EKG for toe amp ?

[dannyboy1]

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case from a couple of weeks ago. I preop a patient scheduled for toe amputation 2/2 diabetes/osteomylitis. Hx of HTN, poorly controlled DM, cardiac stent 10 years ago. pt is demented and mostly bedbound. pt is at baseline health status as per family. case will be done under local with a slick podiatrist and minimal (if any) sedation. No EKG in the chart. Pt comes to preop and i get absolutely reamed by attending for not having an ekg. While I agree that for almost everything, this type of patient would definitely need an ekg, I figured that for this patient to which we are basically doing nothing there would be no real need. thoughts?

 

[deleted171991]

You'll always want to have a baseline EKG in a (potential) cardiac patient. Nothing worse than getting surprised when you are already in the room. It will not change management though, most likely.

There is no local or sedation case. Every case is a potential general case and ****fest.

P.S. Learn how to spell medical terms correctly. You are a damn doctor, not a nurse.

 

[deepstate2016]

Medico legally yeah you need one. As pointed out will it change your management? No. Just an example of additional cost to ZERO benefit. FWIW I would not care if there was an ekg or not.

 

[Planktonmd]

Your attending is the typical academic doofus and the EKG is not going to change anything you do!

 

[Ronin786]

It's a low-risk procedure in a patient with less than 4 METs. Per the guidelines you're going to proceed with surgery without further testing.

Those same guidelines do mention the utility of an EKG in someone with a history of CAD, but it won't change management.

 

[Doctor4Life1769]

You'll always want to have a baseline EKG in a (potential) cardiac patient. Nothing worse than getting surprised when you are already in the room. It will not change management though, most likely.

There is no local or sedation case. Every case is a potential general case and ****fest.

P.S. Learn how to spell medical terms correctly. You are a damn doctor, not a nurse.

So misspelling osteomyelitis warrants all that?

Anyways, to the OP - one should have one in the chart given history of CAD and stent, less than 4 mets as baseline but if you could find an ekg in the electronic record within the past year I wouldn't require a preop one. Sounds like he's overall at usual baseline. Nonetheless it won't be changing management, so I probably personally would not care. Agree with Plank, and this is why I despised some of my hardcore academic anesthesia attendings who would require the help of 2 other anesthesiologists and a CRNA to help start AAA cases and would be in academics because they couldn't hack it on their own in PP

Bigger Q is how much he reams you on the resident evaluation and how much your administration is going to ream you out even further for it.

 

[deleted59964]

if the guys toes need to come off, they need to come off.
unless his ECG shows he is infarcting right now, it won't change anything
ankle block, sudoku

 

[caligas]

He gets an ekg....when I hook him up to the ekg leads in the o.r. before I give him 1mg of midaz.

 

[deleted171991]

He gets an ekg....when I hook him up to the ekg leads in the o.r. before I give him 1mg of midaz.

And what if that one shows new BBB or ST changes, or some other strange stuff that could go well with his SOB? 😉

It happened once to me and, trust me, it's much easier to explain to the surgeon in preop why the patient needs more workup, versus to the whole OR team once you are in a room they worked hard to clean and set up. That EKG in preop takes 5-10 minutes; I'll wait.

 

[caligas]

Infected (probably gangrenous) toe needs to come off. Medicine can pontificate over his "new LBBB" later. Throw the leads on in pre op and print a strip if you're really worried. If you can't get this guy through a toe amp than my advice can't help.

 

[Arch Guillotti]

And what if that one shows new BBB or ST changes, or some other strange stuff that could go well with his SOB? 😉

What SOB?

 

[caligas]

What SOB?

The attending is the only SOB in this situation.

 

[kidthor]

First of all, the podiatrist requesting an anesthesiologist for that case is absurd. But yeah it happens.

But if you're going to be involved with said pt, it is a potential set-up... as he's headed down the fem pop chop chop pathway... and periop MIs are common enough in such patients to warrant a pre op MI.

Let's say post op the guy has chest pain from GERD or anxiety... then you'll be compelled to get your post op EKG and what do you do when that's abnormal? Stress yourself and rule him out for MI? Or have the pre op EKG and realize it was weird to begin with.

