Anticoagulation can be a major source of disagreement between surgeons and the clinicians who preoperatively manage patients, but pulmonary or cardiac concerns, comorbidities, and age can also create discussion about whether to continue with elective surgery or how best to proceed when a procedure is absolutely required.
Internists can help ensure that patients are in optimal condition for surgery by managing their medical needs, maintaining familiarity with guidelines for special populations, choosing tests judiciously, and communicating openly and directly with surgeons, experts said.
The depth of the evaluation will depend on the type of surgery, said James E. Spicher, MD, ACP Member, an internist and geriatrician in private practice at General Internal Medicine of Lancaster in Lancaster, Pa.
“Any type of surgery that involves either general or regional anesthesia will require a presurgical visit, but in some situations, such as cataract surgery, it's not as important,” Dr. Spicher said.
Research bears this out. A study appearing in the March 2012 Cochrane Database of Systematic Reviews analyzed 3 randomized trials and found no difference in adverse events between patients who received routine presurgical testing (complete blood count, electrocardiogram, electrolytes, blood urea nitrogen, creatinine, and glucose) before cataract surgery and those who did not. However, 1 study in the review found that the costs were 2.55 times higher for those who received the testing than those who did not, leading the Cochrane researchers to conclude that routine presurgical testing before cataract surgery is inefficient and not cost-effective.
“The most thorough evaluations should be done for thoracic, abdominal, vascular, or other major surgeries,” Dr. Spicher said, adding that for these surgeries, internists are not typically tasked with ordering the tests. “Usually it's the anesthesiologist and, to a lesser extent, surgeon who dictates the tests.”
Steven L. Cohn, MD, FACP, medical director of UHealth Preoperative Assessment Center at the University of Miami Hospital and professor of clinical medicine at the University of Miami Miller School of Medicine, offered a different viewpoint. First, he said, there is no reason most patients need to see a doctor beforehand for local anesthesia and low-risk surgery. A phone screen or visit to an advanced registered nurse practitioner for anesthesia is more than adequate for most patients. Second, he added, academic settings may have standardized preoperative testing protocols developed in conjunction with anesthesiologists.
Dr. Cohn suggested that internists can ensure that a presurgical exam is as cost-effective as possible by observing the “office rule.”
“Just because a patient is having surgery doesn't mean a test should be automatic,” Dr. Cohn said. “If you would not have done the test routinely in an office visit, consider whether the results will have an impact. Very few preoperative lab tests result in any change in management.”
The American College of Physicians' list of “Five Things Physicians and Patients Should Question,” released in 2012 as part of the ABIM Foundation's Choosing Wisely campaign, advises doctors to forgo preoperative chest radiography in the absence of clinical suspicion of intrathoracic pathology because the test rarely changes management or improves outcomes.
Another example is stress testing, said Dr. Cohn. “If a patient has known, stable cardiovascular disease, is taking another look really going to change anything?” he asked. “The exception may be if the surgery is high-risk and the patient has been inactive for a long time and you're not sure if he or she will be symptomatic in the more stressful surgical setting.”
The patient's medical history is a vital part of risk stratification for any surgical procedure. With that in mind, certain patient populations have distinct needs.
Whether to stop anticoagulant medications depends on the kind of surgery the patient is having, experts said. It may not be necessary to stop warfarin therapy for patients having minor dental work, skin procedures such as the removal of a mole, or cataract surgery.
Patients undergoing major surgery should stop warfarin at least 5 days before the procedure, stop IV unfractionated heparin at least 4 to 6 hours preoperatively, and stop low-molecular-weight heparin at least 24 hours preoperatively, according to clinical practice guidelines from the American College of Chest Physicians that appeared in Chest in 2012. However, the guidelines don't discuss when to start unfractionated heparin or low-molecular-weight heparin after discontinuing warfarin, Dr. Cohn pointed out.
“Typically the international normalized ratio will drop below 2.0 after 1 to 2 days, which is why we usually start bridging therapy, if indicated, 36 hours after the last dose of warfarin,” he said. “So patients start heparin therapy 1 to 2 days after stopping warfarin and stop heparin therapy 1 day before surgery, thereby receiving it for 2 to 3 days.”
Dr. Cohn added that investigators in the National Heart, Lung, and Blood Institute's Bridging Anticoagulation in Patients Who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery (BRIDGE) study are about to finish the trial that will hopefully answer the question of whether or not bridging therapy is beneficial.
He added that the American College of Chest Physicians guidelines suggest bridging for high-risk patients, individualizing decisions for intermediate-risk patients, and no bridging for low-risk patients.
