'Difficult' patients

• 'Difficult' patients
• Fresh blood leads to better outcomes
• Six observations about sodium correction
• The high costs of anesthesia awareness

'Difficult' patients

By Lawrence A. Danto, MD, and Valeria Kelly

We've all had them. They arrive with an agenda that goes beyond securing appropriate care. They are unknowingly—or uncaringly—disruptive. They prefer to share what they have learned about their condition from friends and Websites rather than hear what you have learned from years of training and experience about the best way for them to recover. They imagine their problems outweigh anything else happening in your practice. Their inflated sense of self-importance seems to loom even larger than the importance of their health.

When encountering these difficult patients, we may respond as though they choose to be difficult, but often they cannot help behaving as they do. They act this way because their personal and medical histories have sent them in an emotional free-fall, and they are attempting to regain control over their lives by controlling others. As skilled professionals, we want nothing more than to see all our patients treated successfully. This requires learning to manage the problems unique to 'difficult' patients. More than a pill or an operation, they need help re-establishing a sense of control over their health. They need assurance that we empathize with their desire to become healthy and in control.

Fortunately, difficult patients do not come along every day, but when they do, what is the best way to manage them? First and foremost, the difficult patient requires us to exercise patience, with them and ourselves. This is not always easy for a highly sought-out specialist, but there are steps you can take to handle difficult patients more effectively:

Prepare yourself

• Remind yourself that the difficult patient is fearful and deals with this fear by attempting to exert control over others.
• Understand and accept that difficult patients cannot change in the short-term.
• Allot difficult patients extra time, empathy, and accommodation.

Prepare your office

• Train your staff to recognize, understand, and empathize with the difficult patient.
• If your staff suspects that a patient is 'difficult,' ask that they notify you before the appointment and allow extra time for the consultation.
• Instruct your staff to remain courteous to even the most difficult patients.

Prepare the patient

• Advise difficult patients that the consultation process begins as soon as the appointment is scheduled and may take longer than expected.
• Reassure them that they own their medical records but it is important to leave them with you for review until the process is completed.
• Explain that office routines are for more than convenience and exist to ensure patient safety and improve outcomes.
• Emphasize that you are committed to their care, but for the benefit of all patients, appointments should not be prolonged unnecessarily.
• Remain communicative and pleasant, no matter how uncommunicative or unpleasant they sometimes act.
• Be humble and remain patient. You will be surprised how well difficult patients respond once they are confident that you care and are receptive to their concerns.

Surgeons sometimes err in assuming responsibility for ensuring an optimal outcome rather than relegating themselves to providing the best care they can offer irrespective of outcome. Because the patient's contribution is essential to achieving the best outcome, results are something we cannot and should not guarantee, especially when dealing with a difficult patient.

In the end, we surgeons would do well to remember that all patients are potentially difficult and need us to care about them as people even more than we care about them as patients. No matter what, we must remember Primum Non Nocere: a patient should never be mistreated. It is below the standard of care for a professional to lose the confidence and trust of even the most difficult patients—it hurts them and us. The mark of a true professional is to deal successfully with every patient. No one said it would always be easy.

Fresh blood leads to better outcomes

By Christin Melton

When it comes to blood, how old is too old? A recent study published in the New England Journal of Medicine evaluated 6,002 heart surgery patients who underwent blood transfusions during surgery and determined that those who received blood that was more than 14 days old were more likely to experience complications or die. A total of 3,130 patients received the older blood, and the remaining 2,872 were transfused with blood that had been stored 14 days or less. The in-hospital mortality rate for patients receiving blood older than 2 weeks was 2.8% compared with 1.7% for patients who received fresher blood. Patients receiving the older blood also experienced longer periods of mechanical ventilation and increased rates of blood poisoning and kidney failure. This corresponds to a Duke University Medical Center study published in 2007, which found that red blood cells begin losing nitric oxide as soon as the blood leaves the donor's body. Nitric oxide is needed to keep blood vessels open so that the cells can enter tissues and deliver oxygen. Organs that are insufficiently oxygenated are more likely to fail.

