Case

[PPAnesthesia]

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Long time lurker, first time poster. I had this case last week. What would you do? Pre-op, induction, maintenance, post-op?

91 year old male with cholecystitis is scheduled for laparoscopic cholecystectomy. PMH: CAD s/p bypss 20 years ago. Had a NSTEMI 4 months with DES in RCA. LIMA to LAD is occluded and no intervention possible. TTE 4 months ago: EF 25-30%, mild AS (AVA 1.7 cm sq, 7 mm hg gradient), diastolic dysfunction. TTE 1 week ago: EF 55%, mild AS (AVA 1.7 cm sq, 7 mm hg gradient), diastolic dysfunction. He is bed bound due to arthritis and doesn't have much in terms of functional capacity. He is on ASA 81 mg and Plavix 75 mg but Plavix was stopped 3 days ago and now he is on a heparin drip as recommended by cardiology. Heparin drip was stopped 8 hours prior to scheduled surgery. Other medical history includes HTN, hyperlipidemia, osteoarthritis, history of prostrate cancer and mild dementia. Cardiology pre-op "clearance" note states he is moderate-high risk for surgery and don't recommend any further tests for now. Surgeon states he has no other option bedsides surgery and insists to operate. Also, patient is DNR and family will not rescend the DNR for surgery. Surgeon is okay with this. Family, patient and surgeon aware of risks and complications and want surgery.

What else would you like to know before proceeding either way? If you cancel, what else would you want prior to proceeding? If you don't cancel, how do you induce, maintain and recover this patient?

 

[deleted171991]

No elective surgery for 12 months after DES. Next!

If emergent, have the surgeon document it (only things like cholecystitis which is not responsive to antibiotics, gangrene or choledocolithiasis with cholangitis should qualify as such, not patient discomfort or recurrence). Also document why he cannot wait at least another 2 days off-Plavix.

Also, if the surgeon is not good at laparoscopy, ask him to designate one of his better partners to perform the surgery. No games on cardiac 91 year-olds.

Otherwise: pent + sux + tube, frequent NIBP monitoring (maybe A-line for peace of mind).

BTW, I would personally not perform any elective surgery where the patient wants to be DNR for the duration of the surgery. No suicide by anesthesia, thank you very much.

 

[Spinach Dip]

Tell the surgeon: "I don't feel comfortable given all his comorbidities, but I know a CRNA who would gladly take the case."

 

[Planktonmd]

They need to sign a form stating that you are allowed to resuscitate the patient intra-op or no surgery.
Otherwise I don't see why you want to delay or cancel?
Put him to sleep gently and keep everything to a minimum.

 

[pgg]

In before urge ... pent sux tube. Just a smooth GETA, extubate to PACU. Assuming it's not "elective" ...

Edit - as for the DNR nonsense, tell the family that he'll be intubated for surgery and you'll treat any anesthesia- or surgery- related derangements in vitals. Obviously a DNR/DNI form in the chart doesn't preclude intubation for surgery the patient has consented for.

 

[norwood]

BTW, I would personally not perform any elective surgery where the patient wants to be DNR for the duration of the surgery. No suicide by anesthesia, thank you very much.

Yep.

And +1 to having the surgeon document why this particular gallbladder isn't elective.

 

[DrBeaker]

Patient had a normal AV gradient but mild AS by valve area. Most likely this is due to measurement error of the LVOT diameter and I bet there is no AS (though I don't care about mild either). There are three grades of diastolic dysfunction and 2 of them involve elevated filling pressures, I need to know exactly where he is.

Plavix still helping us, and now heparin drip too. Whatever. He should have still been on DAPT. How good is this surgeon, and how likely to open given his skill and the bleeding from the liver that will ensue?

But I guess first and foremost, is this an emergency? Can we do anything else like a perc drainage? Ideally wait 12 months after a DES, possibly 6 months according to some newer data coming out. If not, he doesn't get surgery with me unless he suspends the DNR.

Awake arterial line, gentle induction. I don't think anything crazy if this is truly an emergency.

 

[deleted59964]

surgeon documents it's emergent or it's off.

discussion with family/patient - I will respect wishes of DNR, however there is no clear line between what is anaesthesia and what is resuscitation - so I will do what I need to do in order to give best chance of getting through surgery ... DNR restarts in PACU, don't agree - I can't give an anaesthetic then.

pre-induction art line
fentanyl heavy, propofol light induction
clear plan for when to restart clopidogrel in place, as determined by surgeon and cardiologist.

 

[BLADEMDA]

Nice posts so far. Here is how I handle it.

