Perioperative Medicine

DENVER — Open abdominal aortic surgery had an 11.4% rate of in-hospital postoperative infectious complications—the highest incidence for any type of elective vascular surgery—in a large national study.

This national rate will strike many surgeons as being higher than the rates they have experienced, but that's because it includes postoperative urinary tract infections, pneumonia, and sepsis, as well as the surgical site infections surgeons tend to focus on, Dr. Todd R. Vogel said at the Vascular Annual Meeting.

The study underscored the major economic consequences of infectious complications arising after elective vascular surgery. Hospital charges for affected patients were more than three times as great as those of patients without such complications, noted Dr. Vogel of the Robert Wood Johnson Medical School, New Brunswick, N.J.

He presented an analysis of 870,778 elective vascular surgical procedures performed in adults at U.S. hospitals during 2002–2006. The data came from the Nationwide Inpatient Sample of the Agency for Healthcare Research and Quality.

The overall in-hospital postoperative infectious complication rate was 3.7%. The rate, adjusted for age, gender, race, and comorbid conditions, varied widely by procedure type, with the 1.7% incidence associated with carotid endarterectomy being lowest.

The study showed that the 11.4% infectious complication rate for open abdominal aortic surgery was substantially higher than for aorta-iliac-femoral bypass surgery (8.9%), and the rate for thoracic endovascular aneurysm repair (5.7%) was twice that of endovascular abdominal aneurysm repair (2.8%), Dr. Vogel noted.

Pneumonia, which occurred in 6.6% of patients following open abdominal aortic surgery, was the most common infectious complication associated with that procedure. In contrast, urinary tract infection was the most common infectious complication after thoracic endovascular aneurysm repair and endovascular abdominal aneurysm repair, affecting 2.9% and 1.3% of patients, respectively.

Infectious complications following elective vascular surgery were significantly more common in women than in men, in blacks versus white or Hispanic patients, and in octogenarians versus younger individuals. Rates were higher at urban hospitals, large medical centers, and—contrary to conventional wisdom—teaching hospitals.

Mean hospital length of stay was 13.8 days in patients with infectious complications and 3.5 days in those without. Hospital charges averaged $37,834 in those who experienced such complications, compared with $11,851 in patients who did not.

Several audience members raised the possibility of coding errors in this huge national database, but Dr. Vogel minimized the likely impact of any such mistakes. “If you look globally at the infectious complication rates, you can see there's a problem in terms of race, a problem for women; and there's a problem in terms of the rate for open aortic aneurysm surgery,” he said.

Dr. Ronald M. Fairman, an audience member, noted that the Nationwide Inpatient Sample doesn't track readmissions. As a result, a patient undergoing femoral-popliteal bypass or another typically short-stay operation could develop an infectious complication requiring readmission soon after discharge, yet it wouldn't be listed as a postop infectious complication.

“So your figures could actually be an underestimate of the true infection rate,” said Dr. Fairman, professor and chief of vascular surgery at the University of Pennsylvania, Philadelphia.

DENVER — Open abdominal aortic surgery had an 11.4% rate of in-hospital postoperative infectious complications—the highest incidence for any type of elective vascular surgery—in a large national study.

This national rate will strike many surgeons as being higher than the rates they have experienced, but that's because it includes postoperative urinary tract infections, pneumonia, and sepsis, as well as the surgical site infections surgeons tend to focus on, Dr. Todd R. Vogel said at the Vascular Annual Meeting.

The study underscored the major economic consequences of infectious complications arising after elective vascular surgery. Hospital charges for affected patients were more than three times as great as those of patients without such complications, noted Dr. Vogel of the Robert Wood Johnson Medical School, New Brunswick, N.J.

He presented an analysis of 870,778 elective vascular surgical procedures performed in adults at U.S. hospitals during 2002–2006. The data came from the Nationwide Inpatient Sample of the Agency for Healthcare Research and Quality.

The overall in-hospital postoperative infectious complication rate was 3.7%. The rate, adjusted for age, gender, race, and comorbid conditions, varied widely by procedure type, with the 1.7% incidence associated with carotid endarterectomy being lowest.

The study showed that the 11.4% infectious complication rate for open abdominal aortic surgery was substantially higher than for aorta-iliac-femoral bypass surgery (8.9%), and the rate for thoracic endovascular aneurysm repair (5.7%) was twice that of endovascular abdominal aneurysm repair (2.8%), Dr. Vogel noted.

Pneumonia, which occurred in 6.6% of patients following open abdominal aortic surgery, was the most common infectious complication associated with that procedure. In contrast, urinary tract infection was the most common infectious complication after thoracic endovascular aneurysm repair and endovascular abdominal aneurysm repair, affecting 2.9% and 1.3% of patients, respectively.

Infectious complications following elective vascular surgery were significantly more common in women than in men, in blacks versus white or Hispanic patients, and in octogenarians versus younger individuals. Rates were higher at urban hospitals, large medical centers, and—contrary to conventional wisdom—teaching hospitals.

Mean hospital length of stay was 13.8 days in patients with infectious complications and 3.5 days in those without. Hospital charges averaged $37,834 in those who experienced such complications, compared with $11,851 in patients who did not.

Several audience members raised the possibility of coding errors in this huge national database, but Dr. Vogel minimized the likely impact of any such mistakes. “If you look globally at the infectious complication rates, you can see there's a problem in terms of race, a problem for women; and there's a problem in terms of the rate for open aortic aneurysm surgery,” he said.

Dr. Ronald M. Fairman, an audience member, noted that the Nationwide Inpatient Sample doesn't track readmissions. As a result, a patient undergoing femoral-popliteal bypass or another typically short-stay operation could develop an infectious complication requiring readmission soon after discharge, yet it wouldn't be listed as a postop infectious complication.

“So your figures could actually be an underestimate of the true infection rate,” said Dr. Fairman, professor and chief of vascular surgery at the University of Pennsylvania, Philadelphia.

DENVER — Open abdominal aortic surgery had an 11.4% rate of in-hospital postoperative infectious complications—the highest incidence for any type of elective vascular surgery—in a large national study.

This national rate will strike many surgeons as being higher than the rates they have experienced, but that's because it includes postoperative urinary tract infections, pneumonia, and sepsis, as well as the surgical site infections surgeons tend to focus on, Dr. Todd R. Vogel said at the Vascular Annual Meeting.

The study underscored the major economic consequences of infectious complications arising after elective vascular surgery. Hospital charges for affected patients were more than three times as great as those of patients without such complications, noted Dr. Vogel of the Robert Wood Johnson Medical School, New Brunswick, N.J.

He presented an analysis of 870,778 elective vascular surgical procedures performed in adults at U.S. hospitals during 2002–2006. The data came from the Nationwide Inpatient Sample of the Agency for Healthcare Research and Quality.

The overall in-hospital postoperative infectious complication rate was 3.7%. The rate, adjusted for age, gender, race, and comorbid conditions, varied widely by procedure type, with the 1.7% incidence associated with carotid endarterectomy being lowest.

The study showed that the 11.4% infectious complication rate for open abdominal aortic surgery was substantially higher than for aorta-iliac-femoral bypass surgery (8.9%), and the rate for thoracic endovascular aneurysm repair (5.7%) was twice that of endovascular abdominal aneurysm repair (2.8%), Dr. Vogel noted.

Pneumonia, which occurred in 6.6% of patients following open abdominal aortic surgery, was the most common infectious complication associated with that procedure. In contrast, urinary tract infection was the most common infectious complication after thoracic endovascular aneurysm repair and endovascular abdominal aneurysm repair, affecting 2.9% and 1.3% of patients, respectively.

Infectious complications following elective vascular surgery were significantly more common in women than in men, in blacks versus white or Hispanic patients, and in octogenarians versus younger individuals. Rates were higher at urban hospitals, large medical centers, and—contrary to conventional wisdom—teaching hospitals.

Mean hospital length of stay was 13.8 days in patients with infectious complications and 3.5 days in those without. Hospital charges averaged $37,834 in those who experienced such complications, compared with $11,851 in patients who did not.

Several audience members raised the possibility of coding errors in this huge national database, but Dr. Vogel minimized the likely impact of any such mistakes. “If you look globally at the infectious complication rates, you can see there's a problem in terms of race, a problem for women; and there's a problem in terms of the rate for open aortic aneurysm surgery,” he said.

Dr. Ronald M. Fairman, an audience member, noted that the Nationwide Inpatient Sample doesn't track readmissions. As a result, a patient undergoing femoral-popliteal bypass or another typically short-stay operation could develop an infectious complication requiring readmission soon after discharge, yet it wouldn't be listed as a postop infectious complication.

“So your figures could actually be an underestimate of the true infection rate,” said Dr. Fairman, professor and chief of vascular surgery at the University of Pennsylvania, Philadelphia.

BERLIN — Rivaroxaban, an investigational oral anticoagulant, significantly cut the combined rate of symptomatic venous thromboembolism and death, compared with enoxaparin, in orthopedic surgery patients in an analysis of four trials involving more than 12,000 patients.

Rivaroxaban produced this and other efficacy benefits vs. enoxaparin without causing a significant increase in most bleeding measures, Dr. Sylvia Haas said at the annual congress of the European Hematology Association.

The RECORD (Regulation of Coagulation in Orthopedic Surgery to Prevent Deep Vein Thrombosis and Pulmonary Embolism) trials 1-4 included two studies that enrolled patients following hip surgery, and two that enrolled knee surgery patients (N. Engl. J. Med. 2008;358:2765-75; 2776-86; Lancet 2008;372:31-9; 2009;373:1673-80).

Based on the evidence in these four studies with 6,000 orthopedic surgery patients treated with rivaroxaban, the Cardiovascular and Renal Drugs Advisory Committee of the Food and Drug Administration voted 15-2 in favor of approving the drug for this indication. Ortho-McNeil, which is developing the drug with Bayer, later announced that the FDA sent the company additional questions about the application, but did not ask for any new studies. In countries where it has been approved, rivaroxaban has been marketed as Xarelto.

Dr. Haas, a hematologist and professor of medicine at the Technical University of Munich, said she is a consultant to Bayer Schering Pharma, and is a consultant to, or serves on data and safety monitoring boards for, other drug companies.

A direct inhibitor of coagulation factor Xa, rivaroxaban has high oral bioavailability, rapid onset of action, a 5- to 9-hour half-life, and—importantly—a predictable anticoagulant effect that, unlike warfarin, requires no monitoring.

The primary outcome of the combined analysis was the incidence of symptomatic venous thromboembolism (VTE) and all-cause death during active treatment. This occurred in 0.6% of 6,183 patients on rivaroxaban and 1.3% of 6,200 patients on enoxaparin, a 58% relative risk reduction with rivaroxaban.

Rivaroxaban was significantly better than enoxaparin on a composite of death, MI, stroke, symptomatic VTE, and major bleeds. The composite occurred 96 times in the rivaroxaban patients and 139 times among those on enoxaparin, a 31% relative risk reduction with rivaroxaban.

