Hospital Practice

ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20

Update in Perioperative Medicine 2013 Steven L. Cohn MD, Karen F. Mauck MD, MSc, Suparna Dutta MD, MPH, Amir Jaffer MD & Gerald W. Smetana MD To cite this article: Steven L. Cohn MD, Karen F. Mauck MD, MSc, Suparna Dutta MD, MPH, Amir Jaffer MD & Gerald W. Smetana MD (2013) Update in Perioperative Medicine 2013, Hospital Practice, 41:4, 15-23 To link to this article: http://dx.doi.org/10.3810/hp.2013.10.1076

Published online: 13 Mar 2015.

Submit your article to this journal

Article views: 6

View related articles

Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ihop20 Download by: [University of Pennsylvania]

Date: 05 November 2015, At: 16:56

C l i n i c a l F o c u s :   C o n s e n s u s G u i d e l i n e s a n d P a t h w ay s P r e - a n d P o s t- A d m i s s i o n

Downloaded by [University of Pennsylvania] at 16:56 05 November 2015

Update in Perioperative Medicine 2013

Steven L. Cohn, MD 1 Karen F. Mauck, MD, MSc 2 Suparna Dutta, MD, MPH 3 Amir Jaffer, MD 4 Gerald W. Smetana, MD 5 1 Director, University of Miami Hospital Medical Consultation Service, Professor of Clinical Medicine, Division of Hospital Medicine, University of Miami Miller School of Medicine, Miami, FL; 2 Assistant Professor of Medicine, Division of General Internal Medicine, Mayo Clinic and Mayo College of Medicine, Rochester, MN; 3 Assistant Professor of Medicine, Division of Hospital Medicine, Rush University Medical Center, Chicago, IL; 4Professor of Medicine, ChiefDivision of Hospital Medicine, Rush University Medical Center, Chicago, IL; 5Associate Professor of Medicine, Harvard Medical School, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA

DOI: 10.3810/hp.2013.10.1076

Abstract: Perioperative medicine is an important and rapidly expanding area of interest across multiple specialties, including internal medicine, anesthesiology, surgery, and hospital medicine. A multi-specialty team approach that ensures best possible patient outcomes has fostered collaborative strategies across the continuum of patient care. It is difficult to keep current in this multidisciplinary field, as physicians interested in perioperative medicine would need to review multiple specialty journals on a regular basis. To facilitate this process, we performed a focused review of this literature published in 2012. In this update, we review 9 key articles that potentially impact clinical practice in various areas of perioperative medicine including preoperative testing, cardiovascular medicine, pulmonary care, anticoagulation, and medication management. Keywords: perioperative medicine; noncardiac surgery; anticoagulation; stents; preoperative testing; ambulatory surgery; hemorrhage

Introduction

Perioperative medicine, which includes the care of the patient before, during, and following surgery, has grown tremendously and is an area of intense research for many surgeons, anesthesiologists, internists, and hospitalists. In the last few years, there has been a greater emphasis on patient safety and, quality-of-care in this arena, leading to the development of collaborative models of medical and surgical management for patient care. Ensuring optimal perioperative outcomes requires teamwork and partnership between surgeons and internists, as well as the entire team of care providers. This teamwork is particularly important for the care of surgical patients with multiple major medical comorbidities.

Methods

Correspondence: Steven L. Cohn, MD, Professor of Clinical Medicine, University of Miami Miller School of Medicine, 1120 NW 14th St - CRB-1140, Miami, FL 33136. Tel: 305-243-1960 Fax: 305-243-1538 E-mail: [email protected]

Our article is a summary of the content presented by the authors at the Eighth Annual Perioperative Medicine Summit: Using Evidence to Improve Quality, Patient Safety, and Outcomes (March 7–9, 2013, Miami Beach, FL),1 the Society of General Internal Medicine (SGIM) 36th Annual Meeting: Celebrating Generalism: Leading Innovation and Change, (April 24–27, 2013, Denver, CO),2 and Hospital Medicine (SHM) 2013 (May 16–19, 2013, National Harbor, MD).3 We performed a MEDLINE search of English-language medical articles published between March 2012 and February 2013. We searched using free-text queries and medical subject headings (MeSH) terms including, among others, perioperative care, preoperative evaluation, noncardiac surgery, and postoperative complications. Each author independently reviewed the list and developed a list of key articles with the greatest relevance for clinicians,

© Hospital Practice,Volume 41, Issue 4, October/November 2013, ISSN – 2154-8331 15 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]

02_Cohn.indd 15

10/11/13 3:04 PM

Cohn et al

and those articles that had the potential to change clinical practice paradigms. We developed the final list of articles by consensus and present them from an overview perspective. The articles chosen are in the fields of preoperative testing, risk prediction, perioperative cardiovascular medicine, pulmonary care, anticoagulation, and medication management.

