The Perioperative Medicine Consult Handbook

The Perioperative Medicine Consult Handbook

Christopher J. Wong, MD Department of Medicine, Division of General Internal Medicine, University of Washington Medical Center, Seattle, Washington, USA

Nason P. Hamlin, MD, FACP Department of Medicine, Division of General Internal Medicine, University of Washington Medical Center, Seattle, Washington, USA

EditorsChristopher J. Wong, MD Department of Medicine Division of General Internal Medicine University of Washington Medical Center Seattle, WA, USA

Nason P. Hamlin, MD, FACP Department of Medicine, Division of General Internal Medicine University of Washington Medical Center Seattle, WA, USA

ISBN 978-1-4614-3219-7 ISBN 978-1-4614-3220-3 (eBook) DOI 10.1007/978-1-4614-3220-3 Springer New York Heidelberg Dordrecht London

Library of Congress Control Number: 2012950321

© Springer Science+Business Media New York 2013 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, speci fi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on micro fi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied speci fi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a speci fi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

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Springer is part of Springer Science+Business Media (www.springer.com)

We dedicate this book to Dominic F. “Dom” Reilly, MD and Diane Doerner, MD and to our patients.

Dedication

vii

Perioperative medical consultation is an exciting and evolving fi eld of medicine. At the University of Washington Medical Center, medicine consultation as a separate endeavor began in the late 1980s with gen-eral medicine attendings taking medicine consultation calls in addi-tion to their primary care practices. In the early 1990s, a formal Medicine Consult Service was developed, with early pioneers includ-ing Dominic Reilly, MD, and Diane Doerner, MD. Patients were seen on the inpatient wards and in the surgical clinics. By 1995, however, the Medicine Consult Service began its own small clinic in a shared space. Over the ensuing years, the Medicine Consult Service has expanded in number of staff, patients seen, and clinic size. Our focus has been on the evaluation of medically complex patients undergoing noncardiac surgery.

Collaboration and continuity have been hallmarks of the service:

In November of 2003 the Medicine Consult Clinic moved into ■

the Surgical Pavilion, in close proximity to the Pre-Anesthesia Clinic and the Surgical clinics. This location fosters close con-tact with the perioperative team. A unique feature of this service has been its continuity—the ■

same provider who performs the preoperative evaluation also sees the patient postoperatively (see Chap 2, Styles of Medical Consultation). In the current hospitalist era, it is a way in which a general internist can still practice inpatient and outpatient medicine at the same time.

The Medicine Consult Service has always maintained its teaching mis-sion, with housestaff and medical students rotating through the ser-vice. In addition, in the course of performing clinical consultation, we also serve as educators for the surgical residents, holding the belief that a surgeon who knows more medicine will provide better overall care.

The fi rst edition of The Medicine Consult Handbook was published in 2006 as a resource for residents and junior faculty regarding the

Preface

viii PREFACE

science and art of perioperative medicine. As the evidence base for perioperative practice has expanded, so too has this handbook. We have attempted to provide a balanced presentation that includes edu-cation, evidence, common situations, guideline-based care, and pearls of wisdom, while not emphasizing practices that may be unique to our own institution. For the sake of point-of-care use, we have favored brevity and included references to a subset of the perioperative medi-cine literature, rather than creating comprehensive chapters better suited to a traditional textbook.

How to use this book: For those just starting in perioperative medi-cine, we recommend reading Chap 3: The Preoperative Evaluation, Chap 4: Perioperative Medication Management, Chap 6: Cardiovascular Risk Strati fi cation, and Chap 13: Pulmonary Risk Assessment and Management as a general overview. Other topics may be reviewed as needed depending on one’s practice setting and the types of patients seen.

Even with the increasing guidelines and evidence, perioperative medicine remains an art and, as always, there may be local practices that are different from those presented in this book. We fully expect the practice of perioperative medicine to continue to change and welcome your comments and feedback.

