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Wait! Put elective surgery on hold after stent placement
SCOTTSDALE, ARIZ. – The presence of a coronary artery stent is not a barrier to noncardiac surgery, but it may change the timing of surgery and perioperative management of the patient, a hospitalist cautions.
Patients who receive bare-metal stents should delay having elective surgery for at least 6 weeks after stent placement, and those who receive a drug-eluting stent should put off elective procedures for at least a year, said Dr. Amir K. Jaffer, professor of medicine and chief of the division of hospital medicine at Rush University Medical Center in Chicago.
The type of stent, its placement, and the time since placement are just some of the key pieces of information that clinicians need to manage patients, Dr. Jaffer said at a meeting on perioperative medicine sponsored by the University of Miami.
"You want to try to get that [information] card if you can from the patient, about where the stents were placed, and if they don’t have the card handy, you really need to go to the procedure note, because the patient may or may not know if it was a drug-eluting stent," he said.
Other vital pieces of the perioperative puzzle are which coronary vessel the stent was implanted in; when the stent was implanted; what drug, if any (sirolimus or paclitaxel) is eluted by the stent; whether there were surgical or postoperative complications; prior history of stent thrombosis; the patient’s comorbidities; duration of dual-antiplatelet therapy; and how the patient has fared on therapy.
Prior to an elective noncardiac procedure, clinicians must consider patient risk factors, including indication for antithrombotic therapy, risk factors for thrombosis or thromboembolism, and type of antithrombotic agent; and surgical risk factors, including type of procedure, bleeding risk, thromboembolism risk, and time off antithrombotic therapy.
When to stop antithrombotic agents
Dr. Jaffer noted that because aspirin is an irreversible inhibitor of platelet cyclooxygenase and the circulating platelet pool is replaced every 7 to 10 days, patients on aspirin as part of their dual-antiplatelet therapy should stop taking the drug from 7 to 10 days before scheduled surgery.
Thienopyridines/P2Y12 receptor antagonists such as clopidogrel (Plavix) and ticagrelor (Brilinta) work by inhibiting adenosine diphosphate (ADP) receptor-mediated platelet activation and aggregation. Dr. Jaffer said that although guidelines recommend stopping these agents 7 days before surgery, there is evidence to suggest that 5 days may be a sufficient window of safety.
It is also important to take into consideration the pharmacokinetic profiles of the specific antiplatelet agents. For example, ticagrelor has a more rapid onset and greater degree of platelet-aggregation inhibition than clopidogrel, although the time from stopping each agent until the return to near-baseline platelet aggregation is similar, on the order of about 120 hours (5 days) or longer, he said.
Risk varies by surgery type
The type of surgery is also important, as certain procedures – such as neurocranial surgery, spinal canal surgery, and procedures performed in the posterior chamber of the eye – carry a high risk for hemorrhage and are likely to require blood transfusions.
Dr. Jaffer noted that in 2007, the American College of Cardiology and American Heart Association issued a joint advisory on antiplatelet therapy and noncardiac surgery, which warned health care providers about the potentially catastrophic risks of stopping thienopyridines prematurely, which could result in acute stent thrombosis, myocardial infarction, and death. The guidelines recommend waiting a minimum of 6 weeks for noncardiac surgery following implantation of a bare-metal stent, and 1 year after a drug-eluting stent.
He pointed to two studies from the Mayo Clinic published in 2008. The first study showed that the risk of major cardiac adverse events among patients with a bare-metal stent undergoing noncardiac surgery within 30 days of stent placement was approximately 10%, but diminished to 2.7% at 91 days after placement (Anesthesiology 2008;109:588-95). The second study showed that the risk of major cardiac adverse events was 6.1% within 90 days after implantation of a drug-eluting stent, with the risk dwindling to 3.1% after 1 year (Anesthesiology 2008;109:596-604).
If urgent surgery such as a hemicolectomy for colon cancer is required within 6 months of drug-eluting stent implantation, the patient should continue on dual-antiplatelet therapy, Dr. Jaffer said. If the surgery is from 6 months to 1 year after implantation in these patients, the patient should be continued on at least 81 mg aspirin, but if the patient is taking clopidogrel, he or she should have the thienopyridine discontinued 5 days before surgery and the drug resumed as soon as possible after surgery with a 300-mg loading dose, followed by 75 mg daily. If the patient is not yet able to eat, the dual-antiplatelet therapy should be delivered via nasogastric tube, he said.
Dr. Jaffer reported serving as a consultant to Boehringer Ingelheim, Janssen Pharmaceuticals, and other companies. Dr. Jaffer also serves on the editorial advisory board of Hospitalist News.
SCOTTSDALE, ARIZ. – The presence of a coronary artery stent is not a barrier to noncardiac surgery, but it may change the timing of surgery and perioperative management of the patient, a hospitalist cautions.
Patients who receive bare-metal stents should delay having elective surgery for at least 6 weeks after stent placement, and those who receive a drug-eluting stent should put off elective procedures for at least a year, said Dr. Amir K. Jaffer, professor of medicine and chief of the division of hospital medicine at Rush University Medical Center in Chicago.
The type of stent, its placement, and the time since placement are just some of the key pieces of information that clinicians need to manage patients, Dr. Jaffer said at a meeting on perioperative medicine sponsored by the University of Miami.
"You want to try to get that [information] card if you can from the patient, about where the stents were placed, and if they don’t have the card handy, you really need to go to the procedure note, because the patient may or may not know if it was a drug-eluting stent," he said.
Other vital pieces of the perioperative puzzle are which coronary vessel the stent was implanted in; when the stent was implanted; what drug, if any (sirolimus or paclitaxel) is eluted by the stent; whether there were surgical or postoperative complications; prior history of stent thrombosis; the patient’s comorbidities; duration of dual-antiplatelet therapy; and how the patient has fared on therapy.
Prior to an elective noncardiac procedure, clinicians must consider patient risk factors, including indication for antithrombotic therapy, risk factors for thrombosis or thromboembolism, and type of antithrombotic agent; and surgical risk factors, including type of procedure, bleeding risk, thromboembolism risk, and time off antithrombotic therapy.
When to stop antithrombotic agents
Dr. Jaffer noted that because aspirin is an irreversible inhibitor of platelet cyclooxygenase and the circulating platelet pool is replaced every 7 to 10 days, patients on aspirin as part of their dual-antiplatelet therapy should stop taking the drug from 7 to 10 days before scheduled surgery.
Thienopyridines/P2Y12 receptor antagonists such as clopidogrel (Plavix) and ticagrelor (Brilinta) work by inhibiting adenosine diphosphate (ADP) receptor-mediated platelet activation and aggregation. Dr. Jaffer said that although guidelines recommend stopping these agents 7 days before surgery, there is evidence to suggest that 5 days may be a sufficient window of safety.
It is also important to take into consideration the pharmacokinetic profiles of the specific antiplatelet agents. For example, ticagrelor has a more rapid onset and greater degree of platelet-aggregation inhibition than clopidogrel, although the time from stopping each agent until the return to near-baseline platelet aggregation is similar, on the order of about 120 hours (5 days) or longer, he said.
Risk varies by surgery type
The type of surgery is also important, as certain procedures – such as neurocranial surgery, spinal canal surgery, and procedures performed in the posterior chamber of the eye – carry a high risk for hemorrhage and are likely to require blood transfusions.
Dr. Jaffer noted that in 2007, the American College of Cardiology and American Heart Association issued a joint advisory on antiplatelet therapy and noncardiac surgery, which warned health care providers about the potentially catastrophic risks of stopping thienopyridines prematurely, which could result in acute stent thrombosis, myocardial infarction, and death. The guidelines recommend waiting a minimum of 6 weeks for noncardiac surgery following implantation of a bare-metal stent, and 1 year after a drug-eluting stent.
He pointed to two studies from the Mayo Clinic published in 2008. The first study showed that the risk of major cardiac adverse events among patients with a bare-metal stent undergoing noncardiac surgery within 30 days of stent placement was approximately 10%, but diminished to 2.7% at 91 days after placement (Anesthesiology 2008;109:588-95). The second study showed that the risk of major cardiac adverse events was 6.1% within 90 days after implantation of a drug-eluting stent, with the risk dwindling to 3.1% after 1 year (Anesthesiology 2008;109:596-604).
If urgent surgery such as a hemicolectomy for colon cancer is required within 6 months of drug-eluting stent implantation, the patient should continue on dual-antiplatelet therapy, Dr. Jaffer said. If the surgery is from 6 months to 1 year after implantation in these patients, the patient should be continued on at least 81 mg aspirin, but if the patient is taking clopidogrel, he or she should have the thienopyridine discontinued 5 days before surgery and the drug resumed as soon as possible after surgery with a 300-mg loading dose, followed by 75 mg daily. If the patient is not yet able to eat, the dual-antiplatelet therapy should be delivered via nasogastric tube, he said.
Dr. Jaffer reported serving as a consultant to Boehringer Ingelheim, Janssen Pharmaceuticals, and other companies. Dr. Jaffer also serves on the editorial advisory board of Hospitalist News.
SCOTTSDALE, ARIZ. – The presence of a coronary artery stent is not a barrier to noncardiac surgery, but it may change the timing of surgery and perioperative management of the patient, a hospitalist cautions.
Patients who receive bare-metal stents should delay having elective surgery for at least 6 weeks after stent placement, and those who receive a drug-eluting stent should put off elective procedures for at least a year, said Dr. Amir K. Jaffer, professor of medicine and chief of the division of hospital medicine at Rush University Medical Center in Chicago.
The type of stent, its placement, and the time since placement are just some of the key pieces of information that clinicians need to manage patients, Dr. Jaffer said at a meeting on perioperative medicine sponsored by the University of Miami.
"You want to try to get that [information] card if you can from the patient, about where the stents were placed, and if they don’t have the card handy, you really need to go to the procedure note, because the patient may or may not know if it was a drug-eluting stent," he said.
Other vital pieces of the perioperative puzzle are which coronary vessel the stent was implanted in; when the stent was implanted; what drug, if any (sirolimus or paclitaxel) is eluted by the stent; whether there were surgical or postoperative complications; prior history of stent thrombosis; the patient’s comorbidities; duration of dual-antiplatelet therapy; and how the patient has fared on therapy.
Prior to an elective noncardiac procedure, clinicians must consider patient risk factors, including indication for antithrombotic therapy, risk factors for thrombosis or thromboembolism, and type of antithrombotic agent; and surgical risk factors, including type of procedure, bleeding risk, thromboembolism risk, and time off antithrombotic therapy.
When to stop antithrombotic agents
Dr. Jaffer noted that because aspirin is an irreversible inhibitor of platelet cyclooxygenase and the circulating platelet pool is replaced every 7 to 10 days, patients on aspirin as part of their dual-antiplatelet therapy should stop taking the drug from 7 to 10 days before scheduled surgery.
Thienopyridines/P2Y12 receptor antagonists such as clopidogrel (Plavix) and ticagrelor (Brilinta) work by inhibiting adenosine diphosphate (ADP) receptor-mediated platelet activation and aggregation. Dr. Jaffer said that although guidelines recommend stopping these agents 7 days before surgery, there is evidence to suggest that 5 days may be a sufficient window of safety.
It is also important to take into consideration the pharmacokinetic profiles of the specific antiplatelet agents. For example, ticagrelor has a more rapid onset and greater degree of platelet-aggregation inhibition than clopidogrel, although the time from stopping each agent until the return to near-baseline platelet aggregation is similar, on the order of about 120 hours (5 days) or longer, he said.
Risk varies by surgery type
The type of surgery is also important, as certain procedures – such as neurocranial surgery, spinal canal surgery, and procedures performed in the posterior chamber of the eye – carry a high risk for hemorrhage and are likely to require blood transfusions.
Dr. Jaffer noted that in 2007, the American College of Cardiology and American Heart Association issued a joint advisory on antiplatelet therapy and noncardiac surgery, which warned health care providers about the potentially catastrophic risks of stopping thienopyridines prematurely, which could result in acute stent thrombosis, myocardial infarction, and death. The guidelines recommend waiting a minimum of 6 weeks for noncardiac surgery following implantation of a bare-metal stent, and 1 year after a drug-eluting stent.
He pointed to two studies from the Mayo Clinic published in 2008. The first study showed that the risk of major cardiac adverse events among patients with a bare-metal stent undergoing noncardiac surgery within 30 days of stent placement was approximately 10%, but diminished to 2.7% at 91 days after placement (Anesthesiology 2008;109:588-95). The second study showed that the risk of major cardiac adverse events was 6.1% within 90 days after implantation of a drug-eluting stent, with the risk dwindling to 3.1% after 1 year (Anesthesiology 2008;109:596-604).
If urgent surgery such as a hemicolectomy for colon cancer is required within 6 months of drug-eluting stent implantation, the patient should continue on dual-antiplatelet therapy, Dr. Jaffer said. If the surgery is from 6 months to 1 year after implantation in these patients, the patient should be continued on at least 81 mg aspirin, but if the patient is taking clopidogrel, he or she should have the thienopyridine discontinued 5 days before surgery and the drug resumed as soon as possible after surgery with a 300-mg loading dose, followed by 75 mg daily. If the patient is not yet able to eat, the dual-antiplatelet therapy should be delivered via nasogastric tube, he said.