Although patients on rivaroxaban had more major bleeds, surgical-site bleeds, and clinically relevant nonmajor bleeds, most of these categories showed no significant difference between the rivaroxaban and enoxaparin subgroups. The only exception was the combination of major bleeds and clinically relevant nonmajor bleeds, which occurred in 2.55% of patients on enoxaparin and 3.19% of those not on the drug. (See box.)

ELSEVIER GLOBAL MEDICAL NEWS

BERLIN — Rivaroxaban, an investigational oral anticoagulant, significantly cut the combined rate of symptomatic venous thromboembolism and death, compared with enoxaparin, in orthopedic surgery patients in an analysis of four trials involving more than 12,000 patients.

Rivaroxaban produced this and other efficacy benefits vs. enoxaparin without causing a significant increase in most bleeding measures, Dr. Sylvia Haas said at the annual congress of the European Hematology Association.

The RECORD (Regulation of Coagulation in Orthopedic Surgery to Prevent Deep Vein Thrombosis and Pulmonary Embolism) trials 1-4 included two studies that enrolled patients following hip surgery, and two that enrolled knee surgery patients (N. Engl. J. Med. 2008;358:2765-75; 2776-86; Lancet 2008;372:31-9; 2009;373:1673-80).

Based on the evidence in these four studies with 6,000 orthopedic surgery patients treated with rivaroxaban, the Cardiovascular and Renal Drugs Advisory Committee of the Food and Drug Administration voted 15-2 in favor of approving the drug for this indication. Ortho-McNeil, which is developing the drug with Bayer, later announced that the FDA sent the company additional questions about the application, but did not ask for any new studies. In countries where it has been approved, rivaroxaban has been marketed as Xarelto.

Dr. Haas, a hematologist and professor of medicine at the Technical University of Munich, said she is a consultant to Bayer Schering Pharma, and is a consultant to, or serves on data and safety monitoring boards for, other drug companies.

A direct inhibitor of coagulation factor Xa, rivaroxaban has high oral bioavailability, rapid onset of action, a 5- to 9-hour half-life, and—importantly—a predictable anticoagulant effect that, unlike warfarin, requires no monitoring.

The primary outcome of the combined analysis was the incidence of symptomatic venous thromboembolism (VTE) and all-cause death during active treatment. This occurred in 0.6% of 6,183 patients on rivaroxaban and 1.3% of 6,200 patients on enoxaparin, a 58% relative risk reduction with rivaroxaban.

Rivaroxaban was significantly better than enoxaparin on a composite of death, MI, stroke, symptomatic VTE, and major bleeds. The composite occurred 96 times in the rivaroxaban patients and 139 times among those on enoxaparin, a 31% relative risk reduction with rivaroxaban.

Although patients on rivaroxaban had more major bleeds, surgical-site bleeds, and clinically relevant nonmajor bleeds, most of these categories showed no significant difference between the rivaroxaban and enoxaparin subgroups. The only exception was the combination of major bleeds and clinically relevant nonmajor bleeds, which occurred in 2.55% of patients on enoxaparin and 3.19% of those not on the drug. (See box.)

ELSEVIER GLOBAL MEDICAL NEWS

BERLIN — Rivaroxaban, an investigational oral anticoagulant, significantly cut the combined rate of symptomatic venous thromboembolism and death, compared with enoxaparin, in orthopedic surgery patients in an analysis of four trials involving more than 12,000 patients.

Rivaroxaban produced this and other efficacy benefits vs. enoxaparin without causing a significant increase in most bleeding measures, Dr. Sylvia Haas said at the annual congress of the European Hematology Association.

The RECORD (Regulation of Coagulation in Orthopedic Surgery to Prevent Deep Vein Thrombosis and Pulmonary Embolism) trials 1-4 included two studies that enrolled patients following hip surgery, and two that enrolled knee surgery patients (N. Engl. J. Med. 2008;358:2765-75; 2776-86; Lancet 2008;372:31-9; 2009;373:1673-80).

Based on the evidence in these four studies with 6,000 orthopedic surgery patients treated with rivaroxaban, the Cardiovascular and Renal Drugs Advisory Committee of the Food and Drug Administration voted 15-2 in favor of approving the drug for this indication. Ortho-McNeil, which is developing the drug with Bayer, later announced that the FDA sent the company additional questions about the application, but did not ask for any new studies. In countries where it has been approved, rivaroxaban has been marketed as Xarelto.

Dr. Haas, a hematologist and professor of medicine at the Technical University of Munich, said she is a consultant to Bayer Schering Pharma, and is a consultant to, or serves on data and safety monitoring boards for, other drug companies.

A direct inhibitor of coagulation factor Xa, rivaroxaban has high oral bioavailability, rapid onset of action, a 5- to 9-hour half-life, and—importantly—a predictable anticoagulant effect that, unlike warfarin, requires no monitoring.

The primary outcome of the combined analysis was the incidence of symptomatic venous thromboembolism (VTE) and all-cause death during active treatment. This occurred in 0.6% of 6,183 patients on rivaroxaban and 1.3% of 6,200 patients on enoxaparin, a 58% relative risk reduction with rivaroxaban.

Rivaroxaban was significantly better than enoxaparin on a composite of death, MI, stroke, symptomatic VTE, and major bleeds. The composite occurred 96 times in the rivaroxaban patients and 139 times among those on enoxaparin, a 31% relative risk reduction with rivaroxaban.

Although patients on rivaroxaban had more major bleeds, surgical-site bleeds, and clinically relevant nonmajor bleeds, most of these categories showed no significant difference between the rivaroxaban and enoxaparin subgroups. The only exception was the combination of major bleeds and clinically relevant nonmajor bleeds, which occurred in 2.55% of patients on enoxaparin and 3.19% of those not on the drug. (See box.)

ELSEVIER GLOBAL MEDICAL NEWS

Hyperglycemia prior to, and shortly after, initiation of total parenteral nutrition was strongly associated with poor clinical outcomes in critically ill hospitalized patients, whether they had a history of diabetes or not, Emory University researchers determined in a retrospective study.

Patients had an almost threefold risk of dying if their maximum blood glucose before or within 24 hours of starting total parenteral nutrition (TPN) was above 180 mg/dL, compared with those whose levels stayed below 120 mg/dL. Many other factors were taken into account for the statistical analysis, including age, sex, and diabetes status, Dr. Guillermo E. Umpierrez, professor of medicine at Emory University, Atlanta, said at the Southern regional meeting of the American Federation for Medical Research.

Although hyperglycemia is a common complication of TPN, its prevalence and impact on clinical outcomes have been uncertain. Dr. Umpierrez and his associates reviewed the records of 276 medical/surgery patients who required TPN a mean 11 days after admission. Most came from surgical or medical intensive care units or the burn unit, but nearly 25% came from non-ICU floors. Also, 23% had a history of diabetes. Patients received TPN for a mean duration of 15 days. In-hospital mortality was 27% in the study, funded by the American Diabetes Association and the National Institutes of Health.

Patients who died had a higher maximum blood glucose before TPN (mean 147 mg/dL) than those who survived (mean 131 mg/dL), as well as a higher maximum blood glucose within 24 hours of TPN initiation (mean 202 mg/dL vs. 160 mg/dL). The differences in blood glucose were highly statistically significant.

In a multivariate analysis, the risk of pneumonia and the risk of acute renal failure were independently related to maximum blood glucose above 180 mg/dL vs. below 120 mg/dL.

In a later interview, Dr. Umpierrez said that pre-TPN blood glucose levels could alert medical teams to the possibility of TPN-related hyperglycemia. “Hospitalists should pay attention to blood glucose levels, not only in those receiving TPN but in patients with hyperglycemia before TPN,” he said. “Frequent blood glucose monitoring is needed to prevent and/or correct hyperglycemia.”

At his institution, the findings prompted a change in protocol to initiate insulin infusion as TPN is begun or to start insulin infusion in patients on TPN whose blood glucose is “persistently elevated,” which he defined as a level over 140 mg/dL.

Hyperglycemia prior to, and shortly after, initiation of total parenteral nutrition was strongly associated with poor clinical outcomes in critically ill hospitalized patients, whether they had a history of diabetes or not, Emory University researchers determined in a retrospective study.

Patients had an almost threefold risk of dying if their maximum blood glucose before or within 24 hours of starting total parenteral nutrition (TPN) was above 180 mg/dL, compared with those whose levels stayed below 120 mg/dL. Many other factors were taken into account for the statistical analysis, including age, sex, and diabetes status, Dr. Guillermo E. Umpierrez, professor of medicine at Emory University, Atlanta, said at the Southern regional meeting of the American Federation for Medical Research.

Although hyperglycemia is a common complication of TPN, its prevalence and impact on clinical outcomes have been uncertain. Dr. Umpierrez and his associates reviewed the records of 276 medical/surgery patients who required TPN a mean 11 days after admission. Most came from surgical or medical intensive care units or the burn unit, but nearly 25% came from non-ICU floors. Also, 23% had a history of diabetes. Patients received TPN for a mean duration of 15 days. In-hospital mortality was 27% in the study, funded by the American Diabetes Association and the National Institutes of Health.

Patients who died had a higher maximum blood glucose before TPN (mean 147 mg/dL) than those who survived (mean 131 mg/dL), as well as a higher maximum blood glucose within 24 hours of TPN initiation (mean 202 mg/dL vs. 160 mg/dL). The differences in blood glucose were highly statistically significant.

In a multivariate analysis, the risk of pneumonia and the risk of acute renal failure were independently related to maximum blood glucose above 180 mg/dL vs. below 120 mg/dL.

In a later interview, Dr. Umpierrez said that pre-TPN blood glucose levels could alert medical teams to the possibility of TPN-related hyperglycemia. “Hospitalists should pay attention to blood glucose levels, not only in those receiving TPN but in patients with hyperglycemia before TPN,” he said. “Frequent blood glucose monitoring is needed to prevent and/or correct hyperglycemia.”

At his institution, the findings prompted a change in protocol to initiate insulin infusion as TPN is begun or to start insulin infusion in patients on TPN whose blood glucose is “persistently elevated,” which he defined as a level over 140 mg/dL.

Hyperglycemia prior to, and shortly after, initiation of total parenteral nutrition was strongly associated with poor clinical outcomes in critically ill hospitalized patients, whether they had a history of diabetes or not, Emory University researchers determined in a retrospective study.

Patients had an almost threefold risk of dying if their maximum blood glucose before or within 24 hours of starting total parenteral nutrition (TPN) was above 180 mg/dL, compared with those whose levels stayed below 120 mg/dL. Many other factors were taken into account for the statistical analysis, including age, sex, and diabetes status, Dr. Guillermo E. Umpierrez, professor of medicine at Emory University, Atlanta, said at the Southern regional meeting of the American Federation for Medical Research.

