another preop evaluation

[huktonfonix]

Lady in her 70s with long hx of DM2 and HTN coming in for an elective vaginal hysterectomy (takes about 2-3 hours at our place). She supposedly was able to walk for 20 min at an unknown rate of speed but had some increasing shortness of breath at the end of this walk over the past 6 months. Outside preop eval showed a + stress test (adenosine myoview). cath showed essentially clean major coronaries with LVEF 65% and no major valvular issues. Labs ok at preop one month ago (prior to cardiac workup) with the exception of Cr 1.4. Physical exam otherwise wnl. New labs drawn showed NA 124, K 5.5, Cr 1.7. The case ended up being cancelled. Our reasoning being the clinical picture added up to worsening renal function (possibly from the contrast dye?). would anyone have done this case?

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[jetproppilot]

Lady in her 70s with long hx of DM2 and HTN coming in for an elective vaginal hysterectomy (takes about 2-3 hours at our place). She supposedly was able to walk for 20 min at an unknown rate of speed but had some increasing shortness of breath at the end of this walk over the past 6 months. Outside preop eval showed a + stress test (adenosine myoview). cath showed essentially clean major coronaries with LVEF 65% and no major valvular issues. Labs ok at preop one month ago (prior to cardiac workup) with the exception of Cr 1.4. Physical exam otherwise wnl. New labs drawn showed NA 124, K 5.5, Cr 1.7. The case ended up being cancelled. Our reasoning being the clinical picture added up to worsening renal function (possibly from the contrast dye?). would anyone have done this case?

Her Cr has bumped up .3 in a month...

Are there OUTCOME STUDIES showing a difference in outcome with minor variance in preoperative labs?

The difference between academia and private practice is ACADEMIA LOOKS FOR REASONS TO CANCEL A CASE.

If you can't produce OUTCOME LITERATURE showing you're doing this lady harm by doing the case then by definition you are WASTING YOUR TIME AND THE LADIES TIME BY CANCELLING HER CASE.

Try and look at this case from a different perspective....like:

Its highly unlikely that by going ahead with this operation I'm gonna cause harm,

instead of from the perspective-so-prevalent-in-academia which is

WHAT CAN I FIND CONCERNING THIS PATIENT THAT I CAN USE TO CANCEL THIS CASE?

 

[huktonfonix]

ya know jet, I thought the same thing when I heard from my partner the case had been cancelled. I had done the pre anes eval on this patient the day before and thought that she was good to go. Yes, she has some CAD and reversible ischemic defect, BUT its likely microvascular and nonamenable to intervention so thats not the issue. The electrolytes in themselves (ordered day of surgery by the surgeon) were not the issue as she was mentating fine and had no evidence of peripheral or cerebral edema. The K was on the border of high/normal but nothing significant and yes the 0.3 Cr bump was not much. If I had been given that single snapshot I wouldnt have thought much of it. Do the case, have them consult medicine after. However, the labs a month ago had been Na 140, K 4.0, Cr 1.4. Now, this to me indicates some ACUTE renal process going on. Cant tell you if its coming or going, but it has occurred over the last month and it may benefit this lady to wait until this process has gone or stabilized. No use risking the remaining nephrons for a purely elective procedure.

I thought this was a good case to show that electrolyte abnormalities in themselves may not change outcome or be a reason to cancel, but do need to be taken in the overal clinical context.

 

[militarymd]

contrast has a very predictable time course of changes in renal function...and doesn't it usually make your serum sodium go UP?...not down.

I'm on the fence with this one.

 

[periopdoc]

Even in my academic setting this case would not have been delayed. JPP pretty much said what I would have.

-pod

 

[huktonfonix]

contrast has a very predictable time course of changes in renal function...and doesn't it usually make your serum sodium go UP?...not down.

I'm on the fence with this one.

Its definitely out of the usual range of contrast induced nephropathy (7-10 days). However, we had no other good reason why this lady's kidneys would have changed acutely. I'm not actually sure how serum sodium changes with contrast induced nephropathy either acutely or chronically. never seen it mentioned.