David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
Preoperative cardiac evaluation can be facilitated by use of one of the existing tools for estimating perioperative cardiac risk, such as the Revised Cardiac Risk Index.
The role of perioperative β-blockers in reducing surgical risk is uncertain, in light of mixed results of studies using variable dosing schedules. Perioperative β-blockers may decrease the risk of nonfatal MI, but may increase the risk for stroke and death.
Patients with coronary stents should continue aspirin through the perioperative period, unless bleeding risk precludes it. Patients with coronary stents should remain on dual antiplatelet therapy and have elective surgeries delayed for at least 4 weeks after placement of a bare-metal stent and for at least 3 to 6 months after placement of a drug-eluting stent.
Bridging anticoagulation is not recommended for patients with atrial fibrillation without a mechanical heart valve or with a CHADS2 score of 4 or less.
The inability to rapidly prognosticate in cases of OHCA makes it difficult to move from an aggressive resuscitation strategy to either termination of resuscitation efforts or aggressive organ procurement. The use of these clinical criteria could help with this conundrum by rapidly identifying patients who are unlikely to survive and might be appropriate candidates for organ donation.
An editorial notes the complexity of the decisions surrounding OHCA situations and suggests that there is much more to learn about how best to balance the imperatives of saving lives when possible, terminating efforts when futile, and ethically maximizing procurement of transplantable organs.
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Wesorick DH, Chopra V. Annals for Hospitalists - 20 December 2016. Ann Intern Med. ;165:HO1. doi: 10.7326/AFHO201612200
Download citation file:
Published: Ann Intern Med. 2016;165(12):HO1.
Results provided by:
Copyright © 2018 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use