User login
Pulmonary hypertension linked to complications after head and neck procedures
SAN DIEGO – Patients with , compared with their counterparts who do not have the condition. They also face an increase in total charges and length of stay.
The findings come from what is believed to be the first study of its kind to investigate the impact of pulmonary hypertension (PHTN) on major head and neck procedures. “PHTN is a common condition which affects the caliber of lung vasculature, with varied symptom presentation from shortness of breath to syncope, with an estimated prevalence of 2.5 to 7.1 million new cases each year worldwide,” one of the study authors, Nirali M. Patel, said at the Triological Society’s Combined Sections Meeting. “Due to improved therapeutic options, there is an enhanced survival of PHTN patients and higher prevalence of this disease. PHTN has some significant systemic implications. Therefore, cardiopulmonary clearance and a clear understanding of postoperative complications are very important.”
Previous studies have shown PHTN to be an independent predictor of morbidity and mortality in noncardiac procedures, said Ms. Patel, a fourth-year medical student at New Jersey Medical School, Newark. Furthermore, the rate of pulmonary complications is reported to be between 11% and 44.8% following radical head and neck cancer resection. “Despite these findings, there is currently a lack of information regarding perioperative morbidity and mortality of patients with PHTN undergoing major head and neck procedures,” she said.
The researchers queried the National Inpatient Survey from 2002 to 2013 for all cases of major head and neck surgery based on the ICD-9 codes for esophagectomy, glossectomy, laryngectomy, mandibulectomy, and pharyngectomy. They divided patients into two groups: those who had PHTN and those who did not, and performed demographic analyses as well as univariate and multivariate regression analyses.
Ms. Patel reported findings from a cohort of 46,311 patients. Of these, 46,073 had PHTN and 238 did not. The two groups were similar in age (a mean of 69 vs. 60 years in those with and without PHTN, respectively) and race (80% white vs. 79% white, respectively), but there were significantly fewer male patients in the PHTN group (57% vs. 70%; P less than .0001).
Several patient comorbidities were increased in the PHTN group, compared with the non-PHTN group, including coagulopathy (8.4% vs. 3.1%; P less than .0001), chronic heart failure (22.4% vs. 4.1%; P less than .0001), complicated diabetes (4.6% vs. 1.2%; P less than .0001), fluid and electrolyte disorders (30% vs. 18.3%; P less than .0001), and hypertension (63.3% vs. 43.7%; P less than .0001).
Postoperatively, patients with PHTN had a longer length of stay (a mean of 15.80 vs. 11.50 days, respectively; P less than .0001) as well as significantly higher total charges (a mean of $162,021.06 vs. $107,309.46, respectively; P less than .0001). When the researchers evaluated postoperative outcomes between the two cohorts, patients with PHTN had significantly higher rates of cardiac complications (9.2% vs. 3.5%; P less than .0001), iatrogenic pulmonary embolism (2.1% vs. 0.3%; P = .001), pulmonary edema (2.1% vs. 0.4%; P = .003), venous thrombotic events (4.6% vs. 1%; P less than. 0001), pulmonary insufficiency (17.2% vs. 9.7%; P less than .0001), and pneumonia (9.7% vs. 6%; P = .027), as well as higher rates of postoperative tracheostomy (8.4% vs. 4.5%; P = .007).
Multivariate analysis revealed that the following factors predicted in-hospital mortality: coagulopathy, chronic heart failure, fluid and electrolyte disorders, hyperlipidemia, hypertension, hypothyroidism, liver disease, obesity, paralysis, and renal failure. Despite these findings, there was no significant change in overall hospital mortality for those with PHTN, with an odds ratio of 1.055.
“Our study is not without its limitations, many of which are inherent to the use of a database, which is subject to errors in coding and sampling,” Ms. Patel noted at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. “Despite these limitations, the study provides valuable information on the impact of PHTN on major head and neck procedures.
She reported having no financial disclosures.
SOURCE: Patel N et al. Triological CSM, Abstracts.
SAN DIEGO – Patients with , compared with their counterparts who do not have the condition. They also face an increase in total charges and length of stay.
The findings come from what is believed to be the first study of its kind to investigate the impact of pulmonary hypertension (PHTN) on major head and neck procedures. “PHTN is a common condition which affects the caliber of lung vasculature, with varied symptom presentation from shortness of breath to syncope, with an estimated prevalence of 2.5 to 7.1 million new cases each year worldwide,” one of the study authors, Nirali M. Patel, said at the Triological Society’s Combined Sections Meeting. “Due to improved therapeutic options, there is an enhanced survival of PHTN patients and higher prevalence of this disease. PHTN has some significant systemic implications. Therefore, cardiopulmonary clearance and a clear understanding of postoperative complications are very important.”
Previous studies have shown PHTN to be an independent predictor of morbidity and mortality in noncardiac procedures, said Ms. Patel, a fourth-year medical student at New Jersey Medical School, Newark. Furthermore, the rate of pulmonary complications is reported to be between 11% and 44.8% following radical head and neck cancer resection. “Despite these findings, there is currently a lack of information regarding perioperative morbidity and mortality of patients with PHTN undergoing major head and neck procedures,” she said.
The researchers queried the National Inpatient Survey from 2002 to 2013 for all cases of major head and neck surgery based on the ICD-9 codes for esophagectomy, glossectomy, laryngectomy, mandibulectomy, and pharyngectomy. They divided patients into two groups: those who had PHTN and those who did not, and performed demographic analyses as well as univariate and multivariate regression analyses.
Ms. Patel reported findings from a cohort of 46,311 patients. Of these, 46,073 had PHTN and 238 did not. The two groups were similar in age (a mean of 69 vs. 60 years in those with and without PHTN, respectively) and race (80% white vs. 79% white, respectively), but there were significantly fewer male patients in the PHTN group (57% vs. 70%; P less than .0001).
Several patient comorbidities were increased in the PHTN group, compared with the non-PHTN group, including coagulopathy (8.4% vs. 3.1%; P less than .0001), chronic heart failure (22.4% vs. 4.1%; P less than .0001), complicated diabetes (4.6% vs. 1.2%; P less than .0001), fluid and electrolyte disorders (30% vs. 18.3%; P less than .0001), and hypertension (63.3% vs. 43.7%; P less than .0001).
Postoperatively, patients with PHTN had a longer length of stay (a mean of 15.80 vs. 11.50 days, respectively; P less than .0001) as well as significantly higher total charges (a mean of $162,021.06 vs. $107,309.46, respectively; P less than .0001). When the researchers evaluated postoperative outcomes between the two cohorts, patients with PHTN had significantly higher rates of cardiac complications (9.2% vs. 3.5%; P less than .0001), iatrogenic pulmonary embolism (2.1% vs. 0.3%; P = .001), pulmonary edema (2.1% vs. 0.4%; P = .003), venous thrombotic events (4.6% vs. 1%; P less than. 0001), pulmonary insufficiency (17.2% vs. 9.7%; P less than .0001), and pneumonia (9.7% vs. 6%; P = .027), as well as higher rates of postoperative tracheostomy (8.4% vs. 4.5%; P = .007).
Multivariate analysis revealed that the following factors predicted in-hospital mortality: coagulopathy, chronic heart failure, fluid and electrolyte disorders, hyperlipidemia, hypertension, hypothyroidism, liver disease, obesity, paralysis, and renal failure. Despite these findings, there was no significant change in overall hospital mortality for those with PHTN, with an odds ratio of 1.055.
“Our study is not without its limitations, many of which are inherent to the use of a database, which is subject to errors in coding and sampling,” Ms. Patel noted at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. “Despite these limitations, the study provides valuable information on the impact of PHTN on major head and neck procedures.
She reported having no financial disclosures.
SOURCE: Patel N et al. Triological CSM, Abstracts.
SAN DIEGO – Patients with , compared with their counterparts who do not have the condition. They also face an increase in total charges and length of stay.
The findings come from what is believed to be the first study of its kind to investigate the impact of pulmonary hypertension (PHTN) on major head and neck procedures. “PHTN is a common condition which affects the caliber of lung vasculature, with varied symptom presentation from shortness of breath to syncope, with an estimated prevalence of 2.5 to 7.1 million new cases each year worldwide,” one of the study authors, Nirali M. Patel, said at the Triological Society’s Combined Sections Meeting. “Due to improved therapeutic options, there is an enhanced survival of PHTN patients and higher prevalence of this disease. PHTN has some significant systemic implications. Therefore, cardiopulmonary clearance and a clear understanding of postoperative complications are very important.”
Previous studies have shown PHTN to be an independent predictor of morbidity and mortality in noncardiac procedures, said Ms. Patel, a fourth-year medical student at New Jersey Medical School, Newark. Furthermore, the rate of pulmonary complications is reported to be between 11% and 44.8% following radical head and neck cancer resection. “Despite these findings, there is currently a lack of information regarding perioperative morbidity and mortality of patients with PHTN undergoing major head and neck procedures,” she said.
The researchers queried the National Inpatient Survey from 2002 to 2013 for all cases of major head and neck surgery based on the ICD-9 codes for esophagectomy, glossectomy, laryngectomy, mandibulectomy, and pharyngectomy. They divided patients into two groups: those who had PHTN and those who did not, and performed demographic analyses as well as univariate and multivariate regression analyses.
Ms. Patel reported findings from a cohort of 46,311 patients. Of these, 46,073 had PHTN and 238 did not. The two groups were similar in age (a mean of 69 vs. 60 years in those with and without PHTN, respectively) and race (80% white vs. 79% white, respectively), but there were significantly fewer male patients in the PHTN group (57% vs. 70%; P less than .0001).
Several patient comorbidities were increased in the PHTN group, compared with the non-PHTN group, including coagulopathy (8.4% vs. 3.1%; P less than .0001), chronic heart failure (22.4% vs. 4.1%; P less than .0001), complicated diabetes (4.6% vs. 1.2%; P less than .0001), fluid and electrolyte disorders (30% vs. 18.3%; P less than .0001), and hypertension (63.3% vs. 43.7%; P less than .0001).
Postoperatively, patients with PHTN had a longer length of stay (a mean of 15.80 vs. 11.50 days, respectively; P less than .0001) as well as significantly higher total charges (a mean of $162,021.06 vs. $107,309.46, respectively; P less than .0001). When the researchers evaluated postoperative outcomes between the two cohorts, patients with PHTN had significantly higher rates of cardiac complications (9.2% vs. 3.5%; P less than .0001), iatrogenic pulmonary embolism (2.1% vs. 0.3%; P = .001), pulmonary edema (2.1% vs. 0.4%; P = .003), venous thrombotic events (4.6% vs. 1%; P less than. 0001), pulmonary insufficiency (17.2% vs. 9.7%; P less than .0001), and pneumonia (9.7% vs. 6%; P = .027), as well as higher rates of postoperative tracheostomy (8.4% vs. 4.5%; P = .007).
Multivariate analysis revealed that the following factors predicted in-hospital mortality: coagulopathy, chronic heart failure, fluid and electrolyte disorders, hyperlipidemia, hypertension, hypothyroidism, liver disease, obesity, paralysis, and renal failure. Despite these findings, there was no significant change in overall hospital mortality for those with PHTN, with an odds ratio of 1.055.
“Our study is not without its limitations, many of which are inherent to the use of a database, which is subject to errors in coding and sampling,” Ms. Patel noted at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. “Despite these limitations, the study provides valuable information on the impact of PHTN on major head and neck procedures.
She reported having no financial disclosures.
SOURCE: Patel N et al. Triological CSM, Abstracts.
REPORTING FROM THE TRIOLOGICAL CSM
Key clinical point: Pulmonary hypertension (PHTN) is linked with certain head and neck surgical complications.
Major finding: For patients undergoing head and neck surgery, PHTN is associated with an increased risk of cardiac complications (9.2% vs. 3.5%) and iatrogenic pulmonary embolism (2.1% vs. 0.3%).
Study details: A retrospective analysis of 46,311 patient records from the National Inpatient Survey.
Disclosures: The researchers reported having no financial disclosures.
Source: Patel N et al. Triological CSM, Abstracts.
Risk models fail to predict lower-GI bleeding outcomes
In cases of lower gastrointestinal bleeding (LGIB), albumin and hemoglobin levels are the best independent predictors of severe bleeding, according to investigators.
These findings came from a sobering look at LGIB risk-prediction models. While some models could predict specific outcomes with reasonable accuracy, none of the models demonstrated broad predictive power, reported Natalie Tapaskar, MD, of the department of medicine at the University of Chicago, and her colleagues.
LGIB requires intensive resource utilization and proves fatal in 5%-15% of patients, which means timely and appropriate interventions are essential, especially for those with severe bleeding.
“There are limited data on accurately predicting the risk of adverse outcomes for hospitalized patients with LGIB,” the investigators wrote in Gastrointestinal Endoscopy, “especially in comparison to patients with upper gastrointestinal bleeding (UGIB), where tools such as the Glasgow-Blatchford Bleeding Score have been validated to accurately predict important clinical outcomes.”
