Perhaps no admission causes so much consternation and dread amongst caregivers and families as a case of suspected bacterial meningitis. Will the patient live? What infection control precautions are necessary? And, perhaps most urgently, do I need antibiotic prophylaxis? In this article I answer the questions hospitalists most often need to address in such circumstances.

1. Who should have a head CT prior to lumbar puncture (LP) for suspected meningitis? Patients with immunocompromise, papilledema, preexisting CNS disease, new onset seizures, altered level of consciousness, and focal neurological findings should have a head CT prior to LP.1 While herniation is rare after LP for purulent meningitis, patients with increased intracranial pressure at risk for herniation often have normal head CT scans. Therefore, herniation may be an uncommon but unpredictable complication of LP in this setting. The cause-and-effect relationship of herniation and LP has also been questioned.

2. Are there any cerebrospinal fluid (CSF) findings that exclude bacterial meningitis? A number of CSF findings make bacterial meningitis quite likely, including total leukocyte counts of more than 2,000/mm3, a positive gram stain, or very low CSF glucose. It is difficult, if not impossible, however, to exclude bacterial meningitis in patients with any degree of CSF pleocytosis. For example, 10% of patients with bacterial meningitis have less than 100 WBCs/mm3 in CSF, and 10% have lymphocyte predominance at presentation. Therefore, the safest course of action when bacterial meningitis is suspected on clinical grounds and CSF pleocytosis is present is to continue antibiotics until results of CSF cultures are available.

3. Which patients with suspected or proven meningitis should receive steroids? Steroids reduce neurologic damage from the inflammatory surge provoked by antibiotic-induced pneumococcal lysis. In a large European trial, dexamethasone given in 10-mg doses every six hours for four days (before or with the first dose of antibiotics) reduced mortality in pneumococcal meningitis.2 Benefits were not seen in patients with bacterial meningitis from other pathogens. Dexamethasone can be safely stopped as soon as pneumococcal meningitis is excluded.

4. How soon should patients receive antibiotics? When bacterial meningitis is likely, antibiotics should be given immediately, prior to imaging studies and lumbar puncture. In patients with a lower clinical likelihood of bacterial meningitis, antibiotics can be deferred, awaiting the results of diagnostic studies.

5. What empiric antibiotic therapy is appropriate? Adults 18-50 with suspected bacterial meningitis should receive therapy directed against Streptococcus pneumoniae and Neisseria meningitidis. Vancomycin should be dosed to achieve a relatively high trough level of 15-20 mcg/mL. For a 70-kg adult male with normal renal function, doses of vancomycin given at the rate of 1.5 gm IV every 12 hours and ceftriaxone at 2 gm IV every 12 hours are appropriate. Adults over 50, alcoholics, and immunocompromised adults of any age should also receive ampicillin doses of 2 gm IV every four hours to cover Listeria, in addition to vancomycin and ceftriaxone.3,4

6. What infection control precautions are required? Meningococcal meningitis patients should be placed on droplet precautions (private room, mask for all entering the room) until they have completed 24 hours of appropriate antibiotic therapy. Negative pressure ventilation is not required. Patients with pneumococcal or viral meningitis do not require isolation.

7. Who needs antibiotic prophylaxis after patient exposure? Chemoprophylaxis is overprescribed after exposures to patients with meningococcal meningitis. The only social contacts who should receive prophylaxis are household contacts, childcare contacts, and people who have had direct exposure to the patient’s oral secretions through actions such as kissing or sharing utensils or toothbrushes. The only healthcare workers requiring chemoprophylaxis are those who performed mouth-to-mouth resuscitation or any staff who were unmasked during intubation or suctioning of a patient. Regimens for chemoprophylaxis in adults include ciprofloxacin, 500 mg taken orally as a single dose, rifampin taken in doses of 600 mg twice daily for two days, or 250 mg of ceftriaxone, given intramuscularly. Ceftriaxone is preferred for pregnant women. Chemoprophylaxis is unnecessary after exposure to patients with pneumococcal or viral meningitis.

