How often to you bend other guidelines?

[amyl]

As follow up to npo thread, how often to you bend other guidelines.... For example....
A patient had a non stemi 8 days ago.... They bms'ed there rca in two places. The lcx and lad lesions were 50-60% - her symptoms were attributed to rca lesions. Post non stemi she's in renal failure. She has a catheter for dialysis but surgeon wants to do an av fistula now. She also has copd, morbid obesity, etc. guidelines say wait 6 weeks to 30 days for elective surgery.... Thoughts?

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[Ignatius J]

May consider regional. No GA.

 

[deleted59964]

She has a catheter for dialysis but surgeon wants to do an av fistula now

why?
if benefit>risk i would go ahead ... but why cant this wait?

 

[teeva]

Some surgeons do it with straight local and don't involve me.

 

[urge]

As follow up to npo thread, how often to you bend other guidelines.... For example....
A patient had a non stemi 8 days ago.... They bms'ed there rca in two places. The lcx and lad lesions were 50-60% - her symptoms were attributed to rca lesions. Post non stemi she's in renal failure. She has a catheter for dialysis but surgeon wants to do an av fistula now. She also has copd, morbid obesity, etc. guidelines say wait 6 weeks to 30 days for elective surgery.... Thoughts?

Which guideline would you be breaking?

Is it maintain dual antiplatelets, or is it no surgical procedures for 6 weeks?

 

[IlDestriero]

Which guideline would you be breaking?

Is it maintain dual antiplatelets, or is it no surgical procedures for 6 weeks?

Probably both.

 

[amyl]

.... in his opinion he thinks a little versed will be just fine but the real reason it can't wait because he is going on vacation for three weeks and doesn't want to give the rvus to another surgeon.
If she flips out under the drapes what then?
Sorry - if you get me and my name on the chart and to the family we follow the guidelines unless there's a great reason not too.... Surgeon greed isn't a good reason.


Have I mentioned I hate it here..... I'm going to do cases all weekend and not a single emergency amongst them.

 

[IlDestriero]

I like nothing more than saying, "yeah, I don't think we will be able to do that." When they call me about a non emergency on the weekend. The only things we do occasionally is a study or line that would keep a kid in the hospital until Monday afternoon or probably evening, when they could leave Saturday afternoon. I don't mind that, kids shouldn't be in the hospital. They are better off at home.

 

[amyl]

Are you kidding? If I said anything about not doing them the temper tantrums and calls to admin would start.... My partners are pansies that put up with it so I have no back up.

 

[GatorBait1548]

Guidelines are just that...guidelines, not hard and fast rules.....that being said, stuff like stent thrombosis is nothing to scoff at

 

[scudrunner]

Yeah, in stent thrombosis risk is increased something like 40-50x if anti-platelet therapy is stopped in the very early post-stent time frame. The benefit from proceeding with an elective surgery would have to be HUGE.

 

[deleted171991]

Guidelines are just that...guidelines, not hard and fast rules.....

But you have to have good reasons to cross them. In case anything happens, you will have to convince a jury that the benefits far exceeded the well-known risks. The minimum one needs to do is to have a long and honest discussion with patient and family, and then document the hell out of it. I am not afraid to use the word "death" during such discussions.

Usually the patient will change her mind but, even if not, we usually walk away with a good plan (involving the surgeon) to minimize both surgical and anesthetic risks. (If I am convinced that the risk is high, as in stopping antiplatelet meds after a recent MI and stent, I won't do an elective procedure, period.)

 

[Noyac]

Depends!

Is there any viable myocardium left beyond the stent?
Will we continue the anti platelet therapy?

If no to the first or yes to the second question then we proceed. I'm just giving a little versed anyway so what's the big deal?

 

[deleted171991]

I'm just giving a little versed anyway so what's the big deal?

You are also praying that everything goes smoothly. Which can be the case with the right surgeon and the right patient, and all you'll need is a touch of sedation and/or hand-holding.

What happens if:
- local is not enough (either it doesn't work, or the surgeon has to dig through layers of fat)
- sedation is not enough, patient freaks out
- patient becomes atelectatic while supine, especially if sedated, and has trouble breathing
- some epi gets IV
- uncontrollable bleeding occurs
- surgery is prolonged, tourniquet time is prolonged, then all the crap washes into a circulation with a bad heart
Etc. Etc. Etc.

Just thinking out loud here.

As I used to tell my boss, in situations like this: If I were to bet just a few hundred bucks, I would bet on nothing really bad happening. But if I had to bet a few hundred thousands (especially with only a few hundred dollars as payout for me), I'd rather wouldn't bet at all.