To assess existing risk models for LGIB, the investigators performed a prospective observational study involving 170 patients with LGIB who underwent colonoscopy during April 2016–September 2017 at the University of Chicago Medical Center. Data were collected through comprehensive medical record review.
The primary outcome was severe bleeding. This was defined by acute bleeding during the first 24 hours of admission that required a transfusion of 2 or more units of packed red blood cells, and/or caused a 20% or greater decrease in hematocrit; and/or recurrent bleeding 24 hours after clinical stability, involving rectal bleeding with an additional drop in hematocrit of 20% or more, and/or readmission for LGIB within 1 week of discharge. Secondary outcomes included blood transfusion requirements, in-hospital recurrent bleeding, length of stay, ICU admission, intervention (surgery, interventional radiology, endoscopy), and the comparative predictive ability of seven clinical risk stratification models: AIMS65, Charlson Comorbidity Index, Glasgow-Blatchford, NOBLADS, Oakland, Sengupta, and Strate. Area under the receiver operating characteristic curve (AUC) was used to compare model predictive power. Risk of adverse outcomes was calculated by univariable and multivariable logistic regression.
Results showed that median patient age was 70 years. Most of the patients (80%) were African American and slightly more than half were female (58%). These demographic factors were not predictive of severe bleeding, which occurred in about half of the cases (52%). Upon admission, patients with severe bleeding were more likely to have chronic renal failure (30% vs. 17%; P = .05), lower albumin (3.6 g/dL vs. 3.95 g/dL; P less than .0001), lower hemoglobin (8.6 g/dL vs. 11.1 g/dL; P = .0001), lower systolic blood pressure (118 mm Hg vs. 132 mm Hg; P = .01), and higher creatinine (1.3 mg/dL vs. 1 mg/dL; P = .04). After adjustment for confounding variables, the strongest independent predictors of severe bleeding were low albumin (odds ratio, 2.56 per 1-g/dL decrease; P = .02) and low hemoglobin (OR, 1.28 per 1-g/dL decrease; P = .0015).
On average, time between admission and colonoscopy was between 2 and 3 days (median, 62.2 hours). In 3 out of 4 patients (77%), etiology of LGIB was confirmed; diverticular bleeding was most common (39%), followed distantly by hemorrhoidal bleeding (15%).
Compared with milder cases, patients with severe bleeding were more likely to stay in the ICU (49% vs. 19%; P less than .0001), have a blood transfusion (85% vs 36%; P less than .0001), and need to remain in the hospital for a longer period of time (6 days vs. 4 days; P = .0009). These findings exemplify the high level of resource utilization required for LGIB and show how severe bleeding dramatically compounds intensity of care.
Further analysis showed that none of the seven risk models were predictive across all outcomes; however, some predicted specific outcomes better than others. Leaders were the Glasgow-Blatchford score for blood transfusion (AUC 0.87; P less than .0001), the Oakland score for severe bleeding (AUC 0.74; P less than .0001), the Sengupta score for ICU stay (AUC 0.74; P less than .0001), and the Strate score for both recurrent bleeding during hospital stay (AUC 0.66; P = .0008) and endoscopic intervention (AUC 0.62; P = .01).
The investigators noted that the Glasgow-Blatchford score, which also is used in cases of UGIB, has previously demonstrated accuracy in predicting blood transfusion, as it did in the present study, suggesting that, “[i]n instances where there may be uncertainty of the origin of the bleeding, the Blatchford score may be a preferential choice of risk score.”
“Overall, we found that no singular score performed best across all the outcomes studied nor did any score have an extremely strong discriminatory power for any individual variable,” the investigators wrote, concluding that “... simpler and more powerful prediction tools are required for better risk stratification in LGIB.”
The investigators reported no financial support or conflicts of interest.
*This story was updated on Jan. 31, 2019.
SOURCE: Tapaskar N et al. Gastrointest Endosc. 2018 Dec 18. doi: 10.1016/j.gie.2018.12.011.
In cases of lower gastrointestinal bleeding (LGIB), albumin and hemoglobin levels are the best independent predictors of severe bleeding, according to investigators.
These findings came from a sobering look at LGIB risk-prediction models. While some models could predict specific outcomes with reasonable accuracy, none of the models demonstrated broad predictive power, reported Natalie Tapaskar, MD, of the department of medicine at the University of Chicago, and her colleagues.
LGIB requires intensive resource utilization and proves fatal in 5%-15% of patients, which means timely and appropriate interventions are essential, especially for those with severe bleeding.
“There are limited data on accurately predicting the risk of adverse outcomes for hospitalized patients with LGIB,” the investigators wrote in Gastrointestinal Endoscopy, “especially in comparison to patients with upper gastrointestinal bleeding (UGIB), where tools such as the Glasgow-Blatchford Bleeding Score have been validated to accurately predict important clinical outcomes.”
To assess existing risk models for LGIB, the investigators performed a prospective observational study involving 170 patients with LGIB who underwent colonoscopy during April 2016–September 2017 at the University of Chicago Medical Center. Data were collected through comprehensive medical record review.
The primary outcome was severe bleeding. This was defined by acute bleeding during the first 24 hours of admission that required a transfusion of 2 or more units of packed red blood cells, and/or caused a 20% or greater decrease in hematocrit; and/or recurrent bleeding 24 hours after clinical stability, involving rectal bleeding with an additional drop in hematocrit of 20% or more, and/or readmission for LGIB within 1 week of discharge. Secondary outcomes included blood transfusion requirements, in-hospital recurrent bleeding, length of stay, ICU admission, intervention (surgery, interventional radiology, endoscopy), and the comparative predictive ability of seven clinical risk stratification models: AIMS65, Charlson Comorbidity Index, Glasgow-Blatchford, NOBLADS, Oakland, Sengupta, and Strate. Area under the receiver operating characteristic curve (AUC) was used to compare model predictive power. Risk of adverse outcomes was calculated by univariable and multivariable logistic regression.
Results showed that median patient age was 70 years. Most of the patients (80%) were African American and slightly more than half were female (58%). These demographic factors were not predictive of severe bleeding, which occurred in about half of the cases (52%). Upon admission, patients with severe bleeding were more likely to have chronic renal failure (30% vs. 17%; P = .05), lower albumin (3.6 g/dL vs. 3.95 g/dL; P less than .0001), lower hemoglobin (8.6 g/dL vs. 11.1 g/dL; P = .0001), lower systolic blood pressure (118 mm Hg vs. 132 mm Hg; P = .01), and higher creatinine (1.3 mg/dL vs. 1 mg/dL; P = .04). After adjustment for confounding variables, the strongest independent predictors of severe bleeding were low albumin (odds ratio, 2.56 per 1-g/dL decrease; P = .02) and low hemoglobin (OR, 1.28 per 1-g/dL decrease; P = .0015).
On average, time between admission and colonoscopy was between 2 and 3 days (median, 62.2 hours). In 3 out of 4 patients (77%), etiology of LGIB was confirmed; diverticular bleeding was most common (39%), followed distantly by hemorrhoidal bleeding (15%).
Compared with milder cases, patients with severe bleeding were more likely to stay in the ICU (49% vs. 19%; P less than .0001), have a blood transfusion (85% vs 36%; P less than .0001), and need to remain in the hospital for a longer period of time (6 days vs. 4 days; P = .0009). These findings exemplify the high level of resource utilization required for LGIB and show how severe bleeding dramatically compounds intensity of care.
Further analysis showed that none of the seven risk models were predictive across all outcomes; however, some predicted specific outcomes better than others. Leaders were the Glasgow-Blatchford score for blood transfusion (AUC 0.87; P less than .0001), the Oakland score for severe bleeding (AUC 0.74; P less than .0001), the Sengupta score for ICU stay (AUC 0.74; P less than .0001), and the Strate score for both recurrent bleeding during hospital stay (AUC 0.66; P = .0008) and endoscopic intervention (AUC 0.62; P = .01).
The investigators noted that the Glasgow-Blatchford score, which also is used in cases of UGIB, has previously demonstrated accuracy in predicting blood transfusion, as it did in the present study, suggesting that, “[i]n instances where there may be uncertainty of the origin of the bleeding, the Blatchford score may be a preferential choice of risk score.”
“Overall, we found that no singular score performed best across all the outcomes studied nor did any score have an extremely strong discriminatory power for any individual variable,” the investigators wrote, concluding that “... simpler and more powerful prediction tools are required for better risk stratification in LGIB.”
The investigators reported no financial support or conflicts of interest.
*This story was updated on Jan. 31, 2019.
SOURCE: Tapaskar N et al. Gastrointest Endosc. 2018 Dec 18. doi: 10.1016/j.gie.2018.12.011.
In cases of lower gastrointestinal bleeding (LGIB), albumin and hemoglobin levels are the best independent predictors of severe bleeding, according to investigators.
These findings came from a sobering look at LGIB risk-prediction models. While some models could predict specific outcomes with reasonable accuracy, none of the models demonstrated broad predictive power, reported Natalie Tapaskar, MD, of the department of medicine at the University of Chicago, and her colleagues.
LGIB requires intensive resource utilization and proves fatal in 5%-15% of patients, which means timely and appropriate interventions are essential, especially for those with severe bleeding.
“There are limited data on accurately predicting the risk of adverse outcomes for hospitalized patients with LGIB,” the investigators wrote in Gastrointestinal Endoscopy, “especially in comparison to patients with upper gastrointestinal bleeding (UGIB), where tools such as the Glasgow-Blatchford Bleeding Score have been validated to accurately predict important clinical outcomes.”
To assess existing risk models for LGIB, the investigators performed a prospective observational study involving 170 patients with LGIB who underwent colonoscopy during April 2016–September 2017 at the University of Chicago Medical Center. Data were collected through comprehensive medical record review.
The primary outcome was severe bleeding. This was defined by acute bleeding during the first 24 hours of admission that required a transfusion of 2 or more units of packed red blood cells, and/or caused a 20% or greater decrease in hematocrit; and/or recurrent bleeding 24 hours after clinical stability, involving rectal bleeding with an additional drop in hematocrit of 20% or more, and/or readmission for LGIB within 1 week of discharge. Secondary outcomes included blood transfusion requirements, in-hospital recurrent bleeding, length of stay, ICU admission, intervention (surgery, interventional radiology, endoscopy), and the comparative predictive ability of seven clinical risk stratification models: AIMS65, Charlson Comorbidity Index, Glasgow-Blatchford, NOBLADS, Oakland, Sengupta, and Strate. Area under the receiver operating characteristic curve (AUC) was used to compare model predictive power. Risk of adverse outcomes was calculated by univariable and multivariable logistic regression.
Results showed that median patient age was 70 years. Most of the patients (80%) were African American and slightly more than half were female (58%). These demographic factors were not predictive of severe bleeding, which occurred in about half of the cases (52%). Upon admission, patients with severe bleeding were more likely to have chronic renal failure (30% vs. 17%; P = .05), lower albumin (3.6 g/dL vs. 3.95 g/dL; P less than .0001), lower hemoglobin (8.6 g/dL vs. 11.1 g/dL; P = .0001), lower systolic blood pressure (118 mm Hg vs. 132 mm Hg; P = .01), and higher creatinine (1.3 mg/dL vs. 1 mg/dL; P = .04). After adjustment for confounding variables, the strongest independent predictors of severe bleeding were low albumin (odds ratio, 2.56 per 1-g/dL decrease; P = .02) and low hemoglobin (OR, 1.28 per 1-g/dL decrease; P = .0015).
On average, time between admission and colonoscopy was between 2 and 3 days (median, 62.2 hours). In 3 out of 4 patients (77%), etiology of LGIB was confirmed; diverticular bleeding was most common (39%), followed distantly by hemorrhoidal bleeding (15%).
Compared with milder cases, patients with severe bleeding were more likely to stay in the ICU (49% vs. 19%; P less than .0001), have a blood transfusion (85% vs 36%; P less than .0001), and need to remain in the hospital for a longer period of time (6 days vs. 4 days; P = .0009). These findings exemplify the high level of resource utilization required for LGIB and show how severe bleeding dramatically compounds intensity of care.
Further analysis showed that none of the seven risk models were predictive across all outcomes; however, some predicted specific outcomes better than others. Leaders were the Glasgow-Blatchford score for blood transfusion (AUC 0.87; P less than .0001), the Oakland score for severe bleeding (AUC 0.74; P less than .0001), the Sengupta score for ICU stay (AUC 0.74; P less than .0001), and the Strate score for both recurrent bleeding during hospital stay (AUC 0.66; P = .0008) and endoscopic intervention (AUC 0.62; P = .01).
The investigators noted that the Glasgow-Blatchford score, which also is used in cases of UGIB, has previously demonstrated accuracy in predicting blood transfusion, as it did in the present study, suggesting that, “[i]n instances where there may be uncertainty of the origin of the bleeding, the Blatchford score may be a preferential choice of risk score.”
