomerular filtration rate (GFR), markers of damage such as proteinuria, and markers of volume sense, such as edema, ascites, and urinary sodium excretion.

None of these measures is particularly accurate at measuring disease, however. For example, GFR is not observed directly but estimated from creatinine clearance, which is produced by the body in varying amounts daily and which depends on muscle mass, so that values for a young, muscular man will be higher than those of a small, older woman, Dr. Niemann noted.

In addition, even in people without kidney disease, GFR declines gradually with age, from about 116 mL/min per 1.73 m² for people in their 20s, to about 75 mL/min per 1.73 m² in those aged 70 years and older.

In 2002, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) developed a five-stage classification for chronic kidney disease (CKD), based on GFR, with CKD defined as either a GFR of less than 60 mL/min per 1.73 m² for more than 3 months or evidence of kidney damage for more than 3 months, based on the presence of abnormalities such as proteinuria. The classification notes that a combination of GFR less than 60 mL/min per 1.73 m² and proteinuria is prognostic.

The classification includes moderately and severely reduced GFR, with respective rates of 30-59 and 15-29 mL/min per 1.73 m², respectively, and end-stage renal disease, with a GFR less than 15 mL/min per 1.73 m² or a need for dialysis,

The most common cause of CKD is diabetic nephropathy or hypertensive nephrosclerosis, which account for 67% of all cases. About 1 in 5 or 1 in 6 Americans has some form of CKD, and the problem can be lifelong, Dr. Niemann said.

Risk stratification

The goal of perioperative management of patients with CKD is to prevent further renal impairment from acute kidney injury, a rapid reduction in kidney function as measured by a significant rise in serum creatinine levels or reduction in urine output within 48 hours of exposure.

Approximately 5%-7% of all hospitalized patients experience some degree of acute kidney injury and changes in serum creatinine of only 0.3 mg/dL have been associated with greater length of stay and increased morbidity and mortality, Dr. Niemann said.

"What is really necessary is that we do perioperative risk stratification. We want to identify the subset of patients who are at risk, we can do tests potentially, and we want to understand what the procedure is, put it in the context of the patient and his renal disease, and then hopefully define a plan and get him to surgery," Dr. Niemann said.

Defining perioperative renal risk involves determining as best as possible the extent of renal insufficiency or CKD, the etiology of the kidney disease (including severity and complications), and the risk of loss of kidney function from the planned or urgent/emergent surgery. The preop clinical team should also know where the patient will be discharged after surgery (home, ICU, floor).

Risk factors for in-hospital acute renal failure include baseline risks, such as age, diabetes, heart or liver failure, and male sex; acute clinical conditions, such as sepsis, hypotension, shock, volume depletion, or rhabdomyolysis; and use of nephrotoxic agents, such as contrast media, aminoglycosides, chemotherapy drugs, or NSAIDs.

Mixed results

Dr. Niemann noted that in a systematic review of possible interventions for protecting renal function in the perioperative period found little in the way of solid evidence to support the use of various interventions, including dopamine agonists or analogs, loop diuretics, mannitol, calcium inhibitors, angiotensin-converting enzyme (ACE) inhibitors, N-acetylcysteine in contrast studies or surgery, or sodium bicarbonate (Cochrane Database of Syst. Rev. 2013;9:CD003590 [doi:10.1002/14651858.CD003590.pub]).

"The long and the short of it is that no interventions have definitely been shown to make a big difference in randomized trials," he said.

Nonetheless, to prevent further loss of renal function in at-risk patients, clinicians should optimize modifiable variables, such as blood pressure, and discontinue nephrotoxic medications, such as NSAIDs.

In addition, the perioperative team should strive to better control acidosis, anemia, and hyperphosphatemia.

"I think what is really important is that you counsel the patient in the preop clinic," Dr. Niemann said.

Preoperative clinic staff should review the procedure and risks based on the presence and severity of the patient’s CKD and outline possible outcomes based on the best available evidence.

"We do it for the heart, but we don’t do it for the kidney," he commented.

During surgery, the team should be aware of the risks of a potential "second hit" – that is, an acute injury on top of chronic disease, and after surgery, clinicians should monitor for the known risk factors, such as sepsis and infection, he said.

Dr. Niemann reported no relevant conflicts.

SCOTTSDALE, ARIZ. – Optimal management of patients with chronic kidney disease involves knowing what can be modified, understanding that much is uncertain, and having the wisdom to know the difference, suggested an anesthesiologist at a meeting on perioperative medicine sponsored by the University of Miami.

"There is a lot to be done in terms of evaluation of chronic kidney disease and also defining interventions," said Dr. Claus U. Niemann, professor of anesthesia and surgery at the University of California, San Francisco.

Kidney disease is identified either by markers of function such as glomerular filtration rate (GFR), markers of damage such as proteinuria, and markers of volume sense, such as edema, ascites, and urinary sodium excretion.

None of these measures is particularly accurate at measuring disease, however. For example, GFR is not observed directly but estimated from creatinine clearance, which is produced by the body in varying amounts daily and which depends on muscle mass, so that values for a young, muscular man will be higher than those of a small, older woman, Dr. Niemann noted.

In addition, even in people without kidney disease, GFR declines gradually with age, from about 116 mL/min per 1.73 m² for people in their 20s, to about 75 mL/min per 1.73 m² in those aged 70 years and older.

In 2002, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) developed a five-stage classification for chronic kidney disease (CKD), based on GFR, with CKD defined as either a GFR of less than 60 mL/min per 1.73 m² for more than 3 months or evidence of kidney damage for more than 3 months, based on the presence of abnormalities such as proteinuria. The classification notes that a combination of GFR less than 60 mL/min per 1.73 m² and proteinuria is prognostic.

The classification includes moderately and severely reduced GFR, with respective rates of 30-59 and 15-29 mL/min per 1.73 m², respectively, and end-stage renal disease, with a GFR less than 15 mL/min per 1.73 m² or a need for dialysis,

The most common cause of CKD is diabetic nephropathy or hypertensive nephrosclerosis, which account for 67% of all cases. About 1 in 5 or 1 in 6 Americans has some form of CKD, and the problem can be lifelong, Dr. Niemann said.

Risk stratification

The goal of perioperative management of patients with CKD is to prevent further renal impairment from acute kidney injury, a rapid reduction in kidney function as measured by a significant rise in serum creatinine levels or reduction in urine output within 48 hours of exposure.

Approximately 5%-7% of all hospitalized patients experience some degree of acute kidney injury and changes in serum creatinine of only 0.3 mg/dL have been associated with greater length of stay and increased morbidity and mortality, Dr. Niemann said.

"What is really necessary is that we do perioperative risk stratification. We want to identify the subset of patients who are at risk, we can do tests potentially, and we want to understand what the procedure is, put it in the context of the patient and his renal disease, and then hopefully define a plan and get him to surgery," Dr. Niemann said.

Defining perioperative renal risk involves determining as best as possible the extent of renal insufficiency or CKD, the etiology of the kidney disease (including severity and complications), and the risk of loss of kidney function from the planned or urgent/emergent surgery. The preop clinical team should also know where the patient will be discharged after surgery (home, ICU, floor).

Risk factors for in-hospital acute renal failure include baseline risks, such as age, diabetes, heart or liver failure, and male sex; acute clinical conditions, such as sepsis, hypotension, shock, volume depletion, or rhabdomyolysis; and use of nephrotoxic agents, such as contrast media, aminoglycosides, chemotherapy drugs, or NSAIDs.

Mixed results

Dr. Niemann noted that in a systematic review of possible interventions for protecting renal function in the perioperative period found little in the way of solid evidence to support the use of various interventions, including dopamine agonists or analogs, loop diuretics, mannitol, calcium inhibitors, angiotensin-converting enzyme (ACE) inhibitors, N-acetylcysteine in contrast studies or surgery, or sodium bicarbonate (Cochrane Database of Syst. Rev. 2013;9:CD003590 [doi:10.1002/14651858.CD003590.pub]).

"The long and the short of it is that no interventions have definitely been shown to make a big difference in randomized trials," he said.

Nonetheless, to prevent further loss of renal function in at-risk patients, clinicians should optimize modifiable variables, such as blood pressure, and discontinue nephrotoxic medications, such as NSAIDs.

In addition, the perioperative team should strive to better control acidosis, anemia, and hyperphosphatemia.

"I think what is really important is that you counsel the patient in the preop clinic," Dr. Niemann said.

Preoperative clinic staff should review the procedure and risks based on the presence and severity of the patient’s CKD and outline possible outcomes based on the best available evidence.

"We do it for the heart, but we don’t do it for the kidney," he commented.

During surgery, the team should be aware of the risks of a potential "second hit" – that is, an acute injury on top of chronic disease, and after surgery, clinicians should monitor for the known risk factors, such as sepsis and infection, he said.

Dr. Niemann reported no relevant conflicts.

SCOTTSDALE, ARIZ. – The presence of a coronary artery stent is not a barrier to noncardiac surgery, but it may change the timing of surgery and perioperative management of the patient, a hospitalist cautions.

