Steven L. Cohn

Prophylaxis of venous thromboembolism in the US: improving hospital performance

Summary.  Venous thromboembolism (VTE) prevention has been recognized as the most important practice for improving patient safety in hospitals. To be effective, VTE prophylaxis must be appropriately prescribed with respect to type, dose and duration. Large‐scale studies of medical discharge records have highlighted low rates of appropriate thromboprophylaxis in hospitalized medical patients, especially those with cancer or severe lung disease. Lack of prophylaxis and an insufficient duration are the most common forms of inappropriate prophylaxis. Multifaceted, active, quality improvement initiatives have been developed and shown to successfully increase the appropriate prescribing of VTE prophylaxis in patients at risk. By increasing the use of appropriate VTE prophylaxis in at‐risk patients, the disease burden of hospital‐acquired VTE and its resulting complications can be reduced.

Preoperative risk evaluation and perioperative management of patients with coronary artery disease.

We have reviewed the methods of evaluating a patients cardiac risk preoperatively using a careful history, physical examination, and EKG. Based on this information, various risk indices, guidelines, and algorithms can further assist the physician in deciding which patients can undergo surgery without further testing and which patients might benefit from further cardiac evaluation or medical therapy prior to surgery. The physician must keep in mind that a test should not be ordered if it is unlikely to alter the patients management, and it is rarely necessary to perform a revascularization procedure with the sole purpose of getting a patient through surgery. Ongoing research is likely to lead to improvement in perioperative medical therapy.

Perioperative care of the patient with renal failure

Preventing postoperative ARF, especially in subjects with pre-existing chronic kidney disease, and caring for ESRD patients undergoing surgery are challenging and best accomplished by a team comprised of primary care physician, nephrologist, cardiologist, surgeon, anesthesiologist, endocrinologist, and nutritionist. Elimination of risk factors for ARF whenever possible, as well as early diagnosis, may improve the outcome of this devastating illness. Drugs capable of preventing or changing the course of postoperative ARF may be available soon. For uremic patients, a comprehensive approach is necessary to minimize morbidity and mortality imposed by numerous comorbid conditions.

Update in Perioperative Medicine 2011

The field of perioperative medicine continues to mature as evidenced by the growing number of high-quality articles published each year. This is encouraging given the increasingly complex patient population that routinely undergoes major surgery. Furthermore, as surgeons have become more sub-specialized, there is increased reliance on the generalist to perform consultative medicine for the preoperative patient, as well as co-manage patients throughout the hospitalization.

Preoperative cardiac evaluation of lung resection candidates.

Patients who have lung cancer typically have both pulmonary and cardiac disease as a result of cigarette smoking and are potentially at increased risk for perioperative cardiopulmonary complications. Knowledge of risk factors and a careful preoperative assessment will help the medical team stratify the patients level of risk and employ measures to minimize surgical risk. The available literature specific to cardiac risk and lung cancer surgery is minimal, but the general principles of preoperative cardiac risk evaluation and perioperative management have been reviewed. When considering cardiac testing and interventions, the medical consultant must remember that surgery is the treatment of choice for non-small cell lung cancer and must avoid any excessive delay that might compromise the patients chance of a surgical cure.

Update in Perioperative Medicine

Gerald W. Smetana, MD, ~ Steven L. Cohn, MD, 2 Donna L. Mercado, MD, 3 Amir K. Jaffer, MD 4 ~ Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; 2State University of New York Downstate Medical Center, Brooklyn, NY, USA; 3The Division of General Internal Medicine and Geriatrics, Baystate Medical Center, Tufts University School of Medicine, Boston, MA, USA; 4IMPACT (Internal Medicine Preoperative Assessment, Consultation, and Treatment) Center and Anticoagulation Clinic, Department of General internal Medicine, Cleveland Clinic, Cleveland, OH, USA.

Perioperative Medication Management

Every year millions of patients undergo surgery, and most of them take one or more prescriptions or over-the-counter medications. The number of medications increases with age and in patients undergoing major surgical procedures.

Risk factors for postoperative pulmonary complications: an update of the literature

Abstract Perioperative medicine is a growing area of research that brings together internists, anesthesiologists, surgeons, and hospitalists. A medical team approach to ensure the best possible patient outcomes has fostered collaborative strategies across disciplines. Perioperative pulmonary complications are common and can be associated with significant morbidity and mortality. Effective strategies to identify and reduce risks of pulmonary complications can improve patient outcomes. We review the new literature (2013 to early 2014) in the field of perioperative pulmonary medicine that reports new strategies to improve outcomes in the area of perioperative pulmonary care.

Perioperative medicine update.

Evidence-based preoperative risk stratification and implementation of therapies to decrease morbidity and mortality are the focus of the preoperative evaluation that internists often perform in the office or the hospital setting. In this paper, we summarize some recent key advances in the field of perioperative medicine. We used a systematic search strategy to survey the relevant literature for the period January 1, 2007 through April 1, 2008. We performed a MEDLINE search using the medical subject heading (MeSH) terms intraoperative complications, postoperative complications, preoperative care, intraoperative care, perioperative care, postoperative care, intraoperative period, preoperative period, acute renal failure, cirrhosis, venous thromboembolism, and surgery. We added the following text words: intraoperative OR perioperative OR postoperative AND/OR complication OR event. As our target audience is general internists, we excluded studies of transplantation surgery, cardiac surgery, and pediatric surgery. We discuss studies that the four authors agreed had the most important practice implications for perioperative medicine. We have divided the articles into four sections: perioperative cardiac care, perioperative anticoagulant therapy, prevention of postoperative respiratory failure, and predicting postoperative risk of morbidity and mortality.

Preoperative medical consultation

Preoperative medical consultation plays an important role in the practices of both primary care physicians and subspecialists. Despite this fact, many physicians feel inadequately trained to function as consultants in the perioperative period. Prior to 1980, there were essentially no textbooks on the subject, and there were only a few ‘‘landmark’’ papers. The November 1979 issue of the Medical Clinics of North America on ‘‘Medical Evaluation of the Preoperative Patient’’ was essentially the first ‘‘book’’ on the subject. Subsequently, numerous articles and textbooks on various aspects of preoperative medical consultation were published. Preoperative medical consultation was covered in the May 1987 issue, select topics in medical consultation in the March 1993 issue, and postoperative medical complications was the topic of the September 2001 issue of the Medical Clinics of North America. The goal of this current issue is to review and update the major topics in preoperative medical consultation. This publication is not intended to be an all-inclusive reference book. It was written by practicing internists with extensive experience in perioperative medicine and expertise in their selected areas. The vast majority of our authors are general internists and members of the Medical Consultation Interest Group of the Society for General Internal Medicine (www.sgim.org). Based on our experience, we have chosen topics we think are the most important or those most commonly encountered in clinical practice. The 15 articles in this issue range from the role of the consultant, preoperative laboratory testing, and perioperative medication management to preoperative risk assessment of patients with diseases Med Clin N Am 87 (2003) xv–xvi