Expanding the perioperative lens: Does the end justify the means?

In 1994, Fischer et al. established the preoperative clinic for the perioperative services at Stanford University Medical Center. By lowering the risk of cancellation and reducing morbidity and mortality against the push to move surgeries to an outpatient, basis, they demonstrated a return on investment. In the 2000s, Aronson et al. designed the prehabilitation clinics at Duke University with the notion that the preoperative process should not only ensure that patients were appropriately risk-stratified, but also clinically optimized before surgery. With a trend towards ambulatory procedures due to current reimbursement structures, hospital administrators should be searching for potential avenues to bolster sagging profits. In this narrative review, we argue that the perioperative services needs to extend beyond the hospital into the postoperative period.

State of research in adult Hospital Medicine: Updated results of a national survey and longitudinal analysis of national data.

We sought to understand the current state of research in adult Hospital Medicine by repeating a 2018 survey of leaders in Hospital Medicine with changes to improve the response rate of surveyed programs. We also analyzed the public sources of federal research funding and MEDLINE-indexed publications from 2010 through 2019 among members of the Society of Hospital Medicine (SHM). Of the 102 contacted leaders of Hospital Medicine groups across the country, 49 responded, for a total response rate of 48%. Among the 3397 faculty members represented in responding programs, 72 (2%) of faculty were identified as conducting research for more than 50% of their time. Respondents noted difficulties at every stage of the research development pipeline, from a lack of mentors to running a fellowship program to a lack of applicants seeking further research training. Improvements to our research training pipeline will be essential to the long-term improvement of our profession.

Perioperative Glucocorticoids in Patients With Rheumatoid Arthritis Having Total Joint Replacements: Help or Harm?

OBJECTIVE: The optimal strategy for perioperative glucocorticoid (GC) management in patients with rheumatoid arthritis (RA) on chronic GCs is unknown. Although there is a concern for hypotension if inadequate doses are used, higher GC exposure may increase perioperative complications. We aimed to investigate the relationships between perioperative GCs with hemodynamic instability and short-term postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) in patients with RA. METHODS: This retrospective study included patients with RA who underwent THA and TKA. GC exposure was assessed by the total cumulative dose (in prednisone equivalents) during hospitalization. Perioperative complications and hypotension were assessed. RESULTS: Of 432 patients, 387 (90%) received supraphysiologic perioperative GC. Thirty percent of patients were using chronic GCs (mean daily dose, 7 ± 4 mg). Half (54%) underwent TKA. The median age was 65 years, and 79% were women. The median cumulative GC dose during hospitalization was 37 mg (interquartile range, 27-53.3). A lower cumulative dose of GC did not increase odds of hypotension during hospitalization (unadjusted odds ratio, 1.00 [95% confidence interval, 0.99-1.01]; P = 0.66)]. However, postoperative complications were higher among patients who received higher cumulative doses after adjustment for age, body mass index, home GC use, smoking, and Charlson Comorbidity Index. Risk of short-term complications increased by 8.4% (P = 0.017) for every 10-mg increase in GC dose. CONCLUSION: A lower GC dose was not associated with increased hypotension. However, patients with higher GC exposure were more likely to have hyperglycemia and other complications. These findings suggest that harms may be associated with high perioperative GC doses. Further research is needed to determine the optimal perioperative regimen for patients with RA.

Preoperative Management of Surgical Patients Using Dietary Supplements: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement.

The widespread use of complementary products poses a challenge to clinicians in the perioperative period and may increase perioperative risk. Because dietary supplements are regulated differently from traditional pharmaceuticals and guidance is often lacking, the Society for Perioperative Assessment and Quality Improvement convened a group of experts to review available literature and create a set of consensus recommendations for the perioperative management of these supplements. Using a modified Delphi method, the authors developed recommendations for perioperative management of 83 dietary supplements. We have made our recommendations to discontinue or continue a dietary supplement based on the principle that without a demonstrated benefit, or with a demonstrated lack of harm, there is little downside in temporarily discontinuing an herbal supplement before surgery. Discussion with patients in the preoperative visit is a crucial time to educate patients as well as gather vital information. Patients should be specifically asked about use of dietary supplements and cannabinoids, as many will not volunteer this information. The preoperative clinic visit provides the best opportunity to educate patients about the perioperative management of various supplements as this visit is typically scheduled at least 2 weeks before the planned procedure.

State of Research in Adult Hospital Medicine: Results of a National Survey.

