Patients can chew gum immediately before surgery I guess

A study presented at the American Society of Anesthesiologists (ASA) meeting in October of this year found that patients who chew gum in the immediate preoperative period may safely undergo surgery.

The authors, based at the University of Pennsylvania, found that gum chewing increases saliva production and the volume of fluid in the stomach, but stomach acidity was equivalent to that of non-gum chewers. An article about the study said The mean gastric volume, or total amount of liquid in the stomach, was statistically higher in patients who chewed gum before their procedure (13ml) versus those who did not (6ml). A 7 mL difference might be statistically significant, but surely is not clinically important.

The research differed from previous studies because it involved patients who underwent upper gastrointestinal endoscopy, which enabled the investigators to recover all of the fluid in the stomach for testing. Prior studies had been done using nasogastric tubes, and it was impossible to determine whether all gastric fluid was recovered when the tubes were suctioned.

The study involved 34 gum chewers who were allowed to chew any type or any amount of gum compared to 33 patients who did not chew gum.

Another article quoted its lead author.

"We found that although chewing gum before surgery increases the production of saliva and therefore the volume of stomach liquids, it does not affect the level of stomach acidity in a way that would elevate complication risks," explains Dr. Goudra.

He says patients shouldnt be encouraged to chew gum before procedures involving anesthesia, but the habit shouldnt necessitate the cancellation or delay of scheduled cases if other aspiration risk factors arent present.

There has been long-standing debate about the subject of whether using gum and hard candy should be treated the same as ingesting a regular meal.

I wrote about this on my blog back in January 2014 and pointed out that the ASA guidelines do not address the issue.

In an effort to do due diligence, I was able to locate the abstract of this paper on the ASA website. Im glad I did because the abstract came to the opposite conclusion.

When the abstract was submitted, it included fewer patients—24 who chewed gum and 23 who did not.

The average gastric volumes were 9.78 mL for the gum chewers and 24.08 mL for the non-gum chewers (p = 0.027), and pH values were not significantly different (p = 0.094). It looks like regression to the mean occurred as the number of subjects increased.

In the original abstract, the authors concluded the following: Chewing gum in the preoperative fasting period leads to significant increase in the residual gastric volumes, with no difference in pH. We recommend that patients who have inadvertently chewed gum in the fasting period should be treated as full stomach and management modified accordingly. [Emphasis added]

So what is going on here? This would not be the first time that an abstract differed from the final paper. Actually, this sort of thing happens quite frequently. However in this case, the conclusions of the two versions are diametrically opposed to each other.

The study was presented at a meeting. Lets see what happens when it is submitted to a journal for peer review.

The correct way to have done the study would have been to calculate the number of patients needed to be studied (power analysis) beforehand.

Since this was not done, I recommend we go with the conclusion of the larger number of patients studied because it agrees with my bias that chewing gum is not potentially harmful.

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Readmissions Sometimes its the patients

My Twitter friend Dan Diamond (@ddiamond) posted a picture of a slide that said a hospitalized patient was taught to inject insulin using an orange to practice on. When he was readmitted to the hospital with a very high blood sugar, it turned out that instead of injecting himself at home, the patient was injecting his insulin dose into an orange, and then eating it.

Weve all heard stories about patients who took suppositories by mouth instead of the way they were intended.

Since doctors get blamed for just about everything, some would say that patients who take suppositories by mouth or eat an orange filled with insulin do so because they were not properly taught by their doctors (or nurses).

I have blogged before about the problem of who is at fault if patients do not follow up. Although I feel that much of the time its the patient who decides not to return for follow-up, it seems prevailing sentiment and possibly even the courts say its the physician who should be held responsible.

But how do you explain this? A study in Heart, a BMJ journal, found that of 208 hypertensive patients referred to a clinic for suboptimal blood pressure control, 52 (25%) were either completely or partially non-adherent [aka non-compliant] with their antihypertensive medications as determined by urine mass spectrometry.

The authors concluded that urine testing for medications or their metabolites would help doctors avoid ordering unnecessary investigations for patients whose blood pressures were not well-controlled.

The reasons for patient non-adherence were not mentioned. Could all 52 patients not have been told about the importance of taking their medications? I doubt it.

You might think the 15% who were partially non-adherent may have forgotten to take the drugs occasionally, but it turns out that most of those in this group took adequate doses of most of other their prescribed medications. This suggests that they selectively omitted some doses of one or more drugs.

The only explanation I can fathom for the 10% who had no traces of any BP meds in their urine is that they just said "to hell with it" and didnt take their meds at all.

I know someone with type 2 diabetes who doesnt watch her weight or what she eats and doesnt check her blood sugars. She says, "Youve got to die of something. Id rather live my life the way I want to."

Is it that doctors and nurses arent educating the patients or are the patients at fault?

The answer to this question has important implications because of the newly established financial penalties for hospitals with high readmission rates.

