Clearing Patient for Surgery

The ACC guidelines are what we use.

As a physician, you will read literature that is not within your specialty....that is one of the distinctions between a CRNA and a physician who does anesthesia.

cytoskelement said:

Just a topic on my mind,

My interest in anesthesiology has been growing since second year when several pharm lectures on NMBAs and pain meds sparked my interest. I recently was asked by my senior resident to help determine if a pt of ours was "cleared by medicine" for a AAA repair. I used an algorithm from the ACC/AHA for Perioperative Cardiovascular Evaluation for Noncardiac surgery published in Circulation, 2002. It stratifies based on risk of surgery, pt risk factors, and pt METs. It was asserted that these guidelines were somewhat of a gold standard to evaluate pts.

anywho, i was just wondering if this sounds familiar to y'all or if there are comparable "gold standards" in the anes. literature that you occassionaly use. i don't want to make light of the CA training - I'm sure that pts are viewed in much more complexity than what is offered in a journal - just wanted to compare or add this particular one to my future arsenal.

thanks for all the insight everyone. this forum rocks!

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"cleared by medicine" or "cleared by cardiology" is a horrible misnomer. It often implies that the patient is in much better shape than they are.

We want a medical or cardiology "consultation", giving us a clear picture of the patient's current condition and management, and an opinion as to whether or not their condition is as optimized as it can be. We don't need or want their opinion on the appropriate management of the patient - none of this "cleared for spinal anesthesia only" crap for a craniotomy.

cytoskelement said:

i certainly agree. by my saying "cleared by medicine"; i was implying that the Pt was cleared by my service (I'm an MSIII on medicine) for their medical issues. in this case, ID for possible mycotic aneurysm/active TB and Cardio for CV stability. When we consulted surgery when the AAA was an incidental finding on imaging, they naturally wanted to be assured that the medical issues were optimized. So the general medicine team was more like the team captain orchestrating the "medical" clearance.

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This is a total pet peeve of mine. There is no such thing as medical "clearance". If you say that you have "cleared" a patient for surgery, you are implying to both the patient and the surgeon that you don't expect any complications. This is very far from the truth, especially since the patients who require a medicine, pulm, or cards consultation are typically at a higher risk in the first place (otherwise you wouldn't be calling the consult). Instead, what we offer as consultants in medicine, cardiology, and pulmonary are a preoperative risk assessment where we help determine whether the patient's underlying medical conditions significantly increase their surgical risk, and by how much. Often we will stratify them into low, intermediate, and high risk groups. In addition we help to optimize the patients medical conditions in preparation for surgery.

As medical/subspecialty consultants it should not be up to us to decide whether a patient should have surgery or anesthesia. Instead we give our input as to how risky a procedure would be to the patient, and then let the surgeon decide whether they want to proceed with the surgery, and the anesthesiologist can decide whether they feel it's safe to provide anesthesia and what type.

Okay, I'll get off my soapbox now. 🙂

AJM... that was the perfect answer...