Perioperative anemia: clinical practice update.

Perioperative medicine is an evolving area of medicine in which collaboration between internists, hospitalists, surgeons and anesthesiologists is the key to delivering high-quality care. Research in all areas of perioperative medicine, including perioperative anemia, is constantly evolving. Perioperative anemia is a major contributor to mortality and morbidity in the perioperative period. It is associated with an increased likelihood of postoperative wound complications, infections, delirium, increased length of stay and increased risk of readmissions. However, there is a lack of comprehensive guidelines for management of perioperative anemia. We performed an exhaustive review of contemporary literature on perioperative anemia and present evaluation and management recommendations that have the potential to impact clinical practice in the perioperative period.

Gender-Based Discrimination and Sexual Harassment Among Academic Internal Medicine Hospitalists.

BACKGROUND: Gender-based discrimination and sexual harassment, both implicit and overt, have been reported in academic medicine. This study examines experiences of academic hospitalists regarding gender-based discrimination and sexual harassment. METHODS: A survey was distributed to Internal Medicine hospitalists at university-based academic institutions in the United States. Questions assessed experiences regarding gender-based discrimination and sexual harassment in their interactions with patients, as well as with other healthcare providers (HCPs). RESULTS: Eighteen institutions participated in the survey, resulting in 336 individual responses. Female hospitalists more frequently reported inappropriate touch, sexual remarks, gestures, and suggestive looks by patients compared with male peers both over their careers (P < .001) and in the last 30 days (P < .001). Similarly, females more frequently reported being referred to with inappropriate terms of endearment (eg, "dear," "honey," "sweetheart") by patients both over their careers (P < .001) and in the last 30 days (P < .001). Almost 100% of females reported being mistaken by patients for nonphysician HCPs over their careers, compared with 29% of males (P < .001) (76% vs 10%, in the last 30 days; P < .001). Similarly, females more frequently reported sexual harassment over their careers (P < .05) and being mistaken for nonphysician HCPs by colleagues both over their careers (P < .001) and in the last 30 days (P < .001). Females rated their sense of respect both by patients (P < .001) and colleagues (P < .001) lower than males (P < .001). More females than males reported that gender negatively impacted their career opportunities (P < .001). CONCLUSION: This survey demonstrates that gender-based discrimination and sexual harassment are commonly encountered by academic hospitalists, with a significantly higher number of females reporting these experiences.

Surgical venous thromboembolism prophylaxis: clinical practice update.

BACKGROUND: Perioperative medicine continues to evolve as new literature emerges. This article provides an update on prevention of venous thromboembolism (VTE) in surgical patients. METHODS: We reviewed articles on VTE prevention in surgical patients published in peer-reviewed journals since the publication of 2012 ACCP guidelines on VTE prevention in surgical patients. RESULTS: Methods of VTE prophylaxis include aggressive ambulation, mechanical prophylaxis, and pharmacological prophylaxis. In non-orthopedic surgery, the overall approach remains assessment of thrombosis risk with the recommendation to use a risk assessment tool such as the modified Caprini score. Low molecular weight heparin (LMWH) appears to be more effective than unfractionated heparin (UFH) for VTE prophylaxis in non-orthopedic surgery. For orthopedic surgery, recent studies now recognize aspirin as an option for VTE prophylaxis after total hip arthroplasty, total knee arthroplasty, and hip fracture surgery. Extended prophylaxis with LMWH reduces the risk of symptomatic VTE in high risk abdominal and pelvic cancer surgery without an appreciable increase in risk of bleeding and decreased symptomatic VTE in major orthopedic surgery but with more minor but not major bleeding. Prophylactic Inferior vena cava (IVC) filter placement or surveillance compression ultrasonography is not recommended in management or detection of VTE in surgical patients. CONCLUSIONS: This article aims to provide insight into data from last several years which has potential to change clinical practices in perioperative setting.

2019 Update in perioperative cardiovascular medicine.

We performed a MEDLINE search and found 6 studies published February 2018 through January 2019 that should influence perioperative cardiovascular medicine, specifically in preoperative cardiac risk assessment, perioperative medication management, and postoperative cardiac complications.

