http://www.jhcme.com Johns Hopkins Consultative Medicine for Hospitalists Fri, 30 Jul 2010 20:14:16 GMT http://www.jhcme.com/betax/site/article.cfm?ID=37 Anemia is frequently seen in patients undergoing surgery, and patients with preoperative anemia are more likely to receive perioperative allogeneic blood transfusions than patients with normal hemoglobin levels. Allogeneic blood transfusions are associated with an increase in the rate of postoperative complications.<br/> <br/> Evaluation of anemia should be performed in the preoperative period and begins with taking a detailed history and physical examination. All efforts must be used to correct anemia or reduce blood loss during surgery to avoid allogeneic blood transfusion. In this module we will discuss many scenarios commonly faced in perioperative practice. http://www.jhcme.com/betax/site/article.cfm?ID=37 http://www.jhcme.com/betax/site/article.cfm?ID=36 Therapeutic advances in cancer therapy have led to an increase in the number of patients undergoing surgery as part of their cancer treatment. These patients present several unique challenges, including weighing risks against adverse effects of delaying time-sensitive treatment and taking the patient’s cancer and its treatment into account when determining postoperative management. The following module discusses these topics, with an emphasis on cardiovascular and pulmonary toxicities of radiation and chemotherapeutic agents as well as common hematologic problems encountered in patients with cancer. http://www.jhcme.com/betax/site/article.cfm?ID=36 http://www.jhcme.com/betax/site/article.cfm?ID=35 Hospitalists are uniquely positioned to ensure in-hospital vaccinations for diseases ranging from tetanus to influenza. The following module discusses appropriate tetanus, pertussis, pneumococcal, influenza, hepatitis, and post-splenectomy immunizations. Moreover, strategies for improving compliance with recommended protocols and indications and contraindications for various vaccines are reviewed. http://www.jhcme.com/betax/site/article.cfm?ID=35 http://www.jhcme.com/betax/site/article.cfm?ID=33 Atrial fibrillation (AF), a cardiac complication following non-cardiothoracic surgery, is more common and better characterized following cardiac surgery. Postoperative AF often prompts surgeons to consult hospitalists because it can be associated with serious surgical complications such as sepsis and venous thromboembolism. Although typically self-limited, AF can persist to discharge and can lead to an increased length of stay. Furthermore, conditions that are associated with AF contribute to increased mortality. The following module addresses the frequency and risk factors for AF, initial management and evaluation of postoperative AF, and the management of persistent postoperative AF that is still present at discharge. http://www.jhcme.com/betax/site/article.cfm?ID=33 http://www.jhcme.com/betax/site/article.cfm?ID=34 As the use of prednisone to treat various medical illnesses has expanded, so has the concern for hypothalamic-pituitary-adrenal (HPA) axis suppression and subsequent adrenal insufficiency (AI). Despite the fact that most clinicians clearly recognize the potential for AI, many find the sometimes subtle presentation challenging. Furthermore, clinicians often struggle with assessing the likelihood of perioperative AI risk and with preventing it. The following module will address the perioperative management of both patients with known AI and those at risk for HPA axis suppression. http://www.jhcme.com/betax/site/article.cfm?ID=34 http://www.jhcme.com/betax/site/article.cfm?ID=25 http://www.jhcme.com/betax/site/article.cfm?ID=25 http://www.jhcme.com/betax/site/article.cfm?ID=29 Hospitalized patients with diabetes require specific medical management in order to minimize the risk of hyperglycemia. This requires hospitalists to have an understanding of methods for glycemic control in both the critically ill and noncritically ill patient. This module will evaluate the current scientific evidence regarding glycemic control and discuss which medications are best for controlling blood glucose levels in the hospital. In addition, a thorough discussion of how to determine the appropriate insulin dose and develop an insulin regimen for hospitalized patients is provided. http://www.jhcme.com/betax/site/article.cfm?ID=29 http://www.jhcme.com/betax/site/article.cfm?ID=30 Current estimates indicate that 2 to 3 million Americans take warfarin for prevention of thromboembolism from venous thromboembolism, atrial fibrillation, or prosthetic heart valves. Invasive procedures are performed in as many as 250 000 patients taking warfarin on annual basis in the United States. Antiplatelet agents such as aspirin and clopidogrel are taken by many more patients for