Elective Surgery and Decreased GFR

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Noyac said:
I lost interest about post #10. But thanks for the info.

I check GFR on almost every pt. At least every one that has had labs. Been doing this for years.
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Another take away point is that an arterial line on high risk patients helps avoid any significant duration of hypotension. IMHO, the data is supportive that even short times of hypotension can lead to increased morbidity and mortality. Hence, an arterial line can catch that post induction hypotension or other periods of hypotension where the CRNA is distracted from the monitors. In addition, the automated BP cuff will not always detect that initial hypotension but rather fail to read the BP on the screen then begin cycling again. I've seen CRNAS cycle the cuff 3-4 times before realizing the BP is way too low. This time interval between hypotension (recognition of hypotension actually) and its treatment should be minimized whenever possible.
While this may sound basic to many of you failing to treat hypotension in a prompt manner can and has led to cardiac arrest in the operating room. We now know that even short durations of untreated hypotension increases mortality significantly.

In those cases where I'm not placing an arterial line in an ASA3 patient with risk factors I'll change the cycle time on the automated cuff from 5 minutes to 2.5 or 3 minutes.
In the "ACT model" I'm relying on others to recognize and treat significant hypotension and tachycardia. Unfortunately, I need to explain what that means all too often to the provider in the room.
 
BLADEMDA said:
In those cases where I'm not placing an arterial line in an ASA3 patient with risk factors I'll change the cycle time on the automated cuff from 5 minutes to 2.5 or 3 minutes.
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I was unaware that all places didn't routinely do Q3 min BPs or more frequently during OR cases. At my residency and current practice, the default on the machines is 3 minutes. We only back off to Q5 minutes if it's a boring MAC case with minimal sedation. Why not just have Q3 minutes for every case?
 
ASA standards for basic anesthetic monitoring*

Standard 1: Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care

Standard 2: During all anesthetics, the patient's oxygenation, ventilation, circulation, and temperature shall be continually* evaluated

Oxygenation:

Oxygen analyzer for inspired gases
Observation of the patient
Pulse oximetry

Ventilation:

Auscultation of breath sounds
Observation of the patient
Observation of the reservoir bag
Capnography (Carbon dioxide monitoring)

Circulation:

Continuous* ECG display
Heart rate and BP recorded every 5 minutes
Evaluation of circulation
Auscultation of heart sounds
Palpation of pulse
Pulse plethysmography
Pulse oximetry
Intraarterial pressure tracing

Temperature:

Monitor temperature when changes are intended, anticipated, or suspected
 
Mman said:
I was unaware that all places didn't routinely do Q3 min BPs or more frequently during OR cases. At my residency and current practice, the default on the machines is 3 minutes. We only back off to Q5 minutes if it's a boring MAC case with minimal sedation. Why not just have Q3 minutes for every case?
Click to expand...

My place has been every 5 minutes since the routine use of the Dinamap auto BP device in the early 1980s. I do agree that Q3 is better as that is the standard at most top academic departments across the USA. But, I don't get to decide departmental policies; all I can do is decide how to treat my patients.

(In 1976 Dr. Ramsey invented the DINAMAP NIBP monitor. Today, DINAMAP technology is known as the “gold standard” of NIBP measurement for hospital clinical use.)
 
At three large, academic institutions with well established AIMS, we found an incidence of 1.5% – 7.0% of anesthetics in which there were one or more gaps in recording successive BPs that were at least twice the current 5-minute ASA monitoring standard. While the impact of these gaps on patient outcomes is unknown, there may be medico-legal implications of such lapses.7


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3121913/
 
Q3 vitals would be a Royal PITA when doing a complex type A/elephant trunk case at 3am.

For those of you that have Crnas sure.

For those of us in MD only groups, I would argue that charting Q3 vitals would distract from patient care. We are busy enough with TEE/lines/metabolic issues/coagulation & transfusion etc. I don't have time to fill out 3-4 pages worth of vital signs. Q5 is the standard and charting q2-3 vitals adds nothing IMO- especially if you have your vital alarms set correctly.
 
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BLADEMDA said:
Another take away point is that an arterial line on high risk patients helps avoid any significant duration of hypotension. IMHO, the data is supportive that even short times of hypotension can lead to increased morbidity and mortality. Hence, an arterial line can catch that post induction hypotension or other periods of hypotension where the CRNA is distracted from the monitors. In addition, the automated BP cuff will not always detect that initial hypotension but rather fail to read the BP on the screen then begin cycling again. I've seen CRNAS cycle the cuff 3-4 times before realizing the BP is way too low. This time interval between hypotension (recognition of hypotension actually) and its treatment should be minimized whenever possible.
While this may sound basic to many of you failing to treat hypotension in a prompt manner can and has led to cardiac arrest in the operating room. We now know that even short durations of untreated hypotension increases mortality significantly.