 

[deleted171991]

What SOB?

Sorry. I must have been mixing up the cases.

 

[Noyac]

So as you can tell, it's a 50/50 call.

I wouldn't demand one but I wouldn't criticize anyone for getting one either. Apparently, your attending demands one. So do as he or she says and move on.

 

[Mista Suprane]

First of all, the podiatrist requesting an anesthesiologist for that case is absurd

eh - sometimes all a proceduralist wants for these easy MAC cases (toe amp, permcath, etc) on sick patients is a set of experienced hands around in case something goes wrong. if you view our profession (as we all should) not as just "anesthesiology" but rather as consultants/experts in perioperative medicine and pathophysiology, their request makes more sense. bad things happen to sick patients in the OR, even during small cases.

i often don't even give anything, just put in an IV and watch the monitors. sometimes that's all MAC has to be. i'm happy to help. if i was in private practice i'd be even more happy.

to the OP: i get an EKG in this patient, 100% of the time. sometimes common sense/CYA for an inexpensive, rapid, noninvasive, easy test trumps the whole "would this change your management" argument. not sure it's worth getting reamed over, but then again i rarely ream residents for anything - i don't find it to be an effective teaching method.

side note: often the toe amps are done by general surgery/vascular surgery i.e. people that don't know how to do ankle blocks - so any residents reading this: get good at your ankle blocks. when you have a solid ASA IV patient coming for a toe amp a clutch ankle block can help you avoid giving too much sedation or having to give general.

 

[Arch Guillotti]

First of all, the podiatrist requesting an anesthesiologist for that case is absurd.

Why is it absurd?

The podiatrist is consulted or whatever and wants to bring the patient to the OR for an operation. Where else do you expect them to do the operation?

 

[Arch Guillotti]

And what if that one shows new BBB or ST changes, or some other strange stuff that could go well with his SOB? 😉

It happened once to me and, trust me, it's much easier to explain to the surgeon in preop why the patient needs more workup, versus to the whole OR team once you are in a room they worked hard to clean and set up. That EKG in preop takes 5-10 minutes; I'll wait.

How will you know if the BBB is new or not? There isn't anything to compare it to. Same thing for the ST changes unless he is having the big one.

 

[Ignatius J]

What can an EKG show that will change anything? Worst case scenario, you send him to cards, who may just send him right back saying they will look at his heart once his rotting gangrenous toe is taken care of.

 

[Arch Guillotti]

What can an EKG show that will change anything?

Rapid afib, vtach or SVT are all outliers that might change something.

 

[Ignatius J]

Rapid afib, vtach or SVT are all outliers that might change something.

I can see that with a 3 or 5 lead in the OR before any incision is made. I would venture to say without symptoms of SOB or chest pain and a set of vital signs that don't raise suspicion from the floor that the chances of these are infinitesimally small. And I mean, pre-op still gets vital signs. If they call me with a pulse of 130 I would probably take a better look.

 

[Arch Guillotti]

I can see that with a 3 or 5 lead in the OR before any incision is made. I would venture to say without symptoms of SOB or chest pain and a set of vital signs that don't raise suspicion from the floor that the chances of these are infinitesimally small. And I mean, pre-op still gets vital signs. If they call me with a pulse of 130 I would probably take a better look.

Of course the chances are incredibly low but it is possible.

I have had a couple of real stinkers dropped on me from "the floor" though.

 

[deleted59964]

And what if that one shows new BBB or ST changes, or some other strange stuff that could go well with his SOB? 😉

It happened once to me and, trust me, it's much easier to explain to the surgeon in preop why the patient needs more workup, versus to the whole OR team once you are in a room they worked hard to clean and set up. That EKG in preop takes 5-10 minutes; I'll wait.

toes still need to come off, my ankle block will last till after he gets back from cath lab

 

[deleted171991]

How will you know if the BBB is new or not? There isn't anything to compare it to. Same thing for the ST changes unless he is having the big one.

Agree. But both should prompt a cancellation and a cardiology consult.

