Father-in-law consult

[Monty Python]

And the case of the week:

My 82 year old father-in-law (a retired GP/allergist) is still sharp as a tack, completely independent, and spends his time puttering in his garden. Grows awesome tomatoes and green beans. At first glance you would think he was barely 70. He tore a medial meniscus and conservative treatments have been unsatisfactory. His orthopod wants to do a knee scope.

PSH: CABG in 1991, hernia in 1995, bilateral phacos, lum lam for spinal stenosis last year. No problems with any.

PMH: Chronic lymphocytic leukemia, dx last year. Pulmonary fibrosis, dx in 2003. No complaints of DOE, only that he "doesn't have his former energy level." Well, duh, he's only 82. No complaints of angina (that I know about).


He's 6 feet 4 inches, normal/skinny build.

How would you proceed?

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[militarymd]

propofol, lma, gas....


No other meds to avoid PPOCD

 

[Noyac]

propofol, lma, gas....


No other meds to avoid PPOCD

Yeah the same. Or if he wanted to watch I'd do a spinal (plts OK).

 

[coccygodynia]

How about a little versed and fentanyl for an intra-articular block and let him watch in the OR?

What did you end up doing?

 

[jetproppilot]

propofol, lma, gas....


No other meds to avoid PPOCD

ditto.

 

[Monty Python]

And the case of the week:

My 82 year old father-in-law (a retired GP/allergist) is still sharp as a tack, completely independent, and spends his time puttering in his garden. Grows awesome tomatoes and green beans. At first glance you would think he was barely 70. He tore a medial meniscus and conservative treatments have been unsatisfactory. His orthopod wants to do a knee scope.

PSH: CABG in 1991, hernia in 1995, bilateral phacos, lum lam for spinal stenosis last year. No problems with any.

PMH: Chronic lymphocytic leukemia, dx last year. Pulmonary fibrosis, dx in 2003. No complaints of DOE, only that he "doesn't have his former energy level." Well, duh, he's only 82. No complaints of angina (that I know about).


He's 6 feet 4 inches, normal/skinny build.

How would you proceed?

To the previous poster who inquired what did we do, I apologize. I should have originally written that I was asking for a preop consult for his scheduled op in a few weeks. Given his PMH I wanted the collective wisdom of the forum.

Also forgot to add: would you feel comfortable doing him as same-day surgery, or is post-op overnight observation indicated? If done as same-day, that pretty much rules out a spinal.

Just so happens that today my wife informed me that her dad had another appointment yesterday with his orthopod, who is now thinking a total knee replacement might be the best option, considering the underlying arthritis which is also present in addition to the torn meniscus.

For a TKR, and given his PSH and PMH, would you recommend (a) straight GETA, (b) preop fem/sciatic blocks and then GETA or LMA, or (c) combined spinal/epidural with IV sedation? Thanks!

 

[Noyac]

To the previous poster who inquired what did we do, I apologize. I should have originally written that I was asking for a preop consult for his scheduled op in a few weeks. Given his PMH I wanted the collective wisdom of the forum.

Also forgot to add: would you feel comfortable doing him as same-day surgery, or is post-op overnight observation indicated? If done as same-day, that pretty much rules out a spinal.

Just so happens that today my wife informed me that her dad had another appointment yesterday with his orthopod, who is now thinking a total knee replacement might be the best option, considering the underlying arthritis which is also present in addition to the torn meniscus.

For a TKR, and given his PSH and PMH, would you recommend (a) straight GETA, (b) preop fem/sciatic blocks and then GETA or LMA, or (c) combined spinal/epidural with IV sedation? Thanks!

Spinal with duramorph and bupiv, and a cont. fem nerve block.

 

[jetproppilot]

Spinal with duramorph and bupiv, and a cont. fem nerve block.

NOW I go with Noy's recommendation.

For a simple knee scope, even in light of my pro-regional views, the potential problems/frustrations caused by regional for a thirty minute case isnt justified IMHO.

Do a knee scope with propofol/LMA/gas....patient is in their car on the way home an hour after the case.

No worry of urinary retention/return of motor function which comes with regional.

A TKA is a totally different ballgame....now, IMHO, theres no comparison.

Noy's recommendation is the way to go.

 

[jetproppilot]

Spinal with duramorph and bupiv, and a cont. fem nerve block.

with a foley. I'm sure all are thinking that. Just putting it in print.

 

[militarymd]

The surgery just went from a low risk (essentially no risk surgery) to a intermedicate risk surgery from a cardiac standpoint (1% to %5 cardiac morbidity.....although closer to 1% than 5%).


The anesthestic itself doesn't alter the perioperative cardiac risk.

Based on your history, no additional testing is necessary to identify and/or modify risk.

However, perioperative beta-blockade may be beneficial.

