Venous thromboembolism (VTE) is considered to be the most common preventable cause of hospital-related death. Hospitalized patients undergoing major Surgery and hospitalized patients with acute medical illness have an increased risk of VTE. Although there is overwhelming evidence for the need and efficacy of VTE prophylaxis in patients at risk, only about a third of those who are at risk of VTE receive appropriate prophylaxis. To address the shortfall in VTE prophylaxis, the US Joint Commission and the National Quality Forum (NQF) endorse standardized VTE prophylaxis practices, and are identifying and testing measures to monitor these standards. Hospitals in the USA accredited by Centers for Medicare and Medicaid Services to receive medicare patients will need VTE prophylaxis programs in place to conform to these national consensus standards. This review aims to give background information on initiatives to improve the prevention of VTE and to identify key features of a successful quality improvement strategy for prevention of VTE in the hospital. A literature review shows that the key features of effective quality improvement strategies includes an active strategy, a multifaceted approach, and a continuous iterative process of audit and feedback. Risk assessment models may be helpful for deciding which patients should receive prophylaxis and for matching VTE risk with the appropriate intensity of prophylaxis. This approach should assist in implementing the NQF/Joint Commission-endorsed standards, as well as increase the use of appropriate VTE prophylaxis.

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Diabetes is challenging to manage in patients who have end-stage renal disease (ESRD), as both uremia and dialysis can complicate glycemic control by affecting the secretion, clearance, and peripheral tissue sensitivity of insulin. The authors summarize the available evidence and make practical recommendations.

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.

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