New AHA/ACC Guidelines

[Intubate]

Haven't read it yet, but here it is:
http://www.acc.org/qualityandscience/clinical/guidelines/Periop_FullText_2007.pdf

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[milrisome]

Wow, it's totally different! Much simpler, but I think less useful. There are a lot less reasons to send a patient for cardiac eval. It could mean taking a lot more patients who are borderline to the OR when you might feel like they need to get evaluated.

 

[Planktonmd]

Wow, it's totally different! Much simpler, but I think less useful. There are a lot less reasons to send a patient for cardiac eval. It could mean taking a lot more patients who are borderline to the OR when you might feel like they need to get evaluated.

Isn't it sad that the ASA is not even involved in this work?
The only anesthesiologists involved are cardiac anesthesiologists who should not be considered experts on non cardiac surgery.
This guideline is nothing more than an arrogant set of nursing protocols designed to get as many patients into the OR as possible.
This type of guideline results in the type of stupid cardiology consults we get daily: " Patient has acceptable risk, proceed with caution, maintain oxygenation, hemodynamics and volume status. we will follow post op"!

 

[beezar]

I actually think this is a well-thought out, well written document based on a critical review of available evidence. And review of that evidence shows that based on previous guidelines, we likely were overtesting patients.

Does that mean these pts are not at increased risk? No, oftentimes they are. But the point is that testing, revascularization, etc. probably does not decrease their risk of surgery and may lead to delays in necessary surgical procedures, such as vascular surgery or surgery for cancer.

 

[Idiopathic]

Yeah, I think it speaks to the failure of most preoperative evaluation/testing to really affect the outcome of the intermediate risk group.

 

[Robert Loblaw]

Isn't it sad that the ASA is not even involved in this work?
The only anesthesiologists involved are cardiac anesthesiologists who should not be considered experts on non cardiac surgery.
This guideline is nothing more than an arrogant set of nursing protocols designed to get as many patients into the OR as possible.
This type of guideline results in the type of stupid cardiology consults we get daily: " Patient has acceptable risk, proceed with caution, maintain oxygenation, hemodynamics and volume status. we will follow post op"!

With due respect Dr. Plankton, the first name on the document and chairman of the committee is a non-cardiac anesthesiologist.

 

[Planktonmd]

With due respect Dr. Plankton, the first name on the document and chairman of the committee is a non-cardiac anesthesiologist.

There is no mention of the ASA in the document.

 

[BostonGas]

Isn't it sad that the ASA is not even involved in this work?
The only anesthesiologists involved are cardiac anesthesiologists who should not be considered experts on non cardiac surgery.
This guideline is nothing more than an arrogant set of nursing protocols designed to get as many patients into the OR as possible.
This type of guideline results in the type of stupid cardiology consults we get daily: " Patient has acceptable risk, proceed with caution, maintain oxygenation, hemodynamics and volume status. we will follow post op"!

The Chair of the Committee is Lee Fleisher-Do you know who he is?
He's an anesthesiologist.

Most cardiac anesthesiologists and especially vascular anesthesiologists are considered experts on perioperative CV risk in non cardiac surgical patients.

Nursing protocols? This is an attempt at evidence based recommendations for optimizing patients at cardiac risk. This at least attempts to make sense of a process that, prior to the original paper, was haphazard, dogmatic and wasteful, from medical center to medical center and even within the same institution.

If anything, since the original guidelines, I have seen less cardioligist notes saying, "avoid hypotension and trachycardia"

When the original set of guidelines came out, I had the same reaction you are currently are having. But actually reading the guidelines and keeping an open mind and having a collegial discussion with surgeons and cardiologists when a complex patients presents, I have seen their value.

Maybe you should read them.....

 

[Planktonmd]

The Chair of the Committee is Lee Fleisher-Do you know who he is?
He's an anesthesiologist.

Most cardiac anesthesiologists and especially vascular anesthesiologists are considered experts on perioperative CV risk in non cardiac surgical patients.

Nursing protocols? This is an attempt at evidence based recommendations for optimizing patients at cardiac risk. This at least attempts to make sense of a process that, prior to the original paper, was haphazard, dogmatic and wasteful, from medical center to medical center and even within the same institution.

If anything, since the original guidelines, I have seen less cardioligist notes saying, "avoid hypotension and trachycardia"

When the original set of guidelines came out, I had the same reaction you are currently are having. But actually reading the guidelines and keeping an open mind and having a collegial discussion with surgeons and cardiologists when a complex patients presents, I have seen their value.

Maybe you should read them.....

Maybe you should finish your residency, pass your boards then practice anesthesia for a few years then try to look at these protocols and tell us what you think!
and I absolutely disagree with your statement that Cardiac anesthesiologists are experts on cardiac risk for non cardiac surgery! where did you get that idea from?? Your cardiac attendings told you that?
And What is a vascular anesthesiologist??? Is this a new specialty?
Please think before posting inflamatory statements about things you don't fully understand.

