GI & Environmental II (Jan 2016)
Happy New Year!
Review: Luber et al. Care of the Bariatric Patient in the Emergency Department. JEM 2008
AIR: Environmental II
Happy New Year!
Review: Luber et al. Care of the Bariatric Patient in the Emergency Department. JEM 2008
AIR: Environmental II
14 comments
Hunold et al. As short and sexy as a constipation article can get!
Despite significant limitations in the database, I don’t think anyone would argue that we prescribe very little laxatives with our opioids.
Considering 20% of patients with opioids get constipated, and we know laxatives reduce constipation significantly, esp in cancer pts quoted in this study, it’s probably worth prescribing considering the relative safety profile of a short course of laxatives.
Our inpatient colleagues are pretty good at discharging patients with laxatives along with opioids, especially the post-surgical patients. I think we can improve in this aspect.
One might question however, how many patients who receive a short course of 3 days or less opioids actually get constipated. Most of the constipation data come from longer courses of opioid use. Perhaps that’s why very few EMP’s prescribe laxatives because we prescribe such short courses of opioids.
Luber et al.
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A short concise review of bariatric surgery complications to help you sound intelligent with our consultants and to help you manage these patients in the community when surgical consultation is not readily available.
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Unfortunately, it does not contain data about 3 liters of IV fluid in treatment of bariatric patients who present with nausea, vomiting, abdominal pain.
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In fact, I asked Dr. Brian Carmine, one of our experienced bariatric surgeons here at BMC about this. He says there’s really no evidence demonstrating its efficacy. However, from his experience and that of others, it seems to make these patients feel a lot better.
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It’d be very interesting to see if this treatment improves outcomes, or at least helps to avoid CT scanning or admission. Anyone interested in studying this?
Luber et al. I think this is a good comprehensive overview of bariatric surgery complications geared towards EM physicians. The figures demonstrating the different procedures were probably my favorite part of the article because they helped me visualize all the different procedures and where things can go wrong. BMC has a very thorough protocol that we follow whenever we get a bariatric surgery patient in the ED, and I hardly deviate from it. I think most of us have gotten into the habit of 3L IVF and call surgery, but this article really brought up all the reasons why we need to call them. And I did not realize how common hepatobiliary complications were in bariatric surgery patients. It makes sense, but the high incidence of gallbladder sludge and gallstones was surprising. Also I was not aware bariatric surgery patients could/should be prophylactically treated with urosodiol. I wonder if that is a common practice at BMC?
I’m not sure this article will necessarily change my practice, but it has certainly made me more aware of all the different complications that can occur, and in what timeframe to be looking out for them. In terms of potential areas of research, the article discusses the use of possible NGT placement in cases of gastric distention, and how it should be performed carefully. I’d be curious to look at the incidence of NGT placement in these patients at BMC and the complication rates (should we really be worried about placing these?).
Hunold et al. Interesting article. And I agree with Alex, I like that it’s short and sweet. I think this article did a great job of answering a simple (but relevant) question well using a large amount of data. I know ED physicians are not the best at prescribing laxatives in conjunction with opiates, but I was surprised that the number was so low (2.5% of adults). Then again, maybe I shouldn’t be that surprised since I admit I rarely prescribe prophylactic laxatives with opiates. But then again I don’t prescribe opiates very often.
I was glad to see they did a subgroup analysis on the older ED population (>65 y/o). It is true that we worry more about constipation in older individuals, and it is usually these patients that I will prescribe prophylactic laxatives. It is actually in the younger population that I am more likely to forget about this issue, and I would have liked to see a table with age group vs. # of laxative prescriptions to get a sense of whether age itself (even between 18-65) made a difference in prescription habits amongst EM physicians.
I’m not sure that after reading this article I am going to start automatically writing for prophylactic laxatives whenever I prescribe opiates, but it has definitely made me think twice about the issue. Alex does bring up a good point regarding whether a short course of opiates requires laxatives, and I am curious about that as well especially because compared to other specialties I am not sure if EM physicians are known for writing long-course opiates. Plus, I feel that usually we are treating constipation after someone else forgot to write for laxatives when prescribing opiates for whatever reason.
That being said, if it is clinically important and may affect patient outcomes, then we should discuss and consider it.
Hunold et al
Strong like bull – Agree with above. This is a great study because it asks a simple question and gives a definitive answer, which can impact many patients.