Downloaded by [University of Pennsylvania] at 16:56 05 November 2015

Results Preoperative Laboratory Testing Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Benarroch-Gampel J, Sheffield KM, Duncan CB, et al. Ann Surg. 2012;256(3):518– 528.4 Despite guidelines and evidence that discourage routine preoperative laboratory testing, the practice remains common. In the study by Benarroch-Gampel et al, data was collected from the American College of Surgeons (ACS) National Quality Surgical Improvement Program (NSQIP) on testing before ambulatory hernia surgery, an inherently low-risk procedure. Eligible patients were noted, per the American Society of Anesthesiologists (ASA) Physical Status classifications, as grade 1 through 3, and were identified among 258 participating hospitals during 2010. The researchers determined the proportion of patients with preoperative tests and those with abnormal results, then correlated the relationship between testing and results of testing to adverse postoperative outcomes. They used multivariable analysis to adjust for confounders. The authors made the assumption that no testing was indicated for patients with no comorbidities. Among 73 596 patients, 63.8% underwent $ 1 preoperative test. Test ordering was frequent, even for patients with no comorbidities (and hence no indication for testing). Among patients with no comorbidities, tests were obtained as follows: hematology (51.8%), chemistry (41.8%), coagulation (14.8%), and liver function tests (19.6%). Corresponding rates for all patients were 58.6%, 53.5%, 18.7%, and 23.7%. Abnormal results were common, both for patients with and without indications for testing; the rates for any abnormal result were 61.6% and 54.1%, respectively. After multivariate adjustment, neither the decision to test nor abnormal test results predicted major or wound-related complications. This was true for each individual test category, and was equally true among the cohort of patients with no comorbidities. Odds ratios ranged from 0.94 to 1.36, none of which were statistically significant. There were nonsignificant trends towards higher complication rates among patients who were tested, even after adjusting for comorbidities. 16

02_Cohn.indd 16

While clinicians may choose to order preoperative tests in the belief that it will improve patient safety, most abnormal results are either ignored or do not influence perioperative management. For example, in a review of laboratory testing in 2003,5 the incidence of abnormalities that influenced perioperative management ranged from 0% for white blood cell count and prothrombin time, to 2.6% for renal function tests.5

Implications for Clinical Practice The current study by Benarroch-Gampel et al is one of the largest studies on the value of preoperative testing and specifically addressed the issue of patients with no comorbidities undergoing low-risk surgery. Neither the decision to test nor the results predicted adverse outcomes. These findings are similar to those of a large study of patients undergoing cataract surgery, another low-risk procedure.6 In the cataract surgery study, 19 557 patients were randomly assigned to testing or no testing, and postoperative complication rates did not differ between the two groups. The ASA has recently (2012) revised their guidelines for pre-anesthesia evaluation.7 The ASA no longer recommends any routine testing. Instead, the guidelines recommend selective use of testing based on patient-related risk factors and the inherent risks of the planned procedure. The study by Benarroch-Gampel et al provides more evidence to support this approach.

Preoperative Risk Prediction The Surgical Mortality Probability Model: derivation and validation of a simple risk prediction rule for noncardiac surgery. Glance LG, Lustik SJ, Hannan EL, et al. Ann Surg. 2012;255(4):696–702.8 A need exists for a simplified surgical risk-prediction tool that clinicians and surgeons can use to estimate patient mortality after noncardiac surgery (NCS) at the point of care. In Glance et al’s study, the authors identified a cohort of 298 772 patients from the ACS NSQIP database registry, who had a noncardiac surgical procedure requiring general anesthesia between 2005 and 2007. A risk model was developed using 3 prespecified components: 1) the patient ASA Physical Status classification (1–5); 2) surgery-specific risk (low, intermediate, or high); and 3) whether the procedure is emergent or nonemergent surgery. Surgery-specific risk was calculated using logistic regression to control for ASA classification, and emergency surgery and was provided in appendices. Regression coefficients were used to assign a point value to each patient by summing the points earned

© Hospital Practice, Volume 41, Issue 4, October/November 2013, ISSN – 2154-8331 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]

10/11/13 3:04 PM

Update in Perioperative Medicine 2013

for each of the 3 predefined components. The C statistic was 0.899 for the derivation dataset and 0.897 for the validation dataset, indicating excellent discrimination. Table 1 details the final surgical mortality probability model that divides patients into 1 of 3 mortality categories based on the total number of points (maximum of 9 points). Patient mortality ranged from , 0.5% (class 1) to . 10% (class 3).

Downloaded by [University of Pennsylvania] at 16:56 05 November 2015

Implications for Clinical Practice The strength of the Surgical Mortality Probability Model is that it is easy to use at the point of care and patient risk can be easily calculated with readily available clinical information. The limitation of the tool is that the ASA classification system can be subject to significant subjectivity. Additionally, the surgical procedure risk categories are not intuitive and may require referencing the appendix material. This predictive tool, once validated in an independent population, will be useful to the clinician and surgeon in advising their patients about surgical mortality risk.

Perioperative Cardiovascular Medicine Risk of elective major noncardiac surgery after coronary stent insertion: a population-based study. Wijeysundera DN, Wijeysundera CH,Yun L, et al. Circulation. 2012;126(11):1355–1362.9 Recommendations concerning the risk and timing of NCS after percutaneous coronary intervention (PCI) are based on Table 1.  Surgical Mortality Scoring System for Estimating 30-Day Mortality After Noncardiac Surgery8 Risk Factor

