Dumb questions Part Deux (CA- 2 deux)

[DrDre']

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Been in a multi-dis pre-op clinic. Have seen a bunch of people canceled for elective surgeries with "active" medical issues, either undiagnosed, new or unstable.

Intellectually, I understand why an entirely elective procedure can or should be rescheduled BUT...

on the other hand, I look at it the other way. Why not do the surgery and concommitantly work up the other issue?

Am i being a *****, overly cavalier, or am I beginning to understand the hallowed PP jedi mindset?

For example, otherwise stable dude with newly found hyponatremia of 125. No s/sx. Was 137 a year ago...

Shout outs to my heroes on the forum. Been lurkin but too lazy to type! Dre'

 

[seinfeld]

When something bad happends and the dust has settled i always ask myself could i have prevented this from happending.

 

[jetproppilot]

The threshold for cancellation in the academic arena is much lower than out here in private practice land as you would expect, Dre.

Of course there are some good cancellations, but the number that you speak of is part of the obstructionalistic stance ubiquitous in academia.

I think your questioning all the cancellations shows your growth as an anesthesiologist.

At my first gig I remember frequently doing hip ORIFs etc on the elderly with cardiac histories....if there were no extremely serious acute cardiac manifestations, we would consult the cardiologist.......from the PACU.

Your thought process is a good one......since there are no outcome studies showing increased risk for surgery for many of the cancellations you are witnessing, many, many academic cancellations should not occur.

 

[militarymd]

hyponatremia...125....

depends on the type of surgery....low risk...low invasiveness ...low post op pain surgery......breast biopsy...lesion excision...hernia...knee scope....hell yeah...I'd do the case...

Move beyond that...where the post op stress hormone responses and fluid shifts can cause additional changes in serum sodium ...than no.

The lowest Sodium I took to the OR was a little old lady for a very minor lower extremity facial release....Na 115 ..or somewhere around there.

 

[radslooking]

a timely thread. what do you do with a hip fracture and a pneumonia discovered just before surgery? just give the antibiotic and wheel them down to surgery? (question came up today). Only on one liter of 02, but it was a new o2 requirement.

 

[jetproppilot]

hyponatremia...125....

depends on the type of surgery....low risk...low invasiveness ...low post op pain surgery......breast biopsy...lesion excision...hernia...knee scope....hell yeah...I'd do the case...

Move beyond that...where the post op stress hormone responses and fluid shifts can cause additional changes in serum sodium ...than no.

The lowest Sodium I took to the OR was a little old lady for a very minor lower extremity facial release....Na 115 ..or somewhere around there.

http://forums.studentdoctor.net/showthread.php?t=207433&highlight=hyponatremia

 

[Planktonmd]

a timely thread. what do you do with a hip fracture and a pneumonia discovered just before surgery? just give the antibiotic and wheel them down to surgery? (question came up today). Only on one liter of 02, but it was a new o2 requirement.

The hip fracture needs to be fixed with or without a pneumonia because if you don't fix it the patient will most likely die.

 

[2ndyear]

Hip fractures are my new favorite cases. They have to go, but not necessarily at night. I just like getting the page on call from the ER at midnight 'got a hip here for 'ya, she's old and sick....and going on tommorrows add on list.' That's the kicker. Enough time to sort through the old charts, figure out when exactly the coumadin was stopped in the nursing home, but not enough time to waste and do a CABG. My new fav I picked up on here I think. Give a little ketamine, roll bad side down, and 9 of heavy bupiv in the spinal.

 

[militarymd]

http://forums.studentdoctor.net/showthread.php?t=207433&highlight=hyponatremia

different case...but I remember that one.

 

[Consigliere]

"...obstructionalistic stance ubiquitous in academia."

Nice!

 

[jetproppilot]

different case...but I remember that one.

I posted it because it has alotta good stuff concerning the should I cancel discussion.

 

[DrDre']

I posted it because it has alotta good stuff concerning the should I cancel discussion.

the low Na was for a cataract, Mil!

Had to cancel another one today becuz anesthesiologist did not want to do MCP arthroplasty in guy with new-onset AF, uncontrolled in low 100s. No sx.

