Blood pressure and cancelling procedures

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SpineandWine

SpineandWine

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What is your approach to the HTN patient who is getting elective procedures. What is your cancellation threshold?
Lastly, do you have a hand out or dot phrase documenting that this procedure was performed recognizing risk and benefit of elevated BP?
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>180/110 as long as no signs of end-organ damage. There are several papers that use this cutoff (Fleischer et al JAMA, etc.). Anything above that would be difficult to defend. But as lobelsteve mentioned.. no reason you can't be even safer and go lower.
 
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paintrain said:
>180/110 as long as no signs of end-organ damage. There are several papers that use this cutoff (Fleischer et al JAMA, etc.). Anything above that would be difficult to defend. But as lobelsteve mentioned.. no reason you can't be even safer and go lower.
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^ this is what I use too. last thing I want is to worsen that pressure with a needle poke and land in stroke-town(not the place in the red light district). on a side note, I also cancel if glucose over 180 for cases that involve an incision and 250 for RFA. but i usually give them a little insulin and monitor postop again too if too high.
 
Are we talking manual or automated cuff??
 
I check sugar..got a lot of uncontrolled diabetics around me..have had situations where they don’t normally check and when we check their sugar is 300. Not injecting steroids in them. Advise to get the sugar more controlled or actually try to check it more consistently
 
Interesting. I recently sent a patient to the ED with persistent 200/100 pressure and cancelled a LESI, and apparently the guidelines for hypertensive urgency without symptoms and elevated pressures say it’s ok to discharge home. Patient got discharged home with pressure 190/100 to follow up with their PCP.
 
>180/100.


it is appropriate to cancel the LESI because technically the steroid component of the LESI may increase systolic pressures by an additional 10 points or so. if asymptomatic, still preferable to have it rechecked - usually either send to ER or contact PCP and arrange for follow up that day or the day after.
 
We use 180/100. I don’t send them to the ER if they’re asymptomatic. Most likely they’ve been walking around like that for weeks. They’re going to sit there for 10 hours waiting and then discharged home to PCP.

My 88 yo patient followed up with their cardiologist and they told her she needed stronger pain medicine and that is why her BP is 220/100 🙄 I talked to her granddaughter who was exasperated and told me she’s been cutting her BP meds in half and doing half doses because that’s what she was told to do 10 years ago and she decided never to change.
 
dipriMAN said:
Interesting. I recently sent a patient to the ED with persistent 200/100 pressure and cancelled a LESI, and apparently the guidelines for hypertensive urgency without symptoms and elevated pressures say it’s ok to discharge home. Patient got discharged home with pressure 190/100 to follow up with their PCP.
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In the EM world this is called asymptomatic hypertension, and I would stop sending them into the ER. If they wind up in the ER the overly cautious physicians may check labs and an EKG for medicolegal purposes to assess "end organ damage" but when the patient invariably has a little non-specific t-wave inversion or bump in creatinine (that they've likely had for months/years) you are in a bind. Thus most colleagues won't even do that and automatically discharge home shortly after the patient checks in - assuming they are asymptomatic.
 
GatorCHOMPions said:
In the EM world this is called asymptomatic hypertension, and I would stop sending them into the ER. If they wind up in the ER the overly cautious physicians may check labs and an EKG for medicolegal purposes to assess "end organ damage" but when the patient invariably has a little non-specific t-wave inversion or bump in creatinine (that they've likely had for months/years) you are in a bind. Thus most colleagues won't even do that and automatically discharge home shortly after the patient checks in - assuming they are asymptomatic.
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I see your point. But also, as physicians, if we have a patient come in at the "hypertensive urgency" level, we have to do our due diligence to make sure the patient doesn't have "end organ damage." In an outpatient clinic or ASC, I am not equipped to do that so I send the patient to the ED/Urgent care or to immediately contact their PCP. I am not an EM physician, but I certainly could imagine a patient being at the hypertensive urgency level, being asymptomatic, but have some myocardial oxygen supply/demand mismatch that a 12 lead EKG could catch that I won't see in office. Admittedly, it is a lot of CYA, but that is the world we live in now.
 