Dr. Jaffer reported serving as a consultant to Boehringer Ingelheim, Janssen Pharmaceuticals, and other companies. Dr. Jaffer also serves on the editorial advisory board of Hospitalist News.
EXPERT ANALYSIS FROM THE PERIOPERATIVE MEDICINE SUMMIT
Major finding: Elective noncardiac surgery should be delayed for at least 6 weeks following implantation of a bare-metal stent, and 1 year after implantation of a drug-eluting stent.
Data source: Evidence-based review of data on the risk of adverse events following noncardiac surgery in patients with coronary artery stents.
Disclosures: Dr. Jaffer reported serving as a consultant to Boehringer Ingelheim, Janssen Pharmaceuticals, and other companies. Dr. Jaffer also serves on the editorial advisory board of Hospitalist News.
Strong nerves, teamwork key in managing neurosurgical patients, devices
SCOTTSDALE, ARIZ. – Comanaging neurosurgical patients requires a delicate dance between primary practitioners, surgeons, anesthesiologists, and, in some cases, the makers of implantable neurostimulators, according to perioperative medicine specialists.
Special considerations with patients scheduled for neurosurgical procedures include hypertension, fever, hyponatremia, and risk of deep vein thromboembolism (DVT) and coagulopathies, said Dr. Richard Huh, director of the inpatient medical consultation service at Rush University Medical Center in Chicago, at a meeting on perioperative medicine sponsored by the University of Miami.
For example, hospitalists are typically involved in the management of blood pressure in neurosurgery patients because of the importance of controlling intracranial pressure, Dr. Huh noted.
"The trick is for the blood pressure not to get too high or too low. The Handbook of Neurosurgery suggests a goal of 140 over 90 [mm Hg]," he said.
Patients with acute subarachnoid hemorrhage are at risk for vasospasm, most frequently within 7-10 days of hemorrhage. Hypovolemia is a common cause of vasospasm and should be avoided. Medications such as nimodipine (Nimotop) can help prevent this complication.
Patients undergoing spinal procedures tend to have low blood pressure from acute blood loss or intravenous pain medications, and may require hold parameters on medications to avoid complications from hypotension.
However, on the day following spinal surgery, some patients develop hypertension, and may require additional medications for BP control.
Hyponatremia
The reported prevalence of hyponatremia in hospitalized patients ranges from 1%-7%, and the rate is even higher in neurosurgical patients, possibility because the brain’s response to changes in osmolality. Clinicians managing neurosurgical patients should be aware of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting, Dr. Huh said.
Cerebral salt wasting may be cause by damaged brain cells that affect sympathetic neural input to the kidneys, decreasing sodium resorption and an increase in atrial natriuretic peptide and brain natriuretic peptide.
The syndrome looks similar to SIADH, with high urinary sodium and osmolality, low serum osmolality, and decreased serum uric acid. But cerebral salt wasting is distinguished from SIADH by the presence of hypovolemia. Cerebral salt wasting is treated with saline and/or salt tablets.
DVT
Neurosurgical patients are at increased risk for DVT and pulmonary embolism compared with the general postoperative population. However, 2012 guidelines on antithrombotic therapy from the American College of Chest Physicians recommend against pharmacologic prophylaxis except for high risk patients, such as patients with intracranial masses. Dr. Huh said.
Implantable neurostimulators
Patients with implanted devices such as deep-brain stimulators for control of Parkinson’s disease, hypoglossal nerve stimulators for severe sleep apnea, or vagal nerve stimulators for epilepsy also require special consideration throughout the perioperative period.
Issues to consider when managing a patient with an implantable device include the device site and its proximity to the planned surgical field, indication for the device, comorbidities, and the patient’s goals for treatment, said Dr. Deborah Richman, section chief of preoperative services at Stony Brook (New York) University Medical Center.
"What do we do with device itself? This is a team approach, and we find that it’s best coordinated by our nurses in the preop holding area, because they know what time the surgery is, they have the device company rep’s phone number, they make sure the patient is there on time, and they put everything together to prevent delays on the day of surgery," she said.
In general, device manufacturers recommend turning devices off, and to turn the amplitude down to zero to prevent accidental activation of magnetic on-off switches.
The distance from the surgery to the pulse generator should be a minimum of 20 cm, and electrocautery, if used, should be bipolar rather than monopolar, Dr. Richman said.
Patients with implanted devices will also require prophylactic antibiotics to prevent potential bacterial seeding of the device or leads, she said,
Coordination of perioperative care "is best done with clinical management pathways, so that when you have one of these patients who present to you, you have a checklist that includes the device company’s phone number, and it’s an easy go-to, so that you don’t have to start from scratch each time," she concluded.
Dr. Huh and Dr. Richman reported having no financial disclosures.
SCOTTSDALE, ARIZ. – Comanaging neurosurgical patients requires a delicate dance between primary practitioners, surgeons, anesthesiologists, and, in some cases, the makers of implantable neurostimulators, according to perioperative medicine specialists.
Special considerations with patients scheduled for neurosurgical procedures include hypertension, fever, hyponatremia, and risk of deep vein thromboembolism (DVT) and coagulopathies, said Dr. Richard Huh, director of the inpatient medical consultation service at Rush University Medical Center in Chicago, at a meeting on perioperative medicine sponsored by the University of Miami.
For example, hospitalists are typically involved in the management of blood pressure in neurosurgery patients because of the importance of controlling intracranial pressure, Dr. Huh noted.
"The trick is for the blood pressure not to get too high or too low. The Handbook of Neurosurgery suggests a goal of 140 over 90 [mm Hg]," he said.
Patients with acute subarachnoid hemorrhage are at risk for vasospasm, most frequently within 7-10 days of hemorrhage. Hypovolemia is a common cause of vasospasm and should be avoided. Medications such as nimodipine (Nimotop) can help prevent this complication.
Patients undergoing spinal procedures tend to have low blood pressure from acute blood loss or intravenous pain medications, and may require hold parameters on medications to avoid complications from hypotension.
However, on the day following spinal surgery, some patients develop hypertension, and may require additional medications for BP control.
Hyponatremia
The reported prevalence of hyponatremia in hospitalized patients ranges from 1%-7%, and the rate is even higher in neurosurgical patients, possibility because the brain’s response to changes in osmolality. Clinicians managing neurosurgical patients should be aware of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting, Dr. Huh said.
Cerebral salt wasting may be cause by damaged brain cells that affect sympathetic neural input to the kidneys, decreasing sodium resorption and an increase in atrial natriuretic peptide and brain natriuretic peptide.
The syndrome looks similar to SIADH, with high urinary sodium and osmolality, low serum osmolality, and decreased serum uric acid. But cerebral salt wasting is distinguished from SIADH by the presence of hypovolemia. Cerebral salt wasting is treated with saline and/or salt tablets.
DVT
Neurosurgical patients are at increased risk for DVT and pulmonary embolism compared with the general postoperative population. However, 2012 guidelines on antithrombotic therapy from the American College of Chest Physicians recommend against pharmacologic prophylaxis except for high risk patients, such as patients with intracranial masses. Dr. Huh said.
Implantable neurostimulators
Patients with implanted devices such as deep-brain stimulators for control of Parkinson’s disease, hypoglossal nerve stimulators for severe sleep apnea, or vagal nerve stimulators for epilepsy also require special consideration throughout the perioperative period.
Issues to consider when managing a patient with an implantable device include the device site and its proximity to the planned surgical field, indication for the device, comorbidities, and the patient’s goals for treatment, said Dr. Deborah Richman, section chief of preoperative services at Stony Brook (New York) University Medical Center.
"What do we do with device itself? This is a team approach, and we find that it’s best coordinated by our nurses in the preop holding area, because they know what time the surgery is, they have the device company rep’s phone number, they make sure the patient is there on time, and they put everything together to prevent delays on the day of surgery," she said.
In general, device manufacturers recommend turning devices off, and to turn the amplitude down to zero to prevent accidental activation of magnetic on-off switches.
The distance from the surgery to the pulse generator should be a minimum of 20 cm, and electrocautery, if used, should be bipolar rather than monopolar, Dr. Richman said.
Patients with implanted devices will also require prophylactic antibiotics to prevent potential bacterial seeding of the device or leads, she said,
Coordination of perioperative care "is best done with clinical management pathways, so that when you have one of these patients who present to you, you have a checklist that includes the device company’s phone number, and it’s an easy go-to, so that you don’t have to start from scratch each time," she concluded.
Dr. Huh and Dr. Richman reported having no financial disclosures.
SCOTTSDALE, ARIZ. – Comanaging neurosurgical patients requires a delicate dance between primary practitioners, surgeons, anesthesiologists, and, in some cases, the makers of implantable neurostimulators, according to perioperative medicine specialists.
Special considerations with patients scheduled for neurosurgical procedures include hypertension, fever, hyponatremia, and risk of deep vein thromboembolism (DVT) and coagulopathies, said Dr. Richard Huh, director of the inpatient medical consultation service at Rush University Medical Center in Chicago, at a meeting on perioperative medicine sponsored by the University of Miami.
For example, hospitalists are typically involved in the management of blood pressure in neurosurgery patients because of the importance of controlling intracranial pressure, Dr. Huh noted.
"The trick is for the blood pressure not to get too high or too low. The Handbook of Neurosurgery suggests a goal of 140 over 90 [mm Hg]," he said.
Patients with acute subarachnoid hemorrhage are at risk for vasospasm, most frequently within 7-10 days of hemorrhage. Hypovolemia is a common cause of vasospasm and should be avoided. Medications such as nimodipine (Nimotop) can help prevent this complication.
Patients undergoing spinal procedures tend to have low blood pressure from acute blood loss or intravenous pain medications, and may require hold parameters on medications to avoid complications from hypotension.
However, on the day following spinal surgery, some patients develop hypertension, and may require additional medications for BP control.
Hyponatremia
The reported prevalence of hyponatremia in hospitalized patients ranges from 1%-7%, and the rate is even higher in neurosurgical patients, possibility because the brain’s response to changes in osmolality. Clinicians managing neurosurgical patients should be aware of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral salt wasting, Dr. Huh said.
Cerebral salt wasting may be cause by damaged brain cells that affect sympathetic neural input to the kidneys, decreasing sodium resorption and an increase in atrial natriuretic peptide and brain natriuretic peptide.
The syndrome looks similar to SIADH, with high urinary sodium and osmolality, low serum osmolality, and decreased serum uric acid. But cerebral salt wasting is distinguished from SIADH by the presence of hypovolemia. Cerebral salt wasting is treated with saline and/or salt tablets.
DVT
Neurosurgical patients are at increased risk for DVT and pulmonary embolism compared with the general postoperative population. However, 2012 guidelines on antithrombotic therapy from the American College of Chest Physicians recommend against pharmacologic prophylaxis except for high risk patients, such as patients with intracranial masses. Dr. Huh said.
Implantable neurostimulators
Patients with implanted devices such as deep-brain stimulators for control of Parkinson’s disease, hypoglossal nerve stimulators for severe sleep apnea, or vagal nerve stimulators for epilepsy also require special consideration throughout the perioperative period.
Issues to consider when managing a patient with an implantable device include the device site and its proximity to the planned surgical field, indication for the device, comorbidities, and the patient’s goals for treatment, said Dr. Deborah Richman, section chief of preoperative services at Stony Brook (New York) University Medical Center.
"What do we do with device itself? This is a team approach, and we find that it’s best coordinated by our nurses in the preop holding area, because they know what time the surgery is, they have the device company rep’s phone number, they make sure the patient is there on time, and they put everything together to prevent delays on the day of surgery," she said.
In general, device manufacturers recommend turning devices off, and to turn the amplitude down to zero to prevent accidental activation of magnetic on-off switches.
The distance from the surgery to the pulse generator should be a minimum of 20 cm, and electrocautery, if used, should be bipolar rather than monopolar, Dr. Richman said.
Patients with implanted devices will also require prophylactic antibiotics to prevent potential bacterial seeding of the device or leads, she said,
Coordination of perioperative care "is best done with clinical management pathways, so that when you have one of these patients who present to you, you have a checklist that includes the device company’s phone number, and it’s an easy go-to, so that you don’t have to start from scratch each time," she concluded.
Dr. Huh and Dr. Richman reported having no financial disclosures.
AT THE PERIOPERATIVE MEDICINE SUMMIT
Major finding: Neurosurgical procedures are associated with increased risk for complications, such as hyponatremia and deep vein thromboembolism, compared with general surgeries.
Data source: Reviews of recommendations on the perioperative management of neurosurgical patients and those with implanted neurostimulating devices.
Disclosures: Dr. Huh and Dr. Richman reported having no financial disclosures.
Study found low rates, but significant risk factors, for incidental gallbladder cancer in cholecystectomy patients
Only 0.19% of cholecystectomy patients had incidental gallbladder cancer, and incidence was just 0.03% in patients who lacked risk factors for the malignancy, according to investigators. The report was published in Annals of Surgery.
The results were lower than historical reports, probably because cholecystectomy has been increasingly performed in younger patients, said Dr. Susan Pitt of Washington University, St. Louis, and her associates.
