University of Miami: Perioperative Medicine Summit 2012

MIAMI BEACH – When you are called to assess a patient before cancer surgery, how do you know when noninvasive cardiovascular testing is warranted?

Start by asking patients to describe their functional status before they started any treatment to combat their cancer, Dr. Sunil K. Sahai said.

Also assess for any ischemia preoperatively, because its presence might direct a surgeon to prescribe a less cardiotoxic postoperative treatment for your patient, Dr. Sahai said at a meeting on perioperative medicine sponsored by the University of Miami. Occult ischemia might be found if a patient reports shortness of breath during prior chemotherapy administration, he added.

"Everything you’ve heard about perioperative medicine is true for cancer patients, but they are also unique," Dr. Sahai said. The physiologic burden of cancer and its treatment makes preoperative evaluation challenging, but it’s worth doing right to ensure the patient receives the optimal therapy. Also, in some cases, either the patient or surgeon will decide not to proceed with surgery based on your risk assessment, said Dr. Sahai, medical director of the Internal Medicine Perioperative Assessment Center at the University of Texas M.D. Anderson Cancer Center in Houston.

To illustrate some of the challenges, Dr. Sahai described an actual patient, a 60-year-old man referred for preoperative assessment 1 week before a scheduled neck dissection and total laryngectomy. He presented with dysphagia and sore throat. A biopsy revealed postcricoid squamous cell carcinoma. He was otherwise healthy, except for psoriasis and benign prostatic hyperplasia. He had undergone surgery and radiation for nasopharyngeal cancer 15 years earlier. The current physical examination was unremarkable, except for bilateral carotid bruits. Doppler ultrasound findings led to a diagnosis of radiation-induced carotid stenosis with diffuse, bilateral atherosclerosis and greater than 70% stenosis.

Head and neck cancer patients can have double the risk of transient ischemic attack or cerebrovascular accident, compared with a patient with normal pathologic narrowing of the carotid arteries, Dr. Sahai said. This is a controversial area because "data are not clear on what to do."

"We postponed and all discussed with all the providers involved," Dr. Sahai said. A stent was placed in the patient’s right internal carotid artery, and cancer surgery was delayed for 1 month while the patient took clopidogrel and aspirin. "He then went to the operating room on aspirin, and he did well."

Another case, a 70-year-old woman scheduled for a 6-hour cystectomy for bladder cancer, raised issues around preoperative cardiovascular assessment. "She reports fatigue and shortness of breath with exertion on her evening walks," Dr. Sahai said. "Before chemotherapy, she was able to walk eight blocks and up two flights of stairs without stopping. Now she can walk only four blocks and stops to rest between flights." She does not describe typical angina symptoms, he added.

The patient is obese, has diabetes mellitus, and is taking a statin for hyperlipidemia. She does not report any angina symptoms. Her history includes a myocardial infarction 5 years earlier addressed with medical management only.

Cancer can sap a patient’s energy, but the precise etiology in this case was unclear, Dr. Sahai said. Was her shortness of breath related to coronary artery disease, heart failure, pulmonary hypertension, or treatment with cardiotoxic chemotherapy? Should the patient be tested, for example, with an echocardiogram for heart function, stress test for ischemia, or both?

"Because this patient had received cardiotoxic chemotherapy ... we would do a stress echo on this patient," Dr. Sahai said. "In addition, BNP [B-type natriuretic peptide] levels may be helpful to detect cardiomyopathy. I would also optimize cardiac function and heart rate and send her to the operating room with the statin on board."

Patients with no cardiovascular symptoms can generally go to the operating room. If a patient is symptomatic, however, especially if the symptoms are new since cancer therapy was begun, Dr. Sahai said he generally considers further testing and work-up.

Dr. Sahai had no relevant financial disclosures.

MIAMI BEACH – When you are called to assess a patient before cancer surgery, how do you know when noninvasive cardiovascular testing is warranted?

Start by asking patients to describe their functional status before they started any treatment to combat their cancer, Dr. Sunil K. Sahai said.

Also assess for any ischemia preoperatively, because its presence might direct a surgeon to prescribe a less cardiotoxic postoperative treatment for your patient, Dr. Sahai said at a meeting on perioperative medicine sponsored by the University of Miami. Occult ischemia might be found if a patient reports shortness of breath during prior chemotherapy administration, he added.

"Everything you’ve heard about perioperative medicine is true for cancer patients, but they are also unique," Dr. Sahai said. The physiologic burden of cancer and its treatment makes preoperative evaluation challenging, but it’s worth doing right to ensure the patient receives the optimal therapy. Also, in some cases, either the patient or surgeon will decide not to proceed with surgery based on your risk assessment, said Dr. Sahai, medical director of the Internal Medicine Perioperative Assessment Center at the University of Texas M.D. Anderson Cancer Center in Houston.

To illustrate some of the challenges, Dr. Sahai described an actual patient, a 60-year-old man referred for preoperative assessment 1 week before a scheduled neck dissection and total laryngectomy. He presented with dysphagia and sore throat. A biopsy revealed postcricoid squamous cell carcinoma. He was otherwise healthy, except for psoriasis and benign prostatic hyperplasia. He had undergone surgery and radiation for nasopharyngeal cancer 15 years earlier. The current physical examination was unremarkable, except for bilateral carotid bruits. Doppler ultrasound findings led to a diagnosis of radiation-induced carotid stenosis with diffuse, bilateral atherosclerosis and greater than 70% stenosis.

Head and neck cancer patients can have double the risk of transient ischemic attack or cerebrovascular accident, compared with a patient with normal pathologic narrowing of the carotid arteries, Dr. Sahai said. This is a controversial area because "data are not clear on what to do."

"We postponed and all discussed with all the providers involved," Dr. Sahai said. A stent was placed in the patient’s right internal carotid artery, and cancer surgery was delayed for 1 month while the patient took clopidogrel and aspirin. "He then went to the operating room on aspirin, and he did well."

Another case, a 70-year-old woman scheduled for a 6-hour cystectomy for bladder cancer, raised issues around preoperative cardiovascular assessment. "She reports fatigue and shortness of breath with exertion on her evening walks," Dr. Sahai said. "Before chemotherapy, she was able to walk eight blocks and up two flights of stairs without stopping. Now she can walk only four blocks and stops to rest between flights." She does not describe typical angina symptoms, he added.

The patient is obese, has diabetes mellitus, and is taking a statin for hyperlipidemia. She does not report any angina symptoms. Her history includes a myocardial infarction 5 years earlier addressed with medical management only.

Cancer can sap a patient’s energy, but the precise etiology in this case was unclear, Dr. Sahai said. Was her shortness of breath related to coronary artery disease, heart failure, pulmonary hypertension, or treatment with cardiotoxic chemotherapy? Should the patient be tested, for example, with an echocardiogram for heart function, stress test for ischemia, or both?

"Because this patient had received cardiotoxic chemotherapy ... we would do a stress echo on this patient," Dr. Sahai said. "In addition, BNP [B-type natriuretic peptide] levels may be helpful to detect cardiomyopathy. I would also optimize cardiac function and heart rate and send her to the operating room with the statin on board."

Patients with no cardiovascular symptoms can generally go to the operating room. If a patient is symptomatic, however, especially if the symptoms are new since cancer therapy was begun, Dr. Sahai said he generally considers further testing and work-up.

Dr. Sahai had no relevant financial disclosures.

MIAMI BEACH – When you are called to assess a patient before cancer surgery, how do you know when noninvasive cardiovascular testing is warranted?

Start by asking patients to describe their functional status before they started any treatment to combat their cancer, Dr. Sunil K. Sahai said.

Also assess for any ischemia preoperatively, because its presence might direct a surgeon to prescribe a less cardiotoxic postoperative treatment for your patient, Dr. Sahai said at a meeting on perioperative medicine sponsored by the University of Miami. Occult ischemia might be found if a patient reports shortness of breath during prior chemotherapy administration, he added.

"Everything you’ve heard about perioperative medicine is true for cancer patients, but they are also unique," Dr. Sahai said. The physiologic burden of cancer and its treatment makes preoperative evaluation challenging, but it’s worth doing right to ensure the patient receives the optimal therapy. Also, in some cases, either the patient or surgeon will decide not to proceed with surgery based on your risk assessment, said Dr. Sahai, medical director of the Internal Medicine Perioperative Assessment Center at the University of Texas M.D. Anderson Cancer Center in Houston.

To illustrate some of the challenges, Dr. Sahai described an actual patient, a 60-year-old man referred for preoperative assessment 1 week before a scheduled neck dissection and total laryngectomy. He presented with dysphagia and sore throat. A biopsy revealed postcricoid squamous cell carcinoma. He was otherwise healthy, except for psoriasis and benign prostatic hyperplasia. He had undergone surgery and radiation for nasopharyngeal cancer 15 years earlier. The current physical examination was unremarkable, except for bilateral carotid bruits. Doppler ultrasound findings led to a diagnosis of radiation-induced carotid stenosis with diffuse, bilateral atherosclerosis and greater than 70% stenosis.

Head and neck cancer patients can have double the risk of transient ischemic attack or cerebrovascular accident, compared with a patient with normal pathologic narrowing of the carotid arteries, Dr. Sahai said. This is a controversial area because "data are not clear on what to do."

"We postponed and all discussed with all the providers involved," Dr. Sahai said. A stent was placed in the patient’s right internal carotid artery, and cancer surgery was delayed for 1 month while the patient took clopidogrel and aspirin. "He then went to the operating room on aspirin, and he did well."

Another case, a 70-year-old woman scheduled for a 6-hour cystectomy for bladder cancer, raised issues around preoperative cardiovascular assessment. "She reports fatigue and shortness of breath with exertion on her evening walks," Dr. Sahai said. "Before chemotherapy, she was able to walk eight blocks and up two flights of stairs without stopping. Now she can walk only four blocks and stops to rest between flights." She does not describe typical angina symptoms, he added.

The patient is obese, has diabetes mellitus, and is taking a statin for hyperlipidemia. She does not report any angina symptoms. Her history includes a myocardial infarction 5 years earlier addressed with medical management only.

Cancer can sap a patient’s energy, but the precise etiology in this case was unclear, Dr. Sahai said. Was her shortness of breath related to coronary artery disease, heart failure, pulmonary hypertension, or treatment with cardiotoxic chemotherapy? Should the patient be tested, for example, with an echocardiogram for heart function, stress test for ischemia, or both?

"Because this patient had received cardiotoxic chemotherapy ... we would do a stress echo on this patient," Dr. Sahai said. "In addition, BNP [B-type natriuretic peptide] levels may be helpful to detect cardiomyopathy. I would also optimize cardiac function and heart rate and send her to the operating room with the statin on board."

Patients with no cardiovascular symptoms can generally go to the operating room. If a patient is symptomatic, however, especially if the symptoms are new since cancer therapy was begun, Dr. Sahai said he generally considers further testing and work-up.

Dr. Sahai had no relevant financial disclosures.

MIAMI BEACH – "Green suit hypertension" can result in cancellation of procedures on the scheduled day of surgery, according to researchers who retrospectively studied 9,543 preoperative patients at the VA Nebraska – Western Iowa Health System.

And about half of these cases of preoperative hypertension result from withholding or missing antihypertensive medications on the morning of surgery, Dr. Joleen Fixley said at a meeting on perioperative medicine sponsored by the University of Miami.

Dr. Fixley and her colleagues found that 2,947 – or 31% of the total cohort of presurgical patients seen between 2004 and 2009 – had significant increases in blood pressure readings (blood pressure over 140 mmHg/90 mmHg) on the day of their procedure. This so-called green suit hypertension has been attributed to patients seeing their surgeons in green scrubs on the day of their operation. The group included 1,389 patients with previously controlled hypertension.

Those with green suit hypertension had a statistically significant average increase of 16 mmHg systolic and 23 mmHg diastolic over their baseline blood pressure measures as compared with other patients at the VA Nebraska – Western Iowa Health System, where Dr. Fixley is an attending in the department of internal medicine and medical director of the preoperative clinic.

Preoperative hypertension resulted in surgical cancellations for 73 patients overall, including 38 patients with green suit hypertension. These 38 patients had an average blood pressure increase from baseline of 47 mmHg systolic and 27 mmHg diastolic just before surgery.

"Holding or missing antihypertensive medications on the morning of surgery was responsible for almost half [45%] of our cancellations due to preoperative hypertension," Dr. Fixley said. This included 22% who skipped their diuretics, 15% who skipped their ACE inhibitors, and 8% who skipped both.

"Patient adherence to antihypertensive medication regimen is a factor in the perioperative period. The controversial practice of holding diuretics and ACE-inhibitors should cease," Dr. Fixley said.

Use of baseline blood pressure readings taken anywhere within their institution within 90 days of surgery was a potential limitation of the study, Dr. Fixley said. In addition, the study included a predominantly male population (94% were men; the average age was 63 years).

Future trials that assess intraoperative beta blockade therapy could include a cohort of patients with green suit hypertension to determine any beneficial effect, Dr. Fixley said.

Dr. Fixley said that she had no relevant financial disclosures.

MIAMI BEACH – "Green suit hypertension" can result in cancellation of procedures on the scheduled day of surgery, according to researchers who retrospectively studied 9,543 preoperative patients at the VA Nebraska – Western Iowa Health System.

And about half of these cases of preoperative hypertension result from withholding or missing antihypertensive medications on the morning of surgery, Dr. Joleen Fixley said at a meeting on perioperative medicine sponsored by the University of Miami.

Dr. Fixley and her colleagues found that 2,947 – or 31% of the total cohort of presurgical patients seen between 2004 and 2009 – had significant increases in blood pressure readings (blood pressure over 140 mmHg/90 mmHg) on the day of their procedure. This so-called green suit hypertension has been attributed to patients seeing their surgeons in green scrubs on the day of their operation. The group included 1,389 patients with previously controlled hypertension.

Those with green suit hypertension had a statistically significant average increase of 16 mmHg systolic and 23 mmHg diastolic over their baseline blood pressure measures as compared with other patients at the VA Nebraska – Western Iowa Health System, where Dr. Fixley is an attending in the department of internal medicine and medical director of the preoperative clinic.

Preoperative hypertension resulted in surgical cancellations for 73 patients overall, including 38 patients with green suit hypertension. These 38 patients had an average blood pressure increase from baseline of 47 mmHg systolic and 27 mmHg diastolic just before surgery.

"Holding or missing antihypertensive medications on the morning of surgery was responsible for almost half [45%] of our cancellations due to preoperative hypertension," Dr. Fixley said. This included 22% who skipped their diuretics, 15% who skipped their ACE inhibitors, and 8% who skipped both.

"Patient adherence to antihypertensive medication regimen is a factor in the perioperative period. The controversial practice of holding diuretics and ACE-inhibitors should cease," Dr. Fixley said.

Use of baseline blood pressure readings taken anywhere within their institution within 90 days of surgery was a potential limitation of the study, Dr. Fixley said. In addition, the study included a predominantly male population (94% were men; the average age was 63 years).

Future trials that assess intraoperative beta blockade therapy could include a cohort of patients with green suit hypertension to determine any beneficial effect, Dr. Fixley said.

Dr. Fixley said that she had no relevant financial disclosures.

MIAMI BEACH – "Green suit hypertension" can result in cancellation of procedures on the scheduled day of surgery, according to researchers who retrospectively studied 9,543 preoperative patients at the VA Nebraska – Western Iowa Health System.

And about half of these cases of preoperative hypertension result from withholding or missing antihypertensive medications on the morning of surgery, Dr. Joleen Fixley said at a meeting on perioperative medicine sponsored by the University of Miami.

Dr. Fixley and her colleagues found that 2,947 – or 31% of the total cohort of presurgical patients seen between 2004 and 2009 – had significant increases in blood pressure readings (blood pressure over 140 mmHg/90 mmHg) on the day of their procedure. This so-called green suit hypertension has been attributed to patients seeing their surgeons in green scrubs on the day of their operation. The group included 1,389 patients with previously controlled hypertension.

Those with green suit hypertension had a statistically significant average increase of 16 mmHg systolic and 23 mmHg diastolic over their baseline blood pressure measures as compared with other patients at the VA Nebraska – Western Iowa Health System, where Dr. Fixley is an attending in the department of internal medicine and medical director of the preoperative clinic.

Preoperative hypertension resulted in surgical cancellations for 73 patients overall, including 38 patients with green suit hypertension. These 38 patients had an average blood pressure increase from baseline of 47 mmHg systolic and 27 mmHg diastolic just before surgery.

"Holding or missing antihypertensive medications on the morning of surgery was responsible for almost half [45%] of our cancellations due to preoperative hypertension," Dr. Fixley said. This included 22% who skipped their diuretics, 15% who skipped their ACE inhibitors, and 8% who skipped both.

"Patient adherence to antihypertensive medication regimen is a factor in the perioperative period. The controversial practice of holding diuretics and ACE-inhibitors should cease," Dr. Fixley said.

Use of baseline blood pressure readings taken anywhere within their institution within 90 days of surgery was a potential limitation of the study, Dr. Fixley said. In addition, the study included a predominantly male population (94% were men; the average age was 63 years).

Future trials that assess intraoperative beta blockade therapy could include a cohort of patients with green suit hypertension to determine any beneficial effect, Dr. Fixley said.

Dr. Fixley said that she had no relevant financial disclosures.

MIAMI BEACH – Recommendations to stop taking aspirin therapy 7-10 days before surgery aren’t optimal for everyone, according to several experts who sought to tease out the best approach for multiple clinical scenarios given the lack of data on the issue.