8. What is the significance of arthritis after meningococcal meningitis? A significant number of patients with meningococcal disease develop inflammatory polyarthritis about a week after the onset of infection. In most cases, this is a sterile, immune complex phenomenon that responds to anti-inflammatory therapy. If joint effusions are present, they should be aspirated to exclude septic arthritis and crystalline arthritis. TH

Dr. Ross is a hospitalist at Brigham and Women’s Hospital (Boston) and a fellow of the Infectious Diseases Society of America.

References

1. Hasbun R, Abrahams J, Jekel J, et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001 Dec 13;345(24):1727-1733.
2. de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. European dexamethasone in adulthood bacterial meningitis. N Engl J Med. 2002;347(20):1549-156.
3. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-1284.
4. van de Beek D, de Gans J, Tunkel AR, et al. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006 Jan 5;354(1):44-53.

Perhaps no admission causes so much consternation and dread amongst caregivers and families as a case of suspected bacterial meningitis. Will the patient live? What infection control precautions are necessary? And, perhaps most urgently, do I need antibiotic prophylaxis? In this article I answer the questions hospitalists most often need to address in such circumstances.

1. Who should have a head CT prior to lumbar puncture (LP) for suspected meningitis? Patients with immunocompromise, papilledema, preexisting CNS disease, new onset seizures, altered level of consciousness, and focal neurological findings should have a head CT prior to LP.1 While herniation is rare after LP for purulent meningitis, patients with increased intracranial pressure at risk for herniation often have normal head CT scans. Therefore, herniation may be an uncommon but unpredictable complication of LP in this setting. The cause-and-effect relationship of herniation and LP has also been questioned.

2. Are there any cerebrospinal fluid (CSF) findings that exclude bacterial meningitis? A number of CSF findings make bacterial meningitis quite likely, including total leukocyte counts of more than 2,000/mm3, a positive gram stain, or very low CSF glucose. It is difficult, if not impossible, however, to exclude bacterial meningitis in patients with any degree of CSF pleocytosis. For example, 10% of patients with bacterial meningitis have less than 100 WBCs/mm3 in CSF, and 10% have lymphocyte predominance at presentation. Therefore, the safest course of action when bacterial meningitis is suspected on clinical grounds and CSF pleocytosis is present is to continue antibiotics until results of CSF cultures are available.

3. Which patients with suspected or proven meningitis should receive steroids? Steroids reduce neurologic damage from the inflammatory surge provoked by antibiotic-induced pneumococcal lysis. In a large European trial, dexamethasone given in 10-mg doses every six hours for four days (before or with the first dose of antibiotics) reduced mortality in pneumococcal meningitis.2 Benefits were not seen in patients with bacterial meningitis from other pathogens. Dexamethasone can be safely stopped as soon as pneumococcal meningitis is excluded.

4. How soon should patients receive antibiotics? When bacterial meningitis is likely, antibiotics should be given immediately, prior to imaging studies and lumbar puncture. In patients with a lower clinical likelihood of bacterial meningitis, antibiotics can be deferred, awaiting the results of diagnostic studies.

5. What empiric antibiotic therapy is appropriate? Adults 18-50 with suspected bacterial meningitis should receive therapy directed against Streptococcus pneumoniae and Neisseria meningitidis. Vancomycin should be dosed to achieve a relatively high trough level of 15-20 mcg/mL. For a 70-kg adult male with normal renal function, doses of vancomycin given at the rate of 1.5 gm IV every 12 hours and ceftriaxone at 2 gm IV every 12 hours are appropriate. Adults over 50, alcoholics, and immunocompromised adults of any age should also receive ampicillin doses of 2 gm IV every four hours to cover Listeria, in addition to vancomycin and ceftriaxone.3,4

6. What infection control precautions are required? Meningococcal meningitis patients should be placed on droplet precautions (private room, mask for all entering the room) until they have completed 24 hours of appropriate antibiotic therapy. Negative pressure ventilation is not required. Patients with pneumococcal or viral meningitis do not require isolation.