Points

ASA Physical Status classification

a

 1

0

 2

2

 3

4

 4

5

 5

6

Procedure Risk  Low

0

 Intermediate

1

 High

2

Emergent Status   Non-emergent surgery

0

  Emergent surgery

1

ASA Class 1: (0–4 points) < 0.5% mortality; Class 2: (5–6 points) 1.5%–4% mortality; Class 3: (7–9 points) > 10% mortality. Adapted with permission from Lippincott Williams and Wilkins/Wolters Kluwer Health: Glance LG, Lustik SJ, Hannan EL, et al. The Surgical Mortality Probability Model: Derivation and validation of a simple risk prediction rule for noncardiac surgery. Ann Surg. 2012;255(4):696–702.8 © 2012. Abbreviation: ASA, American Society of Anesthesiologists. a

limited data. Current guidelines10,11 agree that elective surgery should be delayed for 30 to 45 days after bare-metal stent (BMS) placement and  $  6, if not 12, months after drugeluting stents (DES)10,11; however, the 6-to-12-month waiting period is controversial. Using linked registry and populationbased administrative databases from 2003 through 2009 in Ontario, Canada, Wijeysundera et al analyzed a cohort of 8116 patients who underwent PCI within 10 years before NCS, 905 patients (33%) of whom received DES. Those patients who had surgery within 2 years (2725, 34%) had more comorbid disease and a higher mean revised cardiac risk index (RCRI) score than did patients who had surgery . 2 years after PCI. Thirty-day major adverse cardiac events (MACE), which included mortality, readmission for acute coronary syndrome, or repeat coronary revascularization, occurred in 2.1% of patients. Incidents of MACE were highest when NCS occurred within 45 days of either type of stent placement. The earliest optimal time for elective NCS was 4 to 180 days for BMS and . 180 days for DES (Table 2), at which time the MACE rate approached that of intermediate-risk non-revascularized patients. Wijeysundera et al’s results were consistent with other studies12,13 confirming higher risk of MACE within 6 weeks of PCI and relatively low risk for both BMS and DES after 6 weeks and 6 months, respectively. Limitations of the study include low event rates, which limited statistical power; potential unmeasured biases inherent in observational data; use of administrative data, which may not capture in-hospital complications accurately; lack of medication data on perioperative antiplatelet use; lack of specific procedural information from the PCI registry; and unmeasured confounding. Additionally, the American College of Cardiology (ACC) practice guidelines were updated in 200714 to recommend longer waiting periods for NCS after Table 2.  Impact of Timing Between PCI and Subsequent Noncardiac Surgery on Postoperative Cardiac Complication Rates9 Interval between PCI and surgery, days

30-day MACE BMS, %

DES, %

1–45

6.7

20.0

45–180

2.6a

3.9

181–365

3.4

1.2a

366–730

2.1

2.2

Approached rates of MACE if intermediate-risk non-revascularized patients. Data from Wijeysundera DN, Wijeysundera CH,Yun L, et al. Risk of elective major noncardiac surgery after coronary stent insertion. Circulation. 2012;126(11):1355–1362.9 Abbreviations: BMS, bare-metal stent; DES, drug-eluting stent; MACE, major adverse cardiac event; PCI, percutaneous coronary intervention. a

© Hospital Practice, Volume 41, Issue 4, October/November 2013, ISSN – 2154-8331 17 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]

02_Cohn.indd 17

10/11/13 3:04 PM

Cohn et al

PCI with DES (previously, recommendations were 3 months after sirolimus and 6 months after paclitaxel stents).

Downloaded by [University of Pennsylvania] at 16:56 05 November 2015

Implications for Clinical Practice The results of the study support current guidelines to have patients wait 30 to 45 days after BMS and suggest that risk may increase after 180 days. For patients with DES, other studies have reported mixed results, and the optimal waiting period remains unclear. However, in contrast to the American Heart Association (AHA)/ACC guidelines10 recommending delaying NCS for . 1 year, Wijeysundera et al’s study, using observational data, suggests that surgery may be performed reasonably safely in carefully selected patients after a minimum of 6 months post-DES placement, similar to recommendations from the American College of Chest Physician (ACCP) guidelines.11 Association between major perioperative hemorrhage and stroke or Q-wave myocardial infarction. Kamel H, Johnston SC, Kirkham JC, et al. Circulation. 2012;126(2):207–212.15 Perioperative stroke and myocardial infarction (MI) are associated with patient mortality rates 4 to 8 times higher than mortality rates after uncomplicated surgery and are important targets for improving surgical outcomes.16,17 The impact of perioperative hemorrhage on the risk of developing ischemia and subsequent postoperative ischemic stroke or MI is uncertain. The aim of Kamel et al’s study was to examine the relationship between major perioperative hemorrhage and stroke or MI in a large cohort of patients undergoing surgery. Kamel et al designed a prospective cohort study of patients enrolled in the ACS NSQIP database registry from 2005 through 2009. The exposure of interest was perioperative hemorrhage, defined as the transfusion of . 4 units packed red blood cells (pRBCs). The primary outcome was patient stroke or MI during surgery or # 30 days postoperatively. The cumulative rate of stroke or Q-wave MI in patients who experienced perioperative hemorrhage was significantly higher than in patients who did not hemorrhage (2.62% vs 0.42%; P , 0.001). Hemorrhage was independently associated with subsequent stroke (hazard ratio [HR] 2.5), subsequent MI (HR 2.7), and composite outcome (HR 2.6). There was also a dose-response relationship between the number of units of pRBC transfused and risk of subsequent stroke or MI; the HR was 1.11 for each unit pRBCs transfused. When patients who received only 2 units of pRBCs were excluded from the data, sensitivity analyses found the HR for development of stroke or MI increased to 4.2. 18