Yet many clinicians have reservations about continuing aspirin perioperatively because, unlike other antiplatelet agents, it irreversibly inhibits platelet cyclooxygenase. In other words, once a platelet is inhibited by aspirin, the effect lasts for the 7-10 days it takes the body to replace circulating platelets.

As a result, most low-risk patients who are taking aspirin therapy for primary prevention of cardiovascular disease currently are advised to stop taking it 7 to 10 days before surgery," said Dr. Amir Jaffer, chief of the Division of Hospital Medicine and member of the medicine faculty at the University of Miami. New guidelines from the American College of Chest Physicians shore up that practice by advising an interruption of an aspirin regimen 7-10 days prior to major or minor surgery if the patient is at lower risk (Chest 2012;141:e326S-50S).

But such a blanket recommendation isn’t necessarily the best approach for every patient taking therapy for primary prevention, according to Dr. Jaffer and others at the meeting. Instead, aspirin should in many cases probably be continued perioperatively at least for some of the time.

Changing practice is a systems issue, he added. "We need to get all the stakeholders together and create an algorithm or guideline so you can keep patients on their aspirin at the time of surgery."

It should be noted that the ACCP guidelines recommend continuing aspirin prior to major or minor surgery if the patient is at higher risk for cardiovascular events and taking the agent as a means of secondary prevention.

In a separate presentation, Dr. Steven L. Cohn said that "3-5 days before surgery may be the most ideal for stopping aspirin if you are going to stop it at all." He added, "Try to continue aspirin as much as possible."

It comes down to balancing the potential for perioperative bleeding with the risk for potential rebound clotting effects after aspirin withdrawal, said Dr. Cohn, director of the University of Miami Hospital Medical Consultation Service and professor of medicine at the University of Miami.

And given the paucity of great evidence on the issue, it makes sense to consider expert consensus, Dr. Cohn said. For example, continue aspirin for minor surgery, according to an international consensus paper (Thromb. Haemost. 2011;105:743-9).

In the setting of primary prevention, stop aspirin 5 days before surgery. Continue aspirin for secondary prevention except if surgery is to take place in a closed space or a major bleeding complication is anticipated (in those cases, stop 5 days before surgery and restart in a stable patient 24 hours postoperatively), he said.

Experts at the meeting also agreed that elective surgery should be delayed for patients on a dual agent regimen. If the surgery is semi-elective or urgent, "you may need to prematurely stop one of the agents," Dr. Cohn said. In the case of emergency surgery, "you won’t have a choice." Have platelets available for transfusion during emergency procedures, these experts recommend.

Dr. Kurt J. Pfeifer also outlined the benefits and risks of perioperative aspirin continuation and offered advice on optimal dosing.

There is stronger evidence of aspirin’s benefits outside the perioperative setting, Dr. Pfeiffer said. However, data to support continuation of aspirin perioperatively include a decrease in incidence of intra- and postoperative stroke (grade 1A evidence, ACCP guidelines); peripheral arterial disease (Br. J. Surg. 2001;88:777-800); and myocardial infarction and other major cardiovascular events (Br. J. Anaesth. 2010;104:305-12).

Stent thrombosis risk is clearly increased when you withdraw aspirin therapy in patients, said Dr. Pfeifer, an attending in Perioperative and Consultative Medicine at Froedtert Hospital and member of the medicine faculty at the Medical College of Wisconsin, Milwaukee.

© Darren Hester/Fotolia.com

The risk is further elevated if patients have renal insufficiency, diabetes mellitus, or multiple stents. In contrast, the risk is lower for patients on dual clopidogrel-aspirin therapy who discontinue clopidogrel only preoperatively, he added.

The incidence of thrombosis ranges up to 15% within 90 days of stent placement to about 1% of drug-eluting stents up to 1 year (J. Am. Coll. Cardiol. 2007;49:734-9).

"Even though it’s 1%, up to 45% die, so it’s a big deal," Dr. Pfeifer said.

The risks related to in-stent thrombosis obviously also differ based on location of the stent, Dr. Pfeifer said. Risks for myocardial infarction and death are elevated with cardiac stents, for example. Occlusion at other sites can be serious as well, he added, "but you have more time to do something."

"It appears that operating on aspirin appears to be safe," Dr. Pfeifer said. Exceptions include intracranial procedures and surgery on the medullary canal of the spine; posterior eye chamber; and non-laser transurethral resection of the prostate.

In terms of perioperative dose, the best available evidence suggests no benefit to increasing aspirin dose above 100 mg for most patients, Dr. Pfeifer said (JAMA 2007;297:2018-24).

And dose increases mean increased risk of bleeding as well, he added.

"It seems reasonable to use 81 mg as your perioperative dose, and then to give them a higher dose after that," Dr. Pfeifer said. "The old saying of an aspirin a day keeps the doctor away does not apply to the surgeon."

More definitive answers could come from POISE-2 (PeriOperative ISchemic Evaluation Trial), which is currently enrolling participants with a goal of including 10,000 patients, Dr. Cohn said. Researchers aim to compare patients taking clonidine, aspirin, both, or neither. The results are scheduled for release in 2014.

Dr. Jaffer is a medical advisor to Hospitalist News. Dr. Jaffer, Dr. Cohn, and Dr. Pfeifer had no relevant disclosures.

MIAMI BEACH – Recommendations to stop taking aspirin therapy 7-10 days before surgery aren’t optimal for everyone, according to several experts who sought to tease out the best approach for multiple clinical scenarios given the lack of data on the issue.

Yet many clinicians have reservations about continuing aspirin perioperatively because, unlike other antiplatelet agents, it irreversibly inhibits platelet cyclooxygenase. In other words, once a platelet is inhibited by aspirin, the effect lasts for the 7-10 days it takes the body to replace circulating platelets.

As a result, most low-risk patients who are taking aspirin therapy for primary prevention of cardiovascular disease currently are advised to stop taking it 7 to 10 days before surgery," said Dr. Amir Jaffer, chief of the Division of Hospital Medicine and member of the medicine faculty at the University of Miami. New guidelines from the American College of Chest Physicians shore up that practice by advising an interruption of an aspirin regimen 7-10 days prior to major or minor surgery if the patient is at lower risk (Chest 2012;141:e326S-50S).

But such a blanket recommendation isn’t necessarily the best approach for every patient taking therapy for primary prevention, according to Dr. Jaffer and others at the meeting. Instead, aspirin should in many cases probably be continued perioperatively at least for some of the time.

Changing practice is a systems issue, he added. "We need to get all the stakeholders together and create an algorithm or guideline so you can keep patients on their aspirin at the time of surgery."

It should be noted that the ACCP guidelines recommend continuing aspirin prior to major or minor surgery if the patient is at higher risk for cardiovascular events and taking the agent as a means of secondary prevention.

In a separate presentation, Dr. Steven L. Cohn said that "3-5 days before surgery may be the most ideal for stopping aspirin if you are going to stop it at all." He added, "Try to continue aspirin as much as possible."

It comes down to balancing the potential for perioperative bleeding with the risk for potential rebound clotting effects after aspirin withdrawal, said Dr. Cohn, director of the University of Miami Hospital Medical Consultation Service and professor of medicine at the University of Miami.

And given the paucity of great evidence on the issue, it makes sense to consider expert consensus, Dr. Cohn said. For example, continue aspirin for minor surgery, according to an international consensus paper (Thromb. Haemost. 2011;105:743-9).

In the setting of primary prevention, stop aspirin 5 days before surgery. Continue aspirin for secondary prevention except if surgery is to take place in a closed space or a major bleeding complication is anticipated (in those cases, stop 5 days before surgery and restart in a stable patient 24 hours postoperatively), he said.

Experts at the meeting also agreed that elective surgery should be delayed for patients on a dual agent regimen. If the surgery is semi-elective or urgent, "you may need to prematurely stop one of the agents," Dr. Cohn said. In the case of emergency surgery, "you won’t have a choice." Have platelets available for transfusion during emergency procedures, these experts recommend.

Dr. Kurt J. Pfeifer also outlined the benefits and risks of perioperative aspirin continuation and offered advice on optimal dosing.

There is stronger evidence of aspirin’s benefits outside the perioperative setting, Dr. Pfeiffer said. However, data to support continuation of aspirin perioperatively include a decrease in incidence of intra- and postoperative stroke (grade 1A evidence, ACCP guidelines); peripheral arterial disease (Br. J. Surg. 2001;88:777-800); and myocardial infarction and other major cardiovascular events (Br. J. Anaesth. 2010;104:305-12).

Stent thrombosis risk is clearly increased when you withdraw aspirin therapy in patients, said Dr. Pfeifer, an attending in Perioperative and Consultative Medicine at Froedtert Hospital and member of the medicine faculty at the Medical College of Wisconsin, Milwaukee.

© Darren Hester/Fotolia.com

The risk is further elevated if patients have renal insufficiency, diabetes mellitus, or multiple stents. In contrast, the risk is lower for patients on dual clopidogrel-aspirin therapy who discontinue clopidogrel only preoperatively, he added.

The incidence of thrombosis ranges up to 15% within 90 days of stent placement to about 1% of drug-eluting stents up to 1 year (J. Am. Coll. Cardiol. 2007;49:734-9).

"Even though it’s 1%, up to 45% die, so it’s a big deal," Dr. Pfeifer said.

The risks related to in-stent thrombosis obviously also differ based on location of the stent, Dr. Pfeifer said. Risks for myocardial infarction and death are elevated with cardiac stents, for example. Occlusion at other sites can be serious as well, he added, "but you have more time to do something."

"It appears that operating on aspirin appears to be safe," Dr. Pfeifer said. Exceptions include intracranial procedures and surgery on the medullary canal of the spine; posterior eye chamber; and non-laser transurethral resection of the prostate.

In terms of perioperative dose, the best available evidence suggests no benefit to increasing aspirin dose above 100 mg for most patients, Dr. Pfeifer said (JAMA 2007;297:2018-24).

And dose increases mean increased risk of bleeding as well, he added.

"It seems reasonable to use 81 mg as your perioperative dose, and then to give them a higher dose after that," Dr. Pfeifer said. "The old saying of an aspirin a day keeps the doctor away does not apply to the surgeon."

More definitive answers could come from POISE-2 (PeriOperative ISchemic Evaluation Trial), which is currently enrolling participants with a goal of including 10,000 patients, Dr. Cohn said. Researchers aim to compare patients taking clonidine, aspirin, both, or neither. The results are scheduled for release in 2014.

Dr. Jaffer is a medical advisor to Hospitalist News. Dr. Jaffer, Dr. Cohn, and Dr. Pfeifer had no relevant disclosures.

MIAMI BEACH – Recommendations to stop taking aspirin therapy 7-10 days before surgery aren’t optimal for everyone, according to several experts who sought to tease out the best approach for multiple clinical scenarios given the lack of data on the issue.

Yet many clinicians have reservations about continuing aspirin perioperatively because, unlike other antiplatelet agents, it irreversibly inhibits platelet cyclooxygenase. In other words, once a platelet is inhibited by aspirin, the effect lasts for the 7-10 days it takes the body to replace circulating platelets.

As a result, most low-risk patients who are taking aspirin therapy for primary prevention of cardiovascular disease currently are advised to stop taking it 7 to 10 days before surgery," said Dr. Amir Jaffer, chief of the Division of Hospital Medicine and member of the medicine faculty at the University of Miami. New guidelines from the American College of Chest Physicians shore up that practice by advising an interruption of an aspirin regimen 7-10 days prior to major or minor surgery if the patient is at lower risk (Chest 2012;141:e326S-50S).

But such a blanket recommendation isn’t necessarily the best approach for every patient taking therapy for primary prevention, according to Dr. Jaffer and others at the meeting. Instead, aspirin should in many cases probably be continued perioperatively at least for some of the time.

Changing practice is a systems issue, he added. "We need to get all the stakeholders together and create an algorithm or guideline so you can keep patients on their aspirin at the time of surgery."

It should be noted that the ACCP guidelines recommend continuing aspirin prior to major or minor surgery if the patient is at higher risk for cardiovascular events and taking the agent as a means of secondary prevention.

In a separate presentation, Dr. Steven L. Cohn said that "3-5 days before surgery may be the most ideal for stopping aspirin if you are going to stop it at all." He added, "Try to continue aspirin as much as possible."

It comes down to balancing the potential for perioperative bleeding with the risk for potential rebound clotting effects after aspirin withdrawal, said Dr. Cohn, director of the University of Miami Hospital Medical Consultation Service and professor of medicine at the University of Miami.

And given the paucity of great evidence on the issue, it makes sense to consider expert consensus, Dr. Cohn said. For example, continue aspirin for minor surgery, according to an international consensus paper (Thromb. Haemost. 2011;105:743-9).

In the setting of primary prevention, stop aspirin 5 days before surgery. Continue aspirin for secondary prevention except if surgery is to take place in a closed space or a major bleeding complication is anticipated (in those cases, stop 5 days before surgery and restart in a stable patient 24 hours postoperatively), he said.

Experts at the meeting also agreed that elective surgery should be delayed for patients on a dual agent regimen. If the surgery is semi-elective or urgent, "you may need to prematurely stop one of the agents," Dr. Cohn said. In the case of emergency surgery, "you won’t have a choice." Have platelets available for transfusion during emergency procedures, these experts recommend.

Dr. Kurt J. Pfeifer also outlined the benefits and risks of perioperative aspirin continuation and offered advice on optimal dosing.

There is stronger evidence of aspirin’s benefits outside the perioperative setting, Dr. Pfeiffer said. However, data to support continuation of aspirin perioperatively include a decrease in incidence of intra- and postoperative stroke (grade 1A evidence, ACCP guidelines); peripheral arterial disease (Br. J. Surg. 2001;88:777-800); and myocardial infarction and other major cardiovascular events (Br. J. Anaesth. 2010;104:305-12).

Stent thrombosis risk is clearly increased when you withdraw aspirin therapy in patients, said Dr. Pfeifer, an attending in Perioperative and Consultative Medicine at Froedtert Hospital and member of the medicine faculty at the Medical College of Wisconsin, Milwaukee.

© Darren Hester/Fotolia.com

The risk is further elevated if patients have renal insufficiency, diabetes mellitus, or multiple stents. In contrast, the risk is lower for patients on dual clopidogrel-aspirin therapy who discontinue clopidogrel only preoperatively, he added.

The incidence of thrombosis ranges up to 15% within 90 days of stent placement to about 1% of drug-eluting stents up to 1 year (J. Am. Coll. Cardiol. 2007;49:734-9).

"Even though it’s 1%, up to 45% die, so it’s a big deal," Dr. Pfeifer said.

The risks related to in-stent thrombosis obviously also differ based on location of the stent, Dr. Pfeifer said. Risks for myocardial infarction and death are elevated with cardiac stents, for example. Occlusion at other sites can be serious as well, he added, "but you have more time to do something."

"It appears that operating on aspirin appears to be safe," Dr. Pfeifer said. Exceptions include intracranial procedures and surgery on the medullary canal of the spine; posterior eye chamber; and non-laser transurethral resection of the prostate.

In terms of perioperative dose, the best available evidence suggests no benefit to increasing aspirin dose above 100 mg for most patients, Dr. Pfeifer said (JAMA 2007;297:2018-24).

And dose increases mean increased risk of bleeding as well, he added.

"It seems reasonable to use 81 mg as your perioperative dose, and then to give them a higher dose after that," Dr. Pfeifer said. "The old saying of an aspirin a day keeps the doctor away does not apply to the surgeon."

More definitive answers could come from POISE-2 (PeriOperative ISchemic Evaluation Trial), which is currently enrolling participants with a goal of including 10,000 patients, Dr. Cohn said. Researchers aim to compare patients taking clonidine, aspirin, both, or neither. The results are scheduled for release in 2014.

Dr. Jaffer is a medical advisor to Hospitalist News. Dr. Jaffer, Dr. Cohn, and Dr. Pfeifer had no relevant disclosures.

MIAMI BEACH – What do the timing of smoking cessation prior to surgery, reliable prediction of postoperative respiratory failure, and biomarkers that point to elevated postoperative myocardial infarction risk have in common? They emerged as some of the most prominent findings published in the past year, according to three experts in hospital medicine.

Dr. Gerald W. Smetana, Dr. Steven L. Cohn, and Dr. Paul J. Grant each selected studies of particular relevance to hospitalists and explained why during a panel presentation at a meeting on perioperative medicine sponsored by the University of Miami:

© milosluz/istockphoto.com

• Preoperative Smoking Cessation. When a patient stops smoking up to 8 weeks before noncardiac surgery, it does not significantly change the total or pulmonary complication rates, according to a systematic literature review (Arch. Intern. Med. 2011;171:983-9).

"Many patients who quit smoking report they feel worse before they feel better," said Dr. Smetana, an attending in the general medicine division at Beth Israel Deaconess Medical Center, Boston.

Increased cough and sputum production are common right after quitting, he said. "This could be a plausible mechanism to explain why recent quitters might be at increased risk for postoperative pulmonary complications."

However, there was no statistically significant difference in total complications (relative risk of 0.78 for recent quitters, compared with a reference value of 1.0 for current smokers) in the nine eligible studies with 889 participants. Five of the trials assessed pulmonary complications, and found that recent quitters had a nonsignificant increased risk (RR, 1.18) compared with patients who continued to smoke.

Until there is consensus based on large randomized trials, stopping smoking before surgery can be considered safe, said Dr. Smetana, who is also on the medicine faculty at Harvard Medical School. In addition, longer periods of cessation are likely better than shorter ones. He added that despite the lack of a significant finding, it is still worthwhile to counsel patients because any time before surgery is a still a teachable moment for smoking cessation.