BACKGROUND: Little is known about the state of research in academic hospital medicine (HM) despite the substantial growth of this specialty. METHODS: We used the Society of Hospital Medicine (SHM) membership database to identify research programs and their leadership. In addition, the members of the SHM Research Committee identified individuals who lead research programs in HM. A convenience sample of programs and individuals was thus created. A survey instrument containing questions regarding institutional information, research activities, training opportunities, and funding sources was pilot tested and refined for electronic dissemination. Data were summarized using descriptive statistics. RESULTS: A total of 100 eligible programs and corresponding individuals were identified. Among these programs, 28 completed the survey in its entirety (response rate 28%). Among the 1,586 faculty members represented in the 28 programs, 192 (12%) were identified as engaging in or having obtained extramural funding for research, and 656 (41%) were identified as engaging in quality improvement efforts. Most programs (61%) indicated that they received $500,000 or less in research funding, whereas 29% indicated that they received >$1 million in funding. Major sources of grant support included the Agency for Healthcare Research and Quality, National Institutes of Health, and the Veterans Health Administration. Only five programs indicated that they currently have a research fellowship program in HM. These programs cited lack of funding as a major barrier to establishing fellowships. Almost half of respondents (48%) indicated that their faculty published between 11-50 peer-reviewed manuscripts each year. CONCLUSION: This survey provides the first national summary of research activities in HM. Future waves of the survey can help determine whether the research footprint of the field is growing.

Optimizing Rheumatoid Arthritis Patients for Surgery.

PURPOSE OF REVIEW: The purpose of this review is to guide providers on how best to optimize the health of patients with rheumatoid arthritis (RA) planning surgery, to reduce risk and complications and achieve the best outcomes. RECENT FINDINGS: The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) have issued a recent guideline on perioperative management of antirheumatic medications in patients with RA. Patients with RA will continue to need surgery. Newer literature is helping to plan the perioperative period to help reduce complications and improve outcomes.

Does my patient have a pulmonary embolism? The Wells vs. PISA 2 rule in orthopedic patients.

The diagnosis of venous thromboembolism is difficult in the postoperative setting because signs such as hypoxemia, leg pain, and swelling are so common. CTPA can also detect subsegmental PE (SSPE), of which the clinical significance has been widely debated. Clinical decision rules (CDR), such as the Wells and PISA 2, have been developed to identify symptomatic patients at low risk for PE who could forgo imaging. We performed this study in order to (1) compare the performance of the Wells and PISA 2 CDR in orthopedic patients; (2) compare CDR scores in patients with subsegmental PE (SSPE) versus larger clots; and (3) identify variables that improve performance of the Wells in orthopedic patients. This retrospective cohort study included all orthopedic surgery patients that underwent computerized tomographic pulmonary angiography at a single institution from 1/1/13 to 12/31/14 and had data to calculate both Wells and PISA 2 scores. CDR sensitivity, specificity and c-statistics were calculated. Multivariable logistic regression was used to identify variables that improved CDR performance. 402 patients were included in the study. The Wells rule (cutoff > 4) had sensitivity 74% and specificity 45%. PISA 2 (cutoff 0.6) had sensitivity 90% and specificity 11%. The Wells performed better than PISA 2: c-statistic 0.60 vs. 0.50; p = 0.007. The mean Wells score was 5.20 ± 1.68 for patients with SSPE and 5.41 ± 1.86 for patients with larger clots. Adding the variables prior smoking and varicose veins improved the performance of the Wells rule (c-statistic 0.66 vs. 0.60, p = 0.008). The Wells rule (cutoff > 4) performs better than PISA 2 in orthopedic patients. Neither can distinguish patients with SSPE from those with larger clots. Although adding past smoking and varicose veins to the Wells improves its performance, this requires validation in other populations.

Postoperative Tachycardia: Clinically Meaningful or Benign Consequence of Orthopedic Surgery?

OBJECTIVE: To determine the clinical significance of tachycardia in the postoperative period. PATIENTS AND METHODS: Individuals 18 years or older undergoing hip and knee arthroplasty were included in the study. Two data sets were collected from different time periods: development data set from January 1, 2011, through December 31, 2011, and validation data set from December 1, 2012, through September 1, 2014. We used the development data set to identify the optimal definition of tachycardia with the strongest association with the vascular composite outcome (pulmonary embolism and myocardial necrosis and infarction). The predictive value of this definition was assessed in the validation data set for each outcome of interest, pulmonary embolism, myocardial necrosis and infarction, and infection using multiple logistic regression to control for known risk factors. RESULTS: In 1755 patients in the development data set, a maximum heart rate (HR) greater than 110 beats/min was found to be the best cutoff as a correlate of the composite vascular outcome. Of the 4621 patients who underwent arthroplasty in the validation data set, 40 (0.9%) had pulmonary embolism. The maximum HR greater than 110 beats/min had an odds ratio (OR) of 9.39 (95% CI, 4.67-18.87; sensitivity, 72.5%; specificity, 78.0%; positive predictive value, 2.8%; negative predictive value, 99.7%) for pulmonary embolism. Ninety-seven patients (2.1%) had myocardial necrosis (elevated troponin). The maximum HR greater than 110 beats/min had an OR of 4.71 (95% CI, 3.06-7.24; sensitivity, 47.4%; specificity, 78.1%; positive predictive value, 4.4%; negative predictive value, 98.6%) for this outcome. Thirteen (.3%) patients had myocardial infarction according to our predetermined definition, and the maximum HR greater than 110 beats/min had an OR of 1.72 (95% CI, 0.47-6.27). CONCLUSION: Postoperative tachycardia within the first 4 days of surgery should not be dismissed as a postoperative variation in HR, but may precede clinically significant adverse outcomes.