02_Cohn.indd 18

In his accompanying editorial, Goldman noted that the ratio of postoperative MI to stroke in the NSQIP database was low compared with that found in previous large studies such as the Perioperative Ischemic Evaluation (POISE) trial,18 where the rate of postoperative MI:stroke was 7:1. If the ACS NSQIP database underestimated a large number of postoperative patient MIs because it only included Q-wave MIs, Kamel et al may have actually underestimated the risk of postoperative MI attributable to patient hemorrhage.19

Implications for Clinical Practice Preoperative assessment of the patient should include an estimation of the risk for intraoperative bleeding, as surgical patients who develop intraoperative hemorrhage are at increased risk for both MI and stroke. Medical consultants, anesthesiologists, and surgeons need to discuss the risks and benefits as well as the timing of continuing or stopping antiplatelet, antithrombotic, and bridging therapy perioperatively. Postoperative medical care should also include closer monitoring of those patients who did develop intraoperative hemorrhage, given these patients increased risk for MI and stroke. Ultimately, we will need better data, optimally randomized controlled trials (RCTs), to guide management of antithrombotic use in the perioperative setting.

Preoperative Pulmonary Care Preoperative physical therapy for elective cardiac surgery patients. Hulzebos EHJ, Smit Y, Helders PPJM, van Meeteren NLU. Cochrane Database Syst Rev. 2012;11:CD010118.20 Patients undergoing thoracic and upper abdominal surgeries are at particularly high risk for postoperative pulmonary complications (PPC). Postoperative lung expansion maneuvers, including incentive spirometry and deep breathing exercises, reduce PPC rates. Whether lung expansion maneuvers before surgery are effective is less well established. In a systematic review, Hulzebos et al review the literature to identify randomized or quasi-RCTS that compare any type of preoperative physical therapy with no therapy or sham therapy for elective cardiac surgery patients. The authors identified 8 eligible trials that included a total of 856 patients; 5 were studies of inspiratory muscle training and the remaining 3 studies used a mixed intervention of either aerobic exercise or breathing exercises. All studies subjects were patients undergoing coronary bypass (CABG) surgery. Preoperative physical therapy significantly reduced rates of atelectasis (RR 0.52; 95% CI, 0.32–0.87; P  =  0.01) and pneumonia (RR 0.45; 95% CI, 0.24–0.83;

© Hospital Practice, Volume 41, Issue 4, October/November 2013, ISSN – 2154-8331 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]

10/11/13 3:04 PM

Downloaded by [University of Pennsylvania] at 16:56 05 November 2015

Update in Perioperative Medicine 2013

P = 0.01). Patient length of stay was significantly reduced (–3.21 days; 95% CI, –5.73 to –0.69; P = 0.01). There was no effect on rates of respiratory failure (RR 0.55; 95% CI, 0.03–9.20; P = 0.68) or all-cause mortality (RR 0.66; 95% CI, 0.02–18.48; P = 0.81). In 2006, the American College of Physicians (ACP) performed a systematic review of interventions to reduce PPCs in patients, and determined that only postoperative lung expansion maneuvers showed enough efficacy to earn a level-A recommendation from the organization.21 The first trial to suggest risk-reduction value for preoperative lung expansion maneuvers was published in 200622 and is included in the review by Hulzebos and colleagues.20 Our review also amplifies and confirms the findings of the 2006 study. A program of preoperative chest physical therapy, in particular inspiratory muscle training, reduces rates of atelectasis and pneumonia in patients after CABG surgery. Whether the intervention would reduce patient PPC risk after other high-risk surgeries, such as esophagectomy or upper abdominal surgery, is unknown. However, there is no reason to suspect that it would be less effective in these settings.

Implications for Clinical Practice The particular intervention of inspiratory muscle training is well described in the 2006 study by Hulzebos et al22 and the technique requires that a dedicated therapist learn the details of the intervention and translate it into effective patient care. The benefit of the intervention is now well established; institutions should train therapists to provide the service to highrisk patients undergoing CABG surgery, and potentially for those patients undergoing surgeries with high risk for PPCs. Preoperative risk stratification for thoracic surgery using the American College of Surgeons National Surgical Quality Improvement Program data set: functional status predicts morbidity and mortality. Tsiouris A, Horst HM, Paone G, Hordari A, Eichenhorn M, Rubenfield I. J Surg Res. 2012;177(1):1–6.23 It is unclear if functional status is an important predictor of morbidity and mortality in patients undergoing thoracic surgery. In the study by Tsiouris et al, a cohort of 6373 thoracic surgery patients was identified from the ACS NSQIP database, accessed from the years 2005 to 2009. Patients were stratified by preoperative functional status, grouped as independent or dependent. An independent patient was defined as one who does not require any help from another individual to perform activities of daily living (ADL). A dependent patient was defined as one who requires some

or total assistance with ADL. Study outcomes were patient length of stay, perioperative complications (pneumonia, pulmonary embolism, reintubation, failure to wean from the ventilator, wound infection, other infections), and mortality. Only 13% of the study patients were dependent in the sample; they were significantly older than the independent patients (mean age, 65 vs 52 years, respectively) and had more emergent surgeries (18% vs 4%, respectively). Dependent patients also had lower albumin and higher creatinine blood levels, and higher ASA classifications at baseline. Postoperative complications occurred in 31% of the study patients; there was an increased risk of most postoperative complications in the dependent group compared with the independent group (Table 3). Multivariate analysis confirmed dependent functional status as an independent risk factor for morbidity and mortality, even after adjustment for coexisting risk factors common among these patients.