• Predicting Postoperative Pulmonary Failure. Type of procedure, emergency surgery, poor dependent functional status, sepsis, and higher American Society of Anesthesiologists classification were the five independent preoperative factors that significantly predicted postoperative respiratory failure in a multicenter database study (Chest 2011;140:1207-15).

The study included 211,410 participants undergoing all types of surgery. Mortality was 26% among those with postoperative respiratory failure, compared with 1% for unaffected patients. "This shows how important pulmonary complications can be," Dr. Smetana said.

The researchers incorporated these five predictors into a surgical risk calculator that is downloadable for free.

Dr. Smetana said, "It is a nice tool that ... helps to stratify patients. It makes a difference in identifying which patients for which you will pull out all the stops."

• Preoperative Peptide Gauges Risk. Although multiple researchers have looked at preoperative B-type natriuretic peptide (BNP) as a predictor of postoperative cardiac events or death, there remain "a lot of unknowns for BNP at this point," said Dr. Cohn, director of the University of Miami Hospital Medical Consultation Service and professor of medicine at the University of Miami.

A recent meta-analysis may shed some light on the predictive value of BNP (J. Am. Coll. Cardiol. 2011;58:522-9). Investigators assessed five BNP studies with 632 patients to determine cutoff values for screening (high sensitivity) and diagnosis (high specificity), and an optimal value that combines both.

The researchers found that patients with BNP above the optimal cutoff point of 116 pg/mL had a significantly elevated risk for the composite outcome of nonfatal myocardial infarction or cardiovascular death (unadjusted odds ratio, 7.36). Compared with use of the Revised Cardiac Risk Index, the optimal BNP cutoff classification improved risk prediction by 58%. This means some patients moved to a more accurate ranking among the low-, intermediate- and high-risk categories, Dr. Cohn said.

• Troponin and Postoperative MI Risk. Myocardial infarction is the most common major, perioperative vascular complication, so investigators continue to search for an accurate way to identify high-risk patients. Some propose elevated serum levels of the protein troponin as a predictor, Dr. Cohn said, but the question remains: Would it change patient management and improve outcomes?

Researchers found that increased troponin after noncardiac surgery did in fact independently predict postoperative MI mortality in a meta-analysis (Anesthesiology 2011;114:796-806).

Elevated levels significantly predicted increased risk in the 14 studies with 3,318 patients overall (OR, 3.4). However, prediction within the first year was higher (OR, 6.7) compared with studies that measured troponin more than 12 months out (OR, 1.8).

These findings could have implications for practice, because the majority of perioperative MIs are asymptomatic, Dr. Cohn said. "Maybe we should, as the authors suggest, recommend routine troponins after high-risk surgery."

More frequent vital-sign monitoring; transfer to a unit with additional monitoring; and/or screening for hypoxia and anemia could be implemented in patients identified as high risk, Dr. Cohn said. Optimization of intravascular volume and initiation of cardiac medications are additional strategies. Also, closely monitored patients who experience an MI potentially could be transferred for cardiac catheterization or revascularization more quickly.

"It is thought provoking that we can change the management," Dr. Cohn said.

• HF, AF, and Cardiovascular Risk. Heart failure and atrial fibrillation should factor more prominently into cardiovascular risk stratification prior to noncardiac surgery, according to a population-based cohort study of more than 38,000 consecutive patients (Circulation 2011:124:289-96).

"There are many cardiovascular risk stratification tools available with quite a bit of variation. Coronary artery disease [CAD] is typically weighted heavily on most models," said Dr. Grant, director of perioperative and consultative medicine and member of the medicine faculty at the University of Michigan in Ann Arbor.

However, researchers found that ischemic and nonischemic heart failure and atrial fibrillation were more commonly associated with 30-day mortality and readmission rates than CAD in this large cohort, Dr. Grant said. The authors concluded that these risk factors are likely underestimated in current prediction models.

• Liberal vs. Conservative Blood Transfusion. "The hemoglobin level at which we decide to transfuse patients after surgery is controversial," Dr. Grant said, "and has not been adequately studied to date. Great variations in practice exist."

A randomized controlled trial of 2,016 hip fracture surgery patients found no significant difference between liberal and conservative postoperative blood transfusion policies in terms of mortality or ability to walk independently at 60 days for patients at high cardiovascular risk (N. Engl. J. Med. 2011;365:2453-62).

The liberal policy allowed transfusions to maintain hemoglobin at 10 g/dL. In contrast, patients randomized to a conservative approach could only be transfused if they had symptoms of anemia or at the physician’s discretion once hemoglobin was below 8 g/dL.

"Implications for practice, from my point of view, include some more evidence that maybe using more of a restrictive transfusion practice may be reasonable, including for higher-risk populations," Dr. Grant said. However, "red-cell transfusion practices still need to be individualized for your perioperative patient."

Dr. Smetana, Dr. Cohn, and Dr. Grant had no relevant financial disclosures.

MIAMI BEACH – What do the timing of smoking cessation prior to surgery, reliable prediction of postoperative respiratory failure, and biomarkers that point to elevated postoperative myocardial infarction risk have in common? They emerged as some of the most prominent findings published in the past year, according to three experts in hospital medicine.

Dr. Gerald W. Smetana, Dr. Steven L. Cohn, and Dr. Paul J. Grant each selected studies of particular relevance to hospitalists and explained why during a panel presentation at a meeting on perioperative medicine sponsored by the University of Miami:

© milosluz/istockphoto.com

• Preoperative Smoking Cessation. When a patient stops smoking up to 8 weeks before noncardiac surgery, it does not significantly change the total or pulmonary complication rates, according to a systematic literature review (Arch. Intern. Med. 2011;171:983-9).

"Many patients who quit smoking report they feel worse before they feel better," said Dr. Smetana, an attending in the general medicine division at Beth Israel Deaconess Medical Center, Boston.

Increased cough and sputum production are common right after quitting, he said. "This could be a plausible mechanism to explain why recent quitters might be at increased risk for postoperative pulmonary complications."

However, there was no statistically significant difference in total complications (relative risk of 0.78 for recent quitters, compared with a reference value of 1.0 for current smokers) in the nine eligible studies with 889 participants. Five of the trials assessed pulmonary complications, and found that recent quitters had a nonsignificant increased risk (RR, 1.18) compared with patients who continued to smoke.

Until there is consensus based on large randomized trials, stopping smoking before surgery can be considered safe, said Dr. Smetana, who is also on the medicine faculty at Harvard Medical School. In addition, longer periods of cessation are likely better than shorter ones. He added that despite the lack of a significant finding, it is still worthwhile to counsel patients because any time before surgery is a still a teachable moment for smoking cessation.

• Predicting Postoperative Pulmonary Failure. Type of procedure, emergency surgery, poor dependent functional status, sepsis, and higher American Society of Anesthesiologists classification were the five independent preoperative factors that significantly predicted postoperative respiratory failure in a multicenter database study (Chest 2011;140:1207-15).

The study included 211,410 participants undergoing all types of surgery. Mortality was 26% among those with postoperative respiratory failure, compared with 1% for unaffected patients. "This shows how important pulmonary complications can be," Dr. Smetana said.

The researchers incorporated these five predictors into a surgical risk calculator that is downloadable for free.

Dr. Smetana said, "It is a nice tool that ... helps to stratify patients. It makes a difference in identifying which patients for which you will pull out all the stops."

• Preoperative Peptide Gauges Risk. Although multiple researchers have looked at preoperative B-type natriuretic peptide (BNP) as a predictor of postoperative cardiac events or death, there remain "a lot of unknowns for BNP at this point," said Dr. Cohn, director of the University of Miami Hospital Medical Consultation Service and professor of medicine at the University of Miami.

A recent meta-analysis may shed some light on the predictive value of BNP (J. Am. Coll. Cardiol. 2011;58:522-9). Investigators assessed five BNP studies with 632 patients to determine cutoff values for screening (high sensitivity) and diagnosis (high specificity), and an optimal value that combines both.

The researchers found that patients with BNP above the optimal cutoff point of 116 pg/mL had a significantly elevated risk for the composite outcome of nonfatal myocardial infarction or cardiovascular death (unadjusted odds ratio, 7.36). Compared with use of the Revised Cardiac Risk Index, the optimal BNP cutoff classification improved risk prediction by 58%. This means some patients moved to a more accurate ranking among the low-, intermediate- and high-risk categories, Dr. Cohn said.

• Troponin and Postoperative MI Risk. Myocardial infarction is the most common major, perioperative vascular complication, so investigators continue to search for an accurate way to identify high-risk patients. Some propose elevated serum levels of the protein troponin as a predictor, Dr. Cohn said, but the question remains: Would it change patient management and improve outcomes?

Researchers found that increased troponin after noncardiac surgery did in fact independently predict postoperative MI mortality in a meta-analysis (Anesthesiology 2011;114:796-806).

Elevated levels significantly predicted increased risk in the 14 studies with 3,318 patients overall (OR, 3.4). However, prediction within the first year was higher (OR, 6.7) compared with studies that measured troponin more than 12 months out (OR, 1.8).

These findings could have implications for practice, because the majority of perioperative MIs are asymptomatic, Dr. Cohn said. "Maybe we should, as the authors suggest, recommend routine troponins after high-risk surgery."

More frequent vital-sign monitoring; transfer to a unit with additional monitoring; and/or screening for hypoxia and anemia could be implemented in patients identified as high risk, Dr. Cohn said. Optimization of intravascular volume and initiation of cardiac medications are additional strategies. Also, closely monitored patients who experience an MI potentially could be transferred for cardiac catheterization or revascularization more quickly.

"It is thought provoking that we can change the management," Dr. Cohn said.

• HF, AF, and Cardiovascular Risk. Heart failure and atrial fibrillation should factor more prominently into cardiovascular risk stratification prior to noncardiac surgery, according to a population-based cohort study of more than 38,000 consecutive patients (Circulation 2011:124:289-96).

"There are many cardiovascular risk stratification tools available with quite a bit of variation. Coronary artery disease [CAD] is typically weighted heavily on most models," said Dr. Grant, director of perioperative and consultative medicine and member of the medicine faculty at the University of Michigan in Ann Arbor.

However, researchers found that ischemic and nonischemic heart failure and atrial fibrillation were more commonly associated with 30-day mortality and readmission rates than CAD in this large cohort, Dr. Grant said. The authors concluded that these risk factors are likely underestimated in current prediction models.

• Liberal vs. Conservative Blood Transfusion. "The hemoglobin level at which we decide to transfuse patients after surgery is controversial," Dr. Grant said, "and has not been adequately studied to date. Great variations in practice exist."

A randomized controlled trial of 2,016 hip fracture surgery patients found no significant difference between liberal and conservative postoperative blood transfusion policies in terms of mortality or ability to walk independently at 60 days for patients at high cardiovascular risk (N. Engl. J. Med. 2011;365:2453-62).

The liberal policy allowed transfusions to maintain hemoglobin at 10 g/dL. In contrast, patients randomized to a conservative approach could only be transfused if they had symptoms of anemia or at the physician’s discretion once hemoglobin was below 8 g/dL.

"Implications for practice, from my point of view, include some more evidence that maybe using more of a restrictive transfusion practice may be reasonable, including for higher-risk populations," Dr. Grant said. However, "red-cell transfusion practices still need to be individualized for your perioperative patient."

Dr. Smetana, Dr. Cohn, and Dr. Grant had no relevant financial disclosures.

MIAMI BEACH – What do the timing of smoking cessation prior to surgery, reliable prediction of postoperative respiratory failure, and biomarkers that point to elevated postoperative myocardial infarction risk have in common? They emerged as some of the most prominent findings published in the past year, according to three experts in hospital medicine.

Dr. Gerald W. Smetana, Dr. Steven L. Cohn, and Dr. Paul J. Grant each selected studies of particular relevance to hospitalists and explained why during a panel presentation at a meeting on perioperative medicine sponsored by the University of Miami:

© milosluz/istockphoto.com

• Preoperative Smoking Cessation. When a patient stops smoking up to 8 weeks before noncardiac surgery, it does not significantly change the total or pulmonary complication rates, according to a systematic literature review (Arch. Intern. Med. 2011;171:983-9).

"Many patients who quit smoking report they feel worse before they feel better," said Dr. Smetana, an attending in the general medicine division at Beth Israel Deaconess Medical Center, Boston.

Increased cough and sputum production are common right after quitting, he said. "This could be a plausible mechanism to explain why recent quitters might be at increased risk for postoperative pulmonary complications."

However, there was no statistically significant difference in total complications (relative risk of 0.78 for recent quitters, compared with a reference value of 1.0 for current smokers) in the nine eligible studies with 889 participants. Five of the trials assessed pulmonary complications, and found that recent quitters had a nonsignificant increased risk (RR, 1.18) compared with patients who continued to smoke.

Until there is consensus based on large randomized trials, stopping smoking before surgery can be considered safe, said Dr. Smetana, who is also on the medicine faculty at Harvard Medical School. In addition, longer periods of cessation are likely better than shorter ones. He added that despite the lack of a significant finding, it is still worthwhile to counsel patients because any time before surgery is a still a teachable moment for smoking cessation.

• Predicting Postoperative Pulmonary Failure. Type of procedure, emergency surgery, poor dependent functional status, sepsis, and higher American Society of Anesthesiologists classification were the five independent preoperative factors that significantly predicted postoperative respiratory failure in a multicenter database study (Chest 2011;140:1207-15).

The study included 211,410 participants undergoing all types of surgery. Mortality was 26% among those with postoperative respiratory failure, compared with 1% for unaffected patients. "This shows how important pulmonary complications can be," Dr. Smetana said.

The researchers incorporated these five predictors into a surgical risk calculator that is downloadable for free.

Dr. Smetana said, "It is a nice tool that ... helps to stratify patients. It makes a difference in identifying which patients for which you will pull out all the stops."

• Preoperative Peptide Gauges Risk. Although multiple researchers have looked at preoperative B-type natriuretic peptide (BNP) as a predictor of postoperative cardiac events or death, there remain "a lot of unknowns for BNP at this point," said Dr. Cohn, director of the University of Miami Hospital Medical Consultation Service and professor of medicine at the University of Miami.

A recent meta-analysis may shed some light on the predictive value of BNP (J. Am. Coll. Cardiol. 2011;58:522-9). Investigators assessed five BNP studies with 632 patients to determine cutoff values for screening (high sensitivity) and diagnosis (high specificity), and an optimal value that combines both.

The researchers found that patients with BNP above the optimal cutoff point of 116 pg/mL had a significantly elevated risk for the composite outcome of nonfatal myocardial infarction or cardiovascular death (unadjusted odds ratio, 7.36). Compared with use of the Revised Cardiac Risk Index, the optimal BNP cutoff classification improved risk prediction by 58%. This means some patients moved to a more accurate ranking among the low-, intermediate- and high-risk categories, Dr. Cohn said.

• Troponin and Postoperative MI Risk. Myocardial infarction is the most common major, perioperative vascular complication, so investigators continue to search for an accurate way to identify high-risk patients. Some propose elevated serum levels of the protein troponin as a predictor, Dr. Cohn said, but the question remains: Would it change patient management and improve outcomes?

Researchers found that increased troponin after noncardiac surgery did in fact independently predict postoperative MI mortality in a meta-analysis (Anesthesiology 2011;114:796-806).

Elevated levels significantly predicted increased risk in the 14 studies with 3,318 patients overall (OR, 3.4). However, prediction within the first year was higher (OR, 6.7) compared with studies that measured troponin more than 12 months out (OR, 1.8).

These findings could have implications for practice, because the majority of perioperative MIs are asymptomatic, Dr. Cohn said. "Maybe we should, as the authors suggest, recommend routine troponins after high-risk surgery."

More frequent vital-sign monitoring; transfer to a unit with additional monitoring; and/or screening for hypoxia and anemia could be implemented in patients identified as high risk, Dr. Cohn said. Optimization of intravascular volume and initiation of cardiac medications are additional strategies. Also, closely monitored patients who experience an MI potentially could be transferred for cardiac catheterization or revascularization more quickly.

"It is thought provoking that we can change the management," Dr. Cohn said.

• HF, AF, and Cardiovascular Risk. Heart failure and atrial fibrillation should factor more prominently into cardiovascular risk stratification prior to noncardiac surgery, according to a population-based cohort study of more than 38,000 consecutive patients (Circulation 2011:124:289-96).

"There are many cardiovascular risk stratification tools available with quite a bit of variation. Coronary artery disease [CAD] is typically weighted heavily on most models," said Dr. Grant, director of perioperative and consultative medicine and member of the medicine faculty at the University of Michigan in Ann Arbor.

However, researchers found that ischemic and nonischemic heart failure and atrial fibrillation were more commonly associated with 30-day mortality and readmission rates than CAD in this large cohort, Dr. Grant said. The authors concluded that these risk factors are likely underestimated in current prediction models.

• Liberal vs. Conservative Blood Transfusion. "The hemoglobin level at which we decide to transfuse patients after surgery is controversial," Dr. Grant said, "and has not been adequately studied to date. Great variations in practice exist."

A randomized controlled trial of 2,016 hip fracture surgery patients found no significant difference between liberal and conservative postoperative blood transfusion policies in terms of mortality or ability to walk independently at 60 days for patients at high cardiovascular risk (N. Engl. J. Med. 2011;365:2453-62).

The liberal policy allowed transfusions to maintain hemoglobin at 10 g/dL. In contrast, patients randomized to a conservative approach could only be transfused if they had symptoms of anemia or at the physician’s discretion once hemoglobin was below 8 g/dL.

"Implications for practice, from my point of view, include some more evidence that maybe using more of a restrictive transfusion practice may be reasonable, including for higher-risk populations," Dr. Grant said. However, "red-cell transfusion practices still need to be individualized for your perioperative patient."