1. We are supposed to wait 6 months after the DES before doing any semi-elective surgery so surgeon must document Emergency Surgery before we proceed.
2. Being off plavix for 3 days may be long enough or he could need another day or two. I'd discuss this with the surgeon and run a Verify Now Plavix Now test. http://www.accumetrics.com/products/verifynow-prutest
3. Discuss increased risk of MI, Stent thrombosis and worsening dementia with the Family. It could be rough postop for the family.
4. Arterial Line pre-induction with good IV access.
5. Gentle Induction with Ketamine 30 mg, Fentanyl 50 ug, Propofol 40 mg and VEC/ROC followed by Intubation.
6. BIS monitor to limit exposure to volatile anesthetic and perhaps decrease postop morbidity

This guy isn't too different from cases which I see quite regularly in my practice. At my hospital all consents clearly state DNR is suspended intraop and in the PACU. You can't ethically do the case with the DNR intact as the anesthetic may be the cause of his downward spiral.

 

[BLADEMDA]

Br J Anaesth. 2011 Dec;107(6):966-71. doi: 10.1093/bja/aer298. Epub 2011 Oct 3.
Determination of residual antiplatelet activity of clopidogrel before neuraxial injections.
Benzon HT1, McCarthy RJ, Benzon HA, Kendall MC, Robak S, Lindholm PF, Kallas PG, Katz JA.
Author information

Abstract
BACKGROUND:
Guidelines recommend discontinuation of clopidogrel for 7 days before a neuraxial injection, while other directives suggest that 5 days might be adequate. We examined the time course of antiplatelet activity after clopidogrel discontinuation in patients undergoing epidural injections.

METHODS:
Thirteen patients were studied at baseline, 3, 5, and 7 days after discontinuation of clopidogrel. P(2)Y(12) determinations were performed using the VerifyNow(®) assay (Accumetrics, San Diego, CA, USA), and clot closure times with stimulation by collagen/epinephrine and collagen/adenosine diphosphate using the PFA-100(®) (Platelet Function Analyzer, Siemens Diagnostics, Deerfield, IL, USA). Repeated-measures ANOVA was used to evaluate P(2)Y(12) platelet reaction units, PFA-100 closure times, and per cent P(2)Y(12) inhibition values. Wilcoxon's signed-rank test was used to compare the frequencies of ≥30%, 11-29%, and ≤10% platelet inhibition between the baseline and subsequent sampling points after discontinuation of clopidogrel.

RESULTS:
On day 3 after clopidogrel discontinuation, two subjects had ≥30%, seven subjects had 11-29%, and four subjects had ≤10% platelet inhibition; the corresponding numbers were 0, 3, and 10 subjects on day 5 (P=0.04). There were no differences between the ≥30%, 11-29%, and <10% platelet inhibition groups between days 5 and 7 (0, 0, and 13 subjects, P=1.0). PFA-ADP closure times were normal throughout the study period except in one patient.

CONCLUSIONS:
These findings support the recommendation that discontinuation of clopidogrel for 5 days allows >70% of platelet function and might be adequate before a neuraxial injection is performed.

 

[BLADEMDA]

http://forums.studentdoctor.net/threads/cardiac-stent-elective-case.1111815/#post-15988437

Please read this thread.

 

[BuzzPhreed]

Long time lurker, first time poster. I had this case last week. What would you do? Pre-op, induction, maintenance, post-op?

91 year old male with cholecystitis is scheduled for laparoscopic cholecystectomy. PMH: CAD s/p bypss 20 years ago. Had a NSTEMI 4 months with DES in RCA. LIMA to LAD is occluded and no intervention possible. TTE 4 months ago: EF 25-30%, mild AS (AVA 1.7 cm sq, 7 mm hg gradient), diastolic dysfunction. TTE 1 week ago: EF 55%, mild AS (AVA 1.7 cm sq, 7 mm hg gradient), diastolic dysfunction. He is bed bound due to arthritis and doesn't have much in terms of functional capacity. He is on ASA 81 mg and Plavix 75 mg but Plavix was stopped 3 days ago and now he is on a heparin drip as recommended by cardiology. Heparin drip was stopped 8 hours prior to scheduled surgery. Other medical history includes HTN, hyperlipidemia, osteoarthritis, history of prostrate cancer and mild dementia. Cardiology pre-op "clearance" note states he is moderate-high risk for surgery and don't recommend any further tests for now. Surgeon states he has no other option bedsides surgery and insists to operate. Also, patient is DNR and family will not rescend the DNR for surgery. Surgeon is okay with this. Family, patient and surgeon aware of risks and complications and want surgery.

What else would you like to know before proceeding either way? If you cancel, what else would you want prior to proceeding? If you don't cancel, how do you induce, maintain and recover this patient?

I will tell you what I would do if you explain the importance of all those things first. Thank you in advance. (Sorry, you got no "street cred" coming here with one post.)