The investigators reported that significant risk factors for incidental gall bladder cancer (iGBC) included open (vs. laparoscopic) cholecystectomy, older age, Asian or African-American race, female sex, and an elevated alkaline phosphatase (ALP) level (Ann. Surg. 2014 Feb. 6 [doi:10.1097/SLA.0000000000000485]).
The retrospective cohort study included 91,260 patients aged 16 years and older who underwent laparoscopic (n = 80,924 [88.7%]) or open (n = 10,336 [11.3%]) cholecystectomy from 2005 to 2009. Patients were identified through the American College of Surgeons-National Surgical Quality Improvement Program Participant Use File.
Only 0.05% of laparoscopic patients had iGBC, vs. 0.60% of laparoscopic converted to open cholecystectomy patients (P less than .001) and 1.13% of open cholecystectomy patients (P less than .001), the researchers said. Multivariable predictors for iGBC included open vs. laparoscopic approach (odds ratio, 12.0; 95% confidence interval, 8.5-16.7); age 65 years or older (OR, 5.3; 95% CI, 3.7-7.4); Asian (OR, 2.2; 95% CI, 1.1-4.4) or African-American race (OR, 1.7; 95% CI, 1.1-2.6); alkaline phosphatase level 120 units/L or greater (OR, 1.7; 95% CI, 1.3-2.3); and female sex (OR, 1.6; 95% CI, 1.1-2.2).
"Even in the presence of all these risk factors, the incidence of iGBC is only 1.4%, although it is nearly 50-fold higher than a patient without any risk factors," Dr. Pitt and her associates wrote. Identifying patients at risk of iGBC before surgery "might allow a surgeon to be prepared to perform an adequate R0 resection at the initial procedure or refer the patient to a center with expertise in liver surgery, especially in the presence of a gallbladder polyp or mass on imaging," they added.
Within 30 days of surgery, patients with iGBC had significantly higher rates of death, serious morbidity, overall morbidity, surgical site infection, and organ space surgical site infection (P less than .001 for all outcomes), the researchers reported.
The study database lacked information on symptoms, preoperative diagnoses, or diagnostic studies specific to gallbladder disease, Dr. Pitt and her coworkers noted. The large sample size increased the possibility of type I error because small differences might reach statistical significance even if they lacked clinical importance, they added.
The authors received no funding for the study. One of the investigators, Dr. Bruce Hall, is a paid consultant for the American College of Surgeons.
Only 0.19% of cholecystectomy patients had incidental gallbladder cancer, and incidence was just 0.03% in patients who lacked risk factors for the malignancy, according to investigators. The report was published in Annals of Surgery.
The results were lower than historical reports, probably because cholecystectomy has been increasingly performed in younger patients, said Dr. Susan Pitt of Washington University, St. Louis, and her associates.
The investigators reported that significant risk factors for incidental gall bladder cancer (iGBC) included open (vs. laparoscopic) cholecystectomy, older age, Asian or African-American race, female sex, and an elevated alkaline phosphatase (ALP) level (Ann. Surg. 2014 Feb. 6 [doi:10.1097/SLA.0000000000000485]).
The retrospective cohort study included 91,260 patients aged 16 years and older who underwent laparoscopic (n = 80,924 [88.7%]) or open (n = 10,336 [11.3%]) cholecystectomy from 2005 to 2009. Patients were identified through the American College of Surgeons-National Surgical Quality Improvement Program Participant Use File.
Only 0.05% of laparoscopic patients had iGBC, vs. 0.60% of laparoscopic converted to open cholecystectomy patients (P less than .001) and 1.13% of open cholecystectomy patients (P less than .001), the researchers said. Multivariable predictors for iGBC included open vs. laparoscopic approach (odds ratio, 12.0; 95% confidence interval, 8.5-16.7); age 65 years or older (OR, 5.3; 95% CI, 3.7-7.4); Asian (OR, 2.2; 95% CI, 1.1-4.4) or African-American race (OR, 1.7; 95% CI, 1.1-2.6); alkaline phosphatase level 120 units/L or greater (OR, 1.7; 95% CI, 1.3-2.3); and female sex (OR, 1.6; 95% CI, 1.1-2.2).
"Even in the presence of all these risk factors, the incidence of iGBC is only 1.4%, although it is nearly 50-fold higher than a patient without any risk factors," Dr. Pitt and her associates wrote. Identifying patients at risk of iGBC before surgery "might allow a surgeon to be prepared to perform an adequate R0 resection at the initial procedure or refer the patient to a center with expertise in liver surgery, especially in the presence of a gallbladder polyp or mass on imaging," they added.
Within 30 days of surgery, patients with iGBC had significantly higher rates of death, serious morbidity, overall morbidity, surgical site infection, and organ space surgical site infection (P less than .001 for all outcomes), the researchers reported.
The study database lacked information on symptoms, preoperative diagnoses, or diagnostic studies specific to gallbladder disease, Dr. Pitt and her coworkers noted. The large sample size increased the possibility of type I error because small differences might reach statistical significance even if they lacked clinical importance, they added.
The authors received no funding for the study. One of the investigators, Dr. Bruce Hall, is a paid consultant for the American College of Surgeons.
Only 0.19% of cholecystectomy patients had incidental gallbladder cancer, and incidence was just 0.03% in patients who lacked risk factors for the malignancy, according to investigators. The report was published in Annals of Surgery.
The results were lower than historical reports, probably because cholecystectomy has been increasingly performed in younger patients, said Dr. Susan Pitt of Washington University, St. Louis, and her associates.
The investigators reported that significant risk factors for incidental gall bladder cancer (iGBC) included open (vs. laparoscopic) cholecystectomy, older age, Asian or African-American race, female sex, and an elevated alkaline phosphatase (ALP) level (Ann. Surg. 2014 Feb. 6 [doi:10.1097/SLA.0000000000000485]).
The retrospective cohort study included 91,260 patients aged 16 years and older who underwent laparoscopic (n = 80,924 [88.7%]) or open (n = 10,336 [11.3%]) cholecystectomy from 2005 to 2009. Patients were identified through the American College of Surgeons-National Surgical Quality Improvement Program Participant Use File.
Only 0.05% of laparoscopic patients had iGBC, vs. 0.60% of laparoscopic converted to open cholecystectomy patients (P less than .001) and 1.13% of open cholecystectomy patients (P less than .001), the researchers said. Multivariable predictors for iGBC included open vs. laparoscopic approach (odds ratio, 12.0; 95% confidence interval, 8.5-16.7); age 65 years or older (OR, 5.3; 95% CI, 3.7-7.4); Asian (OR, 2.2; 95% CI, 1.1-4.4) or African-American race (OR, 1.7; 95% CI, 1.1-2.6); alkaline phosphatase level 120 units/L or greater (OR, 1.7; 95% CI, 1.3-2.3); and female sex (OR, 1.6; 95% CI, 1.1-2.2).
"Even in the presence of all these risk factors, the incidence of iGBC is only 1.4%, although it is nearly 50-fold higher than a patient without any risk factors," Dr. Pitt and her associates wrote. Identifying patients at risk of iGBC before surgery "might allow a surgeon to be prepared to perform an adequate R0 resection at the initial procedure or refer the patient to a center with expertise in liver surgery, especially in the presence of a gallbladder polyp or mass on imaging," they added.
Within 30 days of surgery, patients with iGBC had significantly higher rates of death, serious morbidity, overall morbidity, surgical site infection, and organ space surgical site infection (P less than .001 for all outcomes), the researchers reported.
The study database lacked information on symptoms, preoperative diagnoses, or diagnostic studies specific to gallbladder disease, Dr. Pitt and her coworkers noted. The large sample size increased the possibility of type I error because small differences might reach statistical significance even if they lacked clinical importance, they added.
The authors received no funding for the study. One of the investigators, Dr. Bruce Hall, is a paid consultant for the American College of Surgeons.
FROM ANNALS OF SURGERY
Major finding: Overall incidence of incidental gallbladder cancer was 0.19%. Risk factors included open vs. laparoscopic approach (odds ratio, 12.0); age at least 65 years (OR, 5.3); Asian (OR, 2.2) or African-American race (OR, 1.7); alkaline phosphatase greater than 120 units/L (OR, 1.7); and female sex (OR, 1.6).
Data source: Retrospective cohort study of 91,260 patients aged 16 years or older who underwent laparoscopic (n = 80,924 [88.7%]) or open (n = 10,336 [11.3%]) cholecystectomy from 2005 to 2009.
Disclosures: The authors received no funding for the study. One of the investigators is a paid consultant for the American College of Surgeons.
Hold the immunomodulators for surgery? Maybe yes, maybe no
SCOTTSDALE, ARIZ. – When patients on immunosuppressive therapies need surgery, the risks of disease flare and compromised postoperative recovery and rehabilitation must be weighed against the risk of increased infections and impaired wound healing.
"I’m not sure that there is necessarily a right answer, but I think most people would stop biologic [agents] beforehand," Dr. Paul Grant said at a meeting on perioperative medicine sponsored by the University of Miami.
The decision whether to suspend a disease-modifying antirheumatic drug before surgery may depend on the individual drug and on the patient, said Dr. Grant, director of perioperative and consultative medicine at the University of Michigan Health System in Ann Arbor.
For example, it appears to be safe for patients on methotrexate to continue on therapy during elective orthopedic surgery. Evidence for this comes from a randomized clinical trial in which patients with rheumatoid arthritis (RA) were assigned to either continue on methotrexate (MTX) or suspend taking it for 2 weeks before and 2 weeks after surgery. The study also contained a control of patients with RA who were not on MTX (Ann. Rheum. Dis. 2001;60:214-7).
The investigators found that there were no significant differences in early complication rates or in complications up to 1 year of follow-up between patients who suspended or remained on MTX. Patients who stayed on the drug had significantly lower rates of RA flare.
Additionally, two systematic reviews, one looking at eight studies echoes the findings of the aforementioned randomized trial, and the other looking at four studies, in which the reviewer concluded that "continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares (Clin. Exp. Rheumatol. 2009;27:856-62) (Clin. Rheumatol. 2008;27:1217-20).None of the examined papers addresses the issue of safety in connection with comorbidities, age, or high doses of methotrexate."
"The bottom line here is that methotrexate should be continued for most surgeries. I think it might be reasonable to hold it in certain situations, for example if the patient has pretty bad kidney or liver disease, or if it’s surgery to treat a major infection," Dr. Grant said.
TNF-alpha antagonists
In contrast, the data on tumor necrosis factor–alpha (TNF-alpha) antagonists are fuzzier, with limited and conflicting information on perioperative use of these agents (etanercept, infliximab, adalimumab, certolizumab, golimumab).
"The major concern with these drugs is infection," Dr. Grant said. He pointed to a meta-analysis published in JAMA in 2006, which showed that taking the drugs doubled the risk of serious infections in general. The study did not specifically look at perioperative use of TNF-alpha antagonists (JAMA 2006;295:2275-85).
A retrospective cohort studyof 127 patients with RA who were undergoing various orthopedic procedures found that there were no differences in surgical site infections but more cases of wound dehiscence in patients who continued on the drugs, compared with those who interrupted their use perioperatively (Clin. Exp. Rheumatol. 2007;25:430-6).
A second, prospective study in 31 patients with RA undergoing foot/ankle surgery found that there were no significant differences in infection or healing between patients who interrupted therapy and those who did not (Foot Ankle Clin. 2007;12:509-24).
Other studies and systematic reviews in patients with RA or Crohn’s disease generally found no significant differences in serious infection rates, but they did detect a higher incidence of skin and soft-tissue infections among patients on anti-TNF-alpha agents vs. other disease-modifying antirheumatic drugs.
The risk of infections tends to be highest at the start of therapy with a TNF-alpha antagonist and stopping therapy is more likely to result in RA flares among patients with established disease, compared with those in the early stages of RA. Therefore, TNF blocker therapy should be restarted as soon as possible after surgery to prevent flare, Dr. Grant said.
The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks. These agents should also be held for 10-14 days after surgery or until wound healing is satisfactory.
"It’s probably safe to continue these medications for minor surgeries," Dr. Grant said.
Other agents
The anti-CD20 agent rituximab (Rituxan) – currently used to treat RA, vasculitis, hematologic malignancies, and other conditions – has a lower risk for bacterial infections than does TNF-alpha antagonists and has been shown to be safe in patients with a history of recurrent bacterial infections.
"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.
There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.
There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.
Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.
"Stress dose steroids are not routinely needed as long as the patients continue their normal dose. That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.
Dr. Grant reported having no financial disclosures.
SCOTTSDALE, ARIZ. – When patients on immunosuppressive therapies need surgery, the risks of disease flare and compromised postoperative recovery and rehabilitation must be weighed against the risk of increased infections and impaired wound healing.
"I’m not sure that there is necessarily a right answer, but I think most people would stop biologic [agents] beforehand," Dr. Paul Grant said at a meeting on perioperative medicine sponsored by the University of Miami.
The decision whether to suspend a disease-modifying antirheumatic drug before surgery may depend on the individual drug and on the patient, said Dr. Grant, director of perioperative and consultative medicine at the University of Michigan Health System in Ann Arbor.