“Overall, we found that no singular score performed best across all the outcomes studied nor did any score have an extremely strong discriminatory power for any individual variable,” the investigators wrote, concluding that “... simpler and more powerful prediction tools are required for better risk stratification in LGIB.”
The investigators reported no financial support or conflicts of interest.
*This story was updated on Jan. 31, 2019.
SOURCE: Tapaskar N et al. Gastrointest Endosc. 2018 Dec 18. doi: 10.1016/j.gie.2018.12.011.
FROM GASTROINTESTINAL ENDOSCOPY
Key clinical point: In cases of lower gastrointestinal bleeding (LGIB), albumin and hemoglobin levels are the best independent predictors of severe bleeding.
Major finding: After adjustment for confounding variables, low albumin upon admission was the strongest independent predictor of severe bleeding (OR, 2.56 per 1 g/dL decrease; P = .02).
Study details: A prospective, observational study of 170 patients with LGIB who underwent colonoscopy during April 2016–September 2017 at the University of Chicago Medical Center.
Disclosures: The investigators reported no financial support or conflicts of interest.
Source: Tapaskar N et al. Gastrointest Endosc. 2018 Dec 18. doi: 10.1016/j.gie.2018.12.011.
No change in postoperative pain with restrictive opioid protocol
Opioid prescriptions after gynecologic surgery can be significantly reduced without impacting postoperative pain scores or complication rates, according to a paper published in JAMA Network Open.
A tertiary care comprehensive care center implemented an ultrarestrictive opioid prescription protocol (UROPP) then evaluated the outcomes in a case-control study involving 605 women undergoing gynecologic surgery, compared with 626 controls treated before implementation of the new protocol.
The ultrarestrictive protocol was prompted by frequent inquiries from patients who had used very little of their prescribed opioids after surgery and wanted to know what to do with the unused pills.
The new protocol involved a short preoperative counseling session about postoperative pain management. Following that, ambulatory surgery, minimally invasive surgery, or laparotomy patients were prescribed a 7-day supply of nonopioid pain relief. Laparotomy patients were also prescribed a 3-day supply of an oral opioid.
Any patients who required more than five opioid doses in the 24 hours before discharge were also prescribed a 3-day supply of opioid pain medication as needed, and all patients had the option of requesting an additional 3-day opioid refill.
Researchers saw no significant differences between the two groups in mean postoperative pain scores 2 weeks after surgery, and a similar number of patients in each group requested an opioid refill. There was also no significant difference in the number of postoperative complications between groups.
Implementation of the ultrarestrictive protocol was associated with significant declines in the mean number of opioid pills prescribed dropped from 31.7 to 3.5 in all surgical cases, from 43.6 to 12.1 in the laparotomy group, from 38.4 to 1.3 in the minimally invasive surgery group, and from 13.9 to 0.2 in patients who underwent ambulatory surgery.
“These data suggest that the implementation of a UROPP in a large surgical service is feasible and safe and was associated with a significantly decreased number of opioids dispensed during the perioperative period, particularly among opioid-naive patients,” wrote Jaron Mark, MD, of the department of gynecologic oncology at Roswell Park Comprehensive Cancer Center, Buffalo, N.Y., and his coauthors. “The opioid-sparing effect was also marked and statistically significant in the laparotomy group, where most patients remained physically active and recovered well with no negative sequelae or elevated pain score after surgery.”
The researchers also noted that patients who were discharged home with an opioid prescription were more likely to call and request a refill within 30 days, compared with patients who did not receive opioids at discharge.
The study was supported by the Roswell Park Comprehensive Cancer Center, the National Cancer Institute and the Roswell Park Alliance Foundation. Two authors reported receiving fees and nonfinancial support from the private sector unrelated to the study.
SOURCE: Mark J et al. JAMA Netw Open. 2018 Dec 7. doi: 10.1001/jamanetworkopen.2018.5452.
The ultrarestrictive postoperative opioid prescribing protocol described in this study is a promising strategy for reducing opioid prescribing without increasing pain and limiting the potential for diversion and misuse of opioids. An important element of this protocol is the preoperative counseling, because setting patient expectations is likely to be an important factor in improving postoperative outcomes.
It is also worth noting that this study focused on patients undergoing major and minor gynecologic surgery, so more research is needed to explore these outcomes particularly among patients undergoing procedures that may be associated with a higher risk of persistent postoperative pain and/or opioid use. It is also a management strategy explored in patients at low risk of chronic postoperative opioid use, but a similar pathway should be developed and explored in more high-risk patients.
Dr. Jennifer M. Hah is from the department of anesthesiology, perioperative, and pain management at Stanford University (Calif.). These comments are taken from an accompanying editorial (JAMA Network Open. 2018 Dec 7. doi: 10.1001/jamanetworkopen.2018.5432). No conflicts of interest were reported.
The ultrarestrictive postoperative opioid prescribing protocol described in this study is a promising strategy for reducing opioid prescribing without increasing pain and limiting the potential for diversion and misuse of opioids. An important element of this protocol is the preoperative counseling, because setting patient expectations is likely to be an important factor in improving postoperative outcomes.
It is also worth noting that this study focused on patients undergoing major and minor gynecologic surgery, so more research is needed to explore these outcomes particularly among patients undergoing procedures that may be associated with a higher risk of persistent postoperative pain and/or opioid use. It is also a management strategy explored in patients at low risk of chronic postoperative opioid use, but a similar pathway should be developed and explored in more high-risk patients.
Dr. Jennifer M. Hah is from the department of anesthesiology, perioperative, and pain management at Stanford University (Calif.). These comments are taken from an accompanying editorial (JAMA Network Open. 2018 Dec 7. doi: 10.1001/jamanetworkopen.2018.5432). No conflicts of interest were reported.
The ultrarestrictive postoperative opioid prescribing protocol described in this study is a promising strategy for reducing opioid prescribing without increasing pain and limiting the potential for diversion and misuse of opioids. An important element of this protocol is the preoperative counseling, because setting patient expectations is likely to be an important factor in improving postoperative outcomes.
It is also worth noting that this study focused on patients undergoing major and minor gynecologic surgery, so more research is needed to explore these outcomes particularly among patients undergoing procedures that may be associated with a higher risk of persistent postoperative pain and/or opioid use. It is also a management strategy explored in patients at low risk of chronic postoperative opioid use, but a similar pathway should be developed and explored in more high-risk patients.
Dr. Jennifer M. Hah is from the department of anesthesiology, perioperative, and pain management at Stanford University (Calif.). These comments are taken from an accompanying editorial (JAMA Network Open. 2018 Dec 7. doi: 10.1001/jamanetworkopen.2018.5432). No conflicts of interest were reported.
Opioid prescriptions after gynecologic surgery can be significantly reduced without impacting postoperative pain scores or complication rates, according to a paper published in JAMA Network Open.
A tertiary care comprehensive care center implemented an ultrarestrictive opioid prescription protocol (UROPP) then evaluated the outcomes in a case-control study involving 605 women undergoing gynecologic surgery, compared with 626 controls treated before implementation of the new protocol.
The ultrarestrictive protocol was prompted by frequent inquiries from patients who had used very little of their prescribed opioids after surgery and wanted to know what to do with the unused pills.
The new protocol involved a short preoperative counseling session about postoperative pain management. Following that, ambulatory surgery, minimally invasive surgery, or laparotomy patients were prescribed a 7-day supply of nonopioid pain relief. Laparotomy patients were also prescribed a 3-day supply of an oral opioid.
Any patients who required more than five opioid doses in the 24 hours before discharge were also prescribed a 3-day supply of opioid pain medication as needed, and all patients had the option of requesting an additional 3-day opioid refill.
Researchers saw no significant differences between the two groups in mean postoperative pain scores 2 weeks after surgery, and a similar number of patients in each group requested an opioid refill. There was also no significant difference in the number of postoperative complications between groups.
Implementation of the ultrarestrictive protocol was associated with significant declines in the mean number of opioid pills prescribed dropped from 31.7 to 3.5 in all surgical cases, from 43.6 to 12.1 in the laparotomy group, from 38.4 to 1.3 in the minimally invasive surgery group, and from 13.9 to 0.2 in patients who underwent ambulatory surgery.
“These data suggest that the implementation of a UROPP in a large surgical service is feasible and safe and was associated with a significantly decreased number of opioids dispensed during the perioperative period, particularly among opioid-naive patients,” wrote Jaron Mark, MD, of the department of gynecologic oncology at Roswell Park Comprehensive Cancer Center, Buffalo, N.Y., and his coauthors. “The opioid-sparing effect was also marked and statistically significant in the laparotomy group, where most patients remained physically active and recovered well with no negative sequelae or elevated pain score after surgery.”
The researchers also noted that patients who were discharged home with an opioid prescription were more likely to call and request a refill within 30 days, compared with patients who did not receive opioids at discharge.
The study was supported by the Roswell Park Comprehensive Cancer Center, the National Cancer Institute and the Roswell Park Alliance Foundation. Two authors reported receiving fees and nonfinancial support from the private sector unrelated to the study.
SOURCE: Mark J et al. JAMA Netw Open. 2018 Dec 7. doi: 10.1001/jamanetworkopen.2018.5452.
Opioid prescriptions after gynecologic surgery can be significantly reduced without impacting postoperative pain scores or complication rates, according to a paper published in JAMA Network Open.
A tertiary care comprehensive care center implemented an ultrarestrictive opioid prescription protocol (UROPP) then evaluated the outcomes in a case-control study involving 605 women undergoing gynecologic surgery, compared with 626 controls treated before implementation of the new protocol.
The ultrarestrictive protocol was prompted by frequent inquiries from patients who had used very little of their prescribed opioids after surgery and wanted to know what to do with the unused pills.
The new protocol involved a short preoperative counseling session about postoperative pain management. Following that, ambulatory surgery, minimally invasive surgery, or laparotomy patients were prescribed a 7-day supply of nonopioid pain relief. Laparotomy patients were also prescribed a 3-day supply of an oral opioid.
Any patients who required more than five opioid doses in the 24 hours before discharge were also prescribed a 3-day supply of opioid pain medication as needed, and all patients had the option of requesting an additional 3-day opioid refill.
Researchers saw no significant differences between the two groups in mean postoperative pain scores 2 weeks after surgery, and a similar number of patients in each group requested an opioid refill. There was also no significant difference in the number of postoperative complications between groups.
Implementation of the ultrarestrictive protocol was associated with significant declines in the mean number of opioid pills prescribed dropped from 31.7 to 3.5 in all surgical cases, from 43.6 to 12.1 in the laparotomy group, from 38.4 to 1.3 in the minimally invasive surgery group, and from 13.9 to 0.2 in patients who underwent ambulatory surgery.
“These data suggest that the implementation of a UROPP in a large surgical service is feasible and safe and was associated with a significantly decreased number of opioids dispensed during the perioperative period, particularly among opioid-naive patients,” wrote Jaron Mark, MD, of the department of gynecologic oncology at Roswell Park Comprehensive Cancer Center, Buffalo, N.Y., and his coauthors. “The opioid-sparing effect was also marked and statistically significant in the laparotomy group, where most patients remained physically active and recovered well with no negative sequelae or elevated pain score after surgery.”
The researchers also noted that patients who were discharged home with an opioid prescription were more likely to call and request a refill within 30 days, compared with patients who did not receive opioids at discharge.
The study was supported by the Roswell Park Comprehensive Cancer Center, the National Cancer Institute and the Roswell Park Alliance Foundation. Two authors reported receiving fees and nonfinancial support from the private sector unrelated to the study.
SOURCE: Mark J et al. JAMA Netw Open. 2018 Dec 7. doi: 10.1001/jamanetworkopen.2018.5452.
Key clinical point: A ultrarestrictive postoperative opioid protocol is not associated with higher postoperative pain scores.
Major finding: The protocol achieves significant reductions in opioid use.
Study details: A case-control study in 1,231 women undergoing gynecologic surgery.
Disclosures: The study was supported by the Roswell Park Comprehensive Cancer Center, the National Cancer Institute, and the Roswell Park Alliance Foundation. Two authors reported receiving fees and nonfinancial support from the private sector unrelated to the study.
Source: Mark J et al. JAMA Netw Open. 2018 Dec 7. doi: 10.1001/jamanetworkopen.2018.5452.
Overprescribing opioids leads to higher levels of consumption
according to a population-based study of surgery patients.
Ryan Howard, MD, FACS, of the department of surgery at the University of Michigan, Ann Arbor, and his coauthors analyzed data from the Michigan Surgical Quality Collaborative and sampled 2,392 patients who underwent 1 of 12 common surgical procedures in Michigan between Jan. 1 and Sept. 30, 2017, and were prescribed opioids for pain. For all patients, the quantity of opioid prescribed – converted to oral morphine equivalents (OMEs) to adjust for varying potency – was considerably greater than the quantity actually consumed by the patient, wrote Dr. Howard and his colleagues in JAMA Surgery.
