What kind of physician are you?

[urge]

The kind that needs to treat every abnormal value/situation or the kind that thinks it is almost normal so let it be?

Treat or no?:

iCa 1.05
K 3.6
Bis of 65 with mild emg activity
Glucose 180
Paroxysmal a fib intra op, give amiodarone?
Ef 40%, start inotrope?
Post cpb platelet count 80, INR 2.1
Cardiac index 1.9

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[GeorgiaAnes]

The kind that needs to treat every abnormal value/situation or the kind that thinks it is almost normal so let it be?

Treat or no?:

iCa 1.05 If we are coming off CPB and there is hypotension or the ECHO looks hypokinetic, I would tx with an amp of calcium ... otherwise no
K 3.6 No
Bis of 65 with mild emg activity At this point no ... I do not use the BIS but some of our anesthetists do. When I was a resident, one attending always wanted us to use it. If VSS, I might increase the gas a touch but otherwise I'd leave it be.
Glucose 180 No unless we are doing a heart, they prefer tight control and an insulin drip would be started
Paroxysmal a fib intra op, give amiodarone? No, rate control ... zap it if becomes unstable
Ef 40%, start inotrope? No unless it is a heart, in which case these type of patient's we would start milrinone
Post cpb platelet count 80, INR 2.1 No unless the surgeon is complaining that the patient seems oozy
Cardiac index 1.9If VSS stable, then no. If not stable, then depends on the entire picture (what does the ECHO show, hypotensive, tachycardic, etc)

 

[pgg]

On first glance, that's a whole lotta "meh" but context might make me care about some of those, some of the time. I'd need a more specific question to give a more specific answer.

 

[psychbender]

As GeaorgiaAnes indicated, it depends on the actual clinical situation.

iCa 1.05

If this was on my initial gas prior to coming off bypass, I'd treat. If I was transfusing a patient, and expected to continue to transfuse, I'd treat. If this was a regular gas checked on a patient on during a relatively routine case, and there are no hemodynamic derangements, probably not.

K 3.6

Most likely not. However, if I'm giving a bunch of insulin, and the trend is worsening hypokalemia, then yes. If the patient is starting to have hemodynamically significant arrhythmias, yes.

Bis of 65 with mild emg activity

I almost never use the BIS. But, if my end-tidal gas is adequate, I can see EMG activity/have twitches, or I recently gave ketamine, I would not do anything. If I'm doing a TIVA with muscle relaxation, and for some reason decided to put a BIS on, I might give more vec (if no EMG activity was part of my plan), and only increase the propofol rate if the BIS remains persistently elevated, vitals indicate that the patient may be getting light, and I have no other explanation for the elevated BIS (I usually give ketamine in my TIVAs, so have noticed the BIS run a little higher).

Glucose 180

Most likely not, unless the trend is showing that the glucose is steadily increasing, or special situations like being on bypass or pts with head trauma.

Paroxysmal a fib intra op, give amiodarone?

If no effect on BP, no. If some mild effect, rapid, or I have a particular reason to want to avoid a-fib (aortic stenosis), then I'd rate control, and possibly try to convert (electrically, in the case of AS).

Ef 40%, start inotrope?

If this was a depressed EF coming off bypass, then probably. Otherwise, plenty of people walk around with EF 40% at baseline, I'm not starting epi just because they're now in front of me having their knee scoped.

Post cpb platelet count 80, INR 2.1

If not clinically bleeding, then no. I'd reverse the heparin, and give various products based on the clinical bleeding, and what diagnostic tools are available. If this was a particularly long pump run, pt with AS, and some other test shows decreased platelet function, then yes.

Cardiac index 1.9

See the EF 40% answer.

 

[Noyac]

I like to think of myself as a minimalist.

 

[Consigliere]

The kind that ignores threads like these.

 

[deleted162650]

I like to think of myself as a minimalist.

That's what she said.



Sorry, I really tried, but I just couldn't let that one go.

 

[urge]

I like to think of myself as a minimalist.

So do I.

I find it awkward handing off between anesthesiologists of different styles. When I take over cases from people who start every drip on low dose I wonder what the heck they were thinking. I spend the next 30 min or more weaning off drips and taking down pumps.

