Anesthesiologists Overkill

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Aether2000

Aether2000

algosdoc
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Anesthesiologists providing general anesthesia, MAC, or regional around the country have published matrixes of preop labs/CXR/ECG that are required by them before rendering any of these anesthetics, as though the risks are equal. The vast majority of surgeons and gastroenterologists polled feel this is overkill for their purposes when IV sedation is used. In many cases, the preop evaluation will cost more than the surgeon receives for performing the procedure. With respect to pain medicine procedures, do you feel the anesthesiologist's paradigm for massive numbers of labs/ECG/CXR are justified since many of these models use age as one of the main factors in performance of these tests. For those that administer or direct sedation in offices, do you order the same tests for your patients that anesthesiologists require to do the same administration of IV sedation in a hospital or ASC?
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for those not trained in anesthesiology our approach may seem "conservative". however, i assure you, as a practitioner of a specialty that revolutionized patient safety, made quality assurance a part of modern medicine, and decreased mortality/morbidity relatively more than any other branch of medicine - all those tests ARE necessary.

i love it when a non-anesthesiologist says - "oh, it's just MAC." guess what? most things go wrong during just mac cases. so if your specialist consultant wants a certain piece of info to safely perform his job, or worse case cover his ***** (and we're all guilty of that practice) i think you should abide.

i'm pretty sure if we let GI guys or surgeons dictate anesthetics many patients would not do well.
 
As a board certified anesthesiologist that was an assistant prof in a university program for several years, I am quite familiar with the safety profiles of various anesthetics. Beyond that, I am equally familiar at how anesthesiologists build their reputations as the voice of reason and safety based on shoddy retrospective reviews of tens of thousands of patients in order to find any differences at all in techniques, and usually when a power study is performed, find the studies are statistically meaningless. One would be hard pressed to find scientific statistics that a nurse administered physician directed IV sedation delivery is any more deleterious than an anesthesiologist personally delivering the same. You would also be hard pressed to definitively state the tens to hundreds of millions of dollars spent each year in paradigms have any statistical value in reducing morbidity or mortality for IV sedation cases. Surgeons frequently give IV midazolam and fentanyl in their offices for conscious sedation or mild sedation for short cases when monitoring with NIBP and pulse oximetry is used. They are increasingly questioning a the rigid monolithic approach to preop testing imposed by anesthesiologists. Perhaps the rest of medicine should do the same- demand the same levels of evidence that we are required to produce in order to justify the approach. We all have access to the same tools used by anesthesiology in monitoring patients and that specialty can certainly not claim exclusionary rights to IV sedation (although they are increasingly trying to legislate their continued existence through eggregious office anesthesia statutes that force short procedures requiring minimal sedation back into hospitals and surgery centers). It was not an anesthesiologist that invented pulse oximetry nor capnography, two of the most significant advances of the past 30 years. The question is: should we force outpatient pain procedure patients to undergo CXR, ECG, and massive blood work for brief non-blood loss cases that can be interrupted at any time simply because we give them IV sedation? Show me statistics, and desist from the self serving proclamations.
 
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algosdoc said:
As a board certified anesthesiologist that was an assistant prof in a university program for several years, I am quite familiar with the safety profiles of various anesthetics. Beyond that, I am equally familiar at how anesthesiologists build their reputations as the voice of reason and safety based on shoddy retrospective reviews of tens of thousands of patients in order to find any differences at all in techniques, and usually when a power study is performed, find the studies are statistically meaningless. One would be hard pressed to find scientific statistics that a nurse administered physician directed IV sedation delivery is any more deleterious than an anesthesiologist personally delivering the same. You would also be hard pressed to definitively state the tens to hundreds of millions of dollars spent each year in paradigms have any statistical value in reducing morbidity or mortality for IV sedation cases. Surgeons frequently give IV midazolam and fentanyl in their offices for conscious sedation or mild sedation for short cases when monitoring with NIBP and pulse oximetry is used. They are increasingly questioning a the rigid monolithic approach to preop testing imposed by anesthesiologists. Perhaps the rest of medicine should do the same- demand the same levels of evidence that we are required to produce in order to justify the approach. We all have access to the same tools used by anesthesiology in monitoring patients and that specialty can certainly not claim exclusionary rights to IV sedation (although they are increasingly trying to legislate their continued existence through eggregious office anesthesia statutes that force short procedures requiring minimal sedation back into hospitals and surgery centers). It was not an anesthesiologist that invented pulse oximetry nor capnography, two of the most significant advances of the past 30 years. The question is: should we force outpatient pain procedure patients to undergo CXR, ECG, and massive blood work for brief non-blood loss cases that can be interrupted at any time simply because we give them IV sedation? Show me statistics, and desist from the self serving proclamations.
Click to expand...

while not an anesthesiologist, it does seem that pre-op labs, ECG, and CXR is overkill for conscious sedation of most pain procedures. however, this begs the question: do we really need conscious sedation at all? if the risks of conscious sedation would require all of these pre-procedure tests, then it would seem that it is unnecessailry risky...
 