The study findings have troubling implications, the authors suggested. “Overprescribing was universally observed in this cohort, affecting each of the 12 procedures analyzed. This phenomenon was not limited to single, outlier institutions, but was widespread across many hospitals. This resulted in increased opioid consumption among patients who received larger prescriptions, as well as tens of thousands of leftover pills in 9 months that entered communities across the state of Michigan.”
The median amount prescribed was 150 OMEs, the equivalent of 30 pills of hydrocodone/acetaminophen, 5/325 mg. The median consumed, as reported by patients, was 45 OMEs, or 9 pills, meaning only 27% of the prescribed amount was used. Prescription size was also strongly associated with higher consumption; patients used an additional 0.53 OMEs (95% confidence interval, 0.40-0.65; P less than .001), or 5.3 more pills, for every 10 extra pills prescribed. The larger the initial prescription, the more patients used, an association that persisted when the data were adjusted for procedure and patient-specific factors such as postoperative pain.
The study’s acknowledged limitations included an inability to estimate how many patients were contacted for patient-reported outcome collection, which obscures how representative this sample may be of the patient population in general. There was also no data gathered regarding preoperative opioid use, a near certainty in this cohort given a 3%-4% prevalence of chronic opioid use.
That said, the investigators noted that “intentionally keeping future recommendations liberal in quantity may ultimately aid with widespread adoption, especially for clinicians concerned that prescribing reductions may lead to increased pain and calls for refills after surgery.” They commended local efforts already underway to combat this issue– including their own work at the University of Michigan, where evidence-based prescribing recommendations resulted in a 63% reduction in opioid prescription size without an increase in refills or pain – but reiterated that more needs to be done at a state level.
The authors offered a possible reason for the link between prescription size and patient consumption. “A plausible explanation for the association between prescription size and medication use is the anchoring and adjustment heuristic. This is a psychologic heuristic wherein a piece of information serves as an anchor on which adjustments are made to reach an estimation or decision. For example, obesity literature has shown that food intake increases with portion size. In this case, a larger amount of opioids may serve as a mental anchor by which patients estimate their analgesic needs.”
Michael Englesbe, MD, Jennifer Waljee,MD, and Chad Brummett, MD, reported receiving funding from the Michigan Department of Health and Human Services and the National Institute on Drug Abuse. Joceline Vu, MD, reported receiving funding from the National Institutes of Health Ruth L. Kirschstein National Research Service Award; Jay Lee, MD, reported receiving funding from the National Cancer Institute.
SOURCE: Howard R et al. JAMA Surg. 2018 Nov 7. doi: 10.1001/jamasurg.2018.4234.
according to a population-based study of surgery patients.
Ryan Howard, MD, FACS, of the department of surgery at the University of Michigan, Ann Arbor, and his coauthors analyzed data from the Michigan Surgical Quality Collaborative and sampled 2,392 patients who underwent 1 of 12 common surgical procedures in Michigan between Jan. 1 and Sept. 30, 2017, and were prescribed opioids for pain. For all patients, the quantity of opioid prescribed – converted to oral morphine equivalents (OMEs) to adjust for varying potency – was considerably greater than the quantity actually consumed by the patient, wrote Dr. Howard and his colleagues in JAMA Surgery.
The study findings have troubling implications, the authors suggested. “Overprescribing was universally observed in this cohort, affecting each of the 12 procedures analyzed. This phenomenon was not limited to single, outlier institutions, but was widespread across many hospitals. This resulted in increased opioid consumption among patients who received larger prescriptions, as well as tens of thousands of leftover pills in 9 months that entered communities across the state of Michigan.”
The median amount prescribed was 150 OMEs, the equivalent of 30 pills of hydrocodone/acetaminophen, 5/325 mg. The median consumed, as reported by patients, was 45 OMEs, or 9 pills, meaning only 27% of the prescribed amount was used. Prescription size was also strongly associated with higher consumption; patients used an additional 0.53 OMEs (95% confidence interval, 0.40-0.65; P less than .001), or 5.3 more pills, for every 10 extra pills prescribed. The larger the initial prescription, the more patients used, an association that persisted when the data were adjusted for procedure and patient-specific factors such as postoperative pain.
The study’s acknowledged limitations included an inability to estimate how many patients were contacted for patient-reported outcome collection, which obscures how representative this sample may be of the patient population in general. There was also no data gathered regarding preoperative opioid use, a near certainty in this cohort given a 3%-4% prevalence of chronic opioid use.
That said, the investigators noted that “intentionally keeping future recommendations liberal in quantity may ultimately aid with widespread adoption, especially for clinicians concerned that prescribing reductions may lead to increased pain and calls for refills after surgery.” They commended local efforts already underway to combat this issue– including their own work at the University of Michigan, where evidence-based prescribing recommendations resulted in a 63% reduction in opioid prescription size without an increase in refills or pain – but reiterated that more needs to be done at a state level.
The authors offered a possible reason for the link between prescription size and patient consumption. “A plausible explanation for the association between prescription size and medication use is the anchoring and adjustment heuristic. This is a psychologic heuristic wherein a piece of information serves as an anchor on which adjustments are made to reach an estimation or decision. For example, obesity literature has shown that food intake increases with portion size. In this case, a larger amount of opioids may serve as a mental anchor by which patients estimate their analgesic needs.”
Michael Englesbe, MD, Jennifer Waljee,MD, and Chad Brummett, MD, reported receiving funding from the Michigan Department of Health and Human Services and the National Institute on Drug Abuse. Joceline Vu, MD, reported receiving funding from the National Institutes of Health Ruth L. Kirschstein National Research Service Award; Jay Lee, MD, reported receiving funding from the National Cancer Institute.
SOURCE: Howard R et al. JAMA Surg. 2018 Nov 7. doi: 10.1001/jamasurg.2018.4234.
according to a population-based study of surgery patients.
Ryan Howard, MD, FACS, of the department of surgery at the University of Michigan, Ann Arbor, and his coauthors analyzed data from the Michigan Surgical Quality Collaborative and sampled 2,392 patients who underwent 1 of 12 common surgical procedures in Michigan between Jan. 1 and Sept. 30, 2017, and were prescribed opioids for pain. For all patients, the quantity of opioid prescribed – converted to oral morphine equivalents (OMEs) to adjust for varying potency – was considerably greater than the quantity actually consumed by the patient, wrote Dr. Howard and his colleagues in JAMA Surgery.
The study findings have troubling implications, the authors suggested. “Overprescribing was universally observed in this cohort, affecting each of the 12 procedures analyzed. This phenomenon was not limited to single, outlier institutions, but was widespread across many hospitals. This resulted in increased opioid consumption among patients who received larger prescriptions, as well as tens of thousands of leftover pills in 9 months that entered communities across the state of Michigan.”
The median amount prescribed was 150 OMEs, the equivalent of 30 pills of hydrocodone/acetaminophen, 5/325 mg. The median consumed, as reported by patients, was 45 OMEs, or 9 pills, meaning only 27% of the prescribed amount was used. Prescription size was also strongly associated with higher consumption; patients used an additional 0.53 OMEs (95% confidence interval, 0.40-0.65; P less than .001), or 5.3 more pills, for every 10 extra pills prescribed. The larger the initial prescription, the more patients used, an association that persisted when the data were adjusted for procedure and patient-specific factors such as postoperative pain.
The study’s acknowledged limitations included an inability to estimate how many patients were contacted for patient-reported outcome collection, which obscures how representative this sample may be of the patient population in general. There was also no data gathered regarding preoperative opioid use, a near certainty in this cohort given a 3%-4% prevalence of chronic opioid use.
That said, the investigators noted that “intentionally keeping future recommendations liberal in quantity may ultimately aid with widespread adoption, especially for clinicians concerned that prescribing reductions may lead to increased pain and calls for refills after surgery.” They commended local efforts already underway to combat this issue– including their own work at the University of Michigan, where evidence-based prescribing recommendations resulted in a 63% reduction in opioid prescription size without an increase in refills or pain – but reiterated that more needs to be done at a state level.
The authors offered a possible reason for the link between prescription size and patient consumption. “A plausible explanation for the association between prescription size and medication use is the anchoring and adjustment heuristic. This is a psychologic heuristic wherein a piece of information serves as an anchor on which adjustments are made to reach an estimation or decision. For example, obesity literature has shown that food intake increases with portion size. In this case, a larger amount of opioids may serve as a mental anchor by which patients estimate their analgesic needs.”
Michael Englesbe, MD, Jennifer Waljee,MD, and Chad Brummett, MD, reported receiving funding from the Michigan Department of Health and Human Services and the National Institute on Drug Abuse. Joceline Vu, MD, reported receiving funding from the National Institutes of Health Ruth L. Kirschstein National Research Service Award; Jay Lee, MD, reported receiving funding from the National Cancer Institute.
SOURCE: Howard R et al. JAMA Surg. 2018 Nov 7. doi: 10.1001/jamasurg.2018.4234.
FROM JAMA SURGERY
Key clinical point: Patients recovering from 12 common surgical procedures were universally overprescribed opioids.
Major finding: Surgery patients used 5.3 more pills for every 10 additional pills prescribed.
Study details: A retrospective, population-based study of 2,392 patients who underwent 1 of 12 surgeries in Michigan between Jan. 1 and Sept. 30, 2017, and were prescribed opioids for pain.
Disclosures: Michael Englesbe, MD, Jennifer Waljee, MD, and Chad Brummett, MD, reported receiving funding from the Michigan Department of Health and Human Services and the National Institute on Drug Abuse. Joceline Vu, MD, reported receiving funding from the National Institutes of Health Ruth L. Kirschstein National Research Service Award; Jay Lee, MD, reported receiving funding from the National Cancer Institute.
Source: Howard R et al. JAMA Surg. 2018 Nov 7. doi: 10.1001/jamasurg.2018.4234.
How to slash colorectal surgery infection rates
BOSTON – driven mostly by a reduction in deep organ space infections from 5.5% to 1.7%.
It was a remarkable finding that got the attention of attendees at the annual clinical congress of the American College of Surgeons. The Cleveland Clinic had been an outlier, in the wrong direction, compared with other centers, and administrators wanted a solution.
I. Emre Gorgun, MD, FACS, a colorectal surgeon and quality improvement officer at Cleveland Clinic, led the search for evidence-based interventions. Eventually, big changes were made to perioperative antibiotics, mechanical bowel prep, preop shower routines, and intraoperative procedures. The efforts paid off (Dis Colon Rectum. 2018 Jan;61[1]:89-98).
To help surgeons lower their own infection rates, Dr. Gorgun agreed to an interview at the meeting to explain exactly what was done.
There was resistance at first from surgeons who wanted to stick with their routines, but they came around once they were shown the data backing the changes. Eventually, “everyone was on board. We believe in this,” Dr. Gorgun said.
BOSTON – driven mostly by a reduction in deep organ space infections from 5.5% to 1.7%.
It was a remarkable finding that got the attention of attendees at the annual clinical congress of the American College of Surgeons. The Cleveland Clinic had been an outlier, in the wrong direction, compared with other centers, and administrators wanted a solution.
I. Emre Gorgun, MD, FACS, a colorectal surgeon and quality improvement officer at Cleveland Clinic, led the search for evidence-based interventions. Eventually, big changes were made to perioperative antibiotics, mechanical bowel prep, preop shower routines, and intraoperative procedures. The efforts paid off (Dis Colon Rectum. 2018 Jan;61[1]:89-98).
To help surgeons lower their own infection rates, Dr. Gorgun agreed to an interview at the meeting to explain exactly what was done.
There was resistance at first from surgeons who wanted to stick with their routines, but they came around once they were shown the data backing the changes. Eventually, “everyone was on board. We believe in this,” Dr. Gorgun said.
BOSTON – driven mostly by a reduction in deep organ space infections from 5.5% to 1.7%.
It was a remarkable finding that got the attention of attendees at the annual clinical congress of the American College of Surgeons. The Cleveland Clinic had been an outlier, in the wrong direction, compared with other centers, and administrators wanted a solution.
I. Emre Gorgun, MD, FACS, a colorectal surgeon and quality improvement officer at Cleveland Clinic, led the search for evidence-based interventions. Eventually, big changes were made to perioperative antibiotics, mechanical bowel prep, preop shower routines, and intraoperative procedures. The efforts paid off (Dis Colon Rectum. 2018 Jan;61[1]:89-98).
To help surgeons lower their own infection rates, Dr. Gorgun agreed to an interview at the meeting to explain exactly what was done.
There was resistance at first from surgeons who wanted to stick with their routines, but they came around once they were shown the data backing the changes. Eventually, “everyone was on board. We believe in this,” Dr. Gorgun said.
REPORTING FROM THE ACS CLINICAL CONGRESS
Palliative care update highlights role of nonspecialists
The new edition of providing care for critically ill patients, not just those clinicians actively specialized in palliative care.