My OR cancellation was a case of very frequent PVCs in an asymptomatic patient who was booked for a 3 hour-GA case (I think laparoscopic). Both the patient and the surgeon agreed to not take chances, and get it worked up first.

 

[Ignatius J]

Of course the chances are incredibly low but it is possible.

I have had a couple of real stinkers dropped on me from "the floor" though.

I still don't agree with a pre-op EKG in the face of reasonable vital signs. In any event, not worth chastising a resident for.

As I'm assuming this patient had. You could find a STEMI in a 30 year old here for knee scope. Not at all likely. But it can happen. Slippery slope.

 

[Arch Guillotti]

Agree. But both should prompt a cancellation and a cardiology consult.

I wouldn't cancel just for a funny looking ekg in an asymptomatic patient for a minor operation.

 

[Arch Guillotti]

I still don't agree with a pre-op EKG in the face of reasonable vital signs. In any event, not worth chastising a resident for.

I wouldn't have gotten an ekg, let alone chastise the resident.

 

[deleted171991]

I wouldn't cancel just for a funny looking ekg in an asymptomatic patient for a minor operation.

And you would be right in 95% of the cases.

It is still reasonable to get an ECG in a diabetic, particularly one poorly-controlled, particularly one with known CAD, particularly one who's sedentary, so there is no known MET tolerance level. Yes, it is a minor procedure, until some genius injects epi or too much local into the general circulation, or until the patient aspirates, or becomes agitated, or cannot lie supine etc.

 

[Arch Guillotti]

And you would be right in 95% of the cases.

It is still reasonable to get an ECG in a diabetic, particularly one poorly-controlled, particularly one with known CAD, particularly one who's sedentary, so there is no known MET tolerance level. Yes, it is a minor procedure, until some genius injects epi or too much local into the general circulation, or until the patient aspirates, or becomes agitated, or cannot lie supine etc.

Of course it's reasonable to get an ekg. I don't think it is reasonable to cancel the case and get a cardiology consult though.

 

[Noyac]

Yes, it is a minor procedure, until some genius injects epi or too much local into the general circulation, or until the patient aspirates, or becomes agitated, or cannot lie supine etc.

Yes but these things wou,d cause trouble in a young healthy 25 yo. An EKG won't change that.

I can't believe we are debating this as much as we are. If you want an EKG on this pt then get one. If not then move on. It's a personal call. The issue is that the residents attending wanted one, so get one. Berating the resident doesn't make the situation any better. But I betcha the next time this resident works with this nervous attending he or she will get an EKG. Hell I'd get an EKG for a hangnail if I worked with this attending just to prove the point.

 

[Arch Guillotti]

Yes, it is a minor procedure, until some genius injects epi or too much local into the general circulation, or until the patient aspirates, or becomes agitated, or cannot lie supine etc.

Of course, that is why every procedure should be done under general endotracheal anesthesia with invasive access and a cardiopulmonary bypass circuit primed up just in case

 

[partydoc]

Of course, that is why every procedure should be done under general endotracheal anesthesia with invasive access and a cardiopulmonary bypass circuit primed up just in case

Don't forget to prep the groin

 

[PainDrain]

So I got stuck with a foot wound debridement case recently that turned into a clusterF and it went like this. 70 year old brittle diabetic vasculopath with MI X 4 and stent x7. HCT=28, low due to anemia of chronic dz and CKD. Talked with podiatrist and it was billed as a simple debridement of a previous partial TMA. Well, 500-800 mls of blood loss later and I am kicking myself for not having blood on hand. Guy is hypotensive and on phenylephrine infusion post-op. Looking back in hindsight should have ordered a type and screen. I will never go without necessary labs/ekg again. V

 

[deleted171991]

Of course, that is why every procedure should be done under general endotracheal anesthesia with invasive access and a cardiopulmonary bypass circuit primed up just in case

You forgot to book the ICU bed.