Although hyperglycemia is a common complication of TPN, its prevalence and impact on clinical outcomes have been uncertain. Dr. Umpierrez and his associates reviewed the records of 276 medical/surgery patients who required TPN a mean 11 days after admission. Most came from surgical or medical intensive care units or the burn unit, but nearly 25% came from non-ICU floors. Also, 23% had a history of diabetes. Patients received TPN for a mean duration of 15 days. In-hospital mortality was 27% in the study, funded by the American Diabetes Association and the National Institutes of Health.

Patients who died had a higher maximum blood glucose before TPN (mean 147 mg/dL) than those who survived (mean 131 mg/dL), as well as a higher maximum blood glucose within 24 hours of TPN initiation (mean 202 mg/dL vs. 160 mg/dL). The differences in blood glucose were highly statistically significant.

In a multivariate analysis, the risk of pneumonia and the risk of acute renal failure were independently related to maximum blood glucose above 180 mg/dL vs. below 120 mg/dL.

In a later interview, Dr. Umpierrez said that pre-TPN blood glucose levels could alert medical teams to the possibility of TPN-related hyperglycemia. “Hospitalists should pay attention to blood glucose levels, not only in those receiving TPN but in patients with hyperglycemia before TPN,” he said. “Frequent blood glucose monitoring is needed to prevent and/or correct hyperglycemia.”

At his institution, the findings prompted a change in protocol to initiate insulin infusion as TPN is begun or to start insulin infusion in patients on TPN whose blood glucose is “persistently elevated,” which he defined as a level over 140 mg/dL.

MIAMI BEACH — When performing a preoperative assessment of the patient with liver disease, consider specific risk factors during the history and physical examination, said Dr. Paul Martin at a meeting on perioperative medicine sponsored by the University of Miami.

Also assess the likelihood of renal insufficiency and portal hypertension, two of the most concerning perioperative developments.

“Assessing liver patients for surgery is one of the most common consults we get in the hospital,” said Dr. Martin, professor of medicine and chief of hepatology at the University of Miami.

Taking a careful history is essential. “You really want to know if the patient has ever had variceal hemorrhage, ascites, encephalopathy, or jaundice,” Dr. Martin said. Also, if the patient has a relevant surgical history, ask: What did the surgeon say your liver looked like? Did you have any bleeding problems afterward? Correct any coagulopathy before surgery, he added. “Coagulopathy and thrombocytopenia are really the important clues of underlying liver disease.”

Exclude patients with acute hepatitis from surgery. “If patients really had a compelling reason for surgery, I would wait until the liver enzymes are trending downward.”

A patient with cirrhosis is at increased risk for renal insufficiency and/or portal hypertension during surgery. Advise the surgeon and anesthesiologist to watch for onset of renal insufficiency, “because it's a marker of markedly reduced survival,” Dr. Martin said.

Although evidence of renal insufficiency “is what concerns us most” during the perioperative period, avoiding perioperative hypotension also is important, he noted. “Patients with hypotension are poorly tolerant of any drop in blood pressure.”

What has changed in assessment of liver disease is the Model for End-Stage Liver Disease (MELD) score (visit www.unos.org/resources

Operative risk can also be predicted using the Child-Turcotte-Pugh (CTP) classification, which assigns points based on values for bilirubin, albumin, prolonged prothrombin time/INR, ascites, and encephalopathy stage. The classification system correlates with mortality among patients with liver cirrhosis (Hepatogastroenterology 2008;55:1034–40).

A patient with a CTP-A classification generally has no limitations for surgery, Dr. Martin said. Perioperative mortality increases for someone classified as CTP-B, and major hepatic surgery should be avoided. A CTP-C patient is not a candidate for any major elective surgery, and instead should be considered for liver transplantation, he said.

A meeting attendee asked for advice about a common patient type: “I get asked a lot to assess a class Child's B cirrhotic plus, approaching a C, with hip fracture.” Dr. Martin replied: “That patient should not have a general anesthetic, if possible. Use a spinal. There is a substantial risk [of complications], as high as 50%.” He added, “If there is a nonoperative option, that would be the best option, but often, we don't have that luxury.”

Also, cirrhotic patients who experience intraoperative hypotension, who have a respiratory procedure (such as thoracotomy) or who have biliary and liver procedures, are more likely to run into problems after surgery, he said.

MIAMI BEACH — When performing a preoperative assessment of the patient with liver disease, consider specific risk factors during the history and physical examination, said Dr. Paul Martin at a meeting on perioperative medicine sponsored by the University of Miami.

Also assess the likelihood of renal insufficiency and portal hypertension, two of the most concerning perioperative developments.

“Assessing liver patients for surgery is one of the most common consults we get in the hospital,” said Dr. Martin, professor of medicine and chief of hepatology at the University of Miami.

Taking a careful history is essential. “You really want to know if the patient has ever had variceal hemorrhage, ascites, encephalopathy, or jaundice,” Dr. Martin said. Also, if the patient has a relevant surgical history, ask: What did the surgeon say your liver looked like? Did you have any bleeding problems afterward? Correct any coagulopathy before surgery, he added. “Coagulopathy and thrombocytopenia are really the important clues of underlying liver disease.”

Exclude patients with acute hepatitis from surgery. “If patients really had a compelling reason for surgery, I would wait until the liver enzymes are trending downward.”

A patient with cirrhosis is at increased risk for renal insufficiency and/or portal hypertension during surgery. Advise the surgeon and anesthesiologist to watch for onset of renal insufficiency, “because it's a marker of markedly reduced survival,” Dr. Martin said.

Although evidence of renal insufficiency “is what concerns us most” during the perioperative period, avoiding perioperative hypotension also is important, he noted. “Patients with hypotension are poorly tolerant of any drop in blood pressure.”

What has changed in assessment of liver disease is the Model for End-Stage Liver Disease (MELD) score (visit www.unos.org/resources

Operative risk can also be predicted using the Child-Turcotte-Pugh (CTP) classification, which assigns points based on values for bilirubin, albumin, prolonged prothrombin time/INR, ascites, and encephalopathy stage. The classification system correlates with mortality among patients with liver cirrhosis (Hepatogastroenterology 2008;55:1034–40).

A patient with a CTP-A classification generally has no limitations for surgery, Dr. Martin said. Perioperative mortality increases for someone classified as CTP-B, and major hepatic surgery should be avoided. A CTP-C patient is not a candidate for any major elective surgery, and instead should be considered for liver transplantation, he said.

A meeting attendee asked for advice about a common patient type: “I get asked a lot to assess a class Child's B cirrhotic plus, approaching a C, with hip fracture.” Dr. Martin replied: “That patient should not have a general anesthetic, if possible. Use a spinal. There is a substantial risk [of complications], as high as 50%.” He added, “If there is a nonoperative option, that would be the best option, but often, we don't have that luxury.”

Also, cirrhotic patients who experience intraoperative hypotension, who have a respiratory procedure (such as thoracotomy) or who have biliary and liver procedures, are more likely to run into problems after surgery, he said.

MIAMI BEACH — When performing a preoperative assessment of the patient with liver disease, consider specific risk factors during the history and physical examination, said Dr. Paul Martin at a meeting on perioperative medicine sponsored by the University of Miami.

Also assess the likelihood of renal insufficiency and portal hypertension, two of the most concerning perioperative developments.

“Assessing liver patients for surgery is one of the most common consults we get in the hospital,” said Dr. Martin, professor of medicine and chief of hepatology at the University of Miami.

Taking a careful history is essential. “You really want to know if the patient has ever had variceal hemorrhage, ascites, encephalopathy, or jaundice,” Dr. Martin said. Also, if the patient has a relevant surgical history, ask: What did the surgeon say your liver looked like? Did you have any bleeding problems afterward? Correct any coagulopathy before surgery, he added. “Coagulopathy and thrombocytopenia are really the important clues of underlying liver disease.”

Exclude patients with acute hepatitis from surgery. “If patients really had a compelling reason for surgery, I would wait until the liver enzymes are trending downward.”

A patient with cirrhosis is at increased risk for renal insufficiency and/or portal hypertension during surgery. Advise the surgeon and anesthesiologist to watch for onset of renal insufficiency, “because it's a marker of markedly reduced survival,” Dr. Martin said.

Although evidence of renal insufficiency “is what concerns us most” during the perioperative period, avoiding perioperative hypotension also is important, he noted. “Patients with hypotension are poorly tolerant of any drop in blood pressure.”

What has changed in assessment of liver disease is the Model for End-Stage Liver Disease (MELD) score (visit www.unos.org/resources

Operative risk can also be predicted using the Child-Turcotte-Pugh (CTP) classification, which assigns points based on values for bilirubin, albumin, prolonged prothrombin time/INR, ascites, and encephalopathy stage. The classification system correlates with mortality among patients with liver cirrhosis (Hepatogastroenterology 2008;55:1034–40).

A patient with a CTP-A classification generally has no limitations for surgery, Dr. Martin said. Perioperative mortality increases for someone classified as CTP-B, and major hepatic surgery should be avoided. A CTP-C patient is not a candidate for any major elective surgery, and instead should be considered for liver transplantation, he said.

A meeting attendee asked for advice about a common patient type: “I get asked a lot to assess a class Child's B cirrhotic plus, approaching a C, with hip fracture.” Dr. Martin replied: “That patient should not have a general anesthetic, if possible. Use a spinal. There is a substantial risk [of complications], as high as 50%.” He added, “If there is a nonoperative option, that would be the best option, but often, we don't have that luxury.”

Also, cirrhotic patients who experience intraoperative hypotension, who have a respiratory procedure (such as thoracotomy) or who have biliary and liver procedures, are more likely to run into problems after surgery, he said.

MIAMI BEACH — With the aging of the U.S. population, hospitalists increasingly act as perioperative geriatricians and manage the unique challenges of this population, including increased cognitive dysfunction and delirium.

“Acute hospital care is becoming acute geriatric care,” Dr. Robert M. Palmer said. People aged 65 years and older accounted for 13% of the U.S. population and 38% of hospital discharges in 2005, according to a report based on data from the National Hospital Discharge Survey (Vital Health Stat. 13. 2007;165:1–209).

“There is something very different about these elderly perioperative patients,” said Dr. Palmer, clinical director of the division of geriatric medicine and gerontology, University of Pittsburgh.

Cognitive dysfunction is more common than delirium among elderly patients, but the two conditions are part of the same spectrum, Dr. Palmer said at a meeting on perioperative medicine sponsored by the University of Miami.

In a study of patients undergoing major noncardiac surgery, postoperative cognitive dysfunction occurred in 41% of patients aged 60 years and older, 37% of patients aged 18-39 years, and 30% of those aged 40–59 (Anesthesiology 2008;108:18–30).