In those cases where I'm not placing an arterial line in an ASA3 patient with risk factors I'll change the cycle time on the automated cuff from 5 minutes to 2.5 or 3 minutes.
In the "ACT model" I'm relying on others to recognize and treat significant hypotension and tachycardia. Unfortunately, I need to explain what that means all too often to the provider in the room.
Click to expand...
Teachable moment for the residents:
There is another easy sign to suggest that the patient is hypotensive when one walks into a room: if the O2 sat is low or much lower than before, or the pulse ox signal is weak or flat. Many providers ignore this very important and early sign of hypoperfusion, and sit on the hypotension for 5-10-15 minutes, before realizing that it's not the cuff.

If the signal is great and the sat is 100% and the patient is warm, and the pulse is strong, one should keep playing with the NIBP.
 
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sevoflurane said:
Q3 vitals would be a Royal PITA when doing a complex type A/elephant trunk case at 3am.

For those of you that have Crnas sure.

For those of us in MD only groups, I would argue that charting Q3 vitals would distract from patient care. We are busy enough with TEE/lines/metabolic issues/coagulation & transfusion etc. I don't have time to fill out 3-4 pages worth of vital signs. Q5 is the standard and charting q2-3 vitals adds nothing IMO- especially if you have your vital alarms set correctly.
Click to expand...

As Arch mentioned, you can cycle the cuff every 3 and only chart every 5. I mean we already know people using paper charts are not charting every vital sign that pops up on the screen. Also on a big case you have an a-line so it isn't really applicable to how often the cuff is going up and down.

But the main point, please get an electronic medical record. I still can't believe places do big cases with paper charting. It's crazy to me. Electronic charting means you don't have to waste 1 second writing the vital signs down during the case, it transfer automatically. And I've used at least 5 different electronic anesthesia record systems and while they all have good and bad aspects, they are all light years better than paper charting.
 
The best thing about EMRs is that they don't record 100/60 ... 100/60 ... 100/60 ... 100/60 ... 100/60 ... 100/60 ... 100/60 ... 100/60 ... 100/60 ...

When the actual monitor reads 100/60 ... 90/50 ... 85/45 ... 70/30 ... 70/30 ... 180/120 ... 170/100 ... 140/80 ... 100/60 ...

The other thing EMRs don't do is chart the next 45 minutes of vitals, extubation, and PACU signout while the periop RN is prepping the patient.
 
pgg said:
..

The other thing EMRs don't do is chart the next 45 minutes of vitals, extubation, and PACU signout while the periop RN is prepping the patient.
Click to expand...
Yes they lack the ability to forecast the future which could be seen as a disadvantage IMHO!
 
FFP said:
Teachable moment for the residents:
There is another easy sign to suggest that the patient is hypotensive when one walks into a room: if the O2 sat is low or much lower than before, or the pulse ox signal is weak or flat. Many providers ignore this very important and early sign of hypoperfusion, and sit on the hypotension for 5-10-15 minutes, before realizing that it's not the cuff.

If the signal is great and the sat is 100% and the patient is warm, and the pulse is strong, one should keep playing with the NIBP.
Click to expand...

Agree. Look at the pulse oximetry wave form and check the radial arterial pulse. If the pulse is weak treat the BP immediately as some HTN is much better tolerated than hypotension (see the studies listed on this thread).

Serious hypotension can lead to lower saturation readings (fairly common) and even low ETCO2 (that's not common and requires immediate intervention).
 
FFP said:
Teachable moment for the residents:
There is another easy sign to suggest that the patient is hypotensive when one walks into a room: if the O2 sat is low or much lower than before, or the pulse ox signal is weak or flat. Many providers ignore this very important and early sign of hypoperfusion, and sit on the hypotension for 5-10-15 minutes, before realizing that it's not the cuff.

If the signal is great and the sat is 100% and the patient is warm, and the pulse is strong, one should keep playing with the NIBP.
Click to expand...
And this is why I harp my padawans that the pulse oximeter is the FIRST thing that goes on the patient when they hit the OR, if not sooner for sicker patients.

And for those that do mission work, Masimo has one that plugs into smartphones and tablets:

Micro USB.

Lightning/iPhone

They make one that is Bluetooth, but in mission work, I can see it disappearing. The only problem is the lack of a charging port on the device itself.
 