Gnarvin said:
I see your point. But also, as physicians, if we have a patient come in at the "hypertensive urgency" level, we have to do our due diligence to make sure the patient doesn't have "end organ damage." In an outpatient clinic or ASC, I am not equipped to do that so I send the patient to the ED/Urgent care or to immediately contact their PCP. I am not an EM physician, but I certainly could imagine a patient being at the hypertensive urgency level, being asymptomatic, but have some myocardial oxygen supply/demand mismatch that a 12 lead EKG could catch that I won't see in office. Admittedly, it is a lot of CYA, but that is the world we live in now.
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I’m just telling you how it is on the other side of things. These patient encounters are wasteful, albeit easy, for us to take care of in an ER setting. Most of my colleagues, myself included, don’t check EKGs on these patients you are sending to us. If they do have a little non-specific change the patient probably buys themselves an observation stay with serial troponin testing and quite possibly an ECHO. All for what, CYA medicine. There are also downstream consequences. You’ve taken up a bed for someone sicker, and that ECHO is far from perfect and could lead to further unnecessary testing. As another poster said above these patients have been at 200/120 for a long, long time. This is not good patient care. All it takes are a couple screening questions about dizziness/headache and chest pain/SOB and you’ve done what a prudent ER doc would do.
 
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GatorCHOMPions said:
I’m just telling you how it is on the other side of things. These patient encounters are wasteful, albeit easy, for us to take care of in an ER setting. Most of my colleagues, myself included, don’t check EKGs on these patients you are sending to us. If they do have a little non-specific change the patient probably buys themselves an observation stay with serial troponin testing and quite possibly an ECHO. All for what, CYA medicine. There are also downstream consequences. You’ve taken up a bed for someone sicker, and that ECHO is far from perfect and could lead to further unnecessary testing. As another poster said above these patients have been at 200/120 for a long, long time. This is not good patient care. All it takes are a couple screening questions about dizziness/headache and chest pain/SOB and you’ve done what a prudent ER doc would do.
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Good to know. Unless symptomatic I tell them to contact their PCP immediately, and start keeping a home BP log if they have a cuff.
 
GatorCHOMPions said:
I’m just telling you how it is on the other side of things. These patient encounters are wasteful, albeit easy, for us to take care of in an ER setting. Most of my colleagues, myself included, don’t check EKGs on these patients you are sending to us. If they do have a little non-specific change the patient probably buys themselves an observation stay with serial troponin testing and quite possibly an ECHO. All for what, CYA medicine. There are also downstream consequences. You’ve taken up a bed for someone sicker, and that ECHO is far from perfect and could lead to further unnecessary testing. As another poster said above these patients have been at 200/120 for a long, long time. This is not good patient care. All it takes are a couple screening questions about dizziness/headache and chest pain/SOB and you’ve done what a prudent ER doc would do.
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As an EM physician, if you want to make that call that is great. But I am not going to accept the risk if anything were to happen with the patient that I didn't more fully evaluate the patient for end organ damage than just ask about symptoms. I agree it is CYA medicine, but I have seen people get sued for a lot less.
 
lobelsteve said:
190/100 and no thanks.
180/100 in the canal.
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paintrain said:
>180/110 as long as no signs of end-organ damage. There are several papers that use this cutoff (Fleischer et al JAMA, etc.). Anything above that would be difficult to defend. But as lobelsteve mentioned.. no reason you can't be even safer and go lower.
Click to expand...
Multimodal said:
^ this is what I use too. last thing I want is to worsen that pressure with a needle poke and land in stroke-town(not the place in the red light district). on a side note, I also cancel if glucose over 180 for cases that involve an incision and 250 for RFA. but i usually give them a little insulin and monitor postop again too if too high.
Click to expand...

The Fleischer article does a nice job of summarizing the literature. At the same time, it's 20 years old and an expert opinion of 1. Anybody have a more recent paper on the subject that they like?

Gnarvin said:
As an EM physician, if you want to make that call that is great. But I am not going to accept the risk if anything were to happen with the patient that I didn't more fully evaluate the patient for end organ damage than just ask about symptoms. I agree it is CYA medicine, but I have seen people get sued for a lot less.
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I hear you. There is unfortunately risk with any medical decision and we can all be sued for anything. "Dr, Gnarvin, can you tell the court why you sent your asymptomatic patient with long-standing htn to the ER where the solo NP on duty gave 40mg of hydralazine which then stroked the pt out?"

I worked at a place where an ortho sent an asymptomatic htn pt into the ED and pt was seen by an old school IM-trained doc working there. Said doc succumbed to the pt/families demands to be admitted "because my specialist said my BP was an emergency!", and then said patient stroked out on the floor when the hospitalist went wild with bp meds because of BS nursing/hospital "BP requirements" for pts in med/surg beds. Family filed a suit and all 3 of these docs got named. Ortho and IM doc in the ED were eventually dropped after a year...but still. These things absolutely happen.