Implications for Clinical Practice The study by Tsiouris et al effectively highlights the actuality that patients with a dependent functional status fare more poorly after thoracic surgery than patients who are independent. One limitation of the study was that the study sample was taken from the NSQIP database, thus, not all pertinent patient information was available, such as preoperative pulmonary function testing results and arterial blood gas measures. The findings by Tsiouris et al are not surprising given that patient functional status is a factor considered in many of the surgical risk-assessment tools currently used to assess postoperative cardiac and pulmonary outcomes.14,24–26 Dependent functional status is associated with increased patient morbidity, mortality, and length of hospital stay. Clinicians should consider the impact of functional status when determining patient candidacy for thoracic surgery.

Perioperative Anticoagulation/ Bridging Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thromboembolic rates. Siegal D,Yudin J, Kaatz S, Douketis JD, Lim W, Spyropoulos AC. Circulation. 2012;126(13):1630–1639.27 Approximately 10% of patients receiving long-term warfarin therapy may require interruption of treatment when undergoing invasive procedures or surgery. Stopping warfarin may increase patient risk of thromboembolic events, whereas continuation of warfarin in the periprocedural period may increase patient risk of bleeding. The 2012 guidelines of

© Hospital Practice, Volume 41, Issue 4, October/November 2013, ISSN – 2154-8331 19 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]

02_Cohn.indd 19

10/11/13 3:04 PM

Downloaded by [University of Pennsylvania] at 16:56 05 November 2015

Cohn et al

the ACCP on antithrombotic therapy11 recommend an individualized approach to determining the need for bridging anticoagulation, with either unfractionated heparin or lowmolecular-weight heparin (LMWH), based on the patient’s estimated thromboembolic risk and periprocedural bleeding risk.11 However, the grades of these recommendations are weak (Level 2C), reflecting the lack of high-quality evidence. Therefore, systematic reviews and meta-analyses are helpful in guiding the management of patients on anticoagulant therapy who are surgical candidates. The investigators searched MEDLINE, Embase, and Cochrane Library databases between 2001 and 2010 for studies that included patients receiving heparin bridging during interruption of vitamin-K antagonists for elective procedures. The final review included 34 studies with 1 randomized trial. Thromboembolic events occurred in 73 of 7118 bridged patients (0.9%; 95% CI, 0.0–3.4) and 32 of 5160 non-bridged patients (0.6%; 95% CI, 0.0–1.2). Pooled incidence rates of overall and major bleeding in the total bridged cohort were 13.1% (34 studies; 95% CI, 0.0–45.2) and 4.2% (24 studies; 95% CI, 0.0–11.3), respectively. In the nonbridged cohort, pooled incidence rates of overall and major bleeding were 3.4% (13 studies; 95% CI, 1.1–5.8) and 0.9% (5 studies; 95% CI, 0.2–1.6), respectively. There was no difference in the risk of thromboembolic events in 8 studies comparing bridged with non-bridged groups (odds ratio [OR] 0.80; 95% CI, 0.42–1.54). Use of bridging was associated with an increased patient risk of overall bleeding in 13 studies (OR 5.40; 95% CI, 3.00–9.74) and major bleeding in 5 studies (OR 3.60; 95% CI, 1.52–8.50). There was no difference in thromboembolic events (OR 0.30; 95% CI, 0.04–2.09) but an increased patient risk of overall bleeding (OR 2.28; 95% CI, 1.27–4.08) with full versus prophylactic/intermediate-dose LMWH bridging. Low– thromboembolic-risk and/or non–vitamin-K-antagonist

patient groups were used for comparison. Study quality was poor with heterogeneity for some analyses. The study concluded that vitamin-K-antagonist-treated patients receiving periprocedural heparin bridging appear to be at increased risk of overall and major bleeding events and at similar risk for thromboembolic events compared with non-bridged patients.

Implications for Clinical Practice Siegal et al’s analysis suggests that bridging anticoagulation, especially in therapeutic-dose regimens and in patients not at high thromboembolic risk undergoing high-bleed-risk procedures, should be avoided in the periprocedural setting. To address this research question, 2 large randomized, placebo-controlled trials (Effectiveness of Bridging Anticoagulation for Surgery [BRIDGE]28 and A Safety and Effectiveness Study of LMWH Bridging Therapy Versus Placebo Bridging Therapy for Patients on Long Term Warfarin and Require Temporary Interruption of Their Warfarin [PERIOP-2]29) assessing bridging with therapeutic-dose LMWH are ongoing. The HAS BLED score predicts bleedings during bridging of chronic oral anticoagulation. Results from the national multicentre BNK Online Bridging Registry (BORDER). Omran H, Bauersachs R, Rübenacker S, Goss F, Hammerstingl C. Thromb Haemost. 2012;108(1):65–73.30 Bridging oral anticoagulation (OAC) prior to invasive procedures or surgery is recommended in patients at increased thromboembolic risk. However, bleeding complications from bridging should not be underestimated. The Hypertension, Age, Stroke history, previous Bleeding/bleeding risk, Labile INR, EtOH usage, and renal Disease (HAS BLED) score is often used for assessing bleeding risk in patients with atrial fibrillation when making decisions on long-term anticoagu-

Table 3.  Comparisons of Postoperative Complications Between Independent and Non-independent Patients21 Complication

Independent Group (N = 5561)