Update in Hospital Medicine: Practical Lessons from Current Literature.

BACKGROUND: Hospital medicine continues to grow in workforce, clinical scope, and academic inquiry. This article provides a summary of recent high-impact publications for busy clinicians who provide care to hospitalized adults. METHODS: Authors reviewed articles that were published between March 2017 and March 2018 for the Update in Hospital Medicine presentations at the 2018 Society of Hospital Medicine and Society of General Internal Medicine annual meetings. Nine of the 29 articles presented were selected for this review based on quality and potential to influence practice. RESULTS: The following key insights were gained: (1) the perioperative continuation of aspirin in patients with previous percutaneous intervention is beneficial; (2) delaying hip fracture surgery beyond a 24-hour window increases complications; (3) oral antibiotics may be effective treatment for select bloodstream infections; (4) pulmonary embolism may not be as common a cause of syncope as previously suggested; (5) balanced intravenous fluids and normal saline are similar with respect to hospital-free days but a difference exists in renal events at 30 days favoring balanced crystalloids; (6) speaker introductions may reveal gender bias in academic medicine; (7) edoxaban is a reasonable choice for the treatment of venous thromboembolism in cancer; (8) high-flow nasal cannula reduces the need for intubation in respiratory failure when compared with usual oxygen therapy and noninvasive positive pressure ventilation; and (9) diagnostic errors in spinal epidural abscess lead to delays and morbidity. CONCLUSIONS: This research provides insight into how we can approach common medical problems in the care of hospitalized adults. The selected works have the potential to change or confirm current practices.

Perioperative cardiovascular medicine: 5 questions for 2018.

A MEDLINE search was performed from January 2017 to February 2018, and articles were selected for this update based on their significant influence on the practice of perioperative cardiovascular medicine.

Renal disease and the surgical patient: Minimizing the impact.

Chronic kidney disease (CKD) is common in patients scheduled for surgery and increases the risk of postoperative acute kidney injury, major adverse cardiac events, and death. Acute kidney injury is a common complication of cardiac and noncardiac surgery and negatively affects both short- and long-term outcomes. If we can detect underlying CKD and other risk factors for acute kidney injury before surgery, we may in theory be able to give preventive therapies and improve perioperative outcomes.

Postoperative Day 1 Glucose May Be Associated With Wound Complications in Sarcomas Treated With Preoperative Radiation.

BACKGROUND: Uncontrolled blood glucose impacts key phases of the wound healing process. Various factors have been associated with postoperative wound complications in soft tissue sarcomas; however, the association of postoperative early morning blood glucose with wound complications, if any, remains to be determined. Because blood glucose levels may be modified, understanding whether glucose levels are associated with wound complications has potential therapeutic importance. QUESTIONS/PURPOSES: The purposes of this study were (1) to evaluate if postoperative early morning blood glucose is associated with the development of wound complications in soft tissue sarcomas; (2) to determine a blood glucose cutoff that may be associated with an increased risk of wound complications; and (3) to evaluate if patients with diabetes have higher postoperative blood glucose and an associated increased risk of wound complications. METHODS: From 2000 to 2015, 298 patients with Stage I to III soft tissue sarcomas of the extremity or chest wall were treated with preoperative radiation ± chemotherapy followed by limb-sparing resection. Of those, 191 (64%) patients had demographic, treatment, and postoperative variables and wound outcomes available; these patients' results were retrospectively evaluated. None of the 191 patients were lost to followup. Early morning blood glucose levels on postoperative day (POD) 1 were available in all patients. Wound complications were defined as those resulting in an operative procedure or prolonged wound care for 6 months postresection. Variables that may be associated with wound complications were evaluated using logistic regression for multivariate analysis. Receiver operative curve (ROC) analysis was used to assess the early morning blood glucose level that best was associated postoperative wound complications. RESULTS: After controlling for potentially relevant confounding variables such as patient comorbidities, tumor size, and location, lower extremity soft tissue sarcomas (p = 0.002, odds ratio [OR], 6.4; 95% confidence interval [CI], 1.97-20.84) and elevated POD 1 early morning blood sugars (p < 0.001; OR, 1.1; 95% CI, 1.04-1.11) were associated with increased wound complications postoperatively. ROC analysis revealed that early morning POD 1 blood glucose of > 127 mg/dL was associated with postoperative wound complications with a sensitivity of 89% (area under the curve 0.898, p < 0.001). Median POD 1 early morning blood glucose in patients without diabetes was 118 mg/dL and 153 mg/dL in patients with diabetes (p = 0.023). However, with the numbers available, there was no increase in wound complications in patients with diabetes compared with those without it. CONCLUSIONS: Our study provides preliminary information suggesting that POD 1 early morning blood glucose in patients with soft tissue sarcomas may be associated with a slightly increased risk of postoperative wound complications. An early morning blood glucose of > 127 mg/dL may be a threshold associated with this outcome. Although patients with diabetes had higher POD 1 early morning blood glucose levels, diabetes itself was not associated with the development of wound complications. We cannot conclude that better glycemic control will reduce wound complications in patients who receive preoperative radiation, but our data suggest this should be further studied in a larger, prospective study. LEVEL OF EVIDENCE: Level III, therapeutic study.