For example, an 82-year-old woman who has been independent in all activities of daily living prior to a hip fracture “is at high risk, greater than 40%, of postoperative cognitive dysfunction” after hip surgery, Dr. Palmer said. “We don't totally understand the etiology.”

A meeting attendee asked about quick assessment of cognitive function. “Ask [the patients] about activities of daily living—have they been able to pay bills, do finances, and take medication without assistance?” Dr. Palmer said. Also ask patients or family members about history of memory loss. Also consider a bedside digit span test. “Ask them to repeat a random string of numbers. Give them the numbers 1 second apart in a monotone,” he said. “Someone with delirium can only repeat three or fewer numbers.”

Cognitive dysfunction can be long-lasting in some patients. “Even at months after surgery, 13% [of those aged 60 and older] had signs of postoperative cognitive dysfunction versus none in an age-matched control group,” he said. None of the younger or middle-aged patients had cognitive dysfunction at 3 months.

In contrast, postoperative delirium is more likely to last only 24–72 hours after surgery (Anesthesiology 2007;106:622–8). This disorder of attention and cognition also can exist preoperatively and/or emerge in the recovery room.

Predictors of delirium following elective surgery include age 70 or older, alcohol abuse, baseline cognitive impairment, severe physical impairment, abnormal preoperative electrolyte or glucose levels, abdominal aortic aneurysm surgery, and noncardiac thoracic surgery (JAMA 1994;271:134–9). Risk was 2% in patients with none of these predictors, 11% among those with one or two risk factors, and 50% in patients with three or more risk factors.

Anticholinergics, benzodiazepines, and meperidine can increase the risk of postoperative delirium, according to consensus data (Arch. Intern. Med. 2003;163:2716–24). “These agents, generally speaking, should be avoided in all elderly patients,” Dr. Palmer said.

In addition to cessation of any high-risk medication, the use of supplemental oxygen, adequate nutritional intake, and ambulation on postoperative day 1 can reduce the risk of postoperative delirium. It is also important to treat any severe pain, he said. “Patients who are in pain cannot participate in physical therapy, so you need to address pain before you do everything else.

'There is something very different about [the responses of] these elderly perioperative patients.' DR. PALMER

MIAMI BEACH — With the aging of the U.S. population, hospitalists increasingly act as perioperative geriatricians and manage the unique challenges of this population, including increased cognitive dysfunction and delirium.

“Acute hospital care is becoming acute geriatric care,” Dr. Robert M. Palmer said. People aged 65 years and older accounted for 13% of the U.S. population and 38% of hospital discharges in 2005, according to a report based on data from the National Hospital Discharge Survey (Vital Health Stat. 13. 2007;165:1–209).

“There is something very different about these elderly perioperative patients,” said Dr. Palmer, clinical director of the division of geriatric medicine and gerontology, University of Pittsburgh.

Cognitive dysfunction is more common than delirium among elderly patients, but the two conditions are part of the same spectrum, Dr. Palmer said at a meeting on perioperative medicine sponsored by the University of Miami.

In a study of patients undergoing major noncardiac surgery, postoperative cognitive dysfunction occurred in 41% of patients aged 60 years and older, 37% of patients aged 18-39 years, and 30% of those aged 40–59 (Anesthesiology 2008;108:18–30).

For example, an 82-year-old woman who has been independent in all activities of daily living prior to a hip fracture “is at high risk, greater than 40%, of postoperative cognitive dysfunction” after hip surgery, Dr. Palmer said. “We don't totally understand the etiology.”

A meeting attendee asked about quick assessment of cognitive function. “Ask [the patients] about activities of daily living—have they been able to pay bills, do finances, and take medication without assistance?” Dr. Palmer said. Also ask patients or family members about history of memory loss. Also consider a bedside digit span test. “Ask them to repeat a random string of numbers. Give them the numbers 1 second apart in a monotone,” he said. “Someone with delirium can only repeat three or fewer numbers.”

Cognitive dysfunction can be long-lasting in some patients. “Even at months after surgery, 13% [of those aged 60 and older] had signs of postoperative cognitive dysfunction versus none in an age-matched control group,” he said. None of the younger or middle-aged patients had cognitive dysfunction at 3 months.

In contrast, postoperative delirium is more likely to last only 24–72 hours after surgery (Anesthesiology 2007;106:622–8). This disorder of attention and cognition also can exist preoperatively and/or emerge in the recovery room.

Predictors of delirium following elective surgery include age 70 or older, alcohol abuse, baseline cognitive impairment, severe physical impairment, abnormal preoperative electrolyte or glucose levels, abdominal aortic aneurysm surgery, and noncardiac thoracic surgery (JAMA 1994;271:134–9). Risk was 2% in patients with none of these predictors, 11% among those with one or two risk factors, and 50% in patients with three or more risk factors.

Anticholinergics, benzodiazepines, and meperidine can increase the risk of postoperative delirium, according to consensus data (Arch. Intern. Med. 2003;163:2716–24). “These agents, generally speaking, should be avoided in all elderly patients,” Dr. Palmer said.

In addition to cessation of any high-risk medication, the use of supplemental oxygen, adequate nutritional intake, and ambulation on postoperative day 1 can reduce the risk of postoperative delirium. It is also important to treat any severe pain, he said. “Patients who are in pain cannot participate in physical therapy, so you need to address pain before you do everything else.

'There is something very different about [the responses of] these elderly perioperative patients.' DR. PALMER

MIAMI BEACH — With the aging of the U.S. population, hospitalists increasingly act as perioperative geriatricians and manage the unique challenges of this population, including increased cognitive dysfunction and delirium.

“Acute hospital care is becoming acute geriatric care,” Dr. Robert M. Palmer said. People aged 65 years and older accounted for 13% of the U.S. population and 38% of hospital discharges in 2005, according to a report based on data from the National Hospital Discharge Survey (Vital Health Stat. 13. 2007;165:1–209).

“There is something very different about these elderly perioperative patients,” said Dr. Palmer, clinical director of the division of geriatric medicine and gerontology, University of Pittsburgh.

Cognitive dysfunction is more common than delirium among elderly patients, but the two conditions are part of the same spectrum, Dr. Palmer said at a meeting on perioperative medicine sponsored by the University of Miami.

In a study of patients undergoing major noncardiac surgery, postoperative cognitive dysfunction occurred in 41% of patients aged 60 years and older, 37% of patients aged 18-39 years, and 30% of those aged 40–59 (Anesthesiology 2008;108:18–30).

For example, an 82-year-old woman who has been independent in all activities of daily living prior to a hip fracture “is at high risk, greater than 40%, of postoperative cognitive dysfunction” after hip surgery, Dr. Palmer said. “We don't totally understand the etiology.”

A meeting attendee asked about quick assessment of cognitive function. “Ask [the patients] about activities of daily living—have they been able to pay bills, do finances, and take medication without assistance?” Dr. Palmer said. Also ask patients or family members about history of memory loss. Also consider a bedside digit span test. “Ask them to repeat a random string of numbers. Give them the numbers 1 second apart in a monotone,” he said. “Someone with delirium can only repeat three or fewer numbers.”

Cognitive dysfunction can be long-lasting in some patients. “Even at months after surgery, 13% [of those aged 60 and older] had signs of postoperative cognitive dysfunction versus none in an age-matched control group,” he said. None of the younger or middle-aged patients had cognitive dysfunction at 3 months.

In contrast, postoperative delirium is more likely to last only 24–72 hours after surgery (Anesthesiology 2007;106:622–8). This disorder of attention and cognition also can exist preoperatively and/or emerge in the recovery room.

Predictors of delirium following elective surgery include age 70 or older, alcohol abuse, baseline cognitive impairment, severe physical impairment, abnormal preoperative electrolyte or glucose levels, abdominal aortic aneurysm surgery, and noncardiac thoracic surgery (JAMA 1994;271:134–9). Risk was 2% in patients with none of these predictors, 11% among those with one or two risk factors, and 50% in patients with three or more risk factors.

Anticholinergics, benzodiazepines, and meperidine can increase the risk of postoperative delirium, according to consensus data (Arch. Intern. Med. 2003;163:2716–24). “These agents, generally speaking, should be avoided in all elderly patients,” Dr. Palmer said.

In addition to cessation of any high-risk medication, the use of supplemental oxygen, adequate nutritional intake, and ambulation on postoperative day 1 can reduce the risk of postoperative delirium. It is also important to treat any severe pain, he said. “Patients who are in pain cannot participate in physical therapy, so you need to address pain before you do everything else.

'There is something very different about [the responses of] these elderly perioperative patients.' DR. PALMER

MIAMI BEACH — The perioperative risk of thromboembolism is small but real for warfarin patients who discontinue anticoagulation to undergo noncardiac surgery or other procedures. Bridging therapy can reduce this risk, but it increases the likelihood of postoperative bleeding, so clinical judgment, guideline recommendations, and individual patient and surgical factors remain paramount, Dr. Amir K. Jaffer said.

“This whole area lacks randomized, controlled trials, and management is guided by observational data and consensus,” Dr. Jaffer said at a meeting on perioperative medicine sponsored by the University of Miami. “You have to balance risk of bleeding against the risk of clotting.”

Patients often require an individualized approach. For example, the population of patients with older-generation mechanical heart valves or mechanical valves in the mitral position are at higher risk for thromboembolic events, according to the most recent guidelines on perioperative management of antithrombotic therapy from the American College of Chest Physicians (Chest 2008;133[suppl 6]:299S-339S). The valve type and its position are two important factors to consider, Dr. Jaffer said. Risk is generally greater among patients with a mitral valve or older device (for example, ball-in-cage type), compared with patients with an atrial bileaflet valve (Circulation 1994;89:635–41).

“Warfarin is a tricky drug,” said Dr. Jaffer, chief of the division of hospital medicine at the University of Miami, and a coauthor of the ACCP guidelines. “It is a highly litigated area of perioperative medicine. Every week or so I have an attorney calling me to serve as an expert; the plaintiffs' attorneys are always going after these types of cases.” One reason warfarin is big business for lawyers is that an estimated 3 million patients are taking the drug in North America, and 400,000 of these are evaluated for bridging therapy each year, according to the American Heart Association 2002 Heart and Stroke Statistical Update.

Although the dangers are clinically significant, they affect only a minority of patients. “The risk of thromboembolism is low. It's not zero; it is about 1%,” Dr. Jaffer said. For example, 2 of 224 (0.9%) of warfarin patients experienced a cardiac thromboembolism in one study (Circulation 2004;110:1658–63).

The risk of major bleeding in this series was 6.9%. However, the average risk of major bleeding is 3%–3.5% across studies in the literature for patients with a valve or other indication who have warfarin discontinued and receive low-molecular-weight heparin (LMWH) as a bridge. For example, major bleeding occurred in 3.5% of 260 patients in one study (J. Thromb. Haemost. 2007;5:2211–8) and 3.3% of 721 patients in another (J. Thromb. Haemost. 2006;4:1246–52).