 

[militarymd]

the low Na was for a cataract, Mil!

Had to cancel another one today becuz anesthesiologist did not want to do MCP arthroplasty in guy with new-onset AF, uncontrolled in low 100s. No sx.

You shouldn't be checking labs in Cataracts...period...Wilmer Eye Institute published a PRCT around the turn of the century in NEJM.....maybe you should pull the article and show your "Academic" attending.


As for the AF.......what can I say?

 

[nutmegs]

Had one this week... 72 w/mild dementia and CAD s/p MI for elective hip re-do (anticipated to be a complicated 4-6 hour case based on whatever they saw on xrays...), induce, a-line, position, had sent baseline gas which comes back 7.12/38/310/12.1/-16.8 prior to incision. Verified on repeat. Curious what the PP guys think?

 

[jetproppilot]

Had one this week... 72 w/mild dementia and CAD s/p MI for elective hip re-do (anticipated to be a complicated 4-6 hour case based on whatever they saw on xrays...), induce, a-line, position, had sent baseline gas which comes back 7.12/38/310/12.1/-16.8 prior to incision. Verified on repeat. Curious what the PP guys think?

She needs fluid. Or blood.

Or both.

BTW, a complex redo hip should be TWO AND A HALF HOURS MAX.

SIX HOURS FOR A HIP?

Jet faints.

 

[nutmegs]

She needs fluid. Or blood.

Or both.

BTW, a complex redo hip should be TWO AND A HALF HOURS MAX.

SIX HOURS FOR A HIP?

Jet faints.

Good volume of clear yellow urine in the Foley bag, pressures maintaining well without support, lactate was 0.9, we haven't done **** except intubate at this point so no blood loss, I think her Hgb was around 12... nothing to suggest she needed much fluid or blood.

We get it, academics isn't like private practice. Thanks.

So you start the case with fluids wide open?

 

[militarymd]

Had one this week... 72 w/mild dementia and CAD s/p MI for elective hip re-do (anticipated to be a complicated 4-6 hour case based on whatever they saw on xrays...), induce, a-line, position, had sent baseline gas which comes back 7.12/38/310/12.1/-16.8 prior to incision. Verified on repeat. Curious what the PP guys think?

She needs fluid. Or blood.

Or both.

BTW, a complex redo hip should be TWO AND A HALF HOURS MAX.

SIX HOURS FOR A HIP?

Jet faints.

Jet....you're right on about everything else...but in this case....I don't quite agree.

What's the CHEM 7 show....is this anion gap or Non-anion gap.

If this person came in as a same day admit for this surgery...I would guess this is a Non-anion gap acidosis....RTA type....rather than a hypoperfusion type Acidosis which has an anion gap.

If an anion gap is present, and the guy truly is that acidotic, then he's going to die pretty soon anyways....so I would get the surgery started ASAP so that you finish before he dies.


If an anion gap is not present, which I suspect...than Damn the Torpedoes...Full Speed ahead...treat with bicarb as necessary.

 

[jetproppilot]

Good volume of clear yellow urine in the Foley bag, pressures maintaining well without support, lactate was 0.9, we haven't done **** except intubate at this point so no blood loss, I think her Hgb was around 12... nothing to suggest she needed much fluid or blood.

We get it, academics isn't like private practice. Thanks.

So you start the case with fluids wide open?

Guess I jumped the gun and assumed she'd be way behind.

Sounds like she's isovolemic so no-fluids-wide-open since she's as you describe....Hb 12, urine, etc.

Mil eloquently corrects my assumption above.👍

 

[seinfeld]

the low Na was for a cataract, Mil!

Had to cancel another one today becuz anesthesiologist did not want to do MCP arthroplasty in guy with new-onset AF, uncontrolled in low 100s. No sx.

so i dont get it, no one is concerned about new onset afib? No one questions whether pt has CAD, just thrown a PE, has a Cardiomyopathy, Pulm HTN or some other reason for increased atrial diameter. What if he has developed an atrial clot as a result and threw it during the surgery?

