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Jeff Simmons MD, MSHQS, FASA Profile picture
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12 Oct 19, 23 tweets, 14 min read
How do you enhance recovery before surgery? Let's talk about preoperative #optimization initiatives with goal of #prehabilitation! #EB4S 1/

#MedThread #Tweetorial
@aoglasser @TomVargheseJr @KurtPfeifer @afedwardMD @Docbasia @dremilym @tony_breu @ruthi_landau Image
1st, goal is optimization for everyone, but that may not be possible in your place. You want to risk stratify your patients. We use the NSQIP Surgical Risk Calculator, Gupta MICA Calculator, and the Duke Activity Status Index DASI. 2/
riskcalculator.facs.org/RiskCalculator/
You can learn about risk stratification here:
Remember: it's not always just about the heart. Kidney, Lungs, Brain, etc. are at risk. 3/

@ruthi_landau threadreaderapp.com/thread/1177181…

sciencedirect.com/science/articl…

sciencedirect.com/science/articl…
@KurtPfeifer has a combined approach on his website. 4/

preopevalguide.com/ischemic-disea…

It uses the RCRI, DASI, and Gupta MICA in a nice algorithm.
P.J. Devereaux advocates for the use of biomarkers in the Canadian CV Society Guidelines on Perioperative Risk Assessment. 5/
1. Monitor daily troponin after surgery
2. Measure proBNP before surgery

perioperative-risk.amjmed.com/sites/default/…
Once risk stratified, a systematic approach to modifying risk factors is next. 6/

Manage:
1. Smoking
2. Weight
3. Hyperglycemia
4. HTN
5. Malnutrition
6. Elder Care
7. OSA
8. Anemia
9. Opioid Use
10. Medications
11. Dentition
12. Mobility
13. Vaccines Image
Smoking Cessation:
We prescribe Nicotine Patches and Gum directly in our preop clinic. Very easy to implement and cost effective. 7/

Evidence:
journals.lww.com/annalsofsurger…
onlinelibrary.wiley.com/doi/full/10.11… Image
Weight Management:
This can be more expensive. You don't want patient to starve themselves. Bundle this with a prescribed exercise regimen and nutrition counseling. Discussed later

bmcanesthesiol.biomedcentral.com/articles/10.11…
8/ Image
Hyperglycemia:
Measure HgA1C on patients >45 and BMI>25. Combine with preoperative insulin protocol.
Perioperative Goals = HbA1C<8 and BS 120-180
9/
Evidence:
journals.lww.com/anesthesia-ana…

jamanetwork.com/journals/jamas… Image
HTN:
Blood pressure is tricky because immediate preoperative intervention has not been shown to decrease risk. Evaluate HISTORICAL blood pressures and maintain tight control perioperatively (within 20% of historical baseline MAP). 10/

academic.oup.com/bja/article/92… Image
Malnutrition:
@Paul_Wischmeyer has done great work on this.

Objectively measure nutrition with PONS. Brief course of protein and Vitamin D supplementation (5 days before surgery) may have benefit. 11/

Image
Elder Care:
Objectively measure cognition and mobility with ADLs. Involve Geriatric Medicine early. Avoid Beers Criteria Drugs. Openly discuss risks with patient. Notify surgery early. 12/

facs.org/quality-progra…

link.springer.com/article/10.100… Image
OSA:
Screen everyone for risk of OSA. We use STOP-BANG. Arrange for CPAP use postop, multimodal pain meds, regional techniques. Develop PACU monitoring standards. 13/

jamanetwork.com/journals/jama/… Image
Anemia: 14/
The most underappreciated risk IMO. Screen for anemia. Prescribe oral or IV iron if deficient. Arrange for TXA use and Cell Saver. Discuss with surgery.

journals.lww.com/anesthesia-ana… Image
Opioid Use: 15/
Patients on opioids: multimodal pain meds ordered and regional techniques employed. Don't wean buprenorphine in almost all cases. Consult pain service early. We prescribe Narcan for emergency use after surgery.

Medication magement: 16/
Develop a standardized med management guideline. Here is our current one.

dropbox.com/s/3g38q53ww8mi…
Dentition: 17/
Pretty easy one. Consult with dentistry if the patient has very poor dentition if the risk of seeding new implant is a risk. Ortho is willing to cooperate in almost all cases IMO.
Mobility: 18/
Our European brothers and sisters are doing a great job with this. Prescribe a reasonable walking regimen or activity schedule before surgery. The goal is movement, not marathon running.
academic.oup.com/bja/article/11…
Vaccines: 19/
We simply administer Flu and Pneumonia Vaccines in preop clinic. Easy.
Want more information: 20/







Checklist: 21/


dropbox.com/s/2x4wtlq4t7q6…
@Anaes_Journal has an entire supplement on optimization.
@topmedtalk @AbaPhysicians @ASALifeline

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More from @jeffsimmons

Jeff Simmons MD, MSHQS, FASA Profile picture
25 Oct 20
Quick tweetorial on perioperative care of the frail patient. You might do things differently, I would love to know what you do!
@TomVargheseJr @aoglasser @KurtPfeifer @SPAQIedu @ASER_hq @Jeanna_BlitzMD @BobbieJeanSwei1 @afedwardMD @uabmedicine @UABSurgery @UAB_Anesthesia
1/ Image
Older patients and frail patients require adjustments in perioperative care.
2/ Image
All patients should be screened for frailty! Older patients are especially at high risk for frailty!

UAB PACT uses cognitive function, nutrition, and mobility screening to identify at risk patients.

PACT = Preoperative Assessment, Consultation, and Treatment Clinic

3/ Image
Read 16 tweets
Jeff Simmons MD, MSHQS, FASA Profile picture
27 Mar 20
There's been a lot of talk about us being at war with #COVID19 and that is true in many ways, but it is somewhat unfair to healthcare workers. (thread) 1/

@Docbasia @somedocs @aoglasser @afedwardMD @dr_rajgupta @kari_jerge @karenerrichetti Image
Military: there is clear command and control that is ALWAYS present. You walk around with rank on your sleeve.

Hospitals: there are silos, departments, employees, faculty, etc. A pandemic command center pops up with the facility manager and ID Doc as leaders.

Not the same. 2/ Image
Military: we plan and train for crisis regularly. We actually ALL go into a field and act like we are at war.

Hospital: we plan for efficiency and quality. We do not simulate pandemic regularly hospital-wide.

Not the same. 3/ Image
Read 12 tweets
Jeff Simmons MD, MSHQS, FASA Profile picture
7 Sep 19
#TRAUMA: #medthread on the coagulopathic changes in severe trauma.

This is the WHY behind trauma resuscitation efforts.
#traumaanesthesia #damagecontrol #resuscitation
@UABSurgery @UAB_Anesthesia @uabmedicine 1/ Image
Post-trauma hemorrhage and hypotension leads to a unique physiologic derangement called Acute Traumatic Coagulopathy. Resuscitation requires management of both hemodynamics and coagulation status. 2/ Image
Why does this happen? If you were to simply cut your finger, your body would sense the injury and begin clot formation (platelet>factor signaling>fibrin net>more platelets). But to restore blood flow, it would need to break down that clot. 3/ Image
Read 19 tweets

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