1. How do you manage perioperative patients taking anticoagulants?
Say you've got an atrial fibrillation patient with a CHADS2 score of 1 or 2. In the next room over, there's a patient with a relatively new aortic valve. Both are scheduled for surgery. To mitigate stroke risk, should you bridge anticoagulants for the first person or the second?
Dr. Cheng may have surprised the audience when he said "neither." But according to research as well as guidance from the American College of Chest Physicians (ACCP), he is correct.
The ACCP stratifies stroke risk and the need for bridging from low to high based on a combination of factors among patients with atrial fibrillation and mechanical valves. These include CHADS2 scores (the lower the score, the lower the need for bridging), and valve design and type (modern aortic valves pose the least risk).
2. How do you prevent and assess risk for post-op delirium?
Given that delirium can increase mortality risks up to 20% after every 48 hours, the dangers of this condition warrant diligence. But while risk factors are straightforward (such as being 65 or older), prevention can be tricky.
The literature supports a combination of preventive measures, and Dr. Cheng lists several to try. First and foremost, minimize opioids, anticholinergics, benzodiazepines, and other sedatives — and since antipsychotics treat distress and not delirium, turn to behavioral interventions first.
3. How long should you wait to perform surgery after a heart attack or stroke?
While it's wise to avoid scheduling surgery too soon after a recent cardiovascular event, Dr. Cheng's lecture emphasizes that there are plateaus to any waiting period.
In the case of myocardial infarction (MI), guidelines recommend delaying surgery for two months. Research indicates that a heart attack survivor’s risk of experiencing postoperative MI plateaus 60 days after the initial event.
Stroke delays should be longer — but not as long as you might think. According to a study that compared postoperative cardiac events among stroke survivors, the risk was lower after waiting three to six months and plateaued after nine months.
4. How can you predict the risks of surgery in cirrhosis patients?
Of all topics discussed, Dr. Cheng says he loses the most sleep over cirrhotic patients because their mortality risk is surprisingly high.
Such risk had traditionally been classified using the Child-Pugh score, which stratified patients into three classes. But given the risks for this system to underscore at-risk patients, the model for end-stage liver disease (MELD) may be preferable.
The MELD score calculates international normalized ratios of bilirubin and creatinine and sets a cutoff: For those over 14, surgery may not be helpful not because of the postoperative risks, but because of the long-term risks of not getting a transplant. Ultimately, patients in this group may not live long enough to see the benefits of elective surgery.
5. Should you limit "curbside" consultations?
Are ad-hoc consults detrimental to patient care? The answer is far from simple.
In a study comparing informal and formal consultations between clinicians and hospitalists, "curbside" consultants gave incomplete or wrong clinical information up to a third of the time. Moreover, the recommendations of a formal and an informal consultation were different more than half the time.
A "just say no" policy may not be any better, because the high threshold for consults may dissuade colleagues from seeking an expert opinion. Consider this compromise: If the question is basic, one-time, and not concerning a very ill patient, curbside counsel is probably fine. But you should still offer formal consultations when asked.
Hospitalists routinely find themselves at a clinical crossroads. If you've experienced similar situations, give this lecture a listen — Dr. Cheng clearly walks through each of these scenarios (plus two others). And with on-demand access, you can keep up with these and other internal medicine topics anywhere at any time.