Patients who receive bare-metal stents should delay having elective surgery for at least 6 weeks after stent placement, and those who receive a drug-eluting stent should put off elective procedures for at least a year, said Dr. Amir K. Jaffer, professor of medicine and chief of the division of hospital medicine at Rush University Medical Center in Chicago.

© Darren Hester/Fotolia.com

The type of stent, its placement, and the time since placement are just some of the key pieces of information that clinicians need to manage patients, Dr. Jaffer said at a meeting on perioperative medicine sponsored by the University of Miami.

"You want to try to get that [information] card if you can from the patient, about where the stents were placed, and if they don’t have the card handy, you really need to go to the procedure note, because the patient may or may not know if it was a drug-eluting stent," he said.

Other vital pieces of the perioperative puzzle are which coronary vessel the stent was implanted in; when the stent was implanted; what drug, if any (sirolimus or paclitaxel) is eluted by the stent; whether there were surgical or postoperative complications; prior history of stent thrombosis; the patient’s comorbidities; duration of dual-antiplatelet therapy; and how the patient has fared on therapy.

Prior to an elective noncardiac procedure, clinicians must consider patient risk factors, including indication for antithrombotic therapy, risk factors for thrombosis or thromboembolism, and type of antithrombotic agent; and surgical risk factors, including type of procedure, bleeding risk, thromboembolism risk, and time off antithrombotic therapy.

When to stop antithrombotic agents

Dr. Jaffer noted that because aspirin is an irreversible inhibitor of platelet cyclooxygenase and the circulating platelet pool is replaced every 7 to 10 days, patients on aspirin as part of their dual-antiplatelet therapy should stop taking the drug from 7 to 10 days before scheduled surgery.

Thienopyridines/P2Y12 receptor antagonists such as clopidogrel (Plavix) and ticagrelor (Brilinta) work by inhibiting adenosine diphosphate (ADP) receptor-mediated platelet activation and aggregation. Dr. Jaffer said that although guidelines recommend stopping these agents 7 days before surgery, there is evidence to suggest that 5 days may be a sufficient window of safety.

It is also important to take into consideration the pharmacokinetic profiles of the specific antiplatelet agents. For example, ticagrelor has a more rapid onset and greater degree of platelet-aggregation inhibition than clopidogrel, although the time from stopping each agent until the return to near-baseline platelet aggregation is similar, on the order of about 120 hours (5 days) or longer, he said.

Risk varies by surgery type

The type of surgery is also important, as certain procedures – such as neurocranial surgery, spinal canal surgery, and procedures performed in the posterior chamber of the eye – carry a high risk for hemorrhage and are likely to require blood transfusions.

Dr. Jaffer noted that in 2007, the American College of Cardiology and American Heart Association issued a joint advisory on antiplatelet therapy and noncardiac surgery, which warned health care providers about the potentially catastrophic risks of stopping thienopyridines prematurely, which could result in acute stent thrombosis, myocardial infarction, and death. The guidelines recommend waiting a minimum of 6 weeks for noncardiac surgery following implantation of a bare-metal stent, and 1 year after a drug-eluting stent.

He pointed to two studies from the Mayo Clinic published in 2008. The first study showed that the risk of major cardiac adverse events among patients with a bare-metal stent undergoing noncardiac surgery within 30 days of stent placement was approximately 10%, but diminished to 2.7% at 91 days after placement (Anesthesiology 2008;109:588-95). The second study showed that the risk of major cardiac adverse events was 6.1% within 90 days after implantation of a drug-eluting stent, with the risk dwindling to 3.1% after 1 year (Anesthesiology 2008;109:596-604).

If urgent surgery such as a hemicolectomy for colon cancer is required within 6 months of drug-eluting stent implantation, the patient should continue on dual-antiplatelet therapy, Dr. Jaffer said. If the surgery is from 6 months to 1 year after implantation in these patients, the patient should be continued on at least 81 mg aspirin, but if the patient is taking clopidogrel, he or she should have the thienopyridine discontinued 5 days before surgery and the drug resumed as soon as possible after surgery with a 300-mg loading dose, followed by 75 mg daily. If the patient is not yet able to eat, the dual-antiplatelet therapy should be delivered via nasogastric tube, he said.

Dr. Jaffer reported serving as a consultant to Boehringer Ingelheim, Janssen Pharmaceuticals, and other companies. Dr. Jaffer also serves on the editorial advisory board of Hospitalist News.

SCOTTSDALE, ARIZ. – The presence of a coronary artery stent is not a barrier to noncardiac surgery, but it may change the timing of surgery and perioperative management of the patient, a hospitalist cautions.

Patients who receive bare-metal stents should delay having elective surgery for at least 6 weeks after stent placement, and those who receive a drug-eluting stent should put off elective procedures for at least a year, said Dr. Amir K. Jaffer, professor of medicine and chief of the division of hospital medicine at Rush University Medical Center in Chicago.

© Darren Hester/Fotolia.com

The type of stent, its placement, and the time since placement are just some of the key pieces of information that clinicians need to manage patients, Dr. Jaffer said at a meeting on perioperative medicine sponsored by the University of Miami.

"You want to try to get that [information] card if you can from the patient, about where the stents were placed, and if they don’t have the card handy, you really need to go to the procedure note, because the patient may or may not know if it was a drug-eluting stent," he said.

Other vital pieces of the perioperative puzzle are which coronary vessel the stent was implanted in; when the stent was implanted; what drug, if any (sirolimus or paclitaxel) is eluted by the stent; whether there were surgical or postoperative complications; prior history of stent thrombosis; the patient’s comorbidities; duration of dual-antiplatelet therapy; and how the patient has fared on therapy.

Prior to an elective noncardiac procedure, clinicians must consider patient risk factors, including indication for antithrombotic therapy, risk factors for thrombosis or thromboembolism, and type of antithrombotic agent; and surgical risk factors, including type of procedure, bleeding risk, thromboembolism risk, and time off antithrombotic therapy.

When to stop antithrombotic agents

Dr. Jaffer noted that because aspirin is an irreversible inhibitor of platelet cyclooxygenase and the circulating platelet pool is replaced every 7 to 10 days, patients on aspirin as part of their dual-antiplatelet therapy should stop taking the drug from 7 to 10 days before scheduled surgery.

Thienopyridines/P2Y12 receptor antagonists such as clopidogrel (Plavix) and ticagrelor (Brilinta) work by inhibiting adenosine diphosphate (ADP) receptor-mediated platelet activation and aggregation. Dr. Jaffer said that although guidelines recommend stopping these agents 7 days before surgery, there is evidence to suggest that 5 days may be a sufficient window of safety.

It is also important to take into consideration the pharmacokinetic profiles of the specific antiplatelet agents. For example, ticagrelor has a more rapid onset and greater degree of platelet-aggregation inhibition than clopidogrel, although the time from stopping each agent until the return to near-baseline platelet aggregation is similar, on the order of about 120 hours (5 days) or longer, he said.

Risk varies by surgery type

The type of surgery is also important, as certain procedures – such as neurocranial surgery, spinal canal surgery, and procedures performed in the posterior chamber of the eye – carry a high risk for hemorrhage and are likely to require blood transfusions.

Dr. Jaffer noted that in 2007, the American College of Cardiology and American Heart Association issued a joint advisory on antiplatelet therapy and noncardiac surgery, which warned health care providers about the potentially catastrophic risks of stopping thienopyridines prematurely, which could result in acute stent thrombosis, myocardial infarction, and death. The guidelines recommend waiting a minimum of 6 weeks for noncardiac surgery following implantation of a bare-metal stent, and 1 year after a drug-eluting stent.

He pointed to two studies from the Mayo Clinic published in 2008. The first study showed that the risk of major cardiac adverse events among patients with a bare-metal stent undergoing noncardiac surgery within 30 days of stent placement was approximately 10%, but diminished to 2.7% at 91 days after placement (Anesthesiology 2008;109:588-95). The second study showed that the risk of major cardiac adverse events was 6.1% within 90 days after implantation of a drug-eluting stent, with the risk dwindling to 3.1% after 1 year (Anesthesiology 2008;109:596-604).

If urgent surgery such as a hemicolectomy for colon cancer is required within 6 months of drug-eluting stent implantation, the patient should continue on dual-antiplatelet therapy, Dr. Jaffer said. If the surgery is from 6 months to 1 year after implantation in these patients, the patient should be continued on at least 81 mg aspirin, but if the patient is taking clopidogrel, he or she should have the thienopyridine discontinued 5 days before surgery and the drug resumed as soon as possible after surgery with a 300-mg loading dose, followed by 75 mg daily. If the patient is not yet able to eat, the dual-antiplatelet therapy should be delivered via nasogastric tube, he said.

Dr. Jaffer reported serving as a consultant to Boehringer Ingelheim, Janssen Pharmaceuticals, and other companies. Dr. Jaffer also serves on the editorial advisory board of Hospitalist News.

SCOTTSDALE, ARIZ. – The presence of a coronary artery stent is not a barrier to noncardiac surgery, but it may change the timing of surgery and perioperative management of the patient, a hospitalist cautions.