Preoperative Diabetes Optimization Program.

IN BRIEF "Quality Improvement Success Stories" are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a successful effort to improve glycemic control in presurgical patients with an A1C >8%.

2017 Update in perioperative medicine: 6 questions answered.

The authors performed a MEDLINE search to identify articles published between January 2016 and April 2017 that had significant impact on perioperative care. They identified 6 topics for discussion.

Hospital Medicine and Perioperative Care: A Framework for High-Quality, High-Value Collaborative Care.

BACKGROUND: Hospitalists have long been involved in optimizing perioperative care for medically complex patients. In 2015, the Society of Hospital Medicine organized the Perioperative Care Work Group to summarize this experience and to develop a framework for providing optimal perioperative care. METHODS: The work group, which consisted of perioperative care experts from institutions throughout the United States, reviewed current hospitalist-based perioperative care programs, compiled key issues in each perioperative phase, and developed a framework to highlight essential elements to be considered. The framework was reviewed and approved by the board of the Society of Hospital Medicine. RESULTS: The Perioperative Care Matrix for Inpatient Surgeries was developed. This matrix characterizes perioperative phases, coordination, and metrics of success. Additionally, concerns and potential risks were tabulated. Key questions regarding program effectiveness were drafted, and examples of models of care were provided. CONCLUSIONS: The Perioperative Care Matrix for Inpatient Surgeries provides an essential collaborative framework hospitalists can use to develop and continually improve perioperative care programs. Journal of Hospital Medicine 2017;12:277-282.

Update in perioperative cardiac medicine.

Recent studies have shed light on preoperative risk assessment, medical therapy to reduce postoperative cardiac complications (beta-blockers, statins, and angiotensin II receptor blockers [ARBs]), perioperative management of patients with coronary stents on antiplatelet therapy, and perioperative bridging anticoagulation.

Preoperative Clinics.

Preoperative evaluation clinics have been shown to enhance operating room efficiency, decrease day-of-surgery cancellations, reduce hospital costs, and improve the quality of patient care. Although programs differ in staffing, structure, financial support, and daily operations, they share the common goal of preoperative risk reduction in order for patients to proceed safely through the perioperative period. Effective preoperative evaluation occurs if processes are standardized to ensure clinical, regulatory, and accreditation guidelines are met while keeping medical optimization and patient satisfaction at the forefront. Although no universally accepted standard model exists, there are key components to a successful preoperative process.

Hyperglycemia and Acute Kidney Injury During the Perioperative Period.