Christopher J. Wong, MD Seattle, WA, USA Nason P. Hamlin, MD, FACP March 2012

ix

Perioperative Management of the Patient with Rheumatologic Disease Gregory C. Gardner, MD , Professor, Rheumatology , University of Washington

Valvular Heart Disease Philip A. Vedovatti, MD

Implantable Cardiac Devices Philip A. Vedovatti, MD

Perioperative Diabetes Management Irl B. Hirsch, MD , Professor of Medicine , University of Washington Anthony DeSantis, MD , Clinical Assistant Professor of Medicine , University of Washington Janet Kelly, PharmD , Clinical Professor, Dept. of Pharmacy, School of Pharmacy, University of Washington Cindy Sayre, ARNP , Director/Assistant Administrator, Patient Care Services , University of Washington

Ischemic Heart Disease Steven L. Goldberg, MD, Clinical Associate Professor of Medicine, Division of Cardiology, University of Washington Laurie A. Soine, PhD, ARNP, Teaching Associate in the Department of Radiology and Department of Medicine, Division of Cardiology, University of Washington

Surgical Procedures Overview John L. Gore, MD , Assistant Professor, Department of Urology , University of Washington Daniel W. Lin, MD , Associate Professor, Department of Urology , University of Washington

Acknowledgments

x ACKNOWLEDGMENTS

Frederick A Matsen III, MD , Professor, Department of Orthopaedics and Sports Medicine , University of Washington Seth S. Leopold, MD , Professor, Department of Orthopaedics and Sports Medicine , University of Washington Matthew P. Sweet, MD , Assistant Professor, Surgery , University of Washington Mark H. Meissner, MD , Professor, Surgery, Division of Vascular Surgery, University of Washington

Perioperative Care of the Bariatric Patient Saurabh Khandelwal, MD , Assistant Professor, Surgery , University of Washington

Preoperative Evaluation of Disorders of HemostasisTerry Gernsheimer, MD, Professor of Medicine, Division of Hematology, University of Washington

Perioperative Management of AnemiaTerry Gernsheimer, MD, Professor of Medicine, Division of Hematology, University of Washington

xi

Preface ................................................................................. vii

Acknowledgments ............................................................... ix

Contributors ........................................................................ xix

I. Introduction

1 Introduction ............................................................ 3General Guidelines for Providing • Outstanding Medical Consultation ................... 3“Comanagement” Versus “Consultation”• .......... 6

2 Styles of Medical Consultation ............................... 7

II. Preoperative Evaluation

3 The Preoperative Evaluation .................................. 11Pre-op History and Physical• .............................. 11Summarize Your Findings• ................................. 16Recommendations• ............................................. 17Communicate Your Evaluation• ......................... 18

III. Medication Management

4 Perioperative Medication Management ................. 21Preoperative Management• ................................. 21Postoperative Management• ............................... 21Discussion• ........................................................... 23

IV. Anesthesia

5 Anesthesia Pearls ..................................................... 31What Are the Main Concerns • of Anesthesiologists in the Perioperative Period? ................................................................ 31

Contents

xii CONTENTS

Some “Pearls” to Think About• ........................... 32What Anesthesiologists Find Helpful • in a Medicine Consult Note ............................... 33Statements/Advice to Avoid in a Medicine • Consult Note ....................................................... 34When Should You Think About • Consulting a Subspecialty Anesthesiologist? .... 34Anesthesiology Terms to Be Familiar with• ....... 35

V. Cardiology

6 Cardiovascular Risk Stratification ......................... 39Functional Capacity/Exercise Tolerance• ........... 39Estimation of Cardiac Risk• ............................... 41Other Guidelines• ................................................ 42Noninvasive Cardiac Stress Testing• .................. 43Other Cardiac Testing• ........................................ 46Examples of Stress Tests and Potential • Management Strategies ..................................... 46

7 Ischemic Heart Disease........................................... 49Preoperative Evaluation• .................................... 49Postoperative Management• ............................... 49Discussion• ........................................................... 51

8 Perioperative Beta-Blockers ................................... 53Preoperative Evaluation• .................................... 53Postoperative Management• ............................... 53Discussion• ........................................................... 53

9 Atrial Fibrillation .................................................... 57Preoperative Evaluation• .................................... 57Postoperative Management• ............................... 60Discussion• ........................................................... 62

10 Hypertension ........................................................... 67Preoperative Evaluation• .................................... 67Postoperative Management• ............................... 67Discussion• ........................................................... 69

11 Valvular Heart Disease ............................................ 71Aortic Stenosis• .................................................... 71Mitral Stenosis• ................................................... 74

xiiiCONTENTS

Aortic Regurgitation• .......................................... 74Mitral Regurgitation• .......................................... 75Prosthetic Heart Valves• ...................................... 75Other Structural Heart Disease• ......................... 78

12 Implantable Cardiac Devices .................................. 79Pacemaker and ICD Function• ........................... 79Electromagnetic Interference• ............................ 81Perioperative Management• ................................ 82Intra-operative Management• ............................. 83Postoperative Management• ............................... 85Company Contact Information• ......................... 86

