Breakout Sessions
This presentation was a playful banter between two experts—Steven Cohn, MD, of Miller School of Medicine in Miami and Lenny Feldman, MD, of Johns Hopkins in Baltimore—who showed us the evidence (and lack thereof) for several perioperative matters:
Session Analysis: Controversies in Perioperative Medicine
This presentation was a playful banter between two experts—Steven Cohn, MD, of Miller School of Medicine in Miami and Lenny Feldman, MD, of Johns Hopkins in Baltimore—who showed us the evidence (and lack thereof) for several perioperative matters:
Timing of noncardiac surgery after cardiac stent placement. AHA/ACC guide-lines suggest waiting 12 months after placement of a drug-eluting stent and 30 to 45 days for bare-metal stents. The speakers suggested that, based on limited data, waiting only six months might be sufficient for patients to undergo noncardiac surgery. They were in support of the 30- to 45-day waiting period for bare-metal stents.
Care approach for hip fracture patients. Current models include admission to the hospitalist or orthopedic service, or true comanagement models. Studies suggest higher nurse and surgeon satisfaction with comanagement, but Dr. Cohn suggested there is limited benefit in hospitalist comanagement of low-risk, straightforward cases. There are some data suggesting a decrease in time to surgery, UTI, DVT, and pressure ulcers with comanagement.
Routine, post-operative troponin monitoring for silent MI. Data showed 65% of patients with post-op MIs will not have symptoms but might have a troponin leak or ECG changes. The controversy is that even if we detect a post-op MI, there are no good data that any interventions (e.g. aspirin and statins, transferring to CCU or telemetry, performing cardiac catherization) will improve mortality. There are data that show the higher the troponin leak in post-operative patients, the higher the mortality, except in low-risk patients.
Pre-operative dosing of glargine insulin. There are no guidelines in the U.S. In the U.K., National Health Services recommends continuing glargine at 100% the dose, which is what Dr. Cohn recommends for patients with blood sugars >120 and without kidney disease. Dr. Feldman recommends to reduce the glargine dosing to 50% to 80%, taking it the night before or the morning of surgery, as it is easier and safer to manage hyper-than hypoglycemia (being mindful of the complications associated with perioperative hyperglycemia). Ultimately, the dosing needs to be individualized to minimize both hypo- and hyperglycemia in the perioperative period.
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