KevinMD: Are preoperative consultations worthless?

[Carbocation1]

http://www.kevinmd.com/blog/2015/06/are-preoperative-consultations-worthless.html

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[Carbocation1]

• 
  PracticeBalance • 32 minutes ago
  Preoperative consults should be performed by anesthesiologists, who are the true decision makers on the day of surgery regarding whether the patient is optimized or not.

• Dr. Drake Ramoray • 3 hours ago
  Obtaining pre-operative consultations (much like radiologists hedging on reports in another thread) seek to diffuse the responsibility of the the provider requesting the consult/test should there be future litigation. In that sense, they are not worthless. Are they often wasteful, inefficient, probably not required sure, but they always achieve the diffusion of responsibility for a potential bad outcome.
  
  As a student if you find yourself as a specialist performing a pre-operative consult or surgical clearance never use those words. The patient is very low risk, low risk, moderate risk, high risk, or very high risk for a procedure. Never take the bait and say a patient is cleared for surgery.
  
  Physician bias.... again no mention of the concern for litigation and defensive medicine.
  
  Bundled paykments...... Will encourage doctors not to accept/treat the most complicated cases.
  
  "Risk stratify.. : "Use AHA guidelines/algorithm to assess low-risk patients......" Following guidelines won't protect you from malpractice.
  
  http://www.kevinmd.com/blog/20...
  
  Look a the pre-operative consult through the lens of defensive medicine and the eyes of a prosecuting attorney and you will understand the prevalence of preoperative consults and it will all start to make sense (this should not be confused with endorsing a practice).

 

[BLADEMDA]

When I order a preop consult it is to answer a specific question:

1. EF? Any Stenosis or Regurgitation? Medically optimized?
2. If mets less than 4 and major surgery I want a stress test or cath
3. Pulmonary disease? PFTs prior to major surgery or lung resection. Medically optimized?
4. AICD with pacer function. EF? Underlying cardiac rhthym? Turn off AICD and reprogram pacer.
5. DM? Hgba1c of 11? Can we do better prior to the CABG or VAT?
6. Severe HTN? Please treat prior to surgery.

I am no martyr. I want to diffuse malpractice risk on these ASA4 patients as much as the next guy because an adverse event or postop complication could be lethal to the patient.

I ask specific questions because I want specific answers.

 

[deleted682700]

Unless the liability is changed, it doesn't matter what it costs, because I would not want to be defending alone as the previous post has pointed.
Financial incentive ! the greedy surgeon would want all of the bundled payment and would point to the anesthesiologist to take all the liability and the fall guy when problems happen. I will be happy when the single payers become a reality because these good for nothing surgeons are going to loose more.
Spending time preop is very valuable , spent an hr on a sick esrd with chef, htn,dm, now for craniotomy for biopsy of suspected tumor ? Talked with the chief of anesthesiology about the case 10 min. Talked to a relative on the phone -10 minutes
Preop instructions
Stop tube feeds at midnite
Dialysis early in morn
Lyres, CBC, pt, ptt after the dialysis and want the results in the chart.
What did I get paid? Zero.
But the satisfaction and relief of knowing what I am going to get into the next day-priceless

 

[Noyac]

I believe the vast majority of pre-op clearance visits are arranged so that the surgeon doesn't have his case cancelled on the day of surgery.

 

[psychbender]

I wouldn't mind preop visits with the PCP or other specialist if they actually did what they were supposed to do, namely get me the information that I need to make the decisions regarding how to appropriately manage the patient perioperatively. I deal with a lot of VA patients, and get a lot of notes that are a jumble of tests with no good indication, and a one-liner that says 'cleared for surgery' that the surgeon then waves about as a defense when we start asking questions about the patients' history (because none of it is in the chart). Recently, I was reading a patient's notes, and saw in the reason for consult that "Anesthesia at XX will reject the patient without this clearance." This, then, prompted a delay, as the PCP did not feel comfortable 'clearing' a patient with CKD3 and HTN, and arranged an appointment with a Cardiologist, who did another ECG (one already in the chart from the month before) and ordered a stress test (guy had good functional capacity, only limited slightly by knee pain) delaying his knee replacement by weeks. I keep trying to talk to this particular surgeon, and tell him that we do not need CXRs, ECGs, a full slew of labs on every person that comes to the OR, and that if he has any questions to please talk to me preop, but he refuses to listen, telling me that if he doesn't get all of those tests, then someone might cancel because it wasn't done.

 

[Urzuz]

...but he refuses to listen, telling me that if he doesn't get all of those tests, then someone might cancel because it wasn't done.