Otherwise... Short answer? I don't need to know anything else. The dude is a demented 91 year-old with a DNR. This is what we call in the parlance a "no brainer". Total wallet biopsy going on here. You can't bill a dead patient after all.

Or, if (as I suspect) you are a CRNA masquerading as a physician on this forum, are you going to suggest that we should do some additional million-dollar work-up on this patient? Please enlighten us. (Sorry, you got no "street cred" with your one post.)

 

[B-Bone]

I'm surprised to hear so many people refuse to honor a DNR in the OR. At my current facility as well as my training institution, it's considered completely reasonable for patients to maintain DNR status through the perioperative period. It's kind of rare, but I probably do it once or twice a month. I just have a frank discussion about their wishes, explain that anesthesia may cause reversible physiologic derangements, and figure out what they want me to do in the event of an emergency. The most common request is "do everything you can, but no chest compressions or defibrillation". I frequently offer that I would treat everything I consider reversible and related to anesthesia, but stop short of futille measures. I then document all this on the preop. DNR folks wear a purple armband in our hospital, and those who've rescinded their DNR for the perioperative period get an additional orange wristband that gets cut off on leaving the PACU (indicating that their DNR is back in place). I think it's important to note that patients have the right to refuse some interventions while accepting others. I found this was explained well in a thread on AMA sign-outs in the EM forum.

 

[PPAnesthesia]

I will tell you what I would do if you explain the importance of all those things first. Thank you in advance. (Sorry, you got no "street cred" coming here with one post.)

Otherwise... Short answer? I don't need to know anything else. The dude is a demented 91 year-old with a DNR. This is what we call in the parlance a "no brainer". Total wallet biopsy going on here. You can't bill a dead patient after all.

Or, if (as I suspect) you are a CRNA masquerading as a physician on this forum, are you going to suggest that we should do some additional million-dollar work-up on this patient? Please enlighten us. (Sorry, you got no "street cred" with your one post.)

I will have to earn the "street cred" I guess. No, I am not a CRNA masquerading as a physician here. I've been honest with everything up there. I'm one of the newer attendings and I don't have much experience in dealing with all these issues on my own. As a resident there's plenty of time for mental jerking but in private practice world things just happen. The case was interesting and I decided to see what everyone else thought about multiple issues presented in the case. So here's what finally happened. I had a discussion with the surgeon, family and patient about alternatives to surgery. I emphasized the DES duration and the chances of stent thrombosis and reinfarction. Surgeon insisted there were no alternatives and that this is an emergency. I discussed the issue of DNR during anesthetic and we agreed to rescend it during the operation. He had good IV access. I placed an awake arterial catheter, gentle induction with propofol, fentanyl, phenylephrine, some esmolol before laryngoscopy. His BP was stable throughout and HR stayed in the 60s. Surgery was quick and done in 40 minutes. He maintained his pressures and HR throughout and was successfully extubated. DNR went back postop in telemetry.

Thanks for all the posts so far.

 

[deleted171991]

I'm surprised to hear so many people refuse to honor a DNR in the OR. At my current facility as well as my training institution, it's considered completely reasonable for patients to maintain DNR status through the perioperative period. It's kind of rare, but I probably do it once or twice a month. I just have a frank discussion about their wishes, explain that anesthesia may cause reversible physiologic derangements, and figure out what they want me to do in the event of an emergency. The most common request is "do everything you can, but no chest compressions or defibrillation". I frequently offer that I would treat everything I consider reversible and related to anesthesia, but stop short of futille measures. I then document all this on the preop. DNR folks wear a purple armband in our hospital, and those who've rescinded their DNR for the perioperative period get an additional orange wristband that gets cut off on leaving the PACU (indicating that their DNR is back in place). I think it's important to note that patients have the right to refuse some interventions while accepting others. I found this was explained well in a thread on AMA sign-outs in the EM forum.

I refuse to honor an absolute DNR: " If anything happens, just let me die."

I will honor any reasonable wishes related to futile care. Usually, my patients and I end up agreeing that I am allowed any short-term measures I deem necessary, if I think that the condition is pretty much reversible with short-term treatment without any significant sequelae. I treat my patients wishes as I would like to be treated in their place, but I always explain to them that I cannot put them at risk of death with no possibility to intervene. That's just not in my menu.

 

[pgg]

Nice, well done.

I'm surprised to hear so many people refuse to honor a DNR in the OR.

I don't follow you.

If I take a DNR'd patient to the OR, induce general anesthesia ... he'll be DEAD in minutes unless I support his life with some combination of drugs and ventilation management that likely involves placing some kind of plastic in his airway and connecting him to a machine. What does "DNR" mean in the context of anesthesia for a surgical procedure? No tube? No drugs? No ACLS? No chest compressions?