7. Who needs antibiotic prophylaxis after patient exposure? Chemoprophylaxis is overprescribed after exposures to patients with meningococcal meningitis. The only social contacts who should receive prophylaxis are household contacts, childcare contacts, and people who have had direct exposure to the patient’s oral secretions through actions such as kissing or sharing utensils or toothbrushes. The only healthcare workers requiring chemoprophylaxis are those who performed mouth-to-mouth resuscitation or any staff who were unmasked during intubation or suctioning of a patient. Regimens for chemoprophylaxis in adults include ciprofloxacin, 500 mg taken orally as a single dose, rifampin taken in doses of 600 mg twice daily for two days, or 250 mg of ceftriaxone, given intramuscularly. Ceftriaxone is preferred for pregnant women. Chemoprophylaxis is unnecessary after exposure to patients with pneumococcal or viral meningitis.

8. What is the significance of arthritis after meningococcal meningitis? A significant number of patients with meningococcal disease develop inflammatory polyarthritis about a week after the onset of infection. In most cases, this is a sterile, immune complex phenomenon that responds to anti-inflammatory therapy. If joint effusions are present, they should be aspirated to exclude septic arthritis and crystalline arthritis. TH

Dr. Ross is a hospitalist at Brigham and Women’s Hospital (Boston) and a fellow of the Infectious Diseases Society of America.

References

1. Hasbun R, Abrahams J, Jekel J, et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001 Dec 13;345(24):1727-1733.
2. de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. European dexamethasone in adulthood bacterial meningitis. N Engl J Med. 2002;347(20):1549-156.
3. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-1284.
4. van de Beek D, de Gans J, Tunkel AR, et al. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006 Jan 5;354(1):44-53.

Perhaps no admission causes so much consternation and dread amongst caregivers and families as a case of suspected bacterial meningitis. Will the patient live? What infection control precautions are necessary? And, perhaps most urgently, do I need antibiotic prophylaxis? In this article I answer the questions hospitalists most often need to address in such circumstances.

1. Who should have a head CT prior to lumbar puncture (LP) for suspected meningitis? Patients with immunocompromise, papilledema, preexisting CNS disease, new onset seizures, altered level of consciousness, and focal neurological findings should have a head CT prior to LP.1 While herniation is rare after LP for purulent meningitis, patients with increased intracranial pressure at risk for herniation often have normal head CT scans. Therefore, herniation may be an uncommon but unpredictable complication of LP in this setting. The cause-and-effect relationship of herniation and LP has also been questioned.

2. Are there any cerebrospinal fluid (CSF) findings that exclude bacterial meningitis? A number of CSF findings make bacterial meningitis quite likely, including total leukocyte counts of more than 2,000/mm3, a positive gram stain, or very low CSF glucose. It is difficult, if not impossible, however, to exclude bacterial meningitis in patients with any degree of CSF pleocytosis. For example, 10% of patients with bacterial meningitis have less than 100 WBCs/mm3 in CSF, and 10% have lymphocyte predominance at presentation. Therefore, the safest course of action when bacterial meningitis is suspected on clinical grounds and CSF pleocytosis is present is to continue antibiotics until results of CSF cultures are available.

3. Which patients with suspected or proven meningitis should receive steroids? Steroids reduce neurologic damage from the inflammatory surge provoked by antibiotic-induced pneumococcal lysis. In a large European trial, dexamethasone given in 10-mg doses every six hours for four days (before or with the first dose of antibiotics) reduced mortality in pneumococcal meningitis.2 Benefits were not seen in patients with bacterial meningitis from other pathogens. Dexamethasone can be safely stopped as soon as pneumococcal meningitis is excluded.

4. How soon should patients receive antibiotics? When bacterial meningitis is likely, antibiotics should be given immediately, prior to imaging studies and lumbar puncture. In patients with a lower clinical likelihood of bacterial meningitis, antibiotics can be deferred, awaiting the results of diagnostic studies.

