Anybody preop endo pt's night before?

[turnupthevapor]

WONDERING IF ANYONE HAS THEIR ENDO LIST PREOP'D NIGHT BEFORE FOR INPATIENTS. We are considering this since their charts are 4 inches thick and our GI dudes are complaining we take to long to review the chart prior to starting the procedure.


also a quick poll

Who thinks an ekg is necessary before an endo on a patient 89 yo, CABG 20 years ago hx of mod AS and CHF

my answer

I don't think so if they don't have an active cardiac condition and rhythm strip doesn't show high degree av block or major arrythmia


2nd question...who thinks a K is necessary day of the procedure on ESRD patients

thanks for your help

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[militarymd]

my preop for endo's


"what did you eat today?"

 

[Arch Guillotti]

my preop for endo's


"what did you eat today?"

lol

That's exactly what the nurses I work with do!

 

[militarymd]

lol

That's exactly what the nurses I work with do!

and as I've said many times before.... nurses are smarter and more competent than many JUNIOR physicians are willing to give them credit for.

and we know who the JUNIOR physicians are ....right?

 

[2win]

and as I've said many times before.... nurses are smarter and more competent than many JUNIOR physicians are willing to give them credit for.

and we know who the JUNIOR physicians are ....right?

Shet! I have to agree with mmd (though not about the nurses) . I would ask the same question....And I will agree with the nurse if she's cute and willing. Like the one on tv - nurse LOLA.

 

[Arch Guillotti]

and as I've said many times before.... nurses are smarter and more competent than many JUNIOR physicians are willing to give them credit for.

and we know who the JUNIOR physicians are ....right?

Not the ones I work with in endoscopy.

 

[rsgillmd]

We used to preop our endo patients where I trained. They were some of the sickest patients I took care of. Well worth it to keep yourself out of potential trouble.

 

[2ndyear]

Unless they are complaining of chest pain, no EKG. Actually had this scenario not too long ago, sure enough big ST elevations. Went right downtown and had the sharp end of the sternal saw on him a few hours later.

Potassium, plus/minus. What are you going to do if it is low? Nothing, right? The question then is will you cancel if it is high. How high? Does it matter?

 

[turnupthevapor]

I agree if they don't have unstable angina, critical as, active CHF or major arrythmia there is not much evidence to cancel a low risk case. That being said I feel irresponsible if I haven't flipped through the chart and start pushing drugs. for example they may have been admitted earlier that week with a stemi or been on levo night before for sepsis.....all these things you would have to do a chart review to figure out and when the GI is holding the scope in his hand Its not the time to preop the pt

A colleague of mine did an ESRD endo, had a little trouble with the airway and the pt fibrillated. K ended up being 6.5 and was dialized day before? So maybe there can be a case to make sure K is under 6 prior to starting

 

[Frank Rizzo]

WONDERING IF ANYONE HAS THEIR ENDO LIST PREOP'D NIGHT BEFORE FOR INPATIENTS. We are considering this since their charts are 4 inches thick and our GI dudes are complaining we take to long to review the chart prior to starting the procedure.

We only preop the ones that are scheduled for GA

 

[Noyac]

If the GI guys don't want you to review the chart b/4 the case then tell them to dictate and accurate summary the day b/4 the endo. I would not be preop'ing these pts the day b/4, I have better things to do. If they don't think that is feasible then tell them to do their own sedation.

If I felt the cardiac status was stable then I don't need an ECG but I would have an old one available to review.

The K is a tough one in my opinion. I'd review the chart to see if the pt has had large swings in K in the past. If not then I don't need a K value.

 

[Noyac]

I don't consider myself a junior physician but when nurses take poor histories from pts it's usually b/c they don't know enough to get an accurate history. When you do it Mil it's b/c you have all the information you need.

 

[Arch Guillotti]

I don't consider myself a junior physician but when nurses take poor histories from pts it's usually b/c they don't know enough to get an accurate history. When you do it Mil it's b/c you have all the information you need.

Apparently I am a junior physician. Not much I can do though except keep on plugging away. As a junior physician and mod of this board I am able to take a joke and laugh at things (unlike some others around here).

The nurses don't know enough to take an accurate history and even if they did take an accurate history they wouldn't know the relevance of the findings most of the time. We do endo on some very sick patients, ESRD, bad hearts, morbidley obese, crappy lungs, valvular disorders, etc, etc. You can argue all day over this but I want to know all the information possible beforehand. Does it make a difference in treatment and outcome - I don't know. But asking a couple of quick questions and verifying NPO status and allergies is what a nurse does for a preop.