Dr. Smetana, Dr. Cohn, and Dr. Grant had no relevant financial disclosures.

MIAMI BEACH – You get along with most of your colleagues in the hospital, but there is that one physician who doesn’t follow the rules, disrupts everyone’s workday, and ramps up the tension when they walk onto the ward.

Advice on which strategies work best to change disruptive and other problematic physician behavior comes from an anesthesiologist who oversees a South Florida health system of more than 1,400 doctors.

Focusing on changing behavior "is primarily what I do now more than anything else. ... It is about getting people to all pull in one direction," said Dr. David Lubarsky, who in September 2011 became CEO of UHealth Physician Practice and associate vice president for UHealth Practice administration at the University of Miami.

Disruptive or above-the-law behavior may garner the most attention, but behaviors related to low productivity, poor resource utilization, or poor patient satisfaction scores also need to change in this era of heightened accountability, Dr. Lubarsky said at a meeting on perioperative medicine sponsored by the University of Miami.

Sometimes there is a significant disconnect between how a disruptive physician perceives their own behavior compared with the impressions of clinicians around them. In such instances, a program such as Physicians Universal Leadership Skills Survey Enhancement (P.U.L.S.E.) 360 can help. "I have referred physicians for this," Dr. Lubarsky said. Essentially, the doctor in question first rates their own workplace behavior, and then the multidisciplinary team around them also completes surveys. Next, the doctor receives very specific feedback on both positive and negative behaviors.

"When they are confronted with this and told specifically what they are doing that isn’t really working, and given alternatives about how to approach a situation – and they see their scores getting better – they get better, they feel better. The whole team operates better. It’s a very positive experience."

Another tip: Don’t expend energy getting physicians to change their behavior when a technologic solution can achieve the same result, said Dr. Lubarsky, who retains his title as Emanuel M. Papper Professor and Chair, Department of Anesthesiology, Perioperative Medicine, and Pain Management, at the University of Miami.

A computerized prompt to administer preoperative antibiotics on time is an example. If this does not happen, other preparations for surgery automatically stop. Another successful intervention addresses incomplete chart documentation. This used to be an issue at the University of Miami when support staff had to "chase down a doctor for a signature," Dr. Lubarsky said. Now, if an attending forgets their documentation, they receive a page. "Incomplete chart documentation is now close to zero."

"You have to make it easy for everyone to do the right thing," he said.

Providing incentives can improve behaviors as well, but some ideas work better than others. Find out what the physicians value to devise meaningful incentives, Dr. Lubarsky said.

Increased commitment and motivation often ensue when physicians and others participate in setting specific, measurable goals. Difficult but achievable goals generate better performance than easy or impossible ones, Dr. Lubarsky noted. "The doctor must believe the goal is within reach."

Keep the plan simple. "Three to five goals are preferable to six or more goals," he said. Avoid complex incentive plans that assign two points for writing a paper, one point for attending a conference, and one point for staying late at work because "nobody understands this."

This era of tracking benchmark data for individual providers raises the question: Why is changing how people deliver care so difficult?

Part of it stems from physician experience and attitude, Dr. Lubarsky said. "After 4 years of college, 4 years of medical school, an average 4 years of training, and an average $150,000 of debt ... you paid for the right to call yourself a physician." Professional autonomy is deeply valued by physicians, he added.

However, "benchmarking, or use of external data, is very common now and it’s very powerful," Dr. Lubarsky said.

Physicians often balk when presented with their numbers, Dr. Lubarsky said. "I have not met a doctor yet who believes they are average or below average. I hear all this time: ‘The numbers are wrong. You have to get the right data.’ " Other reactions include, "So what?" or "My numbers are worse because my patients are sicker." Or there are physicians who dismiss what they perceive as a cookbook approach to medicine: "Are you planning to really make us do all you say and not individualize it for each patient?"

Benchmarking also relates to resource utilization. Physician attitude and behaviors are important because doctors dictate about 85% of the money spent in the hospital, he said.

Dr. Lubarsky said that he had no relevant financial disclosures.

MIAMI BEACH – You get along with most of your colleagues in the hospital, but there is that one physician who doesn’t follow the rules, disrupts everyone’s workday, and ramps up the tension when they walk onto the ward.

Advice on which strategies work best to change disruptive and other problematic physician behavior comes from an anesthesiologist who oversees a South Florida health system of more than 1,400 doctors.

Focusing on changing behavior "is primarily what I do now more than anything else. ... It is about getting people to all pull in one direction," said Dr. David Lubarsky, who in September 2011 became CEO of UHealth Physician Practice and associate vice president for UHealth Practice administration at the University of Miami.

Disruptive or above-the-law behavior may garner the most attention, but behaviors related to low productivity, poor resource utilization, or poor patient satisfaction scores also need to change in this era of heightened accountability, Dr. Lubarsky said at a meeting on perioperative medicine sponsored by the University of Miami.

Sometimes there is a significant disconnect between how a disruptive physician perceives their own behavior compared with the impressions of clinicians around them. In such instances, a program such as Physicians Universal Leadership Skills Survey Enhancement (P.U.L.S.E.) 360 can help. "I have referred physicians for this," Dr. Lubarsky said. Essentially, the doctor in question first rates their own workplace behavior, and then the multidisciplinary team around them also completes surveys. Next, the doctor receives very specific feedback on both positive and negative behaviors.

"When they are confronted with this and told specifically what they are doing that isn’t really working, and given alternatives about how to approach a situation – and they see their scores getting better – they get better, they feel better. The whole team operates better. It’s a very positive experience."

Another tip: Don’t expend energy getting physicians to change their behavior when a technologic solution can achieve the same result, said Dr. Lubarsky, who retains his title as Emanuel M. Papper Professor and Chair, Department of Anesthesiology, Perioperative Medicine, and Pain Management, at the University of Miami.

A computerized prompt to administer preoperative antibiotics on time is an example. If this does not happen, other preparations for surgery automatically stop. Another successful intervention addresses incomplete chart documentation. This used to be an issue at the University of Miami when support staff had to "chase down a doctor for a signature," Dr. Lubarsky said. Now, if an attending forgets their documentation, they receive a page. "Incomplete chart documentation is now close to zero."

"You have to make it easy for everyone to do the right thing," he said.

Providing incentives can improve behaviors as well, but some ideas work better than others. Find out what the physicians value to devise meaningful incentives, Dr. Lubarsky said.

Increased commitment and motivation often ensue when physicians and others participate in setting specific, measurable goals. Difficult but achievable goals generate better performance than easy or impossible ones, Dr. Lubarsky noted. "The doctor must believe the goal is within reach."

Keep the plan simple. "Three to five goals are preferable to six or more goals," he said. Avoid complex incentive plans that assign two points for writing a paper, one point for attending a conference, and one point for staying late at work because "nobody understands this."

This era of tracking benchmark data for individual providers raises the question: Why is changing how people deliver care so difficult?

Part of it stems from physician experience and attitude, Dr. Lubarsky said. "After 4 years of college, 4 years of medical school, an average 4 years of training, and an average $150,000 of debt ... you paid for the right to call yourself a physician." Professional autonomy is deeply valued by physicians, he added.

However, "benchmarking, or use of external data, is very common now and it’s very powerful," Dr. Lubarsky said.

Physicians often balk when presented with their numbers, Dr. Lubarsky said. "I have not met a doctor yet who believes they are average or below average. I hear all this time: ‘The numbers are wrong. You have to get the right data.’ " Other reactions include, "So what?" or "My numbers are worse because my patients are sicker." Or there are physicians who dismiss what they perceive as a cookbook approach to medicine: "Are you planning to really make us do all you say and not individualize it for each patient?"

Benchmarking also relates to resource utilization. Physician attitude and behaviors are important because doctors dictate about 85% of the money spent in the hospital, he said.

Dr. Lubarsky said that he had no relevant financial disclosures.

MIAMI BEACH – You get along with most of your colleagues in the hospital, but there is that one physician who doesn’t follow the rules, disrupts everyone’s workday, and ramps up the tension when they walk onto the ward.

Advice on which strategies work best to change disruptive and other problematic physician behavior comes from an anesthesiologist who oversees a South Florida health system of more than 1,400 doctors.

Focusing on changing behavior "is primarily what I do now more than anything else. ... It is about getting people to all pull in one direction," said Dr. David Lubarsky, who in September 2011 became CEO of UHealth Physician Practice and associate vice president for UHealth Practice administration at the University of Miami.

Disruptive or above-the-law behavior may garner the most attention, but behaviors related to low productivity, poor resource utilization, or poor patient satisfaction scores also need to change in this era of heightened accountability, Dr. Lubarsky said at a meeting on perioperative medicine sponsored by the University of Miami.

Sometimes there is a significant disconnect between how a disruptive physician perceives their own behavior compared with the impressions of clinicians around them. In such instances, a program such as Physicians Universal Leadership Skills Survey Enhancement (P.U.L.S.E.) 360 can help. "I have referred physicians for this," Dr. Lubarsky said. Essentially, the doctor in question first rates their own workplace behavior, and then the multidisciplinary team around them also completes surveys. Next, the doctor receives very specific feedback on both positive and negative behaviors.

"When they are confronted with this and told specifically what they are doing that isn’t really working, and given alternatives about how to approach a situation – and they see their scores getting better – they get better, they feel better. The whole team operates better. It’s a very positive experience."

Another tip: Don’t expend energy getting physicians to change their behavior when a technologic solution can achieve the same result, said Dr. Lubarsky, who retains his title as Emanuel M. Papper Professor and Chair, Department of Anesthesiology, Perioperative Medicine, and Pain Management, at the University of Miami.

A computerized prompt to administer preoperative antibiotics on time is an example. If this does not happen, other preparations for surgery automatically stop. Another successful intervention addresses incomplete chart documentation. This used to be an issue at the University of Miami when support staff had to "chase down a doctor for a signature," Dr. Lubarsky said. Now, if an attending forgets their documentation, they receive a page. "Incomplete chart documentation is now close to zero."

"You have to make it easy for everyone to do the right thing," he said.

Providing incentives can improve behaviors as well, but some ideas work better than others. Find out what the physicians value to devise meaningful incentives, Dr. Lubarsky said.

Increased commitment and motivation often ensue when physicians and others participate in setting specific, measurable goals. Difficult but achievable goals generate better performance than easy or impossible ones, Dr. Lubarsky noted. "The doctor must believe the goal is within reach."

Keep the plan simple. "Three to five goals are preferable to six or more goals," he said. Avoid complex incentive plans that assign two points for writing a paper, one point for attending a conference, and one point for staying late at work because "nobody understands this."

This era of tracking benchmark data for individual providers raises the question: Why is changing how people deliver care so difficult?

Part of it stems from physician experience and attitude, Dr. Lubarsky said. "After 4 years of college, 4 years of medical school, an average 4 years of training, and an average $150,000 of debt ... you paid for the right to call yourself a physician." Professional autonomy is deeply valued by physicians, he added.

However, "benchmarking, or use of external data, is very common now and it’s very powerful," Dr. Lubarsky said.

Physicians often balk when presented with their numbers, Dr. Lubarsky said. "I have not met a doctor yet who believes they are average or below average. I hear all this time: ‘The numbers are wrong. You have to get the right data.’ " Other reactions include, "So what?" or "My numbers are worse because my patients are sicker." Or there are physicians who dismiss what they perceive as a cookbook approach to medicine: "Are you planning to really make us do all you say and not individualize it for each patient?"

Benchmarking also relates to resource utilization. Physician attitude and behaviors are important because doctors dictate about 85% of the money spent in the hospital, he said.

Dr. Lubarsky said that he had no relevant financial disclosures.

MIAMI BEACH – When you get a call in the hospital to evaluate a patient with postoperative hyponatremia, you need to worry primarily about three causes, according to an expert.

Increased free water intake, sodium loss that exceeds free water loss, and – "what we see all the time" – an inability to excrete free water will be your main concerns with these inpatients, Dr. Rachel E. Thompson said.

Initially rule out the most serious potential consequences of hyponatremia. "Assess mental status first to rule out increased intracranial pressure," said Dr. Thompson, founder and director of the Medicine Consult Service at Harborview Medical Center in Seattle. She spoke at a meeting on perioperative medicine sponsored by the University of Miami. "We have rigid skulls. There is very little space for tissue expansion." Left unchecked, intracranial hypertension can lead to brain damage, herniation, and respiratory arrest. "You can die from this."

It’s also important to distinguish neurology patients from others, Dr. Thompson said. Neurologic surgeons often want patients to have sodium levels above 140 mEq/L. "However, in other populations, if there is not brain damage that is going to be worsened by this, we are a lot more laissez faire. We might allow it to go lower, and people don’t get too worried about it until you’re in the mid to low 120s."

Dr. Thompson cited a neurosurgery patient as a case example. You get a call about a 66-year-old woman currently in the rehabilitation unit following endovascular coiling for aneurysmal subarachnoid hemorrhage repair two weeks earlier. The rehabilitation specialist reports her sodium is low at 126 mEq/L (it was 142 mEq/L when she left the neurosurgery unit 7 days earlier).

Dr. Thompson electronically polled meeting attendees regarding the next appropriate step. Of the total 91 responses, 33% would evaluate the patient’s volume status, 29% would evaluate mental status, 24% would check serum osmolality, and the remaining 14% would recheck the sodium level.

"I like that you want to see the volume status, and another third of you want to check the mental status. That means you are going to go see the patient. That is great," Dr. Thompson said.

Early assessment of mental status is key in Dr. Thompson’s four-step practical model for perioperative providers caring for hyponatremia patients:

• Step 1. Go to the bedside to assess mental status. Does it reflect what you expect for that sodium level? Assess acuity and severity, check which fluids are running, determine if the patient is hypovolemic, and find out if the patient had any recent vomiting or diarrhea that could facilitate volume loss.

• Step 2. Review medications. Did the patient take any diuretics or medications known to cause syndrome of inappropriate antidiuretic hormone (SIADH)? For more information on this syndrome, see (Nephron. Clin. Pract. 2011;119:c62-73).

• Step 3. Order appropriate studies. You might repeat the sodium level and check serum osmolality; also measure urine osmolality and sodium. Which brings us to the final step ...

• Step 4. "The urine is going to be where your answers are," Dr. Thompson said. If the urine is dilute, think primary polydipsia or "tea and toast diet syndrome." If the urine is concentrated, causes include chronic kidney disease, thiazides, hypothyroidism, or glucocorticoid deficiency.

It is important to be thorough and closely monitor hyponatremia patients either way, Dr. Thompson said.

Hyponatremia comes with risks. In one retrospective cohort study, hospital-acquired hyponatremia was associated with increased in-hospital mortality (adjusted odds ratio, 1.66); a 64% adjusted increase in length of stay; and a greater likelihood of discharge to a short- or long-term care facility (OR, 1.64) compared to unaffected patients (Arch. Intern. Med. 2010;8:294-302). The researchers found 38% of more than 55,000 inpatients at a single center over 7 years had hospital-acquired hyponatremia, defined as a decrease in serum sodium to below 138 mEq/L following normal levels at admission.

Although management of inpatients with hyponatremia might appear complex, there are two main treatment choices. "You either give fluids or you restrict fluids," Dr. Thompson said.

Give fluids to patients who are hypovolemic, have cerebral salt wasting, or display acute mental status changes. Go slow with treatment, she added, with a goal correction of no more than 0.5 mEq/L per hour or 12 mEq/L every 24 hours. Some clinicians recommend a more conservative increase of 6 mEq/L per 24 hours, she added.

Restrict fluids to patients with SIADH or primary polydipsia. Restriction to 1L to 2L free water is generally appropriate, Dr. Thompson said.

Sodium chloride tablets and vasopressin antagonists are two additional treatment options. Consider administration of sodium chloride tablets to patients with cerebral salt wasting, Dr. Thompson said. Some clinicians are reluctant to treat with salt tablets. "I was one of the people who used to think this was a terrible thing, but it actually works in cerebral salt wasting." The tablets also are indicated as a treatment for chronic SIADH, she said.

Vasopressin antagonists can be given I.V. or oral and are considered a treatment of last resort, she added. "Save them for the severely symptomatic patient. Yes, the sodium comes up, but there are no data on better outcomes in the acute setting." At an estimated daily cost of $260-$550, "they are extremely expensive." She cautioned that patients need to be watched for rapid overcorrection with these agents.

Dr. Thompson did not have any relevant disclosures.

MIAMI BEACH – When you get a call in the hospital to evaluate a patient with postoperative hyponatremia, you need to worry primarily about three causes, according to an expert.

Increased free water intake, sodium loss that exceeds free water loss, and – "what we see all the time" – an inability to excrete free water will be your main concerns with these inpatients, Dr. Rachel E. Thompson said.

Initially rule out the most serious potential consequences of hyponatremia. "Assess mental status first to rule out increased intracranial pressure," said Dr. Thompson, founder and director of the Medicine Consult Service at Harborview Medical Center in Seattle. She spoke at a meeting on perioperative medicine sponsored by the University of Miami. "We have rigid skulls. There is very little space for tissue expansion." Left unchecked, intracranial hypertension can lead to brain damage, herniation, and respiratory arrest. "You can die from this."

It’s also important to distinguish neurology patients from others, Dr. Thompson said. Neurologic surgeons often want patients to have sodium levels above 140 mEq/L. "However, in other populations, if there is not brain damage that is going to be worsened by this, we are a lot more laissez faire. We might allow it to go lower, and people don’t get too worried about it until you’re in the mid to low 120s."

Dr. Thompson cited a neurosurgery patient as a case example. You get a call about a 66-year-old woman currently in the rehabilitation unit following endovascular coiling for aneurysmal subarachnoid hemorrhage repair two weeks earlier. The rehabilitation specialist reports her sodium is low at 126 mEq/L (it was 142 mEq/L when she left the neurosurgery unit 7 days earlier).