There can be increased bleeding immediately postoperatively with full-dose LMWH or unfractionated heparin, “but this can likely be minimized by delaying reinitiation of full-dose heparin … for up to 48 hours, depending on the type of surgery,” Dr. Jaffer said. In the interim, lower prophylactic doses may be warranted. “Those centers who dose everyone with full doses were at [six times] higher risk for major bleeding than those who did not give full doses,” according to unpublished data on 500 patients.

Guidelines support bridging patients with therapeutic doses of subcutaneous LMWH, rather than intravenous unfractionated heparin, as there is a paucity of data for intravenous unfractionated heparin, said Dr. Jaffer, who is also associate professor of medicine at the University of Miami. Dr. Jaffer is a consultant for Sanofi-Aventis, AstraZeneca, Bristol-Myers Squibb, and Boehringer Ingelheim. He receives research and grant support from AstraZeneca and is on the speakers bureau for Sanofi-Aventis and Roche Diagnostics.

Although both thromboembolic events and major bleeding can be fatal, mortality and morbidity rates differ for the two conditions. “With bleeding, patients can be resuscitated; with a thromboembolic event, they can have long-lasting disability,” Dr. Jaffer said. Major bleeding events rarely result in permanent disability, but 9%-13% are fatal (Ann. Intern. Med. 2003;139:893–900). In contrast, an estimated 20% of arterial thromboembolic events are fatal, and more than 50% result in permanent disability (Arch. Intern. Med. 1994;154:1449–57).

Ultimately, the decision on how to manage warfarin patients perioperatively relies on individual risk factors. The patients' indication for anticoagulation, their risk profile for thromboembolism, the type of surgery, and the likely amount of time they will be off warfarin therapy are important considerations, Dr. Jaffer said. “Weigh the consequences of thromboembolism and bleeding and then determine the need for bridging therapy.

'Weigh the consequences of thromboembolism and bleeding and then determine the need for bridging therapy.' DR. JAFFER

MIAMI BEACH — The perioperative risk of thromboembolism is small but real for warfarin patients who discontinue anticoagulation to undergo noncardiac surgery or other procedures. Bridging therapy can reduce this risk, but it increases the likelihood of postoperative bleeding, so clinical judgment, guideline recommendations, and individual patient and surgical factors remain paramount, Dr. Amir K. Jaffer said.

“This whole area lacks randomized, controlled trials, and management is guided by observational data and consensus,” Dr. Jaffer said at a meeting on perioperative medicine sponsored by the University of Miami. “You have to balance risk of bleeding against the risk of clotting.”

Patients often require an individualized approach. For example, the population of patients with older-generation mechanical heart valves or mechanical valves in the mitral position are at higher risk for thromboembolic events, according to the most recent guidelines on perioperative management of antithrombotic therapy from the American College of Chest Physicians (Chest 2008;133[suppl 6]:299S-339S). The valve type and its position are two important factors to consider, Dr. Jaffer said. Risk is generally greater among patients with a mitral valve or older device (for example, ball-in-cage type), compared with patients with an atrial bileaflet valve (Circulation 1994;89:635–41).

“Warfarin is a tricky drug,” said Dr. Jaffer, chief of the division of hospital medicine at the University of Miami, and a coauthor of the ACCP guidelines. “It is a highly litigated area of perioperative medicine. Every week or so I have an attorney calling me to serve as an expert; the plaintiffs' attorneys are always going after these types of cases.” One reason warfarin is big business for lawyers is that an estimated 3 million patients are taking the drug in North America, and 400,000 of these are evaluated for bridging therapy each year, according to the American Heart Association 2002 Heart and Stroke Statistical Update.

Although the dangers are clinically significant, they affect only a minority of patients. “The risk of thromboembolism is low. It's not zero; it is about 1%,” Dr. Jaffer said. For example, 2 of 224 (0.9%) of warfarin patients experienced a cardiac thromboembolism in one study (Circulation 2004;110:1658–63).

The risk of major bleeding in this series was 6.9%. However, the average risk of major bleeding is 3%–3.5% across studies in the literature for patients with a valve or other indication who have warfarin discontinued and receive low-molecular-weight heparin (LMWH) as a bridge. For example, major bleeding occurred in 3.5% of 260 patients in one study (J. Thromb. Haemost. 2007;5:2211–8) and 3.3% of 721 patients in another (J. Thromb. Haemost. 2006;4:1246–52).

There can be increased bleeding immediately postoperatively with full-dose LMWH or unfractionated heparin, “but this can likely be minimized by delaying reinitiation of full-dose heparin … for up to 48 hours, depending on the type of surgery,” Dr. Jaffer said. In the interim, lower prophylactic doses may be warranted. “Those centers who dose everyone with full doses were at [six times] higher risk for major bleeding than those who did not give full doses,” according to unpublished data on 500 patients.

Guidelines support bridging patients with therapeutic doses of subcutaneous LMWH, rather than intravenous unfractionated heparin, as there is a paucity of data for intravenous unfractionated heparin, said Dr. Jaffer, who is also associate professor of medicine at the University of Miami. Dr. Jaffer is a consultant for Sanofi-Aventis, AstraZeneca, Bristol-Myers Squibb, and Boehringer Ingelheim. He receives research and grant support from AstraZeneca and is on the speakers bureau for Sanofi-Aventis and Roche Diagnostics.

Although both thromboembolic events and major bleeding can be fatal, mortality and morbidity rates differ for the two conditions. “With bleeding, patients can be resuscitated; with a thromboembolic event, they can have long-lasting disability,” Dr. Jaffer said. Major bleeding events rarely result in permanent disability, but 9%-13% are fatal (Ann. Intern. Med. 2003;139:893–900). In contrast, an estimated 20% of arterial thromboembolic events are fatal, and more than 50% result in permanent disability (Arch. Intern. Med. 1994;154:1449–57).

Ultimately, the decision on how to manage warfarin patients perioperatively relies on individual risk factors. The patients' indication for anticoagulation, their risk profile for thromboembolism, the type of surgery, and the likely amount of time they will be off warfarin therapy are important considerations, Dr. Jaffer said. “Weigh the consequences of thromboembolism and bleeding and then determine the need for bridging therapy.

'Weigh the consequences of thromboembolism and bleeding and then determine the need for bridging therapy.' DR. JAFFER

MIAMI BEACH — The perioperative risk of thromboembolism is small but real for warfarin patients who discontinue anticoagulation to undergo noncardiac surgery or other procedures. Bridging therapy can reduce this risk, but it increases the likelihood of postoperative bleeding, so clinical judgment, guideline recommendations, and individual patient and surgical factors remain paramount, Dr. Amir K. Jaffer said.

“This whole area lacks randomized, controlled trials, and management is guided by observational data and consensus,” Dr. Jaffer said at a meeting on perioperative medicine sponsored by the University of Miami. “You have to balance risk of bleeding against the risk of clotting.”

Patients often require an individualized approach. For example, the population of patients with older-generation mechanical heart valves or mechanical valves in the mitral position are at higher risk for thromboembolic events, according to the most recent guidelines on perioperative management of antithrombotic therapy from the American College of Chest Physicians (Chest 2008;133[suppl 6]:299S-339S). The valve type and its position are two important factors to consider, Dr. Jaffer said. Risk is generally greater among patients with a mitral valve or older device (for example, ball-in-cage type), compared with patients with an atrial bileaflet valve (Circulation 1994;89:635–41).

“Warfarin is a tricky drug,” said Dr. Jaffer, chief of the division of hospital medicine at the University of Miami, and a coauthor of the ACCP guidelines. “It is a highly litigated area of perioperative medicine. Every week or so I have an attorney calling me to serve as an expert; the plaintiffs' attorneys are always going after these types of cases.” One reason warfarin is big business for lawyers is that an estimated 3 million patients are taking the drug in North America, and 400,000 of these are evaluated for bridging therapy each year, according to the American Heart Association 2002 Heart and Stroke Statistical Update.

Although the dangers are clinically significant, they affect only a minority of patients. “The risk of thromboembolism is low. It's not zero; it is about 1%,” Dr. Jaffer said. For example, 2 of 224 (0.9%) of warfarin patients experienced a cardiac thromboembolism in one study (Circulation 2004;110:1658–63).

The risk of major bleeding in this series was 6.9%. However, the average risk of major bleeding is 3%–3.5% across studies in the literature for patients with a valve or other indication who have warfarin discontinued and receive low-molecular-weight heparin (LMWH) as a bridge. For example, major bleeding occurred in 3.5% of 260 patients in one study (J. Thromb. Haemost. 2007;5:2211–8) and 3.3% of 721 patients in another (J. Thromb. Haemost. 2006;4:1246–52).

There can be increased bleeding immediately postoperatively with full-dose LMWH or unfractionated heparin, “but this can likely be minimized by delaying reinitiation of full-dose heparin … for up to 48 hours, depending on the type of surgery,” Dr. Jaffer said. In the interim, lower prophylactic doses may be warranted. “Those centers who dose everyone with full doses were at [six times] higher risk for major bleeding than those who did not give full doses,” according to unpublished data on 500 patients.

Guidelines support bridging patients with therapeutic doses of subcutaneous LMWH, rather than intravenous unfractionated heparin, as there is a paucity of data for intravenous unfractionated heparin, said Dr. Jaffer, who is also associate professor of medicine at the University of Miami. Dr. Jaffer is a consultant for Sanofi-Aventis, AstraZeneca, Bristol-Myers Squibb, and Boehringer Ingelheim. He receives research and grant support from AstraZeneca and is on the speakers bureau for Sanofi-Aventis and Roche Diagnostics.

Although both thromboembolic events and major bleeding can be fatal, mortality and morbidity rates differ for the two conditions. “With bleeding, patients can be resuscitated; with a thromboembolic event, they can have long-lasting disability,” Dr. Jaffer said. Major bleeding events rarely result in permanent disability, but 9%-13% are fatal (Ann. Intern. Med. 2003;139:893–900). In contrast, an estimated 20% of arterial thromboembolic events are fatal, and more than 50% result in permanent disability (Arch. Intern. Med. 1994;154:1449–57).

Ultimately, the decision on how to manage warfarin patients perioperatively relies on individual risk factors. The patients' indication for anticoagulation, their risk profile for thromboembolism, the type of surgery, and the likely amount of time they will be off warfarin therapy are important considerations, Dr. Jaffer said. “Weigh the consequences of thromboembolism and bleeding and then determine the need for bridging therapy.

'Weigh the consequences of thromboembolism and bleeding and then determine the need for bridging therapy.' DR. JAFFER

Stimulation of the P6 acupuncture point on the wrist significantly reduced the risk of postoperative nausea and vomiting, according to a new meta-analysis of 40 randomized, controlled trials involving 4,856 participants.