 

[dhb]

We used to preop our endo patients where I trained. They were some of the sickest patients I took care of.

Yes we do and it sucks the patient are often very sick but there's nothing you can do to modify their condition. So outside of active cardiac condition there's nothing to stop you.

Reviewing 4 inch thick charts for little gain is very annoying.

 

[Arch Guillotti]

Yes we do and it sucks the patient are often very sick but there's nothing you can do to modify their condition. So outside of active cardiac condition there's nothing to stop you.

Reviewing 4 inch thick charts for little gain is very annoying.

So forget about it and just ask them what they had to eat today

 

[dhb]

So forget about it and just ask them what they had to eat today

I would if the attendings weren't already all over me for my "alternate approach to anesthesia"

 

[turnupthevapor]

thanks all

 

[BDanes]

The preop is so much different in private practice compared to academic practice. We don't do endo, but we do sedation with local on a ton of patients.

One of the things I asked guys who finished before me was how they handle the same day preop. The reality is that most cases are low or intermediate risk. Once you have a basic history and have excluded active symptoms, you are pretty much ready.

I've found it true that my major goal is defining their pathology and it's severity. Then I make a judgement on what I could run into and proceed.

There are many cases I would have never been allowed to proceed with in residency. It is an adjustment for sure, but as you will see-the cases are gonna get done one way or another. I will not cancel/postpone a case unless it is absolutely necessary.

 

[mille125]

and as I've said many times before.... nurses are smarter and more competent than many JUNIOR physicians are willing to give them credit for.

and we know who the JUNIOR physicians are ....right?

a pack of lies and he knows it

 

[Noyac]

The preop is so much different in private practice compared to academic practice. We don't do endo, but we do sedation with local on a ton of patients.

One of the things I asked guys who finished before me was how they handle the same day preop. The reality is that most cases are low or intermediate risk. Once you have a basic history and have excluded active symptoms, you are pretty much ready.

I've found it true that my major goal is defining their pathology and it's severity. Then I make a judgement on what I could run into and proceed.

There are many cases I would have never been allowed to proceed with in residency. It is an adjustment for sure, but as you will see-the cases are gonna get done one way or another. I will not cancel/postpone a case unless it is absolutely necessary.

Very well said.

 

[tucker27705]

We have a gi suite with 3 or 4 rooms running daily. We do not preop the night before. Usually one of the rooms is inpts, the others fairly healthy outpts. But not always. We typically stay on time and do not hold up the gi guys with our chart reviews. Occasionally a pt gets taken back before I see them, then I get called to the suite for a quick h&p, annoying since we have a place on the schedule which indicates whether or not I have seen the pt yet. But its really a factory and they get carried away sometimes.
Pre op K? I admit I haven't really thought about this one for GI/propofol sedation, though I probably should. Always get one for cases in the main OR. We have an istat to check quickly on day of surgery so there are no delays--unless of course you get an elevated K.
My cut off is generally 5.7, but I will fudge on that depending. We waited on one ga case for the K, I was told it came back, the anesthestist took the pt to the room and gave the standard anesthestist "2 and 2". I asked what the K was, well it was 5.8. Damn, after 2 and 2 you know its above 6. What the? We induced and I told her to hypervent the pt (obviously no succ.).
I really hate supervising when the the midlevels think they know what they are doing and don't take well to supervision.
Much prefer doing cases myself.
Tuck

 

[Idiopathic]

why would the K go up after "2 and 2", from the respiratory depression = mild acidosis?

 

[Foodie]

I'm bumping this old thread to address a similar issue at our hospital GI suite. I turn to you guys to give me some direction here.

FYI, we have no CRNAs and we do all our own cases.

True to my OCD tendencies, I review charts the night before on MAC colonoscopies and ERCP patients, who often are obese ASA 4 with cardiac probs, OSA, IVDA. Because in the past none of my colleagues have asked for these GI MAC patients' medical histories and pertinent workup that we require for all OR MAC patients, I was left to my own devices in terms of calling the pt's PMDs for the latest visit note, past workup, etc. I have not asked medical clearances (or new labs unless ESRD for K and DM for FS DOS), which as we all know, are meaningless unless they state that the patient is not medically optimized for surgery/procedure.