 

[BostonGas]

Maybe you should finish your residency, pass your boards then practice anesthesia for a few years then try to look at these protocols and tell us what you think!
and I absolutetly disagree with your statement that Cardiac anesthesiologists are experts on cardiac risk for non cardiac surgery! where did you get that idea from?? QUOTE]

Actually I have done all the things described in your first sentence.
I got the idea that cardiac anesthesiologists can have an expertise in peri-op cardiac risk assessment of non cardiac surgical patients by my current and past colleagues who are national experts in the field who happen to be both cardiac and vascular anesthesiologists. This is also based on current research we are involved with looking at risk.

Also, this is a guideline, not a protocol.

 

[Planktonmd]

Maybe you should finish your residency, pass your boards then practice anesthesia for a few years then try to look at these protocols and tell us what you think!
and I absolutetly disagree with your statement that Cardiac anesthesiologists are experts on cardiac risk for non cardiac surgery! where did you get that idea from?? QUOTE]

Actually I have done all the things described in your first sentence.
I got the idea that cardiac anesthesiologists can have an expertise in peri-op cardiac risk assessment of non cardiac surgical patients by my current and past colleagues who are national experts in the field who happen to be both cardiac and vascular anesthesiologists. This is also based on current research we are involved with looking at risk.

Also, this is a guideline, not a protocol.

What field? and who gave your friends the title of national experts?
You keep saying vascular anesthesiologists, when did we start having vascular anesthesiologits? did you just make it up?
I just don't understand how someone can be an expert on somethimg they don't practice!
if all you do is cardiac anesthesia how are you going to be an expert on non cardiac surgery?? It's a totally different game!
For these statement that you just made I can't believe that you are anything more than a CA2 resident at best trying to be someone you are not.

 

[BostonGas]

What field? and who gave your friends the title of national experts?
You keep saying vascular anesthesiologists, when did we start having vascular anesthesiologits? did you just make it up?
I just don't understand how someone can be an expert on somethimg they don't practice!
if all you do is cardiac anesthesia how are you going to be an expert on non cardiac surgery?? It's a totally different game!
For these statement that you just made I can't believe that you are anything more than a CA2 resident at best trying to be someone you are not.

We have a division of vascular anesthesia. You seem to be locked in on the fact that cardiac anesthesiologist do no other types of cases. Maybe this is all you know from your experiences.

Because you don't agree with the guidelines doesn't mean that I come off as a CA-2. Others here seem to think they have value.

As far as national experts here is one, I can link to many more articles or refer to the editorial boards they are on or have been on

http://216.109.125.130/search/cache...park+anesthesia&d=eLQ7xedmPbIT&icp=1&.intl=us

 

[Planktonmd]

We have a division of vascular anesthesia. You seem to be locked in on the fact that cardiac anesthesiologist do no other types of cases. Maybe this is all you know from your experiences.

Because you don't agree with the guidelines doesn't mean that I come off as a CA-2. Others here seem to think they have value.

As far as national experts here is one, I can link to many more articles or refer to the editorial boards they are on or have been on

http://216.109.125.130/search/cache...park+anesthesia&d=eLQ7xedmPbIT&icp=1&.intl=us

Again,
With experience you will start viewing things differently and eventually you will realize that you don't need this type of protocol that you call a guideline
because you are a physician and you have judgement and experience that allows you to decide what's best for the patient.
The recommendations in these protocols are very basic and most of them are
common sense. The only problem is that patients can not and should not be standarized, and by creating these protocols " guidelines", people with concrete thinking, like you and your national experts, will start standarizing patients and forget that you need first to use your skills and be a doctor.

 

[BostonGas]

Guidelines do not replace clinical judgement or common sense, they serve as another tool physicians have to use. When the ASA Monitoring Standards came out years ago, there were many anesthesiologists who felt that their clinical judgement was better than a monitor or protocol and didn't need anyone telling them how to practice. They knew when the patient was desaturating by the color of the blood in the field and didn't need a pulse ox. They always knew that their tube was in the right hole and never needed a capnograph. These standards have helped to make anesthesia extremely safe as witnessed by the plummeting malpratice rates over the last 20 years. Does anyone still feel these standards should not be used or be subjugated by clinical judgement?

Now the ACC/AHA document is just a guideline to be used as a tool which doesn't carry the same weight as a protocol, or (especially) a standard. (There is a huge difference between the two, which you have difficulty distinguishing, ) It gives anesthesiologists, cardiologists and surgeons a common language to speak and it tries to base recommendations on evidence. As more studies come along, the recommendations may need to be amended like they were in this current release. It makes people think about why they order tests and what additional data they are trying to obtain, and what they will do with that information. It may help reduce waste and decrease the risk to patients by unecessary testing.