Patients who receive bare-metal stents should delay having elective surgery for at least 6 weeks after stent placement, and those who receive a drug-eluting stent should put off elective procedures for at least a year, said Dr. Amir K. Jaffer, professor of medicine and chief of the division of hospital medicine at Rush University Medical Center in Chicago.

© Darren Hester/Fotolia.com

The type of stent, its placement, and the time since placement are just some of the key pieces of information that clinicians need to manage patients, Dr. Jaffer said at a meeting on perioperative medicine sponsored by the University of Miami.

"You want to try to get that [information] card if you can from the patient, about where the stents were placed, and if they don’t have the card handy, you really need to go to the procedure note, because the patient may or may not know if it was a drug-eluting stent," he said.

Other vital pieces of the perioperative puzzle are which coronary vessel the stent was implanted in; when the stent was implanted; what drug, if any (sirolimus or paclitaxel) is eluted by the stent; whether there were surgical or postoperative complications; prior history of stent thrombosis; the patient’s comorbidities; duration of dual-antiplatelet therapy; and how the patient has fared on therapy.

Prior to an elective noncardiac procedure, clinicians must consider patient risk factors, including indication for antithrombotic therapy, risk factors for thrombosis or thromboembolism, and type of antithrombotic agent; and surgical risk factors, including type of procedure, bleeding risk, thromboembolism risk, and time off antithrombotic therapy.

When to stop antithrombotic agents

Dr. Jaffer noted that because aspirin is an irreversible inhibitor of platelet cyclooxygenase and the circulating platelet pool is replaced every 7 to 10 days, patients on aspirin as part of their dual-antiplatelet therapy should stop taking the drug from 7 to 10 days before scheduled surgery.

Thienopyridines/P2Y12 receptor antagonists such as clopidogrel (Plavix) and ticagrelor (Brilinta) work by inhibiting adenosine diphosphate (ADP) receptor-mediated platelet activation and aggregation. Dr. Jaffer said that although guidelines recommend stopping these agents 7 days before surgery, there is evidence to suggest that 5 days may be a sufficient window of safety.

It is also important to take into consideration the pharmacokinetic profiles of the specific antiplatelet agents. For example, ticagrelor has a more rapid onset and greater degree of platelet-aggregation inhibition than clopidogrel, although the time from stopping each agent until the return to near-baseline platelet aggregation is similar, on the order of about 120 hours (5 days) or longer, he said.

Risk varies by surgery type

The type of surgery is also important, as certain procedures – such as neurocranial surgery, spinal canal surgery, and procedures performed in the posterior chamber of the eye – carry a high risk for hemorrhage and are likely to require blood transfusions.

Dr. Jaffer noted that in 2007, the American College of Cardiology and American Heart Association issued a joint advisory on antiplatelet therapy and noncardiac surgery, which warned health care providers about the potentially catastrophic risks of stopping thienopyridines prematurely, which could result in acute stent thrombosis, myocardial infarction, and death. The guidelines recommend waiting a minimum of 6 weeks for noncardiac surgery following implantation of a bare-metal stent, and 1 year after a drug-eluting stent.

He pointed to two studies from the Mayo Clinic published in 2008. The first study showed that the risk of major cardiac adverse events among patients with a bare-metal stent undergoing noncardiac surgery within 30 days of stent placement was approximately 10%, but diminished to 2.7% at 91 days after placement (Anesthesiology 2008;109:588-95). The second study showed that the risk of major cardiac adverse events was 6.1% within 90 days after implantation of a drug-eluting stent, with the risk dwindling to 3.1% after 1 year (Anesthesiology 2008;109:596-604).

If urgent surgery such as a hemicolectomy for colon cancer is required within 6 months of drug-eluting stent implantation, the patient should continue on dual-antiplatelet therapy, Dr. Jaffer said. If the surgery is from 6 months to 1 year after implantation in these patients, the patient should be continued on at least 81 mg aspirin, but if the patient is taking clopidogrel, he or she should have the thienopyridine discontinued 5 days before surgery and the drug resumed as soon as possible after surgery with a 300-mg loading dose, followed by 75 mg daily. If the patient is not yet able to eat, the dual-antiplatelet therapy should be delivered via nasogastric tube, he said.

Dr. Jaffer reported serving as a consultant to Boehringer Ingelheim, Janssen Pharmaceuticals, and other companies. Dr. Jaffer also serves on the editorial advisory board of Hospitalist News.

SCOTTSDALE, ARIZ. – Comanaging neurosurgical patients requires a delicate dance between primary practitioners, surgeons, anesthesiologists, and, in some cases, the makers of implantable neurostimulators, according to perioperative medicine specialists.

Special considerations with patients scheduled for neurosurgical procedures include hypertension, fever, hyponatremia, and risk of deep vein thromboembolism (DVT) and coagulopathies, said Dr. Richard Huh, director of the inpatient medical consultation service at Rush University Medical Center in Chicago, at a meeting on perioperative medicine sponsored by the University of Miami.

For example, hospitalists are typically involved in the management of blood pressure in neurosurgery patients because of the importance of controlling intracranial pressure, Dr. Huh noted.

"The trick is for the blood pressure not to get too high or too low. The Handbook of Neurosurgery suggests a goal of 140 over 90 [mm Hg]," he said.

Patients with acute subarachnoid hemorrhage are at risk for vasospasm, most frequently within 7-10 days of hemorrhage. Hypovolemia is a common cause of vasospasm and should be avoided. Medications such as nimodipine (Nimotop) can help prevent this complication.

Patients undergoing spinal procedures tend to have low blood pressure from acute blood loss or intravenous pain medications, and may require hold parameters on medications to avoid complications from hypotension.

However, on the day following spinal surgery, some patients develop hypertension, and may require additional medications for BP control.

Hyponatremia

The reported prevalence of hyponatremia in hospitalized patients ranges from 1%-7%, and the rate is even higher in neurosurgical patients, possibility because the brain’s response to changes in osmolality. Clinicians managing neurosurgical patients should be aware of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting, Dr. Huh said.

Cerebral salt wasting may be cause by damaged brain cells that affect sympathetic neural input to the kidneys, decreasing sodium resorption and an increase in atrial natriuretic peptide and brain natriuretic peptide.

The syndrome looks similar to SIADH, with high urinary sodium and osmolality, low serum osmolality, and decreased serum uric acid. But cerebral salt wasting is distinguished from SIADH by the presence of hypovolemia. Cerebral salt wasting is treated with saline and/or salt tablets.

DVT

Neurosurgical patients are at increased risk for DVT and pulmonary embolism compared with the general postoperative population. However, 2012 guidelines on antithrombotic therapy from the American College of Chest Physicians recommend against pharmacologic prophylaxis except for high risk patients, such as patients with intracranial masses. Dr. Huh said.

Implantable neurostimulators

Patients with implanted devices such as deep-brain stimulators for control of Parkinson’s disease, hypoglossal nerve stimulators for severe sleep apnea, or vagal nerve stimulators for epilepsy also require special consideration throughout the perioperative period.

Issues to consider when managing a patient with an implantable device include the device site and its proximity to the planned surgical field, indication for the device, comorbidities, and the patient’s goals for treatment, said Dr. Deborah Richman, section chief of preoperative services at Stony Brook (New York) University Medical Center.

"What do we do with device itself? This is a team approach, and we find that it’s best coordinated by our nurses in the preop holding area, because they know what time the surgery is, they have the device company rep’s phone number, they make sure the patient is there on time, and they put everything together to prevent delays on the day of surgery," she said.

In general, device manufacturers recommend turning devices off, and to turn the amplitude down to zero to prevent accidental activation of magnetic on-off switches.

The distance from the surgery to the pulse generator should be a minimum of 20 cm, and electrocautery, if used, should be bipolar rather than monopolar, Dr. Richman said.

Patients with implanted devices will also require prophylactic antibiotics to prevent potential bacterial seeding of the device or leads, she said,

Coordination of perioperative care "is best done with clinical management pathways, so that when you have one of these patients who present to you, you have a checklist that includes the device company’s phone number, and it’s an easy go-to, so that you don’t have to start from scratch each time," she concluded.

Dr. Huh and Dr. Richman reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Comanaging neurosurgical patients requires a delicate dance between primary practitioners, surgeons, anesthesiologists, and, in some cases, the makers of implantable neurostimulators, according to perioperative medicine specialists.

Special considerations with patients scheduled for neurosurgical procedures include hypertension, fever, hyponatremia, and risk of deep vein thromboembolism (DVT) and coagulopathies, said Dr. Richard Huh, director of the inpatient medical consultation service at Rush University Medical Center in Chicago, at a meeting on perioperative medicine sponsored by the University of Miami.

For example, hospitalists are typically involved in the management of blood pressure in neurosurgery patients because of the importance of controlling intracranial pressure, Dr. Huh noted.

"The trick is for the blood pressure not to get too high or too low. The Handbook of Neurosurgery suggests a goal of 140 over 90 [mm Hg]," he said.

Patients with acute subarachnoid hemorrhage are at risk for vasospasm, most frequently within 7-10 days of hemorrhage. Hypovolemia is a common cause of vasospasm and should be avoided. Medications such as nimodipine (Nimotop) can help prevent this complication.

