Nick Fitterman

Risk Assessment for and Strategies To Reduce Perioperative Pulmonary Complications for Patients Undergoing Noncardiothoracic Surgery: A Guideline from the American College of Physicians

Recommendations Recommendation 1: All patients undergoing noncardiothoracic surgery should be evaluated for the presence of the following significant risk factors for postoperative pulmonary complications in order to receive pre- and postoperative interventions to reduce pulmonary risk: chronic obstructive pulmonary disease, age older than 60 years, American Society of Anesthesiologists (ASA) class of II or greater, functionally dependent, and congestive heart failure. The following are not significant risk factors for postoperative pulmonary complications: obesity and mild or moderate asthma. Recommendation 2: Patients undergoing the following procedures are at higher risk for postoperative pulmonary complications and should be evaluated for other concomitant risk factors and receive pre- and postoperative interventions to reduce pulmonary complications: prolonged surgery (>3 hours), abdominal surgery, thoracic surgery, neurosurgery, head and neck surgery, vascular surgery, aortic aneurysm repair, emergency surgery, and general anesthesia. Recommendation 3: A low serum albumin level (<35 g/L) is a powerful marker of increased risk for postoperative pulmonary complications and should be measured in all patients who are clinically suspected of having hypoalbuminemia; measurement should be considered in patients with 1 or more risk factors for perioperative pulmonary complications. Recommendation 4: All patients who after preoperative evaluation are found to be at higher risk for postoperative pulmonary complications should receive the following postoperative procedures in order to reduce postoperative pulmonary complications: 1) deep breathing exercises or incentive spirometry and 2) selective use of a nasogastric tube (as needed for postoperative nausea or vomiting, inability to tolerate oral intake, or symptomatic abdominal distention). Recommendation 5: Preoperative spirometry and chest radiography should not be used routinely for predicting risk for postoperative pulmonary complications. Preoperative pulmonary function testing or chest radiography may be appropriate in patients with a previous diagnosis of chronic obstructive pulmonary disease or asthma. Recommendation 6: The following procedures should not be used solely for reducing postoperative pulmonary complication risk: 1) right-heart catheterization and 2) total parenteral nutrition or total enteral nutrition (for patients who are malnourished or have low serum albumin levels). Introduction Postoperative pulmonary complications play a significant role in the risk for surgery and anesthesia. The most important and morbid postoperative pulmonary complications are atelectasis, pneumonia, respiratory failure, and exacerbation of underlying chronic lung disease. While clinicians are very conscious of the importance of, and risk factors for, cardiac complications, clinicians who care for patients in the perioperative period may be surprised to learn that postoperative pulmonary complications are equally prevalent and contribute similarly to morbidity, mortality, and length of stay (1-5). Pulmonary complications may also be more likely than cardiac complications to predict long-term mortality after surgery, particularly among older patients (6). This guideline is based on a 2-part systematic review prepared by Smetana and colleagues (7) and Lawrence and colleagues (8). The American College of Physicians (ACP) developed these guidelines to 1) guide clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery and 2) evaluate the efficacy of strategies to reduce the risk for postoperative pulmonary complications. Studies of immunosuppressive states other than HIV infection (for example, organ transplantation) and of risk factors for postoperative venous thromboembolism were excluded from the review. The target audience is general internists or other clinicians involved in perioperative management of surgical patients. This guideline applies to adult patients undergoing noncardiopulmonary surgery. The perioperative period as defined in the studies ranged from 2 to 3 months before surgery and up to 3 months after surgery. A more in-depth discussion of the methods and the inclusion and exclusion criteria is available in the accompanying background papers in this issue (7, 8). In this paper, patient- and procedure-related risk factors are discussed separately. Patient-Related Risk Factors Potential patient-related risk factors fell into the following general categories: age; chronic lung disease; cigarette use; congestive heart failure; functional dependence; American Society of Anesthesiologists (ASA) classification; obesity; asthma; obstructive sleep apnea; impaired sensorium, abnormal findings on chest examination, alcohol use, and weight loss; and exercise capacity, diabetes, and HIV infection. Age The evidence review found that advanced age is an important predictor of postoperative pulmonary complications, even after adjustment for comorbid conditions. Ten multivariable studies showed that age was a significant risk predictor and was the second most commonly identified risk factor. The odds ratio was 2.09 (95% CI, 1.70 to 2.58) for patients 60 to 69 years of age and 3.04 (CI, 2.11 to 4.39) for those 70 to 79 years of age compared with younger patients (those <60 years of age). Chronic Lung Disease Among studies reporting multivariable analyses, chronic obstructive pulmonary disease was the most commonly identified risk factor for postoperative pulmonary complications (odds ratio, 1.79 [CI, 1.44 to 2.22]). No eligible study determined the incremental risk for postoperative pulmonary complications in patients with chronic restrictive lung disease or restrictive physiologic characteristics due to neuromuscular disease or chest wall deformity, such as kyphoscoliosis. While clinicians may consider such patients with severe limitations to have an increased risk for postoperative pulmonary complications, the literature did not support an estimate of the magnitude of this risk in this group. Cigarette Use The available data are mixed but suggest a modest increase in risk for postoperative pulmonary complications among current smokers. The odds ratio for cigarette use was 1.26 (CI, 1.01 to 1.56). It is important to assess history of current smoking status and support for smoking cessation intervention very early in the preparation for nonemergency surgery. Congestive Heart Failure Good-quality evidence identified congestive heart failure as a significant risk factor for postoperative pulmonary complications (odds ratio, 2.93 [CI, 1.02 to 8.43]). Functional Dependence The evidence review showed that functional dependence is an important predictor of postoperative pulmonary complications. Total dependence was the inability to perform any activities of daily living, and partial dependence was the need for equipment or devices and assistance from another person for some activities of daily living. The odds ratio was 2.51 (CI, 1.99 to 3.15) for total dependence and 1.65 (CI, 1.36 to 2.01) for partial dependence. ASA Classification Several integrated measures of comorbidity have been evaluated as potential predictors of postoperative pulmonary complications. The ASA classification (Table) aims to predict perioperative mortality rates but has since been proven to predict both postoperative pulmonary and cardiac complications (9). Higher ASA class was associated with a substantial increase in risk when an ASA class of II or greater was compared with an ASA class of less than II (odds ratio, 4.87 [CI, 3.34 to 7.10]) and when an ASA class of III or greater was compared with an ASA class of less than III (odds ratio, 2.25 [CI, 1.73 to 3.76]). Table. American Society of Anesthesiologists Classification Obesity Studies evaluating clinically meaningful pulmonary complications after surgery have generally found no increased risk attributable to obesity, even for patients with morbid obesity (10, 11). Definitions of obesity varied from a body mass index of more than 25 kg/m2 to morbid obesity. Postoperative pulmonary complication rates were 6.3% and 7.0% for obese and nonobese patients, respectively, in studies that reported only univariate data. Asthma Good evidence suggested that asthma is not a risk factor for postoperative pulmonary complications. Only 1 of 4 studies that examined the rate of postoperative pulmonary complications among patients with asthma included a control group; the rate in this study was 3%. Obstructive Sleep Apnea Obstructive sleep apnea increases the risk for airway management difficulties in the immediate postoperative period, but its influence on postoperative pulmonary complications has not been well studied. The evidence review identified a single univariate study that evaluated the risk due to obstructive sleep apnea among patients undergoing hip or knee replacement (12). In this casecontrol study, nonsignificant trends were seen toward higher rates of reintubation, hypercapnia, and hypoxemia for patients with obstructive sleep apnea. This finding suggests that postoperative pulmonary complication rates may have been higher among patients with obstructive sleep apnea, but this needs to be confirmed by more studies. Impaired Sensorium, Abnormal Findings on Chest Examination, Alcohol Use, and Weight Loss Fair evidence shows that impaired sensorium, abnormal findings on chest examination, alcohol use, and weight loss modestly increase the risk for postoperative pulmonary complications. Impaired sensorium is defined as 1) an acutely confused or delirious patient who is able to respond to verbal stimulation, mild tactile stimulation, or both, or 2) a patient with mental status changes, delirium, or both in the context of current illness. This definition excludes patients with stable chronic mental illness or dementia. Exercise Capacity, Diabetes, and HIV Infection Evidence was insufficient to support w