Weaknesses – The large, de-identified database NHAMCS can miss a lot of intricacies that chart review or prospective studies can pick up (counseling on hydration, high-fiber foods, OTC medications). Also a lot of patients (especially older ones) are ALREADY on 2-3 laxatives, which this study may miss.
Main point – Only 2.5% of patients of US adults given pain medications are prescribed laxatives. Even if the number were “10%” it is astonishing.
Definitely practice changing for me because I rarely prescribe laxatives with constipation…but will start (as well as recommending hydration and high-fiber foods). Honestly who couldn’t use a little more fiber?
* How has reading the article changed your practice?
This article won’t really change my practice because of the strict protocols already in place with our Bariatric Surgery patients. It will be interesting to see if any of those change now that they have just hired a new attending to that practice.
*What information had you believed in previously that were debunked by reading this article?
Classifying the different procedures into restrictive vs malabsorptive procedures was an interesting way to differentiate them, and put some context to the complications that are seen.
* What new information did you learn from reading this article?
I didn’t realize that neurological complications (post-op neuropathy from vitamin deficiencies) was so common, 4-8% sounds pretty high to me. I wonder if vitamin supplementation would make a difference? Just seems a little odd.
*What are current areas of uncertainty on this topic that can be potential areas for research?
Obviously, do we need 3 (and now I’m hearing we have to do 4?) liters of fluid in these patients.
*What are some strengths of the study?
By having a clear question and answer that could use a retrospective review, they were able to get a good sample size as well, making the results they found pretty reliable, as well as allowing them to do subgroup analyses by age.
*What are the limitations?
The limitations are mostly related to the nature of a retrospective chart review, ie they don’t really know what happened if it wasn’t recorded – patients could have been told to get laxatives over the counter, as well as educated about hydration and fiber (as Christine and Travis mentioned)
*What are the main outcomes of the study?
The main outcome was the proportion of patients with opioid prescriptions that were also prescribed laxatives to combat the constipation seen as a side effect.
*Does reading this article change your practice? If so, how?
This article might change my practice slightly, because I am definitely guilty of not prescribing laxatives when I write for opioids. I rarely write for them to begin with, and never for more than 10 pills to be dispensed, but there is really no downside to prescribing laxatives along with the pain meds, so I may start! At the very least, I’ll make an effort to educate people about the constipation that they may get as a side effect so they’re not surprised by it (and don’t come back to the ED when they haven’t pooped).
Luber et al:
How has reading the article changed your practice? I’m not really sure that it has changed my practice all that much. I do think that my suspicion for anastomotic leak and gastric distention is higher than before.
What information had you believed in previously that were debunked by reading this article?
Nothing was really debunked.
What new information did you learn from reading this article? I learned that I should take hiccups WAY more seriously than I had before. These pts are really at high risk for badness to happen, and so a higher index of suspicion is important. i.e. anastomotic leak, PE, hardware erosion/movement, dumping syndrome/malnutrition, etc
What are current areas of uncertainty on this topic that can be potential areas for research? Would be interesting to know more about dumping syndrome/management. I’d also be curious to learn about patients that went to the OR for a diagnostic lap for a benign abd exam, but persistent pain with neg CT–> what were those findings?
Luber, et al:
How has reading the article changed your practice? – this article won’t necessarily change my practice at BMC, but it helped me think about when specific complications occur (i.e. a postop day 5 patient is very different from a postop day 90 patient)
What information had you believed in previously that were debunked by reading this article?
nothing was debunked
What new information did you learn from reading this article?
I didn’t know that cholelithiasis was a common problem after weight loss surgery
What areas of uncertainty on this topic can be potential areas of research?
I’d be interested in seeing more specific numbers about how often a patient with a negative CT scan has a positive finding on ex-lap. For instance, the paper mentions specifically that radiographs are not very sensitive for diagnosing anastamotic leaks immediately postop.
Bariatric Surgery – Luber:
How has reading the article changed your practice? – Like Wilbur, I am now more cognizant of the complication timeline with bariatric surgery, especially Peritonitis and the subtle ways it can present
What information had you believed in previously that were debunked by reading this article?
I never knew DVT/PE was the 2nd leading cause of death, I thought it was all abdominal complications
What new information did you learn from reading this article?
Patients with tachycardia and respiratory distress have a 20% chance of having an anastomotic leak…so don’t be happy with a negative CTPA or V/Q scan! Also…Wernicke’s encephalopathy can occur due to thiamine deficiency after bariatric surgery.
What areas of uncertainty on this topic can be potential areas of research?