When the original guidelines came out in 2002, I too felt that anesthesiologists should not be expected to follow a recipe that was concocted by cardiologists. Over time my opinion changed and realized that they provide added value. Dr. Fleischer gives them credibility within our field. I am sure that when the ASA Monitoring Standards first came out there were many who resisted change or being told what to do. Over time most amended their practice; those who did not are probably live somewhere near you and are playing shuffleboard.

If you are trying to be offensive by saying anyone who sees value in guidelines is a concrete thinker, so be it. Using guidelines and showing clinical judgement are not mutually exclusive. Critical care has become intensely protocol driven also.

 

[Planktonmd]

You are comparing apples and oranges:
The ASA standards for monitoring were born from within the specialty and intimately related to the daily practice of anesthesiology.
Your guidelines were written by cardiologists with the main goal being to facilitate the job of the consultant in pushing as many patients to the OR as possible.
Pre operative guidelines should not be the domain of internists who have never visited the OR.
Anyway, obviously you are at a stage of your career where it's better for you and your patients that you follow some written protocol and I can't discourage that.

 

[BostonGas]

Your guidelines were written by cardiologists with the main goal being to facilitate the job of the consultant in pushing as many patients to the OR as possible.
.

Lee Fleischer-Chair

 

[VentdependenT]

Thanks for the post!

 

[Idiopathic]

Anyway, obviously you are at a stage of your career where it's better for you and your patients that you follow some written protocol and I can't discourage that.

Pathetic.

 

[Heeed!]

Wow. Nice match we have going here.

 

[jd1572]

Lee Fleisher is the chairman of the Department of Anesthesiology and Critical Care at the University of Pennsylvania.

 

[Idiopathic]

I think weve established who Dr. Fleisher is. Thats not the argument at this point.

 

[Planktonmd]

Lee Fleisher is the chairman of the Department of Anesthesiology and Critical Care at the University of Pennsylvania.

He is not officially representing anesthesiologists or the ASA and actually his name is followed by: FAHA and FACC without any reference to his specialty.
So, he could be the guy who invented anesthesia, still on this document he does not represent us.

 

[Intubate]

Just to stir the pot a bit (I still haven't read the whole document)...

Plankton, you keep saying how the recommendations are worthless protocols (for nurses?) and you go on about experience being so important (I don't disagree), etc. Of course medicine in general, and anesthesia especially, are not exact sciences where we can predict the future reliably, and guidelines are just a guide, but you have to use scientific method and evidence to guide your practice in some way. Presumably you refer to the same literature used by the authors of this document to guide your own practice. Is it guidelines in general, or just the aha/acc guidelines that you don't like? If you want to see some really bad guidelines, look at the ASA guidelines, on OSA for example... no guidance whatsoever there, just the admission that we don't know what to do.

 

[Planktonmd]

Just to stir the pot a bit (I still haven't read the whole document)...

Plankton, you keep saying how the recommendations are worthless protocols (for nurses?) and you go on about experience being so important (I don't disagree), etc. Of course medicine in general, and anesthesia especially, are not exact sciences where we can predict the future reliably, and guidelines are just a guide, but you have to use scientific method and evidence to guide your practice in some way. Presumably you refer to the same literature used by the authors of this document to guide your own practice. Is it guidelines in general, or just the aha/acc guidelines that you don't like? If you want to see some really bad guidelines, look at the ASA guidelines, on OSA for example... no guidance whatsoever there, just the admission that we don't know what to do.

My point is:
Pre operative evaluation is an essential part of peri-operative medicine that we claim to practice. So, it doesn't make sense to have the guidelines dictated by Cardiologists without any official input from practicing anesthesiologists and the ASA.
These guidelines might be just a tool as you mentioned but remember they will be considered the standard of care by insurance companies, surgeons and administrators. So if you order a test that seems unjustified according to these guidelines your patient might have to pay cash for it.
Also, If you decide that it's not safe to anesthetize a patient although the guideline is saying "go to the OR", then the surgeon and administration will accuse you of ignoring the guideline.
I am not against guidelines and protocols and agree with you that many ASA guidelines are worthless, but a preoperative guideline created by another specialty to dictate the way we practice is not acceptable.

 

[brmc]

So you have nothing against guidlines in principal just the authors of these guidline in particular?

 

[Planktonmd]

So you have nothing against guidlines in principal just the authors of these guidline in particular?

No,
That's not what I said.
They can write what ever they want but it doesn't make sense to have pre-operative evaluation guidelines established without the input from the main peri-operative Providers (Anesthesiologists), because the result would be guidelines that ignore imprortant elements that may be invisible to other specialties, specifically when it comes to assigning a degree of risk to certain surgeries without considering specific patient and anesthetic factors and ignoring postoperative pain as a crucial contributant to the overall morbidity and mortality.
To put it in simple words: A surgery that might be considered low risk by a cardiologist could be seen as high risk by an Anesthesiologist in certain patients and under certain conditions.