I practice at several different hospitals. You know what I HATE about Epic? Having to sign in to a computer in Pacu and entering a bunch of BS when I should really be at bedside talking to the nurse and watching my patient before I peel off to the next case- maybe there is a better version?

I might be a little old school, but the disconnection that happens while taking care of patients with OR nurses and the rest of staff due to "data" entry is ridiculous. I sound like a dinasour I know. But I work in both systems currently and I still prefer my paper charts. I spend more time at bedside and actually watching my patient- specifically in Pacu during handoff.

How you guys do t&a's with rapid turnovers is beyond me.

Paper chart those cases 4 sure.
 
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sevoflurane said:
I practice at several different hospitals. You know what I HATE about Epic? Having to sign in to a computer in Pacu and entering a bunch of BS when I should really be at bedside talking to the nurse and watching my patient before I peel off to the next case- maybe there is a better version?

I might be a little old school, but the disconnection that happens while taking care of patients with OR nurses and the rest of staff due to "data" entry is ridiculous. I sound like a dinasour I know. But I work in both systems currently and I still prefer my paper charts. I spend more time at bedside and actually watching my patient- specifically in Pacu during handoff.

How you guys do t&a's with rapid turnovers is beyond me.
Click to expand...
They had just started Epic (Fail) in one of the hospitals I rotated to in residency before I graduated. It made labor epidurals a pain in the semperini. I had to do a similar thing about transferring vitals from the OB nurses to my mobile chart, and then transferring it back to nursing again when it was done.

I still wonder what the designers were smoking when they did the surgery/anesthesiology modules for Epic. Very clunky, and feels like we had very little involvement in helping design it, at least the version they gave our hospital.

We had AIMS at one hospital, and it felt much more like an anesthesia record we had a heavy hand in designing.
 
BTW, I would argue that if you need prolonged q2-3 vitals for a case maybe you should put in an A-line or other noninvasive continual BP device. Just saying...
 
sevoflurane said:
BTW, I would argue that if you need prolonged q2-3 vitals for a case maybe you should put in an A-line or other noninvasive continual BP device. Just saying...
Click to expand...

I've never been in an OR that didn't use Q3 minutes as the baseline for checking BPs. From level 1 trauma centers to VAs to surgery centers to podunk community hospitals.
 
Mman said:
I've never been in an OR that didn't use Q3 minutes as the baseline for checking BPs. From level 1 trauma centers to VAs to surgery centers to podunk community hospitals.
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That's funny, because I have never worked at a place where q3 bps is a standard.
That includes the same exact places you are referring to.
 
sevoflurane said:
That's funny, because I have never worked at a place where q3 bps is a standard.
That includes the same exact places you are referring to.
Click to expand...

Really? Even in residency? How long ago did you finish training?
 
BLADEMDA said:
Easy to post these things when you haven't had patients die perioperatively on you. I guarantee that after a few of these renal patients (Stage 4 or 5) die in the O.R. the risk will become all too real for you. The screening process is too lax in my opinion as these patients are at high risk of mortality. Despite these deaths nothing has changed in terms of preop testing at my institution. I am very cognizant of their increased risk and avoid GA whenever possible (despite lack of evidence this decreases mortality). In addition, I place arterial lines frequently in this population.
Click to expand...
The issue is that what's the evidence stress testing a vascular disease population does anything? As you probably know, the majority of CV events are plaque rupture, not demand ischemia. Stress testing hasn't been shown to help as far as I'm aware.
 
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Mman said:
Really? Even in residency? How long ago did you finish training?
Click to expand...

NEVER in residency as far as I remember- and this was at the only adult/peds trauma center in the state, children's hospital, all the big adult and pedi hearts, neuro and vascular cases, endocrine, etc.
 
For a routine case, q5 min vitals is more than enough- that's why it's the ASA standard.
If I get a low BP, I correct it and hit the BP after a couple of min.

Maybe it's different when supervising, I don't know.
 
I have never seen it as a local practice standard either. Plus I have never used it myself for an entire case - risk of tissue injury. I agree that such a case would probably need an A-line.
 
FFP said:
I have never seen it as a local practice standard either. Plus I have never used it myself for an entire case - risk of tissue injury. I agree that such a case would probably need an A-line.
Click to expand...

Dare I ask how often nurses cycle the BP in the ICU's when patients are on some dex, fent, propofol and/or other gtts.... 😉
 
FFP said:
I have never seen it as a local practice standard either. Plus I have never used it myself for an entire case - risk of tissue injury. I agree that such a case would probably need an A-line.
Click to expand...