If things go wrong in the OR with a high risk patient with a DNR, I'm going to support life as best I can until the patient gets out of the OR and to the ICU, because the immediate insult causing instability and a circle around the drain is ME and my anesthesia (and/or the surgeon). If the family wants to withdraw care later, that's OK.

Most patients and families who object to rescinding DNR in the OR don't really get this dynamic. So this is what I tell them: No. I will conduct the anesthetic as safely and comfortably as I can, and do all I can to get him safely out of the OR, including intubation, drugs, and ACLS. If he survives to the ICU and his condition at that time conflicts with documented wishes or the appropriately empowered family member's interpretation of those wishes, THEN they can choose to withdraw care.

There should be no rush to withdraw or withhold care in the short time a patient is in the OR.

This isn't a negotiation; if they don't like it, I won't do the case. I'm not in the assisted suicide business.

 

[urge]

In before urge ... pent sux tube. Just a smooth GETA, extubate to PACU. Assuming it's not "elective" ...

Edit - as for the DNR nonsense, tell the family that he'll be intubated for surgery and you'll treat any anesthesia- or surgery- related derangements in vitals. Obviously a DNR/DNI form in the chart doesn't preclude intubation for surgery the patient has consented for.

Well done.

Pent Sux Tube

Agree with surgeon documenting emergency. I would discuss with family doing all interventions possible but no actual chest compressions if they insist on the DNR.

 

[urge]

I will have to earn the "street cred" I guess. No, I am not a CRNA masquerading as a physician here. I've been honest with everything up there. I'm one of the newer attendings and I don't have much experience in dealing with all these issues on my own. As a resident there's plenty of time for mental jerking but in private practice world things just happen. The case was interesting and I decided to see what everyone else thought about multiple issues presented in the case. So here's what finally happened. I had a discussion with the surgeon, family and patient about alternatives to surgery. I emphasized the DES duration and the chances of stent thrombosis and reinfarction. Surgeon insisted there were no alternatives and that this is an emergency. I discussed the issue of DNR during anesthetic and we agreed to rescend it during the operation. He had good IV access. I placed an awake arterial catheter, gentle induction with propofol, fentanyl, phenylephrine, some esmolol before laryngoscopy. His BP was stable throughout and HR stayed in the 60s. Surgery was quick and done in 40 minutes. He maintained his pressures and HR throughout and was successfully extubated. DNR went back postop in telemetry.

Thanks for all the posts so far.

This is not a particularly complicated case intra op. Basically a low EF patient which we should all be able to handle. The headache is post op if the stent clots, of if he has a good ol' MI. There is really not much that you can offer this patient. The key is to make the family aware that their relative is at the end of the road.

 

[BuzzPhreed]

I will have to earn the "street cred" I guess. No, I am not a CRNA masquerading as a physician here.

No problem. There have been CRNAs that have come here trying to "teach us how much smarter" they are by playing games with cases, etc.

Otherwise Urge is right. The issue with the drug-eluting stents is usually in the post-op period. But as I said before -- this case is a no-brainer.

 

[Ronin2258]

I would ask the surgeon if a cholecystostomy tube would be better. IR could place one easily, with less morbidity than a cholecystectomy.

The DNR/DNI has to be rescinded. WE have to put the tube in (the "I") and have to keep them going (the "R.") until the case is done. I would balk at doing this case without that rescinded. I have framed it to patient's families like this:

"We HAVE to suspend the DNR/DNI to perform the case. Otherwise, everything we do as anesthesiologists violate the goals of the DNR/DNI. We will do our best to return your loved one to their baseline state, but if worse comes to worse and we have to leave the tube in, we will bring them to the ICU, and the final decision can be discussed in a less acute environment than the operating room."

And for the love of all that's holy, document the heck out of the discussion.

My intern location mandated if the patient agreed to surgery, the DNR/DNI was forced suspended from the time the come off the floor to 48 hours after they arrive back.

 

[OB1🤙]

I think-and our hospital policy supports- that patients are well within their right to decline chest compressions in the event of an unstable rhythm.

What is appropriate for each situation will depend on that patient having that surgery under that anesthetic technique.

I strongly disagree that there should just be a blanket rescinding of all aspects of DNRs just because the patient is having surgery.

 

[deleted171991]

I strongly disagree that there should just be a blanket rescinding of all aspects of DNRs just because the patient is having surgery.

Until one of your patients codes, you don't resuscitate, and the family sues you for the negative outcome, questioning every, single, minor, decision, you made during that surgery.
,
A doctor never really wins a malpractice suit, not even when it's dropped. It always takes a toll.

 

[narcusprince]

Late to this post but very interesting nonetheless. So I would ask the surgeon why can't they do percutaneous draininage on the patient? Also have interventional radiology get involved maybe they would place a perc tube. Also to the prop sux tube folks. I would not use Sux in this case this patient is bed ridden and likely may have some sensative extrajunctional receptors. Prop roc tube and a pre-induction arterial line. DNR removed for time in OR then once recovered from the anesthesia the DNR can be resumed.