I agree with Alex. Does hydration after surgery improve outcomes and lower the # of imaging tests ordered? Also, I’d like to see studies on pox gallbladder removal and if it helps with complications.
Bariatric Surgery:
How has reading the article changed your practice?
– It’s commonplace to think about the acute complications from any surgery but we think less about the long term side effects. In the case of bariatric surgery I will try to think of both acute and long term complications (i.e. nutritional deficiencies and peripheral neuropathy) when approaching a patient with a hx of bariatric surgery.
What information had you believed in previously that was debunked by reading this article?
– I was unaware that in the US the roux-en-y was the most popular procedure carried out. I know that laparoscopic banding has become the preferred procedure in the UK and Ireland.
What new information did I learn from reading this article?
– I have never actually read through all the different options in terms of bariatric surgery. This article provides a good explanation of each procedure so you can think through which complications may present in each subset of patients.
What areas of uncertainty on this topic can be potential areas of research?
– While newer laparoscopic bariatric surgery is described here, the review did not discuss the long-term outcomes comparing the laparoscopic procedures to the traditional open ones.
Constipation Prophylaxis is Rare for Adults:
What are the strengths of this article?
– This retrospective cohort study used datat from the NHAMCS which provided for a very large sample size. By analyzing such a large cohort it can be further broken down. In this case the authors looked at those over 65 with constipation and younger patients with constipation.
What are the limitations of this article?
The limitations of this article are clearly related to the accuracy of the data. The two studies noted that have used the NHAMCS data reveal pretty deplorable findings related to patients with ectopics not receiving a pregnancy test and intubated patients being discharged home.
What were the outcomes?
The authors found that only 1% of patients discharged with opiates received laxative prophylaxis. At most they estimate that 2.5% of adults discharged from EDs with a Rx for opioids received laxatives as well.
Would the results of this article change my practice?
In a busy ED, I often find that I forget to mention the side effects of opiates. Discussion re: constipation should clearly be a priority as it results in re-presentations to the ED and associated complications. I don’t know that I would routinely prescribe laxatives when prescribing an opiate seeing as only 20% of people receiving opiates overall develop constipation and many laxatives are available OTC.
Hunold –
1. Strengths: Large sample size; looked further into the >65 years subset due to the higher incidence of opioid induced constipation
2. Limitations: retrospective, documented inaccuracies in NHAMCS, no documentation of home meds to check if patients were already taking laxatives, data size insufficient to analyze sub groups by region or hospital type
3.Main outcomes: among adults who are discharged from ED with opioids, 1% receive prescriptions for laxatives (similar in group 65 years and older); whereas 42% of adults presenting with a complaint of constipation receive laxatives.
4. I’ll probably be more likely to prescribe laxatives, particularly in the case of elderly patients who are to receive a significant number of opiates. However, with the chronic abuse of opiates that is now becoming more and more of an issue (at least in the media), I don’t plan on prescribing an inordinate amount of opiates if I don’t have to. I can pass that on to the PCP. I will say though if the data suggests that “one week” of opioids can cause acute constipation, it’s definitely something to consider and a conversation to be had with the patient. On the other hand, what are the down sides to prescribing some laxatives? Probably not too bad.
How has reading the article changed your practice?
We’re fortunate at BMC to have a protocol for when bariatric surgery patients come to the ED. The few times I’ve been involved in a case, I stick to the manuscript closely. However, I think the article does a good job of discussing issues that lay outside the surgical consulting realms. These include DVT/PE, gall stones, neuro complaints, ulcers, etc. Moving forward I think I’ll have more of a bird’s eye view while simultaneously looking up our bariatric protocol. I also thought the article did a good job of stating the complications in the context of time. It’s always good to know what to be looking for and when is it most common.
What information had you believed in previously that were debunked by reading this article?
I was unaware that we still perform strictly gastric restriction procedures in the US. I had thought they al had some component of intestinal malabsorption (ie, roux-en-y).
What new information did you learn from reading this article?
Common bariatric complications that fall outside the “surgical complications” realm. Criteria for bariatric surgery. How although peritonitis secondary to anastomotic breakdown is the most common cause of death s/p surgery, bariatric sx patients presentation is not at all classic. The breakdown of complications by time (ie, early, late, etc.)
What are current areas of uncertainty on this topic that can be potential areas for research?
Outcomes for prophylactic cholecystectomy in patients s/p bariatric sx, stratified by time since surgery. There seems to be some debate on the issue.