Compared with sham treatment, several forms of P6 stimulation reduced the risk of nausea by 29%, the risk of vomiting by 30%, and the need for rescue antiemetics by 31%, wrote Dr. Anna Lee and Dr. Lawrence T.Y. Fan for the Cochrane Collaboration (Cochrane Database Syst. Rev. 2009 [doi:10.1002/14651858.CD003281.pub3

Those relative risks were statistically significant. In direct comparisons with antiemetic drugs, P6 stimulation proved to be equally effective in reducing nausea, vomiting, and the need for rescue antiemetics.

The side effects of P6 stimulation were minor, whether the stimulation was performed with traditional acupuncture needles, electroacupuncture, laser acupuncture, transcutaneous electrical stimulation, an acustimulation device, acupressure, or capsicum plaster.

Acupuncture needles produced hematomas on rare occasions, and some patients reported pain, irritation, redness, fatigue, or sleepiness. Patients receiving acupressure with wrist bands occasionally complained of discomfort, red indentations, blisters, and swelling. One patient complained of mild irritation at the site of the capsicum plaster.

“Drugs only partially prevent postoperative nausea and vomiting, and they, of course, have a lot of adverse side effects,” said Dr. Geno J. Merli in an interview. Dr. Merli, chief medical officer of Thomas Jefferson University Hospital, Philadelphia, was not involved in the meta-analysis. Patients on antiemetic drugs can have changes in mental status and can develop confusion or disorientation. Some patients become stimulated by the antiemetic agent, while others can experience oculogyric crises, a very rare complication.

Dr. Merli was especially intrigued by the notion that wrist stimulation could be used prophylactically to prevent nausea and vomiting. Antiemetic medications are typically given as needed if postop patients develop symptoms.

Dr. Lee and Dr. Fan, both from the Chinese University of Hong Kong, acknowledged that publication bias is a frequent problem in randomized, controlled trials of traditional Chinese medicine. Negative studies are less likely to be published than are positive ones. But using a statistical technique called “contour enhanced funnel plots,” the investigators found no evidence of publication bias among the studies included in their meta-analysis.

“I was not a believer in acupuncture as a postoperative nausea and vomiting preventative,” Dr. Merli said. “I saw this review and said we should be doing this more often.”

However, hospitals would have to be convinced of the cost-effectiveness of P6 stimulation, Dr. Merli added. He noted that the acupressure wristbands available in drugstores cost about $10. Even if hospitals could get that cost down to $5, they would have to compare that to 5 cents or so for a dose of prochlorperazine. The real savings would come, Dr. Merli noted, if P6 stimulation reduced the average length of hospital stays.

Dr. Merli suggested that P6 stimulation might be reserved for patients for whom postop nausea and vomiting present a particular risk, such as those undergoing abdominal, thoracic, or brain surgery.

P6 stimulation “is a good option,” said Dr. Jessica Zuleta, an internal medicine hospitalist at the University of Miami. But it shouldn't completely replace antiemetics, she added, because the studies are limited. She called for more rigidly controlled, blinded studies comparing P6 stimulation and antiemetic drugs.

Dr. Lee and Dr. Fan said they had no relevant conflicts of interest. The study was supported by the U.S. National Center for Complementary and Alternative Medicine, the Chinese University of Hong Kong's department of anesthesia and intensive care, and the Cochrane Complementary Medicine Field Bursary.

EMILY BRANNAN/ILLUSTRATION

Stimulation of the P6 acupuncture point on the wrist significantly reduced the risk of postoperative nausea and vomiting, according to a new meta-analysis of 40 randomized, controlled trials involving 4,856 participants.

Compared with sham treatment, several forms of P6 stimulation reduced the risk of nausea by 29%, the risk of vomiting by 30%, and the need for rescue antiemetics by 31%, wrote Dr. Anna Lee and Dr. Lawrence T.Y. Fan for the Cochrane Collaboration (Cochrane Database Syst. Rev. 2009 [doi:10.1002/14651858.CD003281.pub3

Those relative risks were statistically significant. In direct comparisons with antiemetic drugs, P6 stimulation proved to be equally effective in reducing nausea, vomiting, and the need for rescue antiemetics.

The side effects of P6 stimulation were minor, whether the stimulation was performed with traditional acupuncture needles, electroacupuncture, laser acupuncture, transcutaneous electrical stimulation, an acustimulation device, acupressure, or capsicum plaster.

Acupuncture needles produced hematomas on rare occasions, and some patients reported pain, irritation, redness, fatigue, or sleepiness. Patients receiving acupressure with wrist bands occasionally complained of discomfort, red indentations, blisters, and swelling. One patient complained of mild irritation at the site of the capsicum plaster.

“Drugs only partially prevent postoperative nausea and vomiting, and they, of course, have a lot of adverse side effects,” said Dr. Geno J. Merli in an interview. Dr. Merli, chief medical officer of Thomas Jefferson University Hospital, Philadelphia, was not involved in the meta-analysis. Patients on antiemetic drugs can have changes in mental status and can develop confusion or disorientation. Some patients become stimulated by the antiemetic agent, while others can experience oculogyric crises, a very rare complication.

Dr. Merli was especially intrigued by the notion that wrist stimulation could be used prophylactically to prevent nausea and vomiting. Antiemetic medications are typically given as needed if postop patients develop symptoms.

Dr. Lee and Dr. Fan, both from the Chinese University of Hong Kong, acknowledged that publication bias is a frequent problem in randomized, controlled trials of traditional Chinese medicine. Negative studies are less likely to be published than are positive ones. But using a statistical technique called “contour enhanced funnel plots,” the investigators found no evidence of publication bias among the studies included in their meta-analysis.

“I was not a believer in acupuncture as a postoperative nausea and vomiting preventative,” Dr. Merli said. “I saw this review and said we should be doing this more often.”

However, hospitals would have to be convinced of the cost-effectiveness of P6 stimulation, Dr. Merli added. He noted that the acupressure wristbands available in drugstores cost about $10. Even if hospitals could get that cost down to $5, they would have to compare that to 5 cents or so for a dose of prochlorperazine. The real savings would come, Dr. Merli noted, if P6 stimulation reduced the average length of hospital stays.

Dr. Merli suggested that P6 stimulation might be reserved for patients for whom postop nausea and vomiting present a particular risk, such as those undergoing abdominal, thoracic, or brain surgery.

P6 stimulation “is a good option,” said Dr. Jessica Zuleta, an internal medicine hospitalist at the University of Miami. But it shouldn't completely replace antiemetics, she added, because the studies are limited. She called for more rigidly controlled, blinded studies comparing P6 stimulation and antiemetic drugs.

Dr. Lee and Dr. Fan said they had no relevant conflicts of interest. The study was supported by the U.S. National Center for Complementary and Alternative Medicine, the Chinese University of Hong Kong's department of anesthesia and intensive care, and the Cochrane Complementary Medicine Field Bursary.

EMILY BRANNAN/ILLUSTRATION

Stimulation of the P6 acupuncture point on the wrist significantly reduced the risk of postoperative nausea and vomiting, according to a new meta-analysis of 40 randomized, controlled trials involving 4,856 participants.

Compared with sham treatment, several forms of P6 stimulation reduced the risk of nausea by 29%, the risk of vomiting by 30%, and the need for rescue antiemetics by 31%, wrote Dr. Anna Lee and Dr. Lawrence T.Y. Fan for the Cochrane Collaboration (Cochrane Database Syst. Rev. 2009 [doi:10.1002/14651858.CD003281.pub3

Those relative risks were statistically significant. In direct comparisons with antiemetic drugs, P6 stimulation proved to be equally effective in reducing nausea, vomiting, and the need for rescue antiemetics.

The side effects of P6 stimulation were minor, whether the stimulation was performed with traditional acupuncture needles, electroacupuncture, laser acupuncture, transcutaneous electrical stimulation, an acustimulation device, acupressure, or capsicum plaster.

Acupuncture needles produced hematomas on rare occasions, and some patients reported pain, irritation, redness, fatigue, or sleepiness. Patients receiving acupressure with wrist bands occasionally complained of discomfort, red indentations, blisters, and swelling. One patient complained of mild irritation at the site of the capsicum plaster.

“Drugs only partially prevent postoperative nausea and vomiting, and they, of course, have a lot of adverse side effects,” said Dr. Geno J. Merli in an interview. Dr. Merli, chief medical officer of Thomas Jefferson University Hospital, Philadelphia, was not involved in the meta-analysis. Patients on antiemetic drugs can have changes in mental status and can develop confusion or disorientation. Some patients become stimulated by the antiemetic agent, while others can experience oculogyric crises, a very rare complication.

Dr. Merli was especially intrigued by the notion that wrist stimulation could be used prophylactically to prevent nausea and vomiting. Antiemetic medications are typically given as needed if postop patients develop symptoms.

Dr. Lee and Dr. Fan, both from the Chinese University of Hong Kong, acknowledged that publication bias is a frequent problem in randomized, controlled trials of traditional Chinese medicine. Negative studies are less likely to be published than are positive ones. But using a statistical technique called “contour enhanced funnel plots,” the investigators found no evidence of publication bias among the studies included in their meta-analysis.

“I was not a believer in acupuncture as a postoperative nausea and vomiting preventative,” Dr. Merli said. “I saw this review and said we should be doing this more often.”

However, hospitals would have to be convinced of the cost-effectiveness of P6 stimulation, Dr. Merli added. He noted that the acupressure wristbands available in drugstores cost about $10. Even if hospitals could get that cost down to $5, they would have to compare that to 5 cents or so for a dose of prochlorperazine. The real savings would come, Dr. Merli noted, if P6 stimulation reduced the average length of hospital stays.

Dr. Merli suggested that P6 stimulation might be reserved for patients for whom postop nausea and vomiting present a particular risk, such as those undergoing abdominal, thoracic, or brain surgery.

P6 stimulation “is a good option,” said Dr. Jessica Zuleta, an internal medicine hospitalist at the University of Miami. But it shouldn't completely replace antiemetics, she added, because the studies are limited. She called for more rigidly controlled, blinded studies comparing P6 stimulation and antiemetic drugs.

Dr. Lee and Dr. Fan said they had no relevant conflicts of interest. The study was supported by the U.S. National Center for Complementary and Alternative Medicine, the Chinese University of Hong Kong's department of anesthesia and intensive care, and the Cochrane Complementary Medicine Field Bursary.

EMILY BRANNAN/ILLUSTRATION

MIAMI BEACH — Early identification of surgical patients who could benefit from postoperative consults minimizes complications, a pilot study has shown.

After an administrative review showed that hospitalists were being consulted late in the perioperative period, Dr. Elizabeth Marlow and Dr. Chad Whelan, both of the University of Chicago, designed a system to preoperatively identify patients at a higher risk of postoperative complications. “We were getting called a few days after we should have been consulted. This got me to think—is there a way to identify patients earlier to avoid complications?” Dr. Marlow said.