 

[Shimmy8]

Just to chime in as well, our academic institution mandates and has a particular form to be filled out for rescinding DNR intra-op until they leave PACU. Don't even think we have wriggle room.

There has only been one case during residency thus far (about a month ago) where we took a young-ish ASA VE to the OR for an ex-lap and based on the pt's status at that time told the family that we would not be performing compressions due to futility, good of the patient, etc.

 

[OB1🤙]

Until one of your patients codes, you don't resuscitate, and the family sues you for the negative outcome, questioning every, single, minor, decision, you made during that surgery.

A doctor never really wins a malpractice suit, not even when it's dropped. It always takes a toll.

I couldn't disagree more. You don't get sued for malpractice in this situation. This is a hypothetical patient and family who have thought about it and specifically asked for no compressions. I have come across this situation a number of times, and not once have I worried about being sued. I have, however, been profusely thanked for giving them the option to retain some autonomy in a tough situation.

 

[deleted171991]

Have you ever had a DNR patient code during surgery and just let him die? Because that's my hypothesis.

Of course, I always respect patient autonomy. I am their number one advocate in the OR, and I let my patients feel it. This is why I haven't had (yet) a patient who would not suspend his/her DNR, at least to the level where they allowed me to resuscitate if I felt there was a good chance for recovery without major sequelae. That's all I ask for, not futile care.

 

[BLADEMDA]

If the DNR is in force for the surgery they don't need my services. If I am going to make the effort to safely anesthetize someone then I don't need my hands tied behind my back. Once we Induce the patient we have an ethical duty to see that patient through surgery to the pacu. This doesn't mean you need to do chest compressions for 30 min but sometimes one shock or a little CPR and the patient comes right back into NSR.

Im not in the business of euthanasia and I suspect most of you aren't either.

 

[Noyac]

I have to say, I have never gone to the OR with a DNR order still intact. Never.

 

[pgg]

I couldn't disagree more. You don't get sued for malpractice in this situation. This is a hypothetical patient and family who have thought about it and specifically asked for no compressions. I have come across this situation a number of times, and not once have I worried about being sued. I have, however, been profusely thanked for giving them the option to retain some autonomy in a tough situation.

I do like this sentiment, mostly. Patient autonomy and freedom to refuse care is of course the highest authority and should guide what we do whenever possible. Where I differ is that I think we need to talk to patients and families and clearly show them how a brief period of time in the OR for a procedure is a special case, and that we can honor the patient's wishes even though the DNR/DNI needs to be rescinded for surgery.


The problem is that DNR/DNI directives are kind of like ACLS, created in a context completely unrelated to and totally removed from an operating room. And this is what I mean by that -

People code in the OR for vastly different reasons than they code outside the OR. Most OR codes are iatrogenic, directly caused either by anesthesia or surgery. Rigid adherence to ACLS for a code in the operating room is probably wrong because 99 times out of 100 you're going to know exactly what caused it (you were there! it was probably something you did!) and the correct thing is to fix the underlying cause first and then consider amiodarone vs vasopressin and Hs/Ts etc. The ACLS guidelines are based on data from witnessed and unwitnessed arrests outside a hospital when care is many minutes away. In the OR with witnessed codes of a different etiology with expert doctors right there, outcomes are better and deviating from the ACLS algorithms is the right thing to do as often as not.

I communicate a similar line of thought to patients/families about rescinding DNR/DNI orders for surgery. They are invariably concerned with not wanting prolonged, futile, and especially painful care, but when you drill down to the details, the fate they're hoping to avoid isn't five minutes of resuscitation in the OR during surgery ... it's being tortured for hours or days or weeks or longer in an ICU with uncomfortable tubes and wires everywhere while they suffer the semi-conscious indignity of it all, finally culminating with chest compressions and electric shocks and more wires and tubes when they inevitably die.

What we should be doing when these patients come to the OR for a procedure, palliative or not, Hospice or not, is explaining to them that surgery and anesthesia themselves may cause temporary, but typically reversible, derangements in their physiology that can be treated with various interventions that they may not otherwise want if they were awake/semi-conscious in an ICU, and that just because they need to be intubated for surgery doesn't mean they have to be intubated for weeks if the procedure goes poorly, and just because they many need ACLS drugs for surgery doesn't mean they have to be kept alive on those drugs for days if the procedure goes poorly, and just because they code under anesthesia and need compressions while we correct a specific cause doesn't mean they have to get CPR until they die in an ICU.

If you want anesthesia and surgery, you have to agree to let me do the things necessary to counter the physiologic derangements that anesthesia and surgery cause, for the duration of the anesthesia and surgery. Or I won't do it.