Recognizing that blood degrades, the Food and Drug Administration (FDA) established 42 days as the maximum time limit for storing blood, but ongoing nationwide shortages of blood result in most of it being used within 15 days of donation. Dr. Colleen Gorman Koch, lead author of the Cleveland Clinic study in NEJM, believes that "Blood should be classified as outdated earlier than current recommendations." FDA officials are not so sure and point out that the study, while interesting, was "narrow and non-randomized," and they are calling for more "definitive scientific information" before modifying blood storage procedures.

Possible options for improving outcomes for heart surgery patients include limiting blood transfusions to emergency cases, recycling the patient's own blood, or administering drugs during surgery that minimize the likelihood a transfusion will be required. A companion editorial to the Cleveland Clinic study proposed another possibility: prioritizing blood supplies, reserving the freshest blood for cardiac patients and using older blood in those with low-risk conditions like anemia. Research is also underway to evaluate whether adding nitric oxide back to red blood cells prior to transfusion can improve surgical outcomes for cardiac patients.

Approximately 43,000 pints of donated blood are used daily in the United States and Canada, but a growing list of restrictions on who can donate blood has cut into the amount of blood collected each year. Sixteen states sought to address this by lowering their donor age to 16, and legislation is pending to do the same in nine more states. It is worth noting that just one day after the terrorist attacks on September 11, 2001, the nation's blood supply was filled to capacity as 500,000 Americans donated blood. The easiest way to ensure that fresh blood is always available for heart surgery patients is for more Americans to roll up their sleeves more often.

Six observations about sodium correction

By Praveen Kandula, MD, MPH

Sodium imbalances are common in hospitalized patients. Here are six interesting observations about sodium correction.

1. Normal saline is isotonic, yet it has 154 mEq/L of sodium. Blood plasma comprises 90% water and 10% cellular material. Normal sodium plasma levels average 140 mEq/L, which is the amount of sodium found in the liquid portion of plasma. To get a true concentration of sodium in a crystalloid solution, the 10% cellular component needs to be accounted for. This means that the normal sodium level of 140 mEq/L must be increased by 10%, or 14 mEq, for a total of 154 mEq/L, which is the level of sodium found in normal saline solution.

1. Hypokalemia needs to be corrected to correct for hyponatremia. Sodium (Na ) is the predominant extracellular electrolyte, and potassium (K ) is the predominant intracellular electrolyte. Their concentrations are regulated by constant exchange using sodium potassium adenosine triphosphatase (ATPase) and reflect the relative proportions of solute and water and not the absolute amount of either solute or water. Plasma sodium concentrations are represented by the following equations: Plasma Na = Exchangeable Na Exchangeable K Total body water or Plasma Na = Total body Na Total body K Total body water As these equations demonstrate, plasma sodium levels cannot improve unless the level of plasma potassium is corrected.

1. There are 154 ? 0.023 grams ≈ 3.5 grams of sodium in 1 L of normal saline solution. The atomic weight of sodium is 23.0 grams; thus, 1 mmol has 0.023 grams. Normal saline solution has 154 mEq/L of sodium because 1 mEq is equal to 1 mmol of sodium. It is important that clinicians know this, because many patients are kept on "maintenance fluids," which can add up to a lot of sodium when paired with the patient's normal diet.

1. The sodium concentrations in normal saline solution and Ringer's lactate are different. Normal saline solution has 154 mEq/L of sodium, and Ringer's lactate has 130 mEq/L of sodium. While the latter solution is used more commonly in surgical patients, the two fluids are nonetheless interchangeable for most purposes. It is important to remember that Ringer's lactate contains an additional 4 mEq/L of potassium and 28 mEq/L of lactate. Lactate is converted to bicarbonate in the liver and primarily helps in combating acidosis.

1. There are methods to estimate FENa in a patient on furosemide (Lasix). Fractional excretion of sodium (FENa) is commonly used to determine whether the etiology of a case of acute renal insufficiency is pre-renal or intrinsic; however, this calculation can have limited usefulness in patients who are on diuretics because these drugs interfere with sodium reabsorption. Several alternative calculations can be used, including calculating the fractional excretion of urea, uric acid, or lithium. All follow the same principle, which is that patient's in pre-renal states demonstrate avid salt and water reabsorption at the proximal tubule. Lithium, urea, and uric acid are also absorbed in the proximal tubule, but these are not affected by furosemide. The equivalents of FENa levels below 1% for lithium, uric acid, and urea are values lower than 15%, 12%, and 35%, respectively. Similarly, the equivalent of FENa levels above 1% for lithium, uric acid, and urea are values higher than 25%, 20%, and 35%, respectively. The fractional excretion of urea is thought to be the most sensitive and specific calculation in patients receiving diuretics.

