#219 Post-Op Care and Complications with Avital O’Glasser MD

June 15, 2020 | By Matthew Watto, MD

What Hospitalists Should Know About How to Prevent and Manage Postoperative Complications

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.

Listeners can claim Free CE credit through VCU Health at http://curbsiders.vcuhealth.org/ (CME goes live at 0900 ET on the episode’s release date).

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Credits

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

Sponsor

Join the American College of Physicians today! Post-training physicians can take advantage of an exclusive limited-time $100 dues discount. Visit acponline.org/member and use the code ACPDISCOUNT. Discount is only available until June 30, 2020.  

We are excited to announce that the Curbsiders are now partnering with VCU Health Continuing Education to offer continuing education credits for physicians and other healthcare professionals. Check out curbsiders.vcuhealth.org for more information.

Time Stamps

• 00:00 Sponsors
• 00:30 Intro, disclaimer, guest bio
• 02:53 Guest one-liner, Picks of the Week*: 12 Angry Men 1957 Movie; Hedwig and the Angry Inch Cast Recording; PCSSNow Buprenorphine Waiver Training for Medical Students
• 09:28 Sponsor
• 10:17 Kashlak case; How to collaborate with our surgical colleagues
• 13:45 Questions to ask at the time of transfer

• 23:00 Routine Post-Op Care: Bowel regimen, pain control, delirium prevention, glucose, antihypertensives, and nausea
• 44:25 Comanaging Complications and Fever/Tachycardia; Brief discussion of VTE prophylaxis

• 57:55 Outro

Postoperative Complication Pearls

1. Don’t forget to actually review the operative record. While estimated blood loss may be “as expected”, it still may be hemodynamically significant; similarly, the consulting surgical team may not have all of the information about hemodynamics or medications given during the case.
2. Urinary retention may cause postoperative delirium (cystocerebral syndrome); also consider withdrawal syndromes and pre- or intra- operative anticholinergic administration as causes of delirium that may be overlooked in postoperative patients.
3. Atelectasis does not cause post-op fever! Look for other causes of early postoperative inflammatory response.
4. Post-operative care can be collaborative. Dr. O’Glasser recommends framing the conversation in terms of humility, and understanding that your surgical colleagues are asking for your help.

Post-Operative Care Notes

Post-Operative Care Basics

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 vs. Comanagement

Definitions

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)

Considerations for the Surgical Patient

Defining the Comanagement Arrangement

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.

Key Post-Operative Questions

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.

Common Post-Op Care Questions

Dr. O’Glasser provides brief evidence updates and expert advice on how to comanage several common issues in post-op care.

Comanaging Routine Post-Op Care

Bowel Regimen

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.

Pain Control

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)

Glucose Management

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.

ACE Inhibitors and Other Antihypertensives

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. 

Postoperative Nausea/Vomiting (PONV)

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.

Thromboprophylaxis

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.

Post-Op Complications

Delirium Prevention and Diagnosis

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)

Post-Op Fever

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.

Post-Op Tachycardia

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.

Links*

1. 12 Angry Men 1957 Movie
2. Hedwig and the Angry Inch Cast Recording
3. PCSSNow Buprenorphine Waiver Training for Medical Students

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goal

Listeners will effectively comanage perioperative patients with surgical colleagues.

Learning objectives

After listening to this episode listeners will…  

1. Identify effective strategies to improve safety at the time of transfer acceptance.
2. Develop an approach for asking appropriate perioperative questions to the surgical team.
3. Recognize common mistakes that hospitalists make when accepting a transfer.
4. Become familiar with evidence based post-operative care to prevent and treat common post-op complications
5. Develop a differential diagnosis and management approach for post-op fever
6. Develop a differential diagnosis and management approach for delirium

Disclosures

Dr. O’Glasser reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

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.

