“It's a dance between you, the anesthesiologist and maybe the pain service and maybe the surgeon,” Read Pierce, MD, ACP Member, told attendees at the Rocky Mountain Hospital Medicine Symposium.
Dr. Pierce, an assistant professor of internal medicine at the University of Colorado Hospital in Aurora, was speaking specifically of postoperative pain management, but add a few more partners—such as the patient's comorbidities, medications and complications—and his statement also applies to the general area of perioperative care.
Hospitalists attending the annual Rocky Mountain meeting, held in Denver last September, picked up some dance pointers from a track of speakers focused on perioperative hospital medicine.
Pain might be thought of as a postoperative issue, but effective treatment of it can begin preoperatively, according to Dr. Pierce. “There are some ways we can help as hospitalists before the patient even makes it to the operating room. If you give things before surgery, it decreases pain receptor signaling,” he said.
Such things include commonly prescribed medications. “It turns out NSAIDs like ibuprofen and ketorolac result in 25% to 40% reduced opioid use after surgery. Clonidine can as well,” said Dr. Pierce, but it is less commonly used because it carries more side-effect risks. Gabapentin and nerve blocks may also be options for some patients, he added, though the latter require someone with the time and expertise to provide them.
This is where the dancing comes in. “Some surgeons might say ‘I don't want my patient getting ibuprofen before surgery, because I'm already worried about renal function.’ You have this conversation up front before you order these medications. Negotiating the preferences becomes important,” said Dr. Pierce.
Patient preference should also be a consideration in pain treatment, both before and after surgery. Patient-controlled analgesia (PCA) may be appealing to some but worrisome for others. Dr. Pierce reviewed the advantages and disadvantages of PCA compared to opioid boluses.
“With PCAs, both pain control and patient satisfaction tend to be better. You'll notice, though, that patients do use more total opioid if you put them on PCA. That's probably why patients on PCA tend to report more itching. But for other outcomes we care about at the patient level—nausea and constipation, for instance—those are no different,” he said.
For the best results, clinicians need to have a certain amount of comfort with the technology, too. “You have to think about your local environment. Do you have the staffing and familiarity and experience so that the PCA will work?” Dr. Pierce asked.
It'll be an uncomfortable experience for almost any hospitalist when an opioid-tolerant patient comes in for surgery. “All of us get a little nervous when we see high-dose opioids on a medication reconciliation. We worry about how much higher are they going to go,” said Dr. Pierce.
But don't let worry get in the way of adequately treating pain. “It's OK to go up a little bit,” he said. “I can essentially guarantee those high baseline needs of opioids are going to go higher. The patients are going to need really big doses in the hospital.”
Opioid-tolerant patients are less likely to suffer respiratory depression at high doses, because they have built up some protection. But they are likely to suffer from pain if their opioid level is not consistently maintained. “These are the folks who may need a continuous basal dosing,” said Dr. Pierce. If patients were taking methadone before hospitalization, they should be put back on it as soon as oral medications are allowed.
In general, oral pain medications can usually be given to any patient who is allowed to eat. “Usually there's a tray at the bedside, based on the surgeon's orders, to let you know,” said Dr. Pierce.
Blood pressure and other complications
The use of oral medications perioperatively is not only a dilemma in pain management. Blood pressure medications pose a challenge, too. “There's a lot of anesthesia data that says that the hypotensive effects of anesthetic agents wear off about 30 minutes after surgery. This rise in blood pressure 30 minutes after is very expected,” said Joseph Sweigart, MD, ACP Member, an instructor in internal medicine at the University of Colorado.
The dilemma is how to treat such increases in blood pressure. Giving a surgical patient his or her usual antihypertensives can create risk of hypotension. “Most of us think that low blood pressure is scarier and more dangerous,” said Dr. Sweigart. “I think it makes sense to hold the blood pressure medications. Holding the diuretics is almost definitely the right thing to do. The ACE inhibitor, there's data in both directions.”
Hypotension risks vary depending on the surgery, he noted—larger and longer surgeries are associated with lower blood pressures. Another consideration in postoperative hypertension treatment is that pain increases blood pressure. “If someone has high blood pressure from pain and we bring it down aggressively with antihypertensive medicine, and then control their pain, we could potentially change their blood pressure drastically,” Dr. Sweigart said.