Sure surgical risk is low and you will do a great box standard anesthetic avoiding the classic hypotension and hypoxia all the IM guys tell us to do but is this patient truly informed about his risk of anesthesia if you cant tell him their is no malignant cause of his AFIB?

Had a aunt in her early 50's who went for FESS (at private practice hospital), was cancelled by anesthesiologist who heard a murmur which she did not have previously and put it together with vague hx of increasing dyspnea with activity ( the oh i am just getting older so i dont get around like i used to excuse) . Got an ECHO had AS with mean gradient over 100. I am glad they did not put her to sleep induce some hypotension to control bleeding during the FESS.

I guess in the back of my mind i see myself sitting on the stand.

 

[Planktonmd]

Had one this week... 72 w/mild dementia and CAD s/p MI for elective hip re-do (anticipated to be a complicated 4-6 hour case based on whatever they saw on xrays...), induce, a-line, position, had sent baseline gas which comes back 7.12/38/310/12.1/-16.8 prior to incision. Verified on repeat. Curious what the PP guys think?

Have I known this Blood gas before inducing anesthesia I would have waited and tried to figure out why she has severe metabolic acidosis.
But you already put her to sleep so do the best you can (volume and try to hyperventilate to compensate for the metabolic acidosis).
Make sure she is not diabetic in DKA or something like that.
There is a long list of things to consider but your number one job is to keep the patient alive at this point and you know how to do that.

 

[militarymd]

Hey Nut....so how about some followup?

How did it go?

Was I off base?

Had one this week... 72 w/mild dementia and CAD s/p MI for elective hip re-do (anticipated to be a complicated 4-6 hour case based on whatever they saw on xrays...), induce, a-line, position, had sent baseline gas which comes back 7.12/38/310/12.1/-16.8 prior to incision. Verified on repeat. Curious what the PP guys think?

Jet....you're right on about everything else...but in this case....I don't quite agree.

What's the CHEM 7 show....is this anion gap or Non-anion gap.

If this person came in as a same day admit for this surgery...I would guess this is a Non-anion gap acidosis....RTA type....rather than a hypoperfusion type Acidosis which has an anion gap.

If an anion gap is present, and the guy truly is that acidotic, then he's going to die pretty soon anyways....so I would get the surgery started ASAP so that you finish before he dies.


If an anion gap is not present, which I suspect...than Damn the Torpedoes...Full Speed ahead...treat with bicarb as necessary.

 

[toughlife]

Jet....you're right on about everything else...but in this case....I don't quite agree.

What's the CHEM 7 show....is this anion gap or Non-anion gap.

If this person came in as a same day admit for this surgery...I would guess this is a Non-anion gap acidosis....RTA type....rather than a hypoperfusion type Acidosis which has an anion gap.

If an anion gap is present, and the guy truly is that acidotic, then he's going to die pretty soon anyways....so I would get the surgery started ASAP so that you finish before he dies.


If an anion gap is not present, which I suspect...than Damn the Torpedoes...Full Speed ahead...treat with bicarb as necessary.

I second RTA with a bicarb of 12, a normal lactate and no AG.

 

[radslooking]

I second RTA with a bicarb of 12, a normal lactate and no AG.

i dont' think he said the AG was normal, just said lactate was normal. that takes out the L of MUDPILES, but I agree, i think it will likely be RTA too.

 

[Planktonmd]

i dont' think he said the AG was normal, just said lactate was normal. that takes out the L of MUDPILES, but I agree, i think it will likely be RTA too.

What in the available data makes you think that?
All we know so far is that she has a metabolic acidosis everything else is speculation.

 

[Planktonmd]

.

 

[radslooking]

What in the available data makes you think that?
All we know so far is that she has a metabolic acidosis everything else is speculation.

well, if its not a lactic acidosis, then it leaves other AG acidoses or non AG acidoses. 72 yo with DKA is unlikely, uremia is possible i guess, but no renal failure has been mentioned. The other causes of an anion gap acidosis are fairly rare. Anyhow, I went with a common non-anion gap acidosis (i doubted diarrrhea) as what I felt was most likely given the information I heard.

 

[nutmegs]

Hey Nut....so how about some followup?

How did it go?

Was I off base?