For example, it appears to be safe for patients on methotrexate to continue on therapy during elective orthopedic surgery. Evidence for this comes from a randomized clinical trial in which patients with rheumatoid arthritis (RA) were assigned to either continue on methotrexate (MTX) or suspend taking it for 2 weeks before and 2 weeks after surgery. The study also contained a control of patients with RA who were not on MTX (Ann. Rheum. Dis. 2001;60:214-7).
The investigators found that there were no significant differences in early complication rates or in complications up to 1 year of follow-up between patients who suspended or remained on MTX. Patients who stayed on the drug had significantly lower rates of RA flare.
Additionally, two systematic reviews, one looking at eight studies echoes the findings of the aforementioned randomized trial, and the other looking at four studies, in which the reviewer concluded that "continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares (Clin. Exp. Rheumatol. 2009;27:856-62) (Clin. Rheumatol. 2008;27:1217-20).None of the examined papers addresses the issue of safety in connection with comorbidities, age, or high doses of methotrexate."
"The bottom line here is that methotrexate should be continued for most surgeries. I think it might be reasonable to hold it in certain situations, for example if the patient has pretty bad kidney or liver disease, or if it’s surgery to treat a major infection," Dr. Grant said.
TNF-alpha antagonists
In contrast, the data on tumor necrosis factor–alpha (TNF-alpha) antagonists are fuzzier, with limited and conflicting information on perioperative use of these agents (etanercept, infliximab, adalimumab, certolizumab, golimumab).
"The major concern with these drugs is infection," Dr. Grant said. He pointed to a meta-analysis published in JAMA in 2006, which showed that taking the drugs doubled the risk of serious infections in general. The study did not specifically look at perioperative use of TNF-alpha antagonists (JAMA 2006;295:2275-85).
A retrospective cohort studyof 127 patients with RA who were undergoing various orthopedic procedures found that there were no differences in surgical site infections but more cases of wound dehiscence in patients who continued on the drugs, compared with those who interrupted their use perioperatively (Clin. Exp. Rheumatol. 2007;25:430-6).
A second, prospective study in 31 patients with RA undergoing foot/ankle surgery found that there were no significant differences in infection or healing between patients who interrupted therapy and those who did not (Foot Ankle Clin. 2007;12:509-24).
Other studies and systematic reviews in patients with RA or Crohn’s disease generally found no significant differences in serious infection rates, but they did detect a higher incidence of skin and soft-tissue infections among patients on anti-TNF-alpha agents vs. other disease-modifying antirheumatic drugs.
The risk of infections tends to be highest at the start of therapy with a TNF-alpha antagonist and stopping therapy is more likely to result in RA flares among patients with established disease, compared with those in the early stages of RA. Therefore, TNF blocker therapy should be restarted as soon as possible after surgery to prevent flare, Dr. Grant said.
The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks. These agents should also be held for 10-14 days after surgery or until wound healing is satisfactory.
"It’s probably safe to continue these medications for minor surgeries," Dr. Grant said.
Other agents
The anti-CD20 agent rituximab (Rituxan) – currently used to treat RA, vasculitis, hematologic malignancies, and other conditions – has a lower risk for bacterial infections than does TNF-alpha antagonists and has been shown to be safe in patients with a history of recurrent bacterial infections.
"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.
There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.
There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.
Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.
"Stress dose steroids are not routinely needed as long as the patients continue their normal dose. That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.
Dr. Grant reported having no financial disclosures.
SCOTTSDALE, ARIZ. – When patients on immunosuppressive therapies need surgery, the risks of disease flare and compromised postoperative recovery and rehabilitation must be weighed against the risk of increased infections and impaired wound healing.
"I’m not sure that there is necessarily a right answer, but I think most people would stop biologic [agents] beforehand," Dr. Paul Grant said at a meeting on perioperative medicine sponsored by the University of Miami.
The decision whether to suspend a disease-modifying antirheumatic drug before surgery may depend on the individual drug and on the patient, said Dr. Grant, director of perioperative and consultative medicine at the University of Michigan Health System in Ann Arbor.
For example, it appears to be safe for patients on methotrexate to continue on therapy during elective orthopedic surgery. Evidence for this comes from a randomized clinical trial in which patients with rheumatoid arthritis (RA) were assigned to either continue on methotrexate (MTX) or suspend taking it for 2 weeks before and 2 weeks after surgery. The study also contained a control of patients with RA who were not on MTX (Ann. Rheum. Dis. 2001;60:214-7).
The investigators found that there were no significant differences in early complication rates or in complications up to 1 year of follow-up between patients who suspended or remained on MTX. Patients who stayed on the drug had significantly lower rates of RA flare.
Additionally, two systematic reviews, one looking at eight studies echoes the findings of the aforementioned randomized trial, and the other looking at four studies, in which the reviewer concluded that "continued MTX therapy appears to be safe perioperatively and seems also to be associated with a reduced risk of flares (Clin. Exp. Rheumatol. 2009;27:856-62) (Clin. Rheumatol. 2008;27:1217-20).None of the examined papers addresses the issue of safety in connection with comorbidities, age, or high doses of methotrexate."
"The bottom line here is that methotrexate should be continued for most surgeries. I think it might be reasonable to hold it in certain situations, for example if the patient has pretty bad kidney or liver disease, or if it’s surgery to treat a major infection," Dr. Grant said.
TNF-alpha antagonists
In contrast, the data on tumor necrosis factor–alpha (TNF-alpha) antagonists are fuzzier, with limited and conflicting information on perioperative use of these agents (etanercept, infliximab, adalimumab, certolizumab, golimumab).
"The major concern with these drugs is infection," Dr. Grant said. He pointed to a meta-analysis published in JAMA in 2006, which showed that taking the drugs doubled the risk of serious infections in general. The study did not specifically look at perioperative use of TNF-alpha antagonists (JAMA 2006;295:2275-85).
A retrospective cohort studyof 127 patients with RA who were undergoing various orthopedic procedures found that there were no differences in surgical site infections but more cases of wound dehiscence in patients who continued on the drugs, compared with those who interrupted their use perioperatively (Clin. Exp. Rheumatol. 2007;25:430-6).
A second, prospective study in 31 patients with RA undergoing foot/ankle surgery found that there were no significant differences in infection or healing between patients who interrupted therapy and those who did not (Foot Ankle Clin. 2007;12:509-24).
Other studies and systematic reviews in patients with RA or Crohn’s disease generally found no significant differences in serious infection rates, but they did detect a higher incidence of skin and soft-tissue infections among patients on anti-TNF-alpha agents vs. other disease-modifying antirheumatic drugs.
The risk of infections tends to be highest at the start of therapy with a TNF-alpha antagonist and stopping therapy is more likely to result in RA flares among patients with established disease, compared with those in the early stages of RA. Therefore, TNF blocker therapy should be restarted as soon as possible after surgery to prevent flare, Dr. Grant said.
The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks. These agents should also be held for 10-14 days after surgery or until wound healing is satisfactory.
"It’s probably safe to continue these medications for minor surgeries," Dr. Grant said.
Other agents
The anti-CD20 agent rituximab (Rituxan) – currently used to treat RA, vasculitis, hematologic malignancies, and other conditions – has a lower risk for bacterial infections than does TNF-alpha antagonists and has been shown to be safe in patients with a history of recurrent bacterial infections.
"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.
There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.
There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.
Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.
"Stress dose steroids are not routinely needed as long as the patients continue their normal dose. That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.
Dr. Grant reported having no financial disclosures.
AT THE PERIOPERATIVE MEDICINE SUMMIT
Major finding: Some immunomodulating agents for inflammatory and autoimmune diseases can be safely continued in the perioperative period.
Data source: A review of evidence on the use of various immunomodulators.
Disclosures: Dr. Grant reported having no financial disclosures.
Defining patients’ risk helps prevent postop urinary retention
SCOTTSDALE, ARIZ. – Early hospital readmissions are not good for patients and can be terrible for a hospital’s bottom line, but at least one cause of readmission – urinary retention after surgery – can be significantly reduced.
"Postoperative urinary retention is a prevalent and mostly avoidable complication," said Dr. Sarita Khemani, a surgical comanagement hospitalist at Stanford (Calif.) University Medical Center.
Postoperative urinary retention can be defined as the inability to void in the presence of symptoms or bladder distension. However, as some patients may retain urine without feeling symptoms or the urge to void, it can also be defined as the inability to void with a bladder volume greater than 500 mL, or the presence of a postvoid residual volume greater than 200 mL on bladder scan, she said at a meeting on perioperative medicine sponsored by the University of Miami.
Identify high-risk patients
"For management, identifying the high-risk patient is very important," said Dr. Khemani.
She and her colleagues are working to develop a scoring system for identifying patients at risk for postoperative retention, she noted.
Depending on the risk factor, patients may require continued use of benign prostatic hyperplasia (BPH) medications (a strategy currently under clinical investigation), multimodal anesthesia, monitoring of IV fluids during and after surgery, and, when necessary, catheterization.
"There is really no consensus as to what is the best catheterization strategy we should use when it comes to urinary retention," Dr. Khemani said.
Low-risk patients undergoing outpatient procedures can be safely sent home without voiding, she said. High-risk patients undergoing ambulatory surgery can be managed with intermittent catheterization.
Patients who are undergoing major but uncomplicated surgery but are at low risk for postoperative retention do not generally need to have Foley catheters placed before surgery. Indwelling catheters should be limited, if possible, to 24 hours after surgery, and the patient can be managed with bladder scans every 6 hours if needed.
Patients scheduled for extensive, complicated procedures and those at high risk may require an indwelling catheter for up to 5 days after surgery. Studies have shown that in these patients early catheter removal actually increases the risk for postoperative urinary retention, Dr. Khemani said.
"It really needs to be followed by bladder scanning very closely, every 6 hours, to try to prevent overdistention and complications after that," she said.
The incidence of postoperative urinary retention among general surgery patients is 3.8%, but can range as high 70% after orthopedic surgery, 50% after anorectal procedures, 40% following spinal surgeries, and 38% after herniorrhaphy, Dr. Khemani said.
Preoperative risk factors for urinary retention after surgery include age over 50; male sex; history of retention; BPH; history of diabetes, stroke, or spinal lesions; or use of drugs such anticholinergic agents or beta-blockers.
Intraoperative and postoperative risk factors include the type and duration of surgery, anesthesia (especially spinal and epidural anethesias), systemic analgesia with opioids (especially patient-controlled analgesia, or PCA), and the use of intraoperative intravenous fluids. High IV fluid infusion causes rapid distention of the bladder detrusor muscles, leading to inability of the muscles to contract after surgery, Dr. Khemani noted.
Complications of postoperative urinary retention can include:
• Autonomic responses to bladder distention, leading to effects such as bradycardia, hypotension, vomiting, and delirium in some elderly patients.
• Infectious complications – urinary tract infections, sepsis, and joint infections.
• Prolonged need for catheterization.
• Bladder dysfunction.
A recent systematic review of drugs for treatment of urinary retention after surgery in adults found that of seven studies involving a total of 494 patients, neither cholinergic agents, alpha blockers, nor sedatives made a significant difference in reducing the incidence of retention. Only prostaglandins, and only when those agents were given intravesically, appeared to offer any benefit, the authors found.
"At this point we definitely need more studies to look at pharmacological alternatives to catheterization for treatment and prevention of this condition," Dr. Khemani concluded.
She reported having no financial disclosures.
SCOTTSDALE, ARIZ. – Early hospital readmissions are not good for patients and can be terrible for a hospital’s bottom line, but at least one cause of readmission – urinary retention after surgery – can be significantly reduced.
"Postoperative urinary retention is a prevalent and mostly avoidable complication," said Dr. Sarita Khemani, a surgical comanagement hospitalist at Stanford (Calif.) University Medical Center.
Postoperative urinary retention can be defined as the inability to void in the presence of symptoms or bladder distension. However, as some patients may retain urine without feeling symptoms or the urge to void, it can also be defined as the inability to void with a bladder volume greater than 500 mL, or the presence of a postvoid residual volume greater than 200 mL on bladder scan, she said at a meeting on perioperative medicine sponsored by the University of Miami.
Identify high-risk patients
"For management, identifying the high-risk patient is very important," said Dr. Khemani.
She and her colleagues are working to develop a scoring system for identifying patients at risk for postoperative retention, she noted.
Depending on the risk factor, patients may require continued use of benign prostatic hyperplasia (BPH) medications (a strategy currently under clinical investigation), multimodal anesthesia, monitoring of IV fluids during and after surgery, and, when necessary, catheterization.
"There is really no consensus as to what is the best catheterization strategy we should use when it comes to urinary retention," Dr. Khemani said.
Low-risk patients undergoing outpatient procedures can be safely sent home without voiding, she said. High-risk patients undergoing ambulatory surgery can be managed with intermittent catheterization.
Patients who are undergoing major but uncomplicated surgery but are at low risk for postoperative retention do not generally need to have Foley catheters placed before surgery. Indwelling catheters should be limited, if possible, to 24 hours after surgery, and the patient can be managed with bladder scans every 6 hours if needed.
Patients scheduled for extensive, complicated procedures and those at high risk may require an indwelling catheter for up to 5 days after surgery. Studies have shown that in these patients early catheter removal actually increases the risk for postoperative urinary retention, Dr. Khemani said.
