Thursday, November 18, 2010

ICU Rounds Report - November 18th 2010

Sticky Platelets. Back in the days when the only thing to do with an MI was to talk about it (i.e. the 60 and 70's), physicians noticed that heart attacks tended to happen most commonly in the morning. Same for strokes and TIAs. Why? Partly because platelets tend to have diurnal variation and aggregate more avidly in the AM, particularly when people first assume the upright position after lying recumbent all night. These events also to the corresponds to the typically highest blood pressures of the day.

The platelet part of this theory was confirmed in the 1980's in a series of studies that measured platelet function in healthy men around the clock. Reliably, platelets are more likely to aggregate between 6-10am. The implications of this are two: first, don't get out of bed unless you really have to. Second, if you're treating patients at risk for arterial thrombosis with anti-platelet agents, make sure you're covering the morning.
Tofler GH, Concurrent morning increase in platelet aggregability and the risk of myocardial infarction and sudden cardiac death. N Engl J Med. 1987 Jun 11;316(24):1514-8.

Teachable Moments. Patients undergoing major surgery or trauma are significantly more likely to pay attention to healthful suggestions, like to drink less or stop smoking. Multiple randomized trials of smoking cessation prior to major surgery have shown big benefits, particularly with cardiac and wound complications. Other trials have shown that repeatedly reminding patients to stop smoking and drink less makes an real, measurable impact. This is especially true at stressful times (i.e. new cancer diagnosis, major surgery, trauma).

Alcohol abuse is common problem in our patients and of course a significant risk factor for trauma. Up to 50% of trauma patients will screen positive to alcohol abuse. To decrease the trauma burden, researcher at Harborview Medical Center randomized over 700 trauma patients who screened positive for abuse symptoms to a brief (30 minute) intervention from an addiction counselor or routine care. Patients were told they were in a study regarding trauma outcomes and were not aware that the addiction intervention was part of the study.  The results were striking.

At one year, alcohol use was reduced (self-reported) by 22 drinks per week (P<0.03). There was a 47% reduction in injuries requiring either emergency department or trauma center admission (hazard ratio 0.53, 95% confidence interval 0.26 to 1.07, p = 0.07) and a 48% reduction in injuries requiring hospital admission (3 years follow-up).

Given the risks, benefits and costs of this intervention, it seems like alcohol counseling should be routinely given to at risk trauma patients. While that happens from an institutional stand point, it seems reasonable for all of us to take some time and address alcohol and smoking in our patients in these "teachable moments."
Warner, DO. Surgery as a Teachable Moment Lost Opportunities to Improve Public Health Arch Surg. 2009;144(12):1106-1107.
Shi, Y et Al. Surgery as a Teachable Moment for Smoking Cessation. Anesthesiology.  2010 112(1): 102-107

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