So with my CA-1 self and a brand spankin new attending at an academic center, we actually ended up aborting the case (everybody in PP wince! in unison!!). We hung around for a little while he talked to the renal attending and some of the other attendings and her family and sent a full chem panel. The rest was unremarkable except the CO2 of 10 and a slightly elevated creatinine for her weight and age. His throught was she was pretty acidotic for an unknown reason and if we got into blood loss, etc (I'm learning more about this surgeon's reputation- not favorable in the least, "slow" even for academics 😱) it would only get worse, since this was totally elective wanted to get her sorted out. Renal consult in the PACU thought yes on the RTA, and then just not hyperventilated as she probably is usually and therefore uncompensated acidosis. We took her to the PACU where she promptly went into uncontrolled a-fib. Stayed inpatient, got bicarb, labs improved.

 

[jwk]

I am glad they did not put her to sleep induce some hypotension to control bleeding during the FESS.

Bleeding is treated with adequate hemostasis, not hypotension. 😉

 

[Planktonmd]

So with my CA-1 self and a brand spankin new attending at an academic center, we actually ended up aborting the case (everybody in PP wince! in unison!!). We hung around for a little while he talked to the renal attending and some of the other attendings and her family and sent a full chem panel. The rest was unremarkable except the CO2 of 10 and a slightly elevated creatinine for her weight and age. His throught was she was pretty acidotic for an unknown reason and if we got into blood loss, etc (I'm learning more about this surgeon's reputation- not favorable in the least, "slow" even for academics 😱) it would only get worse, since this was totally elective wanted to get her sorted out. Renal consult in the PACU thought yes on the RTA, and then just not hyperventilated as she probably is usually and therefore uncompensated acidosis. We took her to the PACU where she promptly went into uncontrolled a-fib. Stayed inpatient, got bicarb, labs improved.

I am a little curious:
Why didn't you have a chemistry preop in this patient?

 

[militarymd]

After you go around the block a few times, this kind of stuff becomes routine.

You know why I knew the answer to your dilemma???

I've seen this half a dozen times.

The first time, when i was a resident, I did what you guys did.....punt.

After that, I knew better....I've learned to order additional labs...I've learned to proceed with the case...and I've learned the art of differentiating between the "bad" acidoses and the "benigh" acidoses.

RTA is benigh in the perioperative period.

I've conducted a couple of M&M's during my academic part of my career on cases like this....I mocked the guys who cancelled these cases to the point where they wanted to take contracts with hit men out on me....

but , in the end....they became better physicians.

So with my CA-1 self and a brand spankin new attending at an academic center, we actually ended up aborting the case (everybody in PP wince! in unison!!). We hung around for a little while he talked to the renal attending and some of the other attendings and her family and sent a full chem panel. The rest was unremarkable except the CO2 of 10 and a slightly elevated creatinine for her weight and age. His throught was she was pretty acidotic for an unknown reason and if we got into blood loss, etc (I'm learning more about this surgeon's reputation- not favorable in the least, "slow" even for academics 😱) it would only get worse, since this was totally elective wanted to get her sorted out. Renal consult in the PACU thought yes on the RTA, and then just not hyperventilated as she probably is usually and therefore uncompensated acidosis. We took her to the PACU where she promptly went into uncontrolled a-fib. Stayed inpatient, got bicarb, labs improved.

 

[nutmegs]

I am a little curious:
Why didn't you have a chemistry preop in this patient?

As I got to listen to the surgeon rant about: "we don't order a full chem on all patients. it's not cost effective. we only get a potassium, creatinine, and sodium" (?) and "I sent her to a general medical doctor!!!" (he sent her to a cardiologist).

agh.

 

[jetproppilot]

After you go around the block a few times, this kind of stuff becomes routine.

You know why I knew the answer to your dilemma???

I've seen this half a dozen times.

The first time, when i was a resident, I did what you guys did.....punt.

After that, I knew better....I've learned to order additional labs...I've learned to proceed with the case...and I've learned the art of differentiating between the "bad" acidoses and the "benigh" acidoses.

RTA is benigh in the perioperative period.

