, 27 tweets, 13 min read Read on Twitter
As voted upon, a #Tweeotorial #Medthread:
#perioperative medicine meets #backtobedside
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.
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so let’s talk about functional capacity and METS!

1/x
METS?
“metabolic equivalent of task”

Huh?

Have you ever seen that report out on exercise equipment? Usually a number < 10?
It’s a measure of physical activity via oxygen consumption

Again, huh? #backtobedside??
Stay with me…
2/x
en.wikipedia.org/wiki/Metabolic…
Recall that the 2007 and 2014 ACC/AHA perioperative guidelines both include a step in their algorithms that no additional ischemic testing is recommended for patients who can achieve > 4 METS

So...how about those METS???
3/x
Many #perioperative medicine experts emphasize that a high-value, patient-centered pre-op risk assessment (it’s NOT clearance!) depends on a high quality HISTORY & PHYSICAL—and that this is MORE important than any potential pre-op testing….
4/x
...and do you know what’s integral to a high quality “H&P”?
The SOCIAL HISTORY!
Not just “tobacco/alcohol/illicits”
.
.
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For me, the most important part of the #preop is the SOCIAL HISTORY, in large part because it gets to the key “ > 4 METS” question
#backtobedside
5/x
BUT…
I don’t just come right out and ask someone “how many METS do you achieve…”
I also don’t ask “how much exercise do you get”?
Ask more open-ended questions!
Frame it as an integral part of your #preoperative social history

< or > 4 METS is more than a check box

6/x
what’s the most active thing you do for…
(…and now repeat after me….)
⏺️exercise
⏺️activity
⏺️fun
⏺️work
⏺️life
7/x
It’s so much more than a static “what can you do” line of questioning.

…Who are you?
…as a patient?
…doing these things?
…in the content of your life?
…and the need or opportunity to get ready for a surgery, whatever your surgical indications are?
8/x
What can you tell me that helps me determine if you are optimized for surgery…AND…lets me understand YOU AS A PERSON getting ready for surgery!

(disclaimer—these are hybrids of 1000s of patients I’ve seen in preop clinic over the years, not any one participate patient)

9/x
Let’s go through my list:

Exercise?
“I exercise”➡️should be pretty cut & dry➡️> 4 METS
But if you end there, that’s where you’re missing out!
WHAT? HOW do you exercise?

“I joined the YMCA next to the sober housing I’m now staying at”

>4 METS
(and even more)

10/x
Activity? Fun? Work?
“I don’t exercise, but I’m really active”

A few years back, I started generating the “Oregon METS” list
I’ve learned some awesome things about patients…and the State I live in
Bonus—fantastic weekend activity suggestions.
Take. Notes!

> 4 METS

11/x
People are wonderfully creative and fascinating.
Ask them!!

Live Action Role Playing (LARPing)?
Walking 5 miles around perimeter of the 100year old family farm & sharing fresh apples w clinic?
Mushrooming in the foothills? Hey, it’s chanterelle season finally!

> 4 METS

12/x
Your patient doesn’t look like the “active type”?

When you assume, you make an…
Just because they’re having surgery for functional limitations (ex ortho) doesn’t mean they aren’t active.

“I can’t walk 50 feet but open-ocean kayaked for 3 hours last weekend”

> 4 METS

13/x
so now, let’s add another element of connecting with your patient in the content of their surgical indications…

✅exercise
✅activity
✅fun
✅work
OR
🔘LIFE and
🔘NECESSITY

14/x
Understand the task of fitting in surgery to one’s overall life and roles

“I don’t exercise, because I don’t have time-I’m caring for my two elderly parents with dementia, running up/down stairs, lifting them for transfers…& scrambling to arrange care for them”

> 4 METS

15/x
Frame your inquiry with acknowledgement and respect for #SDoH

“My car is broken, so I walk a mile in each direction to the grocery store, carry back all my bags, and climb to my 4th floor apartment because the elevator is also broken”

> 4 METS

16/x
learn about the fears surrounding the surgery itself

“we just took the trip of a lifetime, walking miles a day around European cities…before I started neoadjuvant chemo before this surgery…in case that was my only chance to cross that off my bucket list”

> 4 METS

17/x
learn about what aspiration your patient has for a successful recovery process

“I’m missing my favorite triathlon this summer because of the herniated disc, and I really hope I’ll be hoping to be able to participate next year”

> 4 METS (until very recently)

18/x
Sometimes it’s not the aerobic expenditure, but the expenditures to be permitted to do the things that make them “them” that add tremendous value & insight into the assessment

“I’ve had my biannual stress test to maintain my ____”
pilot’s license
school bus drivers license

19/x
and sometimes, “< 4 METS” esp when part of a narrative arc for your patient, is the clue you need to provide pre-op testing recommendations

“I can’t keep up with my grandkids anymore…”
“I haven’t been walking the 18 holes this summer, I’ve been using the cart”

< 4 METS

20/x
(btw, if you ever use the information about how often they walk their dog to confirm functional capacity, ask the name of the dog…and the breed)
21/x
nejm.org/doi/full/10.10…
but…sigh…You might have heard about the METS trial published last year, which concluded objective quantification was better than subjective (the DASI)

“Subjectively assessed functional capacity should not be used for preoperative risk evaluation”

22/x

thelancet.com/journals/lance…
(brakes come to a screeching halt…)

what was the point of this #tweetorial!?!?

as excited as I am for this validated marker of periop risk, part of me definitely bristled when the study was published.

(actually, it's a fascinating, well done, well written study!!)
23/x
however, the DASI is just a potential component of the global periop assessment, and if you look at the questions, they are still very much in the experience of living as a patient with surgical indications

check it out

24/x

mdcalc.com/duke-activity-…
so if we move away from the < or > 4 METS branch point of the preop algorithm…

if we get rid of that check box, am I going to stop asking about functional capacity as part of my #preop social history?

No

because it very never about the check box

#backtobedside

25/FIN
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