New Delhi: It is a common practice throughout the world that patients are admitted to the surgical intensive care unit (SICU) after emergency and elective surgery. Patients are also taken into the surgical ICU after elective surgery, for further support, or to manage coexisting comorbidities.
There are only a handful of doctors around the globe who are deeply vested in de-escalating the postoperative situation by meticulous clinical care, so that these critically ill patients are stepped down to a lesser level of intensity of care after appropriate recovery from the stress of surgery.
Sreerupa Patronobish interviewed one such pioneering anesthesiologist, Dr. Rudram Muppuri, a NRI physician who earlier accomplished his MD in Anesthesiology before relocating to the United States to establish these unique principles of care for the vulnerablesurgical patients in his current practice at McLaren Healthcare Systems, Michigan. Dr. Muppuri is on the Board of Directors of Michigan Society of Anesthesiologists. Dr. Muppuri is a recent recipient of Top Doctor Awards.
Following is an excerpt of the interview.
SP: You are considered a pioneer in the field of quick discharges after surgery. What motivated you to this unique stratum of patient care?
RM: The implementation of the ERAS (Enhanced recovery after surgery) protocols in surgery should decrease the need for ICU beds, but there will always be unpredicted complications after surgery. The concept was introduced by Dr. Henrik Kehlet, but its acclimatization into general anesthesiology practice stems from my deep interest in pain management.
Apart from my lead as anesthesiologist, I have obtained professional training and board certification in pain management. The ability to strike balance to control pain effectively in the post-operative period is at the root of success in recovery of the surgical patient. At the same time, expert and conscientious prescribing is the key to prevent an individual from getting addicted to the pain medications, especially the opioid class of medications, which has now turned into a national epidemic.
SP: What are the exclusive things you do for our surgical patients in ICU to further enhance their recovery?
RM: These will require individual management. Some of the most important aspects include to promote early enhanced recovery in surgical intensive care—SICU. There are three areas that need to be addressed on a war footing: sedation, analgesia, and delirium. I am deeply interested in generating newer tools for measurement and protocols for management in these three areas which ensure best practice in each SICU.
SP: What additional areas merits to be emphasized for efficient recovery after complex surgical treatments?
RM: The fourth important area is Nutrition. Surgical nutrition is a sophisticated area that needs finesse in delivery to the patients. The patients are in pain and anorexic, and they need a level of nutritional support to transform from the catabolic state after surgery to one of enhanced metabolic recovery. Preoperative screening and post-operative measurement of the state of nutrition also need to be developed in the SICU.
SP: Do the patients feel safe regarding this rapid method of recovery?
RM: An important area that I emphasize post-surgery is early mobilization. Early mobilization of the critically ill patients is also required, even if on mechanical ventilation. An overarching aim is to push the patient to threshold for physiological recovery. Early mobilization is possible, and I stress on its implementation by special multidisciplinary ICU team. I am also passionate about educating all team members with protocols, so that they are fluent and are able to implement them in their field of expertise. Personal and professional attitudes are critical for implementation.
SP: Factors that limit early recovery include pain and different organ system dysfunctions. Can you please elaborate your contributions in these areas.
RM: I was among the first to perform an efficiency study and device a model for evaluating the efficacy of placement of catheters for epidural placement during childbirth and impact on post-obstetric pain. In fact, we are one of the few groups in the world who have performed this study. This study of inadequate labor analgesia was published in the Middle East Journal of Anesthesiology. For enhanced recovery, a multimodal, evidence – based approach is required. Implementation of this innovative concept was facilitated by the simultaneous development of new regional anesthesia techniques for pain control like epidurals etc. I am a robust advocate of the concept of “e CASH” (early Comfort using Analgesia, minimal Sedatives and maximal Human care). Effective pain control enables early ambulation.
SP: What is the impact of sleep on post-surgical recovery?
RM: Sleep is extremely important for restoring homeostasis. Benzodiazepines in the sedation of SICU patients should be excluded under all circumstances, and non-sedative medications use such as propofol (popularly called “milk of amnesia”) or dexmedetomidine should be encouraged. Several modifiable risk factors for delirium should be addressed meticulously, including cognitive impairment, sleep deprivation, immobility and visual and hearing impairment.
SP: How would you define delirium, and its impact on recovery of the patient post-surgery?
RM: Delirium is “acute mental confusion”, some changes in behavior that was not previously present. The patient may be agitated, or may be quiet but may still have features of delirium. Delirium is a common problem in some SICU patients intensely affecting outcome in terms of prolonged ICU stay, persistent cognitive decline, reintubation, and worse overall outcome. Delirium is frequent in the medical and surgical Intensive Care Units (ICUs) with prevalence rates from 32.3 to 77% and the incidence rates somewhere from 45 to 87%.
SP: Thank you for this exciting discussion Dr. Muppuri.
RM: Thank you for having me. A neglect of recovery can turn out fatal for patients. In the core of all our efforts should be the patient and his well-being. Every time a patient is anesthetized, it carries a certain amount of risk. The post-operative period merits intense monitoring by the team of anesthesiologists, with an overarching goal of inducing health. Hawk’s eye vision is required to prevent blood clotting in deep veins of the legs; also to detect any postoperative bleeding or surgical shock.
Any cause of delirium should be aggressively investigated. Care for patients start in the preoperative period, and potential need for post-operative ICU admission should be discussed with the patient before surgery. The impact of my practices can be felt across the hospital, as efficient perioperative care reduces the needs for ICU beds. Patients’ well-being and needs remains my top priority. The patient and the family is at the center of the drama, and should be provided the “classy” management that they rightfully deserve in this part of their journey in the hospital.