5. What empiric antibiotic therapy is appropriate? Adults 18-50 with suspected bacterial meningitis should receive therapy directed against Streptococcus pneumoniae and Neisseria meningitidis. Vancomycin should be dosed to achieve a relatively high trough level of 15-20 mcg/mL. For a 70-kg adult male with normal renal function, doses of vancomycin given at the rate of 1.5 gm IV every 12 hours and ceftriaxone at 2 gm IV every 12 hours are appropriate. Adults over 50, alcoholics, and immunocompromised adults of any age should also receive ampicillin doses of 2 gm IV every four hours to cover Listeria, in addition to vancomycin and ceftriaxone.3,4

6. What infection control precautions are required? Meningococcal meningitis patients should be placed on droplet precautions (private room, mask for all entering the room) until they have completed 24 hours of appropriate antibiotic therapy. Negative pressure ventilation is not required. Patients with pneumococcal or viral meningitis do not require isolation.

7. Who needs antibiotic prophylaxis after patient exposure? Chemoprophylaxis is overprescribed after exposures to patients with meningococcal meningitis. The only social contacts who should receive prophylaxis are household contacts, childcare contacts, and people who have had direct exposure to the patient’s oral secretions through actions such as kissing or sharing utensils or toothbrushes. The only healthcare workers requiring chemoprophylaxis are those who performed mouth-to-mouth resuscitation or any staff who were unmasked during intubation or suctioning of a patient. Regimens for chemoprophylaxis in adults include ciprofloxacin, 500 mg taken orally as a single dose, rifampin taken in doses of 600 mg twice daily for two days, or 250 mg of ceftriaxone, given intramuscularly. Ceftriaxone is preferred for pregnant women. Chemoprophylaxis is unnecessary after exposure to patients with pneumococcal or viral meningitis.

8. What is the significance of arthritis after meningococcal meningitis? A significant number of patients with meningococcal disease develop inflammatory polyarthritis about a week after the onset of infection. In most cases, this is a sterile, immune complex phenomenon that responds to anti-inflammatory therapy. If joint effusions are present, they should be aspirated to exclude septic arthritis and crystalline arthritis. TH

Dr. Ross is a hospitalist at Brigham and Women’s Hospital (Boston) and a fellow of the Infectious Diseases Society of America.

References

1. Hasbun R, Abrahams J, Jekel J, et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001 Dec 13;345(24):1727-1733.
2. de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. European dexamethasone in adulthood bacterial meningitis. N Engl J Med. 2002;347(20):1549-156.
3. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-1284.
4. van de Beek D, de Gans J, Tunkel AR, et al. Community-acquired bacterial meningitis in adults. N Engl J Med. 2006 Jan 5;354(1):44-53.

Supplement Editor:
Phillip Hall, MD

Contents

Hyponatremia: More to the story than disordered sodium homeostasis
Phillip Hall, MD

Hyponatremia:Why it matters, how it presents, how we can manage it
Ivor Douglas, MD, MRCP(UK)

Exercise-induced hyponatremia: Causes, risks, prevention, and management
Robert E. O’Connor, MD, MPH

The role of vasopressin in congestive heart failure
Steven R. Goldsmith, MD

AVP receptor antagonists as aquaretics: Review and assessment of clinical data
Joseph G. Verbalis, MD

Supplement Editor:
Phillip Hall, MD

Contents

Hyponatremia: More to the story than disordered sodium homeostasis
Phillip Hall, MD

Hyponatremia:Why it matters, how it presents, how we can manage it
Ivor Douglas, MD, MRCP(UK)

Exercise-induced hyponatremia: Causes, risks, prevention, and management
Robert E. O’Connor, MD, MPH

The role of vasopressin in congestive heart failure
Steven R. Goldsmith, MD

AVP receptor antagonists as aquaretics: Review and assessment of clinical data
Joseph G. Verbalis, MD