Patients undergoing spinal procedures tend to have low blood pressure from acute blood loss or intravenous pain medications, and may require hold parameters on medications to avoid complications from hypotension.

However, on the day following spinal surgery, some patients develop hypertension, and may require additional medications for BP control.

Hyponatremia

The reported prevalence of hyponatremia in hospitalized patients ranges from 1%-7%, and the rate is even higher in neurosurgical patients, possibility because the brain’s response to changes in osmolality. Clinicians managing neurosurgical patients should be aware of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting, Dr. Huh said.

Cerebral salt wasting may be cause by damaged brain cells that affect sympathetic neural input to the kidneys, decreasing sodium resorption and an increase in atrial natriuretic peptide and brain natriuretic peptide.

The syndrome looks similar to SIADH, with high urinary sodium and osmolality, low serum osmolality, and decreased serum uric acid. But cerebral salt wasting is distinguished from SIADH by the presence of hypovolemia. Cerebral salt wasting is treated with saline and/or salt tablets.

DVT

Neurosurgical patients are at increased risk for DVT and pulmonary embolism compared with the general postoperative population. However, 2012 guidelines on antithrombotic therapy from the American College of Chest Physicians recommend against pharmacologic prophylaxis except for high risk patients, such as patients with intracranial masses. Dr. Huh said.

Implantable neurostimulators

Patients with implanted devices such as deep-brain stimulators for control of Parkinson’s disease, hypoglossal nerve stimulators for severe sleep apnea, or vagal nerve stimulators for epilepsy also require special consideration throughout the perioperative period.

Issues to consider when managing a patient with an implantable device include the device site and its proximity to the planned surgical field, indication for the device, comorbidities, and the patient’s goals for treatment, said Dr. Deborah Richman, section chief of preoperative services at Stony Brook (New York) University Medical Center.

"What do we do with device itself? This is a team approach, and we find that it’s best coordinated by our nurses in the preop holding area, because they know what time the surgery is, they have the device company rep’s phone number, they make sure the patient is there on time, and they put everything together to prevent delays on the day of surgery," she said.

In general, device manufacturers recommend turning devices off, and to turn the amplitude down to zero to prevent accidental activation of magnetic on-off switches.

The distance from the surgery to the pulse generator should be a minimum of 20 cm, and electrocautery, if used, should be bipolar rather than monopolar, Dr. Richman said.

Patients with implanted devices will also require prophylactic antibiotics to prevent potential bacterial seeding of the device or leads, she said,

Coordination of perioperative care "is best done with clinical management pathways, so that when you have one of these patients who present to you, you have a checklist that includes the device company’s phone number, and it’s an easy go-to, so that you don’t have to start from scratch each time," she concluded.

Dr. Huh and Dr. Richman reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Comanaging neurosurgical patients requires a delicate dance between primary practitioners, surgeons, anesthesiologists, and, in some cases, the makers of implantable neurostimulators, according to perioperative medicine specialists.

Special considerations with patients scheduled for neurosurgical procedures include hypertension, fever, hyponatremia, and risk of deep vein thromboembolism (DVT) and coagulopathies, said Dr. Richard Huh, director of the inpatient medical consultation service at Rush University Medical Center in Chicago, at a meeting on perioperative medicine sponsored by the University of Miami.

For example, hospitalists are typically involved in the management of blood pressure in neurosurgery patients because of the importance of controlling intracranial pressure, Dr. Huh noted.

"The trick is for the blood pressure not to get too high or too low. The Handbook of Neurosurgery suggests a goal of 140 over 90 [mm Hg]," he said.

Patients with acute subarachnoid hemorrhage are at risk for vasospasm, most frequently within 7-10 days of hemorrhage. Hypovolemia is a common cause of vasospasm and should be avoided. Medications such as nimodipine (Nimotop) can help prevent this complication.

Patients undergoing spinal procedures tend to have low blood pressure from acute blood loss or intravenous pain medications, and may require hold parameters on medications to avoid complications from hypotension.

However, on the day following spinal surgery, some patients develop hypertension, and may require additional medications for BP control.

Hyponatremia

The reported prevalence of hyponatremia in hospitalized patients ranges from 1%-7%, and the rate is even higher in neurosurgical patients, possibility because the brain’s response to changes in osmolality. Clinicians managing neurosurgical patients should be aware of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting, Dr. Huh said.

Cerebral salt wasting may be cause by damaged brain cells that affect sympathetic neural input to the kidneys, decreasing sodium resorption and an increase in atrial natriuretic peptide and brain natriuretic peptide.

The syndrome looks similar to SIADH, with high urinary sodium and osmolality, low serum osmolality, and decreased serum uric acid. But cerebral salt wasting is distinguished from SIADH by the presence of hypovolemia. Cerebral salt wasting is treated with saline and/or salt tablets.

DVT

Neurosurgical patients are at increased risk for DVT and pulmonary embolism compared with the general postoperative population. However, 2012 guidelines on antithrombotic therapy from the American College of Chest Physicians recommend against pharmacologic prophylaxis except for high risk patients, such as patients with intracranial masses. Dr. Huh said.

Implantable neurostimulators

Patients with implanted devices such as deep-brain stimulators for control of Parkinson’s disease, hypoglossal nerve stimulators for severe sleep apnea, or vagal nerve stimulators for epilepsy also require special consideration throughout the perioperative period.

Issues to consider when managing a patient with an implantable device include the device site and its proximity to the planned surgical field, indication for the device, comorbidities, and the patient’s goals for treatment, said Dr. Deborah Richman, section chief of preoperative services at Stony Brook (New York) University Medical Center.

"What do we do with device itself? This is a team approach, and we find that it’s best coordinated by our nurses in the preop holding area, because they know what time the surgery is, they have the device company rep’s phone number, they make sure the patient is there on time, and they put everything together to prevent delays on the day of surgery," she said.

In general, device manufacturers recommend turning devices off, and to turn the amplitude down to zero to prevent accidental activation of magnetic on-off switches.

The distance from the surgery to the pulse generator should be a minimum of 20 cm, and electrocautery, if used, should be bipolar rather than monopolar, Dr. Richman said.

Patients with implanted devices will also require prophylactic antibiotics to prevent potential bacterial seeding of the device or leads, she said,

Coordination of perioperative care "is best done with clinical management pathways, so that when you have one of these patients who present to you, you have a checklist that includes the device company’s phone number, and it’s an easy go-to, so that you don’t have to start from scratch each time," she concluded.

Dr. Huh and Dr. Richman reported having no financial disclosures.

SCOTTSDALE, ARIZ. – When patients on immunosuppressive therapies need surgery, the risks of disease flare and compromised postoperative recovery and rehabilitation must be weighed against the risk of increased infections and impaired wound healing.

"I’m not sure that there is necessarily a right answer, but I think most people would stop biologic [agents] beforehand," Dr. Paul Grant said at a meeting on perioperative medicine sponsored by the University of Miami.

The decision whether to suspend a disease-modifying antirheumatic drug before surgery may depend on the individual drug and on the patient, said Dr. Grant, director of perioperative and consultative medicine at the University of Michigan Health System in Ann Arbor.

For example, it appears to be safe for patients on methotrexate to continue on therapy during elective orthopedic surgery. Evidence for this comes from a randomized clinical trial in which patients with rheumatoid arthritis (RA) were assigned to either continue on methotrexate (MTX) or suspend taking it for 2 weeks before and 2 weeks after surgery. The study also contained a control of patients with RA who were not on MTX (Ann. Rheum. Dis. 2001;60:214-7).

The investigators found that there were no significant differences in early complication rates or in complications up to 1 year of follow-up between patients who suspended or remained on MTX. Patients who stayed on the drug had significantly lower rates of RA flare.

Additionally, two systematic reviews, one looking at eight studies echoes the findings of the aforementioned randomized trial, and the other looking at four studies, in which the reviewer concluded that "continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares (Clin. Exp. Rheumatol. 2009;27:856-62) (Clin. Rheumatol. 2008;27:1217-20).None of the examined papers addresses the issue of safety in connection with comorbidities, age, or high doses of methotrexate."

"The bottom line here is that methotrexate should be continued for most surgeries. I think it might be reasonable to hold it in certain situations, for example if the patient has pretty bad kidney or liver disease, or if it’s surgery to treat a major infection," Dr. Grant said.

TNF-alpha antagonists

In contrast, the data on tumor necrosis factor–alpha (TNF-alpha) antagonists are fuzzier, with limited and conflicting information on perioperative use of these agents (etanercept, infliximab, adalimumab, certolizumab, golimumab).

"The major concern with these drugs is infection," Dr. Grant said. He pointed to a meta-analysis published in JAMA in 2006, which showed that taking the drugs doubled the risk of serious infections in general. The study did not specifically look at perioperative use of TNF-alpha antagonists (JAMA 2006;295:2275-85).

A retrospective cohort studyof 127 patients with RA who were undergoing various orthopedic procedures found that there were no differences in surgical site infections but more cases of wound dehiscence in patients who continued on the drugs, compared with those who interrupted their use perioperatively (Clin. Exp. Rheumatol. 2007;25:430-6).