I must be the worst employee for not risking my own livelihood just for the sake of my employer's or some surgeon's profits (even if the patient insists).

If I bend the rules, it has be to be for the patient, because the benefits far outweigh the risks. I have never regretted helping a patient; can't say the same thing about surgeons.

 

[Noyac]

You are also praying that everything goes smoothly. Which can be the case with the right surgeon and the right patient, and all you'll need is a touch of sedation and/or hand-holding.

What happens if:
- local is not enough (either it doesn't work, or the surgeon has to dig through layers of fat)
- sedation is not enough, patient freaks out
- patient becomes atelectatic while supine, especially if sedated, and has trouble breathing
- some epi gets IV
- uncontrollable bleeding occurs
- surgery is prolonged, tourniquet time is prolonged, then all the crap washes into a circulation with a bad heart
Etc. Etc. Etc.

Just thinking out loud here.

As I used to tell my boss, in situations like this: If I were to bet just a few hundred bucks, I would bet on nothing really bad happening. But if I had to bet a few hundred thousands (especially with only a few hundred dollars as payout), I'd rather wouldn't bet at all.

Local not enough? Been working with this surgeon for 10yrs and haven't seen this yet.
Sedation not enough? Actually I would be an idiot if I sedated the pt more than the occasional mg of versed. I don't sedate these pt hardly.
We don't use a tourniquet. We use vessel loops. Just like a carotid.
What Epi? I know how to treat a pt that gets a small dose of Epi. Shouldn't have any lasting effect.

 

[deleted171991]

Local not enough? Been working with this surgeon for 10yrs and haven't seen this yet.
Sedation not enough? Actually I would be an idiot if I sedated the pt more than the occasional mg of versed. I don't sedate these pt hardly.
We don't use a tourniquet. We use vessel loops. Just like a carotid.
What Epi? I know how to treat a pt that gets a small dose of Epi. Shouldn't have any lasting effect.

Despite my contradicting you twice in recent days, I have a tremendous respect (even when I play the devil's advocate).

I would go to the moon for a certain surgeon. I do stuff with her that I would never do with the other dinguses. But then she would be the first to come and tell me that she can't do the surgery the way I want it (not lie, and then get into trouble); she would never put a patient at risk unnecessarily. But I have a feeling that amyl's surgeon is not the same.

Btw, I have seen what "a small dose of Epi" does when it gets into the circulation, 250/120 and 120 bpm. Either nothing or another NSTEMI might happen. In my case it was nothing, but it was an ASA 2 patient and I caught it early.

tl;dr: Almost any case can be done well with the right surgeon. But they are the exceptions, not the rule.

 

[urge]

#######= moved to npo thread


What I see every new and then is patients that had coffee with whole milk before checking in.

How long would you delay the case for a cup of coffee with whole milk? 6 hrs per guidelines? Would you even delay? How much milk is in there? Let's say it is a big case. Do you want to start a big case at 2pm? Is that better for the patient overall?

 

[fakin' the funk]

As follow up to npo thread, how often to you bend other guidelines.... For example....
A patient had a non stemi 8 days ago.... They bms'ed there rca in two places. The lcx and lad lesions were 50-60% - her symptoms were attributed to rca lesions. Post non stemi she's in renal failure. She has a catheter for dialysis but surgeon wants to do an av fistula now. She also has copd, morbid obesity, etc. guidelines say wait 6 weeks to 30 days for elective surgery.... Thoughts?

Temporary (Vascath) or tunneled HD catheter?

Not that it really matters...

Local/regional with zero to minimal sedation. Next.

 

[deleted171991]

Local/regional with zero to minimal sedation. Next.

Local/Regional fail in the middle of surgery. Ketamine, fentanyl not enough. What next? Some form of GA, and back to square one.

 

[fakin' the funk]

Local/Regional fail in the middle of surgery. What next?

Why would local fail?

 

[deleted171991]

Why would local fail?

Might not be enough. Surgeon might not be good at it. Patient might be a rapid metabolizer or might be taking a cytochrome-inducing drug. Etc. Or simply because of Murphy's law, oral boards style.

"This is not a 10 minute-surgery, and this patient had just had a heart attack. Why did you rush to do it that day, doctor?"

 

[fakin' the funk]

Might not be enough. Surgeon might not be good at it. Patient might be a rapid metabolizer or might be taking a cytochrome-inducing drug. Etc. Or simply because of Murphy's law, oral boards style.

Wankery. These settings are farfetched and of low consequence.

If you really can't do it under local/regional with zero to minimal sedation, then you abort. As per your previous agreement with the surgeon.

