Answers to common questions in post-op care with our Kashlak Chief of Perioperative Medicine Dr. Avital O’Glasser. She provides updates in delirium prevention, perioperative medication management, pain control, and even clarifies a lesson from Meredith Grey about causes of post-op fever.
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Written: Hannah Abrams MD, Avital O’Glasser MD
Produced by, Infographic and Cover Art by: Hannah Abrams MD
Hosts: Hannah Abrams MD; Matthew Watto MD, FACP; Paul Williams MD, FACP
Editor: Avital O’Glasser MD (written materials); Clair Morgan of nodderly.com
Guest: Avital O’Glasser MD
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Dr. O’Glasser describes basic tenets of post-operative comanagement and what key questions you should ask when accepting a consult or beginning comanagement.
Consult: Asking a defined question of another service. Comanagement: a shared responsibility model, usually in context of a preset agreement between service lines, wherein each service’s responsibilities are usually arranged in advance as a solution for medical complexity of surgical patients or for system efficiency. (SHM 2017) This concept dates back to 1929! (Mason 1929)
Dr. O’Glasser recommends clarifying the comanagement relationship, or the reason for consult, when asked to see a post-op patient. Some questions she asks of her surgical colleagues include: “What are you worried about?”, “What clinical events have happened in this patient’s care?”, and she advises approaching the relationship from a lens of humility.
Post-operative specific questions Dr. O’Glasser asks include questions about the operative course and any intraoperative events or PACU events, medications and fluids received during surgery, and total blood loss; she also checks the op note and anesthesia record for these. She cautions that phrases like “normal blood loss” or “hemodynamically stable throughout the case” might not mention the fact that the blood loss was 2-3L, or that the patient may have required pressors to maintain hemodynamic stability!
Common intraoperative events that the postoperative surgical team may not be aware of and may need to be found in the EMR include administration of anticoagulants, antiemetics, fluids, or pressors. Specifying the type of anesthesia may also provide key insights into diagnosing causes of delirium.
Dr. O’Glasser provides brief evidence updates and expert advice on how to comanage several common issues in post-op care.
Unless it’s a patient who has had abdominal surgery, Dr. O’Glasser recommends that hospitalists can take ownership of the bowel regimen. For patients who are post major abdominal surgery, she advises that internists should communicate with the surgical team specifically about this.
Key aspects of post-operative pain management that Dr. O’Glasser recommends thinking about include understanding the expected post-op pain associated with the specific procedure the patient had, identifying both narcotics and undertreated pain as potential sources of delirium in the post-op patient, and knowing the usual recovery course for the procedure. Dr. O’Glasser recommends that pain management should be consistently discussed with the surgical team.
Non-narcotic analgesics like transdermal lidocaine may be helpful, but should be discussed with the surgical team if near an incision. (Smoker 2019) Evidence for use of gabapentinoids post-operatively remains unclear, and in general prescribers should be aware of the risk of polypharmacy with opioid-sparing regimens. (Verret 2019) NSAIDs may also be a helpful adjunct for postoperative pain and inflammation. (Greer 2020)
Literature on the effect of preoperative glucose and hemoglobin A1c on postoperative infections are mixed; however, more liberal glucose targets are currently recommended for post-op patients because of the metabolic stress of surgery and the risk of hypoglycemia. (Buchleitner 2012, Mongkolpun 2019) Dr. O’Glasser notes that most management principles for glucose management in ill inpatients apply; she recommends particular caution with resumption of SLGT2 inhibitors (SGLT2i) because of the risk of euglycemic DKA.
Continuing ACEi perioperatively had equal number needed to treat (NNT) and number needed to harm (NNH). (Shiffermiller 2018) Dr. O’Glasser’s practice is to resume ACEi on POD1 if the clinical course is stable, the patient is hypertensive, and renal function is unchanged.
Dr. O’Glasser continues beta blockers and calcium channel blockers so long as the patient is not bradycardic or hypotensive, but will also consider reducing the dose. In choosing when to resume diuretics, Dr. O’Glasser recommends looking at the patient’s total volume picture including intraoperative fluid losses and being aware of postoperative inflammatory third spacing.
Inhaled isopropyl alcohol may be as effective as ondansetron and other antiemetics. (Lindblad 2018) PONV is easier to prevent than to treat, so Dr. O’Glasser cautions to be aware of whether your patient has already received antiemetics such as promethazine or dexamethasone preoperatively or in the PACU as a preventative. There is limited data to support use of aromatherapy for PONV (Hines 2018), and some evidence to support acupuncture. (Martin 2019)
Dr. O’Glasser also points out that in her experience, PONV often manifests early in the postoperative course, and so new nausea or vomiting on POD2 or beyond should be investigated and not assumed to be the direct consequence of anesthesia.
Several clinical guidelines exist for management of VTE prophylaxis perioperatively; Dr. O’Glasser recommends that internists comanaging surgical patients communicate with surgeons specifically about when they are comfortable initiating prophylaxis and bearing weight for ambulation.
Proactive geriatric consultation may help reduce postoperative delirium in older patients. (Marcantonio 2018, Wang 2019) Dr. O’Glasser points out that delirium is easier to prevent than treat (Hughes 2020), and points out that for some patients, comanagement by Geriatrics rather than Medicine may be more appropriate.
Other considerations for hidden causes of post-op delirium include pre-op anticholinergic use (McIsaac 2019), cannabis/cannabinoid withdrawal (Ladha 2019), and cystocerebral syndrome (urinary retention). (Waardenburg 2008)
As featured on the pilot of Grey’s Anatomy, the “5 Ws” often taught in medical school are wind (atelectasis), water, wound, walking, and wonder drugs. (Rhimes 2004) Atelectasis, however, does not actually cause post-op fever. (Mavros 2011, Larsen 2020) Magnitude of fever, too, does not predict infection. (Wilson 1988) Early post-operative fever, however, is more likely to be inflammatory and noninfectious. (Garibaldi 1985) Dr. O’Glasser recommends reviewing the operative record for information about intraoperative events that may predispose to infection.
Unique considerations Dr. O’Glasser includes in her approach to tachycardia for post-op patients include an increased risk of volume depletion after surgery, increased risk of perioperative cardiac ischemia, inadequate pain control, withdrawal, and pulmonary embolism.
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Listeners will effectively comanage perioperative patients with surgical colleagues.
After listening to this episode listeners will…
Dr. O’Glasser reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
O’Glasser AY, Abrams HR, Williams PN, Watto MF. “#219 Post-Op Care and Complications with Avital O’Glasser MD”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list June 15, 2020.
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