Sedation is not needed for brain surgery but for those patients, anything less than significant sedation or a general anesthetic is considered barbaric by patients, their families, and surgeons. For patients with acute pain (disc herniation), it is rarely needed. However, it is not your pain and it has been demonstrated in several studies that physicians are unable to gauge the pain of their patients. Chronic pain is a disease, and in many cases, sedation is not infrequently used for procedures such as RF or discography. Is it necessary? No. Is it barbaric to withhold such a simple and very low risk intervention when appropriate? Ask my patients that swear they will never go to the doctor that tortured them during pain procedures. These same docs may not ever see the patient back again in follow up and mistakenly conclude the patient handled the procedure well. Again, it is not the physician we are treating with sedation, it is the patient. Dentists are smart enough to know painful procedures sometimes require sedation in one form or another but physicians who uniformly deny all patients sedation apparently missed that lesson.
The risk of complications from the procedure itself is statistically many many times more likely than a complication from IV sedation when appropriate monitoring and systems are in place. My point is that I think the anesthesiologists are devising an expensive and expansive testing protocol that is probably necessary for general anesthesia, but is unnecessary for mild to moderate IV sedation. Their argument is that one may have to convert to a general anesthetic in their realm of practice (true), but this is not true in our realm. If our patient's cannot tolerate the procedure with mild to moderate IV sedation, we can simply stop the procedure. This option is not available to an anesthesiologist that is working with a patient that may be filleted open by the surgeon without the possibility of safely stopping the procedure. But the unwarranted monolithic approach of the anesthesiologist is being imposed on all physicians. If you think the ASA and AANA uses evidence based medicine in their position statements on their websites, you are correct, they do. It is level V evidence...OPINION only. We would be laughed out of insurance companies offices if we wanted coverage for procedures based on level V evidence. Pre-op testing should be based on more than conjecture or opinion...we passed that milestone years ago in other specialties.
 
Wow...I missed that discussion....
My contention is that physicians, pain physicians, need to have adequate airway management skills and resuscitation skills whether they administer sedation or not (contrast reactions), but that a trained pain physician, just as a trained gastroenterologist, trained emergency room physician, dentist, oral surgeon, pulmonologist, ENT, etc etc etc are fully capable of administering sedation by directing nurses. Anesthesiologists make ridiculous statements regarding safety based on case reports, but where are the stats? How is it that 99% of the millions of endoscopic surgeries performed each year under moderate sedation IV are done without anesthesiologists or CRNAs and yet we do not see a massive decrease in our population due to these feral-by-proxy physicians.
Regarding the specious straw man arguement that if pain patients were not sedated, they would not be injured is as innane as arguing that spine surgeons should do all of their spine cases awake in case they ding a nerve or that they should do all carpal tunnel cases with superficial local anesthesia only for fear of injury to the median nerve. What is frequently left out of the arguments are: 1. injury can occur to the spine or to nerves with or without sedation as feedback is definitely not assured by an awake patient and 2. given enough people doing procedures, there will be injuries to the cord and nerves and we do not have statistics that show patients would be safer without anesthesia. Nevertheless, I do not contend all patients need anesthesia, but rather that we as pain physicians, should not be restricted in our medical practice in the absence of data to suggest a practice is unsafe, especially when this is coming from another specialty whose physicians do not do what we do everyday. Conjecture, opinion, and hyperbole based on case reports is just that...unsubstantiated claims that should be taken at face value of what they represent. Once we accept that we are real doctors, just as are gastroenterologists, pulmonologists, emergency physicians, oncologists, and dentists that give IV sedation, we can then move into the sphere of discussion as to why an anesthesiology matrix of expensive and largely unnecessary lab/CXR/ECG tests would have any bearing on us at all when there is no clear data to support the use of these tests for IV sedation in pain patients. Thanks for the article!!
 
Algos,


Your point is well taken. I am also a board certified anesthesiologist (even though I only do pain now). I feel that expensive preop testing for our cases is ridiculous for several reasons:

1) There is no blood loss.
2) There are no fluid shifts.
3) There is no risk of conversion to GA because the procedure can be aborted at any time.


I have performed ESI's on 90+ year olds with marginal cardiac reserve with no preop labs and no complications. My standard approach is PO valium. However, on patient request, I will provide IV sedation. IV sedation is offered for RF and stims even though quite a few patients have refused.


I really have not run into anesthesiologists requesting a battery of preop tests. Has this been your experience Algos? If so, you need to talk to the head of the group because it is unnecessary.
 
I am independent of anesthesiology groups locally but they all have their matrixes that are enforced by their scheduling offices for cases done in their ASCs or hospitals, even MAC cases. The anesthesiologists claim that medicare requires them to do so but that it represents "good patient care". Many times, the anesthesiologists don't even look at the results of what they have ordered. It is a perfunctory exercise in futility when they administer a milligram of versed IV and require these massive workups. Some of the groups actually have a preop clinic that the patient must attend or the procedure might be cancelled. More insidious is the imposition of this type of thinking into legislative and regulatory policies that serve to design office anesthesia rules, that include anesthesia evaluations with the implied testing that must be done. Anesthesiologists, without data to support the need for such testing for the types of procedures we do are bludgeoning the state medical boards with safety concerns about office anesthesia causing more and more rules to be promulgated.
 