“I think this is reasonable, although I am not convinced bridging is beneficial. Preoperatively, the risk of thromboembolism for the 3- to 5-day period the patient is off anticoagulation, or subtherapeutic, in general should be very low. I feel the highest-risk groups are those with mechanical mitral valves or a recent arterial or venous thromboembolism,” Dr. Cohn said. “I think a discussion of risks and benefits should occur between the internist/hospitalist and patient as well as with the surgeon to decide on the plan for any given patient, taking into account the reason for anticoagulation and bleeding risk of the surgical procedure. I don't think one answer fits all.”
Regarding novel oral anticoagulants such as dabigatran, rivaroxaban, apixaban, and edoxaban, Dr. Cohn feels bridging is not necessary as these drugs are stopped as little as 1 day before surgery and usually not more than 4 days before surgery.
“This time frame depends on the drug, its half-life and metabolism, the patient's renal function, and the bleeding risk of the surgery,” Dr. Cohn said. “For impaired renal function, an additional day is added and similarly, for high or important bleeding risk procedures, another day can be added making it a total of 3 to 4 days before in these cases. Dabigatran has the greatest dependence on renal metabolism followed by rivaroxaban. Apixaban is the least renally metabolized.”
Timing the visit is crucial, said Dr. Cohn. “If you want to stop warfarin 5 days before and the patient's appointment isn't until 3 days before the operation, that doesn't help you.”
Whether to discontinue aspirin presents another challenge, Dr. Cohn said. “Most physicians I know are reluctant to stop aspirin in patients taking it for secondary prevention after a myocardial infarction, cardiac stent, coronary artery bypass grafting, or stroke, but there is some evidence that there is no benefit to continuing it.”
Researchers in the Perioperative Ischemic Evaluation 2 (POISE-2) trial published data in the April 17 New England Journal of Medicine suggesting that taking aspirin before surgery and throughout the early postsurgical period did not have a significant impact on rates of nonfatal myocardial infarction (MI) but increased the risk of major bleeding.
Internists should perform a careful but pragmatic review of the patient's medical history, Dr. Cohn said. “Everyone is afraid the patient will have a heart attack and die, but does the patient have any cardiac history? Are they short of breath or wheezing? Do they have chronic obstructive pulmonary disease [COPD] or another pulmonary condition?”
He added that active cardiac conditions such as recent myocardial infarction, unstable angina, decompensated heart failure, severe valvular disease, and arrhythmias such as atrial fibrillation with a rapid ventricular response are red flags. “That's when you say to stop with elective surgery.” The ACC/AHA just released new guidelines for perioperative evaluation and management of patients undergoing noncardiac surgery that internists should review (see sidebar on this page).
Pulmonary risk is a major concern for patients undergoing surgery. Patients can be separated into 2 main groups, those who need thoracic surgery and those who are undergoing nonthoracic surgery but have a high risk of complications, said Gregory C. Kane, MD, FACP, the Jane and Leonard Korman Professor of Pulmonary Medicine at Jefferson Medical College in Philadelphia.
“Patients who require surgery in the chest cavity that involves lung tissue may see a pulmonologist, but in general all should be seen by an internist. They need the attention because they often have coexisting conditions, such as patients with lung cancer who have COPD. Operating on them is challenging, and they need to be prepared for how well they will function after portions of the lungs are resected,” said Dr. Kane.
Patients undergoing nonthoracic surgery who are at high risk because of advanced age or a significant comorbidity like cardiovascular disease should also see an internist, Dr. Kane added. “They have the greatest risk for postop respiratory issues like pneumonia or respiratory failure. The patient and family need to be aware of the long-term concerns should the patient require a respirator.” He added that internists should encourage physical activity because there is some evidence that this improves respiratory outcomes.
Dr. Kane favors as long a lead time before the surgery as possible. “For thoracic surgery, the visit should take place as soon as surgery is contemplated. Time may be of the essence [in terms of addressing presurgical issues] in patients with lung disease or lung cancer.”
He added, “Internists should ensure that patients with chronic lung disease do not undergo elective surgery during or soon after a flare of their underlying condition.”
For a patient who smokes and is undergoing nonthoracic surgery, Dr. Kane suggested a 2-month lead to give internists an opportunity to encourage smoking cessation and to give the patient's body time to adjust.
“If the patient quits more than 6 weeks in advance, it can be beneficial. However, some studies show that the risk of complications increases in recent quitters [of less than 4 weeks],” Dr. Kane said. “Shortly after quitting, patients will experience increased cough and sputum production as the ciliated cells lining the respiratory epithelium come back to life and resume normal function. This period of increased clearance may account for diverse outcomes [in the literature].”