A second, prospective study in 31 patients with RA undergoing foot/ankle surgery found that there were no significant differences in infection or healing between patients who interrupted therapy and those who did not (Foot Ankle Clin. 2007;12:509-24).

Other studies and systematic reviews in patients with RA or Crohn’s disease generally found no significant differences in serious infection rates, but they did detect a higher incidence of skin and soft-tissue infections among patients on anti-TNF-alpha agents vs. other disease-modifying antirheumatic drugs.

The risk of infections tends to be highest at the start of therapy with a TNF-alpha antagonist and stopping therapy is more likely to result in RA flares among patients with established disease, compared with those in the early stages of RA. Therefore, TNF blocker therapy should be restarted as soon as possible after surgery to prevent flare, Dr. Grant said.

The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks. These agents should also be held for 10-14 days after surgery or until wound healing is satisfactory.

"It’s probably safe to continue these medications for minor surgeries," Dr. Grant said.

Other agents

The anti-CD20 agent rituximab (Rituxan) – currently used to treat RA, vasculitis, hematologic malignancies, and other conditions – has a lower risk for bacterial infections than does TNF-alpha antagonists and has been shown to be safe in patients with a history of recurrent bacterial infections.

"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.

There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.

There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.

Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.

"Stress dose steroids are not routinely needed as long as the patients continue their normal dose. That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.

Dr. Grant reported having no financial disclosures.

SCOTTSDALE, ARIZ. – When patients on immunosuppressive therapies need surgery, the risks of disease flare and compromised postoperative recovery and rehabilitation must be weighed against the risk of increased infections and impaired wound healing.

"I’m not sure that there is necessarily a right answer, but I think most people would stop biologic [agents] beforehand," Dr. Paul Grant said at a meeting on perioperative medicine sponsored by the University of Miami.

The decision whether to suspend a disease-modifying antirheumatic drug before surgery may depend on the individual drug and on the patient, said Dr. Grant, director of perioperative and consultative medicine at the University of Michigan Health System in Ann Arbor.

For example, it appears to be safe for patients on methotrexate to continue on therapy during elective orthopedic surgery. Evidence for this comes from a randomized clinical trial in which patients with rheumatoid arthritis (RA) were assigned to either continue on methotrexate (MTX) or suspend taking it for 2 weeks before and 2 weeks after surgery. The study also contained a control of patients with RA who were not on MTX (Ann. Rheum. Dis. 2001;60:214-7).

The investigators found that there were no significant differences in early complication rates or in complications up to 1 year of follow-up between patients who suspended or remained on MTX. Patients who stayed on the drug had significantly lower rates of RA flare.

Additionally, two systematic reviews, one looking at eight studies echoes the findings of the aforementioned randomized trial, and the other looking at four studies, in which the reviewer concluded that "continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares (Clin. Exp. Rheumatol. 2009;27:856-62) (Clin. Rheumatol. 2008;27:1217-20).None of the examined papers addresses the issue of safety in connection with comorbidities, age, or high doses of methotrexate."

"The bottom line here is that methotrexate should be continued for most surgeries. I think it might be reasonable to hold it in certain situations, for example if the patient has pretty bad kidney or liver disease, or if it’s surgery to treat a major infection," Dr. Grant said.

TNF-alpha antagonists

In contrast, the data on tumor necrosis factor–alpha (TNF-alpha) antagonists are fuzzier, with limited and conflicting information on perioperative use of these agents (etanercept, infliximab, adalimumab, certolizumab, golimumab).

"The major concern with these drugs is infection," Dr. Grant said. He pointed to a meta-analysis published in JAMA in 2006, which showed that taking the drugs doubled the risk of serious infections in general. The study did not specifically look at perioperative use of TNF-alpha antagonists (JAMA 2006;295:2275-85).

A retrospective cohort studyof 127 patients with RA who were undergoing various orthopedic procedures found that there were no differences in surgical site infections but more cases of wound dehiscence in patients who continued on the drugs, compared with those who interrupted their use perioperatively (Clin. Exp. Rheumatol. 2007;25:430-6).

A second, prospective study in 31 patients with RA undergoing foot/ankle surgery found that there were no significant differences in infection or healing between patients who interrupted therapy and those who did not (Foot Ankle Clin. 2007;12:509-24).

Other studies and systematic reviews in patients with RA or Crohn’s disease generally found no significant differences in serious infection rates, but they did detect a higher incidence of skin and soft-tissue infections among patients on anti-TNF-alpha agents vs. other disease-modifying antirheumatic drugs.

The risk of infections tends to be highest at the start of therapy with a TNF-alpha antagonist and stopping therapy is more likely to result in RA flares among patients with established disease, compared with those in the early stages of RA. Therefore, TNF blocker therapy should be restarted as soon as possible after surgery to prevent flare, Dr. Grant said.

The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks. These agents should also be held for 10-14 days after surgery or until wound healing is satisfactory.

"It’s probably safe to continue these medications for minor surgeries," Dr. Grant said.

Other agents

The anti-CD20 agent rituximab (Rituxan) – currently used to treat RA, vasculitis, hematologic malignancies, and other conditions – has a lower risk for bacterial infections than does TNF-alpha antagonists and has been shown to be safe in patients with a history of recurrent bacterial infections.

"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.

There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.

There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.

Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.

"Stress dose steroids are not routinely needed as long as the patients continue their normal dose. That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.

Dr. Grant reported having no financial disclosures.

SCOTTSDALE, ARIZ. – When patients on immunosuppressive therapies need surgery, the risks of disease flare and compromised postoperative recovery and rehabilitation must be weighed against the risk of increased infections and impaired wound healing.

"I’m not sure that there is necessarily a right answer, but I think most people would stop biologic [agents] beforehand," Dr. Paul Grant said at a meeting on perioperative medicine sponsored by the University of Miami.

The decision whether to suspend a disease-modifying antirheumatic drug before surgery may depend on the individual drug and on the patient, said Dr. Grant, director of perioperative and consultative medicine at the University of Michigan Health System in Ann Arbor.

For example, it appears to be safe for patients on methotrexate to continue on therapy during elective orthopedic surgery. Evidence for this comes from a randomized clinical trial in which patients with rheumatoid arthritis (RA) were assigned to either continue on methotrexate (MTX) or suspend taking it for 2 weeks before and 2 weeks after surgery. The study also contained a control of patients with RA who were not on MTX (Ann. Rheum. Dis. 2001;60:214-7).

The investigators found that there were no significant differences in early complication rates or in complications up to 1 year of follow-up between patients who suspended or remained on MTX. Patients who stayed on the drug had significantly lower rates of RA flare.

Additionally, two systematic reviews, one looking at eight studies echoes the findings of the aforementioned randomized trial, and the other looking at four studies, in which the reviewer concluded that "continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares (Clin. Exp. Rheumatol. 2009;27:856-62) (Clin. Rheumatol. 2008;27:1217-20).None of the examined papers addresses the issue of safety in connection with comorbidities, age, or high doses of methotrexate."

"The bottom line here is that methotrexate should be continued for most surgeries. I think it might be reasonable to hold it in certain situations, for example if the patient has pretty bad kidney or liver disease, or if it’s surgery to treat a major infection," Dr. Grant said.

TNF-alpha antagonists

In contrast, the data on tumor necrosis factor–alpha (TNF-alpha) antagonists are fuzzier, with limited and conflicting information on perioperative use of these agents (etanercept, infliximab, adalimumab, certolizumab, golimumab).

"The major concern with these drugs is infection," Dr. Grant said. He pointed to a meta-analysis published in JAMA in 2006, which showed that taking the drugs doubled the risk of serious infections in general. The study did not specifically look at perioperative use of TNF-alpha antagonists (JAMA 2006;295:2275-85).

A retrospective cohort studyof 127 patients with RA who were undergoing various orthopedic procedures found that there were no differences in surgical site infections but more cases of wound dehiscence in patients who continued on the drugs, compared with those who interrupted their use perioperatively (Clin. Exp. Rheumatol. 2007;25:430-6).

A second, prospective study in 31 patients with RA undergoing foot/ankle surgery found that there were no significant differences in infection or healing between patients who interrupted therapy and those who did not (Foot Ankle Clin. 2007;12:509-24).

Other studies and systematic reviews in patients with RA or Crohn’s disease generally found no significant differences in serious infection rates, but they did detect a higher incidence of skin and soft-tissue infections among patients on anti-TNF-alpha agents vs. other disease-modifying antirheumatic drugs.

The risk of infections tends to be highest at the start of therapy with a TNF-alpha antagonist and stopping therapy is more likely to result in RA flares among patients with established disease, compared with those in the early stages of RA. Therefore, TNF blocker therapy should be restarted as soon as possible after surgery to prevent flare, Dr. Grant said.

The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks. These agents should also be held for 10-14 days after surgery or until wound healing is satisfactory.

"It’s probably safe to continue these medications for minor surgeries," Dr. Grant said.

Other agents

The anti-CD20 agent rituximab (Rituxan) – currently used to treat RA, vasculitis, hematologic malignancies, and other conditions – has a lower risk for bacterial infections than does TNF-alpha antagonists and has been shown to be safe in patients with a history of recurrent bacterial infections.