To be fair, there are quite a few anesthesiologists out there who are living in the dark ages and will demand these tests even on patients who don't require them. Whether it's because they are trying to appease the lawyers or they actually feel like it allows them to deliver a safer anesthetic, I'm not sure.

 

[psychbender]

That is true, but he's been at my hospital for years now, and none of the anesthesiologists are that bad (one or two are very conservative, but not that stuck in the Dark Ages). We have a few CRNAs that have practiced since the 1980s that think like that, but they don't get to make periop decisions (they just complain when told to do the case).

 

[aneftp]

The real issue is if the primary care wants say a stress test on a patient before proceeding. (Say elective carotid surgery).

You (anesthesiologist) say patient had normal stress test 15 months ago. No symptoms. No new changes. (We all know some patients aren't best historian).

Anyways. Patient has MI 24 hours after surgery.

So you got on chart primary care says wait for new stress test.

But you proceed.

It's all fine and dandy if nothing happens.

But if there is a periop event like Mi.

You the anesthesiologist will be screwed and thrown under the bus. Lawyers will point out primary care wanted new stress echo despite normal stress echo 15 months ago.

Lawyer says it elective carotid (patient curently without symptoms). Surgeon will throw you under the bus as well

What are you going to do in that case?

This is a real case that happened last year by the way and they may settle it for $200k by the way.

 

[Arch Guillotti]

When I order a preop consult it is to answer a specific question:

1. EF? Any Stenosis or Regurgitation? Medically optimized?
Why do you need a consult to tell you the EF or to describe valvular abnormalities? Order the echo yourself.
2. If mets less than 4 and major surgery I want a stress test or cath
What do you consider major? Lots of patients have mets less than 4 and hardly any get a cath or stress test.
3. Pulmonary disease? PFTs prior to major surgery or lung resection. Medically optimized?
I thought PFT's were largely useless.
4. AICD with pacer function. EF? Underlying cardiac rhthym? Turn off AICD and reprogram pacer.
This shouldn't require a consult, just a brief note. I almost never turn off an AICD or have a pacer reprogrammed.
5. DM? Hgba1c of 11? Can we do better prior to the CABG or VAT?
This is reasonable. Are you checking the AIC?
6. Severe HTN? Please treat prior to surgery.
Agree.

I am no martyr. I want to diffuse malpractice risk on these ASA4 patients as much as the next guy because an adverse event or postop complication could be lethal to the patient.

I ask specific questions because I want specific answers.

 

[nimbus]

The real issue is if the primary care wants say a stress test on a patient before proceeding. (Say elective carotid surgery).

You (anesthesiologist) say patient had normal stress test 15 months ago. No symptoms. No new changes. (We all know some patients aren't best historian).

Anyways. Patient has MI 24 hours after surgery.

So you got on chart primary care says wait for new stress test.

But you proceed.

It's all fine and dandy if nothing happens.

But if there is a periop event like Mi.

You the anesthesiologist will be screwed and thrown under the bus. Lawyers will point out primary care wanted new stress echo despite normal stress echo 15 months ago.

Lawyer says it elective carotid (patient curently without symptoms). Surgeon will throw you under the bus as well

What are you going to do in that case?

This is a real case that happened last year by the way and they may settle it for $200k by the way.

Repeat stress echo was not indicated. But I would not have proceeded with that note in the chart. How did that patient even get scheduled for surgery and present to the operating room with a pcp note like that?

 

[Hernandez]

pfts

Essentially useless.....unless you're planning on removing part of the lung. A functional status evaluation such as a 6MW has more utility.

 

[BLADEMDA]

Ever had a patient die on you perioperatively with less than 4 mets? Once that happens to you I firmly believe your view on this matter will change. In my practice I've seen it twice undergoing intermediate surgery.

 

[BLADEMDA]

 

[BLADEMDA]

Patients with clinical risk factors need careful assessment, weighed together with functional capacity and procedural risk, to decide on the need for noninvasive cardiac stress testing:

• For patients with three or more clinical risk factors and poor (<4 metabolic equivalents) or unknown functional capacity, who require vascular surgery (emergency aortic and other major vascular surgery), it is reasonable to perform noninvasive stress testing if it will change management (class IIa).
• For patients with at least one clinical risk factor and poor or unknown functional capacity, who require intermediate-risk or vascular surgery, noninvasive stress testing may be considered if it will change management (class IIb).
• Noninvasive testing is not useful for patients with no clinical risk factors undergoing intermediate-risk noncardiac surgery (class III).
• Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (class III).

http://www.clevelandclinicmeded.com...tification-for-noncardiac-surgery/Default.htm

The mortality rate of patients with perioperative MI is substantial, ranging from 30% to 50%.