 

[deleted162650]

So I got stuck with a foot wound debridement case recently that turned into a clusterF and it went like this. 70 year old brittle diabetic vasculopath with MI X 4 and stent x7. HCT=28, low due to anemia of chronic dz and CKD. Talked with podiatrist and it was billed as a simple debridement of a previous partial TMA. Well, 500-800 mls of blood loss later and I am kicking myself for not having blood on hand. Guy is hypotensive and on phenylephrine infusion post-op. Looking back in hindsight should have ordered a type and screen. I will never go without necessary labs/ekg again. V

Ever heard of a tourniquet??

 

[deleted171991]

Ever heard of a tourniquet??

Yeah. It's a very efficient tool for decreasing blood loss. You put it around the surgeon's neck... 😛

 

[Arch Guillotti]

Yeah. It's a very efficient tool for decreasing blood loss. You put it around the surgeon's neck... 😛

Exactly, if the surgeon doesn't want to use one what are you going to do?

 

[Arch Guillotti]

Don't forget to prep the groin

I have them put wires in just in case they need to cannulate.

 

[Arch Guillotti]

So I got stuck with a foot wound debridement case recently that turned into a clusterF and it went like this. 70 year old brittle diabetic vasculopath with MI X 4 and stent x7. HCT=28, low due to anemia of chronic dz and CKD. Talked with podiatrist and it was billed as a simple debridement of a previous partial TMA. Well, 500-800 mls of blood loss later and I am kicking myself for not having blood on hand. Guy is hypotensive and on phenylephrine infusion post-op. Looking back in hindsight should have ordered a type and screen. I will never go without necessary labs/ekg again. V

What would have changed other than the possibility of a transfusion?

 

[PainDrain]

Ever heard of a tourniquet??

Couldn't be used because patient had stents/angioplasty to femoral arteries. Surgeon worried it would clot the stent and rightly so.

 

[Noyac]

Couldn't be used because patient had stents/angioplasty to femoral arteries. Surgeon worried it would clot the stent and rightly so.

Put it on the calf.

 

[Noyac]

Couldn't be used because patient had stents/angioplasty to femoral arteries. Surgeon worried it would clot the stent and rightly so.

Also, you as an anesthesiologist should know more about the pts risks with his stents and plasty. Why let the podiatrist (not surgeon) make that call? It's stupid in my opinion. How old are the stents? When was the angioplasty?
My take on this is that you found yourself in this position because you were passive and let a podiatrist with way less medical knowledge and understanding make the call. Not because you didn't get an EKG or labs. Tell the foot guy that he's using a tourniquet or at least putting one on in case it bleeds. No questions asked. And if I was in the situation you described I would have called for a sterile one and placed it on myself if I had to before watching 800 cc of blood loss from a foot. Sorry to be so harsh but you are the doctor in the room so act like it.

 

[deleted162650]

Agree with above. An ankle tourniquet poses minimal risk to this guy's femoral vessels and is certainly less risky than letting him lose than much blood.

Plus, he'll be back in a few months for BKA v AKA anyways.

 

[Ignatius J]

So I got stuck with a foot wound debridement case recently that turned into a clusterF and it went like this. 70 year old brittle diabetic vasculopath with MI X 4 and stent x7. HCT=28, low due to anemia of chronic dz and CKD. Talked with podiatrist and it was billed as a simple debridement of a previous partial TMA. Well, 500-800 mls of blood loss later and I am kicking myself for not having blood on hand. Guy is hypotensive and on phenylephrine infusion post-op. Looking back in hindsight should have ordered a type and screen. I will never go without necessary labs/ekg again. V

That's a very interesting case. I do plenty of these and circulation is usually so bad that there is minimal bleeding even without the tourniquet. All that blood loss implies good blood flow to the area and I would think theoretical ability to heal. So I am wondering what the hell the podiatrist was doing to lose that much. Sounds like a well-perfused area he was debriding.

 

[deleted59964]

I do plenty of these and circulation is usually so bad that there is minimal bleeding even without the tourniquet. All that blood loss implies good blood flow to the area and I would think theoretical ability to heal.

That's my experience too -- generally minimal blood loss, because you know their toes aren't perfused.
a lot guys like this hardly even need an ankle block - most can't feel anything.