Having had the opportunity to perform all the procedures in the office,ASC, and hospital setting: The pre-op eval is a big wste of time for 99% of all that I do.

It adds to the expense and I have never seen ti add to the safety. I can understand the need on ASA-4's, but I rarely see those folks in the office setting.

I'm often wondering why certain cases have to go to the hospital when I would be more comfortable in the office/ASC running the show and not dealing with added red tape, expense, and wasted time.
 
I think pre-op evals tend to be a bit of overkill...

at my hospital ever patient get sends to a med consult before every procedure almost... even the GI docs send the patients to see their internist.... which is kind of rediculous because if you think about it....

non invasive procedures, sedation- in my mind the work up should be keep it simple stupid. ECG if they are at risk or havent had one recently (pretty much anyone over 50). I truly don't care what their other labs are if they aren't symptomatic (ie if they are lethargic then yeah get me a sodium and glucose)....

I did a shoulder scope in a 21 yr old the other day. He got med consult and CBC, Chem 10, LFTS, and ECG... ridiculous... I asked the surgeon why he sent the patient to med consult- he replied that his office sends everyone because if a patient isn't properly worked up the anesthesiologist could cancel the case...
 
Sounds like that group is RIPE for a better/more recently trained group to take their contract away.

Macs/ GA are all the same as far as safety....the differences is in what procedure they are having done.

The days of unnecessary testing will be coming to an end.....guys like the above poster will likely be losing their job....or getting paid a LOT less because the cost of testing will come out of their bottomline.

algosdoc said:
I am independent of anesthesiology groups locally but they all have their matrixes that are enforced by their scheduling offices for cases done in their ASCs or hospitals, even MAC cases. The anesthesiologists claim that medicare requires them to do so but that it represents "good patient care". Many times, the anesthesiologists don't even look at the results of what they have ordered. It is a perfunctory exercise in futility when they administer a milligram of versed IV and require these massive workups. Some of the groups actually have a preop clinic that the patient must attend or the procedure might be cancelled. More insidious is the imposition of this type of thinking into legislative and regulatory policies that serve to design office anesthesia rules, that include anesthesia evaluations with the implied testing that must be done. Anesthesiologists, without data to support the need for such testing for the types of procedures we do are bludgeoning the state medical boards with safety concerns about office anesthesia causing more and more rules to be promulgated.
Click to expand...
 
I'm not sure what y'all do, but we have very few requirements for GA, and essentially no requirements for MAC cases unless we see an issue on the day of surgery. An 80 yr old for a 5 minute EGD with propofol-only sedation simply does not need an EKG, CXR, or labwork.
 
Results of a survey of surgeons I conducted on Sermo...as you can see, surgeons also view anesthesiology routine orders as overkill and routinely ignore them when they administer IV sedation.

Do you routinely order the anesthesiolgy pre-op lab, ECG, and CXRs on patients receiving minimal to mild IV sedation for short duration, non-blood loss procedures in your office or ASC?

Results

No, the cost cannot typically be justified based on the very limited benefit 76% (16/21)

Yes, I follow the same anesthesiology pre-op testing protocol regardless of the procedure simplicity, duration, or location 14% (3/21)

Only on very rare occasions 10% (2/21)
 
I'm a BC anesthesiologist and I work in a variety of settings, often giving sedation for pain procedures.

The value of preop testing has been in our radar for years now and most of the current data points to less and less expensive testing and more to just a reliable history. That's how I practice. Unfortunately, in one practice of mine, every patient gets everything and an another no patient gets anything. Neither is correct in my view. I've had patients come to me with unstable angina, decompenstated CHF and an asthmatic so tight I thought I heard her whistling dixie. So, no not every patient should get done, and a good history is likely to pick up 90% of things. I rarely cancel lab values, ekgs or chest x-rays. If by history they are not likely to show anything then I don't get them. Simple.

It's about RISK. When you ask me to be there, I assume the majority of the risk should the patient have a bad outcome. I don't want a bad outcome for a patient under my care so I will do what I can to minimize that risk. Simple. The problem is there are a lot of bad gas passers, as there are a lot of bad docs from every specialty who take the easy road. Those who don't want to think. The non-thinker orders every test because it's easier. The non-thinker does the block knowing it won't have any benefit or the upper endoscopy on the patient who has gas pain.

The call to base our testing reccs on real data is a valid one. Taking into account the invasiveness of the procedure is important but it doesn't mean that ALL patients don't need testing.
 
Check out the latest ISIS email blast for our practice survey results that reflect current practices in this arena of pain medicine by pain physicians...
 
i recently cut the anesthesiologists out of virtually ALL of my procedures, and somehow, they don't bother me at all. We order no ROUTINE testing, and order only things that are appropriate, which is basically nothing. To my knowledge, the GI docs also do not order anything ROUTINE, and they are typically using much deeper sedation than what i require/want.
Patients much prefer it this way...and over sedation is never an issue, as Algos states: if we cannot get adequate sedation, we stop. This has only happened 1 time to me...
 
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