 

[powermd]

No preop stress test here? The guy has CAD s/p CABG waaaaay back in '91. No one is concerned about his coronaries?

 

[militarymd]

No preop stress test here? The guy has CAD s/p CABG waaaaay back in '91. No one is concerned about his coronaries?

You ARE kidding ...right?

 

[TIVA]

Gentlemen, Esteemed Colleagues,

Two quick points:

1. Cardiac evaluation in this guy would be necessary unless his functional status is better than 4 mets (i.e. able to ambulate up a flight of stairs without stopping in the middle due to shortness of breath).

Just because he can putter around in his garden is not enough information that he is cardiovascularly fit. Furthermore, if he is unable to to climb a flight of stairs because of his lumbar spinal stenosis, then a chemical stress echo would be in order (I'd choose adenosine assuming he's already on a betablocker). The results of the stress echo would dictate further evaluations.

2. Volatiles have been shown to be cardioprotective by improving ischemic preconditioning of the heart. Thus, I would argue that to withhold volatiles in this gentleman would be to subject him to a suboptimal anesthetic.

Hence, I would recommend a balanced technique: pre-operative epidural placement (for purposes of post-operative pain relief, and to minimize post-op narcotic use in someone with pulm fibrosis), and then proceed with GA with gas maintenance and heavy-handed use of intraoperative fentanyl (for vagotonic effects on heart).

Respectfully,

 

[militarymd]

Gentlemen, Esteemed Colleagues,

Two quick points:

1. Cardiac evaluation in this guy would be necessary unless his functional status is better than 4 mets (i.e. able to ambulate up a flight of stairs without stopping in the middle due to shortness of breath).

Just because he can putter around in his garden is not enough information that he is cardiovascularly fit. Furthermore, if he is unable to to climb a flight of stairs because of his lumbar spinal stenosis, then a chemical stress echo would be in order (I'd choose adenosine assuming he's already on a betablocker). The results of the stress echo would dictate further evaluations.

2. Volatiles have been shown to be cardioprotective by improving ischemic preconditioning of the heart. Thus, I would argue that to withhold volatiles in this gentleman would be to subject him to a suboptimal anesthetic.

Hence, I would recommend a balanced technique: pre-operative epidural placement (for purposes of post-operative pain relief, and to minimize post-op narcotic use in someone with pulm fibrosis), and then proceed with GA with gas maintenance and heavy-handed use of intraoperative fentanyl (for vagotonic effects on heart).

Respectfully,

You guys HAVE to be kidding ....RIGHT?

I CANNOT believe that there are attending anesthesiologists out there who would even CONSIDER testing someone like this for a LOW risk surgery.

Tell me you are JOKING.....PLEASE.....I need faith in the ABA examination process.

Tell me that you ARE NOT serious about possible performing CABG or PCI for someone like this prior to a KNEE SCOPE.

Come on....come back and say...yes ....I was kidding.

 

[militarymd]

For a TKA....testing would only be even considered if CABG or PCI is a possible option prior to the surgery.

 

[TIVA]

No, no, not for a knee scope. For a knee scope go straight to the OR and just do a quick and clean GA as described earlier: propofol, LMA, gas.

For TKA, or any other moderate to highly invasive surgery for that matter, 2 out of 3 criteria warrants further testing:

1. Hi risk surgery -- which this isn't.
2. Functional status -- which we don't have enough info on ... yet.
3. Symptoms (i.e. anginal equivalents/sob/chest pain, etc) ... which have also not been elaborated on unless we can agree that happily puttering around the garden is being symptom-free. Is he happy to putter around? Or is he only able to putter around, lest anything remotely more active precipitates symptoms?

Thus, knowing functional status is the key to the decision-making tree here.

 

[militarymd]

The other key to testing is what would you do with the result.


Would this patient undergo PCI or CABG based on testing?

I would say unlikely...regardless of the results of testing.

In private practice, many of these patients do get tested because the cardiologists are interested in a insurance/wallet bx.

 

[Noyac]

Gentlemen, Esteemed Colleagues,

Two quick points:

1. Cardiac evaluation in this guy would be necessary unless his functional status is better than 4 mets (i.e. able to ambulate up a flight of stairs without stopping in the middle due to shortness of breath).

Just because he can putter around in his garden is not enough information that he is cardiovascularly fit. Furthermore, if he is unable to to climb a flight of stairs because of his lumbar spinal stenosis, then a chemical stress echo would be in order (I'd choose adenosine assuming he's already on a betablocker). The results of the stress echo would dictate further evaluations.

2. Volatiles have been shown to be cardioprotective by improving ischemic preconditioning of the heart. Thus, I would argue that to withhold volatiles in this gentleman would be to subject him to a suboptimal anesthetic.
Hence, I would recommend a balanced technique: pre-operative epidural placement (for purposes of post-operative pain relief, and to minimize post-op narcotic use in someone with pulm fibrosis), and then proceed with GA with gas maintenance and heavy-handed use of intraoperative fentanyl (for vagotonic effects on heart).