Supplement Editor:
Phillip Hall, MD

Contents

Hyponatremia: More to the story than disordered sodium homeostasis
Phillip Hall, MD

Hyponatremia:Why it matters, how it presents, how we can manage it
Ivor Douglas, MD, MRCP(UK)

Exercise-induced hyponatremia: Causes, risks, prevention, and management
Robert E. O’Connor, MD, MPH

The role of vasopressin in congestive heart failure
Steven R. Goldsmith, MD

AVP receptor antagonists as aquaretics: Review and assessment of clinical data
Joseph G. Verbalis, MD

Supplement Co-Editors and Summit Co-Directors:
Amir K. Jaffer, MD, and Franklin A. Michota, Jr., MD

Summit Co-Directors:
Angela M. Bader, MD, and Raymond Borkowski, MD

Contents

Summit Faculty

Summit Program

IMPACT Consults

Does elevated blood pressure at the time of surgery increase perioperative cardiac risk?
Collin Kroen, MD

When is it appropriate to stop antiplatelet therapy in a patient with a drug-eluting stent prior to noncardiac surgery?
Anitha Rajamanickam, MD; Vaishali Singh, MD, MPH, MBA; and Ashish Aneja, MD

Should statins be discontinued preoperatively?
Paul J. Grant, MD, and Navin Kedia, DO

What is the appropriate means of perioperative risk assessment for patients with cirrhosis?
Brian Harte, MD

Who is at risk for developing acute renal failure after surgery?
Vesselin Dimov, MD; Ali Usmani, MD; Saira Noor, MD; and Ajay Kumar, MD

Why treat anemia in the preoperative period of joint replacement surgery with erythropoietin?
Ajay Kumar, MD, and Vesselin Dimov, MD

Obstructive sleep apnea: What to do in the surgical patient?
Roop Kaw, MD, and Joseph Golish, MD

What is the optimal venous thromboembolism prophylaxis for patients undergoing bariatric surgery?
David V. Gugliotti, MD

Do hip fractures need to be repaired withing 24 hours of injury?
Christopher M. Whinney, MD

Is postoperative atrial fibrillation in patients undergoing noncardiothoracic surgery an important problem?
Ashish Aneja, MD, and Wassim H. Fares, MD

How can postoperative ileus be prevented and treated?
Vaishali Singh, MD, MPH, MBA

Abstracts

Oral Abstracts

Is discontinuation of antiplatelet therapy after 6 months safe in patients with drug-eluting stents undergoing noncardiac surgery?
Mihir Bakhru, Wael Saber, Daniel Brotman, Deepak Bhatt, Ashish Aneja, Katherina Tillan-Martinez, and Amir Jaffer

Initiating a preoperative cardiac risk assessment quality improvement program: The hurdles to changing traditional paradigms
Eric Hixson, Karl McCleary, Vikram Kashyap, Vaishali Singh, Brian Harte, Ashish Aneja, Brian Parker, Raymond Borkowski, Walter Maurer, Venkatesh Krishnamurthi, Sue Vitagliano, Jacqueline Matthews, Linda Vopat, Michael Henderson, and Amir Jaffer

Impact of a preoperative medical clinic on operating room cancellation rates in orthopedic surgery
Peter Kallas, Anjali Desai, and Jeanette Bauer

Poster Abstracts

Innovations in Perioperative Medicine

Abstract 1: Best safety practices to prevent postoperative myocardial infarction

Abstract 2: Blog web site as a new educational and promotional medium in perioperative medicine

Abstract 3: Development of a validated questionnaire: The satisfaction with general anesthesia scale

Abstract 4: Perioperative medicine and pain: A required advanced core clerkship for third-year medical students

Abstract 5: Optimal administration of perioperative antibiotics using system redesign

Abstract 6: Blood conservation protocol with erythropoietin in the preoperative period of joint replacement surgery

Abstract 7: Evolution of the nurse practitioner (NP) role in the Center for Preoperative Evaluation (CPE) at Brigham and Women's Hospital