 

[Noyac]

"This is not a 10 minute-surgery, and this patient had just had a heart attack. Why did you rush to do it that day, doctor?"

Because the pt is in renal failure and needs further treatment today or tomorrow or in the week. The pt can't have a Vascath for dialysis for 3 months.

It's like doing a 1hr carpal tunnel.

 

[urge]

Wouldn't you guys be breaking ASRA guidelines by doing a block on a patient on dual antiplatelet therapy?

 

[Planktonmd]

Are you kidding? If I said anything about not doing them the temper tantrums and calls to admin would start.... My partners are pansies that put up with it so I have no back up.

The surgeons are the customers that the admin cares about and the quicker you reach peace with that fact the better for your career.

 

[deleted171991]

Because the pt is in renal failure and needs further treatment today or tomorrow or in the week. The pt can't have a Vascath for dialysis for 3 months.

That's true. The fistula needs time to mature.

But then the whole discussion is moot. The anesthesiologist needs a note from the nephrologist saying that the patient needs a fistula done soon, and it can't wait 4-6 weeks. Even then, every day this surgery is postponed decreases the chances of cardiac complications for the patient (which are very small with local/regional, I know).

I am beginning to develop a new line for medical students: if you are the kind of person who gets a high from playing roulette in the casino, this is the specialty for you.

 

[deleted162650]

May consider regional. No GA.

I don't really agree with this line of thinking. In my opinion it's the operation itself not the anesthetic that is "dangerous" for this guy. It's the pro-inflammatory state/stress response from the physical trauma of surgery that puts this guys myocardium and fresh stents at risk. Now I'll agree that these things are very minor and almost negligible when we're talking about an AVF. I'm just saying that poppin in an LMA and lettin this guy suck some sevo is not gonna stress his heart any more than makin him sit there and get poked in the arm with local multiple times with little to no sedation.

 

[pgg]

Wouldn't you guys be breaking ASRA guidelines by doing a block on a patient on dual antiplatelet therapy?

Yes.

But a peripheral nerve block doesn't carry the risk of catastrophic complications from a neuraxial block on DAT. Consequently, the risk/benefit assessment is different.

I think ASRA's stance on PNBs on clopidogrel is ******ed, but because of that guideline, I wouldn't do a purely elective PNB on a patient on DAT. However, for patients who have compelling reasons to get PNBs as opposed to GA+opiates, I have and will do them.

 

[deleted171991]

I don't really agree with this line of thinking. In my opinion it's the operation itself not the anesthetic that is "dangerous" for this guy. It's the pro-inflammatory state/stress response from the physical trauma of surgery that puts this guys myocardium and fresh stents at risk.

I respectfully disagree. There are multiple components to periop stress, and inflammation/surgical trauma is just one of them. Certain types of anesthesia can be a virtual stress test for a patient with a bad heart, lung and other comorbidities.

In this particular case, the main risk comes from 1. the procoagulant effect of surgery (even if the antiplatelet meds are not stopped) 2. the potential for tachycardia, hypertension and hypoxia, all destabilizers of a delicate cardiac oxygen delivery-consumption balance. Not only the BMS is far from epithelialized, but there is unhealed myocardium at risk, and a new injury will definitely not help.

Plus she must have had some serious atherosclerosis or pre-existing kidney disease for a NSTEMI to put her into end-stage renal disease. Unless it was from the contrast.

Now we can debate what the likelihood is for this particular surgery, under local/regional anesthesia, to need GA, or for the GA to turn into fun.

 

[Twiggidy]

I don't really agree with this line of thinking. In my opinion it's the operation itself not the anesthetic that is "dangerous" for this guy. It's the pro-inflammatory state/stress response from the physical trauma of surgery that puts this guys myocardium and fresh stents at risk. Now I'll agree that these things are very minor and almost negligible when we're talking about an AVF. I'm just saying that poppin in an LMA and lettin this guy suck some sevo is not gonna stress his heart any more than makin him sit there and get poked in the arm with local multiple times with little to no sedation.

This was my thinking too. I work in a place with very demanding surgeons and also with colleagues that tend to do some cases that you may cancel. If the AVF is bresciocamino (sp?) which I believe are small incisions really low in the wrist, I'd tell the surgeon that we're gonna push local as much as possible. Now granted, he's not very comfortable doing local cases (dude looked at me like I was Pookie smoking crack when I mentioned awake carotid) so I'd have the LMA handy and the neo/eph/epi sticks close to keep the pressure up and the myocardium perfusions.

He's what will get me torched on this forum.....

If I had to convert to an LMA and since I want to watch the pressure close, I might consider and A-line, but that may depend on how close he is to being finished. AVF is about 30-45 min when I work.