Treatment of Anemia in Patients With Heart Disease: A Clinical Practice Guideline From the American College of Physicians

DESCRIPTION The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the treatment of anemia and iron deficiency in adult patients with heart disease. METHODS This guideline is based on published literature in the English language on anemia and iron deficiency from 1947 to July 2012 that was identified using MEDLINE and the Cochrane Library. Literature was reassessed in April 2013, and additional studies were included. Outcomes evaluated for this guideline included mortality; hospitalization; exercise tolerance; quality of life; and cardiovascular events (defined as myocardial infarction, congestive heart failure exacerbation, arrhythmia, or cardiac death) and harms, including hypertension, venous thromboembolic events, and ischemic cerebrovascular events. The target audience for this guideline includes all clinicians, and the target patient population is anemic or iron-deficient adult patients with heart disease. This guideline grades the evidence and recommendations using the ACPs clinical practice guidelines grading system. RECOMMENDATION 1 ACP recommends using a restrictive red blood cell transfusion strategy (trigger hemoglobin threshold of 7 to 8 g/dL compared with higher hemoglobin levels) in hospitalized patients with coronary heart disease. (Grade: weak recommendation; low-quality evidence) RECOMMENDATION 2 ACP recommends against the use of erythropoiesis-stimulating agents in patients with mild to moderate anemia and congestive heart failure or coronary heart disease. (Grade: strong recommendation; moderate-quality evidence).

