Optimizing Perioperative Care in Dermatology

In this interview, Dr Golda shared expert perspectives on evidence-based perioperative care, covering the judicious use of prophylactic antibiotics, the management of anticoagulants, and innovative pain relief strategies. Discover how to optimize patient outcomes while minimizing complications in dermatologic surgery as Dr Golda reviews his session, “Evidence-Based Perioperative Care: Improving Satisfaction, Outcomes, and Efficiency,” presented at the 2023 ACMS Annual Meeting.

Nicholas Golda, MD, FAAD, FACMS, is board-certified in both dermatology and micrographic dermatologic surgery. His specializations include skin cancer and Mohs micrographic surgery, which he practices at US Dermatology Partners Lee’s Summit in Lees Summit, MO.

The Dermatologist: What are prophylactic antibiotics and how do they play a part in perioperative care?

Dr Golda: Prophylactic antibiotics are typically given if a surgeon feels that they are working on someone at high risk for developing a postoperative infection, number one, or, number two, if there is an opportunity to get a hematogenous or bloodborne infection that could affect an artificial heart valve, a damaged heart valve, or a replaced joint, like a hip or a knee.

Over the years, in medicine in general, and dermatology specifically, there has been a lot of research. The guidelines from the American Heart Association and the orthopedic groups suggest that we probably do not need to use these antibiotics as frequently as we once thought. This is with respect to damage to heart valves or joints. You really do not need to give these unless you are working on an infected area or an area known for having bacteria, such as a mucosal site or something similar.

For joints, it is primarily in the first 2 years after having the joint. It used to be that within my career arc, we gave them to everybody, regardless of how long they had it or the site we were working on. That is a significant change. It likely saves patients a lot of effort in filling prescriptions and taking antibiotics that they probably do not need.

Another use of prophylactic antibiotics is postoperatively. This falls under a pre-op vs a post-op antibiotic paradigm, where you are working on a site that you believe, due to a break in sterile technique, the complexity of reconstruction, or a site that has been left open for an extended period, requires antibiotics to anticipate and prevent infection. A common scenario for using this is when we are working on a delayed closure. For example, in dermatology, you might perform a staged excision, removing skin cancer and waiting for final pathologic confirmation before proceeding with reconstruction. In this case, you would use an antibiotic because you are working in a contaminated field. That is a brief overview of preoperative antibiotics or prophylactic use of antibiotics.

The Dermatologist: Can you describe the management of anticoagulants in the perioperative period?

Dr Golda: We have traditional antiplatelet and anticoagulant agents, like aspirin and warfarin,  that are well-known. Then, there are newer novel anticoagulants that have emerged, as well as novel antiplatelet agents that do not require laboratory monitoring. Some of them have reversibility with medications, while others do not.

However, the key takeaway for dermatology, specifically regarding dermatologic surgery, is that we do not typically stop antiplatelet or anticoagulant agents before performing dermatologic surgery. Some studies suggest an increased risk of bleeding complications, while others show that this risk is quite negligible. Our goal is to avoid situations where a person, for instance, someone taking an anticoagulant for atrial fibrillation, stops their medication for our surgery and subsequently develops an embolism due to the atrial fibrillation.

To put it in simpler terms for patients, "It is easier to fix your skin than your brain." Dealing with bleeding complications after skin surgery is far more manageable than dealing with the aftermath of a thrombus from the atrium into the brain due to an embolism. If individuals are on these agents for a reason, and typically they have an indication for it, we do not discontinue them.

The Dermatologist: What are the current and new pain management methods that could be utilized following Mohs surgery?

Dr Golda: The aspect I would like to emphasize the most is the research I conducted a few years ago with my colleague Vanessa Voss. We explored the anticipatory use of long-acting injected anesthetics for patients we expected would experience pain, with the goal of preempting that pain and reducing the need for narcotic or non-narcotic analgesia. The idea is to prevent pain from occurring in the first place, rather than treating it after it develops.

In her study, she found significantly reduced use of narcotic analgesics and lower pain scores in the first 24 hours when using a long-acting anesthetic like bupivacaine. This is injected in the immediate postoperative period for individuals expected to experience pain, such as those undergoing extensive nasal reconstructions, scalp closures, or large scalp flaps.

This approach is important as we aim to minimize prescribing narcotic analgesics unless absolutely necessary. While not everyone experiences this, some patients may encounter gastrointestinal upset, vomiting, or retching as side effects of narcotics. In trying to alleviate their pain, we might inadvertently cause different issues. Thus, if we can reduce the need for narcotics, it is a positive step for patients and for society, potentially leading to fewer narcotics in circulation.

Additionally, we anticipate pain with non-narcotic analgesia using acetaminophen and alternating with ibuprofen, which has been shown not to increase the risk of bleeding complications. In some cases, studies suggest that this approach can be as effective as, or even better than, using narcotics. The goal is to ensure patients understand how to use this regimen and not rely exclusively on narcotics. It is not that narcotics should never be used, but we aim to limit their use.

The Dermatologist: Are there any tips or insights you would like to share with your dermatologist colleagues regarding your session at ACMS and/ or evidence-based perioperative care?

Dr Golda: I would like to encourage colleagues to explore the use of topical tranexamic acid in wounds left to heal by granulation as a means to reduce bleeding complications. The entry barrier for this approach is quite low and it isa cost-effective agent,. Implementing it into your practice can help alleviate patient anxiety about postoperative bleeding and reduce after-hours patient contact for you. It is a valuable and low-cost addition to practice.

I also encourage experimentation with the use of long-acting anesthetics, as I mentioned earlier, such as using bupivacaine for patients undergoing closures or procedures expected to be painful. It adds value to the procedure and the cost is relatively low. Lastly, feel reassured that you generally do not need to halt anticoagulation prior to our procedures, except in exceptional cases. Keeping patients on these agents is the right approach. Furthermore, reducing the use of antibiotics is the right direction. The need for antibiotics before and after dermatologic surgeries is diminishing, raising questions about their necessity in the first place. Having data to support these practices is reassuring and confirms that limiting antibiotic use in most cases is the right choice, aligning with the trend over the past 5 years.

Reference

Golda N. Evidence-based perioperative care: improving satisfaction, outcomes and efficiency. Presented at: American College of Mohs Surgery (ACMS) Annual Meeting; May 4–7, 2023; Seattle, WA

Watch Dr Golda's podcast interview!