The researchers conducted the pilot study to see whether surgeons would be receptive to the offer to consult on these patients before their procedures, and if earlier consults would improve outcomes. To test the system, they contacted two high-volume orthopedic surgeons (doing primarily joint replacement surgery) at the university, Dr. Marlow said during a poster session at a meeting on perioperative medicine sponsored by the University of Miami.

Using patient data spanning 6 months, they screened 58, and identified 35, patients before elective surgery who could benefit from a consult. Then Dr. Marlow and Dr. Whelan accessed the patients' electronic medical records (EMRs) to identify risk factors—including age over 75, use of chronic anticoagulation, stage 3 kidney disease, diabetes, hypertension, and heart failure—associated with postoperative complications in orthopedic surgery patients. In addition, some consultations were suggested based on subjective assessment by the hospitalist or surgeon.

“We get a list of scheduled patients, and we review their labs or notes, sometimes 3 months in advance,” said Dr. Marlow, an instructor in the university's hospital medicine section. The surgeons, who can choose to opt out, are informed the week of the planned surgery via the EMR system that they have a patient scheduled who could benefit from a hospitalist consult.

The screening system helped fully identify patient medications preoperatively and has minimized the occurrence of postoperative delirium, for example, Dr. Marlow said. “We can also help with diabetes management and patients on long-term blood thinners.”

The researchers plan to refine their clinical criteria to improve the screening system. The pilot project helped them improve communication among hospitalists and consultative practices by members of their group.

They want to expand this service to other areas of the hospital and are negotiating with vascular surgeons and urologists. Cystectomy patients, for example, could benefit from preoperative screening and postoperative consult. “These patients tend to be older men and women, and they have a lot of comorbidities,” Dr. Marlow said.

Geriatricians at the medical center also are interested in this service. “A lot of orthopedic patients are older,” Dr. Marlow said, adding that some issues are better addressed by a geriatrician.

'We were getting called a few days after we should have been consulted.' DR. MARLOW

MIAMI BEACH — Early identification of surgical patients who could benefit from postoperative consults minimizes complications, a pilot study has shown.

After an administrative review showed that hospitalists were being consulted late in the perioperative period, Dr. Elizabeth Marlow and Dr. Chad Whelan, both of the University of Chicago, designed a system to preoperatively identify patients at a higher risk of postoperative complications. “We were getting called a few days after we should have been consulted. This got me to think—is there a way to identify patients earlier to avoid complications?” Dr. Marlow said.

The researchers conducted the pilot study to see whether surgeons would be receptive to the offer to consult on these patients before their procedures, and if earlier consults would improve outcomes. To test the system, they contacted two high-volume orthopedic surgeons (doing primarily joint replacement surgery) at the university, Dr. Marlow said during a poster session at a meeting on perioperative medicine sponsored by the University of Miami.

Using patient data spanning 6 months, they screened 58, and identified 35, patients before elective surgery who could benefit from a consult. Then Dr. Marlow and Dr. Whelan accessed the patients' electronic medical records (EMRs) to identify risk factors—including age over 75, use of chronic anticoagulation, stage 3 kidney disease, diabetes, hypertension, and heart failure—associated with postoperative complications in orthopedic surgery patients. In addition, some consultations were suggested based on subjective assessment by the hospitalist or surgeon.

“We get a list of scheduled patients, and we review their labs or notes, sometimes 3 months in advance,” said Dr. Marlow, an instructor in the university's hospital medicine section. The surgeons, who can choose to opt out, are informed the week of the planned surgery via the EMR system that they have a patient scheduled who could benefit from a hospitalist consult.

The screening system helped fully identify patient medications preoperatively and has minimized the occurrence of postoperative delirium, for example, Dr. Marlow said. “We can also help with diabetes management and patients on long-term blood thinners.”

The researchers plan to refine their clinical criteria to improve the screening system. The pilot project helped them improve communication among hospitalists and consultative practices by members of their group.

They want to expand this service to other areas of the hospital and are negotiating with vascular surgeons and urologists. Cystectomy patients, for example, could benefit from preoperative screening and postoperative consult. “These patients tend to be older men and women, and they have a lot of comorbidities,” Dr. Marlow said.

Geriatricians at the medical center also are interested in this service. “A lot of orthopedic patients are older,” Dr. Marlow said, adding that some issues are better addressed by a geriatrician.

'We were getting called a few days after we should have been consulted.' DR. MARLOW

MIAMI BEACH — Early identification of surgical patients who could benefit from postoperative consults minimizes complications, a pilot study has shown.

After an administrative review showed that hospitalists were being consulted late in the perioperative period, Dr. Elizabeth Marlow and Dr. Chad Whelan, both of the University of Chicago, designed a system to preoperatively identify patients at a higher risk of postoperative complications. “We were getting called a few days after we should have been consulted. This got me to think—is there a way to identify patients earlier to avoid complications?” Dr. Marlow said.

The researchers conducted the pilot study to see whether surgeons would be receptive to the offer to consult on these patients before their procedures, and if earlier consults would improve outcomes. To test the system, they contacted two high-volume orthopedic surgeons (doing primarily joint replacement surgery) at the university, Dr. Marlow said during a poster session at a meeting on perioperative medicine sponsored by the University of Miami.

Using patient data spanning 6 months, they screened 58, and identified 35, patients before elective surgery who could benefit from a consult. Then Dr. Marlow and Dr. Whelan accessed the patients' electronic medical records (EMRs) to identify risk factors—including age over 75, use of chronic anticoagulation, stage 3 kidney disease, diabetes, hypertension, and heart failure—associated with postoperative complications in orthopedic surgery patients. In addition, some consultations were suggested based on subjective assessment by the hospitalist or surgeon.

“We get a list of scheduled patients, and we review their labs or notes, sometimes 3 months in advance,” said Dr. Marlow, an instructor in the university's hospital medicine section. The surgeons, who can choose to opt out, are informed the week of the planned surgery via the EMR system that they have a patient scheduled who could benefit from a hospitalist consult.

The screening system helped fully identify patient medications preoperatively and has minimized the occurrence of postoperative delirium, for example, Dr. Marlow said. “We can also help with diabetes management and patients on long-term blood thinners.”

The researchers plan to refine their clinical criteria to improve the screening system. The pilot project helped them improve communication among hospitalists and consultative practices by members of their group.

They want to expand this service to other areas of the hospital and are negotiating with vascular surgeons and urologists. Cystectomy patients, for example, could benefit from preoperative screening and postoperative consult. “These patients tend to be older men and women, and they have a lot of comorbidities,” Dr. Marlow said.

Geriatricians at the medical center also are interested in this service. “A lot of orthopedic patients are older,” Dr. Marlow said, adding that some issues are better addressed by a geriatrician.

'We were getting called a few days after we should have been consulted.' DR. MARLOW

MIAMI BEACH — Obstructive sleep apnea is an emerging risk factor for postoperative pulmonary complications, and although evidence does not yet support universal screening, it may be worthwhile to test some elective surgery patients for apnea, Dr. Gerald W. Smetana said.

“If it's not urgent surgery, take a time out and test to confirm sleep apnea,” Dr. Smetana said. “The evidence is more compelling now.”

In one study, researchers prospectively assessed 172 patients with at least two risk factors for obstructive sleep apnea before surgery and measured clinical severity using home nocturnal oximetry (Chest 2008;133:1128–34). They found that patients who experienced five or more oxygen desaturations per hour had significantly higher rates of postoperative pulmonary complications, compared with those with fewer episodes (15% vs. 3%, adjusted odds ratio 7.2).

Postop complications in the study were respiratory (nine patients), cardiovascular (five patients), bleeding (two patients), and gastrointestinal (one patient). Although the numbers were small, results were “pretty significant” for pulmonary complications, Dr. Smetana said at a meeting on perioperative medicine sponsored by the University of Miami.

Older age, American Society of Anesthesiologists' class of 2 or greater, chronic obstructive pulmonary disorder, and heart failure are other risk factors identified in the American College of Physicians guidelines on “risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing non-cardiothoracic surgery” (Ann. Intern. Med. 2006;144:575–80).

“There is class A evidence that these are risk factors,” said Dr. Smetana, a coauthor of the ACP guidelines and an attending physician in the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston.

“Pulmonary vary from cardiovascular risks in an important way—procedural risks are more important than patient risk factors. Even relatively healthy patients can have risk of pulmonary complications,” Dr. Smetana said. Pulmonary complications include pneumonia, respiratory failure, atelectasis, bronchospasm, and exacerbation of COPD.

A meeting attendee asked about asthma. “If it is well controlled, surprisingly, it is not a risk factor for postoperative pulmonary complications,” said Dr. Smetana, who is also on the medicine faculty at Harvard Medical School, Boston.

In terms of risk reduction, lung expansion modalities are the only intervention with good evidence, he said.

Active muscle training before surgery reduces pulmonary complications in high-risk patients, according to a randomized, controlled trial of 279 elective coronary artery bypass graft patients (JAMA 2006;296:1851–7). Preoperative inspiratory muscle training reduced postoperative high-grade pulmonary complications (OR 0.52) and pneumonia (OR 0.40), compared with a usual care group.

A meta-analysis indicated that postoperative continuous positive airway pressure lowers the overall pulmonary complication rate after abdominal surgery (Ann. Surg. 2008;247:617–24), making it “a good option for patients who cannot tolerate active muscle training,” he said.

'If it's not urgent surgery, take a time out and test to confirm sleep apnea.' DR. SMETANA

MIAMI BEACH — Obstructive sleep apnea is an emerging risk factor for postoperative pulmonary complications, and although evidence does not yet support universal screening, it may be worthwhile to test some elective surgery patients for apnea, Dr. Gerald W. Smetana said.

“If it's not urgent surgery, take a time out and test to confirm sleep apnea,” Dr. Smetana said. “The evidence is more compelling now.”

In one study, researchers prospectively assessed 172 patients with at least two risk factors for obstructive sleep apnea before surgery and measured clinical severity using home nocturnal oximetry (Chest 2008;133:1128–34). They found that patients who experienced five or more oxygen desaturations per hour had significantly higher rates of postoperative pulmonary complications, compared with those with fewer episodes (15% vs. 3%, adjusted odds ratio 7.2).

Postop complications in the study were respiratory (nine patients), cardiovascular (five patients), bleeding (two patients), and gastrointestinal (one patient). Although the numbers were small, results were “pretty significant” for pulmonary complications, Dr. Smetana said at a meeting on perioperative medicine sponsored by the University of Miami.

Older age, American Society of Anesthesiologists' class of 2 or greater, chronic obstructive pulmonary disorder, and heart failure are other risk factors identified in the American College of Physicians guidelines on “risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing non-cardiothoracic surgery” (Ann. Intern. Med. 2006;144:575–80).

“There is class A evidence that these are risk factors,” said Dr. Smetana, a coauthor of the ACP guidelines and an attending physician in the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston.