VI. Pulmonary

13 Pulmonary Risk Assessment and Management..... 89Preoperative Evaluation• .................................... 89Postoperative Management• ............................... 91Discussion• ........................................................... 92

14 Asthma and COPD .................................................. 93Preoperative Evaluation• .................................... 93Postoperative Management• ............................... 94Discussion• ........................................................... 95

15 Obstructive Sleep Apnea ......................................... 97Preoperative Evaluation• .................................... 97Postoperative Management• ............................... 99Discussion• ........................................................... 99

16 Pulmonary Hypertension ........................................ 101Background• ........................................................ 101Preoperative Evaluation• .................................... 101Postoperative Management• ............................... 105Discussion• ........................................................... 106

17 Venous Thromboembolic Disease .......................... 109Preoperative Evaluation• .................................... 109Postoperative Management• ............................... 112

VII. Renal

18 Chronic Kidney Disease .......................................... 123Preoperative Evaluation• .................................... 123Postoperative Management• ............................... 125

xiv CONTENTS

19 Acute Kidney Injury ................................................ 127Preoperative Evaluation• .................................... 127Postoperative Management• ............................... 128Discussion• ........................................................... 131

VIII. Gastroenterology

20 Liver Disease and Perioperative Risk ..................... 135Preoperative Evaluation• .................................... 135Risk Stratification• .............................................. 136Preoperative Management• ................................. 137Postoperative Management• ............................... 139

IX. Endocrine

21 Perioperative Diabetes Management ..................... 143Recommendations for Perioperative Use • of Antidiabetic Medication (for Procedures that Require a Restricted Oral Intake) .............. 143Special Situations: TPN and Tube Feeds• .......... 148

22 Stress-Dose Steroids ............................................... 153Assessment of Hypothalamic–• Pituitary–Adrenal Axis ....................................... 153Perioperative Management• ................................ 153Complications• .................................................... 154

X. Hematology

23 Anticoagulation ....................................................... 159Atrial Fibrillation• ............................................... 159Cessation of Warfarin• ........................................ 159Bridging Therapy• ............................................... 164Minor Procedures• ............................................... 165Strategies to Reverse Warfarin Effect• ............... 165Strategies to Reverse Dabigatran Effect• ........... 166

24 Preoperative Evaluation of Disorders of Hemostasis .......................................................... 169

Preoperative Evaluation of Hemostasis• ............ 169Perioperative Management • of Specific Bleeding Disorders .......................... 170

xvCONTENTS

25 Postoperative Thrombocytopenia .......................... 175Background• ........................................................ 175Evaluation• .......................................................... 175Heparin-Induced Thrombocytopenia• ............... 178

26 Perioperative Management of Anemia................... 181Preoperative Evaluation• .................................... 181Intraoperative Management• .............................. 182Postoperative Management• ............................... 182

XI. Neurology

27 Parkinson’s Disease ................................................. 189Preoperative Evaluation• .................................... 189Perioperative Medication Management• ............ 190Postoperative Management• ............................... 191

28 Epilepsy and Seizure Disorders ............................. 193Preoperative Evaluation• .................................... 193Postoperative Management• ............................... 194Discussion• ........................................................... 195

29 Cerebrovascular Disease ......................................... 197Preoperative Evaluation• .................................... 197Postoperative Management• ............................... 198

XII. Rheumatology

30 Perioperative Management of the Patient with Rheumatologic Disease .................................. 203

General Principles• .............................................. 203Rheumatoid Arthritis• ......................................... 203Systemic Lupus Erythematosus• ........................ 205Other Rheumatologic Diseases• ......................... 208

31 Gout and Pseudogout .............................................. 209Discussion• ........................................................... 209

XIII. Special Populations

32 Perioperative Care of the Bariatric Patient ........... 213Preoperative Evaluation• .................................... 213Postoperative Management• ............................... 215Early Postoperative Complications• ................... 218Discussion• ........................................................... 219

xvi CONTENTS

33 Perioperative Care of the Patient with a Solid Organ Transplant ............................... 221

Preoperative Evaluation• .................................... 221Postoperative Management• ............................... 222Discussion• ........................................................... 224

34 Decision-Making Capacity ...................................... 225Risk Factors for Incapacity • .............................. 225Assessing Capacity• ............................................. 226Management of Incapacity • ............................... 227

35 Substance Abuse and Dependence ......................... 229Preoperative Evaluation• .................................... 229Postoperative Management• ............................... 230