Screening for Hereditary Hemochromatosis: A Clinical Practice Guideline from the American College of Physicians

Recommendations Recommendation 1: There is insufficient evidence to recommend for or against screening for hereditary hemochromatosis in the general population. There is currently insufficient evidence to determine whether the benefits of screening the general population outweigh the risks. The C282Y mutation is prevalent in certain populations, particularly white men, and treatment is not costly nor is it associated with any significant harm. Although patients homozygous for C282Y are more likely to have elevated serum ferritin level and transferrin saturation percentage, there currently is no way of predicting which patients will progress to overt disease. For clinicians who choose to screen, 1-time phenotypic screening of asymptomatic non-Hispanic white men with serum ferritin level and transferrin saturation would have the highest yield (1). Recommendation 2: In case-finding for hereditary hemochromatosis, serum ferritin and transferrin saturation tests should be performed. There is no information available on risk-stratifying in patients with an associated condition or conditions such as type 2 diabetes, cardiac arrhythmias and cardiomyopathies, liver failure, hepatomegaly, cirrhosis, elevated liver enzyme levels, hepatocellular carcinoma, arthritis, hypogonadism, or changes in skin pigmentation. The initial symptoms associated with iron overload might be nonspecific, and the decision to perform tests should be based on clinical judgment regarding what may cause such protean manifestations. If testing is performed for these patients, the cutoff values for serum ferritin level of more than 200 g/L in women or more than 300 g/L in men and transferrin saturation greater than 55% may be used as criteria for case-finding; however, there is no general agreement about diagnostic criteria. Case-finding may also be considered if there is a family history of hereditary hemochromatosis for an individual, as the risk for developing the disease may be higher than that of the general population. Recommendation 3: Physicians should discuss the risks, benefits, and limitations of genetic testing in patients with a positive family history of hereditary hemochromatosis or those with elevated serum ferritin level or transferrin saturation. Before genetic testing, individuals should be made aware of the benefits and risks of genetic testing. This should include discussing available treatment and its efficacy; costs involved (2); and social issues, such as impact of disease labeling, insurability and psychological well-being, and the possibility of as-yet-unknown genotypes associated with hereditary hemochromatosis. Recommendation 4: Further research is needed to establish better diagnostic, therapeutic, and prognostic criteria for hereditary hemochromatosis. The lack of information on the natural history of the disease makes it difficult to manage patients with hereditary hemochromatosis. There are no clearly defined criteria to risk-stratify patients into groups more or less likely to develop overt disease. Future developments in technology and genetic screening might help in the diagnosis and management of hereditary hemochromatosis. In addition, there is a need for more uniform diagnostic criteria. Introduction Hereditary hemochromatosis is a genetic disorder of iron metabolism and is characterized by tissue injury resulting from an abnormal accumulation of iron in various organs. This disease is usually a consequence of an increased absorption of iron from the gastrointestinal tract, which results in increased iron deposition in tissue, particularly in the liver, heart, and pancreas. If left untreated, it can lead to organ damage, such as cirrhosis, as well as hepatocellular cancer. However, early diagnosis of hereditary hemochromatosis is difficult because of variability in the case definition and diagnostic standard used. Diagnosis of hereditary hemochromatosis is usually based on a combination of various genetic or phenotypic criteria. Genetically, it can be based on direct DNA testing for the 2 HFE gene mutations (C282Y and H63D) associated with hereditary hemochromatosis. The mutation of C282Y in the HFE gene on chromosome 6 is present in almost 90% of those affected. Most patients are homozygous, and mutation transmission is autosomal recessive. The H63D mutation may be associated with hereditary hemochromatosis, but the actual clinical effects of this mutation are uncertain (3). Although in a small proportion, compound heterozygotes (C282Y/H63D) can develop iron overload. Phenotypic markers of hereditary hemochromatosis may be used to identify the disease. Percentage of transferrin saturation and serum ferritin level have been used to confirm the diagnosis of hereditary hemochromatosis. Transferrin saturation determines how much iron is bound to the protein that carries iron in the blood. Serum ferritin level is elevated in patients with hereditary hemochromatosis and correlates with liver iron and development of cirrhosis. Liver biopsy to measure hepatic iron concentration by staining is considered the gold standard to test for hereditary hemochromatosis. However, with the advent of genetic testing, liver biopsy is not widely used to confirm the diagnosis. There is a consensus on the various diagnostic tests that could be used to diagnose hereditary hemochromatosis. However, the threshold levels that should be used to define the disease remain controversial. On the basis of the review of the background paper by Schmitt and colleagues (4), also in this issue, and considering that lower cutoffs are more sensitive and less