Dr. Thompson electronically polled meeting attendees regarding the next appropriate step. Of the total 91 responses, 33% would evaluate the patient’s volume status, 29% would evaluate mental status, 24% would check serum osmolality, and the remaining 14% would recheck the sodium level.

"I like that you want to see the volume status, and another third of you want to check the mental status. That means you are going to go see the patient. That is great," Dr. Thompson said.

Early assessment of mental status is key in Dr. Thompson’s four-step practical model for perioperative providers caring for hyponatremia patients:

• Step 1. Go to the bedside to assess mental status. Does it reflect what you expect for that sodium level? Assess acuity and severity, check which fluids are running, determine if the patient is hypovolemic, and find out if the patient had any recent vomiting or diarrhea that could facilitate volume loss.

• Step 2. Review medications. Did the patient take any diuretics or medications known to cause syndrome of inappropriate antidiuretic hormone (SIADH)? For more information on this syndrome, see (Nephron. Clin. Pract. 2011;119:c62-73).

• Step 3. Order appropriate studies. You might repeat the sodium level and check serum osmolality; also measure urine osmolality and sodium. Which brings us to the final step ...

• Step 4. "The urine is going to be where your answers are," Dr. Thompson said. If the urine is dilute, think primary polydipsia or "tea and toast diet syndrome." If the urine is concentrated, causes include chronic kidney disease, thiazides, hypothyroidism, or glucocorticoid deficiency.

It is important to be thorough and closely monitor hyponatremia patients either way, Dr. Thompson said.

Hyponatremia comes with risks. In one retrospective cohort study, hospital-acquired hyponatremia was associated with increased in-hospital mortality (adjusted odds ratio, 1.66); a 64% adjusted increase in length of stay; and a greater likelihood of discharge to a short- or long-term care facility (OR, 1.64) compared to unaffected patients (Arch. Intern. Med. 2010;8:294-302). The researchers found 38% of more than 55,000 inpatients at a single center over 7 years had hospital-acquired hyponatremia, defined as a decrease in serum sodium to below 138 mEq/L following normal levels at admission.

Although management of inpatients with hyponatremia might appear complex, there are two main treatment choices. "You either give fluids or you restrict fluids," Dr. Thompson said.

Give fluids to patients who are hypovolemic, have cerebral salt wasting, or display acute mental status changes. Go slow with treatment, she added, with a goal correction of no more than 0.5 mEq/L per hour or 12 mEq/L every 24 hours. Some clinicians recommend a more conservative increase of 6 mEq/L per 24 hours, she added.

Restrict fluids to patients with SIADH or primary polydipsia. Restriction to 1L to 2L free water is generally appropriate, Dr. Thompson said.

Sodium chloride tablets and vasopressin antagonists are two additional treatment options. Consider administration of sodium chloride tablets to patients with cerebral salt wasting, Dr. Thompson said. Some clinicians are reluctant to treat with salt tablets. "I was one of the people who used to think this was a terrible thing, but it actually works in cerebral salt wasting." The tablets also are indicated as a treatment for chronic SIADH, she said.

Vasopressin antagonists can be given I.V. or oral and are considered a treatment of last resort, she added. "Save them for the severely symptomatic patient. Yes, the sodium comes up, but there are no data on better outcomes in the acute setting." At an estimated daily cost of $260-$550, "they are extremely expensive." She cautioned that patients need to be watched for rapid overcorrection with these agents.

Dr. Thompson did not have any relevant disclosures.

MIAMI BEACH – When you get a call in the hospital to evaluate a patient with postoperative hyponatremia, you need to worry primarily about three causes, according to an expert.

Increased free water intake, sodium loss that exceeds free water loss, and – "what we see all the time" – an inability to excrete free water will be your main concerns with these inpatients, Dr. Rachel E. Thompson said.

Initially rule out the most serious potential consequences of hyponatremia. "Assess mental status first to rule out increased intracranial pressure," said Dr. Thompson, founder and director of the Medicine Consult Service at Harborview Medical Center in Seattle. She spoke at a meeting on perioperative medicine sponsored by the University of Miami. "We have rigid skulls. There is very little space for tissue expansion." Left unchecked, intracranial hypertension can lead to brain damage, herniation, and respiratory arrest. "You can die from this."

It’s also important to distinguish neurology patients from others, Dr. Thompson said. Neurologic surgeons often want patients to have sodium levels above 140 mEq/L. "However, in other populations, if there is not brain damage that is going to be worsened by this, we are a lot more laissez faire. We might allow it to go lower, and people don’t get too worried about it until you’re in the mid to low 120s."

Dr. Thompson cited a neurosurgery patient as a case example. You get a call about a 66-year-old woman currently in the rehabilitation unit following endovascular coiling for aneurysmal subarachnoid hemorrhage repair two weeks earlier. The rehabilitation specialist reports her sodium is low at 126 mEq/L (it was 142 mEq/L when she left the neurosurgery unit 7 days earlier).

Dr. Thompson electronically polled meeting attendees regarding the next appropriate step. Of the total 91 responses, 33% would evaluate the patient’s volume status, 29% would evaluate mental status, 24% would check serum osmolality, and the remaining 14% would recheck the sodium level.

"I like that you want to see the volume status, and another third of you want to check the mental status. That means you are going to go see the patient. That is great," Dr. Thompson said.

Early assessment of mental status is key in Dr. Thompson’s four-step practical model for perioperative providers caring for hyponatremia patients:

• Step 1. Go to the bedside to assess mental status. Does it reflect what you expect for that sodium level? Assess acuity and severity, check which fluids are running, determine if the patient is hypovolemic, and find out if the patient had any recent vomiting or diarrhea that could facilitate volume loss.

• Step 2. Review medications. Did the patient take any diuretics or medications known to cause syndrome of inappropriate antidiuretic hormone (SIADH)? For more information on this syndrome, see (Nephron. Clin. Pract. 2011;119:c62-73).

• Step 3. Order appropriate studies. You might repeat the sodium level and check serum osmolality; also measure urine osmolality and sodium. Which brings us to the final step ...

• Step 4. "The urine is going to be where your answers are," Dr. Thompson said. If the urine is dilute, think primary polydipsia or "tea and toast diet syndrome." If the urine is concentrated, causes include chronic kidney disease, thiazides, hypothyroidism, or glucocorticoid deficiency.

It is important to be thorough and closely monitor hyponatremia patients either way, Dr. Thompson said.

Hyponatremia comes with risks. In one retrospective cohort study, hospital-acquired hyponatremia was associated with increased in-hospital mortality (adjusted odds ratio, 1.66); a 64% adjusted increase in length of stay; and a greater likelihood of discharge to a short- or long-term care facility (OR, 1.64) compared to unaffected patients (Arch. Intern. Med. 2010;8:294-302). The researchers found 38% of more than 55,000 inpatients at a single center over 7 years had hospital-acquired hyponatremia, defined as a decrease in serum sodium to below 138 mEq/L following normal levels at admission.

Although management of inpatients with hyponatremia might appear complex, there are two main treatment choices. "You either give fluids or you restrict fluids," Dr. Thompson said.

Give fluids to patients who are hypovolemic, have cerebral salt wasting, or display acute mental status changes. Go slow with treatment, she added, with a goal correction of no more than 0.5 mEq/L per hour or 12 mEq/L every 24 hours. Some clinicians recommend a more conservative increase of 6 mEq/L per 24 hours, she added.

Restrict fluids to patients with SIADH or primary polydipsia. Restriction to 1L to 2L free water is generally appropriate, Dr. Thompson said.

Sodium chloride tablets and vasopressin antagonists are two additional treatment options. Consider administration of sodium chloride tablets to patients with cerebral salt wasting, Dr. Thompson said. Some clinicians are reluctant to treat with salt tablets. "I was one of the people who used to think this was a terrible thing, but it actually works in cerebral salt wasting." The tablets also are indicated as a treatment for chronic SIADH, she said.

Vasopressin antagonists can be given I.V. or oral and are considered a treatment of last resort, she added. "Save them for the severely symptomatic patient. Yes, the sodium comes up, but there are no data on better outcomes in the acute setting." At an estimated daily cost of $260-$550, "they are extremely expensive." She cautioned that patients need to be watched for rapid overcorrection with these agents.

Dr. Thompson did not have any relevant disclosures.

MIAMI BEACH – An internist and an orthopedic surgery recently squared off on the best strategy to prevent deep vein thrombosis following major joint-replacement surgery.

Anticoagulant agents effectively prevent deep vein thrombosis (DVT) after total hip replacement or total knee replacement, according to a large body of scientific studies, the internist argued. In contrast to the well studied, relatively small number of anticoagulants, the myriad of mechanical devices are supported by more limited, less rigorous research in the medical literature, Dr. James D. Douketis said at a meeting on perioperative medicine sponsored by the University of Miami.

The risk of major or clinically relevant bleeding associated with anticoagulant use can be minimized with appropriate administration, such as waiting at least 12 hours after surgery to start therapy, said Dr. Douketis, director of the vascular medicine program at St. Joseph’s Healthcare in Hamilton, Ont.

"I agree that the bleeding risk is relatively low if these drugs are used properly, but why do you have to take any risk?" orthopedic surgeon Dr. Clifford W. Colwell Jr. asked at the meeting.

Most bleeding episodes, when they do occur, are easy to mitigate, Dr. Douketis said. Unlike DVTs, most of these events do not have long-term consequences, he said. In addition, mechanical methods are not always benign. There are reports of trauma associated with use of intermittent compression devices, for example.

Dr. Colwell countered that a zero risk of an adverse bleeding event is one of the main benefits of mechanical devices to prevent DVT. For this reason, these devices are ideal for patients at a high risk for bleeding who cannot take anticoagulants, he said. Enhancement of the effectiveness of drug-based thromboprophylaxis and reduced leg swelling are other potential benefits of these devices.

The effectiveness of mechanical compression devices is directly correlated with how much time they are worn and these devices are nearly complication free, said Dr. Colwell, medical director at the Shiley Center for Orthopaedic Research and Education at Scripps Clinic in La Jolla, Calif.

But why can’t these devices be more portable? The ActiveCare+S.F.T. Portable Intermittent Compression Device, or PICD (Medical Compression Systems Ltd.), is a miniature, battery-powered device that overcomes a major limitation of some mechanical devices: Their design and size can impede ambulation after surgery. The PICD can be worn out of bed and out of the hospital, Dr. Colwell said. It synchronizes compression with the patient’s respiratory phase so it provides a naturalistic phasic venous flow.

An initial study of its efficacy in 121 patients "was small ... I was not convinced," Dr. Colwell said (J. Arthroplasty 2006;21;206-14). A more recent multicenter, prospective study that Dr. Colwell performed with his associates compared effectiveness of the portable device to low-molecular-weight heparin for 10 days for total hip arthroplasties and was more compelling (J. Bone Joint Surg. Am. 2010:92:527-35).

At 3 months, the DVT rate was "essentially the same" at 4.1% in the device group compared with 4.2% in the anticoagulant cohort. There was no fatal PE or any deaths among the 410 randomized participants. In addition, major bleeding occurred for 0% of the device wearers and 5.6% of the pharmacologically treated patients.

"I acknowledge that mechanical prophylaxis has a role after major orthopedic surgery major, but it’s a second-line strategy," said Dr. Douketis, who also is on the medicine faculty at McMaster University. Pharmacologic prophylaxis should be first-line therapy because it has been shown to prevent DVT, and pulmonary embolism (PE), including fatal PE, he said.

A meta-analysis Dr. Douketis performed with his colleagues showed extended duration prophylaxis with heparin or warfarin significantly decreased the frequency of symptomatic venous thromboembolism, compared with placebo after total hip or knee replacement (Lancet 2001;358:9-15).

There is less confidence about prevention of proximal DVTs with mechanical devices, Dr. Douketis said.

The risks should be weighed against this efficacy, Dr. Douketis said. In a study, researchers determined the risk of major or clinically-relevant bleeding was 4% of 1,501 patients treated with apixaban and 5% of 1,508 patients treated with enoxaparin (Lancet 2010;375:807-15).

American College of Chest Physician (ACCP) guidelines recommend use of low-molecular weight heparin to prevent DVT in these surgical populations but list a number of other pharmacologic prophylaxis options (supported by grade 2C/2B evidence). They also recommend addition of an intermittent pneumatic compressive device during the hospital stay of patients taking anticoagulants, but supported by grade 2C evidence. The authors also recommend one of these devices or no prophylaxis for patients at increased bleeding risk (again, grade 2C evidence). The full recommendations were published in February (Chest 2012;141:e278S-325S).

Dr. Colwell said patient compliance is monitored by and clearly reported on the screen of the PICD. Compliance with wearing the device was 86% in an unpublished study that included 3,060 total hip and total knee surgery patients. These patients wore the device a mean of 20 hr/day.

Dr. Douketis remained unconvinced about the PICD and said he preferred to withhold judgment until more studies are completed. "We are much more confident with anticoagulants than mechanical strategies."

Dr. Colwell said the new PICD is akin to an iPhone. "You don’t need 30 years of experience to know it’s a good product."

Dr. Douketis disclosed that he is a consultant for AGEN, Ortho-Janssen, Boehringer Ingelheim, Pfizer, and Bristol-Myers Squibb. He also receives indirect payment as part of the event adjudication and advisory board for Sanofi Aventis, Bayer, Bristol-Myers Squibb, Astra Zeneca, and Boehringer Ingelheim. Dr. Colwell disclosed that he is a consultant for and receives research grants from Medical Compression Systems Inc.

MIAMI BEACH – An internist and an orthopedic surgery recently squared off on the best strategy to prevent deep vein thrombosis following major joint-replacement surgery.

Anticoagulant agents effectively prevent deep vein thrombosis (DVT) after total hip replacement or total knee replacement, according to a large body of scientific studies, the internist argued. In contrast to the well studied, relatively small number of anticoagulants, the myriad of mechanical devices are supported by more limited, less rigorous research in the medical literature, Dr. James D. Douketis said at a meeting on perioperative medicine sponsored by the University of Miami.

The risk of major or clinically relevant bleeding associated with anticoagulant use can be minimized with appropriate administration, such as waiting at least 12 hours after surgery to start therapy, said Dr. Douketis, director of the vascular medicine program at St. Joseph’s Healthcare in Hamilton, Ont.

"I agree that the bleeding risk is relatively low if these drugs are used properly, but why do you have to take any risk?" orthopedic surgeon Dr. Clifford W. Colwell Jr. asked at the meeting.

Most bleeding episodes, when they do occur, are easy to mitigate, Dr. Douketis said. Unlike DVTs, most of these events do not have long-term consequences, he said. In addition, mechanical methods are not always benign. There are reports of trauma associated with use of intermittent compression devices, for example.

Dr. Colwell countered that a zero risk of an adverse bleeding event is one of the main benefits of mechanical devices to prevent DVT. For this reason, these devices are ideal for patients at a high risk for bleeding who cannot take anticoagulants, he said. Enhancement of the effectiveness of drug-based thromboprophylaxis and reduced leg swelling are other potential benefits of these devices.

The effectiveness of mechanical compression devices is directly correlated with how much time they are worn and these devices are nearly complication free, said Dr. Colwell, medical director at the Shiley Center for Orthopaedic Research and Education at Scripps Clinic in La Jolla, Calif.

But why can’t these devices be more portable? The ActiveCare+S.F.T. Portable Intermittent Compression Device, or PICD (Medical Compression Systems Ltd.), is a miniature, battery-powered device that overcomes a major limitation of some mechanical devices: Their design and size can impede ambulation after surgery. The PICD can be worn out of bed and out of the hospital, Dr. Colwell said. It synchronizes compression with the patient’s respiratory phase so it provides a naturalistic phasic venous flow.

An initial study of its efficacy in 121 patients "was small ... I was not convinced," Dr. Colwell said (J. Arthroplasty 2006;21;206-14). A more recent multicenter, prospective study that Dr. Colwell performed with his associates compared effectiveness of the portable device to low-molecular-weight heparin for 10 days for total hip arthroplasties and was more compelling (J. Bone Joint Surg. Am. 2010:92:527-35).

At 3 months, the DVT rate was "essentially the same" at 4.1% in the device group compared with 4.2% in the anticoagulant cohort. There was no fatal PE or any deaths among the 410 randomized participants. In addition, major bleeding occurred for 0% of the device wearers and 5.6% of the pharmacologically treated patients.

"I acknowledge that mechanical prophylaxis has a role after major orthopedic surgery major, but it’s a second-line strategy," said Dr. Douketis, who also is on the medicine faculty at McMaster University. Pharmacologic prophylaxis should be first-line therapy because it has been shown to prevent DVT, and pulmonary embolism (PE), including fatal PE, he said.

A meta-analysis Dr. Douketis performed with his colleagues showed extended duration prophylaxis with heparin or warfarin significantly decreased the frequency of symptomatic venous thromboembolism, compared with placebo after total hip or knee replacement (Lancet 2001;358:9-15).

There is less confidence about prevention of proximal DVTs with mechanical devices, Dr. Douketis said.

The risks should be weighed against this efficacy, Dr. Douketis said. In a study, researchers determined the risk of major or clinically-relevant bleeding was 4% of 1,501 patients treated with apixaban and 5% of 1,508 patients treated with enoxaparin (Lancet 2010;375:807-15).