I've conducted a couple of M&M's during my academic part of my career on cases like this....I mocked the guys who cancelled these cases to the point where they wanted to take contracts with hit men out on me....

but , in the end....they became better physicians.

Very nice, Mil.

Very nice.

 

[Planktonmd]

Renal tubular acidosis is not "benign" and can be a symptom to a number of serious or life threatning diseases.
Drawing a conclusion that an acidosis is RTA without knowing the anion gap is simply guessing.
So, In the presence of a signficant metabolic acidosis the last thing one should do is guess that it must be RTA and then assume that it is benign!

 

[militarymd]

Renal tubular acidosis is not "benign" and can be a symptom to a number of serious or life threatning diseases.
Drawing a conclusion that an acidosis is RTA without knowing the anion gap is simply guessing.
So, In the presence of a signficant metabolic acidosis the last thing one should do is guess that it must be RTA and then assume that it is benign!

people live with these acidoses for years...and it is not "benign" just like hypertension is not "benign"...because over the course of time, it leads to complications....like bone wasting, etc.

In the perioperative period.....it isABSOLUTING FU CKING benign...although it does cause management issues..like sorting out when hypoperfusion occurs...or if it gets bad enough to affect bp.....but that 's why we anesthesiologists get paid the big bucks to deal with.

 

[radslooking]

Renal tubular acidosis is not "benign" and can be a symptom to a number of serious or life threatning diseases.
Drawing a conclusion that an acidosis is RTA without knowing the anion gap is simply guessing.
So, In the presence of a signficant metabolic acidosis the last thing one should do is guess that it must be RTA and then assume that it is benign!

i don't think this was a total guess. From the information we heard, the patient was coming in for an elective hip surgery and didn't appear toxic. With a ph of 7.1 ish either the patient is very ill or has some ongoing chronic everyday problem. Hence the RTA.

methanol-no
uremia-didnt hear about renal failure
dka-72 yr old no
infection/inh-unlikely
lactic acidosis-no
ethylene glycol/ethanol (which works by increasing lactic acid)- no
salicylates-no

non AG acidoses
diarrhea-no
RTA---in a nontoxic individual with a very low ph, this is the best guess

 

[Planktonmd]

i don't think this was a total guess. From the information we heard, the patient was coming in for an elective hip surgery and didn't appear toxic. With a ph of 7.1 ish either the patient is very ill or has some ongoing chronic everyday problem. Hence the RTA.

methanol-no
uremia-didnt hear about renal failure
dka-72 yr old no
infection/inh-unlikely
lactic acidosis-no
ethylene glycol/ethanol (which works by increasing lactic acid)- no
salicylates-no

non AG acidoses
diarrhea-no
RTA---in a nontoxic individual with a very low ph, this is the best guess

I am not sure where you see all these negative clinical finding in the initial post.
The information that was initially availabe:
Demented patient, CAD, coming for hip redo, ABG shows acidosis, that's it!
There was no mention of anything else.
There was no description of how she looked clinically or any clinically helpful data.
Now for someone to go ahead and suggest RTA based on this information is IMHO guessing.

 

[radslooking]

I am not sure where you see all these negative clinical finding in the initial post.
The information that was initially availabe:
Demented patient, CAD, coming for hip redo, ABG shows acidosis, that's it!
There was no mention of anything else.
There was no description of how she looked clinically or any clinically helpful data.
Now for someone to go ahead and suggest RTA based on this information is IMHO guessing.

well nutmegs gave us two posts without mentioning anything else serious going on. as milmd alluded to before, if an AG is present, the patient would appear acutely ill. Anyhow, a very low pH is ominous. But we received no information this patient was acutely ill, just sauntered in for a hip re-do. Thus RTA. I'm not saying i wouldnt do a chem 7, im just saying its the best guess given what we know.

 

[Planktonmd]

well nutmegs gave us two posts without mentioning anything else serious going on. as milmd alluded to before, if an AG is present, the patient would appear acutely ill. Anyhow, a very low pH is ominous. But we received no information this patient was acutely ill, just sauntered in for a hip re-do. Thus RTA. I'm not saying i wouldnt do a chem 7, im just saying its the best guess given what we know.

Fair enough. 👍