"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.

There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.

There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.

Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.

"Stress dose steroids are not routinely needed as long as the patients continue their normal dose. That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.

Dr. Grant reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Early hospital readmissions are not good for patients and can be terrible for a hospital’s bottom line, but at least one cause of readmission – urinary retention after surgery – can be significantly reduced.

"Postoperative urinary retention is a prevalent and mostly avoidable complication," said Dr. Sarita Khemani, a surgical comanagement hospitalist at Stanford (Calif.) University Medical Center.

Postoperative urinary retention can be defined as the inability to void in the presence of symptoms or bladder distension. However, as some patients may retain urine without feeling symptoms or the urge to void, it can also be defined as the inability to void with a bladder volume greater than 500 mL, or the presence of a postvoid residual volume greater than 200 mL on bladder scan, she said at a meeting on perioperative medicine sponsored by the University of Miami.

Identify high-risk patients

"For management, identifying the high-risk patient is very important," said Dr. Khemani.

She and her colleagues are working to develop a scoring system for identifying patients at risk for postoperative retention, she noted.

Depending on the risk factor, patients may require continued use of benign prostatic hyperplasia (BPH) medications (a strategy currently under clinical investigation), multimodal anesthesia, monitoring of IV fluids during and after surgery, and, when necessary, catheterization.

Frontline Medical News

"There is really no consensus as to what is the best catheterization strategy we should use when it comes to urinary retention," Dr. Khemani said.

Low-risk patients undergoing outpatient procedures can be safely sent home without voiding, she said. High-risk patients undergoing ambulatory surgery can be managed with intermittent catheterization.

Patients who are undergoing major but uncomplicated surgery but are at low risk for postoperative retention do not generally need to have Foley catheters placed before surgery. Indwelling catheters should be limited, if possible, to 24 hours after surgery, and the patient can be managed with bladder scans every 6 hours if needed.

Patients scheduled for extensive, complicated procedures and those at high risk may require an indwelling catheter for up to 5 days after surgery. Studies have shown that in these patients early catheter removal actually increases the risk for postoperative urinary retention, Dr. Khemani said.

"It really needs to be followed by bladder scanning very closely, every 6 hours, to try to prevent overdistention and complications after that," she said.

The incidence of postoperative urinary retention among general surgery patients is 3.8%, but can range as high 70% after orthopedic surgery, 50% after anorectal procedures, 40% following spinal surgeries, and 38% after herniorrhaphy, Dr. Khemani said.

Preoperative risk factors for urinary retention after surgery include age over 50; male sex; history of retention; BPH; history of diabetes, stroke, or spinal lesions; or use of drugs such anticholinergic agents or beta-blockers.

Intraoperative and postoperative risk factors include the type and duration of surgery, anesthesia (especially spinal and epidural anethesias), systemic analgesia with opioids (especially patient-controlled analgesia, or PCA), and the use of intraoperative intravenous fluids. High IV fluid infusion causes rapid distention of the bladder detrusor muscles, leading to inability of the muscles to contract after surgery, Dr. Khemani noted.

Complications of postoperative urinary retention can include:

• Autonomic responses to bladder distention, leading to effects such as bradycardia, hypotension, vomiting, and delirium in some elderly patients.

• Infectious complications – urinary tract infections, sepsis, and joint infections.

• Prolonged need for catheterization.

• Bladder dysfunction.

A recent systematic review of drugs for treatment of urinary retention after surgery in adults found that of seven studies involving a total of 494 patients, neither cholinergic agents, alpha blockers, nor sedatives made a significant difference in reducing the incidence of retention. Only prostaglandins, and only when those agents were given intravesically, appeared to offer any benefit, the authors found.

"At this point we definitely need more studies to look at pharmacological alternatives to catheterization for treatment and prevention of this condition," Dr. Khemani concluded.

She reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Early hospital readmissions are not good for patients and can be terrible for a hospital’s bottom line, but at least one cause of readmission – urinary retention after surgery – can be significantly reduced.

"Postoperative urinary retention is a prevalent and mostly avoidable complication," said Dr. Sarita Khemani, a surgical comanagement hospitalist at Stanford (Calif.) University Medical Center.

Postoperative urinary retention can be defined as the inability to void in the presence of symptoms or bladder distension. However, as some patients may retain urine without feeling symptoms or the urge to void, it can also be defined as the inability to void with a bladder volume greater than 500 mL, or the presence of a postvoid residual volume greater than 200 mL on bladder scan, she said at a meeting on perioperative medicine sponsored by the University of Miami.

Identify high-risk patients

"For management, identifying the high-risk patient is very important," said Dr. Khemani.

She and her colleagues are working to develop a scoring system for identifying patients at risk for postoperative retention, she noted.

Depending on the risk factor, patients may require continued use of benign prostatic hyperplasia (BPH) medications (a strategy currently under clinical investigation), multimodal anesthesia, monitoring of IV fluids during and after surgery, and, when necessary, catheterization.

Frontline Medical News

"There is really no consensus as to what is the best catheterization strategy we should use when it comes to urinary retention," Dr. Khemani said.

Low-risk patients undergoing outpatient procedures can be safely sent home without voiding, she said. High-risk patients undergoing ambulatory surgery can be managed with intermittent catheterization.

Patients who are undergoing major but uncomplicated surgery but are at low risk for postoperative retention do not generally need to have Foley catheters placed before surgery. Indwelling catheters should be limited, if possible, to 24 hours after surgery, and the patient can be managed with bladder scans every 6 hours if needed.

Patients scheduled for extensive, complicated procedures and those at high risk may require an indwelling catheter for up to 5 days after surgery. Studies have shown that in these patients early catheter removal actually increases the risk for postoperative urinary retention, Dr. Khemani said.

"It really needs to be followed by bladder scanning very closely, every 6 hours, to try to prevent overdistention and complications after that," she said.

The incidence of postoperative urinary retention among general surgery patients is 3.8%, but can range as high 70% after orthopedic surgery, 50% after anorectal procedures, 40% following spinal surgeries, and 38% after herniorrhaphy, Dr. Khemani said.

Preoperative risk factors for urinary retention after surgery include age over 50; male sex; history of retention; BPH; history of diabetes, stroke, or spinal lesions; or use of drugs such anticholinergic agents or beta-blockers.

Intraoperative and postoperative risk factors include the type and duration of surgery, anesthesia (especially spinal and epidural anethesias), systemic analgesia with opioids (especially patient-controlled analgesia, or PCA), and the use of intraoperative intravenous fluids. High IV fluid infusion causes rapid distention of the bladder detrusor muscles, leading to inability of the muscles to contract after surgery, Dr. Khemani noted.

Complications of postoperative urinary retention can include:

• Autonomic responses to bladder distention, leading to effects such as bradycardia, hypotension, vomiting, and delirium in some elderly patients.

• Infectious complications – urinary tract infections, sepsis, and joint infections.

• Prolonged need for catheterization.

• Bladder dysfunction.

A recent systematic review of drugs for treatment of urinary retention after surgery in adults found that of seven studies involving a total of 494 patients, neither cholinergic agents, alpha blockers, nor sedatives made a significant difference in reducing the incidence of retention. Only prostaglandins, and only when those agents were given intravesically, appeared to offer any benefit, the authors found.

"At this point we definitely need more studies to look at pharmacological alternatives to catheterization for treatment and prevention of this condition," Dr. Khemani concluded.

She reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Early hospital readmissions are not good for patients and can be terrible for a hospital’s bottom line, but at least one cause of readmission – urinary retention after surgery – can be significantly reduced.

"Postoperative urinary retention is a prevalent and mostly avoidable complication," said Dr. Sarita Khemani, a surgical comanagement hospitalist at Stanford (Calif.) University Medical Center.

Postoperative urinary retention can be defined as the inability to void in the presence of symptoms or bladder distension. However, as some patients may retain urine without feeling symptoms or the urge to void, it can also be defined as the inability to void with a bladder volume greater than 500 mL, or the presence of a postvoid residual volume greater than 200 mL on bladder scan, she said at a meeting on perioperative medicine sponsored by the University of Miami.

Identify high-risk patients

"For management, identifying the high-risk patient is very important," said Dr. Khemani.

She and her colleagues are working to develop a scoring system for identifying patients at risk for postoperative retention, she noted.

Depending on the risk factor, patients may require continued use of benign prostatic hyperplasia (BPH) medications (a strategy currently under clinical investigation), multimodal anesthesia, monitoring of IV fluids during and after surgery, and, when necessary, catheterization.

Frontline Medical News

"There is really no consensus as to what is the best catheterization strategy we should use when it comes to urinary retention," Dr. Khemani said.

Low-risk patients undergoing outpatient procedures can be safely sent home without voiding, she said. High-risk patients undergoing ambulatory surgery can be managed with intermittent catheterization.

Patients who are undergoing major but uncomplicated surgery but are at low risk for postoperative retention do not generally need to have Foley catheters placed before surgery. Indwelling catheters should be limited, if possible, to 24 hours after surgery, and the patient can be managed with bladder scans every 6 hours if needed.