American College of Chest Physician (ACCP) guidelines recommend use of low-molecular weight heparin to prevent DVT in these surgical populations but list a number of other pharmacologic prophylaxis options (supported by grade 2C/2B evidence). They also recommend addition of an intermittent pneumatic compressive device during the hospital stay of patients taking anticoagulants, but supported by grade 2C evidence. The authors also recommend one of these devices or no prophylaxis for patients at increased bleeding risk (again, grade 2C evidence). The full recommendations were published in February (Chest 2012;141:e278S-325S).

Dr. Colwell said patient compliance is monitored by and clearly reported on the screen of the PICD. Compliance with wearing the device was 86% in an unpublished study that included 3,060 total hip and total knee surgery patients. These patients wore the device a mean of 20 hr/day.

Dr. Douketis remained unconvinced about the PICD and said he preferred to withhold judgment until more studies are completed. "We are much more confident with anticoagulants than mechanical strategies."

Dr. Colwell said the new PICD is akin to an iPhone. "You don’t need 30 years of experience to know it’s a good product."

Dr. Douketis disclosed that he is a consultant for AGEN, Ortho-Janssen, Boehringer Ingelheim, Pfizer, and Bristol-Myers Squibb. He also receives indirect payment as part of the event adjudication and advisory board for Sanofi Aventis, Bayer, Bristol-Myers Squibb, Astra Zeneca, and Boehringer Ingelheim. Dr. Colwell disclosed that he is a consultant for and receives research grants from Medical Compression Systems Inc.

MIAMI BEACH – An internist and an orthopedic surgery recently squared off on the best strategy to prevent deep vein thrombosis following major joint-replacement surgery.

Anticoagulant agents effectively prevent deep vein thrombosis (DVT) after total hip replacement or total knee replacement, according to a large body of scientific studies, the internist argued. In contrast to the well studied, relatively small number of anticoagulants, the myriad of mechanical devices are supported by more limited, less rigorous research in the medical literature, Dr. James D. Douketis said at a meeting on perioperative medicine sponsored by the University of Miami.

The risk of major or clinically relevant bleeding associated with anticoagulant use can be minimized with appropriate administration, such as waiting at least 12 hours after surgery to start therapy, said Dr. Douketis, director of the vascular medicine program at St. Joseph’s Healthcare in Hamilton, Ont.

"I agree that the bleeding risk is relatively low if these drugs are used properly, but why do you have to take any risk?" orthopedic surgeon Dr. Clifford W. Colwell Jr. asked at the meeting.

Most bleeding episodes, when they do occur, are easy to mitigate, Dr. Douketis said. Unlike DVTs, most of these events do not have long-term consequences, he said. In addition, mechanical methods are not always benign. There are reports of trauma associated with use of intermittent compression devices, for example.

Dr. Colwell countered that a zero risk of an adverse bleeding event is one of the main benefits of mechanical devices to prevent DVT. For this reason, these devices are ideal for patients at a high risk for bleeding who cannot take anticoagulants, he said. Enhancement of the effectiveness of drug-based thromboprophylaxis and reduced leg swelling are other potential benefits of these devices.

The effectiveness of mechanical compression devices is directly correlated with how much time they are worn and these devices are nearly complication free, said Dr. Colwell, medical director at the Shiley Center for Orthopaedic Research and Education at Scripps Clinic in La Jolla, Calif.

But why can’t these devices be more portable? The ActiveCare+S.F.T. Portable Intermittent Compression Device, or PICD (Medical Compression Systems Ltd.), is a miniature, battery-powered device that overcomes a major limitation of some mechanical devices: Their design and size can impede ambulation after surgery. The PICD can be worn out of bed and out of the hospital, Dr. Colwell said. It synchronizes compression with the patient’s respiratory phase so it provides a naturalistic phasic venous flow.

An initial study of its efficacy in 121 patients "was small ... I was not convinced," Dr. Colwell said (J. Arthroplasty 2006;21;206-14). A more recent multicenter, prospective study that Dr. Colwell performed with his associates compared effectiveness of the portable device to low-molecular-weight heparin for 10 days for total hip arthroplasties and was more compelling (J. Bone Joint Surg. Am. 2010:92:527-35).

At 3 months, the DVT rate was "essentially the same" at 4.1% in the device group compared with 4.2% in the anticoagulant cohort. There was no fatal PE or any deaths among the 410 randomized participants. In addition, major bleeding occurred for 0% of the device wearers and 5.6% of the pharmacologically treated patients.

"I acknowledge that mechanical prophylaxis has a role after major orthopedic surgery major, but it’s a second-line strategy," said Dr. Douketis, who also is on the medicine faculty at McMaster University. Pharmacologic prophylaxis should be first-line therapy because it has been shown to prevent DVT, and pulmonary embolism (PE), including fatal PE, he said.

A meta-analysis Dr. Douketis performed with his colleagues showed extended duration prophylaxis with heparin or warfarin significantly decreased the frequency of symptomatic venous thromboembolism, compared with placebo after total hip or knee replacement (Lancet 2001;358:9-15).

There is less confidence about prevention of proximal DVTs with mechanical devices, Dr. Douketis said.

The risks should be weighed against this efficacy, Dr. Douketis said. In a study, researchers determined the risk of major or clinically-relevant bleeding was 4% of 1,501 patients treated with apixaban and 5% of 1,508 patients treated with enoxaparin (Lancet 2010;375:807-15).

American College of Chest Physician (ACCP) guidelines recommend use of low-molecular weight heparin to prevent DVT in these surgical populations but list a number of other pharmacologic prophylaxis options (supported by grade 2C/2B evidence). They also recommend addition of an intermittent pneumatic compressive device during the hospital stay of patients taking anticoagulants, but supported by grade 2C evidence. The authors also recommend one of these devices or no prophylaxis for patients at increased bleeding risk (again, grade 2C evidence). The full recommendations were published in February (Chest 2012;141:e278S-325S).

Dr. Colwell said patient compliance is monitored by and clearly reported on the screen of the PICD. Compliance with wearing the device was 86% in an unpublished study that included 3,060 total hip and total knee surgery patients. These patients wore the device a mean of 20 hr/day.

Dr. Douketis remained unconvinced about the PICD and said he preferred to withhold judgment until more studies are completed. "We are much more confident with anticoagulants than mechanical strategies."

Dr. Colwell said the new PICD is akin to an iPhone. "You don’t need 30 years of experience to know it’s a good product."

Dr. Douketis disclosed that he is a consultant for AGEN, Ortho-Janssen, Boehringer Ingelheim, Pfizer, and Bristol-Myers Squibb. He also receives indirect payment as part of the event adjudication and advisory board for Sanofi Aventis, Bayer, Bristol-Myers Squibb, Astra Zeneca, and Boehringer Ingelheim. Dr. Colwell disclosed that he is a consultant for and receives research grants from Medical Compression Systems Inc.

MIAMI – Patients who are likely to eat up a high proportion of hospital resources after surgery can be identified and risk stratified, a study has shown.

A Holy Grail of hospital medicine has been to identify – ahead of time – those most likely to require additional services, an increased length of stay, and essentially more attention and closer monitoring from a multidisciplinary team of clinicians.

At Geisinger Health System in Danville, Pa., use of the Proactive Risk Stratification and Preemptive Mitigation (PRiSM) continuum of care model has resulted in significant reductions in mortality, for example, for surgical patients compared with historical controls, the pilot study has shown

Most of the benefit was realized because higher-risk patients were transferred to a step-down unit or "progressive care unit" (PCU) versus going to the hospital ward and waiting for them to turn "sour," Dr. Thanjuvar S. Ravikumar said at a meeting on perioperative medicine sponsored by the University of Miami. "This is a safety net. You identify patients during rounds at risk of potential deterioration," he added. "You can improve patient outcomes significantly."

The focus is not surgical ICU mortality. "The focus is to improve mortality, the efficiency, and the length of stay outside of the ICU," he said.

Overall reductions in length of stay and hospital costs also emerged, said Dr. Ravikumar, who was the chief quality officer in surgery and interventional procedures at Geisinger until February of this year. He is now director and CEO of Jawaharlal Institute of Postgraduate Medical Education and Research in India. He is also president and CEO of Integrated Health Strategies, which includes PRiSM Healthcare and owns the PRiSM concept.

"When you put this program in place, you see a dramatic difference in length of stay within 2 months," Dr. Ravikumar said.

Even hospitalists working at institutions with "fantastic" length of stay rates will see their pre–11 a.m. discharges happen more efficiently with this model, Dr. Ravikumar said.

Although the pilot study focused on surgical patients, PRiSM also features descriptive criteria tailored for use during medical rounds. The idea is to predict and direct closer monitoring toward "hawks" or those postoperative patients who need to be "watched like hawks," Dr. Ravikumar said. Normal-risk patients are termed "doves."

Transfer from an ICU, a body mass index greater than 40 kg/m², or an ejection fraction below 30% are among the "hawk’" preoperative criteria for surgery patients. Exacerbated chronic obstructive pulmonary disorder, borderline heart failure decompensation, and pneumonia requiring oxygen or bilevel positive airway pressure therapy are examples of "hawk" criteria for medical patients.

PRiSM saves an estimated $851,111-$2,007,388 from postoperative care unit throughput and decreased ICU utilization, Dr. Ravikumar said. In addition, decreases in utilization of pharmacy, radiology, blood bank, and laboratory services are estimated at $500,000 per top 10 diagnostic-related group codes. Postoperative complications decreased 25%, for an estimated cost savings of $3,000-$18,000 per complication.

A subanalysis of the pilot study data compared a cohort of surgical patients stratified with PRiSM to patients at a comparable hospital with the same number of surgeons. Overall mortality was lower for the PRiSM cohort, 1% vs. 1.4%, as was mortality in the postoperative care unit, 0.4% vs. 1.6%, and the surgical ICU, 8% vs. 9.3%.

Length of stay measured in a variety of settings also was shorter for the PRiSM patients versus the comparator hospital patients. For example, PRiSM patients stayed a mean of 2.7 days vs. 3.7 days in the postoperative care unit and a mean of 4.4 days vs. 4.5 in the surgical ICU. The difference in surgical ICU stays was not statistically significant.

During the question and answer session, Dr. Frank Michota said the Center for Medicaid and Medicare Innovation is promoting the use of a standardized continuum of care model. He asked Dr. Ravikumar if such a model can be achieved on a national rather than a local level. Dr. Michota is director of academic affairs, department of hospital medicine, Cleveland Clinic Ohio.

"There are principles of what you want to do – team building, communication – but the local culture is very important. In terms of how you implement in every hospital, there has to be [some] latitude. If you don’t have hospitalists and you have PAs, you have to work on the PA system," Dr. Ravikumar said. In addition some weighting based on the hospital profile is warranted. For example, if a hospital has a fantastic cardiology program and a weaker renal program, the risk stratification has to be weighted to detect patients at risk for renal complications or whatever is the weaker service at that hospital.

Dr. Ravikumar outlined how a typical day works using the PRiSM strategy. At 7:30 a.m., hospitalist handoff occurs. Pre-rounding on the patient floor, during which time the hospitalist consults with the surgeons, continues until 9 a.m. An agreement to comanage patients with surgery is an essential component, Dr. Ravikumar said.

From 9-10 a.m., simultaneous continuum of care rounds are performed by the multidisciplinary team: hospitalists, surgical team, nurses, care managers, pharmacists, and residents. "Everyone sits in and finishes seeing all those patients in 1 hour, mostly ... for discharge planning in the hospital," Dr. Ravikumar said. From 10-10:30 a.m., the hospitalist and continuum of care physician do the "hawk huddle" to confer on the list of patients who will require more scrutiny.

The use of a rounding tool (either mobile or based in the electronic medical record system) is required to make this multidisciplinary assessment effective, Dr. Ravikumar said. The tool needs to be easily accessible during rounds and easily navigated for each patient by the providers, nurses, occupational therapists, physical therapists, and pharmacists.

Although the hawk criteria are currently descriptive, "we have developed a model composite score based on preoperative variables, intraoperative happenings, and postoperatively, things that happen in the first 2 hours," Dr. Ravikumar said. Decision support based on the score is essential, he added, "so you know what to do in the next hour for this individual patient."

Dr. Ravikumar said that he had no relevant financial disclosures. Dr. Michota is the medical editor of Hospitalist News, an Elsevier publication.

MIAMI – Patients who are likely to eat up a high proportion of hospital resources after surgery can be identified and risk stratified, a study has shown.

A Holy Grail of hospital medicine has been to identify – ahead of time – those most likely to require additional services, an increased length of stay, and essentially more attention and closer monitoring from a multidisciplinary team of clinicians.

At Geisinger Health System in Danville, Pa., use of the Proactive Risk Stratification and Preemptive Mitigation (PRiSM) continuum of care model has resulted in significant reductions in mortality, for example, for surgical patients compared with historical controls, the pilot study has shown

Most of the benefit was realized because higher-risk patients were transferred to a step-down unit or "progressive care unit" (PCU) versus going to the hospital ward and waiting for them to turn "sour," Dr. Thanjuvar S. Ravikumar said at a meeting on perioperative medicine sponsored by the University of Miami. "This is a safety net. You identify patients during rounds at risk of potential deterioration," he added. "You can improve patient outcomes significantly."

The focus is not surgical ICU mortality. "The focus is to improve mortality, the efficiency, and the length of stay outside of the ICU," he said.

Overall reductions in length of stay and hospital costs also emerged, said Dr. Ravikumar, who was the chief quality officer in surgery and interventional procedures at Geisinger until February of this year. He is now director and CEO of Jawaharlal Institute of Postgraduate Medical Education and Research in India. He is also president and CEO of Integrated Health Strategies, which includes PRiSM Healthcare and owns the PRiSM concept.

"When you put this program in place, you see a dramatic difference in length of stay within 2 months," Dr. Ravikumar said.

Even hospitalists working at institutions with "fantastic" length of stay rates will see their pre–11 a.m. discharges happen more efficiently with this model, Dr. Ravikumar said.

Although the pilot study focused on surgical patients, PRiSM also features descriptive criteria tailored for use during medical rounds. The idea is to predict and direct closer monitoring toward "hawks" or those postoperative patients who need to be "watched like hawks," Dr. Ravikumar said. Normal-risk patients are termed "doves."

Transfer from an ICU, a body mass index greater than 40 kg/m², or an ejection fraction below 30% are among the "hawk’" preoperative criteria for surgery patients. Exacerbated chronic obstructive pulmonary disorder, borderline heart failure decompensation, and pneumonia requiring oxygen or bilevel positive airway pressure therapy are examples of "hawk" criteria for medical patients.

PRiSM saves an estimated $851,111-$2,007,388 from postoperative care unit throughput and decreased ICU utilization, Dr. Ravikumar said. In addition, decreases in utilization of pharmacy, radiology, blood bank, and laboratory services are estimated at $500,000 per top 10 diagnostic-related group codes. Postoperative complications decreased 25%, for an estimated cost savings of $3,000-$18,000 per complication.

A subanalysis of the pilot study data compared a cohort of surgical patients stratified with PRiSM to patients at a comparable hospital with the same number of surgeons. Overall mortality was lower for the PRiSM cohort, 1% vs. 1.4%, as was mortality in the postoperative care unit, 0.4% vs. 1.6%, and the surgical ICU, 8% vs. 9.3%.

Length of stay measured in a variety of settings also was shorter for the PRiSM patients versus the comparator hospital patients. For example, PRiSM patients stayed a mean of 2.7 days vs. 3.7 days in the postoperative care unit and a mean of 4.4 days vs. 4.5 in the surgical ICU. The difference in surgical ICU stays was not statistically significant.

During the question and answer session, Dr. Frank Michota said the Center for Medicaid and Medicare Innovation is promoting the use of a standardized continuum of care model. He asked Dr. Ravikumar if such a model can be achieved on a national rather than a local level. Dr. Michota is director of academic affairs, department of hospital medicine, Cleveland Clinic Ohio.

"There are principles of what you want to do – team building, communication – but the local culture is very important. In terms of how you implement in every hospital, there has to be [some] latitude. If you don’t have hospitalists and you have PAs, you have to work on the PA system," Dr. Ravikumar said. In addition some weighting based on the hospital profile is warranted. For example, if a hospital has a fantastic cardiology program and a weaker renal program, the risk stratification has to be weighted to detect patients at risk for renal complications or whatever is the weaker service at that hospital.

Dr. Ravikumar outlined how a typical day works using the PRiSM strategy. At 7:30 a.m., hospitalist handoff occurs. Pre-rounding on the patient floor, during which time the hospitalist consults with the surgeons, continues until 9 a.m. An agreement to comanage patients with surgery is an essential component, Dr. Ravikumar said.

From 9-10 a.m., simultaneous continuum of care rounds are performed by the multidisciplinary team: hospitalists, surgical team, nurses, care managers, pharmacists, and residents. "Everyone sits in and finishes seeing all those patients in 1 hour, mostly ... for discharge planning in the hospital," Dr. Ravikumar said. From 10-10:30 a.m., the hospitalist and continuum of care physician do the "hawk huddle" to confer on the list of patients who will require more scrutiny.

The use of a rounding tool (either mobile or based in the electronic medical record system) is required to make this multidisciplinary assessment effective, Dr. Ravikumar said. The tool needs to be easily accessible during rounds and easily navigated for each patient by the providers, nurses, occupational therapists, physical therapists, and pharmacists.

Although the hawk criteria are currently descriptive, "we have developed a model composite score based on preoperative variables, intraoperative happenings, and postoperatively, things that happen in the first 2 hours," Dr. Ravikumar said. Decision support based on the score is essential, he added, "so you know what to do in the next hour for this individual patient."

Dr. Ravikumar said that he had no relevant financial disclosures. Dr. Michota is the medical editor of Hospitalist News, an Elsevier publication.

