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Medical consultation. These two simple words have become one of the “hotter” terms in healthcare today—along with words and phrases like “curbside consultation,” “telehealth,” and “telemedicine.”
As a Professor of Medicine at the University of California, San Francisco (UCSF) School of Medicine and the Director of Medical Consultation Service at the UCSF Medical Center, Dr. Hugo Quinney Cheng, MD is powerfully positioned to discuss challenging instances, situations, and examples in medical consultation. Due to his ongoing Medical Consultation Service Director role, Dr. Cheng is particularly qualified to address certain scenarios that tend to confront today’s time-crunched, hard-working hospitalist.
In his engaging hour-long lecture entitled Tough Cases in Medical Consultation for the Hospitalist, Dr. Cheng discusses, delineates, and outlines recommendations for a handful of such difficult or daunting medical consultations. The lecture was recorded at the 24th Annual Management of the Hospitalized Patient Symposium, presented virtually by the Division of Hospital Medicine and the Department of Medicine at UCSF in the summer of 2021, and is available now for complimentary listening at AudioDigest.org.
After listening intently to Dr. Cheng’s insightful and detailed lecture, physicians, clinicians and other medical professionals like you will be further educated on the proper management of challenging cases that may be encountered within the realm of perioperative medicine. Thorough absorption and application of Dr. Cheng’s talk will empower you to more immediately and confidently assess a patient’s risk for stroke—and be better equipped to accurately evaluate any need for bridging anticoagulation therapy. This lecture by Dr. Cheng also helps medical professionals:
While ideal for Internal Medicine physicians, clinicians, practitioners, and professionals, this lecture and its many embedded insights can also provide great and enduring value to any General Practitioner who may also desire to learn more about challenging medical consultations in today’s ever-evolving and constantly-shifting medical and social landscapes.
With an ever-aging population comes an always-increasing risk for major cardiovascular events—including serious strokes. After assessing and addressing issues surrounding senior patients and strokes (including bridging anticoagulation therapy), Dr. Cheng turns his attention to the difficult and disorienting challenge of dealing with patients who are experiencing postoperative delirium.
“This is one of the more common consult questions I get,” states Dr. Cheng at the outset of his postoperative delirium analysis.
Dr. Cheng then details how these patients can present either as hyperactive (meaning agitated or “amped-up”) or hypoactive (which often involves laying quiet and motionless in bed). The risk for any postoperative delirium is highest in the first three days following surgery, and Dr. Cheng notes that hip surgery recovery seems particularly concerning—with 44 to 61 percent of patients with hip fractures developing some degree of postoperative delirium. Dr. Cheng also cautions that patients and their family members and support networks should be counseled in advance of surgery about delirium risks.
“Talk to the family and let them know the delirium risk really is this high,” states Dr. Cheng. “It’s going to be very uncomfortable and unpleasant to watch them in that state, but it generally will get better—and their presence will definitely be welcome. Don’t let them learn about the risk of delirium after it happens.”
When it comes to implementing preventative and management methods for patients with postoperative delirium, Dr. Cheng stresses that it’s rare to clearly identify specific, reversible causes of delirium. Urinalysis is recommended to check for a urinary tract infection (UTI), and electrocardiography is helpful when testing for myocardial infarction (MI) or other cardiac abnormalities. Dr. Cheng suggests a review of available medications to limit exposure to anticholinergics, benzodiazepines, opiates, and other drugs with psychogenic properties. Short-acting opiates can be used for immediate pain control if necessary, but it’s ideal to allow the patient to sleep at night without interruptions—as well as provide them with frequent reorientation and reassurance. Dr. Cheng adds that there is limited available data demonstrating that antipsychotics are useful for treating episodes of delirium—and there is no role for neuroleptic agents in the management of hypoactive delirium patients.
“Once you get a couple of days out (from the surgery), the risk for delirium starts diminishing,” sums up Dr. Cheng. “Once you get to day three, you’re usually out of the woods.”
It’s obviously wise to delay a patient’s surgery in the wake of any recent cardiovascular event by the surgery candidate. However, questions and differing opinions may often arise when discussing just how long such surgeries should be put off. The overriding intent is always to limit the possibility of any serious events such as a postoperative myocardial infarction (MI).
Dr. Cheng cites a 2011 study by Masha Livhits et al that assessed a large sample size of around 563,000 patients who had undergone an array of surgeries between 1999 and 2004 to determine the risk for postoperative MI following an acute MI. The nonrandomized, observational study showed that postoperative MI occurred in a full one-third of all patients who underwent surgery less than 30 days after experiencing a MI—and in 20 percent (a significant drop from 33 percent) of patients who underwent surgery during the second month after their MI. Following the 60-day threshold, the risk for postoperative MI dipped substantially before plateauing.
Dr. Cheng notes that active ACC/AHA Guidelines recommend delaying surgery for around two months (or 60+ days) following an acute MI—and that waiting any longer than this wise “cooling-off period” may not have any additional benefit at all.
“Two months should be adequate,” summarizes Dr. Cheng. “Waiting more than two months, three months, six months, may not have any additional benefits.”
Dr. Cheng also notes a 2014 study by Jorgensen et al that examined adults who had suffered a stroke—and then underwent non-cardiac elective surgery. This nonrandomized, observational, six-year-long study illuminated that patients who underwent major surgery within three months after a stroke demonstrated a high incidence of major adverse cardiac events. For patients who waited three to six months following their stroke to undergo surgery, the risk for major cardiac events was substantially lower. After nine months from the stroke, such risk plateaued.
“It’s reasonable to wait three to six months after a stroke for time-sensitive surgeries,” concludes Dr. Cheng. “And nine months for elective procedures.”
When attention turns to the delicate matter of surgery–and its inherent mortality risks–for patients living with liver cirrhosis, Dr. Cheng addresses a 2007 study by Swee H. The, MD et al that examined 772 cirrhotic patients who were also undergoing gastrointestinal (GI), orthopedic, or cardiovascular surgery. The data followed these patients for a five-year period and demonstrated that age and the increasingly popular MELD (Model for End-stage Liver Disease) Score served as the strongest predictors of mortality. As Dr. Cheng mentions, variables used to calculate an individual’s MELD Score include creatinine, bilirubin, and international normalized ratio.
“I often worry about the cirrhotic patient,” says Dr. Cheng. “They often have mortality rates that are surprisingly high.”
Dr. Cheng also dives deeper into a discussion around the use of risk stratification tools to predict these potential complications for this more risk-inclined pool of surgery candidates. There’s also an analysis of the Child-Pugh classification of cirrhosis. Based on older studies of GI surgery patients, “Class A”-assigned patients were predicted as having a 10-percent risk for mortality during surgery—with those figures surging to 30 percent for Class B and a robust 70% for Class C patients.
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Dr. Cheng’s informative, enlightening, in-depth lecture is just one of many helpful, powerful, and always-available resources AudioDigest provides for today’s time-crunched hospitalist.
Want to learn more? Check out our Best Lectures CME Collection for Hospitalists today!