Patients scheduled for extensive, complicated procedures and those at high risk may require an indwelling catheter for up to 5 days after surgery. Studies have shown that in these patients early catheter removal actually increases the risk for postoperative urinary retention, Dr. Khemani said.

"It really needs to be followed by bladder scanning very closely, every 6 hours, to try to prevent overdistention and complications after that," she said.

The incidence of postoperative urinary retention among general surgery patients is 3.8%, but can range as high 70% after orthopedic surgery, 50% after anorectal procedures, 40% following spinal surgeries, and 38% after herniorrhaphy, Dr. Khemani said.

Preoperative risk factors for urinary retention after surgery include age over 50; male sex; history of retention; BPH; history of diabetes, stroke, or spinal lesions; or use of drugs such anticholinergic agents or beta-blockers.

Intraoperative and postoperative risk factors include the type and duration of surgery, anesthesia (especially spinal and epidural anethesias), systemic analgesia with opioids (especially patient-controlled analgesia, or PCA), and the use of intraoperative intravenous fluids. High IV fluid infusion causes rapid distention of the bladder detrusor muscles, leading to inability of the muscles to contract after surgery, Dr. Khemani noted.

Complications of postoperative urinary retention can include:

• Autonomic responses to bladder distention, leading to effects such as bradycardia, hypotension, vomiting, and delirium in some elderly patients.

• Infectious complications – urinary tract infections, sepsis, and joint infections.

• Prolonged need for catheterization.

• Bladder dysfunction.

A recent systematic review of drugs for treatment of urinary retention after surgery in adults found that of seven studies involving a total of 494 patients, neither cholinergic agents, alpha blockers, nor sedatives made a significant difference in reducing the incidence of retention. Only prostaglandins, and only when those agents were given intravesically, appeared to offer any benefit, the authors found.

"At this point we definitely need more studies to look at pharmacological alternatives to catheterization for treatment and prevention of this condition," Dr. Khemani concluded.

She reported having no financial disclosures.

SCOTTSDALE, ARIZ. – Controlling hyperglycemia before and after surgery in patients with diabetes is a balancing act, but when done properly, it can reduce infections and wound complications, according to Dr. David Baldwin.

The key to preoperative planning for patients with diabetes is a full list of medications and an understanding of how well (or how poorly) patients’ glycemia is controlled, said Dr. Baldwin, an endocrinologist at Rush University Medical Center in Chicago.

He discussed strategies for perioperative management of patients with diabetes and thyroid disorders at the Perioperative Medicine Summit 2014."You definitely want to write down exactly what they are and aren’t taking. We find that the medication list for people getting admitted for surgery is often fraught with a lack of little details," he said.

For patients with type 2 diabetes, it’s important to record an accurate description of antidiabetes medications, especially combination oral agents such as Actoplus MET (metformin and pioglitazone) or Janumet (sitagliptin and metformin). For patients with type 1 and 2 diabetes, it is important to record not just the type of insulin but the regimen the patient uses.

Dr. Baldwin noted that many intake staff make the mistake of reporting that patients take "Novolin" or "Humulin," which are brand families of insulin and not specific insulin types.

"We often find, probably at least half of the time, that until we actually go and ask the patients what they take for insulin post-op, the correct information won’t have been in the medical record," he said.

The best way to determine whether a patient has good control of chronic hyperglycemia is with a hemoglobin A_1c (HbA_1c) level. A value above 6.5% is diagnostic for diabetes; well-controlled patients have HbA_1c levels from 6% to 8%. HbA_1c values not more than 2 months old should be a routine part of preoperative evaluations for patients with diabetes or newly discovered hyperglycemia, Dr. Baldwin said.

Preoperative medications

The Rush University protocol for the preoperative management of antidiabetic therapies other than insulin notes that sulfonylureas, metformin, pioglitazone, exenatide, liraglutide, sitagliptin, linagliptin, saxagliptin, alogliptin, alpha-glucosidase inhibitors, and canagaflozin may all be taken with food on the eve of surgery, but none should be taken on the morning of surgery.

Specific rules also apply for patients who use insulin, depending on the insulin type, as follows:

• For long-acting insulins (glargine or detemir), the patient should take the full dose on the evening before surgery or the morning of surgery if the dose is prescribed for either morning or evening administration. Patients with prescriptions for a b.i.d. dose should take the full dose both the evening before and the morning of surgery.

• With intermediate-acting insulin (NPH), the patient should take the full dose on the evening before surgery and 80% of the morning dose on the morning of surgery.

• For rapid-acting insulins (aspart, lispro, glulisine, or regular) and premixed insulins (NPH or rapid acting), the patient should take the full dose with dinner the night before, and none on the morning of surgery.

Dr. Baldwin emphasized that except in rare circumstances, patients on subcutaneous insulin pumps should not use the pumps during surgery, and should get special instructions from their endocrinologists.

Ideally, the patient can convert to insulin glargine the night before surgery, with the dose equivalent to the total 24-hour basal insulin dose delivered by the pump. Two hours after the glargine dose is given, the patient should disconnect the pump and leave it at home.

Glycemic control in the hospital

As noted before, poor glycemic control can lead to poor wound healing from impaired leukocyte function, which can lead to decreased chemotaxis, phagocytosis, and bacteriocidal activity.

The risk of bacteremia is especially high among patients who are on total parenteral nutrition with poorly controlled glucose levels, he noted.

Forces conspiring against glucose control in the hospital can include elevated levels of hormones that counterregulate glucose; nausea/vomiting, anorexia, or nothing-by-mouth orders; erratic meal timing due to tests or interventions; intravenous glucose; glucocorticoid therapy; and "physician indifference and lack of attention to required adjustments in therapy," Dr. Baldwin noted.

Evidence from a randomized study showed that in patients with type 2 diabetes undergoing general surgery, basal-bolus treatment with insulin glargine once daily plus insulin glulisine before meals both improved glycemic control and reduced hospital complications compared with sliding-scale insulin therapy, he reported.

Hyper- and hypothyroid patients

Switching endocrinology hats, Dr. Baldwin said that patients who have significant weight loss or resting tachycardia before surgery should be evaluated for hyperthyroidism. A good rule of thumb is that in patients with hyperthyroidism, all but emergency procedures should be postponed until the condition can be controlled with methimazole.

Patients with undiagnosed or untreated hyperthyroidism who undergo anesthesia and surgery are at high risk for thyroid storm, a provoked crisis of multiorgan failure, he said.

If the surgery cannot be delayed until elevated levels of thyroxine are achieved, the team can initiate oral or intravenous beta-blockade, or if the patient is in critical condition, infusion with the beta-1 receptor blocker esmolol (Brevibloc) is preferred, he said.

Patients should also be started on methimazole 30-40 mg/day, and the patient should be given iodine if she has not already received iodinated radiologic contrast. Stress dose glucocorticoids and adequate volume resuscitation may also provide support in this situation.

In contrast, "hypothyroidism is usually not a big deal," Dr. Baldwin said.

Such patients usually tolerate major surgery without significant complications, he said, but patients with hypothyroidism may be more sensitive to sedatives, slower to wean from ventilation, and handle free-water excretion less well than euthyroid patients.

Patients who take levothyroxine (Synthroid and generics) should always have their free T₄ and thyroid-stimulating hormone (thyrotropin) levels checked during preoperative evaluation, he said.

Dr. Baldwin reported having no relevant financial conflicts of interest.

SCOTTSDALE, ARIZ. – Controlling hyperglycemia before and after surgery in patients with diabetes is a balancing act, but when done properly, it can reduce infections and wound complications, according to Dr. David Baldwin.

The key to preoperative planning for patients with diabetes is a full list of medications and an understanding of how well (or how poorly) patients’ glycemia is controlled, said Dr. Baldwin, an endocrinologist at Rush University Medical Center in Chicago.

He discussed strategies for perioperative management of patients with diabetes and thyroid disorders at the Perioperative Medicine Summit 2014."You definitely want to write down exactly what they are and aren’t taking. We find that the medication list for people getting admitted for surgery is often fraught with a lack of little details," he said.

For patients with type 2 diabetes, it’s important to record an accurate description of antidiabetes medications, especially combination oral agents such as Actoplus MET (metformin and pioglitazone) or Janumet (sitagliptin and metformin). For patients with type 1 and 2 diabetes, it is important to record not just the type of insulin but the regimen the patient uses.

Dr. Baldwin noted that many intake staff make the mistake of reporting that patients take "Novolin" or "Humulin," which are brand families of insulin and not specific insulin types.

"We often find, probably at least half of the time, that until we actually go and ask the patients what they take for insulin post-op, the correct information won’t have been in the medical record," he said.

The best way to determine whether a patient has good control of chronic hyperglycemia is with a hemoglobin A_1c (HbA_1c) level. A value above 6.5% is diagnostic for diabetes; well-controlled patients have HbA_1c levels from 6% to 8%. HbA_1c values not more than 2 months old should be a routine part of preoperative evaluations for patients with diabetes or newly discovered hyperglycemia, Dr. Baldwin said.