Abstract 8: Development and implementation of a web site for the Center for Preoperative Evaluation (CPE)

Abstract 9: Patient education tool for the preoperative process and the role of the medical consultant

Abstract 10: The internal medicine perioperative assessment center: An innovation in the perioperative management of medical comorbidities at a comprehensive cancer center

Abstract 11: PAC collaborative practice model

Abstract 12: Development and implementation of beta-blocker recommendation

Abstract 13: Development of pre-procedure consult services

Perioperative Clinical Vignettes

Abstract 14: Isolated left bundle branch block in a patient undergoing elective noncardiac surgery

Abstract 15: Avoiding delirium

Abstract 16: Cardiac sarcoma—the role of multimodality cardiovascular imaging

Abstract 17: Asymptomatic bacteriuria before nonprosthetic joint surgery

Abstract 18: Negative T waves on the preoperative electrocardiogram—a cause for worry?

Abstract 19: Preoperative hypokalemia

Abstract 20: Preoperative evaluation can aid in the diagnosis of CAD and risk assessment and management

Research in Perioperative Medicine

Abstract 21: Needs analysis for the development of a preoperative clinic protocol for perioperative beta-blockade

Abstract 22: Improving efficiency in a preoperative clinic

Abstract 23: Formalized preoperative assessment for noncardiac surgery at a large tertiary care medical center leads to higher rates of perioperative beta-blocker use

Abstract 24: Insulin errors in hospitalized patients

Abstract 25: A survey of perioperative beta-blockade at a comprehensive cancer center

Abstract 26: Risk factors for long-term mortality among heart failure patients after elective major noncardiac surgery

Index of Authors and Presenters

Supplement Co-Editors and Summit Co-Directors:
Amir K. Jaffer, MD, and Franklin A. Michota, Jr., MD

Summit Co-Directors:
Angela M. Bader, MD, and Raymond Borkowski, MD

Contents

Summit Faculty

Summit Program

IMPACT Consults

Does elevated blood pressure at the time of surgery increase perioperative cardiac risk?
Collin Kroen, MD

When is it appropriate to stop antiplatelet therapy in a patient with a drug-eluting stent prior to noncardiac surgery?
Anitha Rajamanickam, MD; Vaishali Singh, MD, MPH, MBA; and Ashish Aneja, MD

Should statins be discontinued preoperatively?
Paul J. Grant, MD, and Navin Kedia, DO

What is the appropriate means of perioperative risk assessment for patients with cirrhosis?
Brian Harte, MD

Who is at risk for developing acute renal failure after surgery?
Vesselin Dimov, MD; Ali Usmani, MD; Saira Noor, MD; and Ajay Kumar, MD

Why treat anemia in the preoperative period of joint replacement surgery with erythropoietin?
Ajay Kumar, MD, and Vesselin Dimov, MD

Obstructive sleep apnea: What to do in the surgical patient?
Roop Kaw, MD, and Joseph Golish, MD

What is the optimal venous thromboembolism prophylaxis for patients undergoing bariatric surgery?
David V. Gugliotti, MD

Do hip fractures need to be repaired withing 24 hours of injury?
Christopher M. Whinney, MD

Is postoperative atrial fibrillation in patients undergoing noncardiothoracic surgery an important problem?
Ashish Aneja, MD, and Wassim H. Fares, MD

How can postoperative ileus be prevented and treated?
Vaishali Singh, MD, MPH, MBA

Abstracts

Oral Abstracts

Is discontinuation of antiplatelet therapy after 6 months safe in patients with drug-eluting stents undergoing noncardiac surgery?
Mihir Bakhru, Wael Saber, Daniel Brotman, Deepak Bhatt, Ashish Aneja, Katherina Tillan-Martinez, and Amir Jaffer