MIAMI – Patients who are likely to eat up a high proportion of hospital resources after surgery can be identified and risk stratified, a study has shown.

A Holy Grail of hospital medicine has been to identify – ahead of time – those most likely to require additional services, an increased length of stay, and essentially more attention and closer monitoring from a multidisciplinary team of clinicians.

At Geisinger Health System in Danville, Pa., use of the Proactive Risk Stratification and Preemptive Mitigation (PRiSM) continuum of care model has resulted in significant reductions in mortality, for example, for surgical patients compared with historical controls, the pilot study has shown

Most of the benefit was realized because higher-risk patients were transferred to a step-down unit or "progressive care unit" (PCU) versus going to the hospital ward and waiting for them to turn "sour," Dr. Thanjuvar S. Ravikumar said at a meeting on perioperative medicine sponsored by the University of Miami. "This is a safety net. You identify patients during rounds at risk of potential deterioration," he added. "You can improve patient outcomes significantly."

The focus is not surgical ICU mortality. "The focus is to improve mortality, the efficiency, and the length of stay outside of the ICU," he said.

Overall reductions in length of stay and hospital costs also emerged, said Dr. Ravikumar, who was the chief quality officer in surgery and interventional procedures at Geisinger until February of this year. He is now director and CEO of Jawaharlal Institute of Postgraduate Medical Education and Research in India. He is also president and CEO of Integrated Health Strategies, which includes PRiSM Healthcare and owns the PRiSM concept.

"When you put this program in place, you see a dramatic difference in length of stay within 2 months," Dr. Ravikumar said.

Even hospitalists working at institutions with "fantastic" length of stay rates will see their pre–11 a.m. discharges happen more efficiently with this model, Dr. Ravikumar said.

Although the pilot study focused on surgical patients, PRiSM also features descriptive criteria tailored for use during medical rounds. The idea is to predict and direct closer monitoring toward "hawks" or those postoperative patients who need to be "watched like hawks," Dr. Ravikumar said. Normal-risk patients are termed "doves."

Transfer from an ICU, a body mass index greater than 40 kg/m², or an ejection fraction below 30% are among the "hawk’" preoperative criteria for surgery patients. Exacerbated chronic obstructive pulmonary disorder, borderline heart failure decompensation, and pneumonia requiring oxygen or bilevel positive airway pressure therapy are examples of "hawk" criteria for medical patients.

PRiSM saves an estimated $851,111-$2,007,388 from postoperative care unit throughput and decreased ICU utilization, Dr. Ravikumar said. In addition, decreases in utilization of pharmacy, radiology, blood bank, and laboratory services are estimated at $500,000 per top 10 diagnostic-related group codes. Postoperative complications decreased 25%, for an estimated cost savings of $3,000-$18,000 per complication.

A subanalysis of the pilot study data compared a cohort of surgical patients stratified with PRiSM to patients at a comparable hospital with the same number of surgeons. Overall mortality was lower for the PRiSM cohort, 1% vs. 1.4%, as was mortality in the postoperative care unit, 0.4% vs. 1.6%, and the surgical ICU, 8% vs. 9.3%.

Length of stay measured in a variety of settings also was shorter for the PRiSM patients versus the comparator hospital patients. For example, PRiSM patients stayed a mean of 2.7 days vs. 3.7 days in the postoperative care unit and a mean of 4.4 days vs. 4.5 in the surgical ICU. The difference in surgical ICU stays was not statistically significant.

During the question and answer session, Dr. Frank Michota said the Center for Medicaid and Medicare Innovation is promoting the use of a standardized continuum of care model. He asked Dr. Ravikumar if such a model can be achieved on a national rather than a local level. Dr. Michota is director of academic affairs, department of hospital medicine, Cleveland Clinic Ohio.

"There are principles of what you want to do – team building, communication – but the local culture is very important. In terms of how you implement in every hospital, there has to be [some] latitude. If you don’t have hospitalists and you have PAs, you have to work on the PA system," Dr. Ravikumar said. In addition some weighting based on the hospital profile is warranted. For example, if a hospital has a fantastic cardiology program and a weaker renal program, the risk stratification has to be weighted to detect patients at risk for renal complications or whatever is the weaker service at that hospital.

Dr. Ravikumar outlined how a typical day works using the PRiSM strategy. At 7:30 a.m., hospitalist handoff occurs. Pre-rounding on the patient floor, during which time the hospitalist consults with the surgeons, continues until 9 a.m. An agreement to comanage patients with surgery is an essential component, Dr. Ravikumar said.

From 9-10 a.m., simultaneous continuum of care rounds are performed by the multidisciplinary team: hospitalists, surgical team, nurses, care managers, pharmacists, and residents. "Everyone sits in and finishes seeing all those patients in 1 hour, mostly ... for discharge planning in the hospital," Dr. Ravikumar said. From 10-10:30 a.m., the hospitalist and continuum of care physician do the "hawk huddle" to confer on the list of patients who will require more scrutiny.

The use of a rounding tool (either mobile or based in the electronic medical record system) is required to make this multidisciplinary assessment effective, Dr. Ravikumar said. The tool needs to be easily accessible during rounds and easily navigated for each patient by the providers, nurses, occupational therapists, physical therapists, and pharmacists.

Although the hawk criteria are currently descriptive, "we have developed a model composite score based on preoperative variables, intraoperative happenings, and postoperatively, things that happen in the first 2 hours," Dr. Ravikumar said. Decision support based on the score is essential, he added, "so you know what to do in the next hour for this individual patient."

Dr. Ravikumar said that he had no relevant financial disclosures. Dr. Michota is the medical editor of Hospitalist News, an Elsevier publication.

MIAMI BEACH – Knowing if immunomodulators should be stopped in the perioperative period and when would be helpful for hospitalists, surgeons, other clinicians and, ultimately, for patients.

It is important to balance the concerns of patient optimization for surgery vs. the risk of triggering a recurrent inflammatory cascade or organ rejection during cessation, Dr. Christopher Whinney said at a meeting on perioperative medicine sponsored by the University of Miami.

Although there is a dearth of randomized controlled trials to address immunomodulator cessation around the time of surgery, Dr. Whinney reviewed what evidence is available (mostly observational and/or retrospective studies). He provided specific advice regarding tumor necrosis factor (TNF) alpha inhibitors, corticosteroids, calcineurin inhibitors, antiproliferative agents such as mycophenolate mofetil, and mammalian target of rapamycin inhibitors (mTOR).

There is some controversy regarding continuation of TNF-alpha inhibitors during the perioperative period, for example, said Dr. Whinney, chairman of the department of hospital medicine at the Cleveland Clinic. "Some studies suggest an increased risk for [surgical site] infection and others do not. The literature is heterogenous in this area."

Continuation of TNF-alpha agents in patients with rheumatoid arthritis, for example, was not associated with increased risk of surgical site infections in a retrospective study of 1,219 surgical procedures performed in 768 patients (J. Rheum. 2007;34:689-95). In contrast, other researchers conducted a systematic literature review and determined there is evidence of an increased risk of serious infection with TNF-alpha inhibitor use, in general, among patients with rheumatoid arthritis (JAMA 2006;295:2275-85).

"It’s a judgment call," Dr. Whinney said. "Although the weight of evidence suggests the safety of continuation ... my practice would be to withhold these 2 weeks preoperatively, of course in discussion with the rheumatologist or person prescribing these agents."

Corticosteroid supplementation in the perioperative setting is another question with no definitive answer in the literature. Whether or not to provide high "stress dose" steroids on the morning of surgery to minimize the potential for an adrenal crisis in patients with adrenal insufficiency is a question. The stress of surgery can activate the brain’s hypothalamic-pituitary-adrenal (HPA) axis and trigger a rare but serious adrenal crisis. The thinking is that high-dose steroids will suppress the HPA axis activation and prevent these rare crises.

"Current supplementation is probably excessive. We probably give way too [many] stress dose steroids ... and are probably treating ourselves more than we are treating our patients," Dr. Whinney said.

A Cochrane database review supports this position (Cochrane Database Syst. Rev. 2009;4:CD005367).Dr. Whinney said this review revealed that for patients on basal steroid doses, "it was not possible to refute or support perioperative steroid supplementation."

"For most patients who are on steroids for a reason other than existing HPA axis disease, for most surgeries, their daily steroid regimen is acceptable."

Other researchers recommended an amount of steroid supplementation to administer according to surgery type: superficial, minor, moderate, or major (Semin. Arthritis Rheum. 2007;36:278-86).

Aminosalicylates are another type of immunomodulator relevant in the perioperative period. These anti-inflammatory agents are taken by patients with ulcerative colitis or Crohn’s disease. There are little data on perioperative use of these agents, which include sulfasalazine or 5-aminosalicylate, Dr. Whinney said.

Some researchers suggest holding aminosalicylates on the day of surgery for patients with inflammatory bowel disease who are renally cleared, if they have a diminished glomerular filtration rate (for example, patients older than 65 years, those with ASA physical status score of 4 or 5, and/or patients with a revised cardiac risk index score greater than 2) (Mayo Clin. Proc. 2011;86:748-57). This protocol permits reinitiating aminosalicylates on postoperative day 3.

Patients also might present for surgery taking one of the potent calcineurin inhibitors such as cyclosporine or tacrolimus. Although there is no evidence of increased postoperative complications when these agents are continued perioperatively, continue to watch patients for infection and continue to monitor drug levels, Dr. Whinney said. He also recommended switching patients to an intravenous form if they are NPO (nothing by mouth) for an extended time or are placed on mechanical ventilation for more than 24 hours. It is important to consult a transplant surgeon regarding these agents.

Azathioprine and 6-mercaptopurine are antiproliferative agents often administered for their steroid sparing effects. There have been no consistent effects on surgical outcomes or mortality reported, Dr. Whinney said. However, it is probably reasonable to hold these agents on the day of surgery and resume on the third postoperative day, mostly to avoid any adverse effect on anesthesia. Have a conversation with the prescribing physician, he added, before you stop these agents perioperatively.

Mycophenolate mofetil is another antiproliferative agent. Hepatic and renal testing is appropriate if someone is already on these agents. Although there are little to no data to guide perioperative use, "it can be continued in the perioperative period in absence of infection or liver or renal disease," according to Dr. Whinney.

Sirolimus and everolimus are potent antiproliferative agents in the mTOR inhibitor class. An increased risk for wound complications or wound seromas is a relevant perioperative issue. Obesity and concomitant use of steroids add to this risk. A systematic wound care program can reduce the rate of wound healing complications back to baseline, Dr. Whinney said.

Dr. Whinney recommended stopping sirolimus or everolimus 2-4 weeks prior to major or abdominal surgery to allow clearance of this long half-life agent from the body. Replace the agent with an appropriate calcineurin inhibitor. "Again, if you are unfamiliar with these agents, use them in conjunction with a transplant specialist."

Dr. Whinney is a speaker and consultant for Sanofi Aventis.

MIAMI BEACH – Knowing if immunomodulators should be stopped in the perioperative period and when would be helpful for hospitalists, surgeons, other clinicians and, ultimately, for patients.

It is important to balance the concerns of patient optimization for surgery vs. the risk of triggering a recurrent inflammatory cascade or organ rejection during cessation, Dr. Christopher Whinney said at a meeting on perioperative medicine sponsored by the University of Miami.

Although there is a dearth of randomized controlled trials to address immunomodulator cessation around the time of surgery, Dr. Whinney reviewed what evidence is available (mostly observational and/or retrospective studies). He provided specific advice regarding tumor necrosis factor (TNF) alpha inhibitors, corticosteroids, calcineurin inhibitors, antiproliferative agents such as mycophenolate mofetil, and mammalian target of rapamycin inhibitors (mTOR).

There is some controversy regarding continuation of TNF-alpha inhibitors during the perioperative period, for example, said Dr. Whinney, chairman of the department of hospital medicine at the Cleveland Clinic. "Some studies suggest an increased risk for [surgical site] infection and others do not. The literature is heterogenous in this area."

Continuation of TNF-alpha agents in patients with rheumatoid arthritis, for example, was not associated with increased risk of surgical site infections in a retrospective study of 1,219 surgical procedures performed in 768 patients (J. Rheum. 2007;34:689-95). In contrast, other researchers conducted a systematic literature review and determined there is evidence of an increased risk of serious infection with TNF-alpha inhibitor use, in general, among patients with rheumatoid arthritis (JAMA 2006;295:2275-85).

"It’s a judgment call," Dr. Whinney said. "Although the weight of evidence suggests the safety of continuation ... my practice would be to withhold these 2 weeks preoperatively, of course in discussion with the rheumatologist or person prescribing these agents."

Corticosteroid supplementation in the perioperative setting is another question with no definitive answer in the literature. Whether or not to provide high "stress dose" steroids on the morning of surgery to minimize the potential for an adrenal crisis in patients with adrenal insufficiency is a question. The stress of surgery can activate the brain’s hypothalamic-pituitary-adrenal (HPA) axis and trigger a rare but serious adrenal crisis. The thinking is that high-dose steroids will suppress the HPA axis activation and prevent these rare crises.

"Current supplementation is probably excessive. We probably give way too [many] stress dose steroids ... and are probably treating ourselves more than we are treating our patients," Dr. Whinney said.

A Cochrane database review supports this position (Cochrane Database Syst. Rev. 2009;4:CD005367).Dr. Whinney said this review revealed that for patients on basal steroid doses, "it was not possible to refute or support perioperative steroid supplementation."

"For most patients who are on steroids for a reason other than existing HPA axis disease, for most surgeries, their daily steroid regimen is acceptable."

Other researchers recommended an amount of steroid supplementation to administer according to surgery type: superficial, minor, moderate, or major (Semin. Arthritis Rheum. 2007;36:278-86).

Aminosalicylates are another type of immunomodulator relevant in the perioperative period. These anti-inflammatory agents are taken by patients with ulcerative colitis or Crohn’s disease. There are little data on perioperative use of these agents, which include sulfasalazine or 5-aminosalicylate, Dr. Whinney said.

Some researchers suggest holding aminosalicylates on the day of surgery for patients with inflammatory bowel disease who are renally cleared, if they have a diminished glomerular filtration rate (for example, patients older than 65 years, those with ASA physical status score of 4 or 5, and/or patients with a revised cardiac risk index score greater than 2) (Mayo Clin. Proc. 2011;86:748-57). This protocol permits reinitiating aminosalicylates on postoperative day 3.

Patients also might present for surgery taking one of the potent calcineurin inhibitors such as cyclosporine or tacrolimus. Although there is no evidence of increased postoperative complications when these agents are continued perioperatively, continue to watch patients for infection and continue to monitor drug levels, Dr. Whinney said. He also recommended switching patients to an intravenous form if they are NPO (nothing by mouth) for an extended time or are placed on mechanical ventilation for more than 24 hours. It is important to consult a transplant surgeon regarding these agents.

Azathioprine and 6-mercaptopurine are antiproliferative agents often administered for their steroid sparing effects. There have been no consistent effects on surgical outcomes or mortality reported, Dr. Whinney said. However, it is probably reasonable to hold these agents on the day of surgery and resume on the third postoperative day, mostly to avoid any adverse effect on anesthesia. Have a conversation with the prescribing physician, he added, before you stop these agents perioperatively.

Mycophenolate mofetil is another antiproliferative agent. Hepatic and renal testing is appropriate if someone is already on these agents. Although there are little to no data to guide perioperative use, "it can be continued in the perioperative period in absence of infection or liver or renal disease," according to Dr. Whinney.

Sirolimus and everolimus are potent antiproliferative agents in the mTOR inhibitor class. An increased risk for wound complications or wound seromas is a relevant perioperative issue. Obesity and concomitant use of steroids add to this risk. A systematic wound care program can reduce the rate of wound healing complications back to baseline, Dr. Whinney said.

Dr. Whinney recommended stopping sirolimus or everolimus 2-4 weeks prior to major or abdominal surgery to allow clearance of this long half-life agent from the body. Replace the agent with an appropriate calcineurin inhibitor. "Again, if you are unfamiliar with these agents, use them in conjunction with a transplant specialist."

Dr. Whinney is a speaker and consultant for Sanofi Aventis.

MIAMI BEACH – Knowing if immunomodulators should be stopped in the perioperative period and when would be helpful for hospitalists, surgeons, other clinicians and, ultimately, for patients.

It is important to balance the concerns of patient optimization for surgery vs. the risk of triggering a recurrent inflammatory cascade or organ rejection during cessation, Dr. Christopher Whinney said at a meeting on perioperative medicine sponsored by the University of Miami.

Although there is a dearth of randomized controlled trials to address immunomodulator cessation around the time of surgery, Dr. Whinney reviewed what evidence is available (mostly observational and/or retrospective studies). He provided specific advice regarding tumor necrosis factor (TNF) alpha inhibitors, corticosteroids, calcineurin inhibitors, antiproliferative agents such as mycophenolate mofetil, and mammalian target of rapamycin inhibitors (mTOR).

There is some controversy regarding continuation of TNF-alpha inhibitors during the perioperative period, for example, said Dr. Whinney, chairman of the department of hospital medicine at the Cleveland Clinic. "Some studies suggest an increased risk for [surgical site] infection and others do not. The literature is heterogenous in this area."

Continuation of TNF-alpha agents in patients with rheumatoid arthritis, for example, was not associated with increased risk of surgical site infections in a retrospective study of 1,219 surgical procedures performed in 768 patients (J. Rheum. 2007;34:689-95). In contrast, other researchers conducted a systematic literature review and determined there is evidence of an increased risk of serious infection with TNF-alpha inhibitor use, in general, among patients with rheumatoid arthritis (JAMA 2006;295:2275-85).