After a few months, I got fed up with doing scutwork, so I requested the GI nurses to obtain the information the day before the procedure. I haven't delayed/cancelled a single GI case so far, as much as I hate doing endo cases. (case in point: After Death in the GI Suite, Patient's Family Sues CRNA)

Now one GI doc filed a complaint to the hospital administrators that I am taking "procedure time" away from the nurses because a nurse was on the phone with PMD's office trying to get information for a next day patient. My chairperson agrees with me that MAC is a MAC no matter what the procedure is, and that those patients should have the same workup as OR MAC patients undergo. My colleagues gave me the "Well, it's not like it's going to change anything for such short, routine procedures."

In patients with significant comorbidities, even a 30 second procedure is anything but routine in my mind. The purpose of my preop preparation is to have sense of the patient and set a threshold for how quickly I would react should things start to go south in the procedure room.

Someone once said that failing to prepare is preparing to fail. I believe that.

Tell me if I'm being overly cautious here. From this thread, it sounds like some of the guys give the green light as long as the patient hasn't eaten anything DOS.

 

[Planktonmd]

You are contradicting yourself!
You said that you have never canceled or delayed an endoscopy case based on the pre-op evaluation but you still insist on having it done anyway!
You go as far as saying that even ESRD patients do not need that evaluation but you still feel that you need to do it!
Make up your mind...

 

[Foodie]

You are contradicting yourself!
You said that you have never canceled or delayed an endoscopy case based on the pre-op evaluation but you still insist on having it done anyway!
You go as far as saying that even ESRD patients do not need that evaluation but you still feel that you need to do it!
Make up your mind...

I hear what you are saying. I will clarify that I would only cancel/delay an endoscopy case if patient presented with chest pain, short of breath, or K DOS 5.5 or higher...

The purpose of my preop eval is to get a sense of how sick the patient is and to set a threshold for hitting that code button when things start going wrong.

 

[deleted171991]

I have a very high threshold to cancel an endo case. That being said, I still review every single endo patient the night before, so I know ahead who might need further eval/clearance. For me it's common sense, although less than 20% of my colleagues do it.

In our ASC, the patients are called by nurses the day before, and the CC, medical and social history, allergies, height/weight and current medications are saved in the EMR. Thus it's relatively easy to "risk stratify" the patients even before meeting them, and decide who needs the 3 minute-preop and who needs the 30 minute-one. This way, the 3 GI docs almost never have to wait for the anesthesiologist. It also simplifies the admitting process for the GI nurses on the day of the procedure.

For example, just last week I cancelled a AAA patient before she even started to get undressed, because I already knew about her and all I needed was her answer regarding the time of her last surveillance CT (followed by a short educational discussion why she needed to have it before playing colonoscopy). I flagged her for a preadmit interview before we even started our workday, and the nurses were very grateful for saving them time.

Another day, I had a patient with ESRD on PD coming in for a colonoscopy. Some GI docs don't do colonoscopies if the dialysis fluid is still in the peritoneum, so I asked about it first thing in the morning. The case was approved before the patient even arrived, but it could have been cancelled the same easy way. And I could go on with examples like this, where a good phone preop saved us tons of time on the day of the procedure; most of my face-to-face ASA 3/4 preops take less than 5 minutes, most of which are dedicated to answering patient questions (since I know 90% of what I need before I even meet them).

 

[Noyac]

If you need time to learn your pts beyond that given the day of surgery then by all means do it the night before. With that being said, I would imagine the information you learn could be gained in 5 min 99% of the time. I find the last PMD visit is useless. I just need an accurate H&P. GI procedures are not stressful or violating to our pts when a little propofol or whatever is given. Therefore, you can take the sickest mofo in the hospital and pretty much get them thru an EGD/colonoscopy without much fan fare. Get a good idea of their medical history and design a safe gentle anesthetic and move on.

 

[Arch Guillotti]

For example, just last week I cancelled a AAA patient before she even started to get undressed, because I already knew about her and all I needed was her answer regarding the time of her last surveillance CT (followed by a short educational discussion why she needed to have it before playing colonoscopy). I flagged her for a preadmit interview before we even started our workday, and the nurses were very grateful for saving them time.

What exactly are you doing to potentially rupture this AAA?

 

[deleted171991]

What exactly are you doing to potentially rupture this AAA?

Insuflate a ton of air, push a scope and the bowel wall against the retroperitoneum and, worst of all, have a nurse push against the inflated belly to help guide the scope.