But that's just me and what *I* would do.

 

[napman]

1,Are we concerned that patient has recent MI (7-30 days) ? so you feel that the myocardium is irritable and is at risk of recurrent MI periop. so per guidelines we need to delay elective surgeryfor 30 days . But the surgery is time sensitive so it should be ok to proceed
2,Are we concerned that patient had a recent bare metal stent in place in which case we need to delay elective surgery for 6 weeks per guidelines. But if surgery is time sensitive and dual antiplatlets can be continued it is ok to proceed
3, Is it ok to go for a nerve block on dual atiplatlet medications. I think it is a concern with deep blocks like lumbar plexis and paravertebral blocks. Even with the deep blocks my understanding is that the risk is of bleeding rather than nerve damage.

I think in this case I would explain the patient that he/she is above the average risk for periop events and since the surgery is time sensitive it should be ok with proceeding under regional anesthesia. I do not think I will be breaking any guidelines proceeding with the surgery. I agree that type of anesthesia has nothing to do with periop risk of cardiac events

 

[deleted162650]

proceeding under regional anesthesia.

I agree that type of anesthesia has nothing to do with periop risk of cardiac events

So then why would you proceed under regional as opposed to GA?

 

[Mman]

May consider regional. No GA.

There is no good (or even bad?) evidence that type of anesthetic impacts risk of complication from coronary disease. In fact, volatile anesthetic gas is hypothetically better than not because of preconditioning in the case of ischemic heart disease. Do the case or don't, but type of anesthetic is irrelevant to that decision. How you choose to anesthetize them is up to you after you have decided to do the case.

 

[Mman]

She has a catheter for dialysis but surgeon wants to do an av fistula now. She also has copd, morbid obesity, etc. guidelines say wait 6 weeks to 30 days for elective surgery.... Thoughts?

Have cardiologist leave a note to the effect of risks of delaying surgery outweigh risks of doing it right now. Having a cath for dialysis does have some risk of things like line infections so waiting for weeks isn't completely innocuous.

 

[Mman]

I'd have the LMA handy and the neo/eph/epi sticks close to keep the pressure up and the myocardium perfusions.

I like the attention to detail, but I'd take the ephedrine and epi syringes and lock them away. Definitely don't want to increase HR and myocardial oxygen consumption in a recent MI patient if you don't have to and they'd have to be in some serious low output failure for me to reach for them.

 

[Twiggidy]

I like the attention to detail, but I'd take the ephedrine and epi syringes and lock them away. Definitely don't want to increase HR and myocardial oxygen consumption in a recent MI patient if you don't have to and they'd have to be in some serious low output failure for me to reach for them.

I usually prepare all emergency drugs....but again that's just me. I'm not saying everyone or anyone should do what I do. but you are correct in keeping that in mind

 

[seinfeld]

For a fem-pop, carotid in symptomatic patients , cancer surgery etc, perhaps I might bed the rules, But for an AV fistula probably would not unless someone can document why they dont or will not have adequate temporary dialysis access for the next 6 months.

BTW, remember that when they send patient to IR for these temporary dialysis lines, they are monitored in a very rudimentary way, are given versed/fentanyl. Its all about "what are the standards?"

The biggest problem with anesthesia in terms of guidelines is that we have become a speciality where the IVORY tower has placed any bad outcome in the basket of "never events". Our difference in NPO guideline between the ED and anesthesia is also a illustration of this. Not saying that the ED ones are correct but are patients better served with properly trained and highly skilled people or an RN with a 2 years degree? I see this debate happen all the time in ENDO when the GI doc won't wait so they put it as "un"conscience sedation with them and take us out of equation when we ask for cardiology assessment.

I don't know the correct answer but I feel too many guidelines have placed patients at harm when the work around, not having us involved, is higher risk for the patient (it does however decrease our liability risk ) . Also i am sure some Anesthesiolgist would be OK with testifying against us in court as well. Too bad the patients are not well informed enough to make the right decision.

 

[Twiggidy]

Everyone makes good points both pro and con on this thread. The real gist of this thread is how far to go to keep a surgeon (ie business) happy, because the reality is, yes, the patient had an MI and is now in renal failure. Even if there is a need for emergency dialysis, the patient has a method for dialysis via the catheter. So basically given the MI, possible antiplatelet therapy, and other co-morbidities, the patient doesn't need an elective surgery.

That's the book reality

The reality reality is that in the real world with angry surgeons, need to maintain face, hospital contracts, etc, we try to do whatever we can to keep the surgeon happy and not be shamed by our colleagues.


We all know the RIGHT answer is to no do the elective case.

