Steven Cohn, MD, FACP, SFHM; Leonard Feldman, MD, FAAP, FACP, SFHM; Amir Jaffer, MD, MBA, SFHM; Franklin Michota, MD, FHM; Kurt Pfeifer, MD, FACP; Barbara Slawski, MD, MS, FACP
In a session at HM14, a panel of physicians led a discussion about hospitalists’ role in perioperative care. Hospitalists are increasingly asked to take on co-management roles for surgical patients. Controversies remain around a number of topics in perioperative care; it is important to separate evidence-based care from “best practice” and develop standardized approaches to perioperative care in all facilities.
- Invoke the “platinum rule” as a medical consultant: treat others as they wish to be treated. Surgeons’ preferences differ from the traditional teaching regarding “rules of medical consulting.” Examples of surgeon preferences as opposed to traditional teaching: consultants should not limit themselves to specific question(s), just take care of the patient’s non-surgical issues; DO write orders in the chart [which] facilitates care; co-management relationship is desired; literature references placed in chart are NOT helpful; daily progress notes and follow-up is desired regardless of patient acuity; verbal discussion of recommendations not always necessary.
- Do not always defer to the surgeon, speak up for the best interest of the patient. If it is not in the patient’s best interest to go to surgery “@ 0700 in a.m.” then say so. Surgeons want us to speak up.
- Principles of perioperative medication management: most mediations can be safely be continued, many need not be continued. Certain medications are essential (cardiac, pulmonary, steroids) but not necessarily on the morning of surgery; some medications require discontinuation or dose adjustment (hypoglycemics, anticoagulants/antiplatelets).
- Perioperative lab testing: cataract surgery is low-risk surgery; laboratory testing NOT required. Base preoperative lab testing on patient risk factors (targeted H&P) and surgical risk factors (low risk/ambulatory surgeries generally do not require testing; consider testing in surgeries with anticipated blood loss). Develop local guidelines to standardize approach to preoperative lab evaluations at each facility/system.
- Sources for two cardiac risk calculators: www.surgicalriskcalculator.com/miorcardiacarrestriskcalculator.facs.org.
- Periop pulmonary risk assessment: NSQIP Respiratory Failure Index calculator can be found @ www.surgicalriskcalculator.com. Never tell the anesthesiologist what mode of anesthesia to deliver (GETA, regional, neuraxial). ALL surgical patients should use incentive spirometry.
- VTE prophylaxis: VTE prevention is a consequential safety and quality measure, ALL facilities should have a standardized approach to VTE prophylaxis. Surgical patients should be risk-stratified and prophylaxed, weighing risks (VTE and major bleeding). Extended prophylaxis should be used for high-risk cancer and major orthopedic surgery patients.
- Perioperative management of warfarin: INR < 1.2 is achieved by holding warfarin for four doses. Discussion of perioperative anticoagulation strategy with patient, anesthesiologist, and surgeon is critical. Patients on antithrombotic therapy require an individualized custom-tailored approach.
- Perioperative anemia: reserve transfusion for symptoms attributable to anemia, Hgb <7-8 g/dl for hospitalized patients or <8 g/dl in patients with CV disease.
- Post-op fever: atelectasis does NOT cause fever, anesthetics and tissue trauma causing release of pyrogenic cytokines DO cause fever (first 48 hours post-op).
- Visit SHMconsult.com
Julianna Lindsey, MD, MBA, FHM, is Principal COO & Strategist for Synergy Surgicalists and a member of Team Hospitalist.