Non-independent Group (N = 812)

Unadjusted Odds Ratio (95% CI)

P Value

Length of stay (days)

7

19

NA

, 0.001

Pneumonia

4.5%

10.2%

2.7 (1.8–3.0)

, 0.001

Pulmonary embolism

0.7%

1.0%

Not significant

Not significant

Reintubation

3.5%

10.2%

3.1 (2.4–4.0)

, 0.001

Failure to wean

3.3%

24.4%

9.3 (7.5–11.6)

, 0.001

Infection

8.7%

19.6%

2.5 (2.1–3.1)

, 0.001

Mortality

2.8%

18.1%

7.7 (6.1–9.8)

, 0.001

Adapted from Tsiouris A, Horst HM, Paone G, Hodari A, Eichenhorn M, Rubenfield I. Preoperative risk stratification for thoracic surgery using the American College of Surgeons National Surgical Quality Improvement Program data set: functional status predicts morbidity and mortality. J Surg Res. 2012;177(1):1-6.21 © 2012, with permission of Elsevier.

20

02_Cohn.indd 20

© Hospital Practice, Volume 41, Issue 4, October/November 2013, ISSN – 2154-8331 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]

10/11/13 3:04 PM

Downloaded by [University of Pennsylvania] at 16:56 05 November 2015

Update in Perioperative Medicine 2013

lation for prophylaxis of thromboembolism.31 However, the utility of the HAS BLED score to predict risk of patient bleeding during bridging therapy is unknown. Omran et al conducted a prospective cohort study in Germany that used the BNK Online Bridging Registry (BORDER) to recruit a large outpatient cohort. Inclusion criteria included that patients were using OACs and needed periprocedural interruption. Outcome measures included type of bridging therapy used, embolic complications, and 30-day bleeding complications rates. Among patients who were at low risk of thromboembolic complications according to the ACCP 2012 guidelines,11 60% received inappropriately high LMWH doses. Conversely, for patients at high thromboembolic risk, 9% were not treated with full therapeutic doses of bridging anticoagulation. Among patients who received bridging OAC, 22 patients (2.2%) received LMWH at prophylactic dosing, 727 patients (72.7%) were treated with halved therapeutic LMWH doses, and 188 (18.8%) received full therapeutic LMWH doses. Of the total cohort, 3.6% of patients being bridged developed clinically relevant bleeding, whereas only 1.6% of patients without bridging had a bleeding complication; however, the difference was not statistically significant (P = 0.6). None of the patients bridged with prophylactic LMWH dosing developed a bleeding complication, and there was no difference between patients taking halved and full-dose LMWH in development of bleeding complications. Embolic complications occurred in only 4 cases (0.4%). After multivariate regression analysis, the HAS BLED score predicted occurrence of clinically relevant bleeding. Using receive operating curve analysis, a HAS BLED score of $ 3 had the best predictive value to identify patients at risk for bleeding during bridging treatment.

Implications for Clinical Practice The findings by Omran et al indicate that overtreatment with bridging anticoagulation may occur more often than previously thought, and bridging practices may need to change for low-risk patients. The finding that the HAS BLED score could be a significant, independent predictor of patient bleeding during bridging is clinically important. This does not imply that patients at moderate/high risk for thromboembolism should not receive bridging OAC, but rather, that modifiable risk factors should be treated prior to bridging if possible (ie, hypertension), and that close monitoring of patients for potential bleeding complications is wise if the decision is made to bridge.

Postoperative Delirium Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: a randomized control trial. Wang W, Li HL, Wang DX, et al. Crit Care Med. 2012;40(3):731–739.32 Delirium is a syndrome of fluctuation in consciousness and attention that usually develops over a short period of time.33 It is one of the most common CNS complications in elderly patients after surgery; incidence rates range from 15% to 53%.34 Patients who develop postoperative delirium are at risk for longer hospital stays, more frequent postoperative complications, poorer functional recovery, and higher mortality.35 With the aging US population increasing, many more older patients are undergoing surgery more frequently than ever before. In light of this, prevention of delirium in the postoperative setting is extremely important. Typical antipsychotics, like haloperidol, block the dopamine D2 receptor, and are mainstays of delirium treatment. Given that the pathophysiology of postoperative delirium likely involves dopaminergic excess, it was hypothesized that haloperidol could be effective in the prevention of postoperative delirium as well. In the study by Wang et al, the effects of haloperidol prophylaxis in elderly patients after noncardiac surgery were examined. Designed as a RCT and set in the intensive care unit (ICU) of 2 hospitals in Beijing, China, 457 patients, aged . 65 years and admitted to the ICU after surgery, were randomly assigned to receive either intravenous (IV) haloperidol (0.5 mg bolus followed by a 0.1 mg/hour drip 3 12 hours) or placebo on admission. The main endpoint was the incidence of delirium through postoperative day 7. Secondary endpoints included time to onset of delirium, daily prevalence of delirium, and length of stay in ICU. Delirium was assessed using the Confusion Assessment Method (CAM) ICU tool. The incidence of delirium during the first 7 postoperative days was lower for patients in the haloperidol-treated group than in the placebo group, 15.3% compared with 23.2%, respectively (P = 0.031). Daily prevalence of delirium was lower on postoperative days 1 and 3 in haloperidol-treated patients (7.0% [16/229] vs 13.2% [30/228]; P = 0.028; and 1.7% [4/229] vs 5.3% [12/228]; P  =  0.041, respectively). Time to onset of delirium was also longer for patients in the haloperidol group (6.2 vs 5.7 days; P = 0.021) and length of ICU stay was shortened by a few hours (21.3 vs 23 hours; P = 0.024). After adjustment of perioperative variables, the odds ratio for occurrence of postoperative delirium in the haloperidol-treated group was 0.574. From a safety standpoint, no ventricular arrhythmias occurred in either patient

© Hospital Practice, Volume 41, Issue 4, October/November 2013, ISSN – 2154-8331 21 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]

02_Cohn.indd 21

10/11/13 3:04 PM

Cohn et al

group. Changes in QTc interval were similar between groups, and there was no difference in all-cause 28-day mortality.