References

1. The Evolution of Co-Management White Paper. SHM 2017. [https://www.hospitalmedicine.org/globalassets/practice-management/practice-management-pdf/pm-19-0004-co-management-white-paper_minor-update-m.pdf]
2. Mason W. Medical Co-operation in the management of the surgical case. NEJM. 1929. [https://www.nejm.org/doi/full/10.1056/NEJM192909122011101]
3. Smoker J, et al. Transdermal Lidocaine for Perioperative Pain: a Systematic Review of the Literature. Curr Pain Headache Rep. 2019. [https://pubmed.ncbi.nlm.nih.gov/31728770/] 
4. Verret, Michael et al. “Perioperative use of gabapentinoids for the management of postoperative acute pain: protocol of a systematic review and meta-analysis.” Systematic reviews. 2019. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6334388/]
5. Greer AB, et al. Decreasing postoperative opioid use while managing pain: A prospective study of men who underwent scrotal surgery. BJUI Compass. 2020. [https://pubmed.ncbi.nlm.nih.gov/32494777/]
6. Buchleitner AM, et al. Perioperative glycaemic control for diabetic patients undergoing surgery. Cochrane Reviews. 2012. [https://www.cochrane.org/CD007315/ENDOC_perioperative-glycaemic-control-for-diabetic-patients-undergoing-surgery] 
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8.  Shiffermiller JF, Monson BJ, Vokoun CW, et al. Prospective Randomized Evaluation of Preoperative Angiotensin-Converting Enzyme Inhibition (PREOP-ACEI). J Hosp Med. 2018 [https://pubmed.ncbi.nlm.nih.gov/30261084/]
9. Lindblad AJ, et al. Inhaled isopropyl alcohol for nausea and vomiting in the emergency department. Can Fam Physician. 2018. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6189884/]
10. Hines S, et al. Aromatherapy for treating postoperative nausea and vomiting. Cochrane Reviews. 2012. [https://www.cochrane.org/CD007598/ANAESTH_aromatherapy-treating-postoperative-nausea-and-vomiting]
11. Martin CS, et al. Randomized trial of acupuncture with antiemetics for reducing postoperative nausea in children. Acta Anaesthesiol Scand. 2019. [https://pubmed.ncbi.nlm.nih.gov/30397904/] 
12. Marcantonio ER. Delirium in Hospitalized Older Adults. N Engl J Med. 2017. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5706782/]
13. Wang Y, et al. Effect of the Tailored, Family-Involved Hospital Elder Life Program on Postoperative Delirium and Function in Older Adults: A Randomized Clinical Trial. JAMA Intern Med. 2020. [https://pubmed.ncbi.nlm.nih.gov/31633738/]
14. Hughes CG, Boncyk CS, Culley DJ, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention. Anesth Analg. 2020. [https://pubmed.ncbi.nlm.nih.gov/32022748]
15. McIsaac DI, et al. Association of Preoperative Anticholinergic Medication Exposure With Postoperative Healthcare Resource Use and Outcomes: A Population-based Cohort Study. Ann Surg. 2019. [https://pubmed.ncbi.nlm.nih.gov/29672409]  
16. Ladha KS, Manoo V, Virji AF, et al. The Impact of Perioperative Cannabis Use: A Narrative Scoping Review. Cannabis Cannabinoid Res. 2019. [https://pubmed.ncbi.nlm.nih.gov/31872058/]
17. Waardenburg IE. Delirium caused by urinary retention in elderly people: a case report and literature review  on the “cystocerebral syndrome”. J Am Geriatr Soc. 2008 [https://pubmed.ncbi.nlm.nih.gov/19093953/]
18.  Rhimes S. “#100: A Hard Day’s Night”. Grey’s Anatomy. 2004. [http://leethomson.myzen.co.uk/Grey’s_Anatomy/Grey’s_Anatomy_1x01_-_A_Hard_Days_Night.pdf] 
19. Mavros MN, et al. Atelectasis as a cause of postoperative fever: where is the clinical evidence?. Chest. 2011 [https://pubmed.ncbi.nlm.nih.gov/21527508/]
20.  Larsen T (@TylerLarsenMD). “1/ Does atelectasis cause post-operative fever?…” Twitter. 2:25 AM, Feb 18, 2020. [https://twitter.com/TylerLarsenMD/status/1229668322926452737] 
21. Wilson AP, et al. Should the temperature chart influence management in cardiac operations? Result of a prospective study in 314 patients. J Thorac Cardiovasc Surg. 1988 [https://pubmed.ncbi.nlm.nih.gov/3050285/]
22. Garibaldi RA, et al. Evidence for the non-infectious etiology of early postoperative fever. Infect Control. 1985 [https://pubmed.ncbi.nlm.nih.gov/3847403/]