 

[Oggg]

The head cardiologist at my place says that the newer (second) generation of DES stents are so good you can stop plavix sooner than one year. I think he said there is some research out there about it already but not large scale studies?

 

[OB1🤙]

Again, the discussion turns to just a blanket concept of "there is a DNR" or not.

DNRs come in all shapes and sizes. It isn't a binary, one-size-fits-all thing. Every patient has things they may or may not want. Some may not care and defer to your best judgment. Some may not be sophisticated. Some- and I've encountered this- have been coded before, know precisely what it involves, and do not under any circumstances want to experience the broken ribs and other sequelae again.

Some people have DNRs for some severe underlying medical condition- say end stage heart failure. Some people have them because they're old and demented. And some people have them even though they don't want them.

What makes this situation tough is that nobody who understands the OR has had this talk with the patient before. So you, Doctor, have to do what we usually don't find ourselves as anesthesiologists doing- you have to put on your empathy hat and have The Dying Talk with a patient who you've known for less than 5 minutes.

So I go in there. Grab a chair, sit down. Figure out where their head is at. Find a connection, establish rapport. And then go down a list of things that could happen and what you can and can't do about it. Tell them things that are reversible and caused by you, you'll fix, like giving pressors for iatrogenic low BP, blood and fluids for excessive bleeding. If the sugery mandates intubation, tell them it will be temporary for the procedure, and ask IF intubation must be continuted postop, get a sense of how long they're OK with mechanical ventilation. IF an unstable rhythm happens, and it is thought due to a reversible cause, we usually do chest compressions. Are you OK with that? Most will say yes. Some will say no. Then ask if their underlying irreversible process that has led them to have a DNR results in an unstable rhythm, would they want heroic measures then? Most will say no, some may now say yes. All should have the choice.

Most will not have had these choices framed from the point of view of the OR environment before. In fact, most are just told "if you have surgery, you must be considered full code. Period." And that's flat-out wrong IMO.

If you're thinking that, jeez, someone else should have had this talk already, it shouldn't be my job, well, I agree with you. But the thing is, they didn't. And here you are, about to go to surgery, and this is Important Stuff. So suck it up and have the talk. The family appreciates it. More than any PSH bullcrap, this makes you look like a Real Doctor in their eyes. The nurses appreciate it. Some surgeons may be oblivious and wondering why you're delaying the OR, but f them if that's the case.

The ASA, by the way, endorses this concept- link to document here- http://www.asahq.org/sitecore/shell/Controls/Rich Text Editor/~/media/For Members/Standards and Guidelines/2014/ETHICAL GUIDELINES FOR THE ANESTHESIA CARE OF PATIENTS.pdf

So again, the important thing is to figure out what the patient's individual goals of care are, to frame the conduct of the surgery to the patient with potential events given their comorbidities and the nature of the procedure, and figure out what does right by them.

It isn't binary. It isn't all or nothing.

 

[BLADEMDA]

In my small part of the world it is all or nothing. I have the "privilege" of 90 plus year old patients in the O.R. routinely. I cover 4 rooms. I'm busy. The consent says there is no DNR in the O.R. period. If you want DNR then you don't need the surgery. I hate to make things this black and white but it simplifies the process and improves consistency across all anesthetizing locations: Gi, Cath Lab, Interventional Radiology, SDS, Cardiac, OB and the Main O.R.

FYI, even a "simple" Gi procedure can lead to a full code after administering propofol to a frail, elderly patient who just had a bowel prep (one of the joys of supervising midlevels).

 

[anes]

They need to sign a form stating that you are allowed to resuscitate the patient intra-op or no surgery.
Otherwise I don't see why you want to delay or cancel?
Put him to sleep gently and keep everything to a minimum.

What's wrong with a patient remaining DNR during surgery? DNR during surgery means no heroic measures (chest compressions). Any pressor that you use during the course of a normal anesthetic is fine.

I would have had the surgeon document the urgent / emergent nature of the surgery and proceed. Induce with prop, roc, esmolol. Manage hemodynamics as routine. Extubate at the end.

I once had a case with a DNR patient. Stable throughout the case, literally during the last stitch had a v. Fib arrest. I gave pressors (which obviously wouldn't do anything), didn't shock the patient, no chest compressions. That's it, end of case.

The stance of the ASA and ACS is that DNR is to be respected throughout the surgery, unless the patient states otherwise.

 

[deleted59964]

What's wrong with a patient remaining DNR during surgery? DNR during surgery means no heroic measures (chest compressions). Any pressor that you use during the course of a normal anesthetic is fine..

What it means -- is different in every patient. you're making quite a few assumptions there.

 

[nimbus]

What's wrong with a patient remaining DNR during surgery? DNR during surgery means no heroic measures (chest compressions). Any pressor that you use during the course of a normal anesthetic is fine.

