serotonin antagonist; adverse effects: sedation, dizziness.Scopolamine: dopamine antagonist; adverse effects: dizziness, dry mouth.Metoclopramide: dopamine antagonist; adverse effects: hyperglycemia, hypertension.Postoperative nausea and vomiting (PONV) is a common complication following surgery. As more procedures transition to outpatient surgery and enhanced recovery protocols try to minimize hospital stays, the management of postoperative nausea and vomiting becomes more important. Besides antiemetics, other strategies to reduce PONV include local nerve blocks, propofol induction and maintenance, minimizing perioperative narcotics, minimizing volatile anesthetics, avoiding nitrous oxide and reversal agents, and providing adequate perioperative hydration. Ondansetron is a serotonin antagonist and is usually well tolerated, though can cause headaches and constipation. Dexamethasone is a corticosteroid and can cause hyperglycemia and hypertension or hypotension. Promethazine is a histamine (H1) antagonist and causes sedation and dizziness. Scopolamine is an anticholinergic which causes dry mouth, visual disturbances, and dizziness. Metoclopramide is dopamine antagonist which can cause sedation and hypotension.AntiemeticsDrug groupDrugsDoseTiming for PONVAdverse effectsSerotonin (5‐HT3 receptors) antagonistsOndansetron4–8 mg IVGranisetron1 mg IVEnd of surgeryHeadaches, constipation, raised LFTsTropisetron2 mg IVCorticosteroidsDexamethasone4–10 mg IVAfter anesthesia inductionIncreased glucose, hypo/hypertensionButyrophenoneDroperidol0.625 to 1.25 mg IVAfter anesthesia inductionExtrapyramidal disturbances, Parkinson’s, increased QTNeurokinin antagonists (NK‐1 receptors)Aprepitant40 mg PO1–2 hour pre‐opHeadaches, constipation, fatigueAnticholinergicsScopolaminePatchPre‐opDizziness, dry mouth, visualDopamine antagonistsMetoclopramide10–25mg IV15 min prior to end of surgerySedation, hypotension1st generation AntihistaminePromethazine12.5 to 25 mg PO/IM/IVPost‐opSedation, dizziness, extrapyramidal disturbancesAnswer: ACao X, White PF, Ma H . An update on the management of postoperative nausea and vomiting. J Anesth. 2017; 31 (4):617–626.14 A 76‐year‐old man with hypertension, peripheral vascular disease, and diabetes is taking warfarin for atrial fibrillation. He also had a stroke 2 years ago. He will be undergoing a robotic low anterior resection for rectal cancer. What should be the management of his warfarin?Stop warfarin 5 days prior to surgery, resume postoperative (POD) 2.Stop warfarin 5 days prior to surgery, start weight‐based enoxaparin 3 days prior to surgery, stop enoxaparin day of surgery, resume warfarin POD 1.Stop warfarin 5 days prior to surgery, start weight‐based enoxaparin 3 days prior to surgery, stop enoxaparin day before surgery, resume warfarin POD 1.Stop warfarin 3 days prior to surgery, start weight‐based enoxaparin 3 days prior to surgery, stop enoxaparin day before surgery, resume warfarin POD 2.Stop warfarin 3 days prior to surgery, start weight‐based enoxaparin 3 days prior to surgery, stop enoxaparin day before surgery, resume warfarin POD 5.Stopping anticoagulation medication prior to surgery must be weighed against the risk of thromboembolic events and the surgical bleeding risk. This patient has a high CHA2DS2‐VASc score of 7 (hypertension ‐1, age > 75 ‐ 2, diabetes ‐1, stroke ‐2, and vascular disease ‐1) and is high risk for thromboembolic events, and therefore, should not have anticoagulation stopped completely (Answer A). This patient should be placed on enoxaparin therapy, which should be stopped the day before surgery (Answer C) and warfarin should be started POD 1, provided no/minimal bleeding risk. Weight‐based enoxaparin should also be restarted 12–24 hours after surgery depending on bleeding risk, as it will take multiple days for warfarin to reach therapeutic levels.BRIDGE trial anticoagulation protocolDay (around procedure)Protocol−5Stop warfarin−3Start bridging agent (LMWH)−1Stop bridging agent 24 hours prior to procedure0Procedure1Resume warfarin within 24 hours, resume bridging agent within 12 to 24 hours for low risk bleed2 to 3Resume bridging agent within 48–72 hours for high‐risk procedure5 to 10Stop bridging agent when INR > 2Answer: CBarnes GD, Mouland E . Peri‐procedural management of oral anticoagulants in the DOAC Era. Prog Cardiovasc Dis. 2018; 60 (6):600–606.