 

[deleted171991]

The real issue is if the primary care wants say a stress test on a patient before proceeding. (Say elective carotid surgery).

You (anesthesiologist) say patient had normal stress test 15 months ago. No symptoms. No new changes. (We all know some patients aren't best historian).

Anyways. Patient has MI 24 hours after surgery.

So you got on chart primary care says wait for new stress test.

But you proceed.

It's all fine and dandy if nothing happens.

But if there is a periop event like Mi.

You the anesthesiologist will be screwed and thrown under the bus. Lawyers will point out primary care wanted new stress echo despite normal stress echo 15 months ago.

Lawyer says it elective carotid (patient curently without symptoms). Surgeon will throw you under the bus as well

What are you going to do in that case?

Happened to me more than once. Every time I see a cardiologist or PCP wanting any further significant work up, the elective surgery is cancelled. I don't care if the patients have 12 METS. Same goes for undiagnosed/untreated way abnormal stuff, such as a TSH of 25. Even when the risks are truly small, nobody truly appreciates if I put myself and my family at risk, so why would I?

Surgeons will lie if needed, for CYA purposes, including in their notes. Not only that, but the OR staff might be afraid to take the anesthesiologist's side, for fear of repercussions. Look out for yourself, because nobody else does.

 

[BLADEMDA]

American Heart Journal
Preoperative Pulmonary Function and Mortality after Cardiac Surgery
A. Selcuk Adabag, MD, MS; Heba S. Wassif, MD, MPH; Kathryn Rice, MD; Salima Mithani, MD; Deborah Johnson, RN; Jana Bonawitz-Conlin, BSN, MSH; Herbert B. Ward, MD, PhD; Edward O. McFalls, MD, PhD; Michael A. Kuskowski, PhD; Rosemary F. Kelly, MD

Abstract and Introduction
Abstract
Background The aim of the study was to examine the relationship between preoperative pulmonary function and outcomes after cardiac surgery.
Methods We performed preoperative pulmonary function tests (PFTs) in 1,169 patients undergoing cardiac surgery at the Minneapolis Veterans Affairs Medical Center. Airway obstruction was defined as forced expiratory volume in 1 minute (FEV1) to forced vital capacity ratio <0.7.
Results Of the 1,169 patients, 483 (41%) had a prior history of chronic obstructive pulmonary disease (COPD). However, 178 patients with a history of COPD had no airway obstruction on PFT. Conversely, 186 patients without a COPD history had airway obstruction on PFT. Thus, PFT results helped reclassify the COPD status of 364 patients (31%). Operative mortality was 2% in patients with no or mild airway obstruction versus 6.7% in those with moderate or severe obstruction (ie, FEV1 to forced vital capacity ratio <0.7 and FEV1 <80% predicted). Postoperative mortality was higher (odds ratio 3.2, 95% CI 1.6–6.2, P = .001) in patients with moderate or severe airway obstruction and in patients with diffusing capacity of the lung for carbon monoxide <50% of predicted (odds ratio 4.9, 95% CI 2.3–10.8, P = .0001). Notably, mortality risk was 10× higher (95% CI 3.4–27.2, P = .0001) in patients with moderate or severe airway obstruction and diffusing capacity of the lung for carbon monoxide <50% of predicted.
Conclusions These data show that PFT before cardiac surgery reclassifies the COPD status of a substantial number of patients and provides important prognostic information that the current risk estimate models do not capture.

 

[BLADEMDA]

https://www.openanesthesia.org/pulmonary_risk_anesthesia_text/

The link above is worth a quick read. I don't order PFTs in isolation but rather to find out if Bronchodilators or Steroids can help optimize perioperative care of the severe asthmatic or COPD patient.