I would have had the surgeon document the urgent / emergent nature of the surgery and proceed. Induce with prop, roc, esmolol. Manage hemodynamics as routine. Extubate at the end.

I once had a case with a DNR patient. Stable throughout the case, literally during the last stitch had a v. Fib arrest. I gave pressors (which obviously wouldn't do anything), didn't shock the patient, no chest compressions. That's it, end of case.

The stance of the ASA and ACS is that DNR is to be respected throughout the surgery, unless the patient states otherwise.

What a nightmare.

Stable throughout, witnessed VFIB, good chance they would have come back with 1 or 2 shocks which would not have caused pain or suffering since they are anesthetized. Then you can treat the hyperkalemia or ischemia or whatever caused the VFIB. Defibrillation under anesthesia is not heroic, just like 1 min of CPR is not heroic. These are the easiest resuscitations around and the patients don't even know it happened until you explain it to them.

No thanks. My patients get DNR suspended for exactly this scenario. I'm not doing anesthesia standing on stilts with one eye patched and one hand tied behind my back.

 

[anes]

What it means -- is different in every patient. you're making quite a few assumptions there.

What assumptions am I making?

Anything beyond the normal scope of an anesthetic violates DNR. Any case that would, during the course of a normal anesthetic, require an endotracheal tube gets intubated (unless they refuse).

If they refuse intubation the case doesn't get done. I've had a case of a patient who was DNR / DNI who refused to change their status. Once I explained that they would require an ETT, and may remain intubated post operatively, they refused the case.

Again, anything outside of what a normal anesthetic requires will violate DNR. Starting epinephrine infusion on a patient is a violation (unless that is normal for the type of case, ie heart transplant etc). Bolusing phenylephrine is normal and does not violate DNR.

It is really that simple. A septic patient is likely to require norepinephrine infusion. You explain to the patient beforehand, and treat as per standard.

Unless your standard is chest compressions for the majority of your cases, it's easy to honor.

 

[anes]

What a nightmare.

Stable throughout, witnessed VFIB, good chance they would have come back with 1 or 2 shocks which would not have caused pain or suffering since they are anesthetized. It's not heroic, just like 1 min of CPR is not heroic. These are the easiest resuscitations around and the patients don't even know it happened until you explain it to them.

No thanks. My patients get DNR suspended for exactly this scenario.

Read the ASA and ACS guidelines. Doing even one compression/shock is a violation of patient autonomy. You can be prosecuted for battery by doing that single compression.

If you refuse to do a case without rescinded DNR, more power to you. I just don't hesitate to honor a patient's wishes.

 

[nimbus]

Read the ASA and ACS guidelines. Doing even one compression/shock is a violation of patient autonomy. You can be prosecuted for battery by doing that single compression.

If you refuse to do a case without rescinded DNR, more power to you. I just don't hesitate to honor a patient's wishes.

All DNRs are suspended in our ORs.

 

[anes]

In my small part of the world it is all or nothing. I have the "privilege" of 90 plus year old patients in the O.R. routinely. I cover 4 rooms. I'm busy. The consent says there is no DNR in the O.R. period. If you want DNR then you don't need the surgery. I hate to make things this black and white but it simplifies the process and improves consistency across all anesthetizing locations: Gi, Cath Lab, Interventional Radiology, SDS, Cardiac, OB and the Main O.R.

FYI, even a "simple" Gi procedure can lead to a full code after administering propofol to a frail, elderly patient who just had a bowel prep (one of the joys of supervising midlevels).

Agreed. The policy of the ASA and ACS is to continue DNR in the OR. However local hospital policy will trump those guidelines. At my old hospital, DNR was not changed in the O.R.unless specifically discussed. At my new hospital, DNR is automatically rescinded, regardless of patient choice. Most hospitals have a policy on DNR in the OR. I always make sure to know that policy before I do any case in a new hospital.

 

[anes]

Th

All DNRs are suspended in our ORs.

Then there is no discussion. Either the patient agrees, or no surgery.

 

[Planktonmd]

What's wrong with a patient remaining DNR during surgery? DNR during surgery means no heroic measures (chest compressions). Any pressor that you use during the course of a normal anesthetic is fine.

I would have had the surgeon document the urgent / emergent nature of the surgery and proceed. Induce with prop, roc, esmolol. Manage hemodynamics as routine. Extubate at the end.

I once had a case with a DNR patient. Stable throughout the case, literally during the last stitch had a v. Fib arrest. I gave pressors (which obviously wouldn't do anything), didn't shock the patient, no chest compressions. That's it, end of case.

The stance of the ASA and ACS is that DNR is to be respected throughout the surgery, unless the patient states otherwise.