Older methods that may improve adherence are tracking prescription refills and having pharmacists or nurses specifically assigned to explain medications to patients in detail.

Heres something that might help.

A recent meta-analysis showed that adherence to HIV/AIDS antiretroviral therapy was modestly improved when patients were sent reminders to take their medications by text message. Those who were more adherent had lower viral loads and better CD4 counts.

Of course, such an intervention assumes that patients have mobile phones or pagers capable of receiving texts, will check for messages, and will act upon the advice. Compared to patients with HIV/AIDS, those with hypertension might tend to be much older and possibly not as technologically savvy.

So what is the solution? I dont know, but sometimes the problem is the patients.

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Dont jump to conclusions about that JAMA surgical readmissions paper

On February 3, JAMA published a paper online about readmission rates after surgery. The focus of most tweets was on the most common cause for readmission—surgical site infections (SSIs)—in 19.5% of readmitted patients.

At first glance, this suggests that infection rates after surgery were 19.5%, but that is not so. The paper said that 19.5% of the readmissions were caused by infections.

Of 498,875 total operations reviewed, only 30,270 (6.1%) were readmitted for any reason, and only 5576 (1%) of all patients were readmitted for SSIs.

According to the full text of the paper, the authors had two main points:

One, "because most readmissions were attributable to well-described postoperative complications, readmissions after surgery are mostly a proxy measure for postdischarge complications and in effect penalize hospitals twice [my emphasis] for postoperative complications (ie, other pay-for-performance programs include postoperative complications such as SSI)."

Two, "the majority of hospital readmissions were related to SSI and ileus [non-mechanical failure of bowel peristalsis]. Identifying clinical interventions to reduce the occurrence of these complications to below current levels has been challenging."

An article about the paper in US News quoted an editorial by Lucian Leape who said "system-wide changes need to be made." One such system change, the Surgical Care Improvement Project (SCIP), has been ongoing for more than 10 years.

The paper confirms what I wrote in 2010 about SCIP and other process measures and points out that "Most hospitals in the United States have high adherence rates for the SCIP SSI-prevention process measures; however, compliance with these process measures has not been shown to be strongly associated with reduced SSI rates."

And I am unaware of a conclusive study showing that the incidence of postoperative ileus can be lowered by any intervention.

I agree with the comments of the papers authors who say, "It is important to note that many readmissions may be unavoidable and are actually the correct course of action for surgical patients. [My emphasis] Many complications should be treated in the inpatient setting, and surgeons should not be deterred from readmitting patients because of concerns about quality measure performance and resulting penalties."

Every effort should be made to lower the infection rates of all procedures. But this papers results should be viewed not with alarm, but rather as reassurance that the problem is not out of control.

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German airliner crash A system error with a system solution

From the Associated Press: Airlines around the world on Thursday began requiring two crew members to always be present in the cockpit, after details emerged that the co-pilot of Germanwings Flight 9525 had apparently locked himself in the cockpit and deliberately crashed the plane into the mountains below.

This represents an organizations typical response to a problem. The crash, which by all accounts was caused by a single deranged individual, has been perceived as the result of a “system error” and will be dealt with as such.

The idea that a flight attendant going into the cockpit whenever one of the pilots has to pee will prevent anything seems a bit absurd to me. How is a 5’2” 120 pound female flight attendant supposed to stop a 6’3” 210 pound pilot who is hell-bent on committing suicide by airplane?

When I tweeted a similar thought yesterday, someone suggested that she could simply sound an alarm and unlock the cockpit door. I suppose that’s true as long as the crazed pilot does not punch her in the face and knock her out or shoot her first.

After 9/11, a federal law was passed allowing pilots who were properly screened and trained to carry guns. If an armed pilot decides to commit suicide, an unarmed flight attendant will not be able to stop him or her.

According to a CNN story, Andreas Lubitz, the pilot who drove the plane into the mountain, had passed all medical tests before being hired. He recently had been given a medical leave note by a doctor. However, Lubitz ripped it up and threw it in a wastebasket in his apartment. He did not disclose the fact that he had been undergoing medical treatment to the airline. So much for self-reporting which is standard for pilots.

Why didnt the doctor tell the airline? I dont know. Do they have HIPAA in Germany?

The two people in the cockpit rule is smoke and mirrors. The airlines can now say that they have taken steps to prevent something like the Germanwings crash from happening again so dont worry, its still safe to fly. But as I have pointed out, a determined maniac will be able to easily overcome this system solution.

I am reminded of the proposals like arm the janitors, arm the teachers, or give them shields or scissors that always come forward after school shootings.

Footnotes:

1. "Two people in the cockpit” is not an FAA regulation but is said to be a standard policy for US airlines. Its purpose is not to prevent a suicide but to have someone available to let the other pilot back into the cockpit in case the pilot who did not leave passes out or is otherwise disabled.

2. The Germanwings incident represents an unintended consequence of reinforcing and locking cockpit doors after 9/11.

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