Choosing wisely Campaign by ASA

[seinfeld]

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http://www.asahq.org/For the Public and Media/Press Room/ASA News/Choosing Wisely.aspx

From the ASA campaign the top 5

1. Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery – specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal.
2• Don’t obtain baseline diagnostic cardiac testing (trans-thoracic/esophageal echocardiography – TTE/TEE) or cardiac stress testing in asymptomatic stable patients with known cardiac disease (e.g., CAD, valvular disease) undergoing low or moderate risk non-cardiac surgery.
3• Don’t use pulmonary artery catheters (PACs) routinely for cardiac surgery in patients with a low risk of hemodynamic complications (especially with the concomitant use of alternative diagnostic tools (e.g., TEE).
4• Don’t administer packed red blood cells (PRBCs) in a young healthy patient without ongoing blood loss and hemoglobin of ≥ 6 g/dL unless symptomatic or hemodynamically unstable.
5• Don’t routinely administer colloid (dextrans, hydroxylethyl starches, albumin) for volume resuscitation without appropriate indications.


Any objections?

I can tell you that many of colleagues will cancel/delay a cases for #2. Most want cardiology to comment of likelihood of an event.

#3 I still have trouble convincing our surgeons that a PAC in not needed in healthy mitral valve patients let alone CABG or AVRs

#5 i am in complete agreement with, Albumin is way overused and many still quote a 3:1 replacement when the SAFE trial showed in sepsis it was more like 1.4:1

 

[Idiopathic]

agree with all of these, and this is how i practice

i will give colloids if i feel they are warranted. there is no data to suggest that i shouldnt, and i understand the cost aspect. almost everything i do in a resuscitation scenario is goal-directed, so i dont engage in this haphazardly. ill go to pressors quicker than others as well, in order to give a lower volume of intravenous fluids. the routine use of albumin, etc. is not indicated, although i suppose if cost were the same, we would use a lot more of it, right?

 

[Southpaw]

I'm in agreement with all of it. A good number of my partners would cancel/delay for #2. For #3, in residency we got to the point where we weren't putting PACs in our 'healthy' heart patients. Guess what? The surgeons would put them in 'post-op' because they liked to hear the numbers when called late at night with issues. Personally, if the surgeon says they're going to put one in regardless, I'd just as well put it in when the central line goes in in the OR because I always felt that's when we were most sterile.

 

[DrRobert]

Of course all of these are reasonable and good practice.

The elephant in the room is that these recommendations are based in an ideal world where trial lawyers don't exist.

The question is... are you willing to risk a career/life-threatening lawsuit by not doing these things? (especially cardiac workups)

I practice in the real world. Therefore, if the decision comes down to lawsuit aversion vs. cost savings and good practice, I will choose lawsuit aversion every single time.

 

[RxBoy]

http://www.asahq.org/For the Public and Media/Press Room/ASA News/Choosing Wisely.aspx

4• Don’t administer packed red blood cells (PRBCs) in a young healthy patient without ongoing blood loss and hemoglobin of ≥ 6 g/dL unless symptomatic or hemodynamically unstable.

Is 6 the new cutoff? 7 was the magic number like 2 years ago when I kept up with all the critical care studies. So are people waiting until they see hgb 5.9 (if stable) and less to transfuse?

Of course all the studies go out the window once the pt is unstable.

 

[Idiopathic]

its fairly arbitrary. im not sure anyone will be able to do the study determining exactly where the Hg cutoff is for morbidity/mortality, but honestly 6 is probably as good as 7 and it could save a lot of transfusions (and potential complications) for those with HCT right at 20

 

[Idiopathic]

but its so vague, honestly - first of all, i think many of these apply to routine OR cases, not critically ill patients; second, any of us could come up with a "symptom of anemia" to justify tranfusion at 6.5-7.5, so really, these just encourage you to think about your therapeutic goals, which is always a good idea.

 

[Pooh & Annie]

agree with all of these, and this is how i practice

i will give colloids if i feel they are warranted. there is no data to suggest that i shouldnt, and i understand the cost aspect. almost everything i do in a resuscitation scenario is goal-directed, so i dont engage in this haphazardly. ill go to pressors quicker than others as well, in order to give a lower volume of intravenous fluids. the routine use of albumin, etc. is not indicated, although i suppose if cost were the same, we would use a lot more of it, right?

Understood, but pressors without adequate resuscitation is something I always try to avoid. If the goal is end organ perfusion, which I'm sure it is, there's a real good chance pressors will only make things worse.

 

[Idiopathic]

theres data that suggests that you are okay to press at a low dose rather than give that extra liter of fluid, especially in abdominal surgery. admittedly, you should avoid this in cases of gross hypovolemia/underresuscitation/shock, but frequently, these OR patients who are suffering more from insensible/third space losses, so theres not much reason you cant do both in a thoughtful manner.

 

[urge]

Is 6 the new cutoff?

I work with plenty of these people who advocate 18% hematocrit as a transfusion trigger. Somehow their patients always end up transfused and with a hematocrit in the mid 30s.

It's just talk.

 

[Gimlet]

Bummer, when I saw the thread about a "Choosing Wisely" campaign from the ASA I was hoping it would be directed at patients for making sure an anesthesiologist will be involved in their care when planning a surgery. Oh well.

 

[norwood]

#1, absolutely. Of course, Murphy's Law dictates that if any patient comes in with the E-ticket workup already done, it will be a PS1 marathon runner.

#2 really depends on the situation. There's "asymptomatic despite routinely doing 10 METS" - in which case, do not pass go, do not collect $200, go directly to the OR - and there's asymptomatic because the patient is bedbound or so sedentary that he essentially never asks anything of his heart. Likewise, there's well-and-truly low risk surgery (cataract under eyedrop block), and then there's a vast expanse of "moderate risk." Combining moderate risk with the aforementioned sedentary pt? Yep, I wouldn't mind a look at the heart.

#3 seems reasonable.

#4 - I too wonder when the cutoff went from 7 to 6. In practice, if the patient is that young and that healthy, I'll go by clinical appearance as long as he's not actively losing blood.

And #5 - Well, sure, if there truly aren't any indications. But I'd say it's usually indicated when we're doing it.

 

[epidural man]

Bummer, when I saw the thread about a "Choosing Wisely" campaign from the ASA I was hoping it would be directed at patients for making sure an anesthesiologist will be involved in their care when planning a surgery. Oh well.

HAHA. me too.