Miscellaneous | UCLA Health Mobile

Perioperative Management
Preoperative
Cardiac clearance for noncardiac surgery (see Cardiology section page 71)
Discontinue aspirin, nonsteroidal anti-inflammatories, and clopidogrel 1 week prior to the surgery, if possible.
Typically, patients are NPO. It is usually okay for patients to have AM medications with small sips of water, especially b-blockers. For diabetic patients, discontinue all oral hypoglycemics the night prior to surgery, start D5 ½ NS or NS, and half the insulin dose in the morning.
Postoperative
It is important that postoperative patients that are sent back to the medicine wards are seen immediately. If you have a patient that is undergoing surgery and is not back by the time you leave, make sure to signout a postoperative check to the medicine float.

Review:
Operative note, blood loss, fluid balance, complications
Antibiotic orders (both prior antibiotics and prophylactic antibiotics for the surgery)
Any postoperative EKGs (for high-risk patients), labs, radiography

Prophylaxis:
Know when to begin DVT prophylaxis, especially after hip or knee surgery
Aspiration precautions
Remove Foley catheter within 24 hours of the surgery, if possible
Early mobilization (call for physical therapy evaluation)
Incentive spirometer every hour while awake to prevent atelectasis and postoperative pneumonia

Nutrition:
Know when the diet can be advanced, usually start with clear liquid diet
Consider nutrition consultation, enteral feeding, supplements

Pain control options:
Patient-controlled analgesia (PCA)
Standing IV or PO analgesia
Symptom-triggered IV or PO analgesia
See http://www.anes.ucla.edu/pain for more discussion about the choices of pain medications, setting the PCA, and how to assess pain.

Pain Medication Conversions
To convert from one pain medicine to another, use the following formula:
The cross-tolerance % accounts for tolerance to a particular narcotic that the patient will not have with a different narcotic. For example, if a patient is on 100 mg of IV morphine per day, converting that to oxycodone would give you 200 mg of oxycodone per day. The patient has developed some tolerance to morphine, but not to oxycodone, so the 200 mg of oxycodone may act like 250 mg.
Therefore, choose a cross-tolerance of at least 25%, which in our example would give a daily oxycodone dose of 150 mg. You can always titrate up!

Narcotic Equivalents
Analgesic	Oral Dose (mg)	Parenteral Dose (mg)
Meperidine (Demerol)	150	50
Codeine (Tylenol #3 x3)	100	60
Hydrocodone (Vicodin x3, Lortab x3)	15	N/A
Morphine (MSIR, Roxanol)	15	5
Oxycodone (Percodan x2, Percocet x2, Tylox x2)	10	N/A
Methadone (Dolophine)	10	5
Hydromorphone (Dilaudid)	4	0.75
Levorphanol (Levo-Dromoran)	2	1
Fentanyl	N/A	0.05

General conversion from oral morphine to a fentanyl patch is:
Morphine 45-134 mg/day = Fentanyl patch 25 mg/hr
Morphine 135-224 mg/day = Fentanyl patch 50 mg/hr
Morphine 225-314 mg/day = Fentanyl patch 75 mg/hr
Morphine 315-404 mg/day = Fentanyl patch 100 mg/hr

Steroid Conversions

Steroid Equivalents
Steroid	Dose (mg)
Cortisone	25
Hydrocortisone	20
Prednisone	5
Prednisolone	5
Methylprednisolone (Solu-Medrol)	4
Dexamethasone (Decadron)	0.75

Gastric Tubes
Compared with parenteral nutrition, it is the preferred delivery method of nutrition and medications because it uses the GI tract, has less infectious complications, and is more cost effective.
Indications
Dysphagia in a patient with intact mental status
Head and neck cancer patients
Gastric decompression

Remember that feeding tubes have never been shown to improve either quality or length of life in severe dementia patients and can create new problems.

Feeding tubes have also not been shown to be effective in preventing aspiration.
Management
Usually placed by Gastroenterology or Interventional Radiology, but can be done surgically in some situations.
Check platelets, PT, and PTT prior to procedure.
After placement, tube should not be used for 24 hours due to frequent ileus
If there is low drainage (< 500 cc/24 hours), start feeding at 20 cc/hr and check residuals after 4 hours
If the residuals are < 2x the rate (40 cc), then continue feedings and advance by 20 cc/hr until the goal feeding rate is met (usually determined by a nutrition consult) as long as residuals remain low.
G-J tubes have 2 ports that allow simultaneous jejunal feeding & gastric drainage; indicated with gastric dysmotility or obstruction.