COPD is clearly a risk [Smetana NEJM 340: 937, 1999] and these patients should be treated aggressively preoperatively if possible. The data on actual treatment are limited but it is possible that bronchodilators, PT, antibiotics, smoking cessation, and corticosteroids may reduce risk in this population. Asthmatics in particular have a higher incidence of bronchospasm [Warner Anesthesiolgoy 85: 460, 1996]

 

[BLADEMDA]

Proposed Pacer/AICD Algorithm 1. Determine device indication, including the patient’s underlying rhythm 2. Acquire magnet, pacing pads, atropine, and isoproteronol 3. Interrogate (model, setting). If voltage < 2.6 V or impedance > 3000, consult the manufacturer re: possibly needing to replace before surgery. An ICD with a charging time > 12 s may need a battery change 4. Turn off all ICD functions (using pacing pads and EKG instead) 5. Turn of all rate enhancements 6. Turn off minute ventilation rate responsiveness 7. Consider increasing the pacing rate (in the past, asynchronous modes were recommended, but now that many pacemakers have bipolar leads, and the risk of EMI is lower [depending on the surgery], availability of a magnet usually will suffice) 8. Determine magnet function 9. Defib pads on all ICD patients 10. Intraoperatively: arterial line, strategic ground placement, bipolar if possible, disable the “artifact filter” on the EKG

https://www.openanesthesia.org/aicds/


Okay Slim, Here is Example of what I see in my practice:

75 year old male presents for a Lap. Cholecystectomy and has an AICD with pacer function.
He is PACED at a rate of 80 on his EKG. AICD has only gone off once in the past 3 years. Surgeon failed to get EP/Cardiology to see him prior to surgery.

What's your plan? Place a Magnet on him and proceed?

 

[aneftp]

Repeat stress echo was not indicated. But I would not have proceeded with that note in the chart. How did that patient even get scheduled for surgery and present to the operating room with a pcp note like that?

Happens a lot at my place in private practice.

No. It wasn't a "scheduled case" we could look at chart 1-2 days in advance (which we usually do).

Sometimes it's a bang bang thing. Patient has Doppler/mri/mra carotid whatever say on a Wednesday morning. Surgeon discuss with patient Wednesday afternoon. OR schedule already made by 2pm Wednesday.

Thursday morning there is already an add on list of cases and cartoid case shows on schedule.

We don't have control over that.

The minute primary care doc documents they want another stress echo before proceeding. All
Bets are off.

You are right. If no primary care note, I would have proceeded. But once primary care wanted further testing. We (anesthesia) must assume defensive/conservative position and postpone case.

 

[caligas]

Proposed Pacer/AICD Algorithm 1. Determine device indication, including the patient’s underlying rhythm 2. Acquire magnet, pacing pads, atropine, and isoproteronol 3. Interrogate (model, setting). If voltage < 2.6 V or impedance > 3000, consult the manufacturer re: possibly needing to replace before surgery. An ICD with a charging time > 12 s may need a battery change 4. Turn off all ICD functions (using pacing pads and EKG instead) 5. Turn of all rate enhancements 6. Turn off minute ventilation rate responsiveness 7. Consider increasing the pacing rate (in the past, asynchronous modes were recommended, but now that many pacemakers have bipolar leads, and the risk of EMI is lower [depending on the surgery], availability of a magnet usually will suffice) 8. Determine magnet function 9. Defib pads on all ICD patients 10. Intraoperatively: arterial line, strategic ground placement, bipolar if possible, disable the “artifact filter” on the EKG

https://www.openanesthesia.org/aicds/


Okay Slim, Here is Example of what I see in my practice:

75 year old male presents for a Lap. Cholecystectomy and has an AICD with pacer function.
He is PACED at a rate of 80 on his EKG. AICD has only gone off once in the past 3 years. Surgeon failed to get EP/Cardiology to see him prior to surgery.

What's your plan? Place a Magnet on him and proceed?

Magnet is good idea to prevent inadvertant discharge. Still needs device checked and placed in asynchronous mode, as he is pacer dependant and magnet wont affect pacing function.

 

[deleted171991]

Magnet is good idea to prevent inadvertant discharge. Still needs device checked and placed in asynchronous mode, as he is pacer dependant and magnet wont affect pacing function.

Magnet on AICD = unpredictable response. It should not be the main plan for an elective surgery, unless recommended by the patient's electrophysiologist (any cardiologist is not enough). Many times the latter does not have an intimate knowledge of the current programming.

 

[Hernandez]

https://www.openanesthesia.org/pulmonary_risk_anesthesia_text/

The link above is worth a quick read. I don't order PFTs in isolation but rather to find out if Bronchodilators or Steroids can help optimize perioperative care of the severe asthmatic or COPD patient.