I've seen several cases of watershed infarcts 2/2 overzealous treatment of asymptomatic BPs and other M&M worthy misadventures including a patient who, at the end of the "asymptomatic 190/80 is an emergency right now" rainbow wound up getting a cath during which there was a coronary aa perf-- massive MI and subsequent ICM. And then there's the excess risk posed to these patients by just being admitted to the hospital ie chance of serious adverse event/care error / hospital-acquired infection / injury just by being admitted. I usually quote patients a risk of ~0.5-2% risk/admission (per To Err is Human report, but other studies quote much higher incidence) to explain to pts why I don't want to admit them and then most get on board with being discharged.

So can you send an asymptomatic pt to the ED? Sure. But recognize that if the patient is asymptomatic, sending them into a hospital may well cause them more harm than good and you will have helped push that boat off to sea. Or at best, your patient will only get a 1k bill for their 5 hour stay in the WR + 10 minute stay in an ER hallway bed where the ER doc (doc, if they're lucky) will confirm they're asymptomatic and then immediately discharge them home with instructions to f/u w/their pcp.

I do agree that the med-mal situation is out of control in many states. Rather than sending asymptomatic htn patients into the ED, another option to protect yourself and these patients is to have your staff call their pcp's office (if you can't speak directly to the pcp on the phone) and ask them to be seen in the next few days and give the patient very strict instructions for pcp f/u as well as on when they should call 911/go to the ER immediately (ie cp, sob, any other new symptoms / concerns). Documenting this (quick macro) will offer you protection as well.
 
the office is the correct initial location for an asymptomatic patient to be seen. urgent care is also appropriate.

recheck blood pressure, look for symptoms. arrange follow up, instruct on low salt diet and weight loss.

however, i am worried about any cavalier attitude regarding asymptomatic hypertension.


i have seen enough cases of patients with "asymptomatic hypertension" who ultimately stroked out because the hypertension was not considered important.

as a guideline: ya 70+ year old with asymptomatic hypertension - ensure close outpatient follow up. probably chronic due to vascular atherosclerosis. has probably been living at that level for years. recheck BP in PCP office before starting meds.


do not do that with a < 50 year old. they should be seen asap.
 
GatorCHOMPions said:
In the EM world this is called asymptomatic hypertension, and I would stop sending them into the ER. If they wind up in the ER the overly cautious physicians may check labs and an EKG for medicolegal purposes to assess "end organ damage" but when the patient invariably has a little non-specific t-wave inversion or bump in creatinine (that they've likely had for months/years) you are in a bind. Thus most colleagues won't even do that and automatically discharge home shortly after the patient checks in - assuming they are asymptomatic.
Click to expand...
I agree that it can be treated outpatient most of the time, but it needs close follow up. Admission is silly as we are supposed to slowly decrease BP.

Patient I had recently was sent from rehab to me with this pressure, how does this happen? She’s just hanging out with 200/100 pressures all day. I’ve tried calling PCP offices to arrange follow up and continuity of care, what always happens is I get a nurse or secretary, I explain t he situation, ask for a call back, patient waits a while, and I get a call back the next day or in 2 days or something by the PCP.

The outpatient PCP offices don’t have capacity for urgent visits.

I’m curious from the ED side, you guys tell them to see their PCP, how often do they end up getting this follow up? Do you guys follow up on these patients?
 
dipriMAN said:
I agree that it can be treated outpatient most of the time, but it needs close follow up. Admission is silly as we are supposed to slowly decrease BP.

Patient I had recently was sent from rehab to me with this pressure, how does this happen? She’s just hanging out with 200/100 pressures all day. I’ve tried calling PCP offices to arrange follow up and continuity of care, what always happens is I get a nurse or secretary, I explain t he situation, ask for a call back, patient waits a while, and I get a call back the next day or in 2 days or something by the PCP.

The outpatient PCP offices don’t have capacity for urgent visits.

I’m curious from the ED side, you guys tell them to see their PCP, how often do they end up getting this follow up? Do you guys follow up on these patients?
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When I made my comments above, I assumed the scenario in question involved an outpatient/elective procedure type of environment. While my pain experience is limited, all those patients seem to already have a PCP who they can see within 2-3 weeks. If the patient says they can reasonably make a follow up appointment with their PCP within that timeframe, I would document it and move on. If they cannot, I would suggest they go to an urgent care/ER, document that, and have the patient say they were sent in because they have poor access to follow up. That will speak our (ER) language and is a lot more reasonable of a situation to do a basic work up and maybe initiate BP management.

Most of my ER work was in an inner city environment and most of the time they had piss poor access to PCP follow up so I have done a basic work up on many patients with asymptomatic HTN (checked it at a CVS machine or something). However I also saw plenty of visits from patients sent in by their PCP of all people, even some within the same hospital network, whom I promptly discharged within a few minutes. Below are a couple of clinical policies from ACEP addressing this issue so there is some "protection" provided here. Note Level C evidence, but nevertheless I and most of my colleagues follow this and do not feel we are taking a huge risk.