The Clinical Practice Guidelines for Quality Palliative Care, 4th Edition, emphasizes the importance of palliative care provided by “clinicians in primary care and specialty care practices, such as oncologists,” the guideline authors stated.
The latest revision of the guideline aims to establish a foundation for “gold-standard” palliative care for people living with serious illness, regardless of diagnosis, prognosis, setting, or age, according to the National Coalition for Hospice and Palliative Care, which published the clinical practice guidelines.
The update was developed by the National Consensus Project for Quality Palliative Care (NCP), which includes 16 national organizations with palliative care and hospice expertise, and is endorsed by more than 80 national organizations, including the American Society of Hematology and the Oncology Nurses Society.
One key reason for the update, according to the NCP, was to acknowledge that today’s health care system may not be meeting patients’ palliative care needs.
Specifically, the guidelines call on all clinicians who are not palliative specialists to integrate palliative care principles into their routine assessment of seriously ill patients with conditions such as heart failure, lung disease, and cancer.
This approach differs from the way palliative care is traditionally practiced, often by fellowship-trained physicians, trained nurses, and other specialists who provide that support.
The guidelines are organized into sections covering palliative care structure and processes, care for the patient nearing the end of life, and specific aspects of palliative care, including physical, psychological, and psychiatric; social; cultural, ethical, and legal; and spiritual, religious, and existential aspects.
“The expectation is that all clinicians caring for seriously ill patients will integrate palliative care competencies, such as safe and effective pain and symptom management and expert communication skills in their practice, and palliative care specialists will provide expertise for those with the most complex needs,” the guideline authors wrote.
Implications for treatment of oncology patients
These new guidelines represent a “blueprint for what it looks like to provide high-quality, comprehensive palliative care to people with serious illness,” said Thomas W. LeBlanc, MD, who is a medical oncologist, palliative care physician, and patient experience researcher at Duke University, Durham, N.C.
“Part of this report to is about trying to raise the game of everybody in medicine and provide a higher basic level of primary palliative care to all people with serious illness, but then also to figure out who has higher levels of needs where the specialists should be applied, since they are a scarce resource,” said Dr. LeBlanc.
An issue with that traditional model is a shortage of specialized clinicians to meet palliative care needs, said Dr. LeBlanc, whose clinical practice and research focuses on palliative care needs of patients with hematologic malignancies.
“Palliative care has matured as a field such that we are now actually facing workforce shortage issues and really fundamental questions about who needs us the most, and how we increase our reach to improve the lives of more patients and families facing serious illness,” he said in an interview.
That’s a major driver behind the emphasis in these latest guidelines on providing palliative care in the community, coordinating care, and dealing with care transitions, he added.
“I hope that this document will help to demonstrate the value and the need for palliative care specialists, and for improvements in primary care in the care of patients with hematologic diseases in general,” he said. “To me, this adds increasing legitimacy to this whole field.”
Palliative care in surgical care
These guidelines are particularly useful to surgeons in part because of their focus on what’s known as primary palliative care, said to Geoffrey P. Dunn, MD, former chair of the American College of Surgeons Committee on Surgical Palliative Care. Palliative care, the new guidelines suggest, can be implemented by nonspecialists.
Primary palliative care includes diverse skills such as breaking adverse news to patients, managing uncomplicated pain, and being able to recognize signs and symptoms of imminent demise. “These are the minimum deliverables for all people dealing with seriously ill patients,” Dr. Dunn said in an interview. “It’s palliative care that any practicing physician should be able to handle.”
Dr. Dunn concurred with Dr. LaBlanc about the workforce shortage in the palliative field. The traditional model has created a shortage of specialized clinicians to meet palliative care needs. Across the board, “staffing for palliative teams is very inconsistent,” said Dr. Dunn. “It’s a classic unfunded mandate.”
While these guidelines are a step forward in recognizing the importance of palliative care outside of the palliative care specialty, there is no reference to surgery anywhere in the text of the 141-page prepublication draft provided by the NCP, Dr. Dunn noted in the interview.
“There’s still a danger of parallel universes, where surgery is developing its own understanding of this in parallel with the more general national palliative care movement,” he said. Despite that, there is a growing connection between surgery and the broader palliative care community. That linkage is especially important given the number of seriously ill patients with high symptom burden that are seen in surgery.
“I think where surgeons are beginning to find [palliative principles] very helpful is dealing with these protracted serial discussions with families in difficult circumstances, such as how long is the life support going to be prolonged in someone with a devastating head injury, or multiple system organ failure in the elderly,” Dr. Dunn added.
The new edition of providing care for critically ill patients, not just those clinicians actively specialized in palliative care.
The Clinical Practice Guidelines for Quality Palliative Care, 4th Edition, emphasizes the importance of palliative care provided by “clinicians in primary care and specialty care practices, such as oncologists,” the guideline authors stated.
The latest revision of the guideline aims to establish a foundation for “gold-standard” palliative care for people living with serious illness, regardless of diagnosis, prognosis, setting, or age, according to the National Coalition for Hospice and Palliative Care, which published the clinical practice guidelines.
The update was developed by the National Consensus Project for Quality Palliative Care (NCP), which includes 16 national organizations with palliative care and hospice expertise, and is endorsed by more than 80 national organizations, including the American Society of Hematology and the Oncology Nurses Society.
One key reason for the update, according to the NCP, was to acknowledge that today’s health care system may not be meeting patients’ palliative care needs.
Specifically, the guidelines call on all clinicians who are not palliative specialists to integrate palliative care principles into their routine assessment of seriously ill patients with conditions such as heart failure, lung disease, and cancer.
This approach differs from the way palliative care is traditionally practiced, often by fellowship-trained physicians, trained nurses, and other specialists who provide that support.
The guidelines are organized into sections covering palliative care structure and processes, care for the patient nearing the end of life, and specific aspects of palliative care, including physical, psychological, and psychiatric; social; cultural, ethical, and legal; and spiritual, religious, and existential aspects.
“The expectation is that all clinicians caring for seriously ill patients will integrate palliative care competencies, such as safe and effective pain and symptom management and expert communication skills in their practice, and palliative care specialists will provide expertise for those with the most complex needs,” the guideline authors wrote.
Implications for treatment of oncology patients
These new guidelines represent a “blueprint for what it looks like to provide high-quality, comprehensive palliative care to people with serious illness,” said Thomas W. LeBlanc, MD, who is a medical oncologist, palliative care physician, and patient experience researcher at Duke University, Durham, N.C.
“Part of this report to is about trying to raise the game of everybody in medicine and provide a higher basic level of primary palliative care to all people with serious illness, but then also to figure out who has higher levels of needs where the specialists should be applied, since they are a scarce resource,” said Dr. LeBlanc.
An issue with that traditional model is a shortage of specialized clinicians to meet palliative care needs, said Dr. LeBlanc, whose clinical practice and research focuses on palliative care needs of patients with hematologic malignancies.
“Palliative care has matured as a field such that we are now actually facing workforce shortage issues and really fundamental questions about who needs us the most, and how we increase our reach to improve the lives of more patients and families facing serious illness,” he said in an interview.
That’s a major driver behind the emphasis in these latest guidelines on providing palliative care in the community, coordinating care, and dealing with care transitions, he added.
“I hope that this document will help to demonstrate the value and the need for palliative care specialists, and for improvements in primary care in the care of patients with hematologic diseases in general,” he said. “To me, this adds increasing legitimacy to this whole field.”
Palliative care in surgical care
These guidelines are particularly useful to surgeons in part because of their focus on what’s known as primary palliative care, said to Geoffrey P. Dunn, MD, former chair of the American College of Surgeons Committee on Surgical Palliative Care. Palliative care, the new guidelines suggest, can be implemented by nonspecialists.
Primary palliative care includes diverse skills such as breaking adverse news to patients, managing uncomplicated pain, and being able to recognize signs and symptoms of imminent demise. “These are the minimum deliverables for all people dealing with seriously ill patients,” Dr. Dunn said in an interview. “It’s palliative care that any practicing physician should be able to handle.”
Dr. Dunn concurred with Dr. LaBlanc about the workforce shortage in the palliative field. The traditional model has created a shortage of specialized clinicians to meet palliative care needs. Across the board, “staffing for palliative teams is very inconsistent,” said Dr. Dunn. “It’s a classic unfunded mandate.”
While these guidelines are a step forward in recognizing the importance of palliative care outside of the palliative care specialty, there is no reference to surgery anywhere in the text of the 141-page prepublication draft provided by the NCP, Dr. Dunn noted in the interview.
“There’s still a danger of parallel universes, where surgery is developing its own understanding of this in parallel with the more general national palliative care movement,” he said. Despite that, there is a growing connection between surgery and the broader palliative care community. That linkage is especially important given the number of seriously ill patients with high symptom burden that are seen in surgery.
“I think where surgeons are beginning to find [palliative principles] very helpful is dealing with these protracted serial discussions with families in difficult circumstances, such as how long is the life support going to be prolonged in someone with a devastating head injury, or multiple system organ failure in the elderly,” Dr. Dunn added.
The new edition of providing care for critically ill patients, not just those clinicians actively specialized in palliative care.
The Clinical Practice Guidelines for Quality Palliative Care, 4th Edition, emphasizes the importance of palliative care provided by “clinicians in primary care and specialty care practices, such as oncologists,” the guideline authors stated.
The latest revision of the guideline aims to establish a foundation for “gold-standard” palliative care for people living with serious illness, regardless of diagnosis, prognosis, setting, or age, according to the National Coalition for Hospice and Palliative Care, which published the clinical practice guidelines.
The update was developed by the National Consensus Project for Quality Palliative Care (NCP), which includes 16 national organizations with palliative care and hospice expertise, and is endorsed by more than 80 national organizations, including the American Society of Hematology and the Oncology Nurses Society.
One key reason for the update, according to the NCP, was to acknowledge that today’s health care system may not be meeting patients’ palliative care needs.
Specifically, the guidelines call on all clinicians who are not palliative specialists to integrate palliative care principles into their routine assessment of seriously ill patients with conditions such as heart failure, lung disease, and cancer.
This approach differs from the way palliative care is traditionally practiced, often by fellowship-trained physicians, trained nurses, and other specialists who provide that support.
The guidelines are organized into sections covering palliative care structure and processes, care for the patient nearing the end of life, and specific aspects of palliative care, including physical, psychological, and psychiatric; social; cultural, ethical, and legal; and spiritual, religious, and existential aspects.
“The expectation is that all clinicians caring for seriously ill patients will integrate palliative care competencies, such as safe and effective pain and symptom management and expert communication skills in their practice, and palliative care specialists will provide expertise for those with the most complex needs,” the guideline authors wrote.
Implications for treatment of oncology patients
These new guidelines represent a “blueprint for what it looks like to provide high-quality, comprehensive palliative care to people with serious illness,” said Thomas W. LeBlanc, MD, who is a medical oncologist, palliative care physician, and patient experience researcher at Duke University, Durham, N.C.
“Part of this report to is about trying to raise the game of everybody in medicine and provide a higher basic level of primary palliative care to all people with serious illness, but then also to figure out who has higher levels of needs where the specialists should be applied, since they are a scarce resource,” said Dr. LeBlanc.
An issue with that traditional model is a shortage of specialized clinicians to meet palliative care needs, said Dr. LeBlanc, whose clinical practice and research focuses on palliative care needs of patients with hematologic malignancies.
“Palliative care has matured as a field such that we are now actually facing workforce shortage issues and really fundamental questions about who needs us the most, and how we increase our reach to improve the lives of more patients and families facing serious illness,” he said in an interview.
That’s a major driver behind the emphasis in these latest guidelines on providing palliative care in the community, coordinating care, and dealing with care transitions, he added.
“I hope that this document will help to demonstrate the value and the need for palliative care specialists, and for improvements in primary care in the care of patients with hematologic diseases in general,” he said. “To me, this adds increasing legitimacy to this whole field.”
Palliative care in surgical care
These guidelines are particularly useful to surgeons in part because of their focus on what’s known as primary palliative care, said to Geoffrey P. Dunn, MD, former chair of the American College of Surgeons Committee on Surgical Palliative Care. Palliative care, the new guidelines suggest, can be implemented by nonspecialists.
Primary palliative care includes diverse skills such as breaking adverse news to patients, managing uncomplicated pain, and being able to recognize signs and symptoms of imminent demise. “These are the minimum deliverables for all people dealing with seriously ill patients,” Dr. Dunn said in an interview. “It’s palliative care that any practicing physician should be able to handle.”
Dr. Dunn concurred with Dr. LaBlanc about the workforce shortage in the palliative field. The traditional model has created a shortage of specialized clinicians to meet palliative care needs. Across the board, “staffing for palliative teams is very inconsistent,” said Dr. Dunn. “It’s a classic unfunded mandate.”
While these guidelines are a step forward in recognizing the importance of palliative care outside of the palliative care specialty, there is no reference to surgery anywhere in the text of the 141-page prepublication draft provided by the NCP, Dr. Dunn noted in the interview.