15 A 45‐year‐old woman pedestrian was struck by a motor vehicle. She has a history of COPD and a penicillin allergy. She sustained bilateral rib fractures with a flail segment on the left, left pulmonary contusion, left diaphragmatic injury (status‐post repair), and left open tibia and fibula fractures (also status‐post repair). She was admitted to the surgical ICU 8 days ago. She has been difficult to wean from the ventilator and has had a central line and left chest tube in place since admission. She began spiking fevers 2 days ago and is now requiring vasopressors. Empiric cefepime, metronidazole, and vancomycin were started, but clinically she has not improved. Her bronchoalveolar lavage (BAL) and blood cultures have come back positive for Candida with species pending. What is the best treatment choice for this patient currently?Continue current antibiotics and give more time to improveFluconazole 200 mg IV dailyVoriconazole 4 mg/kg IV dailyCaspofungin 70 mg IV x1 followed by 50 mg IV dailyFlucytosine 50 mg/kg IV q6 hoursEmpiric antifungal therapy should be considered in critically ill patients with risk factors for invasive candidiasis and no other known cause of fever. This patient is not improving and cultures indicate fungal bacteremia and ventilator‐associated pneumonia (VAP), thus, continuing the current antibiotic regimen would not treat this patient. Empiric antifungal therapy should be started as soon as possible in patients who have risk factors and who have clinical signs of septic shock. The preferred empiric therapy for suspected candidiasis in nonneutropenic patients in the ICU is an echinocandin (micafungin 100 mg IV daily, caspofungin 70 mg IV × 1 followed by 50 mg IV daily, anidulafungin 200 mg IV × 1 followed by 100 mg IV daily). Thus, Answer D is correct. Fluconazole at higher doses 800 mg IV ×1 followed by 400 mg IV daily is an acceptable alternative for patients who have not had recent azole exposure. B is incorrect because the dose is subtherapeutic. Voriconazole is used in much higher doses (6 mg/kg) BID × 2 then 3 mg/kg BID, but offers little advantage over fluconazole as initial therapy. Voriconazole is recommended as step‐down therapy for selected cases of candidemia due to Candida krusei, for additional mold coverage and for neutropenic patients. Flucytosine is usually used in combination with other antifungals and reserved for very severe infections. It is used more commonly in combination with amphotericin B for central nervous system candidiasis. In addition, higher doses (100–200 mg/kg) in 4 doses over 24 hours are recommended.Answer: DPappas PG, Kauffman CA, Andes AR, et. al. Clinical practice guidelines for the management of candidiasis: 2016 update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2016; 62 :e1–50.
16 A 63‐year‐old woman is receiving rivaroxaban following a pulmonary embolism she had 5 months ago. She also has hypertension and hyperlipidemia. She has normal renal function. She will be undergoing a mastectomy with sentinel lymph node biopsy for stage 2 ductal carcinoma. How should her rivaroxaban be managed in the perioperative period?Last dose of the DOAC prior to elective procedureAgentRenal clearanceLow bleed riskHigh or unknown bleed riskRivaroxaban, apixaban, edoxabanCrCl > 30 mL/min>24 hours>48 hoursCrCl 15–29 mL/min>36 hours>72 hoursCrCl < 15 mL/min>48 hoursData lackingDabigatranCrCl > 80 mL/min>24 hours>48 hoursCrCl 50–80 mL/min>36 hours>72 hoursCrCl 30–49 mL/min>48 hours>96 hoursCrCl 15–29 mL/min>72 hours>120 hoursCrCl < 15 mL/minUnknownUnknownStop rivaroxaban 5 days before surgery and restart POD 1.Stop rivaroxaban 2 days before surgery and restart POD 1.Stop rivaroxaban 5 days before surgery, start weight‐based enoxaparin, and restart POD 1.Stop rivaroxaban 2 days before surgery, start weight‐based enoxaparin, and restart POD 2.Stop rivaroxaban day of surgery and restart POD 2.This patient is at intermediate risk for thromboembolic events and should stop anticoagulation in the perioperative period without significant consequence. The direct‐acting oral anticoagulants (DOACs) rarely need bridging therapy (Answers C & D). Provided normal renal function, rivaroxaban should be eliminated entirely by 35–55 hours, since its half‐life is 7–11 hours (4–5 half‐lives for 95% elimination). A mastectomy has a higher risk of bleeding compared to some other surgeries, thus, rivaroxaban should be stopped 2 days prior to surgery and resumed POD 1 provided no bleeding complications.Answer: BBarnes GD, Mouland E . Peri‐procedural management of oral anticoagulants in the DOAC Era. Prog Cardiovasc Dis. 2018; 60 (6):600–606.
17 A 45‐year‐old man was involved in a high‐speed motor vehicle crash and has the following injuries: intraparenchymal hemorrhage, diffuse axonal injury, T4 vertebral body fracture, T4 paraplegia, and multiple bilateral rib fractures. On hospital day 9, the patient remains intubated, spikes a fever, and has thick secretions from