"It really needs to be followed by bladder scanning very closely, every 6 hours, to try to prevent overdistention and complications after that," she said.
The incidence of postoperative urinary retention among general surgery patients is 3.8%, but can range as high 70% after orthopedic surgery, 50% after anorectal procedures, 40% following spinal surgeries, and 38% after herniorrhaphy, Dr. Khemani said.
Preoperative risk factors for urinary retention after surgery include age over 50; male sex; history of retention; BPH; history of diabetes, stroke, or spinal lesions; or use of drugs such anticholinergic agents or beta-blockers.
Intraoperative and postoperative risk factors include the type and duration of surgery, anesthesia (especially spinal and epidural anethesias), systemic analgesia with opioids (especially patient-controlled analgesia, or PCA), and the use of intraoperative intravenous fluids. High IV fluid infusion causes rapid distention of the bladder detrusor muscles, leading to inability of the muscles to contract after surgery, Dr. Khemani noted.
Complications of postoperative urinary retention can include:
• Autonomic responses to bladder distention, leading to effects such as bradycardia, hypotension, vomiting, and delirium in some elderly patients.
• Infectious complications – urinary tract infections, sepsis, and joint infections.
• Prolonged need for catheterization.
• Bladder dysfunction.
A recent systematic review of drugs for treatment of urinary retention after surgery in adults found that of seven studies involving a total of 494 patients, neither cholinergic agents, alpha blockers, nor sedatives made a significant difference in reducing the incidence of retention. Only prostaglandins, and only when those agents were given intravesically, appeared to offer any benefit, the authors found.
"At this point we definitely need more studies to look at pharmacological alternatives to catheterization for treatment and prevention of this condition," Dr. Khemani concluded.
She reported having no financial disclosures.
SCOTTSDALE, ARIZ. – Early hospital readmissions are not good for patients and can be terrible for a hospital’s bottom line, but at least one cause of readmission – urinary retention after surgery – can be significantly reduced.
"Postoperative urinary retention is a prevalent and mostly avoidable complication," said Dr. Sarita Khemani, a surgical comanagement hospitalist at Stanford (Calif.) University Medical Center.
Postoperative urinary retention can be defined as the inability to void in the presence of symptoms or bladder distension. However, as some patients may retain urine without feeling symptoms or the urge to void, it can also be defined as the inability to void with a bladder volume greater than 500 mL, or the presence of a postvoid residual volume greater than 200 mL on bladder scan, she said at a meeting on perioperative medicine sponsored by the University of Miami.
Identify high-risk patients
"For management, identifying the high-risk patient is very important," said Dr. Khemani.
She and her colleagues are working to develop a scoring system for identifying patients at risk for postoperative retention, she noted.
Depending on the risk factor, patients may require continued use of benign prostatic hyperplasia (BPH) medications (a strategy currently under clinical investigation), multimodal anesthesia, monitoring of IV fluids during and after surgery, and, when necessary, catheterization.
"There is really no consensus as to what is the best catheterization strategy we should use when it comes to urinary retention," Dr. Khemani said.
Low-risk patients undergoing outpatient procedures can be safely sent home without voiding, she said. High-risk patients undergoing ambulatory surgery can be managed with intermittent catheterization.
Patients who are undergoing major but uncomplicated surgery but are at low risk for postoperative retention do not generally need to have Foley catheters placed before surgery. Indwelling catheters should be limited, if possible, to 24 hours after surgery, and the patient can be managed with bladder scans every 6 hours if needed.
Patients scheduled for extensive, complicated procedures and those at high risk may require an indwelling catheter for up to 5 days after surgery. Studies have shown that in these patients early catheter removal actually increases the risk for postoperative urinary retention, Dr. Khemani said.
"It really needs to be followed by bladder scanning very closely, every 6 hours, to try to prevent overdistention and complications after that," she said.
The incidence of postoperative urinary retention among general surgery patients is 3.8%, but can range as high 70% after orthopedic surgery, 50% after anorectal procedures, 40% following spinal surgeries, and 38% after herniorrhaphy, Dr. Khemani said.
Preoperative risk factors for urinary retention after surgery include age over 50; male sex; history of retention; BPH; history of diabetes, stroke, or spinal lesions; or use of drugs such anticholinergic agents or beta-blockers.
Intraoperative and postoperative risk factors include the type and duration of surgery, anesthesia (especially spinal and epidural anethesias), systemic analgesia with opioids (especially patient-controlled analgesia, or PCA), and the use of intraoperative intravenous fluids. High IV fluid infusion causes rapid distention of the bladder detrusor muscles, leading to inability of the muscles to contract after surgery, Dr. Khemani noted.
Complications of postoperative urinary retention can include:
• Autonomic responses to bladder distention, leading to effects such as bradycardia, hypotension, vomiting, and delirium in some elderly patients.
• Infectious complications – urinary tract infections, sepsis, and joint infections.
• Prolonged need for catheterization.
• Bladder dysfunction.
A recent systematic review of drugs for treatment of urinary retention after surgery in adults found that of seven studies involving a total of 494 patients, neither cholinergic agents, alpha blockers, nor sedatives made a significant difference in reducing the incidence of retention. Only prostaglandins, and only when those agents were given intravesically, appeared to offer any benefit, the authors found.
"At this point we definitely need more studies to look at pharmacological alternatives to catheterization for treatment and prevention of this condition," Dr. Khemani concluded.
She reported having no financial disclosures.
AT THE PERIOPERATIVE MEDICINE SUMMIT
Major finding: The incidence of postoperative urinary retention may be as high as 70% after orthopedic procedures.
Data source: Review of evidence on the risk factors, prevention, and treatment of postoperative urinary retention.
Disclosures: Dr. Khemani reported having no financial disclosures.
Rising to the challenge of glucose control before and after surgery
SCOTTSDALE, ARIZ. – Controlling hyperglycemia before and after surgery in patients with diabetes is a balancing act, but when done properly, it can reduce infections and wound complications, according to Dr. David Baldwin.
The key to preoperative planning for patients with diabetes is a full list of medications and an understanding of how well (or how poorly) patients’ glycemia is controlled, said Dr. Baldwin, an endocrinologist at Rush University Medical Center in Chicago.
He discussed strategies for perioperative management of patients with diabetes and thyroid disorders at the Perioperative Medicine Summit 2014."You definitely want to write down exactly what they are and aren’t taking. We find that the medication list for people getting admitted for surgery is often fraught with a lack of little details," he said.
For patients with type 2 diabetes, it’s important to record an accurate description of antidiabetes medications, especially combination oral agents such as Actoplus MET (metformin and pioglitazone) or Janumet (sitagliptin and metformin). For patients with type 1 and 2 diabetes, it is important to record not just the type of insulin but the regimen the patient uses.
Dr. Baldwin noted that many intake staff make the mistake of reporting that patients take "Novolin" or "Humulin," which are brand families of insulin and not specific insulin types.
"We often find, probably at least half of the time, that until we actually go and ask the patients what they take for insulin post-op, the correct information won’t have been in the medical record," he said.
The best way to determine whether a patient has good control of chronic hyperglycemia is with a hemoglobin A1c (HbA1c) level. A value above 6.5% is diagnostic for diabetes; well-controlled patients have HbA1c levels from 6% to 8%. HbA1c values not more than 2 months old should be a routine part of preoperative evaluations for patients with diabetes or newly discovered hyperglycemia, Dr. Baldwin said.
Preoperative medications
The Rush University protocol for the preoperative management of antidiabetic therapies other than insulin notes that sulfonylureas, metformin, pioglitazone, exenatide, liraglutide, sitagliptin, linagliptin, saxagliptin, alogliptin, alpha-glucosidase inhibitors, and canagaflozin may all be taken with food on the eve of surgery, but none should be taken on the morning of surgery.
Specific rules also apply for patients who use insulin, depending on the insulin type, as follows:
• For long-acting insulins (glargine or detemir), the patient should take the full dose on the evening before surgery or the morning of surgery if the dose is prescribed for either morning or evening administration. Patients with prescriptions for a b.i.d. dose should take the full dose both the evening before and the morning of surgery.
• With intermediate-acting insulin (NPH), the patient should take the full dose on the evening before surgery and 80% of the morning dose on the morning of surgery.
• For rapid-acting insulins (aspart, lispro, glulisine, or regular) and premixed insulins (NPH or rapid acting), the patient should take the full dose with dinner the night before, and none on the morning of surgery.
Dr. Baldwin emphasized that except in rare circumstances, patients on subcutaneous insulin pumps should not use the pumps during surgery, and should get special instructions from their endocrinologists.
Ideally, the patient can convert to insulin glargine the night before surgery, with the dose equivalent to the total 24-hour basal insulin dose delivered by the pump. Two hours after the glargine dose is given, the patient should disconnect the pump and leave it at home.
Glycemic control in the hospital
As noted before, poor glycemic control can lead to poor wound healing from impaired leukocyte function, which can lead to decreased chemotaxis, phagocytosis, and bacteriocidal activity.
The risk of bacteremia is especially high among patients who are on total parenteral nutrition with poorly controlled glucose levels, he noted.
Forces conspiring against glucose control in the hospital can include elevated levels of hormones that counterregulate glucose; nausea/vomiting, anorexia, or nothing-by-mouth orders; erratic meal timing due to tests or interventions; intravenous glucose; glucocorticoid therapy; and "physician indifference and lack of attention to required adjustments in therapy," Dr. Baldwin noted.
Evidence from a randomized study showed that in patients with type 2 diabetes undergoing general surgery, basal-bolus treatment with insulin glargine once daily plus insulin glulisine before meals both improved glycemic control and reduced hospital complications compared with sliding-scale insulin therapy, he reported.
Hyper- and hypothyroid patients
Switching endocrinology hats, Dr. Baldwin said that patients who have significant weight loss or resting tachycardia before surgery should be evaluated for hyperthyroidism. A good rule of thumb is that in patients with hyperthyroidism, all but emergency procedures should be postponed until the condition can be controlled with methimazole.
Patients with undiagnosed or untreated hyperthyroidism who undergo anesthesia and surgery are at high risk for thyroid storm, a provoked crisis of multiorgan failure, he said.
If the surgery cannot be delayed until elevated levels of thyroxine are achieved, the team can initiate oral or intravenous beta-blockade, or if the patient is in critical condition, infusion with the beta-1 receptor blocker esmolol (Brevibloc) is preferred, he said.
Patients should also be started on methimazole 30-40 mg/day, and the patient should be given iodine if she has not already received iodinated radiologic contrast. Stress dose glucocorticoids and adequate volume resuscitation may also provide support in this situation.
In contrast, "hypothyroidism is usually not a big deal," Dr. Baldwin said.
Such patients usually tolerate major surgery without significant complications, he said, but patients with hypothyroidism may be more sensitive to sedatives, slower to wean from ventilation, and handle free-water excretion less well than euthyroid patients.
Patients who take levothyroxine (Synthroid and generics) should always have their free T4 and thyroid-stimulating hormone (thyrotropin) levels checked during preoperative evaluation, he said.
Dr. Baldwin reported having no relevant financial conflicts of interest.
SCOTTSDALE, ARIZ. – Controlling hyperglycemia before and after surgery in patients with diabetes is a balancing act, but when done properly, it can reduce infections and wound complications, according to Dr. David Baldwin.
The key to preoperative planning for patients with diabetes is a full list of medications and an understanding of how well (or how poorly) patients’ glycemia is controlled, said Dr. Baldwin, an endocrinologist at Rush University Medical Center in Chicago.
He discussed strategies for perioperative management of patients with diabetes and thyroid disorders at the Perioperative Medicine Summit 2014."You definitely want to write down exactly what they are and aren’t taking. We find that the medication list for people getting admitted for surgery is often fraught with a lack of little details," he said.
For patients with type 2 diabetes, it’s important to record an accurate description of antidiabetes medications, especially combination oral agents such as Actoplus MET (metformin and pioglitazone) or Janumet (sitagliptin and metformin). For patients with type 1 and 2 diabetes, it is important to record not just the type of insulin but the regimen the patient uses.
Dr. Baldwin noted that many intake staff make the mistake of reporting that patients take "Novolin" or "Humulin," which are brand families of insulin and not specific insulin types.
"We often find, probably at least half of the time, that until we actually go and ask the patients what they take for insulin post-op, the correct information won’t have been in the medical record," he said.
The best way to determine whether a patient has good control of chronic hyperglycemia is with a hemoglobin A1c (HbA1c) level. A value above 6.5% is diagnostic for diabetes; well-controlled patients have HbA1c levels from 6% to 8%. HbA1c values not more than 2 months old should be a routine part of preoperative evaluations for patients with diabetes or newly discovered hyperglycemia, Dr. Baldwin said.
Preoperative medications
The Rush University protocol for the preoperative management of antidiabetic therapies other than insulin notes that sulfonylureas, metformin, pioglitazone, exenatide, liraglutide, sitagliptin, linagliptin, saxagliptin, alogliptin, alpha-glucosidase inhibitors, and canagaflozin may all be taken with food on the eve of surgery, but none should be taken on the morning of surgery.