Implications for Clinical Practice Wang et al’s study is the largest RCT to date to show that prophylactic use of haloperidol decreases the incidence of postoperative delirium in elderly patients. While more data are needed to validate these results, given the findings, it is reasonable to consider the use of prophylactic, low-dose IV haloperidol as a safe, effective intervention to prevent delirium in postoperative elderly patients in the ICU.

Downloaded by [University of Pennsylvania] at 16:56 05 November 2015

Conclusion

As perioperative medicine continues to advance as a critical area of clinical practice, physicians will need to be apprised of current evidence to ensure that their decision-making processes are informed by the most recent data. Our update provides a summary and critique of the most clinically important recent evidence. Based on the studies reviewed in our article, we recommend the following: 1) Use preoperative testing selectively, not routinely, based on patient-related risk factors and the risk of the surgical procedure. 2) The surgical mortality probability model may be a useful, simple tool to advise patients about surgical mortality risk. 3) Delay elective noncardiac surgery for at least 30 to 45 days after BMS placement. Limited observational data suggest that it may be safe to proceed to surgery after only 6 rather than 12 months following placement of a DES. 4) Consider patient risk of intraoperative bleeding when performing preoperative assessment and perioperative management of antiplatelet and anticoagulant therapy as surgical patients who develop intraoperative hemorrhage are at increased risk for both MI and stroke. 5) Preoperative physical therapy reduces the rate of postoperative pulmonary complications after cardiac surgery; future studies are warranted to estimate the benefit in noncardiac surgery patients. 6) Consider dependent functional status as a risk factor in patient candidacy for thoracic surgery, as dependent status is associated with increased patient morbidity, mortality, and length of hospital stay. 7) Individualize the need for bridging anticoagulation due to increased patient bleeding risk without a definitive reduction in thromboembolic risk. 8) Use the HAS-BLED score when deciding whether or not to use bridging anticoagulation. 9) Consider using prophylactic haloperidol to prevent postoperative delirium in elderly ICU patients.

Conflict of Interest Statement

Steven L. Cohn, MD, claims no relevant conflicts of interest. Karen F. Mauck, MD, MSc, Suparna Dutta, MD, MPH, 22

02_Cohn.indd 22

and Gerald W. Smetana, MD, claim no conflicts of interest. Amir Jaffer, MD, is a consultant for and received funding for authoring a book from Janssen Pharmaceuticals, Inc.; a consultant for Pfizer Inc; a consultant for AstraZeneca-US; an independent contractor for University HealthSystems Consortium; and a member of the advisory committee/board of Boehringer Ingelheim Pharmaceuticals.

References

1. Cohn SL, Smetana GW, Dutta S. Update in perioperative medicine. Session presented at: 8th Annual Perioperative Summit: Using Evidence to Improve Quality, Patient Safety, and Outcomes. March 2013; Miami Beach, FL. 2. Smetana G, Mauck K, Jaffer A. Update in preoperative medicine. Session presented at: 36th Annual Meeting of the Society of General Internal Medicine. April 2013; Denver, CO. 3. Cohn SL. Update in perioperative medicine. Hospital Medicine 2013 — Annual Meeting of the Society of Hospital Medicine. May 16–19, 2013; National Harbor, MD. 4. Benarroch-Gampel J, Sheffield KM, Duncan CB, et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg. 2012;256(3):518–528. 5. Smetana GW, Macpherson DS. The case against routine preoperative laboratory testing. Med Clin N Amer. 2003;87(1):7–40. 6. Schein OD, Katz J, Bass EB, et al. The value of routine preoperative medical testing before cataract surgery. Study of Medical Testing for Cataract Surgery. N Engl J Med. 2000;342(3):168–175. 7. Committee on Standards and Practice Parameters, Apfelbaum JL, Connis Rt, Nickinovich DG; American Society of Anesthesiologists Task Force on Preanesthesia Evaluation, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116(3):522–538. 8. Glance LG, Lustik SJ, Hannan EL, et al. The Surgical Mortality Probability Model: derivation and validation of a simple risk prediction rule for noncardiac surgery. Ann Surg. 2012;255(4):696–702. 9. Wijeysundera DN, Wijeysundera CH, Yun L, et al. Risk of elective major noncardiac surgery after coronary stent insertion. Circulation. 2012;126(11):1355–1362. 10. Grines CL, Bonow RO, Casey DE, Jr, et al; American Heart Association; American College of Cardiology; Society for Cardiovascular Angiography and Interventions; American College of Surgeons; American Dental Association; American College of Physicians. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: A science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. J Am Coll Cardiol. 2007;49(6):734–739. 11. Douketis JD, Spyropoulos AC, Spencer FA, et al; American College of Chest Physicians. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e326S–350S. 12. Huang P, Croce KJ, Bhatt DL, Resnic FS. Recommendations for management of antiplatelet therapy in patients undergoing elective noncardiac surgery after coronary stent implantation. Crit Pathways Cardiol. 2012;11(4):177–185. 13. Hollis RH, Graham LA, Richman JS, Deierhoi RJ, Hawn MT. Adverse cardiac events in patients with coronary stents undergoing noncardiac surgery: a systemic review. Am J Surg. 2012;204(4):494–501.