“There’s still a danger of parallel universes, where surgery is developing its own understanding of this in parallel with the more general national palliative care movement,” he said. Despite that, there is a growing connection between surgery and the broader palliative care community. That linkage is especially important given the number of seriously ill patients with high symptom burden that are seen in surgery.
“I think where surgeons are beginning to find [palliative principles] very helpful is dealing with these protracted serial discussions with families in difficult circumstances, such as how long is the life support going to be prolonged in someone with a devastating head injury, or multiple system organ failure in the elderly,” Dr. Dunn added.
Launching a surgical comanagement project
Improving quality, patient satisfaction
When hospital medicine and surgical departments (usually orthopedics or neurosurgery) have joined in comanagement programs, improvements in quality metrics and patient satisfaction have often resulted.
At the Level 1 regional trauma center in which he works, Charles L. Kast, MD, and his colleagues wanted to try a comanagement agreement between hospital medicine and trauma surgery.
“The surgical team identified a need within their own department, which was to improve patient mortality and satisfaction in the inpatient setting,” said Dr. Kast, who is based at North Shore University Hospital, Manhasset, N.Y. “Their leadership sought out our hospital medicine leadership team, who then worked together to synthesize their metrics. We were able to identify other quality indicators, such as readmission rates and hospital-acquired conditions, which we felt could also benefit from our services in order to help them improve.”
Five hospitalists became members of the comanagement team. A single hospitalist rotated for 2 weeks at a time, during which they were relieved of routine hospital medicine rounding responsibilities. The hospitalist attended daily interdisciplinary rounds with the trauma surgery team, during which he/she identified patients that could benefit from hospital medicine comanagement: Patients who were over age 65 years, had multiple chronic medical conditions, or were on high-risk medications were preferentially selected. Approximately 10 patients were seen daily.
The comanagement program was well received by trauma surgeons, who talked about improved patient communication and a fostered sense of collegiality. Preliminary quality and patient satisfaction metrics were also positive.
A top takeaway is that the benefits of surgical comanagement can be demonstrated in “atypical” collaborations, depending on the needs of the department and the hospital’s vision.
“The gains in improved patient quality metrics are only half of the story,” Dr. Kast said. “Collaborating in surgical comanagement improves the satisfaction of the hospitalists and surgeons involved and can lead to future quality improvement projects or original research, both of which we are currently pursuing.”
Reference
Kast C et al. The successful development of a hospital medicine-trauma surgery co-management program [abstract]. J Hosp Med. 2017;12(suppl 2). Accessed Feb. 2, 2018.
Improving quality, patient satisfaction
Improving quality, patient satisfaction
When hospital medicine and surgical departments (usually orthopedics or neurosurgery) have joined in comanagement programs, improvements in quality metrics and patient satisfaction have often resulted.
At the Level 1 regional trauma center in which he works, Charles L. Kast, MD, and his colleagues wanted to try a comanagement agreement between hospital medicine and trauma surgery.
“The surgical team identified a need within their own department, which was to improve patient mortality and satisfaction in the inpatient setting,” said Dr. Kast, who is based at North Shore University Hospital, Manhasset, N.Y. “Their leadership sought out our hospital medicine leadership team, who then worked together to synthesize their metrics. We were able to identify other quality indicators, such as readmission rates and hospital-acquired conditions, which we felt could also benefit from our services in order to help them improve.”
Five hospitalists became members of the comanagement team. A single hospitalist rotated for 2 weeks at a time, during which they were relieved of routine hospital medicine rounding responsibilities. The hospitalist attended daily interdisciplinary rounds with the trauma surgery team, during which he/she identified patients that could benefit from hospital medicine comanagement: Patients who were over age 65 years, had multiple chronic medical conditions, or were on high-risk medications were preferentially selected. Approximately 10 patients were seen daily.
The comanagement program was well received by trauma surgeons, who talked about improved patient communication and a fostered sense of collegiality. Preliminary quality and patient satisfaction metrics were also positive.
A top takeaway is that the benefits of surgical comanagement can be demonstrated in “atypical” collaborations, depending on the needs of the department and the hospital’s vision.
“The gains in improved patient quality metrics are only half of the story,” Dr. Kast said. “Collaborating in surgical comanagement improves the satisfaction of the hospitalists and surgeons involved and can lead to future quality improvement projects or original research, both of which we are currently pursuing.”
Reference
Kast C et al. The successful development of a hospital medicine-trauma surgery co-management program [abstract]. J Hosp Med. 2017;12(suppl 2). Accessed Feb. 2, 2018.
When hospital medicine and surgical departments (usually orthopedics or neurosurgery) have joined in comanagement programs, improvements in quality metrics and patient satisfaction have often resulted.
At the Level 1 regional trauma center in which he works, Charles L. Kast, MD, and his colleagues wanted to try a comanagement agreement between hospital medicine and trauma surgery.
“The surgical team identified a need within their own department, which was to improve patient mortality and satisfaction in the inpatient setting,” said Dr. Kast, who is based at North Shore University Hospital, Manhasset, N.Y. “Their leadership sought out our hospital medicine leadership team, who then worked together to synthesize their metrics. We were able to identify other quality indicators, such as readmission rates and hospital-acquired conditions, which we felt could also benefit from our services in order to help them improve.”
Five hospitalists became members of the comanagement team. A single hospitalist rotated for 2 weeks at a time, during which they were relieved of routine hospital medicine rounding responsibilities. The hospitalist attended daily interdisciplinary rounds with the trauma surgery team, during which he/she identified patients that could benefit from hospital medicine comanagement: Patients who were over age 65 years, had multiple chronic medical conditions, or were on high-risk medications were preferentially selected. Approximately 10 patients were seen daily.
The comanagement program was well received by trauma surgeons, who talked about improved patient communication and a fostered sense of collegiality. Preliminary quality and patient satisfaction metrics were also positive.
A top takeaway is that the benefits of surgical comanagement can be demonstrated in “atypical” collaborations, depending on the needs of the department and the hospital’s vision.
“The gains in improved patient quality metrics are only half of the story,” Dr. Kast said. “Collaborating in surgical comanagement improves the satisfaction of the hospitalists and surgeons involved and can lead to future quality improvement projects or original research, both of which we are currently pursuing.”
Reference
Kast C et al. The successful development of a hospital medicine-trauma surgery co-management program [abstract]. J Hosp Med. 2017;12(suppl 2). Accessed Feb. 2, 2018.
EHR-guided strategy reduces postop VTE events
BOSTON – Avoiding could result in a reduction in VTE rates, a speaker said at the annual clinical congress of the American College of Surgeons.
The VTE rate dropped by about one-quarter in the trauma care pathway at the University of Pittsburgh Medical Center (UPMC) after implementation of algorithms to risk-stratify patients and guide nursing staff, said Matthew D. Neal, MD, FACS, the Roberta G. Simmons Assistant Professor of Surgery at the University of Pittsburgh.
By incorporating algorithms into the electronic health record (EHR), UPMC was able to realize a “dramatic” 72% reduction in missed doses, from 4,331 missed doses in 2014 to 1,193 in 2015, Dr. Neal told attendees in a session focused on hot topics in surgical patient safety.
That decrease in missed doses has translated into a decreased rate of VTE, from an already relatively low rate of 1.5% in 2015, to 1.1% in 2017, representing a 26.7% reduction, according to data Dr. Neal shared in his podium presentation.
“This has been a sustainable event for us, largely linked to the implementation of an EHR-guided risk assessment pathway to guide the implementation of VTE prophylaxis,” he said.
The change was safe, he added, noting that, since utilization of this pathway, there have been no significant increases in the rate of bleeding events among patients who have mandatory orders.
These results corroborate those of some previous investigations, including one key study from the Johns Hopkins Hospital that described the adoption of a mandatory computerized clinical decision support tool to improve adherence to best practices for VTE prophylaxis.
After incorporation of the tool in the computerized order entry system, there was a significant increase in VTE prophylaxis, translating into a significant drop in preventable harm from VTE, from 1.0% to 0.17% (P = .04), investigators reported in JAMA Surgery.
Reducing missed doses is one of the major contributing factors to decreased VTE rates, according to Dr. Neal.
Missed doses of enoxaparin correlate with increased incidence of deep vein thrombosis (DVT) in trauma and general surgery patients, according to results of one prospective study Dr. Neal described. In that study of 202 patients, reported in JAMA Surgery, DVTs were seen in 23.5% of patients with missed doses, compared with 4.8 for patients with no missed doses (P < .01).
“We need to understand how to risk assess and how to utilize our EHR as a tool,” Dr. Neal told attendees.
Dr. Neal reported disclosures related to Janssen Pharmaceuticals, CSL Behring, Accriva Diagnostics, and Haemonetics, as well as a U.S. patent for a treatment of infectious and inflammatory disorders, and laboratory funding from the National Institutes of Health, Department of Defense, and the Biomedical Advanced Research and Development Authority.
SOURCE: Neal MD. Presentation at the American College of Surgeons Clinical Congress. 2018 Oct 25.
BOSTON – Avoiding could result in a reduction in VTE rates, a speaker said at the annual clinical congress of the American College of Surgeons.
The VTE rate dropped by about one-quarter in the trauma care pathway at the University of Pittsburgh Medical Center (UPMC) after implementation of algorithms to risk-stratify patients and guide nursing staff, said Matthew D. Neal, MD, FACS, the Roberta G. Simmons Assistant Professor of Surgery at the University of Pittsburgh.
By incorporating algorithms into the electronic health record (EHR), UPMC was able to realize a “dramatic” 72% reduction in missed doses, from 4,331 missed doses in 2014 to 1,193 in 2015, Dr. Neal told attendees in a session focused on hot topics in surgical patient safety.
That decrease in missed doses has translated into a decreased rate of VTE, from an already relatively low rate of 1.5% in 2015, to 1.1% in 2017, representing a 26.7% reduction, according to data Dr. Neal shared in his podium presentation.
“This has been a sustainable event for us, largely linked to the implementation of an EHR-guided risk assessment pathway to guide the implementation of VTE prophylaxis,” he said.
The change was safe, he added, noting that, since utilization of this pathway, there have been no significant increases in the rate of bleeding events among patients who have mandatory orders.
These results corroborate those of some previous investigations, including one key study from the Johns Hopkins Hospital that described the adoption of a mandatory computerized clinical decision support tool to improve adherence to best practices for VTE prophylaxis.
After incorporation of the tool in the computerized order entry system, there was a significant increase in VTE prophylaxis, translating into a significant drop in preventable harm from VTE, from 1.0% to 0.17% (P = .04), investigators reported in JAMA Surgery.
Reducing missed doses is one of the major contributing factors to decreased VTE rates, according to Dr. Neal.
Missed doses of enoxaparin correlate with increased incidence of deep vein thrombosis (DVT) in trauma and general surgery patients, according to results of one prospective study Dr. Neal described. In that study of 202 patients, reported in JAMA Surgery, DVTs were seen in 23.5% of patients with missed doses, compared with 4.8 for patients with no missed doses (P < .01).
“We need to understand how to risk assess and how to utilize our EHR as a tool,” Dr. Neal told attendees.
Dr. Neal reported disclosures related to Janssen Pharmaceuticals, CSL Behring, Accriva Diagnostics, and Haemonetics, as well as a U.S. patent for a treatment of infectious and inflammatory disorders, and laboratory funding from the National Institutes of Health, Department of Defense, and the Biomedical Advanced Research and Development Authority.
SOURCE: Neal MD. Presentation at the American College of Surgeons Clinical Congress. 2018 Oct 25.
BOSTON – Avoiding could result in a reduction in VTE rates, a speaker said at the annual clinical congress of the American College of Surgeons.
The VTE rate dropped by about one-quarter in the trauma care pathway at the University of Pittsburgh Medical Center (UPMC) after implementation of algorithms to risk-stratify patients and guide nursing staff, said Matthew D. Neal, MD, FACS, the Roberta G. Simmons Assistant Professor of Surgery at the University of Pittsburgh.
By incorporating algorithms into the electronic health record (EHR), UPMC was able to realize a “dramatic” 72% reduction in missed doses, from 4,331 missed doses in 2014 to 1,193 in 2015, Dr. Neal told attendees in a session focused on hot topics in surgical patient safety.
That decrease in missed doses has translated into a decreased rate of VTE, from an already relatively low rate of 1.5% in 2015, to 1.1% in 2017, representing a 26.7% reduction, according to data Dr. Neal shared in his podium presentation.
“This has been a sustainable event for us, largely linked to the implementation of an EHR-guided risk assessment pathway to guide the implementation of VTE prophylaxis,” he said.
The change was safe, he added, noting that, since utilization of this pathway, there have been no significant increases in the rate of bleeding events among patients who have mandatory orders.
These results corroborate those of some previous investigations, including one key study from the Johns Hopkins Hospital that described the adoption of a mandatory computerized clinical decision support tool to improve adherence to best practices for VTE prophylaxis.