Specific rules also apply for patients who use insulin, depending on the insulin type, as follows:
• For long-acting insulins (glargine or detemir), the patient should take the full dose on the evening before surgery or the morning of surgery if the dose is prescribed for either morning or evening administration. Patients with prescriptions for a b.i.d. dose should take the full dose both the evening before and the morning of surgery.
• With intermediate-acting insulin (NPH), the patient should take the full dose on the evening before surgery and 80% of the morning dose on the morning of surgery.
• For rapid-acting insulins (aspart, lispro, glulisine, or regular) and premixed insulins (NPH or rapid acting), the patient should take the full dose with dinner the night before, and none on the morning of surgery.
Dr. Baldwin emphasized that except in rare circumstances, patients on subcutaneous insulin pumps should not use the pumps during surgery, and should get special instructions from their endocrinologists.
Ideally, the patient can convert to insulin glargine the night before surgery, with the dose equivalent to the total 24-hour basal insulin dose delivered by the pump. Two hours after the glargine dose is given, the patient should disconnect the pump and leave it at home.
Glycemic control in the hospital
As noted before, poor glycemic control can lead to poor wound healing from impaired leukocyte function, which can lead to decreased chemotaxis, phagocytosis, and bacteriocidal activity.
The risk of bacteremia is especially high among patients who are on total parenteral nutrition with poorly controlled glucose levels, he noted.
Forces conspiring against glucose control in the hospital can include elevated levels of hormones that counterregulate glucose; nausea/vomiting, anorexia, or nothing-by-mouth orders; erratic meal timing due to tests or interventions; intravenous glucose; glucocorticoid therapy; and "physician indifference and lack of attention to required adjustments in therapy," Dr. Baldwin noted.
Evidence from a randomized study showed that in patients with type 2 diabetes undergoing general surgery, basal-bolus treatment with insulin glargine once daily plus insulin glulisine before meals both improved glycemic control and reduced hospital complications compared with sliding-scale insulin therapy, he reported.
Hyper- and hypothyroid patients
Switching endocrinology hats, Dr. Baldwin said that patients who have significant weight loss or resting tachycardia before surgery should be evaluated for hyperthyroidism. A good rule of thumb is that in patients with hyperthyroidism, all but emergency procedures should be postponed until the condition can be controlled with methimazole.
Patients with undiagnosed or untreated hyperthyroidism who undergo anesthesia and surgery are at high risk for thyroid storm, a provoked crisis of multiorgan failure, he said.
If the surgery cannot be delayed until elevated levels of thyroxine are achieved, the team can initiate oral or intravenous beta-blockade, or if the patient is in critical condition, infusion with the beta-1 receptor blocker esmolol (Brevibloc) is preferred, he said.
Patients should also be started on methimazole 30-40 mg/day, and the patient should be given iodine if she has not already received iodinated radiologic contrast. Stress dose glucocorticoids and adequate volume resuscitation may also provide support in this situation.
In contrast, "hypothyroidism is usually not a big deal," Dr. Baldwin said.
Such patients usually tolerate major surgery without significant complications, he said, but patients with hypothyroidism may be more sensitive to sedatives, slower to wean from ventilation, and handle free-water excretion less well than euthyroid patients.
Patients who take levothyroxine (Synthroid and generics) should always have their free T4 and thyroid-stimulating hormone (thyrotropin) levels checked during preoperative evaluation, he said.
Dr. Baldwin reported having no relevant financial conflicts of interest.
SCOTTSDALE, ARIZ. – Controlling hyperglycemia before and after surgery in patients with diabetes is a balancing act, but when done properly, it can reduce infections and wound complications, according to Dr. David Baldwin.
The key to preoperative planning for patients with diabetes is a full list of medications and an understanding of how well (or how poorly) patients’ glycemia is controlled, said Dr. Baldwin, an endocrinologist at Rush University Medical Center in Chicago.
He discussed strategies for perioperative management of patients with diabetes and thyroid disorders at the Perioperative Medicine Summit 2014."You definitely want to write down exactly what they are and aren’t taking. We find that the medication list for people getting admitted for surgery is often fraught with a lack of little details," he said.
For patients with type 2 diabetes, it’s important to record an accurate description of antidiabetes medications, especially combination oral agents such as Actoplus MET (metformin and pioglitazone) or Janumet (sitagliptin and metformin). For patients with type 1 and 2 diabetes, it is important to record not just the type of insulin but the regimen the patient uses.
Dr. Baldwin noted that many intake staff make the mistake of reporting that patients take "Novolin" or "Humulin," which are brand families of insulin and not specific insulin types.
"We often find, probably at least half of the time, that until we actually go and ask the patients what they take for insulin post-op, the correct information won’t have been in the medical record," he said.
The best way to determine whether a patient has good control of chronic hyperglycemia is with a hemoglobin A1c (HbA1c) level. A value above 6.5% is diagnostic for diabetes; well-controlled patients have HbA1c levels from 6% to 8%. HbA1c values not more than 2 months old should be a routine part of preoperative evaluations for patients with diabetes or newly discovered hyperglycemia, Dr. Baldwin said.
Preoperative medications
The Rush University protocol for the preoperative management of antidiabetic therapies other than insulin notes that sulfonylureas, metformin, pioglitazone, exenatide, liraglutide, sitagliptin, linagliptin, saxagliptin, alogliptin, alpha-glucosidase inhibitors, and canagaflozin may all be taken with food on the eve of surgery, but none should be taken on the morning of surgery.
Specific rules also apply for patients who use insulin, depending on the insulin type, as follows:
• For long-acting insulins (glargine or detemir), the patient should take the full dose on the evening before surgery or the morning of surgery if the dose is prescribed for either morning or evening administration. Patients with prescriptions for a b.i.d. dose should take the full dose both the evening before and the morning of surgery.
• With intermediate-acting insulin (NPH), the patient should take the full dose on the evening before surgery and 80% of the morning dose on the morning of surgery.
• For rapid-acting insulins (aspart, lispro, glulisine, or regular) and premixed insulins (NPH or rapid acting), the patient should take the full dose with dinner the night before, and none on the morning of surgery.
Dr. Baldwin emphasized that except in rare circumstances, patients on subcutaneous insulin pumps should not use the pumps during surgery, and should get special instructions from their endocrinologists.
Ideally, the patient can convert to insulin glargine the night before surgery, with the dose equivalent to the total 24-hour basal insulin dose delivered by the pump. Two hours after the glargine dose is given, the patient should disconnect the pump and leave it at home.
Glycemic control in the hospital
As noted before, poor glycemic control can lead to poor wound healing from impaired leukocyte function, which can lead to decreased chemotaxis, phagocytosis, and bacteriocidal activity.
The risk of bacteremia is especially high among patients who are on total parenteral nutrition with poorly controlled glucose levels, he noted.
Forces conspiring against glucose control in the hospital can include elevated levels of hormones that counterregulate glucose; nausea/vomiting, anorexia, or nothing-by-mouth orders; erratic meal timing due to tests or interventions; intravenous glucose; glucocorticoid therapy; and "physician indifference and lack of attention to required adjustments in therapy," Dr. Baldwin noted.
Evidence from a randomized study showed that in patients with type 2 diabetes undergoing general surgery, basal-bolus treatment with insulin glargine once daily plus insulin glulisine before meals both improved glycemic control and reduced hospital complications compared with sliding-scale insulin therapy, he reported.
Hyper- and hypothyroid patients
Switching endocrinology hats, Dr. Baldwin said that patients who have significant weight loss or resting tachycardia before surgery should be evaluated for hyperthyroidism. A good rule of thumb is that in patients with hyperthyroidism, all but emergency procedures should be postponed until the condition can be controlled with methimazole.
Patients with undiagnosed or untreated hyperthyroidism who undergo anesthesia and surgery are at high risk for thyroid storm, a provoked crisis of multiorgan failure, he said.
If the surgery cannot be delayed until elevated levels of thyroxine are achieved, the team can initiate oral or intravenous beta-blockade, or if the patient is in critical condition, infusion with the beta-1 receptor blocker esmolol (Brevibloc) is preferred, he said.
Patients should also be started on methimazole 30-40 mg/day, and the patient should be given iodine if she has not already received iodinated radiologic contrast. Stress dose glucocorticoids and adequate volume resuscitation may also provide support in this situation.
In contrast, "hypothyroidism is usually not a big deal," Dr. Baldwin said.
Such patients usually tolerate major surgery without significant complications, he said, but patients with hypothyroidism may be more sensitive to sedatives, slower to wean from ventilation, and handle free-water excretion less well than euthyroid patients.
Patients who take levothyroxine (Synthroid and generics) should always have their free T4 and thyroid-stimulating hormone (thyrotropin) levels checked during preoperative evaluation, he said.
Dr. Baldwin reported having no relevant financial conflicts of interest.
AT THE PERIOPERATIVE MEDICINE SUMMIT 2014
Major finding: Patients with diabetes and thyroid disorder require special handling before, during, and after surgery.
Data source: A review of current practice.
Disclosures: Dr. Baldwin reported having no relevant financial conflicts of interest.
VIDEO: Website collects best practices for reducing readmissions
ORLANDO – Under the Affordable Care Act, hospitals are financially penalized for having higher than average readmission rates for certain conditions. Since the law’s 2010 enactment, hospital leaders have been working to reduce readmission rates.
At the World Congress Leadership Summit on Hospital Readmissions, Josh Luke, Ph.D., said that communication and technology are key elements of reducing readmissions, but implementing effective protocols is also site specific.
To collect best practices in hospitals across the nation, Dr. Luke, who was the meeting’s chair, has created the National Readmission Prevention Collaborative website. Accessing the information is free, and Dr. Luke encouraged others to submit their success stories.
Dr. Luke is the vice president of post acute services at Torrance (Calif.) Memorial Medical Center, and he shared his thoughts and ideas on reducing readmissions during a video interview at the meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @naseemsmiller
ORLANDO – Under the Affordable Care Act, hospitals are financially penalized for having higher than average readmission rates for certain conditions. Since the law’s 2010 enactment, hospital leaders have been working to reduce readmission rates.
At the World Congress Leadership Summit on Hospital Readmissions, Josh Luke, Ph.D., said that communication and technology are key elements of reducing readmissions, but implementing effective protocols is also site specific.
To collect best practices in hospitals across the nation, Dr. Luke, who was the meeting’s chair, has created the National Readmission Prevention Collaborative website. Accessing the information is free, and Dr. Luke encouraged others to submit their success stories.
Dr. Luke is the vice president of post acute services at Torrance (Calif.) Memorial Medical Center, and he shared his thoughts and ideas on reducing readmissions during a video interview at the meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @naseemsmiller
ORLANDO – Under the Affordable Care Act, hospitals are financially penalized for having higher than average readmission rates for certain conditions. Since the law’s 2010 enactment, hospital leaders have been working to reduce readmission rates.
At the World Congress Leadership Summit on Hospital Readmissions, Josh Luke, Ph.D., said that communication and technology are key elements of reducing readmissions, but implementing effective protocols is also site specific.
To collect best practices in hospitals across the nation, Dr. Luke, who was the meeting’s chair, has created the National Readmission Prevention Collaborative website. Accessing the information is free, and Dr. Luke encouraged others to submit their success stories.
Dr. Luke is the vice president of post acute services at Torrance (Calif.) Memorial Medical Center, and he shared his thoughts and ideas on reducing readmissions during a video interview at the meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @naseemsmiller
ANALYSIS FROM THE HOSPITAL READMISSIONS SUMMIT
Surgical checklists failed to improve outcomes
The mandatory use of surgical safety checklists at hospitals across Ontario failed to improve operative mortality, surgical complications, readmissions, or emergency department visits within 30 days after hospital discharge, according to a report published March 12 in the New England Journal of Medicine.
In the 3 months following introduction of checklists at 101 hospitals, mortality remained the same across all subgroups studied, including high-risk groups such as elderly patients and those who required emergency procedures, said Dr. David R. Urbach of the Institute for Clinical Evaluative Sciences and the Institute of Health Policy, Management, and Evaluation, University of Toronto, and his associates.
"There may be value in the use of surgical safety checklists, such as enhanced communication and teamwork, and the promotion of a hospital culture in which safety is a high priority; however, these potential benefits did not translate into meaningful improvements in the outcomes we analyzed," they reported.
The investigators studied about 200,000 surgical procedures performed at "virtually all hospitals providing surgical care for the population of Ontario, [allowing] us to obtain an estimate of the effectiveness of surgical safety checklists that is less susceptible to biases from selective reporting."
Of the 92 hospitals that furnished copies of their checklist, 79 used that of the Canadian Patient Safety Institute, 9 used customized lists, and 4 used the World Health Organization checklist.
A total of 97 hospitals reported that they used a special intervention or educational program to implement the checklist, and almost every hospital reported that it achieved nearly 100% compliance. "The lowest reported compliance by a large community hospital during this period was 91.6%," the investigators said.
The primary outcome measure – overall operative mortality – was 0.71% before introduction of the surgical safety checklist and 0.65% afterward, a nonsignificant difference.
The risk of an emergency department visit within 1 month of hospital discharge was 10.44% before the checklist and 10.55% afterward, and the risk of readmission within 1 month of hospital discharge was 3.11% before the checklist and 3.14% afterward. These differences too were nonsignificant.