The definition of resuscitation under anesthesia is not that simple.
Let's say the surgeon pulls on something causing a severe vagal response and asystole, you need a few chest compressions until circulation returns and for your atropine to reach it's target, will you just let the patient die because of DNR?

 

[anes]

The definition of resuscitation under anesthesia is not that simple.
Let's say the surgeon pulls on something causing a severe vagal response and asystole, you need a few chest compressions until circulation returns and for your atropine to reach it's target, will you just let the patient die because of DNR?

Let's say a patient severely vagals while the nurse on the floor is placing an IV or Foley. Do you do compressions?

Now if the on the floor nurse gives neostigmine for Ogilvies and the patient becomes bradycardia, you will administer atropine, but won't do compressions. Chest compressions never fall under the course of a normal anesthetic.

If a patient becomes brady from vagal stimulation in the or, I will give epinephrine or atropine, but I wouldn't do compressions.

For me, DNR really is that cut and dry.

 

[Planktonmd]

Let's say a patient severely vagals while the nurse on the floor is placing an IV or Foley. Do you do compressions?

Now if the on the floor nurse gives neostigmine for Ogilvies and the patient becomes bradycardia, you will administer atropine, but won't do compressions. Chest compressions never fall under the course of a normal anesthetic.

If a patient becomes brady from vagal stimulation in the or, I will give epinephrine or atropine, but I wouldn't do compressions.
For me, DNR really is that cut and dry.

So... the surgeon pulls on something, the patient goes asystolic, you give atropine (although there is no circulation to carry it), if he does not respond you let him die, is that your plan?
Also, Does DNR mean only no compressions?
Who decides what's OK and what's not?
You? The patient? the ASA?
How do you determine that a certain action or procedure is not violating the patient's wishes?

 

[anes]

So... the surgeon pulls on something, the patient goes asystolic, you give atropine (although there is no circulation to carry it), if he does not respond you let him die, is that your plan?
Also, Does DNR mean only no compressions?
Who decides what's OK and what's not?
You? The patient? the ASA?
How do you determine that a certain action or procedure is not violating the patient's wishes?

To me its not as difficult as everyone is making it. If it's something that would normally occur during a routine anesthetic, it doesn't violate DNR. It's normal to bolus atropine or glyco for bradycardia. Transcutaneous pacing, chest compressions, are not normal and violate DNR.

So say if a patient is DNR, and they have a vagal in the or. You do one single compression and the patient survives. If the patient sues you, what is your reply in court?

Now if the patient has DNR, and you don't do the compression, and the family sues, what is your response? To me, withholding compressions is defensible. Doing a compression is not. Besides, some patients may prefer to die under anesthesia. That doesn't mean I will intentionally kill them, but will honor their wishes.

 

[deleted59964]

sounds like you've got it all sorted out.

 

[epidural man]

Great discussion.

👍

 

[Planktonmd]

sounds like you've got it all sorted out.

😉

 

[madhi]

just curious, mostof the threads were mentioning the use of pentothal for induction. With this 91 yr old lady, I prefer to use Etomidate for low EF that she has. I know all the reasons of cases of post op adrenal suppression. But still it is my favourite drug for induction. I worry more about coronary perfusion during the case.

Any suggestions or advise for favouring pentothal compared to etomidate

 

[deleted171991]

just curious, mostof the threads were mentioning the use of pentothal for induction. With this 91 yr old lady, I prefer to use Etomidate for low EF that she has. I know all the reasons of cases of post op adrenal suppression. But still it is my favourite drug for induction. I worry more about coronary perfusion during the case.

Any suggestions or advise for favouring pentothal compared to etomidate

"Pent, sux, tube!" is just an old saying meaning straightforward induction (and case). We don't have thiopental in the US anymore.

 

[KungPOWChicken]

There

To me its not as difficult as everyone is making it. If it's something that would normally occur during a routine anesthetic, it doesn't violate DNR. It's normal to bolus atropine or glyco for bradycardia. Transcutaneous pacing, chest compressions, are not normal and violate DNR.

So say if a patient is DNR, and they have a vagal in the or. You do one single compression and the patient survives. If the patient sues you, what is your reply in court?

Now if the patient has DNR, and you don't do the compression, and the family sues, what is your response? To me, withholding compressions is defensible. Doing a compression is not. Besides, some patients may prefer to die under anesthesia. That doesn't mean I will intentionally kill them, but will honor their wishes.

There's no real cut and dry answer for dnr in the or. Each patient's circumstances must be taken into consideration. For example, an 84 year old with terminal pancreative cancer who has mets to her thoracic spine. Is having a palliative stent placed. Refusing chest compressions under all circumstances is reasonable. Otherwise how can a Jehovah's Witness refuse blood products. A patient can refuse certain things and if the likelihood of that event happening is low enough I think we can proceed with the patient's wishes kept in mind.