Asymptomatic Elevated Blood Pressure

Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure (Hypertension)
www.acep.org www.acep.org
 
you can "initiate" care in patients such as this by simply instructing them (and maybe printed instructions) on a low salt diet and weight loss.


most PCPs initiate BP treatment if + risk factors or symptoms, or repeated elevated BPs. one key is making sure someone definitely has elevated BP and not "white coat hypertension", so repeated BP checks may be done before starting.

low salt doesnt always work.

true story - patient would get admitted to ICU for a couple of days with CHF, always after he binged at McD. i saw him like 3-4 times during a 2 month ICU rotation.

a few months later, i saw him in ER. he had stayed out of ICU, and he was proud of that and he said that he took my advice and "i stopped putting salt on my (McD) fries"...
 
Ducttape said:
you can "initiate" care in patients such as this by simply instructing them (and maybe printed instructions) on a low salt diet and weight loss.


most PCPs initiate BP treatment if + risk factors or symptoms, or repeated elevated BPs. one key is making sure someone definitely has elevated BP and not "white coat hypertension", so repeated BP checks may be done before starting.

low salt doesnt always work.

true story - patient would get admitted to ICU for a couple of days with CHF, always after he binged at McD. i saw him like 3-4 times during a 2 month ICU rotation.

a few months later, i saw him in ER. he had stayed out of ICU, and he was proud of that and he said that he took my advice and "i stopped putting salt on my (McD) fries"...
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From what I recall, both exercise and DASH diet have very modest effect on BP, like drop it less than 10 mm. I don’t think low salt diet qualifies are standard of care when someone’s pressure is at hulk levels.
 
Does anyone have references handy for aborting procedures based on 180/100?

Do you provide this info to your pts prior to the procedure, eg "your procedure will be cancelled is your BP is xyz or your blood glucose is xyz"?
 
dipriMAN said:
From what I recall, both exercise and DASH diet have very modest effect on BP, like drop it less than 10 mm. I don’t think low salt diet qualifies are standard of care when someone’s pressure is at hulk levels.
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we are not making long term treatment for these patients. you are not going to be prescribing their antihypertensive medications.

fwiw, ACP still recommends weight loss, dietary changes, and exercise.


the exact wording:
Physicians should consider treatment with nonpharmacologic options, including weight loss, dietary changes, and an increase in physical activity, initially or concurrently with pharmacologic treatment.
Click to expand...
 
hyperalgesia said:
Does anyone have references handy for aborting procedures based on 180/100?

Do you provide this info to your pts prior to the procedure, eg "your procedure will be cancelled is your BP is xyz or your blood glucose is xyz"?
Click to expand...
no hard or fast rules, only "guidelines" or suggestions.

for example:
The AoA/BHS guidance advises that patients whose blood pressure in the community is <160/100 mmHg may be referred for elective surgery without delaying for further investigation or treatment of their blood pressure.4 In patients who are referred for elective surgery without a community blood pressure reading, surgery can proceed provided that the blood pressure measurement in the pre-assessment clinic is <180/110 mmHg. If the blood pressure is >180/110 mmHg, the guidelines suggest that surgery should ideally be delayed, allowing antihypertensive treatment to be initiated.
Click to expand...


----
hyperalgesia said:
Does anyone have references handy for aborting procedures based on 180/100?

Do you provide this info to your pts prior to the procedure, eg "your procedure will be cancelled is your BP is xyz or your blood glucose is xyz"?
Click to expand...
some of this can be avoided during the pre procedure visit. i will occasionally not offer injection until someone gets those issues under control beforehand and i do tell patients to take their meds in the AM to avoid having cases cancelled.
 
Ducttape said:
no hard or fast rules, only "guidelines" or suggestions.

for example:



----

some of this can be avoided during the pre procedure visit. i will occasionally not offer injection until someone gets those issues under control beforehand and i do tell patients to take their meds in the AM to avoid having cases cancelled.
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That means we need to start checking BP again.
I stopped checking it in clinic to speed up intake since it isn't counted for billing.
I just let them know to take their meds and if they can check at home the morning of procedure because if they come in high, we need to reschedule.
 