When the data were analyzed according to individual hospitals, "no hospital had a significant change in operative mortality after checklist introduction. Within-hospital changes in other surgical outcomes were mixed. For example, 6 hospitals had significantly fewer complications after introduction of the checklist, whereas 3 had significantly more complications," the investigators reported (N. Engl. J. Med. 2014;370:1029-38).
When the data were further adjusted to account for other factors that might contribute to surgical outcomes, such as patient income, gender, and urban vs. rural residence, the results did not change appreciably. Subgroup analyses also failed to identify any particular group of surgical patients who benefited from implementation of the checklist.
The study was supported by the Canadian Institutes of Health Research and the Institute for Clinical Evaluative Sciences. Dr. Urbach and his associates reported no financial conflicts of interest.
Gaming the system is universal, and true compliance cannot be determined, so "the likely reason for the failure of the surgical checklist in Ontario is that it was not actually used," Dr. Lucian L. Leape said.
An observational study in the United Kingdom revealed that compliance with presurgical checklists there was only 55% and compliance with postsurgical checklists only 9%; a Netherlands study reported full compliance with only 39% of operations. In the Ontario study, "even if full implementation did occur, it is unlikely that an effect would have been seen within 3 months," Dr. Leape noted.
Most hospitals struggle with implementing surgical checklists, and their use probably shouldn’t be mandated as it was in Ontario because "regulation works best when a practice of unquestioned value has become the norm. We are not there yet," Dr. Leape said.
Dr. Leape is at the Harvard School of Public Health, Boston. He reported no potential financial conflicts of interest. These remarks were taken from his editorial accompanying Dr. Urbach’s report (N. Engl. J. Med. 2014;370:1063-4).
Gaming the system is universal, and true compliance cannot be determined, so "the likely reason for the failure of the surgical checklist in Ontario is that it was not actually used," Dr. Lucian L. Leape said.
An observational study in the United Kingdom revealed that compliance with presurgical checklists there was only 55% and compliance with postsurgical checklists only 9%; a Netherlands study reported full compliance with only 39% of operations. In the Ontario study, "even if full implementation did occur, it is unlikely that an effect would have been seen within 3 months," Dr. Leape noted.
Most hospitals struggle with implementing surgical checklists, and their use probably shouldn’t be mandated as it was in Ontario because "regulation works best when a practice of unquestioned value has become the norm. We are not there yet," Dr. Leape said.
Dr. Leape is at the Harvard School of Public Health, Boston. He reported no potential financial conflicts of interest. These remarks were taken from his editorial accompanying Dr. Urbach’s report (N. Engl. J. Med. 2014;370:1063-4).
Gaming the system is universal, and true compliance cannot be determined, so "the likely reason for the failure of the surgical checklist in Ontario is that it was not actually used," Dr. Lucian L. Leape said.
An observational study in the United Kingdom revealed that compliance with presurgical checklists there was only 55% and compliance with postsurgical checklists only 9%; a Netherlands study reported full compliance with only 39% of operations. In the Ontario study, "even if full implementation did occur, it is unlikely that an effect would have been seen within 3 months," Dr. Leape noted.
Most hospitals struggle with implementing surgical checklists, and their use probably shouldn’t be mandated as it was in Ontario because "regulation works best when a practice of unquestioned value has become the norm. We are not there yet," Dr. Leape said.
Dr. Leape is at the Harvard School of Public Health, Boston. He reported no potential financial conflicts of interest. These remarks were taken from his editorial accompanying Dr. Urbach’s report (N. Engl. J. Med. 2014;370:1063-4).
The mandatory use of surgical safety checklists at hospitals across Ontario failed to improve operative mortality, surgical complications, readmissions, or emergency department visits within 30 days after hospital discharge, according to a report published March 12 in the New England Journal of Medicine.
In the 3 months following introduction of checklists at 101 hospitals, mortality remained the same across all subgroups studied, including high-risk groups such as elderly patients and those who required emergency procedures, said Dr. David R. Urbach of the Institute for Clinical Evaluative Sciences and the Institute of Health Policy, Management, and Evaluation, University of Toronto, and his associates.
"There may be value in the use of surgical safety checklists, such as enhanced communication and teamwork, and the promotion of a hospital culture in which safety is a high priority; however, these potential benefits did not translate into meaningful improvements in the outcomes we analyzed," they reported.
The investigators studied about 200,000 surgical procedures performed at "virtually all hospitals providing surgical care for the population of Ontario, [allowing] us to obtain an estimate of the effectiveness of surgical safety checklists that is less susceptible to biases from selective reporting."
Of the 92 hospitals that furnished copies of their checklist, 79 used that of the Canadian Patient Safety Institute, 9 used customized lists, and 4 used the World Health Organization checklist.
A total of 97 hospitals reported that they used a special intervention or educational program to implement the checklist, and almost every hospital reported that it achieved nearly 100% compliance. "The lowest reported compliance by a large community hospital during this period was 91.6%," the investigators said.
The primary outcome measure – overall operative mortality – was 0.71% before introduction of the surgical safety checklist and 0.65% afterward, a nonsignificant difference.
The risk of an emergency department visit within 1 month of hospital discharge was 10.44% before the checklist and 10.55% afterward, and the risk of readmission within 1 month of hospital discharge was 3.11% before the checklist and 3.14% afterward. These differences too were nonsignificant.
When the data were analyzed according to individual hospitals, "no hospital had a significant change in operative mortality after checklist introduction. Within-hospital changes in other surgical outcomes were mixed. For example, 6 hospitals had significantly fewer complications after introduction of the checklist, whereas 3 had significantly more complications," the investigators reported (N. Engl. J. Med. 2014;370:1029-38).
When the data were further adjusted to account for other factors that might contribute to surgical outcomes, such as patient income, gender, and urban vs. rural residence, the results did not change appreciably. Subgroup analyses also failed to identify any particular group of surgical patients who benefited from implementation of the checklist.
The study was supported by the Canadian Institutes of Health Research and the Institute for Clinical Evaluative Sciences. Dr. Urbach and his associates reported no financial conflicts of interest.
The mandatory use of surgical safety checklists at hospitals across Ontario failed to improve operative mortality, surgical complications, readmissions, or emergency department visits within 30 days after hospital discharge, according to a report published March 12 in the New England Journal of Medicine.
In the 3 months following introduction of checklists at 101 hospitals, mortality remained the same across all subgroups studied, including high-risk groups such as elderly patients and those who required emergency procedures, said Dr. David R. Urbach of the Institute for Clinical Evaluative Sciences and the Institute of Health Policy, Management, and Evaluation, University of Toronto, and his associates.
"There may be value in the use of surgical safety checklists, such as enhanced communication and teamwork, and the promotion of a hospital culture in which safety is a high priority; however, these potential benefits did not translate into meaningful improvements in the outcomes we analyzed," they reported.
The investigators studied about 200,000 surgical procedures performed at "virtually all hospitals providing surgical care for the population of Ontario, [allowing] us to obtain an estimate of the effectiveness of surgical safety checklists that is less susceptible to biases from selective reporting."
Of the 92 hospitals that furnished copies of their checklist, 79 used that of the Canadian Patient Safety Institute, 9 used customized lists, and 4 used the World Health Organization checklist.
A total of 97 hospitals reported that they used a special intervention or educational program to implement the checklist, and almost every hospital reported that it achieved nearly 100% compliance. "The lowest reported compliance by a large community hospital during this period was 91.6%," the investigators said.
The primary outcome measure – overall operative mortality – was 0.71% before introduction of the surgical safety checklist and 0.65% afterward, a nonsignificant difference.
The risk of an emergency department visit within 1 month of hospital discharge was 10.44% before the checklist and 10.55% afterward, and the risk of readmission within 1 month of hospital discharge was 3.11% before the checklist and 3.14% afterward. These differences too were nonsignificant.
When the data were analyzed according to individual hospitals, "no hospital had a significant change in operative mortality after checklist introduction. Within-hospital changes in other surgical outcomes were mixed. For example, 6 hospitals had significantly fewer complications after introduction of the checklist, whereas 3 had significantly more complications," the investigators reported (N. Engl. J. Med. 2014;370:1029-38).
When the data were further adjusted to account for other factors that might contribute to surgical outcomes, such as patient income, gender, and urban vs. rural residence, the results did not change appreciably. Subgroup analyses also failed to identify any particular group of surgical patients who benefited from implementation of the checklist.
The study was supported by the Canadian Institutes of Health Research and the Institute for Clinical Evaluative Sciences. Dr. Urbach and his associates reported no financial conflicts of interest.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Major finding: Overall operative mortality was 0.71% before introduction of the surgical safety checklist and 0.65% afterward, a nonsignificant difference.
Data source: A population-based analysis comparing surgical outcomes at 101 Ontario hospitals during the 3 months before and the 3 months after mandatory use of a surgical safety checklist was introduced across the province.
Disclosures: This study was supported by the Canadian Institutes of Health Research and the Institute for Clinical Evaluative Sciences. Dr. Urbach and his associates reported no financial conflicts of interest.
Simultaneous colorectal/liver mets resection saves time and money
MIAMI BEACH – For patients with colorectal cancer and liver metastasis, one-stage surgery cuts hospital time and expense.
Compared to a staged approach, resecting both the primary and metastatic cancers shaved almost $28,000 off total hospital charges. Most of the savings came from the shortened hospital stay – an average of 6 fewer days than for patients with staged procedures, Dr. Aslam Ejaz said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
"The main driving factor [of costs] was the increasing length of stay," said Dr. Ejaz, a research fellow in surgical oncology at Johns Hopkins Hospital, Baltimore. "Each additional day resulted in a mean increase of $3,600."
Most studies have found similar clinical outcomes for such patients, regardless of whether their surgical treatment is staged or simultaneous. But there are few data comparing the techniques’ economic impact.
For the study, Dr. Ejaz used a Johns Hopkins database to examine the staged vs. the one-stage approach. His cohort included 224 patients who, from 1990 to 2012, underwent a liver resection with curative intent for synchronous colorectal liver metastasis. They had a simultaneous procedure (111) or a staged procedure (113).
Most of the patients were in their 50s. Preoperative chemotherapy was significantly more common among those who had staged surgery with liver resection first. Primary rectal cancers were significantly more common among patients who had staged surgery.
The overall hepatectomy-related morbidity rate was similar: 25% in the simultaneous surgery group and 27% in the staged surgery group. Major complications after hepatectomy occurred in 18% of the simultaneous and 13% of the staged group – not significantly different.
Clear margins were obtained in 85% of the simultaneous surgery group and 88% of the staged surgery group. Mortality was similar (1% vs. 2%). The total length of stay was significantly longer in the staged surgery group (13 vs. 7 days.).
When categorized into minor and major hepatectomies, the overall complication rate was similar. For minor hepatectomies, it was 25% in the simultaneous surgery group and 29% in the staged group. For major hepatectomies, the rates were 27% and 28%, respectively.
There were no deaths in the minor hepatectomy group. Among those who had major hepatectomy, 4% of each surgical group died.
The median overall survival was 33 months. In both groups, 5-year survival was about 28%. The median recurrence-free survival was 26 months. The median 5-year recurrence-free survival was 20% in both groups.
A multivariate analysis examined factors associated with complications. There were no significant associations with simultaneous resection, major hepatectomy, rectal tumor, bilateral hepatic disease, or extrahepatic metastasis. However, concurrent resection and ablation doubled the risk of a complication (odds ratio, 2.02).
Patients who had a simultaneous procedure had significantly shorter hospital stays than did those who underwent a staged procedure. Most who had simultaneous surgery went home in 6 days or less (48) or in 6-9 days (38). Just 12 stayed 9-11 days; 13 stayed for 11 or more days.
Among those who had staged procedures, none went home in 6 or fewer days, and only 7 went home in 6-9 days. All other staged surgery patients stayed longer: 26 stayed 9-11 days, 39 stayed 11-13 days, and 41 stayed more than 13 days.
This extra time translated into extra money, Dr. Ejaz said, with each hospital day costing a mean of $3,581. To tease out cost associations, he stratified patients by operative factors and disease-related characteristics.
Charges for patents with unilateral or bilateral disease were significantly different ($48,000 vs. $53,000). There also were significantly different charges for those who had resection only compared to resection plus ablation ($45,500 vs. $57,000), and minor hepatic surgery compared to major hepatic surgery ($44,300 vs. $54,500).
Surgery timing also significantly affected price. The mean total cost for those who had simultaneous surgery was $34,000, while it was $62,000 for those who had staged surgery – a 55% difference amounting to $28,000.
Since clinical outcomes were so similar, the study shows that patients with resectable synchronous colorectal liver metastasis can be safely managed with either simultaneous or staged approach, Dr. Ejaz said. "But a simultaneous approach results in fewer hospital days and overall lower hospital charges, and should be the preferred approach when it’s clinically appropriate and technically feasible."
Dr. Timothy Pawlik – Dr. Ejaz’s preceptor – said that the findings are useful to both patients and systems.
"This study can be used to explain to patients how a simultaneous operation is generally safe," he said in an interview. "It may, in fact, be more beneficial to surgeons and hospitals or health care systems, as it shows that a simultaneous operation can be performed safely and save on health care costs."
