There are no existing guidelines supporting the withdrawal or continuation of renineangiotensinealdosterone system (RAAS) antagonists in the preoperative setting. RAAS antagonists include ACE inhibitors, angiotensin II receptor subtype 1 blockers and direct renin inhibitors (eg, aliskiren), as well as the aldosterone antagonists. The use of these agents before surgery has been associated with a variable incidence of hypotension during the initial 30 min after induction of anaesthesia; however, these hypotensive episodes have not been conclusively linked to any significant postoperative complications, although recent data suggest an increase in postoperative morbidity and mortality in patients undergoing coronary artery bypass grafting. Further studies are required to be able to demonstrate if the organ-protective benefits of RAAS antagonists justify their continuation in the perioperative setting. Temporary withdrawal of RAAS antagonists in these patients may prevent or attenuate intraoperative hypotension and hypovolaemia. Alternatively, the increase in RAAS activity and blood pressure expected with cessation of RAAS antagonist therapy may impair regional circulation secondary to an increase in systemic vascular resistance. Full discussion of the potential implications of perioperative RAAS antagonist therapy with the surgical team is important, and strategies to ensure careful monitoring and maintenance of adequate intravenous volume before induction of anaesthesia are essential.

A 52-year-old man presented to the emergency department (ED) from a skilled nursing facility with a complaint of bilateral upper-quadrant abdominal pain of 48 hours' duration. The pain was sharp, nonradiating, constant, and was associated with nausea, vomiting, and constipation. The patient denied any fever, back pain, dysuria, melena, or hematochezia. In the rehabilitation facility the patient had been initially evaluated for this pain. He was given laxatives and stool softeners for presumed constipation but these measures had not been effective. A computed tomography (CT) scan of the abdomen had only showed stool in the colon and he was sent to the ED for further evaluation.Apart from severe degenerative joint disease in both his knees he was in good health. He was in the skilled nursing facility (SNF) for rehabilitation for bilateral knee replacement surgery done 9 days prior to this presentation. His postoperative course was unremarkable. He had been maintained on prophylaxis for venous thromboembolism with enoxaparin since postoperative day 1 at a daily dose of 40 mg subcutaneously, and was transferred to the SNF on postoperative day 6 on the same dose. His was receiving oxycodone and Tylenol for pain. He was on no other medications.Vital signs on presentation revealed a temperature of 97.5 F, a heart rate of 100 beats per minute, a respiratory rate of 16 breaths per minute, and a blood pressure of 136/ 69 mmHg. He was alert and oriented and in mild distress from the abdominal pain. Examination was normal except for tenderness in the upper quadrants of the abdomen though no rigidity or rebound tenderness were noted. Routine chemistries were normal except for sodium of 134 mg/ dL. His white count, hemoglobin, hematocrit, and platelet levels were noted to be at 17.5K/lL, 10 g/dL, 30%, and 345K/lL, respectively, and were stable with regard to his discharge laboratory values. His serum eosinophil level was normal. A complete workup for hypercoagulable state and bleeding disorders including assays for antibodies associated with heparin-induced thrombocytopenia were negative. He was admitted for further evaluation and treatment. The patient had another CT scan of the abdomen (Figure 1), which when compared to the one done at the SNF 2 days prior showed ''markedly enlarged'' bilateral adrenal glands suggestive of bilateral acute adrenal hemorrhage. The enoxaparin was discontinued and empiric steroid replacement therapy was begun. A random cortisol level was normal but a cosyntropin stimulation test showed an absolute increase in cortisol level of only 0.8 lg/dL at both 30 and 60 minutes after administration of 250 lg of cosyntropin. An investigation was undertaken to determine if the patient had any prior risk factors for bleeding. There was no evidence of infection and a comprehensive evaluation for bleeding, and coagulation disorders was normal. The bilateral adrenal hemorrhage was attributed to the use of enoxaparin in the postoperative setting. Unfortunately, the patient subsequently developed a deep venous thr...

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HOSPITAL MEDICINE CLINICS CHECKLIST1. Acute exacerbations of chronic obstructive pulmonary disease (COPD) are common in the course of chronic COPD, and are associated with substantial morbidity. 2. There are numerous guidelines, but literature suggests that there is substantial variation in care in patients with acute exacerbations of COPD. 3. Key components of acute therapy for most patients include oral steroids, antibiotics, nebulizers, oxygen, and early consideration of noninvasive ventilation. 4. Adjuvant components of care include venous thromboembolism prophylaxis, appropriate immunizations, counseling for smoking cessation, and consideration of pulmonary rehabilitation. DEFINITIONS AND BURDEN OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND EXACERBATIONSHow is chronic obstructive pulmonary disease defined and diagnosed?Chronic obstructive pulmonary disease (COPD) is an acquired and progressive pulmonary disorder. The principal physiologic lesion is airflow limitation, demonstrated on pulmonary function testing. Pathophysiologically, COPD is marked by evidence of chronic airway inflammation, loss of airway elasticity, and destruction of the alveoli. COPD develops over years of exposure to noxious substances. At least 80% of the overall risk is considered attributable to smoking and exposure to smoking. Air pollution and other environmental agents may cause or contribute to COPD, in addition to unusual inherited disorders such as a1-antitrypsin deficiency.

Every system is perfectly designed to get the results it gets." -W. Edwards Deming inspired quote 1