Drastic changes in blood pressure are the biggest concern, he added. “The delta, the change in blood pressure, is probably more significant than any particular value.” If a postsurgical patient has a significant increase in blood pressure, short-acting oral antihypertensives are probably the best treatment, Dr. Sweigart said.
Of the many other complications that can occur after surgery, atelectasis is one of the most common. It occurs in up to 50% of abdominal surgery patients, Dr. Sweigart reported. “It seems to be most severe on the second postoperative day/night but can linger for four or five days,” he said.
There is a growing body of evidence about the best course of treatment. And no, it's not incentive spirometry. “We've all been taught to use it,” said Dr. Sweigart. But a recent Cochrane review found no statistically significant benefit. “That's not to say there's no reason to use it, but the Cochrane review said it's not evidence based,” he said. Chest physiotherapy has similarly uncertain support, he added.
However, continuous positive airway pressure (CPAP) does have evidence of its effectiveness. “A trial of CPAP in the setting of postoperative hypoxia helps that hypoxia, prevents reintubation, and probably prevents meaningful infectious outcomes,” said Dr. Sweigart. “CPAP is the right answer.”
What else is likely to go wrong with your postoperative patient? How about fever? “We know post-operative fevers happen,” said Dr. Sweigart, citing a study finding that 18% of patients had fever after surgery, most often on the first day postop. “When should we go a step further and evaluate these fevers?”
Several studies have tried to assess the value of testing patients with postoperative fevers. In one that used only blood cultures, out of 141 cultures from patients with postoperative fever and tachycardia, only two were positive. Another study found that conducting urine studies and blood cultures in feverish patients resulted in a cost per positive test of $3,300.
The research has identified a group of postoperative patients whose fevers might mean something more serious. “People who are having multiple fevers, fevers after postoperative day three, and probably people with temperatures above 39°—those people probably warrant further investigation,” said Dr. Sweigart. “Until and unless our patients hit those clinical indicators, we're probably OK not evaluating that fever.”
Transfusions and surgeons
But just as one perioperative expert provided a helpful rule of thumb, another took one away. Brian Wolfe, MD, ACP Member, an assistant professor of internal medicine at the University of Colorado, discussed the dilemma of when to give patients blood transfusions. “We've all heard the rule of 10 and 30, [i.e.] transfusing when people fall below 10 g/dL [of hemoglobin] or hematocrit of 30%,” he said. “However, over the last 15 to 20 years, some of that data has been rolled back.”
Transfusions can cause patients problems instead of helping them. “Nearly one in 50 patients that you give blood will have some form of transfusion reaction. Most of those are mild,” he said. “The thing that patients and physicians think the least about is transfusion-related immunomodulation.”
A transfusion's effect on the immune system can increase the risk of surgical infection or pneumonia. “It makes it more difficult to say what exactly you are doing to patients when you give them blood,” Dr. Wolfe said.
Studies indicate that 8 g/dL of hemoglobin or lower may be a better cutoff for transfusion, since surgical patients treated under such restrictive transfusion strategies have actually done better than those transfused at the usual 10 g/dL cutoff.
“The restrictive strategy of transfusing people when they get to that 7 to 8 range, regardless of cardiovascular disease, is probably the way to go,” said Dr. Wolfe. “As hospitalists, it becomes very important that we help our surgeons with this issue. What we need to do is tell them, when we transfuse that patient with the hemoglobin of 8 without symptoms, all we're probably doing is raising their surgical site infections.”
Ideally, surgeons will be eager for your input on comanaged patients. But hospitalists need to be ready for the ones who aren't, said Dennis J. Boyle, MD, during a session on perioperative malpractice risks.
A frequent cause of perioperative malpractice claims is failure to rescue, he said, which can result when a hospitalist notices a patient isn't doing well but doesn't get the patient's surgeon to take action in response. “You need to think about how you're going to deal with that,” said Dr. Boyle, an associate professor of medicine at the University of Colorado. “Plan what you'll do when a colleague fails you.”
The plan can start with a persuasive speech to the surgical colleague: “I promised this patient I would take good care of her.” If that still doesn't elicit action, go over the physician's head, advised Dr. Boyle.
Unclear responsibility for “incidentalomas” and obviously missed findings, like sleep apnea, in preoperative evaluation are two other common sources of perioperative malpractice. Avoid these, and you're more likely to avoid a lawsuit, Dr. Boyle advised.
“You get sued for basic, basic stuff. It's not a knowledge issue. It's your awareness of what's going on,” he said.