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Ir Perioperative Medicine • Anticoagulation and Antithrombotic Management 25  Aggressive medical management triggered by a finding of elevated troponins in the otherwise asymptomatic patient may, therefore, be warranted. Symptomatic infarctions should be addressed according to standard therapy of acute coronary syndromes (see Chapter 4, Ischemic Heart Disease). The major caveat is that bleeding risk with anticoagulants must be carefully considered. Perioperative Anticoagulation and Antithrombotic Management GENERAL PRINCIPLES Patients on chronic anticoagulation for atrial fibrillation, VTE, or mechanical heart valves often need to undergo procedures that pose risk of bleeding.

Flumazenil should be used with caution in patients with a history of seizure disorder or if overdose with tricyclic antidepressants is suspected. Trazodone  Trazodone is a serotonin receptor antagonist antidepressant that may be useful for the treatment of severe anxiety or insomnia. Common dosing is 50 to 100 mg at bedtime. 16 Chapter 1 • Patient Care in Internal Medicine Table 1-2 Characteristics of Selected Benzodiazepines Drug Route Common Uses Alprazolam PO Anxiety disorders Chlordiazepoxide PO Clonazepam PO Diazepam PO Anxiety disorders, alcohol withdrawal Anxiety disorders, seizure disorders Anxiety disorders, seizure disorders, preanesthesia IV Flurazepam PO Insomnia Lorazepamb PO Anxiety disorders IV or IM Preanesthetic medication Midazolam IV Preanesthetic and intraoperative medication Oxazepamb IM PO Anxiety disorders Temazepamb PO Insomnia Triazolam PO Insomnia a Half-life of active metabolites may differ.

Diagnostic Testing Oxygen assessment should take place promptly. Arterial blood gas measurement provides more information than pulse oximetry. Chest radiography is useful in most patients. Other diagnostic and therapeutic measures should be directed by the findings in the initial evaluation and the severity of the suspected diagnosis. TREATMENT Therapeutic measures should be directed by the findings in the initial evaluation and the severity of the suspected diagnoses. If the patient is hypoxic, oxygen administration should be delivered in a prompt fashion.

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