After incorporation of the tool in the computerized order entry system, there was a significant increase in VTE prophylaxis, translating into a significant drop in preventable harm from VTE, from 1.0% to 0.17% (P = .04), investigators reported in JAMA Surgery.
Reducing missed doses is one of the major contributing factors to decreased VTE rates, according to Dr. Neal.
Missed doses of enoxaparin correlate with increased incidence of deep vein thrombosis (DVT) in trauma and general surgery patients, according to results of one prospective study Dr. Neal described. In that study of 202 patients, reported in JAMA Surgery, DVTs were seen in 23.5% of patients with missed doses, compared with 4.8 for patients with no missed doses (P < .01).
“We need to understand how to risk assess and how to utilize our EHR as a tool,” Dr. Neal told attendees.
Dr. Neal reported disclosures related to Janssen Pharmaceuticals, CSL Behring, Accriva Diagnostics, and Haemonetics, as well as a U.S. patent for a treatment of infectious and inflammatory disorders, and laboratory funding from the National Institutes of Health, Department of Defense, and the Biomedical Advanced Research and Development Authority.
SOURCE: Neal MD. Presentation at the American College of Surgeons Clinical Congress. 2018 Oct 25.
AT THE ACS CLINICAL CONGRESS
Post-mastectomy pain strategy allows for safe, same-day discharge
BOSTON – A multimodal pain regimen allowed for safe and effective same-day discharge of women undergoing mastectomy procedures, a recent study showed.
Women had little need for stronger oral narcotic use in the single center, retrospective study presented at the annual clinical congress of the American College of Surgeons.
The analysis included 72 consecutive mastectomies performed at a single center from November 2015 to July 2017. Most mastectomies were bilateral (61, or 84.7%) while 11 (15.3%) were unilateral.
Patients received a standardized pain regimen including 1 gram of IV acetaminophen interoperatively, combined with 30 mg of IV ketorolac and a 4-level intercostal nerve block with liposomal bupivacaine.
Liposomal bupivacaine has a longer half-life than other anesthetics, according to lead study author Radbeh Torabi, MD, a fifth-year plastic surgery resident at Louisiana State University (LSU) Health Science Center in New Orleans.
“That allows for prolonged pain control, especially during the time when the patient’s going to have the most amount of pain, which is the first day to two days postoperatively,” Dr. Torabi said in an interview.
All 72 patients were discharged home on the same day with just a 1-week prescription for acetaminophen with codeine.
Only 5 patients presented to the emergency room in the 30-day postoperative period, and of those, only 2 (2.8%) required readmission for reasons other than mastectomy-related pain, investigators said. The remaining 3 patients did present with pain, but did not require hospital admission.
Taken together, these findings suggest that this multimodal strategy offers excellent pain control and has the potential to minimize inpatient admissions while decreasing oral narcotic use, investigators said in an interview following their presentation.
“The main takeaway is reducing the amount of prescriptions we give,” Dr. Torabi said.
Study co-author Cameron T. Ward Coker, MD, a fourth-year general surgery resident at LSU, said the multimodal pain strategy used in this study could represent a step toward eliminating the risks associated with opioid prescribing.
“From the feedback we got from our lecture and the other surgeons in the room, it seems like that’s already becoming a widespread phenomenon,” Dr. Coker said.
Patients in the study had an average age of about 57 years and an average BMI of 30, according to the investigators.
Dr. Coker and Dr. Torabi had no disclosures related to the presentation.
SOURCE: Torabi R, et al. Scientific forum abstract at American College of Surgeons Clinical Congress. 2018 Oct 23.
BOSTON – A multimodal pain regimen allowed for safe and effective same-day discharge of women undergoing mastectomy procedures, a recent study showed.
Women had little need for stronger oral narcotic use in the single center, retrospective study presented at the annual clinical congress of the American College of Surgeons.
The analysis included 72 consecutive mastectomies performed at a single center from November 2015 to July 2017. Most mastectomies were bilateral (61, or 84.7%) while 11 (15.3%) were unilateral.
Patients received a standardized pain regimen including 1 gram of IV acetaminophen interoperatively, combined with 30 mg of IV ketorolac and a 4-level intercostal nerve block with liposomal bupivacaine.
Liposomal bupivacaine has a longer half-life than other anesthetics, according to lead study author Radbeh Torabi, MD, a fifth-year plastic surgery resident at Louisiana State University (LSU) Health Science Center in New Orleans.
“That allows for prolonged pain control, especially during the time when the patient’s going to have the most amount of pain, which is the first day to two days postoperatively,” Dr. Torabi said in an interview.
All 72 patients were discharged home on the same day with just a 1-week prescription for acetaminophen with codeine.
Only 5 patients presented to the emergency room in the 30-day postoperative period, and of those, only 2 (2.8%) required readmission for reasons other than mastectomy-related pain, investigators said. The remaining 3 patients did present with pain, but did not require hospital admission.
Taken together, these findings suggest that this multimodal strategy offers excellent pain control and has the potential to minimize inpatient admissions while decreasing oral narcotic use, investigators said in an interview following their presentation.
“The main takeaway is reducing the amount of prescriptions we give,” Dr. Torabi said.
Study co-author Cameron T. Ward Coker, MD, a fourth-year general surgery resident at LSU, said the multimodal pain strategy used in this study could represent a step toward eliminating the risks associated with opioid prescribing.
“From the feedback we got from our lecture and the other surgeons in the room, it seems like that’s already becoming a widespread phenomenon,” Dr. Coker said.
Patients in the study had an average age of about 57 years and an average BMI of 30, according to the investigators.
Dr. Coker and Dr. Torabi had no disclosures related to the presentation.
SOURCE: Torabi R, et al. Scientific forum abstract at American College of Surgeons Clinical Congress. 2018 Oct 23.
BOSTON – A multimodal pain regimen allowed for safe and effective same-day discharge of women undergoing mastectomy procedures, a recent study showed.
Women had little need for stronger oral narcotic use in the single center, retrospective study presented at the annual clinical congress of the American College of Surgeons.
The analysis included 72 consecutive mastectomies performed at a single center from November 2015 to July 2017. Most mastectomies were bilateral (61, or 84.7%) while 11 (15.3%) were unilateral.
Patients received a standardized pain regimen including 1 gram of IV acetaminophen interoperatively, combined with 30 mg of IV ketorolac and a 4-level intercostal nerve block with liposomal bupivacaine.
Liposomal bupivacaine has a longer half-life than other anesthetics, according to lead study author Radbeh Torabi, MD, a fifth-year plastic surgery resident at Louisiana State University (LSU) Health Science Center in New Orleans.
“That allows for prolonged pain control, especially during the time when the patient’s going to have the most amount of pain, which is the first day to two days postoperatively,” Dr. Torabi said in an interview.
All 72 patients were discharged home on the same day with just a 1-week prescription for acetaminophen with codeine.
Only 5 patients presented to the emergency room in the 30-day postoperative period, and of those, only 2 (2.8%) required readmission for reasons other than mastectomy-related pain, investigators said. The remaining 3 patients did present with pain, but did not require hospital admission.
Taken together, these findings suggest that this multimodal strategy offers excellent pain control and has the potential to minimize inpatient admissions while decreasing oral narcotic use, investigators said in an interview following their presentation.
“The main takeaway is reducing the amount of prescriptions we give,” Dr. Torabi said.
Study co-author Cameron T. Ward Coker, MD, a fourth-year general surgery resident at LSU, said the multimodal pain strategy used in this study could represent a step toward eliminating the risks associated with opioid prescribing.
“From the feedback we got from our lecture and the other surgeons in the room, it seems like that’s already becoming a widespread phenomenon,” Dr. Coker said.
Patients in the study had an average age of about 57 years and an average BMI of 30, according to the investigators.
Dr. Coker and Dr. Torabi had no disclosures related to the presentation.
SOURCE: Torabi R, et al. Scientific forum abstract at American College of Surgeons Clinical Congress. 2018 Oct 23.
REPORTING FROM THE ACS CLINICAL CONGRESS
Key clinical point:
Major finding: Of 72 women who had same-day discharge after mastectomy, only 3 presented for pain in the 30-day postoperative period.
Study details: A retrospective review of 72 consecutive mastectomies performed at a single surgical center.
Disclosures: The lead author had no disclosures related to the presentation.
Source: Torabi R, et al. Scientific forum abstract at American College of Surgeons Clinical Congress. 2018 Oct 23.
VTE risk after gynecologic surgery lower with laparoscopic procedures
according to a study published in Obstetrics & Gynecology.
The retrospective cohort study looked at data from 37,485 patients who underwent 43,751 gynecologic surgical procedures, including hysterectomy and myomectomy, at two tertiary care academic hospitals.
Overall, 96 patients (0.2%) were diagnosed with postoperative venous thromboembolism. However patients who underwent laparoscopic or vaginal surgery had a significant 78% and 93% lower risk of venous thromboembolism, respectively, than those who underwent laparotomy, even after adjusting for potential confounders such as age, cancer, race, pharmacologic thromboprophylaxis, and surgical time.
The incidence of postoperative thromboembolism was significantly higher among patients undergoing gynecologic surgery for cancer (1.1%). The incidence among those undergoing surgery for benign indications was only 0.2%, and the highest incidence was among patients with cancer who underwent laparotomy (2.2%).
“This study adds to data demonstrating that venous thromboembolism is rare in gynecologic surgery, particularly when a patient undergoes a minimally invasive procedure for benign indications,” wrote Dr. Elisa M. Jorgensen of Beth Israel Deaconess Medical Center, and her coauthors.
Among the 8,273 patients who underwent a hysterectomy, there were 55 cases of venous thromboembolism – representing an 0.7% incidence. However patients who underwent laparotomy had a 1% incidence of postoperative venous thromboembolism, while those who underwent laparoscopic hysterectomy had an 0.3% incidence and those who underwent vaginal hysterectomy had an 0.1% incidence.
Laparotomy was the most common mode of surgery for hysterectomy – accounting for 57% of operations – while 34% were laparoscopic and 9% were vaginal.
However, the authors noted that the use of laparoscopy increased and laparotomy declined over the 9 years of the study. In 2006, 12% of hysterectomies were laparoscopic, compared with 55% in 2015, while over that same period the percentage of laparotomies dropped from 74% to 41%, and the percentage of vaginal procedures declined from 14% to 4%.
“Because current practice guidelines do not account for mode of surgery, we find them to be insufficient for the modern gynecologic surgeon to counsel patients on their individual venous thromboembolism risk or to make ideal decisions regarding selection of thromboprophylaxis,” Dr. Jorgenson and her associates wrote.
Only 5 patients of the 2,851 who underwent myomectomy developed postoperative VTE – an overall incidence of 0.2% – and the authors said numbers were too small to analyze. Vaginal or hysteroscopic myomectomy was the most common surgical method, accounting for 62% of procedures, compared with 23% for laparotomies and 15% for laparoscopies.
More than 90% of patients who experienced postoperative thromboembolism had received some form of thromboprophylaxis before surgery, either mechanical, pharmacologic, or both. In comparison, only 55% of the group who didn’t experience thromboembolism had received thromboprophylaxis.
“The high rate of prophylaxis among patients who developed postoperative venous thromboembolism may reflect surgeons’ abilities to preoperatively identify patients at increased risk, guiding appropriate selection of thromboprophylaxis,” Dr. Jorgenson and her associates wrote.
Addressing the study’s limitations, the authors noted that they were not able to capture data on patients’ body mass index and also were unable to account for patients who might have been diagnosed and treated for postoperative VTE at other hospitals.
No conflicts of interest were declared.
SOURCE: Jorgensen EM et al. Obstet Gynecol. 2018 Nov;132:1275-84.
The aim of this study was to determine the 3-month postoperative incidence of venous thromboembolism among patients undergoing gynecologic surgery. The study also addressed the mode of surgery to allow a comparison between laparotomy and minimally invasive approaches.
Postoperative VTE was defined as deep venous thrombosis of the lower extremities, pulmonary embolism, or both that occurred within 90 days of surgery. A key component of the study was that clinically recognized VTEs that required treatment with anticoagulation, vena caval filter, or both were included.
The study evaluated 43,751 gynecological cases among 37,485 patients. As expected, 59% of the cases were classified as vaginal surgery, 24% were laparoscopic cases, and 17% of the cases were laparotomies.
Of the 8,273 hysterectomies, 57% were via an abdominal approach, 34% were laparoscopic, and 9 were vaginal cases.
Overall, 0.2% of patients were diagnosed with a VTE. As expected, the greatest incidence of VTE was in patients with cancer who underwent a laparotomy. Those with a VTE were significantly more likely to have had an inpatient stay (longer than 24 hours), a cancer diagnosis, a longer surgical time, and an American Society of Anesthesiologists score of 3 or more. They also were older (mean age 56 years vs. 44 years). Of note, 20% of the VTE group identified as black.
Among patients who had a hysterectomy, there were VTEs in 0.7%: 1% in the laparotomy group, 0.3% in the laparoscopic group, and only 0.1% in the vaginal hysterectomy group.