prevention of myocardial infarction and stroke. Consequently, management of antithrombotic agents in the perioperative period is a common and vexing challenge for physicians. Because not all patients are at the same risk of thromboembolism and not all procedures are associated with the same risk of bleeding, it is important for hospitalists to know how to weigh these risks in their patients. The purpose of this module is to review risk factors for thromboembolism and bleeding associated with different thromboembolic disorders and invasive procedures. http://www.jhcme.com/betax/site/article.cfm?ID=30 http://www.jhcme.com/betax/site/article.cfm?ID=24 http://www.jhcme.com/betax/site/article.cfm?ID=24 http://www.jhcme.com/betax/site/article.cfm?ID=28 Although general internists and subspecialists are familiar with prescribing and managing medications in typical outpatient and inpatient venues, the perioperative period represents a challenging and often unfamiliar setting. This module will outline the principles, available evidence, and expert opinion to be considered when making perioperative management recommendations for some of the most commonly prescribed medications. http://www.jhcme.com/betax/site/article.cfm?ID=28 http://www.jhcme.com/betax/site/article.cfm?ID=23 http://www.jhcme.com/betax/site/article.cfm?ID=23 http://www.jhcme.com/betax/site/article.cfm?ID=22 http://www.jhcme.com/betax/site/article.cfm?ID=22 http://www.jhcme.com/betax/site/article.cfm?ID=27 Venous thromboembolism (VTE) prophylaxis in the surgical patient remains an important medical issue. Research has shown that VTE, which includes deep vein thrombosis and pulmonary embolism, occurs frequently in hospitalized patients who have undergone general, major gynecologic, major urologic, major orthopedic, or neurosurgery if preventive measures are not taken. Although it is impossible to predict with certainty which surgical patients will develop VTE, it is important for medical consultants to have a working knowledge of the different risk factors for VTE as well as current prophylaxis recommendations in order to employ appropriate strategies to reduce the risk of VTE. http://www.jhcme.com/betax/site/article.cfm?ID=27 http://www.jhcme.com/betax/site/article.cfm?ID=21 http://www.jhcme.com/betax/site/article.cfm?ID=21 http://www.jhcme.com/betax/site/article.cfm?ID=20 http://www.jhcme.com/betax/site/article.cfm?ID=20 http://www.jhcme.com/betax/site/article.cfm?ID=26 Medical consultation is an important clinical component for most hospitalists. Traditionally, consultants evaluated patients at the request of the referring physician (RP) and provided an assessment and recommendations. Today, hospitalists are also asked to provide both “curbside” advice and more comprehensive comanagement of medical problems. Hospitalists who are effective consultants communicate skillfully and act professionally. The following module describes the different roles that hospitalists can perform as medical consultants and provides strategies for improving communication and RP satisfaction. http://www.jhcme.com/betax/site/article.cfm?ID=26 http://www.jhcme.com/betax/site/article.cfm?ID=19 http://www.jhcme.com/betax/site/article.cfm?ID=19 http://www.jhcme.com/betax/site/article.cfm?ID=18 Although obstetricians play the most critical role in the health of a pregnant woman and her fetus, the internist’s skills are also often needed to assure their health. From caring for chronic medical illnesses during pregnancy to diagnosing and managing acute medical complications of pregnancy, the internist must comfortably practice obstetric medicine. The following module discusses these important topics and explains how to provide a cost-effective and evidence-based preoperative evaluation of a pregnant patient. In addition, a discussion of the use of appropriate intraoperative and postoperative interventions and methods for employing an evidence-based approach to prescribing medications in pregnant patients is included. http://www.jhcme.com/betax/site/article.cfm?ID=18 http://www.jhcme.com/betax/site/article.cfm?ID=17 Perioperative fever has multiple possible etiologies, including infections such as pneumonia, fungal infections, and those related to urinary or central venous catheters. By understanding the typical time frame and common risk factors for each etiology, hospitalists and other perioperative consultants can develop a differential diagnosis for perioperative fever. The following module will provide a general approach for determining the differential diagnosis in patients with a perioperative fever, as well as an outline of the diagnostic and treatment modalities. http://www.jhcme.com/betax/site/article.cfm?ID=17 http://www.jhcme.com/betax/site/article.cfm?ID=16 Surgical site infections (SSIs) are a major cause of