"It’s a judgment call," Dr. Whinney said. "Although the weight of evidence suggests the safety of continuation ... my practice would be to withhold these 2 weeks preoperatively, of course in discussion with the rheumatologist or person prescribing these agents."

Corticosteroid supplementation in the perioperative setting is another question with no definitive answer in the literature. Whether or not to provide high "stress dose" steroids on the morning of surgery to minimize the potential for an adrenal crisis in patients with adrenal insufficiency is a question. The stress of surgery can activate the brain’s hypothalamic-pituitary-adrenal (HPA) axis and trigger a rare but serious adrenal crisis. The thinking is that high-dose steroids will suppress the HPA axis activation and prevent these rare crises.

"Current supplementation is probably excessive. We probably give way too [many] stress dose steroids ... and are probably treating ourselves more than we are treating our patients," Dr. Whinney said.

A Cochrane database review supports this position (Cochrane Database Syst. Rev. 2009;4:CD005367).Dr. Whinney said this review revealed that for patients on basal steroid doses, "it was not possible to refute or support perioperative steroid supplementation."

"For most patients who are on steroids for a reason other than existing HPA axis disease, for most surgeries, their daily steroid regimen is acceptable."

Other researchers recommended an amount of steroid supplementation to administer according to surgery type: superficial, minor, moderate, or major (Semin. Arthritis Rheum. 2007;36:278-86).

Aminosalicylates are another type of immunomodulator relevant in the perioperative period. These anti-inflammatory agents are taken by patients with ulcerative colitis or Crohn’s disease. There are little data on perioperative use of these agents, which include sulfasalazine or 5-aminosalicylate, Dr. Whinney said.

Some researchers suggest holding aminosalicylates on the day of surgery for patients with inflammatory bowel disease who are renally cleared, if they have a diminished glomerular filtration rate (for example, patients older than 65 years, those with ASA physical status score of 4 or 5, and/or patients with a revised cardiac risk index score greater than 2) (Mayo Clin. Proc. 2011;86:748-57). This protocol permits reinitiating aminosalicylates on postoperative day 3.

Patients also might present for surgery taking one of the potent calcineurin inhibitors such as cyclosporine or tacrolimus. Although there is no evidence of increased postoperative complications when these agents are continued perioperatively, continue to watch patients for infection and continue to monitor drug levels, Dr. Whinney said. He also recommended switching patients to an intravenous form if they are NPO (nothing by mouth) for an extended time or are placed on mechanical ventilation for more than 24 hours. It is important to consult a transplant surgeon regarding these agents.

Azathioprine and 6-mercaptopurine are antiproliferative agents often administered for their steroid sparing effects. There have been no consistent effects on surgical outcomes or mortality reported, Dr. Whinney said. However, it is probably reasonable to hold these agents on the day of surgery and resume on the third postoperative day, mostly to avoid any adverse effect on anesthesia. Have a conversation with the prescribing physician, he added, before you stop these agents perioperatively.

Mycophenolate mofetil is another antiproliferative agent. Hepatic and renal testing is appropriate if someone is already on these agents. Although there are little to no data to guide perioperative use, "it can be continued in the perioperative period in absence of infection or liver or renal disease," according to Dr. Whinney.

Sirolimus and everolimus are potent antiproliferative agents in the mTOR inhibitor class. An increased risk for wound complications or wound seromas is a relevant perioperative issue. Obesity and concomitant use of steroids add to this risk. A systematic wound care program can reduce the rate of wound healing complications back to baseline, Dr. Whinney said.

Dr. Whinney recommended stopping sirolimus or everolimus 2-4 weeks prior to major or abdominal surgery to allow clearance of this long half-life agent from the body. Replace the agent with an appropriate calcineurin inhibitor. "Again, if you are unfamiliar with these agents, use them in conjunction with a transplant specialist."

Dr. Whinney is a speaker and consultant for Sanofi Aventis.

MIAMI BEACH – Although hospitalists are gaining more and more recognition for shrinking both costs and lengths of stay, one expert says it’s time to promote yourself and your services using with the V word: value.

"Hospitalists have been known over the last 10 to 15 years to be able to decrease the length of stay and decrease the cost of care within the hospital," said Dr. Joseph Ming Wah Li, director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston. "But I’ve never been entirely comfortable with the notion that people view me as the money saver. I would much rather be perceived as a high-value or high-quality provider."

"Consumers in this country don’t want the cheapest care. They want the highest-value care," noted Dr. Li, who is also president of the Society of Hospital Medicine.

"When I meet with hospitalists around the country, I find a lot are confused about what value really means. But it’s pretty simple ... it’s health care quality divided by costs," he said at a meeting on perioperative medicine sponsored by the University of Miami.

It was value that Dr. Li emphasized when National Public Radio (NPR) news asked him to comment on a 2011 study about hospitalists and costs. Compared with inpatients who did not see a hospitalist, the group of Medicare Part A and B recipients cared for by hospitalists during their stay cost the hospitals less ($338 lower hospital charges per patient) and left the hospitals sooner (0.64 days earlier) (Ann. Intern. Med. 2011;155:152-9).

However, there was a catch. "For the 30 days post-hospital, they found that if you were cared for by a hospitalist, you were less likely to have a follow-up visit with your PCP [primary care physician] within 30 days; you were more likely to be discharged to a nursing home or other facility instead of home; you were more likely to be readmitted to the hospital within 30 days; and the cost of care was about $50 higher per admission, but higher than if you were cared for by a PCP," Dr. Li said. "They were essentially saying that hospitalists were just cost-shifting all these costs to the next 30 days."

Dr. Li decided not to criticize the observational design of the study or its use of a billing database, he said, when speaking with NPR. Instead, he explained that with health care reform, hospitalists and other physicians are trying to improve the value of health care in the United States. For example, the researchers found that a lower proportion of patients was discharged home after care from a hospitalist. The researchers pointed to higher costs, for example, of treating patients transferred to a nursing home setting. Dr. Li explained that it could be that patients not seen by hospitalists and discharged directly home did not receive enough care and therefore were more likely to be readmitted.

"This study could have been true, but we know nothing about the quality of care these patients received. Some may have needed to be readmitted," Dr. Li said.

One lesson Dr. Li learned from having been a hospitalist since 1998 is that it is difficult to improve if you do not know what you are doing. In other words, if you want to demonstrate health care value, start with assessment and tracking of performance measures.

As an example, in 2006 there was a question about whether or not the critical care unit at Beth Israel Deaconess had enough beds. Intensivists alerted hospitalists that they were transferring the least-sick patients out of the ICU earlier than they would have otherwise, because they did not have enough beds. Clinicians approached administration and asked them to construct another ICU.

"Property is not [inexpensive] in Boston. It would have cost tens of millions," Dr. Li said.

The administration asked if instead an appropriate way to shorten length of stay in the existing unit could be identified.

The hospitalists, critical care medicine specialists, and other clinicians targeted ventilator-associated pneumonia (VAP), which played a significant role in high utilization of the ICU. In April 2006, 90% or more of ICU patients received some of the VAP prevention measures recommended in the Institute for Healthcare Improvement Bundle.

"We thought we were doing pretty well," Dr. Li said. However, all of the bundle’s five measures are required for it to count. "Our bundle performance score was in the range of 74% to 83%," Dr. Li said. "We would like to think we were providing high-quality care, but at end of the day, one quarter of patients were not getting the very appropriate care that we were supposed to be providing."

A key strategy – formation of a multidisciplinary team – improved performance measures. "This is not a doctor thing. This is a nurse, a respiratory therapist, a pharmacist, and probably with the least amount of involvement, a physician [thing]." He added: "VAP rates dropped. That new ICU was never built. We don’t have a shortage of beds in our ICU."

Ongoing maintenance and feedback are important components of any intervention to improve value of care based on measurable performance outcomes, Dr. Li said. He applauded transparent efforts by Beth Israel Deaconess Medical Center to post their performance measures online. For the first quarter of 2012, the institution reported 97% performance on VAP prevention efforts, exceeding their 90% goal.

Communication and working together in a true multidisciplinary effort are essential. Dr. Li suggested attendees go back to their institutions, choose a patient at random, and open up chart notes written by physicians and compare them to the notes written by nurses. Often you will discover two different accounts written by clinicians working in parallel but with little interdisciplinary communication, he said.

Dr. Li disclosed that he receives honoraria from publishers Elsevier and Wiley. Elsevier is the parent company of this news service. Dr. Li is also a member of the American Board of Internal Medicine Hospital Medicine Maintenance of Certification Test Committee.

MIAMI BEACH – Although hospitalists are gaining more and more recognition for shrinking both costs and lengths of stay, one expert says it’s time to promote yourself and your services using with the V word: value.

"Hospitalists have been known over the last 10 to 15 years to be able to decrease the length of stay and decrease the cost of care within the hospital," said Dr. Joseph Ming Wah Li, director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston. "But I’ve never been entirely comfortable with the notion that people view me as the money saver. I would much rather be perceived as a high-value or high-quality provider."

"Consumers in this country don’t want the cheapest care. They want the highest-value care," noted Dr. Li, who is also president of the Society of Hospital Medicine.

"When I meet with hospitalists around the country, I find a lot are confused about what value really means. But it’s pretty simple ... it’s health care quality divided by costs," he said at a meeting on perioperative medicine sponsored by the University of Miami.

It was value that Dr. Li emphasized when National Public Radio (NPR) news asked him to comment on a 2011 study about hospitalists and costs. Compared with inpatients who did not see a hospitalist, the group of Medicare Part A and B recipients cared for by hospitalists during their stay cost the hospitals less ($338 lower hospital charges per patient) and left the hospitals sooner (0.64 days earlier) (Ann. Intern. Med. 2011;155:152-9).

However, there was a catch. "For the 30 days post-hospital, they found that if you were cared for by a hospitalist, you were less likely to have a follow-up visit with your PCP [primary care physician] within 30 days; you were more likely to be discharged to a nursing home or other facility instead of home; you were more likely to be readmitted to the hospital within 30 days; and the cost of care was about $50 higher per admission, but higher than if you were cared for by a PCP," Dr. Li said. "They were essentially saying that hospitalists were just cost-shifting all these costs to the next 30 days."

Dr. Li decided not to criticize the observational design of the study or its use of a billing database, he said, when speaking with NPR. Instead, he explained that with health care reform, hospitalists and other physicians are trying to improve the value of health care in the United States. For example, the researchers found that a lower proportion of patients was discharged home after care from a hospitalist. The researchers pointed to higher costs, for example, of treating patients transferred to a nursing home setting. Dr. Li explained that it could be that patients not seen by hospitalists and discharged directly home did not receive enough care and therefore were more likely to be readmitted.

"This study could have been true, but we know nothing about the quality of care these patients received. Some may have needed to be readmitted," Dr. Li said.

One lesson Dr. Li learned from having been a hospitalist since 1998 is that it is difficult to improve if you do not know what you are doing. In other words, if you want to demonstrate health care value, start with assessment and tracking of performance measures.

As an example, in 2006 there was a question about whether or not the critical care unit at Beth Israel Deaconess had enough beds. Intensivists alerted hospitalists that they were transferring the least-sick patients out of the ICU earlier than they would have otherwise, because they did not have enough beds. Clinicians approached administration and asked them to construct another ICU.

"Property is not [inexpensive] in Boston. It would have cost tens of millions," Dr. Li said.

The administration asked if instead an appropriate way to shorten length of stay in the existing unit could be identified.

The hospitalists, critical care medicine specialists, and other clinicians targeted ventilator-associated pneumonia (VAP), which played a significant role in high utilization of the ICU. In April 2006, 90% or more of ICU patients received some of the VAP prevention measures recommended in the Institute for Healthcare Improvement Bundle.

"We thought we were doing pretty well," Dr. Li said. However, all of the bundle’s five measures are required for it to count. "Our bundle performance score was in the range of 74% to 83%," Dr. Li said. "We would like to think we were providing high-quality care, but at end of the day, one quarter of patients were not getting the very appropriate care that we were supposed to be providing."

A key strategy – formation of a multidisciplinary team – improved performance measures. "This is not a doctor thing. This is a nurse, a respiratory therapist, a pharmacist, and probably with the least amount of involvement, a physician [thing]." He added: "VAP rates dropped. That new ICU was never built. We don’t have a shortage of beds in our ICU."

Ongoing maintenance and feedback are important components of any intervention to improve value of care based on measurable performance outcomes, Dr. Li said. He applauded transparent efforts by Beth Israel Deaconess Medical Center to post their performance measures online. For the first quarter of 2012, the institution reported 97% performance on VAP prevention efforts, exceeding their 90% goal.

Communication and working together in a true multidisciplinary effort are essential. Dr. Li suggested attendees go back to their institutions, choose a patient at random, and open up chart notes written by physicians and compare them to the notes written by nurses. Often you will discover two different accounts written by clinicians working in parallel but with little interdisciplinary communication, he said.

Dr. Li disclosed that he receives honoraria from publishers Elsevier and Wiley. Elsevier is the parent company of this news service. Dr. Li is also a member of the American Board of Internal Medicine Hospital Medicine Maintenance of Certification Test Committee.

MIAMI BEACH – Although hospitalists are gaining more and more recognition for shrinking both costs and lengths of stay, one expert says it’s time to promote yourself and your services using with the V word: value.

"Hospitalists have been known over the last 10 to 15 years to be able to decrease the length of stay and decrease the cost of care within the hospital," said Dr. Joseph Ming Wah Li, director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center in Boston. "But I’ve never been entirely comfortable with the notion that people view me as the money saver. I would much rather be perceived as a high-value or high-quality provider."

"Consumers in this country don’t want the cheapest care. They want the highest-value care," noted Dr. Li, who is also president of the Society of Hospital Medicine.

"When I meet with hospitalists around the country, I find a lot are confused about what value really means. But it’s pretty simple ... it’s health care quality divided by costs," he said at a meeting on perioperative medicine sponsored by the University of Miami.

It was value that Dr. Li emphasized when National Public Radio (NPR) news asked him to comment on a 2011 study about hospitalists and costs. Compared with inpatients who did not see a hospitalist, the group of Medicare Part A and B recipients cared for by hospitalists during their stay cost the hospitals less ($338 lower hospital charges per patient) and left the hospitals sooner (0.64 days earlier) (Ann. Intern. Med. 2011;155:152-9).

However, there was a catch. "For the 30 days post-hospital, they found that if you were cared for by a hospitalist, you were less likely to have a follow-up visit with your PCP [primary care physician] within 30 days; you were more likely to be discharged to a nursing home or other facility instead of home; you were more likely to be readmitted to the hospital within 30 days; and the cost of care was about $50 higher per admission, but higher than if you were cared for by a PCP," Dr. Li said. "They were essentially saying that hospitalists were just cost-shifting all these costs to the next 30 days."

Dr. Li decided not to criticize the observational design of the study or its use of a billing database, he said, when speaking with NPR. Instead, he explained that with health care reform, hospitalists and other physicians are trying to improve the value of health care in the United States. For example, the researchers found that a lower proportion of patients was discharged home after care from a hospitalist. The researchers pointed to higher costs, for example, of treating patients transferred to a nursing home setting. Dr. Li explained that it could be that patients not seen by hospitalists and discharged directly home did not receive enough care and therefore were more likely to be readmitted.

"This study could have been true, but we know nothing about the quality of care these patients received. Some may have needed to be readmitted," Dr. Li said.

One lesson Dr. Li learned from having been a hospitalist since 1998 is that it is difficult to improve if you do not know what you are doing. In other words, if you want to demonstrate health care value, start with assessment and tracking of performance measures.

As an example, in 2006 there was a question about whether or not the critical care unit at Beth Israel Deaconess had enough beds. Intensivists alerted hospitalists that they were transferring the least-sick patients out of the ICU earlier than they would have otherwise, because they did not have enough beds. Clinicians approached administration and asked them to construct another ICU.

"Property is not [inexpensive] in Boston. It would have cost tens of millions," Dr. Li said.

The administration asked if instead an appropriate way to shorten length of stay in the existing unit could be identified.

The hospitalists, critical care medicine specialists, and other clinicians targeted ventilator-associated pneumonia (VAP), which played a significant role in high utilization of the ICU. In April 2006, 90% or more of ICU patients received some of the VAP prevention measures recommended in the Institute for Healthcare Improvement Bundle.

"We thought we were doing pretty well," Dr. Li said. However, all of the bundle’s five measures are required for it to count. "Our bundle performance score was in the range of 74% to 83%," Dr. Li said. "We would like to think we were providing high-quality care, but at end of the day, one quarter of patients were not getting the very appropriate care that we were supposed to be providing."

A key strategy – formation of a multidisciplinary team – improved performance measures. "This is not a doctor thing. This is a nurse, a respiratory therapist, a pharmacist, and probably with the least amount of involvement, a physician [thing]." He added: "VAP rates dropped. That new ICU was never built. We don’t have a shortage of beds in our ICU."

Ongoing maintenance and feedback are important components of any intervention to improve value of care based on measurable performance outcomes, Dr. Li said. He applauded transparent efforts by Beth Israel Deaconess Medical Center to post their performance measures online. For the first quarter of 2012, the institution reported 97% performance on VAP prevention efforts, exceeding their 90% goal.

Communication and working together in a true multidisciplinary effort are essential. Dr. Li suggested attendees go back to their institutions, choose a patient at random, and open up chart notes written by physicians and compare them to the notes written by nurses. Often you will discover two different accounts written by clinicians working in parallel but with little interdisciplinary communication, he said.

Dr. Li disclosed that he receives honoraria from publishers Elsevier and Wiley. Elsevier is the parent company of this news service. Dr. Li is also a member of the American Board of Internal Medicine Hospital Medicine Maintenance of Certification Test Committee.