COPD is clearly a risk [Smetana NEJM 340: 937, 1999] and these patients should be treated aggressively preoperatively if possible. The data on actual treatment are limited but it is possible that bronchodilators, PT, antibiotics, smoking cessation, and corticosteroids may reduce risk in this population. Asthmatics in particular have a higher incidence of bronchospasm [Warner Anesthesiolgoy 85: 460, 1996]

For clarification, I'm a Pulmonologist not anesthesiologist, and I said essentially worthless, you can find data arguing that knowing a FEV1 will help risk stratify but at the end of the day, the patient either needs the surgery or they don't. But even FEV1 has limitations and does not tell you much about how their copd behaves, ive got a few with fev1s in the teens that have far less issues than the phenotype of normal fev1 with awful radiographic emphysema. There is actually emerging data that the phenotype with a normal fev1 and bad radiographic emphysema do worse, anecdotally this is likely accurate, I had 2 die within a year of meeting them and both had FEV1s of greater than 90%.

Bronchodilator response on a PFT is worthless for predicting steroid responsiveness or long term bronchodilator response on spirmetric function.

Now that being said, when someone sends me a pt for pre-op eval, I will order a PFT, more to clarify their disease state and often this will be the only time I see the pt and like your study states, so many are misclassified. I've seen people labled steroid dependent copd who do not have copd.

 

[BLADEMDA]

Postoperative mortality was higher (odds ratio 3.2, 95% CI 1.6–6.2, P = .001) in patients with moderate or severe airway obstruction and in patients with diffusing capacity of the lung for carbon monoxide <50% of predicted (odds ratio 4.9, 95% CI 2.3–10.8, P = .0001). Notably, mortality risk was 10× higher (95% CI 3.4–27.2, P = .0001) in patients with moderate or severe airway obstruction and diffusing capacity of the lung for carbon monoxide <50% of predicted.

 

[Hernandez]

Postoperative mortality was higher (odds ratio 3.2, 95% CI 1.6–6.2, P = .001) in patients with moderate or severe airway obstruction and in patients with diffusing capacity of the lung for carbon monoxide <50% of predicted (odds ratio 4.9, 95% CI 2.3–10.8, P = .0001). Notably, mortality risk was 10× higher (95% CI 3.4–27.2, P = .0001) in patients with moderate or severe airway obstruction and diffusing capacity of the lung for carbon monoxide <50% of predicted.

I'm well aware of the data, and yet they either still need the surgery or they don't and not a damn thing can be done to change the post-op risk.

 

[BLADEMDA]

I'm well aware of the data, and yet they either still need the surgery or they don't and not a damn thing can be done to change the post-op risk.

Regional Anesthetic for some cases may mitigate the risk. Many patients prefer "General anesthesia" but with the data on their Airway Obstruction and Diffusing Capacity an informed decision can be made about the risk/benefits. Many surgeries are elective in nature so patients and family members deserve to know they are at increased risk of morbidity/mortality prior to the procedure.

 

[Hernandez]

I should have added the qualifier medically, I also don't like to dictate to another physician how to do their job and don't comment on different anesthesia techniques. but I'm with you, I will bluntly tell my bad copd pts unless it's absolutely necessary surgery, they should consider not proceeding.

 

[jdh71]

I should have added the qualifier medically, I also don't like to dictate to another physician how to do their job and don't comment on different anesthesia techniques. but I'm with you, I will bluntly tell my bad copd pts unless it's absolutely necessary surgery, they should consider not proceeding.

My consults usually make a statement about risk stratification (low, moderate, and high), point out that there is no absolute contraindications to non-lung surgery in lungers usually with a throw away line about "consider the risk versus benefit" unless I'm personally adamant about the surgery (and I almost never am), recommend consideration for regional sedation if appropriate per the anesthesiologist, recommend pulmonary meds post op, cpap if also osa, pulmonary toilet, and early ambulatiom if possible.

It's basically "I can't fix what broke here but if you all want to poke the skunk, good luck, and do the stuff you all know you should do anyway"

Like most folks I "clear" no one. I'm not doing the procedure nor running the anesthesia.

 

[fakin' the funk]

In the interest of day-of-surgery efficiency, a preop H&P by the physician who knows the patient best (PCP or otherwise) with:
- problem list
- current symptoms, if any
- current medications
- functional status (4 METs without symptoms or not, and if not, a reasonable hypothesis why not)

WOULD BE FREAKING AWESOME.

Most preop "clearances" are severely lacking in at least one of these areas. A lot of times you get the 13-system negative ROS and a 40-point problem list, and that's it, which while thorough, is TL;DR.

 

[Arch Guillotti]

Ever had a patient die on you perioperatively with less than 4 mets? Once that happens to you I firmly believe your view on this matter will change. In my practice I've seen it twice undergoing intermediate surgery.

Why did the patients die?