XIV. Postoperative Management: General Principles

36 The Postoperative Evaluation................................. 235Post Anesthesia Care Unit Assessment• ............. 235Daily Postoperative Evaluation• ......................... 237

37 Postoperative Fever ................................................. 239Postoperative Fever Pearls• ................................. 239Timing After Surgery is Key to • Correctly Identifying the Cause of a Fever ....... 239Evaluation: Examine the Patient • Carefully for Possible Source ............................ 240Treatment: Identify and Treat • the Underlying Cause ......................................... 241Fever Prevention• ................................................ 242

38 Postoperative Delirium ........................................... 243Preoperative Evaluation• .................................... 243Definition• ............................................................ 243Incidence• ............................................................ 244Risk Factors• ........................................................ 244Preoperative Screening• ...................................... 244Postoperative Management• ............................... 245Precipitating Etiologies• ..................................... 245Prevention• ........................................................... 246Treatment• ............................................................ 247Discussion• ........................................................... 248

xviiCONTENTS

39 Postoperative Ileus .................................................. 251Key Points• ........................................................... 251Background• ........................................................ 251Evaluation• .......................................................... 252Differential Diagnosis• ........................................ 252Treatment• ............................................................ 253Prevention• ........................................................... 254

XV. Surgery Topics

40 Surgical Procedures Overview ................................ 259Orthopedic Surgery• ............................................ 259General Surgery• ................................................. 263Gynecology and Gynecology–Oncology • Surgery................................................................ 266Urologic Surgery/Procedures• ............................ 268Vascular Surgery• ................................................ 270Carotid Endarterectomy• .................................... 271Head and Neck Surgery• ..................................... 273Neurosurgery• ...................................................... 274Ophthalmologic Surgery• .................................... 274Dental Surgery• .................................................... 274

Appendix: Surgery Abbreviations ...................................... 275

Index .................................................................................... 277

xix

John H. Choe , MD, MPH Department of Medicine , Division of General Internal Medicine, Harborview Medical Center, University of Washington School of Medicine, University of Washington Medical Center , Seattle , WA , USA

Paul B. Cornia , MD Department of Medicine , Division of General Internal Medicine, VA Puget Sound Health Care System, University of Washington , Seattle , WA , USA

Anna L. Golob , MD Department of Medicine, Division of General Internal Medicine, VA Puget Sound Health Care System , University of Washington , Seattle , WA , USA

Nason P. Hamlin , MD, FACP Department of Medicine , Division of General Internal Medicine, University of Washington Medical Center , Seattle , WA , USA

Ronald Huang , MD, MPH Department of Medicine , Division of General Internal Medicine, University of Washington Medical Center , Seattle , WA , USA

Molly Blackley Jackson , MD Department of Medicine , Division of General Internal Medicine, University of Washington Medical Center , Seattle , WA , USA

Contributors

xx CONTRIBUTORS

Reena Julka , MD Department of Medicine, Division of General Internal Medicine , University of Washington , Medical Center, Seattle , WA , USA

Elizabeth Kaplan , MD Department of Medicine, Division of General Internal Medicine , University of Washington Medical Center , Seattle , WA , USA

Kara J. Mitchell , MD Department of Medicine, Division of General Internal Medicine , University of Washington Medical Center , Seattle , WA , USA

Brian S. Porter , MD Department of Medicine , Division of General Internal Medicine, University of Washington Medical Center , Seattle , WA , USA

Ashok Reddy , MD Robert Wood Johnson Foundation Clinical Scholar, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

G. Alec Rooke , MD, PhD Department of Anesthesiology and Pain Medicine , University of Washington Medical Center, Seattle , WA , USA

Lauge Sokol-Hessner , MD Department of Medicine , Division of General Internal Medicine, Beth Israel-Deaconess Medical Center, Boston, MA , USA

Rachel E. Thompson , MD, FHM Department of Medicine , Division of General Internal Medicine, Harborview Medical Center, University of Washington , Seattle , WA , USA

Gail A. Van Norman , MD Department of Anesthesiology and Pain Medicine , University of Washington Medical Center , Seattle , WA , USA

xxi

ICONTRIBUTORS

Kelly Wentworth , MD Department of Medicine, Division of General Internal Medicine , University of Washington Medical Center , Seattle , WA , USA

Andrew A. White , MD Department of Medicine, Division of General Internal Medicine , University of Washington Medical Center , Seattle , WA , USA

Christopher J. Wong , MD Department of Medicine, Division of General Internal Medicine , University of Washington Medical Center,Seattle , WA , USA