I'm sure it's the other way around when I get relieved. The 2nd anesthesiologist must be like "WTF! I'm going to need like 10 pumps. This case is so mismanaged!" I'm sure they spend more than half an hour hanging drips.

Same thing happens with ICU attendings. A good number of them are not happy unless they see a bunch of drips going and the pt goes into afib, so they can start the amio drip and feel good about themselves. "I'm such a good intensivist!"

The good ICU attendings take down drips ( I might be a little biased).

Hand off between 2 minimalists is a thing of beauty. "Take the tube out. See you tomorrow Fred."

 

[urge]

The kind that ignores threads like these.

Thread sounded better in my head after 18hrs straight in a room.

 

[Noyac]

removed

 

[GatorBait1548]

Wow, some of this thread is crazy talk where I have trained....

 

[Mman]

Exactly!
Twice now in the last month I walked into the room of a partner that is double boarded in IM and Anesthesiawho dropped a TEE in on a totally healthy pt. The first case was a D&C on a 20ish yo female with a BP 70/30 on induction. WTF? She's dry but has a strong heart and you just gave her a **** ton of propofol.

And her baseline BP is probably 90/50 so it's barely beyond 20% below baseline. Give 100 mcg of phenylephrine and suggest the surgeon get on with the case.

I can't stand it when people get all crazy about treating things that are borderline normal and aren't causing a problem. The potassium is 3.6? Have some succinylcholine and it will be just fine. EF 40%? Oh well, at least it's not <15%, pay attention and maybe give a dose of ephedrine if they seem to need a small temporary boost.

In general every intervention we make has a risk with it. I'd just as soon not do much of anything unless required. People get way too worked up about small stuff and forget to pay attention to the big stuff.

 

[urge]

Exactly!
Twice now in the last month I walked into the room of a partner that is double boarded in IM and Anesthesiawho dropped a TEE in on a totally healthy pt. The first case was a D&C on a 20ish yo female with a BP 70/30 on induction. WTF? She's dry but has a strong heart and you just gave her a **** ton of propofol. .

The OB didn't freak out?

I'm not so sure I could keep my job if I pulled those stunts repeatedly.

 

[Robokor]

Thread sounded better in my head after 18hrs straight in a room.

18hrs straight. What is the fellow doing. It's June!

 

[GeorgiaAnes]

Exactly!
Twice now in the last month I walked into the room of a partner that is double boarded in IM and Anesthesiawho dropped a TEE in on a totally healthy pt. The first case was a D&C on a 20ish yo female with a BP 70/30 on induction. WTF? She's dry but has a strong heart and you just gave her a **** ton of propofol. The next was a 47 yo guy that had a lap chile and was sent to the floor. He ended up bleeding over night and they needed to bring him back to find the bleeder. I know I'm not as smart as a IM doc but I think I know why his BP is low. I don't need a TEE to tell me. I don't get it one bit.
Now if he says I dropped the probe just to keep my skills up that's one thing. But to tell e surgeons that the others in his group are not as good as he is because they wouldn't have placed a TEE is bull****. This is also the guy that need US for every A-line.

I offered to take the case over for him but he says no. I think he thinks nobody can do as well as he does and that we will just screw things up.

Don't get me wrong here, he is very very good. But not better than the rest of us.

I see malpractice on two different end of the spectrum (besides a major complication which can be bad luck at times). On one end, you did nothing, whether it means you weren't paying attention, the knowledge base was not there, or you were headed down the wrong path. But at the other end, it is someone who does way too much and actually puts the patient at risk. No offense, but dropping a TEE probe on those cases is malpractice in my view. There is nothing benign about shoving that thing down the esophagus. If there was any sort of bleed or injury or complication from that probe, that put the patient at unnecessary risk. Now if the story proceeded to unexplained hypotension despite giving fluids, pressors, checking a gas, 'crit, etc and the BP is still low, then I could totally buy putting a probe down. That's just crazy.

 

[urge]

18hrs straight. What is the fellow doing. It's June!

Academia is not what it used to be. Sometimes you work alone. I had a resident join me but it was a tough case.

 

[Robokor]

Wow. Sounds like a struggle

 

[deleted171991]

Academia is the oldest form of AMC.

 

[Twiggidy]

How we need to treat some of our colleagues ...before the lawyers get to them....

And they say I'M crazy for putting a CVP in an EF 15% patient