If the AAA is growing or big, and ripe to be fixed, then the AAA repair should be done first, before an elective procedure. Same goes for a AAA that's due for checkup (especially if per vascular surgeon notes). If it ruptures, having done the colonoscopy first is pretty indefensible.

We live in a country where patients sue and win huge amounts of money for complications that they assumed the risk for in the informed consent. Why? Because we have lay courts, stuffed with scientifically uneducated "peers", who cannot understand that everything has a risk, and that the same way one can win the lottery one can suffer a complication. In this system, the patients can blame their doctor for their own lack of judgment, as if we were all pediatricians.

I don't know of any other country where a patient cannot waive her right to sue for malpractice (unless egregious or intentional) in exchange for free care. And that speaks volumes about how the balance of malpractice courts is tilted. (I also don't know of any other country where a burglar can demand compensation for slipping and breaking some bones while burglarizing your house.) In most of the world, adults are considered 100% responsible for their own decisions and actions, and the consequences of those.

 

[Noyac]

Insuflate a ton of air, push a scope and the bowel wall against the retroperitoneum and, worst of all, have a nurse push against the inflated belly to help guide the scope.

If the AAA is growing or big, and ripe to be fixed, then the AAA repair should be done first, before an elective procedure. Same goes for a AAA that's due for checkup (especially if per vascular surgeon notes). If it ruptures, having done the colonoscopy first is pretty indefensible.
.

I don't see the "real" risk here. So don't let the nurse push on the abdomen. But insufflation should not bare any risk to the AAA.
What if they wanted to do a work up for possible colon cancer prior to AAA repair?

 

[deleted171991]

I don't see the "real" risk here. So don't let the nurse push on the abdomen. But insufflation should not bare any risk to the AAA.
What if they wanted to do a work up for possible colon cancer prior to AAA repair?

If the surgeon asks for it as a preop workup for the repair, then it's not a truly elective procedure anymore. Same if this is not a screening colonoscopy, but a diagnostic one for GI bleed (which one should fix anyway before vascular surgery and heparinization).

I just don't like to play colonoscopy if the patient is not optimized for the procedure, i.e. s/he has a AAA due for repair.

 

[Noyac]

If the surgeon asks for it as a preop workup for the repair, then it's not a truly elective procedure anymore. Same if this is not a screening colonoscopy, but a diagnostic one for GI bleed (which one should fix anyway before vascular surgery and heparinization).

I don't want to beat this to death. I'll just say this, if we can do it in an urgent case then we should be able to do it electively as well.

 

[deleted171991]

I don't want to beat this to death. I'll just say this, if we can do it in an urgent case then we should be able to do it electively as well.

No offense, that's not true. It's a risks versus benefits discussion. In an urgent situation, the benefits will most likely outweigh most risks. To put it differently: the risks of not doing the procedure are much higher than the risks of doing it.

 

[Planktonmd]

I think seeing a patient or spending time on a chart before the procedure day for an endoscopy is an absolute waste of time and resources.
But... that's my personal opinion.

 

[Noyac]

I think seeing a patient or spending time on a chart before the procedure day for an endoscopy is an absolute waste of time and resources.
But... that's my personal opinion.

Another reason why it's a waste of time, in my mind, is that our schedule is dynamic. Other than the first case of the day, we never really know what cases we are doing until they occur. Schedules change all the time. This is another reason why we don't call our pts the night before in my practice. It would throw some for a loop if we switched on them last minute after someone else has already talked with them.

 

[Noyac]

Anoth

I think seeing a patient or spending time on a chart before the procedure day for an endoscopy is an absolute waste of time and resources.
But... that's my personal opinion.

Another reason why it's a waste of time, in my mind, is that our schedule is dynamic. Other than the first case of the day, we never really know what cases we are doing until they occur. Schedules change all the time. This is another reason why we don't call our pts the night before in my practice. It would throw some for a loop if we switched on them last minute after someone else has already talked with them.

 

[Foodie]

Really appreciate all your answers and reasonings. Thank you all. Our assignments seldom change after they are made, so it hasn't been a huge waste of time to preop patients prior to the surgery.

To give you an update, this is what we decided as a group: preop office nurse will do a phone interview and obtain a copy of last PMD visit note containing patient's problem list along with treatment plans, a cardiologist visit note and previous EKG if significant cardiac history, and any existing labs for an endoscopy patient before the day of procedure. This way the burden is shifted from GI dept to the perioperative office to gather pertinent info. It would be at the anesthesiologist's discretion to order K/FS/HCG DOS.