Clinical Advice for Peri-Operative Patient Care
EDITOR’S NOTE: First in a series of reviews of the “Hospital Medicine: Current Concepts” series by members of Team Hospitalist.
According to the Advisory Board projections of inpatient service line volume through 2017, most service lines will experience a decrease. Those that are projected to increase include neurosurgery, vascular surgery, orthopedic surgery, and general surgery. It seems clear that the need for hospital medicine to engage in the care of the surgical patient is sure to grow.
That makes the publication of this book so prescient. As one in a series titled Hospital Medicine: Current Concepts, edited by Scott Flanders, MD, MHM, and Sanjay Saint, MD, MPH, this is a valuable contribution to hospitalist leaders, policymakers, and anyone routinely caring for the peri-operative patient.
Part one focuses on systems of care. The authors articulate the essential elements of developing a consultation service, a clinic, and a co-management program. Eric Siegal, MD, FHM, authors the second chapter, clearly delineating the important differences between a co-management program and a consultation program. He provides the reader with pearls as well as potential pitfalls.
The first eight chapters of this book will have a long shelf life; they deliver sound advice on quality and practice management in the peri-operative arena. Identifying elements of a successful program, engaging key stakeholders, and managing medications are all skills a hospitalist needs and will not change anytime soon. Anyone planning to build a consultation or co-management service will be well served by the guidance in part one.
The next three parts explore the assessment and management of various risks, post-operative care, and post-operative conditions. Although written by a veritable who’s who of hospital medicine and peri-operative medicine giants, some parts of these sections fall prey to the rapidly changing world of clinical care. For example, Chapter 9 provides a great review of the history of developing cardiac risk assessment tools for the patient undergoing noncardiac surgery. The chapter also reviews strategies to mitigate risk; however, it falls short by failing to discuss the Gupta risk score, which was developed over 200,000 cases, compared with about 4,000 for the revised cardiac risk index. That omission is likely a result of publication timing. Although the chapter does not call out the recent implications of scientific misconduct related to the Dutch peri-operative beta blocker trials, the authors’ conclusions on the use of beta blockers remains appropriate and could have been more timely if it had included a recent meta-analysis omitting the Dutch data.
Similarly, Chapter 10 provides an excellent review of the etiology and burden of peri-operative pulmonary complications. Relatively recent literature that updates previous guidelines, indicating the benefits of respiratory muscle training, is included; however, the recently completed IMPROVE trial was likely published too late for inclusion in this chapter. Thus the benefits of a low tidal volume/lung protective strategy in those at intermediate to high risk could be missed. Still, the clinical foundation provided by the chapters in parts two through four fill the void most of us experienced in training—namely, not learning how to care for the peri-operative patient.
Special sections on the bariatric and neurosurgical patient will be welcomed by those of us never trained in the care of such conditions.
Key Takeaways
As hospitalists become increasingly important in the care of surgical patients, this book will provide an excellent foundation for critical peri-operative concepts and tools.
The authors include specific recommendations that will help in the management of almost every surgical patient encountered. For example, the anticoagulation and glycemic control strategies are well written, as well as easy to understand and apply.