Hyperglycemia and acute kidney injury (AKI) are frequently observed during the perioperative period. Substantial evidence indicates that hyperglycemia increases the prevalence of AKI as a surgical complication. Patients who develop hyperglycemia and AKI during the perioperative period are at significantly elevated risk for poor outcomes such as major adverse cardiac events and all-cause mortality. Early observational and interventional trials demonstrated that the use of intensive insulin therapy to achieve strict glycemic control resulted in remarkable reductions of AKI in surgical populations. However, more recent interventional trials and meta-analyses have produced contradictory evidence questioning the renal benefits of strict glycemic control. Although the exact mechanisms through which hyperglycemia increases the risk of AKI have not been elucidated, multiple pathophysiologic pathways have been proposed. Hypoglycemia and glycemic variability may also play a significant role in the development of AKI. In this literature review, the complex relationship between hyperglycemia and AKI as well as its impact on clinical outcomes during the perioperative period is explored.

Improving preoperative medication compliance with standardized instructions.

BACKGROUND: Patient medication adherence in the perioperative setting is challenging, and failure to comply with medication instructions has serious clinical consequences. Many factors contribute to medication nonadherence, but a modifiable cause is inadequate physician instruction of patients. Variable formats, language and legibility impede patient-physician communication regarding proper use of medications. We hypothesized that the use of a standardized, electronic medical record (EMR)-derived medication instruction template would improve medication compliance on the day of surgery. METHODS: As part of an ongoing quality improvement program, our institution surveyed patient's compliance with preoperative medication instructions. A standardized template was then created within the EMR and implemented by all providers in the preoperative evaluation clinic. Compliance with medications on the morning of surgery was then reassessed by preoperative nursing staff for three months shortly after the intervention and again two years later. RESULTS: Patient adherence to preoperative medication instructions improved significantly immediately after the implementation of the template (from 83.7% to 89.7%, P=0.025). This improvement was also sustained at the two-year follow-up. Although patients' had overall good medication compliance (90% after the intervention), 71% of medication errors were made with medications with significant potential for causing complications (e.g., antithrombotic therapy). CONCLUSION: Use of standardized, EMR-generated preoperative instructions improves patient medication adherence on the morning of surgery. Even with this intervention, medication nonadherence most often involves medications that could seriously interfere with perioperative care.

Updates in perioperative medicine.

BACKGROUND: As our surgical population becomes older and more medically complex, knowledge of the most recent perioperative literature is necessary to optimize perioperative care. We aim to summarize and critique literature published over the past year with the highest potential to impact the clinical practice of perioperative medicine. METHODS: We reviewed articles published between January 2014 and April 2015, identified via MEDLINE search. The final 10 articles selected were determined by consensus among all authors, with criteria for inclusion including scientific rigor and relevance to perioperative medicine practice. RESULTS: Key findings include: long term ß-blockade should be continued prior to surgery, routine screening with postoperative troponin is not recommended, initiation/continuation of aspirin or clonidine in the perioperative period is not beneficial and may increase adverse outcomes, preoperative diagnosis and treatment of obstructive sleep apnea may reduce risk of postoperative cardiovascular complications, new pulmonary risk indices are available that accurately estimate postoperative pulmonary complications, postoperative atrial fibrillation is associated with increased long-term stroke risk, risk scores such as the CHADS2 (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes Mellitus, previous stroke or transient ischemic attack) are superior to the Revised Cardiac Risk Index in predicting adverse postoperative outcomes for patients with nonvalvular atrial fibrillation, and utilization of bridging anticoagulation comes with a much higher risk of bleeding compared to patients who are not bridged. CONCLUSIONS: The body of literature reviewed provides important information for clinicians caring for surgical patients across multiple fronts, including preoperative risk assessment, medication management, and postoperative medical care.

Risk factors for postoperative pulmonary complications: an update of the literature.

Perioperative medicine is a growing area of research that brings together internists, anesthesiologists, surgeons, and hospitalists. A medical team approach to ensure the best possible patient outcomes has fostered collaborative strategies across disciplines. Perioperative pulmonary complications are common and can be associated with significant morbidity and mortality. Effective strategies to identify and reduce risks of pulmonary complications can improve patient outcomes. We review the new literature (2013 to early 2014) in the field of perioperative pulmonary medicine that reports new strategies to improve outcomes in the area of perioperative pulmonary care.