For G-J tubes: medications ONLY go through the G-port and feedings generally go through the J-port
Complications

Infection: look for erythema, tenderness, and increased discharge at entry site

Increased residual: consider ileus®hold feeds for 1-2 hours and recheck residual. If low, restart at previous or reduced rate, if prolonged consider intraperitoneal spilling

Clogged tube: irrigate with warm water or carbonated beverage.
If unsuccessful call IR to clear with guidewire or brush

Tube accidentally removed: usually prevented by balloon or bumper. A sinus tract forms after a tube has been in place for > 1 week allowing for easy replacement at bedside. Ask the nurse to put a Foley in to keep the tract open

Leakage of gastric contents: if causing irritation to skin, frequent dressing changes or ask for Ostomy Nurse consult. If leakage continues for > 2 days, have IR evaluate with contrast study. Intraperitoneal spilling can be a serious problem and may warrant a surgical consult (also consider this with a prolonged ileus)

Aspiration: tube feeds have not been shown to prevent aspiration pneumonia and some studies have shown inc risk with tube feeds. Always use strict aspiration precautions and dental care t.i.d.

Diarrhea: usually not due to tube feeding, so consider other causes like C. difficile.

Premedication For Contrast Allergy
Carefully elicit allergy history®if allergic reaction severe, consider alternate study
If reaction is rash alone, give Benadryl 50 mg IV x 1 on call to scan.
If reaction is unknown or more severe (but not anaphylaxis), give prednisone 50 mg p.o. q12hrs x 3 doses or Solu-Medrol 40 mg IV q12hrs x 3 doses prior to the study in addition to Benadryl 50 mg IV x 1 on call to scan

Care Coordiation Cues

Outpatient Dialysis - Patients who will be starting outpatient dialysis for the first time MUST have the following labs/studies documented prior to discharge. Existing Chronic Hemodialysis patient need to have these labs repeated every 30 days.

CBC, Metabolic Panel

HIV1/HIV2 Antibody Screen

HCV Antibody Screen

Hepatitis B Surface Antibody and Antigen

PPD

Chest Xray

EKG

Medications that often need prior authorization (48-72 hours)

1) Linezolid -Zyvox
2) Treprostinil Sodium--Remodulin-
3) Sidenafil Citrate- Revatio
4) Voricanozole- V- fend
5) Enoxaparin-Lovenox
6) valganciclovir hydrochloride-Valcyte
7) valacyclovir hydrochloride-Valtrex
8) fondaparinux sodium-Arixtra
9) posaconazole-Noxafil
10) filgrastim-Neupogen
11) tacrolimus-Prograf
12) mycophenolate mofetil---Cellcept
13) cyclosporine--Gengraf, Neoral, Sandimmune
Medications that Often Warrant Additional Information to Be Provided
1) atorvastatin calcium- Lipitor
2) rosuvastatin calcium- Crestor
3) clopidogrel bisulfate- Plavix
4) Warfarin- Coumadin

Levels of Care

Home Health Orders - See order set on Forms portal for more information
1. Home Health services require a MD/NP order
2. Can include: RN, LVN, MSW, PT/OT/ST, Wound Care RN, Ostomy RN, Dietician, Home Health Aide
3. RN and PT are the only services that can be ordered without any additional services. Other services require that RN and/or PT be ordered as the primary service.
Skilled Nursing Facilities - Commonly used SNF's. The one's in bold have UCLA Geriatricians that attend at the facility

Berkley East, Arborview, Country Villa Westwood, Goldstar, Rehab Centre of Beverly Hills, Country Villa Mar Vista, Brentwood Rehab, Fireside Convalescent Hospital, New Vista, Hancock Park Rehab, Pacific Convalescent Center, Country Villa South, Berkley West, Santa Monica Health Care, Topanga Terrace, Culver West.

Interfacility Transfer Orders -
1. Required when transferring to ANY facility

i. Hospital to hospital
ii. Hospital to SNF, Acute Rehab, Long Term Acute Care Facility
iii. Hospital to 1-West, NPI, etc

1. Fill out completely as these will be the orders that the staff at the facility will follow until another healthcare provider sees the patient. This could be 72 hours or more in some cases.
2. Orders that are often left off…

i. Diet order (or enteral feeds)
ii. Activity
iii. PRN medications for sleep, constipation, etc.
iv. Labs (especially INR checks)
v. Insulin Orders (basal and sliding scale)

Qualifying For Home Oxygen
1. Medicare will cover home oxygen only for patients with chronic, stable significant hypoxemia if the following conditions are met:

i. Physician determines patient suffers from severe lung disease or hypoxia-related symptoms that may improve with oxygen.
ii. Patient's demonstrates a need for oxygen:
1. PaO₂ < 55 mmHg or O₂^sat < 88% at rest
2. PaO₂ 56-59 mmHg or O₂^sat >= 89% AND dependent edema suggesting CHF OR pulmonary hypertension/cor pulmonale (measured PA pressure, echocardiogram, P pulmonale on EKG®P wave > 3 mm in leads II, III, or aVF)
iii. Nocturnal oxygen therapy only if:
1. PaO₂ < 55 mmHg or O₂^sat < 88% while asleep AND PaO₂ > 56 mmHg or O₂^sat > 89% while awake
2. PaO₂ dec > 10 mmHg or O₂^sat dec > 5% from waking to sleeping AND EKG shows P pulmonale or patient has documented pulmonary HTN and erythrocytosis
iv. Exercise oxygen therapy only if:
1. PaO₂ < 55 mmHg or O₂^sat < 88% during activity for a patient with PaO₂ > 56 mmHg or O₂^sat > 89% during the day at rest, and it is documented that use of oxygen improves hypoxemia with exercise.