Just had to cancel an RFA on a asymptomatic guy who was hanging out at 180-190/110-120. Couldn’t get it to come down so told him to fu with PCP this week and call is when it’s better. Hate to cancel
 
I use 200/100 as my cutoff, but it’s BS bc it’s merely procedural anxiety 98% of the time and I can’t imagine the effect of steroids increasing the BP faster than them going home and getting away from me, which is all they need anyways.
 
powermd said:
Don't take a temperature....
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Always take a temp. That saved me from doing a repeat ESI on a guy who had retroperitoneal abscess. I was getting ready to inject but the temp made me rethink things.
 
clubdeac said:
Always take a temp. That saved me from doing a repeat ESI on a guy who had retroperitoneal abscess. I was getting ready to inject but the temp made me rethink things.
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Uhh..

The Fat Man's Laws of the House of God:

  1. GOMERS don’t die.
  2. GOMERS go to ground.
  3. At a cardiac arrest, the first procedure is to take your own pulse.
  4. The patient is the one with the disease.
  5. Placement comes first.
  6. There is no body cavity that cannot be reached with a #14G needle and a good strong arm.
  7. Age + BUN = Lasix dose.
  8. They can always hurt you more.
Roy Basch’s Further Laws:

  1. The only good admission is a dead admission.
  2. If you don’t take a temperature, you can’t find a fever.
  3. Show me a BMS (Best Medical Student) who only triples my work, and I will kiss his feet.
  4. If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there.
  5. The delivery of good medical care is to do as much nothing as possible.
 
powermd said:
Uhh..

The Fat Man's Laws of the House of God:

  1. GOMERS don’t die.
  2. GOMERS go to ground.
  3. At a cardiac arrest, the first procedure is to take your own pulse.
  4. The patient is the one with the disease.
  5. Placement comes first.
  6. There is no body cavity that cannot be reached with a #14G needle and a good strong arm.
  7. Age + BUN = Lasix dose.
  8. They can always hurt you more.
Roy Basch’s Further Laws:

  1. The only good admission is a dead admission.
  2. If you don’t take a temperature, you can’t find a fever.
  3. Show me a BMS (Best Medical Student) who only triples my work, and I will kiss his feet.
  4. If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there.
  5. The delivery of good medical care is to do as much nothing as possible.
Click to expand...
Ah yes I missed that
 
So how many people do routine BP on table vs not? Pulse ox? EKG? My partner and I have differing opinions on the necessity of this.
 
If it’s done in a facility, all kinds of unnecessary checking and rechecking of vital signs will be performed to justify the facility cost. Most of it if not all is overkill for 95% of what we do
 
drrosenrosen said:
So how many people do routine BP on table vs not? Pulse ox? EKG? My partner and I have differing opinions on the necessity of this.
Click to expand...
Check BP before and after… cut off before is the definition of hypertensive urgency. After is to make sure they don’t drop bp and then vagal as they walk out. During procedure monitor O2 and pulse.

Cya stuff…
 
- BG makes a difference on diabetics. My cutoff is 250 (taking into account HgbA1c, not just having eaten right before)
- agree on BP for hypertensive urgency
- pulse ox only if sedation
- BP- I believe it’s changed management before. I have gotten people to talk to PCP for chronic management. It’s same as checking for depression screening - can help if healthcare done in massive way
 
Can someone explain why you would follow pulse ox and vital during a routine spine procedure?
 
SSdoc33 said:
paywall. whats the conclusion?
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7000 patients with ~1200 patients with SBP >210 or DBP >120 at Penn over 5 years - no severe/bad outcomes regardless of BP if patient asymptomatic pre-procedure.

FM/IM recommend against referral to ER with hypertensive urgency (asymptomatic BP >180/120). Just regular follow up as outpatient and gradual reduction of BP over time.

* edited for more detail
 
Last edited:
Colleague did procedure in hypertensive patient.

Patient admitted to hospital the next day with stroke like symptoms.


Another partner did esi. Didn't see hgA1C a week before was 9+ (I'm not in office so I can't look up exact numbers).

Patient admitted to hospital couple of days later with BGs of 600+, admitted to icu for ketoacidosis.


It's a balancing act. Don't check if that is your wont but don't be surprised when something bad happens.

And the high BP is not an indication that patient has to go to ER. But there is good anesthesia evidence that hypertensive patients have increase complications with surgery. That is the reason to reschedule procedures.
 
Ducttape said:
And the high BP is not an indication that patient has to go to ER. But there is good anesthesia evidence that hypertensive patients have increase complications with surgery. That is the reason to reschedule procedures.
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I know being a Pain Surgeon is all the rage these days, but bread and butter procedures are hardly surgery.
 
they aren't office visits. There are definite risks.


And if we continue to degrade our procedures to make them simpler, insurance companies et al will continue to reduce payments because they are so simple and should cost less and less...
 
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