 

[Gasworks]

- patient becomes atelectatic while supine, especially if sedated, and has trouble breathing

Thanks for mentioning this. There are a large number of sick patients who cant physically tolerate supine position for extended periods of time, sometimes not even 5 minutes. The way I tell it to the surgeons is simple: "laying flat will kill him". You won't be able to reason like this with an orthopod or CT surgeon, but in my experience vascular and general surgeons don't like to operate when you use words like kill, die, code, etc.

 

[napman]

Hi all, not to bump the discussion but would you do a EGD in patient with resent NSTEMI (3days) , with a stent and on dual antiplatelet therapy. Patient drops hemoglobin so GI doctor wants to rule out bleeding peptic ulcer

 

[deleted171991]

Hi all, not to bump the discussion but would you do a EGD in patient with resent NSTEMI (3days) , with a stent and on dual antiplatelet therapy. Patient drops hemoglobin so GI doctor wants to rule out bleeding peptic ulcer

If there is serious concern for ongoing severe upper GI bleed (h/o bleeding ulcer, recent hematemesis/melena, bloody nasogastric lavage etc.), yes. Otherwise please give fluids, PPIs etc., transfuse some blood if needed, and rule out lower bleed first with RBC scans.

Every invasive procedure in a sick patient is debatable while there is a non-invasive alternative available. Both for this and the OP's patient.

 

[Planktonmd]

There is no good (or even bad?) evidence that type of anesthetic impacts risk of complication from coronary disease. In fact, volatile anesthetic gas is hypothetically better than not because of preconditioning in the case of ischemic heart disease. Do the case or don't, but type of anesthetic is irrelevant to that decision. How you choose to anesthetize them is up to you after you have decided to do the case.

Over the years I have seen many ESRD patients have major complications including death during and after simple surgeries like catheter placement or fistula creation, all these who had complications were done under MAC or GA while I have never seen a complication when a nerve block was the sole anesthetic.

 

[Mman]

Over the years I have seen many ESRD patients have major complications including death during and after simple surgeries like catheter placement or fistula creation, all these who had complications were done under MAC or GA while I have never seen a complication when a nerve block was the sole anesthetic.

Then I'd suggest you don't have a big enough N with the respective groups. 30 day morbidity/mortality is equivalent.

 

[Planktonmd]

Then I'd suggest you don't have a big enough N with the respective groups. 30 day morbidity/mortality is equivalent.

I did not say anything about 30 days mortality, which probably is the same with or without the surgery in this poplulation!
I am talking about those ESRD patients who had major complications either in the OR or in PACU, those were overwhelmingly MAC and to a lesser extent GA cases.

 

[Mman]

I did not say anything about 30 days mortality, which probably is the same with or without the surgery in this poplulation!
I am talking about those ESRD patients who had major complications either in the OR or in PACU, those were overwhelmingly MAC and to a lesser extent GA cases.

There is no "major complication" that doesn't show up in 30 day morbidity/mortality IMHO.

 

[amyl]

Crazy patient won't hold still, complains of pain, goes nuts under the drapes.... This surgeon can take awhile to do these... 1.5 hours for sure but possibly more

 

[Ignatius J]

I don't really agree with this line of thinking. In my opinion it's the operation itself not the anesthetic that is "dangerous" for this guy. It's the pro-inflammatory state/stress response from the physical trauma of surgery that puts this guys myocardium and fresh stents at risk. Now I'll agree that these things are very minor and almost negligible when we're talking about an AVF. I'm just saying that poppin in an LMA and lettin this guy suck some sevo is not gonna stress his heart any more than makin him sit there and get poked in the arm with local multiple times with little to no sedation.

I don't agree that the pro-inflammatory/stress state is the same for regional as it is for GA. I'm also not going to be the a**hole who leaves a Quinton in this guy any longer than it needs to be.

 

[Mman]

I don't agree that the pro-inflammatory/stress state is the same for regional as it is for GA. I'm also not going to be the a**hole who leaves a Quinton in this guy any longer than it needs to be.

You don't agree that the tissue trauma is the same? If there was a decreased incidence of postop MI with regional for those cases, we'd have seen it already in large studies.

 

[Planktonmd]

You don't agree that the tissue trauma is the same? If there was a decreased incidence of postop MI with regional for those cases, we'd have seen it already in large studies.

Is there data comparing regional to GA on this specific subgroup (ESRD patients on dialysis undergoing minor surgery)?
I highly doubt it!

 

[Mman]

Is there data comparing regional to GA on this specific subgroup (ESRD patients on dialysis undergoing minor surgery)?

I believe so. I'm too lazy to dig it up for you, though.