Neither Dr. Ejaz nor Dr. Pawlik had any financial disclosures.
MIAMI BEACH – For patients with colorectal cancer and liver metastasis, one-stage surgery cuts hospital time and expense.
Compared to a staged approach, resecting both the primary and metastatic cancers shaved almost $28,000 off total hospital charges. Most of the savings came from the shortened hospital stay – an average of 6 fewer days than for patients with staged procedures, Dr. Aslam Ejaz said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
"The main driving factor [of costs] was the increasing length of stay," said Dr. Ejaz, a research fellow in surgical oncology at Johns Hopkins Hospital, Baltimore. "Each additional day resulted in a mean increase of $3,600."
Most studies have found similar clinical outcomes for such patients, regardless of whether their surgical treatment is staged or simultaneous. But there are few data comparing the techniques’ economic impact.
For the study, Dr. Ejaz used a Johns Hopkins database to examine the staged vs. the one-stage approach. His cohort included 224 patients who, from 1990 to 2012, underwent a liver resection with curative intent for synchronous colorectal liver metastasis. They had a simultaneous procedure (111) or a staged procedure (113).
Most of the patients were in their 50s. Preoperative chemotherapy was significantly more common among those who had staged surgery with liver resection first. Primary rectal cancers were significantly more common among patients who had staged surgery.
The overall hepatectomy-related morbidity rate was similar: 25% in the simultaneous surgery group and 27% in the staged surgery group. Major complications after hepatectomy occurred in 18% of the simultaneous and 13% of the staged group – not significantly different.
Clear margins were obtained in 85% of the simultaneous surgery group and 88% of the staged surgery group. Mortality was similar (1% vs. 2%). The total length of stay was significantly longer in the staged surgery group (13 vs. 7 days.).
When categorized into minor and major hepatectomies, the overall complication rate was similar. For minor hepatectomies, it was 25% in the simultaneous surgery group and 29% in the staged group. For major hepatectomies, the rates were 27% and 28%, respectively.
There were no deaths in the minor hepatectomy group. Among those who had major hepatectomy, 4% of each surgical group died.
The median overall survival was 33 months. In both groups, 5-year survival was about 28%. The median recurrence-free survival was 26 months. The median 5-year recurrence-free survival was 20% in both groups.
A multivariate analysis examined factors associated with complications. There were no significant associations with simultaneous resection, major hepatectomy, rectal tumor, bilateral hepatic disease, or extrahepatic metastasis. However, concurrent resection and ablation doubled the risk of a complication (odds ratio, 2.02).
Patients who had a simultaneous procedure had significantly shorter hospital stays than did those who underwent a staged procedure. Most who had simultaneous surgery went home in 6 days or less (48) or in 6-9 days (38). Just 12 stayed 9-11 days; 13 stayed for 11 or more days.
Among those who had staged procedures, none went home in 6 or fewer days, and only 7 went home in 6-9 days. All other staged surgery patients stayed longer: 26 stayed 9-11 days, 39 stayed 11-13 days, and 41 stayed more than 13 days.
This extra time translated into extra money, Dr. Ejaz said, with each hospital day costing a mean of $3,581. To tease out cost associations, he stratified patients by operative factors and disease-related characteristics.
Charges for patents with unilateral or bilateral disease were significantly different ($48,000 vs. $53,000). There also were significantly different charges for those who had resection only compared to resection plus ablation ($45,500 vs. $57,000), and minor hepatic surgery compared to major hepatic surgery ($44,300 vs. $54,500).
Surgery timing also significantly affected price. The mean total cost for those who had simultaneous surgery was $34,000, while it was $62,000 for those who had staged surgery – a 55% difference amounting to $28,000.
Since clinical outcomes were so similar, the study shows that patients with resectable synchronous colorectal liver metastasis can be safely managed with either simultaneous or staged approach, Dr. Ejaz said. "But a simultaneous approach results in fewer hospital days and overall lower hospital charges, and should be the preferred approach when it’s clinically appropriate and technically feasible."
Dr. Timothy Pawlik – Dr. Ejaz’s preceptor – said that the findings are useful to both patients and systems.
"This study can be used to explain to patients how a simultaneous operation is generally safe," he said in an interview. "It may, in fact, be more beneficial to surgeons and hospitals or health care systems, as it shows that a simultaneous operation can be performed safely and save on health care costs."
Neither Dr. Ejaz nor Dr. Pawlik had any financial disclosures.
MIAMI BEACH – For patients with colorectal cancer and liver metastasis, one-stage surgery cuts hospital time and expense.
Compared to a staged approach, resecting both the primary and metastatic cancers shaved almost $28,000 off total hospital charges. Most of the savings came from the shortened hospital stay – an average of 6 fewer days than for patients with staged procedures, Dr. Aslam Ejaz said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
"The main driving factor [of costs] was the increasing length of stay," said Dr. Ejaz, a research fellow in surgical oncology at Johns Hopkins Hospital, Baltimore. "Each additional day resulted in a mean increase of $3,600."
Most studies have found similar clinical outcomes for such patients, regardless of whether their surgical treatment is staged or simultaneous. But there are few data comparing the techniques’ economic impact.
For the study, Dr. Ejaz used a Johns Hopkins database to examine the staged vs. the one-stage approach. His cohort included 224 patients who, from 1990 to 2012, underwent a liver resection with curative intent for synchronous colorectal liver metastasis. They had a simultaneous procedure (111) or a staged procedure (113).
Most of the patients were in their 50s. Preoperative chemotherapy was significantly more common among those who had staged surgery with liver resection first. Primary rectal cancers were significantly more common among patients who had staged surgery.
The overall hepatectomy-related morbidity rate was similar: 25% in the simultaneous surgery group and 27% in the staged surgery group. Major complications after hepatectomy occurred in 18% of the simultaneous and 13% of the staged group – not significantly different.
Clear margins were obtained in 85% of the simultaneous surgery group and 88% of the staged surgery group. Mortality was similar (1% vs. 2%). The total length of stay was significantly longer in the staged surgery group (13 vs. 7 days.).
When categorized into minor and major hepatectomies, the overall complication rate was similar. For minor hepatectomies, it was 25% in the simultaneous surgery group and 29% in the staged group. For major hepatectomies, the rates were 27% and 28%, respectively.
There were no deaths in the minor hepatectomy group. Among those who had major hepatectomy, 4% of each surgical group died.
The median overall survival was 33 months. In both groups, 5-year survival was about 28%. The median recurrence-free survival was 26 months. The median 5-year recurrence-free survival was 20% in both groups.
A multivariate analysis examined factors associated with complications. There were no significant associations with simultaneous resection, major hepatectomy, rectal tumor, bilateral hepatic disease, or extrahepatic metastasis. However, concurrent resection and ablation doubled the risk of a complication (odds ratio, 2.02).
Patients who had a simultaneous procedure had significantly shorter hospital stays than did those who underwent a staged procedure. Most who had simultaneous surgery went home in 6 days or less (48) or in 6-9 days (38). Just 12 stayed 9-11 days; 13 stayed for 11 or more days.
Among those who had staged procedures, none went home in 6 or fewer days, and only 7 went home in 6-9 days. All other staged surgery patients stayed longer: 26 stayed 9-11 days, 39 stayed 11-13 days, and 41 stayed more than 13 days.
This extra time translated into extra money, Dr. Ejaz said, with each hospital day costing a mean of $3,581. To tease out cost associations, he stratified patients by operative factors and disease-related characteristics.
Charges for patents with unilateral or bilateral disease were significantly different ($48,000 vs. $53,000). There also were significantly different charges for those who had resection only compared to resection plus ablation ($45,500 vs. $57,000), and minor hepatic surgery compared to major hepatic surgery ($44,300 vs. $54,500).
Surgery timing also significantly affected price. The mean total cost for those who had simultaneous surgery was $34,000, while it was $62,000 for those who had staged surgery – a 55% difference amounting to $28,000.
Since clinical outcomes were so similar, the study shows that patients with resectable synchronous colorectal liver metastasis can be safely managed with either simultaneous or staged approach, Dr. Ejaz said. "But a simultaneous approach results in fewer hospital days and overall lower hospital charges, and should be the preferred approach when it’s clinically appropriate and technically feasible."
Dr. Timothy Pawlik – Dr. Ejaz’s preceptor – said that the findings are useful to both patients and systems.
"This study can be used to explain to patients how a simultaneous operation is generally safe," he said in an interview. "It may, in fact, be more beneficial to surgeons and hospitals or health care systems, as it shows that a simultaneous operation can be performed safely and save on health care costs."
Neither Dr. Ejaz nor Dr. Pawlik had any financial disclosures.
AT AHPBA 2014
Major finding: Compared to a staged surgery, simultaneously resecting colorectal cancer and liver metastases saved about 6 days of hospital stay, with a 55% cost savings in total hospital charges.
Data source: A retrospective study of 224 patients.
Disclosures: Neither Dr. Ejaz nor Dr. Pawlik had any financial disclosures.
CMS outlines how to get meaningful use exemptions
As promised, the Centers for Medicare & Medicaid Services has issued guidance on how physicians can apply for a hardship exemption on meeting Stage 2 of the meaningful use of electronic health records in 2014.
Administrator Marilyn Tavenner said at the annual meeting of the Healthcare Information and Management Systems Society on Feb. 27 that CMS would not extend the deadline for meeting Stage 2 criteria, but that it would allow more flexibility in how physicians and other eligible professionals reach the goals.
Physicians who participate in the meaningful use program receive incentive payments from Medicare. If they don’t participate this year, they’ll be penalized next year. On Feb. 21, 48 physician organizations wrote to the Health and Human Services department, asking for delays in some of the deadlines for meaningful use this year and for more flexibility from the CMS.
In a guidance document, the agency now says it is currently accepting applications for exemptions from penalties for 2015. Physicians who have not yet participated in meaningful use at all have until July 1 to apply.
If a physician has demonstrated meaningful use for the 2013 reporting year, there will be no penalty in 2015. If, however, a practice is having trouble implementing 2014 certified EHR technology for a 2014 reporting period, the practice or physician can apply for a hardship exception by July 1, 2015, to avoid a penalty in 2016.
Applications will be reviewed on a case-by-case basis, according to the guidance.
Meaningful use penalties only apply to physicians who participate in the Medicare incentive program, or in both the Medicare and Medicaid programs. There are no penalties for those who participate only in the Medicaid incentive program.
On Twitter @aliciaault
As promised, the Centers for Medicare & Medicaid Services has issued guidance on how physicians can apply for a hardship exemption on meeting Stage 2 of the meaningful use of electronic health records in 2014.
Administrator Marilyn Tavenner said at the annual meeting of the Healthcare Information and Management Systems Society on Feb. 27 that CMS would not extend the deadline for meeting Stage 2 criteria, but that it would allow more flexibility in how physicians and other eligible professionals reach the goals.
Physicians who participate in the meaningful use program receive incentive payments from Medicare. If they don’t participate this year, they’ll be penalized next year. On Feb. 21, 48 physician organizations wrote to the Health and Human Services department, asking for delays in some of the deadlines for meaningful use this year and for more flexibility from the CMS.
In a guidance document, the agency now says it is currently accepting applications for exemptions from penalties for 2015. Physicians who have not yet participated in meaningful use at all have until July 1 to apply.
If a physician has demonstrated meaningful use for the 2013 reporting year, there will be no penalty in 2015. If, however, a practice is having trouble implementing 2014 certified EHR technology for a 2014 reporting period, the practice or physician can apply for a hardship exception by July 1, 2015, to avoid a penalty in 2016.
Applications will be reviewed on a case-by-case basis, according to the guidance.
Meaningful use penalties only apply to physicians who participate in the Medicare incentive program, or in both the Medicare and Medicaid programs. There are no penalties for those who participate only in the Medicaid incentive program.
On Twitter @aliciaault
As promised, the Centers for Medicare & Medicaid Services has issued guidance on how physicians can apply for a hardship exemption on meeting Stage 2 of the meaningful use of electronic health records in 2014.
Administrator Marilyn Tavenner said at the annual meeting of the Healthcare Information and Management Systems Society on Feb. 27 that CMS would not extend the deadline for meeting Stage 2 criteria, but that it would allow more flexibility in how physicians and other eligible professionals reach the goals.
Physicians who participate in the meaningful use program receive incentive payments from Medicare. If they don’t participate this year, they’ll be penalized next year. On Feb. 21, 48 physician organizations wrote to the Health and Human Services department, asking for delays in some of the deadlines for meaningful use this year and for more flexibility from the CMS.
In a guidance document, the agency now says it is currently accepting applications for exemptions from penalties for 2015. Physicians who have not yet participated in meaningful use at all have until July 1 to apply.
If a physician has demonstrated meaningful use for the 2013 reporting year, there will be no penalty in 2015. If, however, a practice is having trouble implementing 2014 certified EHR technology for a 2014 reporting period, the practice or physician can apply for a hardship exception by July 1, 2015, to avoid a penalty in 2016.
Applications will be reviewed on a case-by-case basis, according to the guidance.
Meaningful use penalties only apply to physicians who participate in the Medicare incentive program, or in both the Medicare and Medicaid programs. There are no penalties for those who participate only in the Medicaid incentive program.
On Twitter @aliciaault