90% of the cases I have ever done (both residency and PP) have been with q3min BP's. Nobody's arm has fallen off yet.
 
sevoflurane said:
NEVER in residency as far as I remember- and this was at the only adult/peds trauma center in the state, children's hospital, all the big adult and pedi hearts, neuro and vascular cases, endocrine, etc.
Click to expand...

Interesting. In med school, internship, residency, and current gig I've been in 4 different 1000+ bed level 1 trauma centers and all of them had monitors set to Q3 minutes. I was unaware there were places in the country that didn't do it. Is it geographic? Midwest, northeast, and southeast are the only areas I've worked in ORs in.

I guess I can see only doing it every 5 minutes for a boring case on a healthy patient, but everyone else it would seem every 3 is a little better. I mean in an hour it means you have 20 different measurements instead of 12. I'm 0 for forever at seeing a tissue/nerve injury from the BP cuff cycling that often, even in 6-8 hour cases so it seems like it certainly doesn't hurt to do it.

The ASA minimum standard is definitely 5 minutes and I support that. I just think most patients benefit from more frequent.
 
Mman said:
Interesting. In med school, internship, residency, and current gig I've been in 4 different 1000+ bed level 1 trauma centers and all of them had monitors set to Q3 minutes. I was unaware there were places in the country that didn't do it. Is it geographic? Midwest, northeast, and southeast are the only areas I've worked in ORs in.

I guess I can see only doing it every 5 minutes for a boring case on a healthy patient, but everyone else it would seem every 3 is a little better. I mean in an hour it means you have 20 different measurements instead of 12. I'm 0 for forever at seeing a tissue/nerve injury from the BP cuff cycling that often, even in 6-8 hour cases so it seems like it certainly doesn't hurt to do it.

The ASA minimum standard is definitely 5 minutes and I support that. I just think most patients benefit from more frequent.
Click to expand...

Mman, I have seen Q3 or Q5 depending on the Anesthesiologist as much as the institution. I do agree that many academic centers in the South use Q3 and the data bank includes several million cases without any tissue injury or necrosis secondary to the cuff. I'll change to Q3 when appropriate (about 1/3 of my cases) or just place an arterial line which is a safe procedure but not as safe as Q3 BP measurements. The standard of care as set by the ASA is Q5 minutes.
Unfortunately, the majority of CRNAs I work with use Q5 BP measurements when I would prefer Q3 for most ASA 3 and 4 cases.

http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2475799
 
BLADEMDA said:
Unfortunately, the majority of CRNAs I work with use Q5 BP measurements when I would prefer Q3 for most ASA 3 and 4 cases.
Click to expand...

Can you not change the screen yourself or tell them to do it? You're the supervising physician and its your rules.
 
AdmiralChz said:
Can you not change the screen yourself or tell them to do it? You're the supervising physician and its your rules.
Click to expand...

Of course, I discuss why I want q3 readings with the CRNA and change the screen. It takes 30 seconds. That said, I'm covering at least 4 CRNAs at any one time with many cases per room. So, I typically only "request" the Q3 change on the sickest patients.
 
Ronin2258 said:
They had just started Epic (Fail) in one of the hospitals I rotated to in residency before I graduated. It made labor epidurals a pain in the semperini. I had to do a similar thing about transferring vitals from the OB nurses to my mobile chart, and then transferring it back to nursing again when it was done.

I still wonder what the designers were smoking when they did the surgery/anesthesiology modules for Epic. Very clunky, and feels like we had very little involvement in helping design it, at least the version they gave our hospital.

We had AIMS at one hospital, and it felt much more like an anesthesia record we had a heavy hand in designing.
Click to expand...

You can add an event that pulls 15-45 min of vitals from the nursing record into your anesthesia record without changing data source over and back.

Also, there is a touch and go thing where your badge will log you in, then it is just a few clicks to end the case when you get to PACU. We have a "anesthesia only" computer between every few beds in PACU, so you never really have to go more than 5 steps from the patient.
For those who are really concerned, you can just use a tablet and stay logged in. I used to stuff mine under the mattress for transport and tap the few buttons after I helped hook up monitors, while giving report.


Sent from my iPhone using SDN mobile app
 
FFP said:
Good luck with that approach.
Click to expand...

why? I personally do things like set the vent, adjust the BP interval, etc. all the time. They don't care if you have a good working relationship with them. Treat them like you are their boss, not like you are their parent.
 
FFP said:
Good luck with that approach.
Click to expand...
Respectfully, I don't understand this mentality. YOUR name is on the chart and YOU bear the liability. Surely you must be able to to dictate how YOUR anesthetic is performed. Or am I missing something here?
 
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