postoperative illness, longer hospitalization, and increased healthcare costs, making the prevention and treatment of SSIs an important aspect of patient care for hospitalists. The following module outlines the different patient and procedural risk factors that influence SSIs, examines the basic principles of antimicrobial prophylaxis for SSI, reviews nonantibiotic interventions to lessen the risk of SSI, and outlines evaluation for and treatment of an SSI. In addition, a discussion of the controversy surrounding preoperative decolonization of <em>Staphylococcus aureus</em> is provided. http://www.jhcme.com/betax/site/article.cfm?ID=16 http://www.jhcme.com/betax/site/article.cfm?ID=15 Hip fractures are a frequent cause of acute hospitalization in the elderly population. As the population continues to age, the incidence is expected to increase. Because many hip fracture patients suffer from multiple medical comorbidities, hospitalists increasingly play a critical role in their care. Management of hip fracture patients requires knowledge of multiple consultative medicine topics, including preoperative cardiac and pulmonary risk stratification and reduction strategies, venous thromboembolism prevention, and diagnosis and management of common postoperative complications. Open lines of communication between the hospitalist, surgeon, and anesthesiologist are also essential to optimize patient care. http://www.jhcme.com/betax/site/article.cfm?ID=15 http://www.jhcme.com/betax/site/article.cfm?ID=14 As a consultant, hospitalists commonly risk stratify and offer risk reduction strategies for patients undergoing surgery. Effective perioperative pulmonary risk consultation requires hospitalists to identify patient- and procedure-related predictors for developing postoperative pulmonary complications and to propose strategies to reduce the risk. The following module will examine these topics and provide evidence-based risk reduction strategies. In addition, the role of routine preoperative spirometry and chest radiograph will be discussed. http://www.jhcme.com/betax/site/article.cfm?ID=14 http://www.jhcme.com/betax/site/article.cfm?ID=13 Acute renal failure (ARF) is an important and often preventable complication of hospitalization. Patients with even modest increases in their serum creatinine have increases in their mortality, length of stay, and hospital costs. Postoperative ARF represents 9% to 25% of all cases of hospital-acquired renal insufficiency. Risk factors for postoperative ARF can be identified in advance and preventive measures taken to avoid the development of renal insufficiency. The following module explains the roles of medical treatment in lowering the risk of perioperative ARF, the typical presentation of ARF postoperatively, the diagnostic approach to perioperative ARF, and the initial treatment once ARF develops. http://www.jhcme.com/betax/site/article.cfm?ID=13 http://www.jhcme.com/betax/site/article.cfm?ID=12 Delirium, or acute confusional state, is a syndrome characterized by an acute change in cognition with altered consciousness and impaired attention that fluctuates over time. It is a common diagnosis in the hospitalized patient, especially in the elderly, and can be associated with serious complications. Delirium often goes unrecognized and untreated. Symptoms are wide ranging, thus a clinical diagnosis can be missed without a formal assessment. The following module provides hospitalists with methods for diagnosing and managing delirium. A management strategy for the prevention and treatment of alcohol withdrawal delirium is also discussed. http://www.jhcme.com/betax/site/article.cfm?ID=12 http://www.jhcme.com/betax/site/article.cfm?ID=11 Perioperative cardiac complications are the most widely feared medical issues for the anesthesiologist, surgeon, and medical consultant as they approach a patient with the option of surgery. To assess for the preoperative cardiac risk, hospitalists should follow a step-wise algorithm. The following module reviews the risk assessment process and enables the hospitalist to order appropriate preoperative testing. http://www.jhcme.com/betax/site/article.cfm?ID=11 http://www.jhcme.com/betax/site/article.cfm?ID=10 Perioperative cardiac complications are the most widely feared medical issues for the anesthesiologist, surgeon, and medical consultant as they approach a patient with the option of surgery. Yet, only recently have management strategies been addressed in high-quality studies. The following module explains the roles of medical and interventional treatments in lowering perioperative cardiac event rates. This module also discusses the typical presentation of coronary syndromes postoperatively and the management of antiplatelet and cardiac medications. http://www.jhcme.com/betax/site/article.cfm?ID=10