Dr. Kevin Most: Complications from surgery and the benefits of ice
We heard this weekend of the passing of actor Bill Paxton at the age of 61 following heart surgery. The cause of death was reported as a complication of surgery, further reports shared he had died of a stroke.
Now, I don’t know what happened with Mr Paxson but we can talk general comments. Heart bypass surgery is performed to help increase blood flow to the heart that has been hindered by blockage. These individual unfortunately often have blockage in other arteries in the body. We know these individuals have a higher chance of stroke.So using blood thinners are often used. Now couple that with an individual who has recently had surgery. The balance of keeping the blood “thin” (not clotting) and allowing the surgery to heal without extensive bleeding must be exact. Patients have a higher chance of stroke when their anatomy is diseased and the team works to minimize this complication
The advances that have been made in surgery over the past 25 years are amazing and something we could spend an entire segment on. Surgeries that used to require a large opening in the abdomen are now being done thru a few small cuts that allow for placement of scopes into the abdomen, the surgeon then performs the surgery thru the scopes. This allows patients to heal quickly, in fact many go home the same day. Many have heard of robotic surgery, this is not surgery done by robots, but is a form of laproscopic surgery that has the surgeon sitting at a monitor feet away from the patient. This technology allows for magnification of the field as well as making the fine movements needed in some surgeries even safer. Technology has allowed us to do surgery much safer and with less chance of complications.
The science of pre and post surgery has also advanced, pre op maximizing physical conditioning of the patient when possible, using antibiotics before surgery with very specific timing, using anesthesia that works well but also is cleared from the body quickly, rapid ambulation after surgery, specific pain medication options that cover pain and limit the chance of addiction. The list goes on
The term complications is a broad term, so are due to the bodies response to surgery, some is due to the healing process, most are known as possible complications that are discussed with the patient before surgery. The surgeon discusses the risks and benefits with the patients as many complications cannot be predicted, but when some occur the team is often looking for them and ready to work on correcting them. Complications do occur but with less and less frequency as we perfect the entire process
Surgery has never been safer and advances are being made everyday
We have all heard about the benefits of ice, on a recent muscular injury. The ice helps , as the cold keeps down inflamation and thus minimizes pain. The picture of the Cubs pitcher sitting in the dugout with a bag of ice taped to their shoulder is probably one we can’t wait for. We have shared that the importance of using ice immediately after an injury, the limiting factor is time as our goal is to minimize the inflammation that occurs following trauma and slows the recovery time.
In all honesty, that is the most practical use of cooling but did you know we are using high tech cooling in conditions that make a much bigger impact than the sprain ankle you suffered at the neighborhood picnic. So lets go over a few.
We discussed in the past the super cooling that is being touted as decreasing the inflammatory process to patients by placing them in a canister and surrounding them with liquid nitrogen gas. It lowers the skin temperature for a few minutes and has been shown to decrease inflammation. We discussed this in the past and it has continued to gain interest with athletes as well as patients with other inflammatory illnesses.
Lets discuss some uses of cooling that we have not discussed in the past.
We all have heard of the stories of the individual who fell thru the ice and was submerged for a substantial time and then was revived without any residual physical or mental deficits. The benefit of cooling the body is what allows for the survival of many of these patients. That same concept has proven out in many other areas of medicine and has made huge impacts on patients lives.
The outcomes of these patients has pushed medicine to say, “if it worked in these patients, might it work on cardiac arrest patients that come in to ER’s across the country?” The issue for many of these patients is not getting the heart started again, it is more the problem of decreased blood flow to the brain during the time the heart was not functioning. A study that came out in JAMA about a year ago looked at this, now we need to know that we have been cooling cardiac patients for more than a decade. It has been shown that cooling the patient has good outcomes in quality of life as well as mental function.
This study looked at individuals who had a cardiac arrest in the field and were brought to the ER where heart function was restored. Often these patients had no heart function or minimal function provided by CPR for a period of time. These patients in the ER may be evaluated for the possibility that cooling may help preserve brain function in these patients.
Lowering the body and brain temperature is thought to protect brain cells. Cooling decreases the need for energy in the brain, so decreased blood flow and cooling decreases inflammation and stops the release of toxins that cause more damage. How cold are we talking, well this study lowered some of the patients to 91.4 degrees, remember the normal body temperature is 98.6 degrees. They kept these patients at this lower temperature for 36 hours.
The results from this therapy are very encouraging and great outcomes are noted in many cases. This is not available at all hospitals, at CDH we use it 2-3 times a month.
Childbirth is the most impactful moment in any adults life. The fragility of the newborn and the importance of the first few moments is important as the oxygen supplied by the mother must now be supplied by the newborn breathing. In some cases the newborn does not get the oxygen they need immediately. In the past there was not much we could do for these patients. We now use a device called a CoolCap. This is a cap that is placed on the head of the newborn and is designed to cool the brain of these infants. It has been shown that this can have a major impact on minimizing brain injury. The thought is that by cooling the brain it minimizes the death of brain cells. Now this won’t help all infants who suffered a traumatic delivery but the results overall have been promising and more studies are being completed. CDH is fortunate to have CoolCap available and is used by the neonatologist routinely.
Last month a study was released that showed another great use of cooling. We know that chemotherapy is often focused at cells that divide often, a quality that cancer cells have. The chemo unfortunately often attacks healthy cells as well that turnover rapidly. This is why patients receiving chemo have mouth sores and lose their hair. The loss of hair has not only the physical impact but also the psychological impact. This impacts the moral of patients and in some cases has actually made patients decline chemotherapy.
In the US about 250,000 women are diagnosed with breast cancer each year. Those patients are left to face the decision of chemotherapy, surgery, hormone therapy and radiation. Side effects from each of the therapies must be discussed with each patient before decisions are made. The chance of eliminating or minimizing any of the side effects is a goal for many medical studies
This study showed that using a cap to cool the scalp before , during and after chemotherapy decreased the chance of loss of hair. This therapy has been used in Europe commonly and was approved for use in the US in December of 2015, it is finding its way to more sights in the US. The thought is that by minimizing the blood flow to the scalp, decreases the amount of chemo that is exposed to hair follicles. The cap is placed about 30 minutes before chemo , kept in place while chemo is infusing and then continued for 90 minutes after chemotherapy. The results have been pretty impressive and the side effects are minimal, mainly being headache and discomfort.
The emotional impact this can make on a patient is huge and we know that the fight against cancer is important to have both emotional and physical strength. If this device helps from an emotional view it should be studied more so we can show insurance companies that they should support it. Cost can approach $1,000.
Many of you have probably seen the ads for cool sculpting. This is not a weight loss tool. It is a technology that freezes fat cells just below the skin. The fat cells then break down and the body reabsorbs the the material. The procedure is called Cryolipolysis and it essentially reduces the superficial fat layer in individuals, some have noted 20-80% decrease. This decrease is noted gradually over a 3 month period. Side effects from the treatment include bruising of the skin, redness and some temporary numbness. Although the exact way this works is not totally understood it is being used around the country.
So although we may only think of cooling helping our sore ankle, the impact of cooling has expanded into many medical areas and is making a bigger impact than getting you back on the basketball court sooner.