It is interesting to note that 91% of the patients diagnosed with a VTE did received preoperative VTE prophylaxis. The authors noted that the high rate of prophylaxis may have reflected the surgeon’s ability to identify patients who are at high risk.
The authors recognized that the current guidelines do not stratify VTE risk based on the mode of surgery. Further, they noted that low-risk patients undergoing low-risk surgery may be receiving pharmacologic VTE prophylaxis, thus placing these patients at risk for complications related to such therapy.
This paper by Jorgensen et al. should remind us that VTE prophylaxis should be individualized. Patients may not fit nicely into boxes on our EMR; each clinical decision should be made for each patient and for each clinical scenario. The surgeon’s responsibility is to adopt the evidence-based guidelines that serve each individual patient’s unique risk/benefit profile.
David M. Jaspan, DO, is director of minimally invasive and pelvic surgery and chairman of the department of obstetrics and gynecology at the Einstein Medical Center in Philadelphia. Dr. Jaspan, who was asked to comment on the Jorgenson et al. article, said he had no relevant financial disclosures.
The aim of this study was to determine the 3-month postoperative incidence of venous thromboembolism among patients undergoing gynecologic surgery. The study also addressed the mode of surgery to allow a comparison between laparotomy and minimally invasive approaches.
Postoperative VTE was defined as deep venous thrombosis of the lower extremities, pulmonary embolism, or both that occurred within 90 days of surgery. A key component of the study was that clinically recognized VTEs that required treatment with anticoagulation, vena caval filter, or both were included.
The study evaluated 43,751 gynecological cases among 37,485 patients. As expected, 59% of the cases were classified as vaginal surgery, 24% were laparoscopic cases, and 17% of the cases were laparotomies.
Of the 8,273 hysterectomies, 57% were via an abdominal approach, 34% were laparoscopic, and 9 were vaginal cases.
Overall, 0.2% of patients were diagnosed with a VTE. As expected, the greatest incidence of VTE was in patients with cancer who underwent a laparotomy. Those with a VTE were significantly more likely to have had an inpatient stay (longer than 24 hours), a cancer diagnosis, a longer surgical time, and an American Society of Anesthesiologists score of 3 or more. They also were older (mean age 56 years vs. 44 years). Of note, 20% of the VTE group identified as black.
Among patients who had a hysterectomy, there were VTEs in 0.7%: 1% in the laparotomy group, 0.3% in the laparoscopic group, and only 0.1% in the vaginal hysterectomy group.
It is interesting to note that 91% of the patients diagnosed with a VTE did received preoperative VTE prophylaxis. The authors noted that the high rate of prophylaxis may have reflected the surgeon’s ability to identify patients who are at high risk.
The authors recognized that the current guidelines do not stratify VTE risk based on the mode of surgery. Further, they noted that low-risk patients undergoing low-risk surgery may be receiving pharmacologic VTE prophylaxis, thus placing these patients at risk for complications related to such therapy.
This paper by Jorgensen et al. should remind us that VTE prophylaxis should be individualized. Patients may not fit nicely into boxes on our EMR; each clinical decision should be made for each patient and for each clinical scenario. The surgeon’s responsibility is to adopt the evidence-based guidelines that serve each individual patient’s unique risk/benefit profile.
David M. Jaspan, DO, is director of minimally invasive and pelvic surgery and chairman of the department of obstetrics and gynecology at the Einstein Medical Center in Philadelphia. Dr. Jaspan, who was asked to comment on the Jorgenson et al. article, said he had no relevant financial disclosures.
The aim of this study was to determine the 3-month postoperative incidence of venous thromboembolism among patients undergoing gynecologic surgery. The study also addressed the mode of surgery to allow a comparison between laparotomy and minimally invasive approaches.
Postoperative VTE was defined as deep venous thrombosis of the lower extremities, pulmonary embolism, or both that occurred within 90 days of surgery. A key component of the study was that clinically recognized VTEs that required treatment with anticoagulation, vena caval filter, or both were included.
The study evaluated 43,751 gynecological cases among 37,485 patients. As expected, 59% of the cases were classified as vaginal surgery, 24% were laparoscopic cases, and 17% of the cases were laparotomies.
Of the 8,273 hysterectomies, 57% were via an abdominal approach, 34% were laparoscopic, and 9 were vaginal cases.
Overall, 0.2% of patients were diagnosed with a VTE. As expected, the greatest incidence of VTE was in patients with cancer who underwent a laparotomy. Those with a VTE were significantly more likely to have had an inpatient stay (longer than 24 hours), a cancer diagnosis, a longer surgical time, and an American Society of Anesthesiologists score of 3 or more. They also were older (mean age 56 years vs. 44 years). Of note, 20% of the VTE group identified as black.
Among patients who had a hysterectomy, there were VTEs in 0.7%: 1% in the laparotomy group, 0.3% in the laparoscopic group, and only 0.1% in the vaginal hysterectomy group.
It is interesting to note that 91% of the patients diagnosed with a VTE did received preoperative VTE prophylaxis. The authors noted that the high rate of prophylaxis may have reflected the surgeon’s ability to identify patients who are at high risk.
The authors recognized that the current guidelines do not stratify VTE risk based on the mode of surgery. Further, they noted that low-risk patients undergoing low-risk surgery may be receiving pharmacologic VTE prophylaxis, thus placing these patients at risk for complications related to such therapy.
This paper by Jorgensen et al. should remind us that VTE prophylaxis should be individualized. Patients may not fit nicely into boxes on our EMR; each clinical decision should be made for each patient and for each clinical scenario. The surgeon’s responsibility is to adopt the evidence-based guidelines that serve each individual patient’s unique risk/benefit profile.
David M. Jaspan, DO, is director of minimally invasive and pelvic surgery and chairman of the department of obstetrics and gynecology at the Einstein Medical Center in Philadelphia. Dr. Jaspan, who was asked to comment on the Jorgenson et al. article, said he had no relevant financial disclosures.
according to a study published in Obstetrics & Gynecology.
The retrospective cohort study looked at data from 37,485 patients who underwent 43,751 gynecologic surgical procedures, including hysterectomy and myomectomy, at two tertiary care academic hospitals.
Overall, 96 patients (0.2%) were diagnosed with postoperative venous thromboembolism. However patients who underwent laparoscopic or vaginal surgery had a significant 78% and 93% lower risk of venous thromboembolism, respectively, than those who underwent laparotomy, even after adjusting for potential confounders such as age, cancer, race, pharmacologic thromboprophylaxis, and surgical time.
The incidence of postoperative thromboembolism was significantly higher among patients undergoing gynecologic surgery for cancer (1.1%). The incidence among those undergoing surgery for benign indications was only 0.2%, and the highest incidence was among patients with cancer who underwent laparotomy (2.2%).
“This study adds to data demonstrating that venous thromboembolism is rare in gynecologic surgery, particularly when a patient undergoes a minimally invasive procedure for benign indications,” wrote Dr. Elisa M. Jorgensen of Beth Israel Deaconess Medical Center, and her coauthors.
Among the 8,273 patients who underwent a hysterectomy, there were 55 cases of venous thromboembolism – representing an 0.7% incidence. However patients who underwent laparotomy had a 1% incidence of postoperative venous thromboembolism, while those who underwent laparoscopic hysterectomy had an 0.3% incidence and those who underwent vaginal hysterectomy had an 0.1% incidence.
Laparotomy was the most common mode of surgery for hysterectomy – accounting for 57% of operations – while 34% were laparoscopic and 9% were vaginal.
However, the authors noted that the use of laparoscopy increased and laparotomy declined over the 9 years of the study. In 2006, 12% of hysterectomies were laparoscopic, compared with 55% in 2015, while over that same period the percentage of laparotomies dropped from 74% to 41%, and the percentage of vaginal procedures declined from 14% to 4%.
“Because current practice guidelines do not account for mode of surgery, we find them to be insufficient for the modern gynecologic surgeon to counsel patients on their individual venous thromboembolism risk or to make ideal decisions regarding selection of thromboprophylaxis,” Dr. Jorgenson and her associates wrote.
Only 5 patients of the 2,851 who underwent myomectomy developed postoperative VTE – an overall incidence of 0.2% – and the authors said numbers were too small to analyze. Vaginal or hysteroscopic myomectomy was the most common surgical method, accounting for 62% of procedures, compared with 23% for laparotomies and 15% for laparoscopies.
More than 90% of patients who experienced postoperative thromboembolism had received some form of thromboprophylaxis before surgery, either mechanical, pharmacologic, or both. In comparison, only 55% of the group who didn’t experience thromboembolism had received thromboprophylaxis.
“The high rate of prophylaxis among patients who developed postoperative venous thromboembolism may reflect surgeons’ abilities to preoperatively identify patients at increased risk, guiding appropriate selection of thromboprophylaxis,” Dr. Jorgenson and her associates wrote.
Addressing the study’s limitations, the authors noted that they were not able to capture data on patients’ body mass index and also were unable to account for patients who might have been diagnosed and treated for postoperative VTE at other hospitals.
No conflicts of interest were declared.
SOURCE: Jorgensen EM et al. Obstet Gynecol. 2018 Nov;132:1275-84.
according to a study published in Obstetrics & Gynecology.
The retrospective cohort study looked at data from 37,485 patients who underwent 43,751 gynecologic surgical procedures, including hysterectomy and myomectomy, at two tertiary care academic hospitals.
Overall, 96 patients (0.2%) were diagnosed with postoperative venous thromboembolism. However patients who underwent laparoscopic or vaginal surgery had a significant 78% and 93% lower risk of venous thromboembolism, respectively, than those who underwent laparotomy, even after adjusting for potential confounders such as age, cancer, race, pharmacologic thromboprophylaxis, and surgical time.
The incidence of postoperative thromboembolism was significantly higher among patients undergoing gynecologic surgery for cancer (1.1%). The incidence among those undergoing surgery for benign indications was only 0.2%, and the highest incidence was among patients with cancer who underwent laparotomy (2.2%).
“This study adds to data demonstrating that venous thromboembolism is rare in gynecologic surgery, particularly when a patient undergoes a minimally invasive procedure for benign indications,” wrote Dr. Elisa M. Jorgensen of Beth Israel Deaconess Medical Center, and her coauthors.
Among the 8,273 patients who underwent a hysterectomy, there were 55 cases of venous thromboembolism – representing an 0.7% incidence. However patients who underwent laparotomy had a 1% incidence of postoperative venous thromboembolism, while those who underwent laparoscopic hysterectomy had an 0.3% incidence and those who underwent vaginal hysterectomy had an 0.1% incidence.
Laparotomy was the most common mode of surgery for hysterectomy – accounting for 57% of operations – while 34% were laparoscopic and 9% were vaginal.
However, the authors noted that the use of laparoscopy increased and laparotomy declined over the 9 years of the study. In 2006, 12% of hysterectomies were laparoscopic, compared with 55% in 2015, while over that same period the percentage of laparotomies dropped from 74% to 41%, and the percentage of vaginal procedures declined from 14% to 4%.
“Because current practice guidelines do not account for mode of surgery, we find them to be insufficient for the modern gynecologic surgeon to counsel patients on their individual venous thromboembolism risk or to make ideal decisions regarding selection of thromboprophylaxis,” Dr. Jorgenson and her associates wrote.
Only 5 patients of the 2,851 who underwent myomectomy developed postoperative VTE – an overall incidence of 0.2% – and the authors said numbers were too small to analyze. Vaginal or hysteroscopic myomectomy was the most common surgical method, accounting for 62% of procedures, compared with 23% for laparotomies and 15% for laparoscopies.
More than 90% of patients who experienced postoperative thromboembolism had received some form of thromboprophylaxis before surgery, either mechanical, pharmacologic, or both. In comparison, only 55% of the group who didn’t experience thromboembolism had received thromboprophylaxis.
“The high rate of prophylaxis among patients who developed postoperative venous thromboembolism may reflect surgeons’ abilities to preoperatively identify patients at increased risk, guiding appropriate selection of thromboprophylaxis,” Dr. Jorgenson and her associates wrote.
Addressing the study’s limitations, the authors noted that they were not able to capture data on patients’ body mass index and also were unable to account for patients who might have been diagnosed and treated for postoperative VTE at other hospitals.
No conflicts of interest were declared.
SOURCE: Jorgensen EM et al. Obstet Gynecol. 2018 Nov;132:1275-84.
FROM OBSTETRICS & GYNECOLOGY
Key clinical point: Laparoscopic gynecologic surgery is associated with a lower risk of postoperative VTE than laparotomy.
Major finding: Laparoscopic hysterectomy was associated with a 78% lower incidence of postoperative VTE than laparotomy.
Study details: Retrospective cohort study of 37,485 patients who underwent 43,751 gynecologic surgical procedures
Disclosures: No conflicts of interest were declared.
Source: Jorgensen EM et al. Obstet Gynecol. 2018 Nov;132:1275-84.