1. Alternative treatment measures have been tried or considered and have failed
Determining Level of Care

Physicians determine the appropriate Level of Care for their patients through the care plan.
Case Managers assist with ensuring that patients are at the appropriate level of care for that care delivery.
What is Level of Care?
v Inter Qual Criteria- One Tool for us to use to determine Level of Care.
v Severity Of Illness- How sick is your patient
v Intensity of Service- What type of care are you delivering?
What are the Level of Cares at UCLA?
v Critical Care - Medical, Cardiac, Surgical Trauma
v Intermediate- Cardiac telemetry Med- surg
v Acute Care
v Observation- GONDA UNIT
v Outpatient- OPB SOP- PTU SOU

Observation Services are those services, ordered in writing by a physician, that are reasonable and necessary to evaluate an outpatient's condition (when that patient is presenting with signs, symptoms, or a chronic condition for which treatment is not yet determined) to determine the need for further treatment as an inpatient. The observation service must be ordered and terminated by a physician Observation is by definition the use of appropriate monitoring, diagnostic testing, therapy and assessment of patient symptoms, signs, laboratory tests and response to therapy for the purpose of determining whether a patient will require further treatment as an Inpatient or can be discharged from the hospital setting. ‘Observation status' and ‘admit to observation' is an outpatient diagnostic / treatment category that is expected to be not less than 8 or more than 24 hours, but can be as long as 72 hours

Vaccinations
This is a quick guide, not meant to be comprehensive. Please see the CDC website for more information and recommendations, particularly for international travelers.

Vaccine	Who	What	Contraindication$
Pneumovax	>65, Q5 yrs Chronic disease*, aplenia, alcoholism	Polyvalent 23 capsular polysaccharide antigens	Pregnancy
Influenza (Oct-Nov)	>50, Q1 year Chronic disease* Nursing home resident	Inactivated virus	Prior Guillain-Barre from flu shot
Tetanus-diphteria (Td)	Q10 years OK in pregnancy	Tetanus and diphteria toxoids Primary series 0, 1, 6 months then Q10 year booster	Td preferred over Tdap in pregnancy
Tetanus-diphteria-pertussis (Tdap)	Once as adult- alternative to Td as gives protection for pertussis as well	Tetanus and diphteria toxoids	Severe latex allergy Epilepsy Prior coma or seizure with DTaP as child
Measles-Mumps-Rubella (MMR)	Persons born 1957 ot later, consider in immigrants with no history. Health care workers, international travelers may need 2nd dose	Live attenuated virus	Pregnancy or possible pregnancy within 3 months Immunocompromised Recipients of blood products or immune globulin in past 11 months
Varicella	All adults who are not immune (can ask history or check titers if unsure)	Live attenuated virus Two doses 4-8 weeks apart	Pregnancy or possible pregnancy within one month Immunocompromised, active untreated TB, received blood products in last 6 months, lymphoma/leukemia
Zostavax	Age >60 years One time dose	Live attenuated	Immunodeficiency, lives with patient who is immunocompromised, pregnant, active tuberculosis, high dose steroids, anaphylactic rxns to gelatin, neomycin or components of vaccine
HPV	Currently recommended for girls age 11-12. Catchup vaccine for girls 13-26	Inactivated virus Three doses at 0, 2, 6 months	Pregnancy
Meningococcal	Dose at high school entry, dormatory living, military recruits, aplenia, exposure, international travel	Polysaccharide vaccine Conjugate vaccine (preferred)	Unclear in pregnancy Prior Guillain-Barre
Hepatitis A	Liver disease**, IVDU, MSM Planned travel outside US	Inactivated virus Two shots 6-12 months apart	Unclear in pregnancy
Hepatitis B	Liver disease**, IVDU, MSM, STD risk factors, healthcare worker, renal disease, prison inmate, internation travel, household contact	Recombinant DNA Three doses at 0, 1, 6 months
Diabetes, COPD, heart dz, kidney dz, sickle cell, HIV, cancer, pregnancy, steriod use, lives w/ at risk person Chronic liver disease, HCV, HBV, clotting disorder $Anaphylaxis to vaccine or components is contraindication to any vaccine*