Experts agree that patients with diabetes should visit their internist to address blood glucose control and medication management before surgery. Internists should assess the patient's cardiovascular risk, blood pressure, renal function, and postsurgical risk associated with diabetic complications such as autonomic neuropathy, said Guillermo E. Umpierrez, MD, FACP, professor of medicine and director of the Grady Hospital Research Unit at Emory University in Atlanta.
However, the exact level of blood glucose control necessary for the best outcomes is not known, he added.
“Several studies suggest that patients with a high A1c have more complications, but others suggest that if we manage diabetes well in the hospital, the A1c is not a good predictor of outcome. Nonetheless, we generally want to have the A1c down below 9%,” Dr. Umpierrez said. “If it's higher than 10% or 11%, internists should consider postponing elective surgery, but remember that this doesn't guarantee that the patient will achieve good control in the meantime.”
Dr. Umpierrez stressed that internists should work with patients who have symptoms of diabetes such as weight loss and polyuria and allow several weeks before the surgery for achieving better control. Patients without symptoms may only need to schedule a visit 3 to 5 days before the surgery, if they do not meet the criteria for requiring greater lead times because of comorbidities like known cardiovascular disease.
Dr. Umpierrez also emphasized the need to discuss medication management with patients who have diabetes. “Most patients with diabetes need education on how to take their medications the day before and day of the surgery, especially because they will not be eating for 10 to 12 hours beforehand,” he said.
Balancing medications to avoid or correct hyperglycemia the day of the surgery may have an impact on outcomes. A paper appearing in the January 2013 Annals of Surgery suggests that patients with hyperglycemia (more than 180 mg/dL) the day of their surgery and 2 days immediately afterward have an increased risk of infection, reoperative interventions, or death.
“I am in agreement with that study,” said Dr. Umpierrez. “Several observational and randomized controlled studies in cardiovascular surgery and general noncardiac surgery have shown that hyperglycemia, both in patients with and without diabetes has a deleterious impact on clinical outcome.”
Internists should also address how medications should be taken after discharge and have the patient come back to discuss medication adjustments that may be necessary after surgery, Dr. Umpierrez said.
Experts agree that older surgical patients may be among the most challenging: Their advanced age is a risk factor for postsurgical complications like pneumonia, and they are more likely to be on multiple medications or have several comorbidities, so their medical history is of vital importance.
But beyond that, 2 issues arise in seniors more frequently than in younger patients: cognitive decline and the need to consider what will happen if the surgery doesn't go well, said Dr. Spicher.
“Make sure they understand what the surgery is for, how it will affect them, and what they can expect from it,” Dr. Spicher said. “In most cases where there is known cognitive decline, a family member or other decision-maker will accompany the patient with a power of attorney. But it's important to assess and document the patient's cognitive ability.”
Internists should assess the patient's functional status and how well the patient can communicate or get around, the better to watch for postsurgical challenges, especially because seniors are at greater risk for postoperative delirium than younger patients, Dr. Spicher added.
“Document their status because sometimes after surgery it's not clear in the elderly whether they are having a complication like delirium or it's something like not being able to hear because they aren't wearing their hearing aids,” Dr. Spicher said.
Internists should discuss expectations for the surgery and outcome with the patient and the patient's family, as well as what the patient wants in the event of incapacitation or death, said Dr. Spicher. “Who do they want to be the decision-maker, or who has the power of attorney to decide on issues of life support? Is there an advanced directive? Make sure all of this is in their chart,” he said.
Communicating with surgeons
In some cases, internists may see a red flag during the presurgical visit either upon examining the patient or reviewing test results. The experts agreed that direct communication with the surgeon is the best way to go in such cases.
“In today's day and age, despite beepers, cell phones, texting, and e-mail, direct person-to-person communication between internists and surgeons is the most important thing we can carry out on behalf of our patients. I can't overemphasize the importance of a real-time conversation,” said Dr. Kane.
He added that while patients should be aware that there is a potential issue, they should not be tasked with relaying information back and forth between internist and surgeon.
Fortunately, serious disagreements between internists and surgeons are rare, said Dr. Spicher. “Typically surgeons are all too happy to turn over the medical aspect of things to the medical specialist, the physician. Surgeons just want patients to be in as good a condition as possible before the surgery.”
Finally, internists should choose their words carefully when signing off on patients' charts, noted Dr. Cohn. “Stay away from absolutes. Don't say something like ‘cleared for surgery’ because that implies there is no risk, and all surgeries have some risk,” he said. “What everyone wants to know is that the patient is medically optimized for surgery. But that doesn't mean everything is normal, just as good as it can be given the situation.”