specific, serum ferritin level greater than 200 g/mL and transferrin saturation greater than 55% suggest an increased risk for hereditary hemochromatosis and the need for further investigation (5). Hereditary hemochromatosis is the most common recessive genetic trait in white persons. However, estimating the prevalence of this disease is difficult. Genetic testing of populations originating in northern Europe showed that approximately 0.5% are homozygous for the C282Y mutation (6). The Hemochromatosis and Iron Overload Screening (HEIRS) Study showed that the prevalence of C282Y homozygotes was highest among non-Hispanic white persons (0.44% [95% CI, 0.42% to 0.47%]) (1). Phenotypic screening of the population in the United States demonstrated that 1% to 6% have elevated transferrin saturation and 11% to 22% of this group have an increased serum ferritin level (7). Hereditary hemochromatosis has been estimated to be present in 3 to 5 people per 1000 in the general population (8). Decisions regarding screening are difficult because of the variable penetrance of mutations of the HFE gene and the absence of any definitive trials addressing the benefits and risks of therapeutic phlebotomy in asymptomatic patients or those with only laboratory abnormalities. The purpose of this guideline is to increase physician awareness of hereditary hemochromatosis, particularly the variable penetrance of genetic mutations; aid in case finding; and explain the role of genetic testing. The target audience for this guideline is internists and other primary care physicians. The target patient population is all persons who have a probability or susceptibility of developing hereditary hemochromatosis, including the relatives of individuals who already have the disease. This guideline is based on the systematic review of the evidence in the background paper (4). This guideline attempts to answer the following questions: 1) What is the prevalence of hereditary hemochromatosis in the primary care setting? 2) In asymptomatic patients with hereditary hemochromatosis, what is the risk for end-organ damage or death? 3) How diagnostically useful are transferrin saturation and serum ferritin in identifying patients with hereditary hemochromatosis in the primary care setting? 4) Is phlebotomy efficacious in reducing morbidity or fatal complications in asymptomatic patients with hereditary hemochromatosis? 5) Do the benefits of screening primary care patients for hereditary hemochromatosis outweigh the risks? Prevalence Estimates of the prevalence of hereditary hemochromatosis in the general population vary widely because no set criteria define what constitutes hereditary hemochromatosis (5, 9, 10). Some argue that genotyping should be used as the gold standard and that the sensitivity and specificity of phenotyping should be calculated and compared with those of genotyping. Others support the use of persistently elevated serum ferritin level and percentage of transferrin saturation as the case definition of hereditary hemochromatosis. Studies of differing populations, using strict criteria recommended in the HEIRS Study (11), have estimated that the prevalence of hereditary hemochromatosis ranges from 1 in 357 persons to 1 in 625 persons in the general population to rates almost as high as 1 in 135 persons among Norwegian men (4). The Table lists various studies showing the prevalence of hereditary hemochromatosis in primary care settings. Table. Prevalence of Hereditary Hemochromatosis in Primary Care Settings Risk for Complications in Asymptomatic Patients Asymptomatic individuals are patients in the latent phase of hereditary hemochromatosis who were incidentally identified. These persons have not yet shown any signs or symptoms related to the disease. Although clinical manifestations associated with hereditary hemochromatosis are influenced by age, sex, diet, and other unknown factors, it is imperative to know the path of disease progression for treatment of the disease. Clinical outcomes that can be associated with hereditary hemochromatosis are cirrhosis, hepatocellular carcinoma, type 2 diabetes, congestive heart failure, arthritis, hypogonadism in males, and even death. However, most persons with the mutated gene remain asymptomatic. The literature that discusses the relationship between biochemical primary iron overload (

Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians.

Venous thromboembolism is a common condition affecting 7.1 persons per 10,000 person-years among community residents. Incidence rates for venous thromboembolism are higher in men, African-Americans, and increase substantially with age. It is critical to treat deep venous thrombosis at an early stage to avoid development of further complications, such as pulmonary embolism or recurrent deep venous thrombosis. The target audience for this guideline is all clinicians caring for patients who have been given a diagnosis of deep venous thrombosis or pulmonary embolism. The target patient population is patients receiving a diagnosis of pulmonary embolism or lower-extremity deep venous thrombosis.

Current diagnosis of venous thromboembolism in primary care

This guideline summarizes the current approaches for the diagnosis of venous thromboembolism. The importance of early diagnosis to prevent mortality and morbidity associated with venous thromboembolism cannot be overstressed. This field is highly dynamic, however, and new evidence is emerging periodically that may change the recommendations. The purpose of this guideline is to present recommendations based on current evidence to clinicians to aid in the diagnosis of lower extremity deep venous thrombosis and pulmonary embolism.