Initiating a preoperative cardiac risk assessment quality improvement program: The hurdles to changing traditional paradigms
Eric Hixson, Karl McCleary, Vikram Kashyap, Vaishali Singh, Brian Harte, Ashish Aneja, Brian Parker, Raymond Borkowski, Walter Maurer, Venkatesh Krishnamurthi, Sue Vitagliano, Jacqueline Matthews, Linda Vopat, Michael Henderson, and Amir Jaffer

Impact of a preoperative medical clinic on operating room cancellation rates in orthopedic surgery
Peter Kallas, Anjali Desai, and Jeanette Bauer

Poster Abstracts

Innovations in Perioperative Medicine

Abstract 1: Best safety practices to prevent postoperative myocardial infarction

Abstract 2: Blog web site as a new educational and promotional medium in perioperative medicine

Abstract 3: Development of a validated questionnaire: The satisfaction with general anesthesia scale

Abstract 4: Perioperative medicine and pain: A required advanced core clerkship for third-year medical students

Abstract 5: Optimal administration of perioperative antibiotics using system redesign

Abstract 6: Blood conservation protocol with erythropoietin in the preoperative period of joint replacement surgery

Abstract 7: Evolution of the nurse practitioner (NP) role in the Center for Preoperative Evaluation (CPE) at Brigham and Women's Hospital

Abstract 8: Development and implementation of a web site for the Center for Preoperative Evaluation (CPE)

Abstract 9: Patient education tool for the preoperative process and the role of the medical consultant

Abstract 10: The internal medicine perioperative assessment center: An innovation in the perioperative management of medical comorbidities at a comprehensive cancer center

Abstract 11: PAC collaborative practice model

Abstract 12: Development and implementation of beta-blocker recommendation

Abstract 13: Development of pre-procedure consult services

Perioperative Clinical Vignettes

Abstract 14: Isolated left bundle branch block in a patient undergoing elective noncardiac surgery

Abstract 15: Avoiding delirium

Abstract 16: Cardiac sarcoma—the role of multimodality cardiovascular imaging

Abstract 17: Asymptomatic bacteriuria before nonprosthetic joint surgery

Abstract 18: Negative T waves on the preoperative electrocardiogram—a cause for worry?

Abstract 19: Preoperative hypokalemia

Abstract 20: Preoperative evaluation can aid in the diagnosis of CAD and risk assessment and management

Research in Perioperative Medicine

Abstract 21: Needs analysis for the development of a preoperative clinic protocol for perioperative beta-blockade

Abstract 22: Improving efficiency in a preoperative clinic

Abstract 23: Formalized preoperative assessment for noncardiac surgery at a large tertiary care medical center leads to higher rates of perioperative beta-blocker use

Abstract 24: Insulin errors in hospitalized patients

Abstract 25: A survey of perioperative beta-blockade at a comprehensive cancer center

Abstract 26: Risk factors for long-term mortality among heart failure patients after elective major noncardiac surgery

Index of Authors and Presenters

Supplement Co-Editors and Summit Co-Directors:
Amir K. Jaffer, MD, and Franklin A. Michota, Jr., MD

Summit Co-Directors:
Angela M. Bader, MD, and Raymond Borkowski, MD

Contents

Summit Faculty

Summit Program

IMPACT Consults

Does elevated blood pressure at the time of surgery increase perioperative cardiac risk?
Collin Kroen, MD

When is it appropriate to stop antiplatelet therapy in a patient with a drug-eluting stent prior to noncardiac surgery?
Anitha Rajamanickam, MD; Vaishali Singh, MD, MPH, MBA; and Ashish Aneja, MD

Should statins be discontinued preoperatively?
Paul J. Grant, MD, and Navin Kedia, DO

What is the appropriate means of perioperative risk assessment for patients with cirrhosis?
Brian Harte, MD

Who is at risk for developing acute renal failure after surgery?
Vesselin Dimov, MD; Ali Usmani, MD; Saira Noor, MD; and Ajay Kumar, MD

Why treat anemia in the preoperative period of joint replacement surgery with erythropoietin?
Ajay Kumar, MD, and Vesselin Dimov, MD