© Hospital Practice, Volume 41, Issue 4, October/November 2013, ISSN – 2154-8331 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]

10/11/13 3:04 PM

Downloaded by [University of Pennsylvania] at 16:56 05 November 2015

Update in Perioperative Medicine 2013 14. Fleisher LA, Beckman JA, Brown KA, et al; American College of Cardiology; American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery); American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Rhythm Society; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine and Biology; Society for Vascular Surgery. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography ad Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol. 2007;50(17):e159–e241. 15. Kamel H, Claiborne SC Johnston S, Kirkham JC, et al. Association between major perioperative hemorrhage and stroke or Q-wave myocardial infarction. Circulation. 2012;126(2):207–212. 16. Devereaux PJ, Xavier D, Pogue J, et al; POISE (PeriOperative ISchemic Evaluation) Investigators. Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study. Ann Intern Med. 2011;154(8):523–528. 17. Mashour GA, Shanks AM, Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery. Anesthesiology. 2011;114(6):1289–1296. 18. POISE Study Group, Devereaux PJ, Yang H, Yusuf H, et al. Effects of extended release metoprolol succinate in patients undergoing noncardiac surgery (POISE trial): a randomised control trial. Lancet. 2008;371(9627):1839–1847. 19. Goldman, L. Bleeding is rarely good for you. Circulation. 2012;126(2):169–171. 20. Hulzebos EH, Smit Y, Helders PP, van Meeteren NL. Preoperative physical therapy for elective cardiac surgery patients. Cochrane Database Syst Rev. 2012;11:CD010118. 21. Lawrence VA, Cornell JE, Smetana GW; American College of Physicians. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006;144(8):596–608. 22. Hulzebos EH, Helder PJ, Favie NJ, De Bie RA, Brutel de la Riviere A, van Meeteren NL. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. JAMA. 2006;296(15):1851–1857. 23. Tsiouris A, Horst HM, Paone G, Hodari A, Eichenhorn M, Rubenfield I. Preoperative risk stratification for thoracic surgery using the American College of Surgeons National Surgical Quality Improvement Program data set: functional status predicts morbidity and mortality. J Surg Res. 2012;177(1):1–6.

24. Gupta H, Gupta PK, Fang X, et al. Development and validation of a risk calculator predicting postoperative respiratory failure. Chest. 2011;140(5):1207–1215. 25. Gupta PK, Gupta H, Sundaram A, et al. Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation. 2011;124(4):381–387. 26. Smetana GW, Lawrence VA, Cornell JE; American College of Physicians. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006;144(8):581–595. 27. Siegal D, Yudin J, Kaatz S, Douketis JD, Lim W, Spyropoulos AC. Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thromboembolic rates. Circulation. 2012;126(13):1630–1639. 28. Effectiveness of Bridging Anticoagulation for Surgery (The BRIDGE Study). http://clinicaltrials.gov/ct2/show/NCT00786474?term=bridge +anticoagulation&rank=1. Accessed September 17, 2013. 29. A Double Blind Randomized Control Trial of Post-Operative Low Molecular Weight Heparin Bridging Therapy Versus Placebo Bridging Therapy for Patients Who Are at High Risk for Arterial Thromboembolism (PERIOP 2)—A safety and effectiveness study of LMWH bridging therapy versus placebo bridging therapy for patients on long term warfarin and require temporary interruption of their warfarin. http:// clinicaltrials.gov/ct2/show/NCT00432796?term=periop-2&rank=1. Accessed September 17, 2013. 30. Omran H, Bauersachs R, Rubenacker S, Goss F, Hammerstingl C. The HAS-BLED score predicts bleedings during bridging of chronic oral anticoagulation. Results from the national Multicentre BNK Online Briding Registry (BORDEr). Thromb Haemost. 2012;108(1):65–73. 31. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: The Euro Heart Survey. Chest. 2010;138(5):1093–1100. 32. Wang, W, Li HL, Wang DX, et al. Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery: a randomized control trial. Crit Care Med. 2012;40(3):731–739. 33. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM IV). Washington, DC: American Psychiatric Association; 2000. 34. Demeure MJ, Fain MJ. The elderly surgical patient and postoperative delirium. J Am Coll Surg. 2006;203(5):752–757; Erratum in J Am Coll Surg. 2007;204(1):191. 35. Robinson TN, Eiseman B: Postoperative delirium in the elderly: diagnosis and management. Clin Intern Aging. 2008;3(2):351–355.

© Hospital Practice, Volume 41, Issue 4, October/November 2013, ISSN – 2154-8331 23 ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]

02_Cohn.indd 23

10/11/13 3:04 PM

Update in perioperative medicine 2013.

Perioperative medicine is an important and rapidly expanding area of interest across multiple specialties, including internal medicine, anesthesiology...
482KB Sizes 0 Downloads 0 Views