End Tidal Carbon Dioxide as a Screening Tool for Computed Tomography Angiogram in Postoperative Orthopaedic Patients Suspected of Pulmonary Embolism.

BACKGROUND: Computed tomography pulmonary angiography (CTA) is the gold standard for diagnosing pulmonary embolism (PE) but involves radiation and iodinated contrast exposure. Of orthopedic patients evaluated for PE, a minority have a positive CTA study. Herein, we evaluate end tidal carbon dioxide (ETCO2) as a method to identify patients at low risk for PE and may not require a CTA. We hypothesize that ETCO2 will be useful for predicting the absence of PE in postoperative orthopedic patients. METHODS: In this prospective study, all patients older than 18 years who were admitted for orthopedic surgery and who had a CTA performed for PE were eligible. These patients underwent an ETCO2 measurement. Patients were determined to have PE if they had a positive PE-protocol CT. RESULTS: Between May 2014 and April 2015, 121 patients met the inclusion criteria for the study. Of these patients, 84 had a negative CTA examination, 25 had a positive examination, and 12 had a nondiagnostic examination. We found a statistically significant difference (P = .03) when comparing the average ETCO2 values for the positive and negative CTA groups. An ETCO2 cutoff value of 43 mm Hg was 100% sensitive with a negative predictive value of 100% for absence of PE on CTA. CONCLUSION: This study demonstrates a significant difference in ETCO2 measurements between postoperative orthopedic patients with and without CTA-detected PE. A cutoff value of >43 mm Hg may be useful in excluding patients from undergoing CTA.

Use of Preoperative Testing and Physicians' Response to Professional Society Guidance.

IMPORTANCE: The value of routine preoperative testing before most surgical procedures is widely considered to be low. To improve the quality of preoperative care and reduce waste, 2 professional societies released guidance on use of routine preoperative testing in 2002, but researchers and policymakers remain concerned about the health and cost burden of low-value care in the preoperative setting. OBJECTIVE: To examine the long-term national effect of the 2002 professional guidance from the American College of Cardiology/American Heart Association and the American Society of Anesthesiologists on physicians' use of routine preoperative testing. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of nationally representative data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to examine adults in the United States who were evaluated during preoperative visits from January 1, 1997, through December 31, 2010. A quasiexperimental, difference-in-difference (DID) approach evaluated whether the publication of professional guidance in 2002 was associated with changes in preoperative testing patterns, adjusting for temporal trends in routine testing, as captured by testing patterns in general medical examinations. MAIN OUTCOMES AND MEASURES: Physician orders for outpatient plain radiography, hematocrit, urinalysis, electrocardiogram, and cardiac stress testing. RESULTS: During the 14-year period, the average annual number of preoperative visits in the United States increased from 6.8 million in 1997-1999 to 9.8 million in 2002-2004 and 14.3 million in 2008-2010. After accounting for temporal trends in routine testing, we found no statistically significant overall changes in the use of plain radiography (11.3% in 1997-2002 to 9.9% in 2003-2010; DID, -1.0 per 100 visits; 95% CI, -4.1 to 2.2), hematocrit (9.4% in 1997-2002 to 4.1% in 2003-2010; DID, 1.2 per 100 visits; 95% CI, -2.2 to 4.7), urinalysis (12.2% in 1997-2002 to 8.9% in 2003-2010; DID, 2.7 per 100 visits; 95% CI, -1.7 to 7.1), or cardiac stress testing (1.0% in 1997-2002 to 2.0% in 2003-2010; DID, 0.7 per 100 visits; 95% CI, -0.1 to 1.5) after the publication of professional guidance. However, the rate of electrocardiogram testing fell (19.4% in 1997-2002 to 14.3% in 2003-2010; DID, -6.7 per 100 visits; 95% CI, -10.6 to -2.7) in the period after the publication of guidance. CONCLUSIONS AND RELEVANCE: The release of the 2002 guidance on routine preoperative testing was associated with a reduced incidence of routine electrocardiogram testing but not of plain radiography, hematocrit, urinalysis, or cardiac stress testing. Because routine preoperative testing is generally considered to provide low incremental value, more concerted efforts to understand physician behavior and remove barriers to guideline adherence may improve health care quality and reduce costs.

Treatment of Leptomeningeal Carcinomatosis in a Patient With Metastatic Cholangiocarcinoma.

A 49-year-old woman with cholangiocarcinoma metastatic to the lungs presented with new-onset unrelenting headaches. A lumbar puncture revealed malignant cells consistent with leptomeningeal metastasis from her cholangiocarcinoma. Magnetic resonance imaging (MRI) of the brain revealed leptomeningeal enhancement. An intrathecal (IT) catheter was placed and IT chemotherapy was initiated with methotrexate. Her case is notable for the rarity of cholangiocarcinoma spread to the leptomeninges, the use of IT chemotherapy with cytologic and potentially symptomatic response, and a possible survival benefit in comparison to previously reported cases of leptomeningeal carcinomatosis secondary to cholangiocarcinoma.