“Pulmonary vary from cardiovascular risks in an important way—procedural risks are more important than patient risk factors. Even relatively healthy patients can have risk of pulmonary complications,” Dr. Smetana said. Pulmonary complications include pneumonia, respiratory failure, atelectasis, bronchospasm, and exacerbation of COPD.

A meeting attendee asked about asthma. “If it is well controlled, surprisingly, it is not a risk factor for postoperative pulmonary complications,” said Dr. Smetana, who is also on the medicine faculty at Harvard Medical School, Boston.

In terms of risk reduction, lung expansion modalities are the only intervention with good evidence, he said.

Active muscle training before surgery reduces pulmonary complications in high-risk patients, according to a randomized, controlled trial of 279 elective coronary artery bypass graft patients (JAMA 2006;296:1851–7). Preoperative inspiratory muscle training reduced postoperative high-grade pulmonary complications (OR 0.52) and pneumonia (OR 0.40), compared with a usual care group.

A meta-analysis indicated that postoperative continuous positive airway pressure lowers the overall pulmonary complication rate after abdominal surgery (Ann. Surg. 2008;247:617–24), making it “a good option for patients who cannot tolerate active muscle training,” he said.

'If it's not urgent surgery, take a time out and test to confirm sleep apnea.' DR. SMETANA

MIAMI BEACH — Obstructive sleep apnea is an emerging risk factor for postoperative pulmonary complications, and although evidence does not yet support universal screening, it may be worthwhile to test some elective surgery patients for apnea, Dr. Gerald W. Smetana said.

“If it's not urgent surgery, take a time out and test to confirm sleep apnea,” Dr. Smetana said. “The evidence is more compelling now.”

In one study, researchers prospectively assessed 172 patients with at least two risk factors for obstructive sleep apnea before surgery and measured clinical severity using home nocturnal oximetry (Chest 2008;133:1128–34). They found that patients who experienced five or more oxygen desaturations per hour had significantly higher rates of postoperative pulmonary complications, compared with those with fewer episodes (15% vs. 3%, adjusted odds ratio 7.2).

Postop complications in the study were respiratory (nine patients), cardiovascular (five patients), bleeding (two patients), and gastrointestinal (one patient). Although the numbers were small, results were “pretty significant” for pulmonary complications, Dr. Smetana said at a meeting on perioperative medicine sponsored by the University of Miami.

Older age, American Society of Anesthesiologists' class of 2 or greater, chronic obstructive pulmonary disorder, and heart failure are other risk factors identified in the American College of Physicians guidelines on “risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing non-cardiothoracic surgery” (Ann. Intern. Med. 2006;144:575–80).

“There is class A evidence that these are risk factors,” said Dr. Smetana, a coauthor of the ACP guidelines and an attending physician in the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston.

“Pulmonary vary from cardiovascular risks in an important way—procedural risks are more important than patient risk factors. Even relatively healthy patients can have risk of pulmonary complications,” Dr. Smetana said. Pulmonary complications include pneumonia, respiratory failure, atelectasis, bronchospasm, and exacerbation of COPD.

A meeting attendee asked about asthma. “If it is well controlled, surprisingly, it is not a risk factor for postoperative pulmonary complications,” said Dr. Smetana, who is also on the medicine faculty at Harvard Medical School, Boston.

In terms of risk reduction, lung expansion modalities are the only intervention with good evidence, he said.

Active muscle training before surgery reduces pulmonary complications in high-risk patients, according to a randomized, controlled trial of 279 elective coronary artery bypass graft patients (JAMA 2006;296:1851–7). Preoperative inspiratory muscle training reduced postoperative high-grade pulmonary complications (OR 0.52) and pneumonia (OR 0.40), compared with a usual care group.

A meta-analysis indicated that postoperative continuous positive airway pressure lowers the overall pulmonary complication rate after abdominal surgery (Ann. Surg. 2008;247:617–24), making it “a good option for patients who cannot tolerate active muscle training,” he said.

'If it's not urgent surgery, take a time out and test to confirm sleep apnea.' DR. SMETANA

MIAMI BEACH — A soon-to-be-published Cochrane review is expected to indicate the superiority of intraoperative initiation of fluid management protocols and to quantify the link between perioperative complications and postoperative survival, according to one of the study's coauthors.

The review, “Perioperative Increases in Global Blood Flow to Explicit Defined Goals and Outcomes Following Surgery,” gives evidence-based guidance on these two controversial issues, gleaned from “very different” studies with a total of 4,546 patients, Dr. Mark Hamilton reported at a meeting on perioperative medicine sponsored by the University of Miami.

The 22 studies in the review included elective and emergency patients undergoing general, vascular, or cardiac surgery. Overall perioperative mortality was 10.6%.

Use of a fluid protocol was associated with 216 perioperative deaths. There were 265 deaths among patients treated without a protocol (odds ratio, 0.82). This statistically significant reduction in mortality was “quite clear” for the protocol groups vs. controls, Dr. Hamilton said.

The timing of the intervention is significantly more protective if flow-directed therapy is intraoperative vs. preoperative or postoperative, according to the review, although the final answer on the optimal management strategy remains elusive, said Dr. Hamilton, consultant and honorary senior lecturer in anesthesia and intensive care medicine at St. George's Hospital in London. He had no relevant financial disclosures.

Fundamental problems of perioperative fluid therapy include an inability to accurately evaluate blood volume, identify fluid overload, identify hypovolemia, or precisely evaluate tissue perfusion, Dr. Hamilton said.

Multiple organizations have developed guidelines to steer hospitalists, surgeons, and other perioperative clinicians regarding fluid management, but they are backed by varying levels of evidence, he said.

Dr. Hamilton recommended the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (www.ebpom.org

Another finding is that significant perioperative complications can have a long-term effect on surgery patients.

“This is where it gets more interesting,” Dr. Hamilton said. “This is the most consistent theme in the studies.” A lack of a standard definition for perioperative complications worldwide has impeded previous efforts to compile overall complication rates, he said.

In one study, any of 22 complications in the National Surgical Quality Improvement Program database within 30 days of surgery was the most important factor associated with decreased postoperative survival (Ann. Surg. 2005;242:326–41).

Postoperative complications were associated with a 69% reduction in median survival among 105,951 patients who had surgery between 1991 and 1999, and were more indicative of survival after major surgery than were preoperative or perioperative risk factors.

MIAMI BEACH — A soon-to-be-published Cochrane review is expected to indicate the superiority of intraoperative initiation of fluid management protocols and to quantify the link between perioperative complications and postoperative survival, according to one of the study's coauthors.

The review, “Perioperative Increases in Global Blood Flow to Explicit Defined Goals and Outcomes Following Surgery,” gives evidence-based guidance on these two controversial issues, gleaned from “very different” studies with a total of 4,546 patients, Dr. Mark Hamilton reported at a meeting on perioperative medicine sponsored by the University of Miami.

The 22 studies in the review included elective and emergency patients undergoing general, vascular, or cardiac surgery. Overall perioperative mortality was 10.6%.

Use of a fluid protocol was associated with 216 perioperative deaths. There were 265 deaths among patients treated without a protocol (odds ratio, 0.82). This statistically significant reduction in mortality was “quite clear” for the protocol groups vs. controls, Dr. Hamilton said.

The timing of the intervention is significantly more protective if flow-directed therapy is intraoperative vs. preoperative or postoperative, according to the review, although the final answer on the optimal management strategy remains elusive, said Dr. Hamilton, consultant and honorary senior lecturer in anesthesia and intensive care medicine at St. George's Hospital in London. He had no relevant financial disclosures.

Fundamental problems of perioperative fluid therapy include an inability to accurately evaluate blood volume, identify fluid overload, identify hypovolemia, or precisely evaluate tissue perfusion, Dr. Hamilton said.

Multiple organizations have developed guidelines to steer hospitalists, surgeons, and other perioperative clinicians regarding fluid management, but they are backed by varying levels of evidence, he said.

Dr. Hamilton recommended the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (www.ebpom.org

Another finding is that significant perioperative complications can have a long-term effect on surgery patients.

“This is where it gets more interesting,” Dr. Hamilton said. “This is the most consistent theme in the studies.” A lack of a standard definition for perioperative complications worldwide has impeded previous efforts to compile overall complication rates, he said.

In one study, any of 22 complications in the National Surgical Quality Improvement Program database within 30 days of surgery was the most important factor associated with decreased postoperative survival (Ann. Surg. 2005;242:326–41).

Postoperative complications were associated with a 69% reduction in median survival among 105,951 patients who had surgery between 1991 and 1999, and were more indicative of survival after major surgery than were preoperative or perioperative risk factors.

MIAMI BEACH — A soon-to-be-published Cochrane review is expected to indicate the superiority of intraoperative initiation of fluid management protocols and to quantify the link between perioperative complications and postoperative survival, according to one of the study's coauthors.

The review, “Perioperative Increases in Global Blood Flow to Explicit Defined Goals and Outcomes Following Surgery,” gives evidence-based guidance on these two controversial issues, gleaned from “very different” studies with a total of 4,546 patients, Dr. Mark Hamilton reported at a meeting on perioperative medicine sponsored by the University of Miami.

The 22 studies in the review included elective and emergency patients undergoing general, vascular, or cardiac surgery. Overall perioperative mortality was 10.6%.

Use of a fluid protocol was associated with 216 perioperative deaths. There were 265 deaths among patients treated without a protocol (odds ratio, 0.82). This statistically significant reduction in mortality was “quite clear” for the protocol groups vs. controls, Dr. Hamilton said.

The timing of the intervention is significantly more protective if flow-directed therapy is intraoperative vs. preoperative or postoperative, according to the review, although the final answer on the optimal management strategy remains elusive, said Dr. Hamilton, consultant and honorary senior lecturer in anesthesia and intensive care medicine at St. George's Hospital in London. He had no relevant financial disclosures.

Fundamental problems of perioperative fluid therapy include an inability to accurately evaluate blood volume, identify fluid overload, identify hypovolemia, or precisely evaluate tissue perfusion, Dr. Hamilton said.

Multiple organizations have developed guidelines to steer hospitalists, surgeons, and other perioperative clinicians regarding fluid management, but they are backed by varying levels of evidence, he said.

Dr. Hamilton recommended the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (www.ebpom.org

Another finding is that significant perioperative complications can have a long-term effect on surgery patients.

“This is where it gets more interesting,” Dr. Hamilton said. “This is the most consistent theme in the studies.” A lack of a standard definition for perioperative complications worldwide has impeded previous efforts to compile overall complication rates, he said.

In one study, any of 22 complications in the National Surgical Quality Improvement Program database within 30 days of surgery was the most important factor associated with decreased postoperative survival (Ann. Surg. 2005;242:326–41).

Postoperative complications were associated with a 69% reduction in median survival among 105,951 patients who had surgery between 1991 and 1999, and were more indicative of survival after major surgery than were preoperative or perioperative risk factors.