1. It is generally not appropriate to use normal saline to treat hypernatremia. Hypernatremia frequently develops in hospitalized patients, and almost all cases are attributable to the loss or lack of free water. Iatrogenic salt excess due to intravenous fluids is commonly overlooked. When treating hypernatremia, hypotonic fluids like dextrose 5.0% in water (D5W), 0.2% normal saline, or 0.45% normal saline, are preferred unless the patient is hemodynamically unstable secondary to true volume depletion. If possible, oral supplementation or tube feeding of free water is preferable.

Dr. Kandula is an assistant professor of clinical medicine at Southern Illinois University School of Medicine in Springfield, IL.

The high costs of anesthesia awareness

By Christin Melton

Imagine waking to find yourself unable to move or speak as someone cuts into your abdomen; imagine hearing a drill grinding through bone, smelling cauterized tissue, or feeling each needle-prick as your skin is stitched back together. While this scenario has all the makings of a gruesome nightmare, it is an extreme example of a rare but real phenomenon known as anesthesia awareness or intraoperative awareness.

According to the Joint Commission, approximately .1% to .2% of anesthetized patients regain some degree of consciousness during surgery. This equates to 1 or 2 of every 1,000 patients or 20,000 to 40,000 incidents annually. A February 2007 study in Anesthesiology put the risk significantly lower, finding that only .0068% of 87,361 adult patients who underwent general anesthesia for a surgical procedure—or 1 in 14,000—experienced anesthesia awareness. Those individuals whose condition requires using a lower dose of general anesthetic, such as cardiac, obstetric, and trauma patients, are reportedly ten times more likely to wake during surgery. Hemodynamically unstable patients, chronic drug and alcohol users, and children are also more susceptible to anesthesia awareness.

Most patients who wake during surgery do so only briefly and suffer no lasting psychological harm, but a small number can recall nearly the entire operation. This can happen when the anesthesia's paralytic drugs take full effect, rendering the patient motionless and unable to communicate, but the pain-blocking medications are never administered or prove ineffectual. The patient senses pressure and pain related to the operation and subsequently may develop posttraumatic stress disorder or steadfastly refuse to undergo surgery in the future.

Patients are not the only ones who have reason to fear anesthesia awareness. The American Society of Anesthesiologists' Closed Claims Project reports that "intraoperative awareness associated with general anesthesia accounted for 2% of closed anesthesia malpractice claims from 1990 to 2000." To reduce the likelihood of patients waking during surgery, many hospitals and anesthesiologists have turned to brain-wave monitors, such as Aspect Medical System's bispectral index (BIS). BIS was designed to decrease undermedicating and overmedicating surgical patients by using electrodes to monitor patients' brain patterns and alert anesthesiologists to fluctuations. Two studies published in 2004 found that BIS decreased anesthesia awareness in high-risk patients between 77% and 82%.

A March 2008 report in the New England Journal of Medicine contradicts those findings, however. The NEJM study concluded that the BIS monitor was no more effective at preventing anesthesia awareness than older techniques, which measure exhaled anesthesia gas. Aspect Medical's stock plunged following the study's release, and the president of Aspect Medical has disputed the authors' methods and conclusions. Isaac Ro, a Leerink Swann analyst, told CNN that it seemed likely some anesthesiologists would now forego the $2,000 expense for the questionable BIS units and wait for better technologies to emerge.

The Joint Commission recommends that anesthesiologists inform all high-risk patients about the possibility of anesthesia awareness and offer psychological referrals for those patients who, following surgery, claim to have experienced the condition. For "Strategies to Prevent and Manage Anesthesia Awareness" visit the Joint Commission International Center for Patient Safety Website at www.jcipatientsafety.org/15321.