Preoperative medications

The Rush University protocol for the preoperative management of antidiabetic therapies other than insulin notes that sulfonylureas, metformin, pioglitazone, exenatide, liraglutide, sitagliptin, linagliptin, saxagliptin, alogliptin, alpha-glucosidase inhibitors, and canagaflozin may all be taken with food on the eve of surgery, but none should be taken on the morning of surgery.

Specific rules also apply for patients who use insulin, depending on the insulin type, as follows:

• For long-acting insulins (glargine or detemir), the patient should take the full dose on the evening before surgery or the morning of surgery if the dose is prescribed for either morning or evening administration. Patients with prescriptions for a b.i.d. dose should take the full dose both the evening before and the morning of surgery.

• With intermediate-acting insulin (NPH), the patient should take the full dose on the evening before surgery and 80% of the morning dose on the morning of surgery.

• For rapid-acting insulins (aspart, lispro, glulisine, or regular) and premixed insulins (NPH or rapid acting), the patient should take the full dose with dinner the night before, and none on the morning of surgery.

Dr. Baldwin emphasized that except in rare circumstances, patients on subcutaneous insulin pumps should not use the pumps during surgery, and should get special instructions from their endocrinologists.

Ideally, the patient can convert to insulin glargine the night before surgery, with the dose equivalent to the total 24-hour basal insulin dose delivered by the pump. Two hours after the glargine dose is given, the patient should disconnect the pump and leave it at home.

Glycemic control in the hospital

As noted before, poor glycemic control can lead to poor wound healing from impaired leukocyte function, which can lead to decreased chemotaxis, phagocytosis, and bacteriocidal activity.

The risk of bacteremia is especially high among patients who are on total parenteral nutrition with poorly controlled glucose levels, he noted.

Forces conspiring against glucose control in the hospital can include elevated levels of hormones that counterregulate glucose; nausea/vomiting, anorexia, or nothing-by-mouth orders; erratic meal timing due to tests or interventions; intravenous glucose; glucocorticoid therapy; and "physician indifference and lack of attention to required adjustments in therapy," Dr. Baldwin noted.

Evidence from a randomized study showed that in patients with type 2 diabetes undergoing general surgery, basal-bolus treatment with insulin glargine once daily plus insulin glulisine before meals both improved glycemic control and reduced hospital complications compared with sliding-scale insulin therapy, he reported.

Hyper- and hypothyroid patients

Switching endocrinology hats, Dr. Baldwin said that patients who have significant weight loss or resting tachycardia before surgery should be evaluated for hyperthyroidism. A good rule of thumb is that in patients with hyperthyroidism, all but emergency procedures should be postponed until the condition can be controlled with methimazole.

Patients with undiagnosed or untreated hyperthyroidism who undergo anesthesia and surgery are at high risk for thyroid storm, a provoked crisis of multiorgan failure, he said.

If the surgery cannot be delayed until elevated levels of thyroxine are achieved, the team can initiate oral or intravenous beta-blockade, or if the patient is in critical condition, infusion with the beta-1 receptor blocker esmolol (Brevibloc) is preferred, he said.

Patients should also be started on methimazole 30-40 mg/day, and the patient should be given iodine if she has not already received iodinated radiologic contrast. Stress dose glucocorticoids and adequate volume resuscitation may also provide support in this situation.

In contrast, "hypothyroidism is usually not a big deal," Dr. Baldwin said.

Such patients usually tolerate major surgery without significant complications, he said, but patients with hypothyroidism may be more sensitive to sedatives, slower to wean from ventilation, and handle free-water excretion less well than euthyroid patients.

Patients who take levothyroxine (Synthroid and generics) should always have their free T₄ and thyroid-stimulating hormone (thyrotropin) levels checked during preoperative evaluation, he said.

Dr. Baldwin reported having no relevant financial conflicts of interest.

SCOTTSDALE, ARIZ. – Controlling hyperglycemia before and after surgery in patients with diabetes is a balancing act, but when done properly, it can reduce infections and wound complications, according to Dr. David Baldwin.

The key to preoperative planning for patients with diabetes is a full list of medications and an understanding of how well (or how poorly) patients’ glycemia is controlled, said Dr. Baldwin, an endocrinologist at Rush University Medical Center in Chicago.

He discussed strategies for perioperative management of patients with diabetes and thyroid disorders at the Perioperative Medicine Summit 2014."You definitely want to write down exactly what they are and aren’t taking. We find that the medication list for people getting admitted for surgery is often fraught with a lack of little details," he said.

For patients with type 2 diabetes, it’s important to record an accurate description of antidiabetes medications, especially combination oral agents such as Actoplus MET (metformin and pioglitazone) or Janumet (sitagliptin and metformin). For patients with type 1 and 2 diabetes, it is important to record not just the type of insulin but the regimen the patient uses.

Dr. Baldwin noted that many intake staff make the mistake of reporting that patients take "Novolin" or "Humulin," which are brand families of insulin and not specific insulin types.

"We often find, probably at least half of the time, that until we actually go and ask the patients what they take for insulin post-op, the correct information won’t have been in the medical record," he said.

The best way to determine whether a patient has good control of chronic hyperglycemia is with a hemoglobin A_1c (HbA_1c) level. A value above 6.5% is diagnostic for diabetes; well-controlled patients have HbA_1c levels from 6% to 8%. HbA_1c values not more than 2 months old should be a routine part of preoperative evaluations for patients with diabetes or newly discovered hyperglycemia, Dr. Baldwin said.

Preoperative medications

The Rush University protocol for the preoperative management of antidiabetic therapies other than insulin notes that sulfonylureas, metformin, pioglitazone, exenatide, liraglutide, sitagliptin, linagliptin, saxagliptin, alogliptin, alpha-glucosidase inhibitors, and canagaflozin may all be taken with food on the eve of surgery, but none should be taken on the morning of surgery.

Specific rules also apply for patients who use insulin, depending on the insulin type, as follows:

• For long-acting insulins (glargine or detemir), the patient should take the full dose on the evening before surgery or the morning of surgery if the dose is prescribed for either morning or evening administration. Patients with prescriptions for a b.i.d. dose should take the full dose both the evening before and the morning of surgery.

• With intermediate-acting insulin (NPH), the patient should take the full dose on the evening before surgery and 80% of the morning dose on the morning of surgery.

• For rapid-acting insulins (aspart, lispro, glulisine, or regular) and premixed insulins (NPH or rapid acting), the patient should take the full dose with dinner the night before, and none on the morning of surgery.

Dr. Baldwin emphasized that except in rare circumstances, patients on subcutaneous insulin pumps should not use the pumps during surgery, and should get special instructions from their endocrinologists.

Ideally, the patient can convert to insulin glargine the night before surgery, with the dose equivalent to the total 24-hour basal insulin dose delivered by the pump. Two hours after the glargine dose is given, the patient should disconnect the pump and leave it at home.

Glycemic control in the hospital

As noted before, poor glycemic control can lead to poor wound healing from impaired leukocyte function, which can lead to decreased chemotaxis, phagocytosis, and bacteriocidal activity.

The risk of bacteremia is especially high among patients who are on total parenteral nutrition with poorly controlled glucose levels, he noted.

Forces conspiring against glucose control in the hospital can include elevated levels of hormones that counterregulate glucose; nausea/vomiting, anorexia, or nothing-by-mouth orders; erratic meal timing due to tests or interventions; intravenous glucose; glucocorticoid therapy; and "physician indifference and lack of attention to required adjustments in therapy," Dr. Baldwin noted.

Evidence from a randomized study showed that in patients with type 2 diabetes undergoing general surgery, basal-bolus treatment with insulin glargine once daily plus insulin glulisine before meals both improved glycemic control and reduced hospital complications compared with sliding-scale insulin therapy, he reported.

Hyper- and hypothyroid patients

Switching endocrinology hats, Dr. Baldwin said that patients who have significant weight loss or resting tachycardia before surgery should be evaluated for hyperthyroidism. A good rule of thumb is that in patients with hyperthyroidism, all but emergency procedures should be postponed until the condition can be controlled with methimazole.

Patients with undiagnosed or untreated hyperthyroidism who undergo anesthesia and surgery are at high risk for thyroid storm, a provoked crisis of multiorgan failure, he said.

If the surgery cannot be delayed until elevated levels of thyroxine are achieved, the team can initiate oral or intravenous beta-blockade, or if the patient is in critical condition, infusion with the beta-1 receptor blocker esmolol (Brevibloc) is preferred, he said.

Patients should also be started on methimazole 30-40 mg/day, and the patient should be given iodine if she has not already received iodinated radiologic contrast. Stress dose glucocorticoids and adequate volume resuscitation may also provide support in this situation.

In contrast, "hypothyroidism is usually not a big deal," Dr. Baldwin said.

Such patients usually tolerate major surgery without significant complications, he said, but patients with hypothyroidism may be more sensitive to sedatives, slower to wean from ventilation, and handle free-water excretion less well than euthyroid patients.

Patients who take levothyroxine (Synthroid and generics) should always have their free T₄ and thyroid-stimulating hormone (thyrotropin) levels checked during preoperative evaluation, he said.

Dr. Baldwin reported having no relevant financial conflicts of interest.