More Guidelines Flashcards
In patients requiring Vitamin K antagonists before surgery it should be stopped
5 days prior to surgery
In patients with mechanical valves, atrial fibrillation, or at high risk of VTE in regards to bridging
Bridging anticoagulation is recommended
Low risk VTE patients and bridging
No bridging indicated
dental procedure and vitamin K antagonists
Continue them with coadminstration of prohemostatic agent or stop 2-3 days before procedure
In mod-high risk patients taking ASA requiring non-cardiac surgery
continue ASA
In patients with a bare metal stent or drug eluding stent must wait how long before surgery
More than 6 weeks for bare metal
More than 6 months for drug-eluding
If surgery is indicated and time is less than that indicated for stents, what to do with anticoagulants
continue dual antiplatelet therapy perioperatively
When to restart vitamin K antagonists if stopped prior to surgery
12 to 24 hours after surgery and adequate hemostasis
In patients with derm procedures Vitamin K antagonists should be
continued perioperatively
In patients at low risk for CV events who are taking ASA anticipating surgery
stop 7-10 days prior to surgery
ASA and clopidogrel/prasugrel in regards to CABG
continue ASA
stop clopidogrel/prasugrel 5 days prior
Patients receiving heparin infusion in regards to anticipated surgery
stop 4-6 hours prior to surgery
Dosing of LMWH in regards to anticipated surgery
last dose should be administered 24 hours prior to surgery
Not 12 hours
Patients at high risk of bleeding surgery and resuming LMWH postoperatively
resume 48-72 hours after surgery
Increased risk of bleeding surgeries
Urologic PPM/ICD placement Colonic polyp resection High vascularized organs (spleen, kidney, liver) bowel resection Cardiac, spinal, cranial surgery
Healthy outpatient regimen for starting VKA (warfarin)
10 mg for first 2 days
Recommendations are _____ routine use of pharmacogenetic testing for guiding doses of VKA
against
Patient with acute VTE should start VKA when
day 1-2 of LMWH or UFH
For patients with stable INR, lab testing frequency
every 12 weeks
For patient with stable INR with single out of range INR less than 0.5 above/below range
continue current dose and recheck in 1-2 weeks
In patients with stable INR with single sub therapeutic INR
do not give bridging therapy
Patients taking VKA should _____ use vitamin K supplementation
not
Best practice of providers managing patients on Warfarin
- systematic and coordinated fashion
- patient education
- systematic INR testing
- tracking
- follow-up
- good patient communication of results and dosing decisions
Patients who can demonstrate competency in self-management with VKA
should be allowed to do so without usual outpatient monitoring
When deciding dosages for VKA use
nomograms
Patients taking VKA should avoid what meds due to drug interactions
NSAIDs ASA Clopidogrel Cephalexin cefradine Cephalosporins Metronidazole Ciprofloxacin Levofloxacin Norfloxacin Amoxicillin Augmentin Fluconazole SSRI Co-Enzyme 10 3 G (ginko biloba, ginseng, garlic)
Therapeutic range for VKA
INR 2-3
Patient who are able to discontinue to VKA should
abruptly discontinue
unnecessary to taper
dose for UFH
bolus and maintenance are weight adjusted
VTE
bolus 80 units/kg
maintenance 18 units/kg
Cardiac or stroke
70 followed by 15
or 5000 units bolus followed by 1000 units/hr
outpatient subq UFH dose
333 units/kg once then 250 units/kg without monitoring
Patients with severe renal insufficiency (CrCl
decrease dose
Patients over 100 kg on fodaparinux dose
increase from usual dose of 7.5 mg to 10 mg daily
Supratherapeutic INR treatment
INR 4.5-10 no evidence of bleeding = no Vit K
INR over 10 with no evidence of bleeding= give Vit K
Criterion of prediction for bleeding on VKA
Should NOT solely be judged on clinical prediction
For patients with VKA-associated major bleed should be given
reversal with four-factor prothrombin complex concentrate (PCC) rather than plasma
Use of Vitamin K as a reversal
should be used additionally with reversal coagulation factors
management of purulent skin/soft tissue infection
I and D with culture and sensitivity
Severe- Vancomycin to start until cultures return
Moderate- Bactrim or doxycycline
Mild- JUST I and D
Management of Nonpurulent skin/soft tissue infection
Mild- oral abx, PCN VK or Cephalosporin
Moderate- IV PCN, or IV cefazolin/ceftriaxone
Severe- rule out necrotizing process
Empiric- Vancomycin plus Zosyn; culture and narrow
Systemic symptoms of open wound of surgical site infection
Fever more than 4 days after operation
temp over 38 C
WBC over 12K
Erythema over 5 cm
Management of open wound without systemic symptoms of surgical site infection
dressing changes WITHOUT antibiotics
Management of open wound WITH systemic symptoms of surgical site infection
dressing changes with antibiotics
clean wound, trunk, head, neck, extremity
Cefazolin or Vancomycin until MRSA ruled out
wound of perineum, GI tract, or female GU
Cephalosporin plus Flagyl or
Levofloxacin plus Flagyl or
Carbapenem
Fever in the first 48 hours from operation for surgical site infection
only treat if wound is draining, local signs of inflammation, and cultures are revealing
then open and decried, start PCN and clindamycin