Obstructive sleep apnea: What to do in the surgical patient?
Roop Kaw, MD, and Joseph Golish, MD

What is the optimal venous thromboembolism prophylaxis for patients undergoing bariatric surgery?
David V. Gugliotti, MD

Do hip fractures need to be repaired withing 24 hours of injury?
Christopher M. Whinney, MD

Is postoperative atrial fibrillation in patients undergoing noncardiothoracic surgery an important problem?
Ashish Aneja, MD, and Wassim H. Fares, MD

How can postoperative ileus be prevented and treated?
Vaishali Singh, MD, MPH, MBA

Abstracts

Oral Abstracts

Is discontinuation of antiplatelet therapy after 6 months safe in patients with drug-eluting stents undergoing noncardiac surgery?
Mihir Bakhru, Wael Saber, Daniel Brotman, Deepak Bhatt, Ashish Aneja, Katherina Tillan-Martinez, and Amir Jaffer

Initiating a preoperative cardiac risk assessment quality improvement program: The hurdles to changing traditional paradigms
Eric Hixson, Karl McCleary, Vikram Kashyap, Vaishali Singh, Brian Harte, Ashish Aneja, Brian Parker, Raymond Borkowski, Walter Maurer, Venkatesh Krishnamurthi, Sue Vitagliano, Jacqueline Matthews, Linda Vopat, Michael Henderson, and Amir Jaffer

Impact of a preoperative medical clinic on operating room cancellation rates in orthopedic surgery
Peter Kallas, Anjali Desai, and Jeanette Bauer

Poster Abstracts

Innovations in Perioperative Medicine

Abstract 1: Best safety practices to prevent postoperative myocardial infarction

Abstract 2: Blog web site as a new educational and promotional medium in perioperative medicine

Abstract 3: Development of a validated questionnaire: The satisfaction with general anesthesia scale

Abstract 4: Perioperative medicine and pain: A required advanced core clerkship for third-year medical students

Abstract 5: Optimal administration of perioperative antibiotics using system redesign

Abstract 6: Blood conservation protocol with erythropoietin in the preoperative period of joint replacement surgery

Abstract 7: Evolution of the nurse practitioner (NP) role in the Center for Preoperative Evaluation (CPE) at Brigham and Women's Hospital

Abstract 8: Development and implementation of a web site for the Center for Preoperative Evaluation (CPE)

Abstract 9: Patient education tool for the preoperative process and the role of the medical consultant

Abstract 10: The internal medicine perioperative assessment center: An innovation in the perioperative management of medical comorbidities at a comprehensive cancer center

Abstract 11: PAC collaborative practice model

Abstract 12: Development and implementation of beta-blocker recommendation

Abstract 13: Development of pre-procedure consult services

Perioperative Clinical Vignettes

Abstract 14: Isolated left bundle branch block in a patient undergoing elective noncardiac surgery

Abstract 15: Avoiding delirium

Abstract 16: Cardiac sarcoma—the role of multimodality cardiovascular imaging

Abstract 17: Asymptomatic bacteriuria before nonprosthetic joint surgery

Abstract 18: Negative T waves on the preoperative electrocardiogram—a cause for worry?

Abstract 19: Preoperative hypokalemia

Abstract 20: Preoperative evaluation can aid in the diagnosis of CAD and risk assessment and management

Research in Perioperative Medicine

Abstract 21: Needs analysis for the development of a preoperative clinic protocol for perioperative beta-blockade

Abstract 22: Improving efficiency in a preoperative clinic

Abstract 23: Formalized preoperative assessment for noncardiac surgery at a large tertiary care medical center leads to higher rates of perioperative beta-blocker use

Abstract 24: Insulin errors in hospitalized patients

Abstract 25: A survey of perioperative beta-blockade at a comprehensive cancer center

Abstract 26: Risk factors for long-term mortality among heart failure patients after elective major noncardiac surgery

Index of Authors and Presenters