This presentation was a playful banter between two experts—Steven Cohn of Miller School of Medicine in Miami and Lenny Feldman of Johns Hopkins in Baltimore—who showed us the evidence (and lack thereof) for several perioperative matters.
Issue No. 1: Timing of non-cardiac surgery after cardiac stent placement. The AHA/ACC guidelines suggest waiting 12 months after placement of a drug-eluting stent and 30-45 days for bare -metal stents. The speakers suggested that, based on limited data, waiting only 6 months might be sufficient time for patients to undergo non cardiac surgery. They were in support of the 30-45 day waiting period for bare-metal stents.
Issue No. 2: Care approach for hip fracture patients. Current models include admission to the hospitalist or orthopaedic service, with varying thresholds for medical consultations and subsequent follow ups. Other systems utilize true comanagement models. Experience suggests higher satisfaction from nurses and surgeons when patients are comanaged by hospitalists, but do we as a specialty have enough resources in terms of manpower to be involved in comanaging all ortho and other surgical patients? Is it professionally satisfying for hospitalists to comanage and, ultimately, how are patient outcomes impacted when patients are comanaged by hospitalists?
Dr. Cohn suggested there is limited benefit in hospitalist comanagement of low-risk, straightforward cases. There is data suggesting decrease in time to surgery, decrease in uti,DVT, and pressure ulcers with medical comanagement.
Issue No. 3: Routine, post-operative troponin monitoring for silent myocardial infarcts. Data showed 65% of patients with post-op MIs will not have symptoms. They may have a troponin leak or ECG changes. The controversy is that even if we detect a post-op MI, there is no good data that any interventions (eg, aspirin and statins, transferring to CCU or telemetry, performing cardiac catherization) would improve the patient mortality. There is data that shows the higher the troponin leak in post-operative patients, the higher the mortality except in low risk patients.
Issue No. 4: Preoperative dosing of glargine insulin. There are no guidelines in the U.S. In the U.K., the National Health Services recommends continuing glargine at 100%, which is what Dr. Cohn recommends for patients with sugars greater than 120 and without kidney disease. Dr. Lenny Feldman was more inclined to reduce the glargine dosing for patients, taking it the night before or the morning of surgery. Reduction could be anywhere from 50% to 80% of the patient's usual dose. Certainly it is more safe to deal with hyperglycemia than it is to deal with hypoglycemia. However, we need to be mindful still of the complications associated with perioperative hypergylcemia. Ultimately, the dosing needs to be individualized and we can find the right balance to minimize both hypo and hyperglycemia in the perioperative period.
Dr. Ma is a member of Team Hospitalist.