Respectfully,

Really? There is enough evident to make this statement in your mind?

You would contend that if this pt had a spinal for his surgery and 3 days or 3 months afterwards he suffered an IM. It would be because of the suboptimal anesthetic?

 

[Monty Python]

No, no, not for a knee scope. For a knee scope go straight to the OR and just do a quick and clean GA as described earlier: propofol, LMA, gas.

For TKA, or any other moderate to highly invasive surgery for that matter, 2 out of 3 criteria warrants further testing:

1. Hi risk surgery -- which this isn't.
2. Functional status -- which we don't have enough info on ... yet.
3. Symptoms (i.e. anginal equivalents/sob/chest pain, etc) ... which have also not been elaborated on unless we can agree that happily puttering around the garden is being symptom-free. Is he happy to putter around? Or is he only able to putter around, lest anything remotely more active precipitates symptoms?

Thus, knowing functional status is the key to the decision-making tree here.

This is exactly the type of philosophical provocation I was hoping for. Both for my father-in-law's benefit from the forum's collective wisdom (thank you), and for the benefit of the students/newbies/lurkers on the forum.

To answer the above questions: Prior to tearing his meniscus, my 82 year old relative was pissed that he had to give up his push lawnmower in 2004 and purchase a riding lawnmower, simply due to leg weakness 2ndary to muscle atrophy 2ndary to waiting so long for the lum lam to relieve the spinal stenosis.

Even though he was dx'd with pulmonary fibrosis, he's never voiced DOE complaints to me, and never shared angina complaints with me.

He carried a full patient load as a clinic-based physician, retiring 2 years ago at age 80. No problems keeping up with that schedule.

 

[jetproppilot]

No preop stress test here? The guy has CAD s/p CABG waaaaay back in '91. No one is concerned about his coronaries?

You can do what you want.

No argument from me.

I'm gonna pre-load the guy with 500 mL crystalloid, stick a Tuohy in his back, slide a 26" spinal needle through the Tuohy, squirt in 15 mg hyperbaric bupivicaine with 25ug fentanyl, pull the spinal needle out, thread the epidural catheter, pull the Tuohy out, clamp the blue&black cap on the catheter, flip the catheter over dudes shoulder, put the little yellow spongy thing where the catheter emerges from his back, put the catheter in the slit of the yellow spongy thing, throw some tape on, and lay him down.

Then I'm gonna wheel him back to the OR, put him on the OR table, put the monitors on, put a nasal cannula on the dude, make him somnulent with midazolam, flip some Dave Matthews on the mp3 player sitting in the portable-speaker setup, sit down, and do some paperwork.

 

[TIVA]

Given Trinity's further info on his father-in-law, our algorithm would go as follows:

1. Hi risk surgery? No.

2. Functional status? Moderate (given that he could push a lawnmower until a couple of years ago, and then not since secondary to back/leg pain).

3. Symptoms? No.

Assessment: No need for further cardiac testing per ACC/AHA guidelines.

Plan: Proceed to OR. Continue periop BB and statin.

In terms of type of anesthetic, yes, in my mind to withhold volatiles from someone with known CAD is potentially bad. I believe it's only a matter of 6 months to 1 year before it becomes standard of care to preferentially administer volatiles for patients with CAD.

And with regards to timing of a perioperative MI. The greatest likelihood of post-operative MI in orthopedic patients tends to occur 3 to 5 days post-op. Why? Probably a combination of hypercoagulability secondary to the surgery, aspirin withdrawal syndrome, and most importantly, overnarcosis with opiates causing respiratory depression, ergo low sats.

If the MI occurs 3 months down the road, I along with everyone here (I think) would doubt it was the result of the anesthetic -- more probably the father-in-law decided to take his new knee for a test run in the local marathon, or forgot to restart his ASA, BB, and statin.

 

[militarymd]

Given Trinity's further info on his father-in-law, our algorithm would go as follows:

1. Hi risk surgery? No.

2. Functional status? Moderate (given that he could push a lawnmower until a couple of years ago, and then not since secondary to back/leg pain).

3. Symptoms? No.

Assessment: No need for further cardiac testing per ACC/AHA guidelines.

Plan: Proceed to OR. Continue periop BB and statin.

In terms of type of anesthetic, yes, in my mind to withhold volatiles from someone with known CAD is potentially bad. I believe it's only a matter of 6 months to 1 year before it becomes standard of care to preferentially administer volatiles for patients with CAD.

It's been years since Mangano, Polderman and others have published ACTUAL CLINICAL data on REAL HUMANS in REAL LIFE clinical scenarios and Beta Blockers is still not "standard of care"......and you think in 6 months, volatile anesthetics is going to be "standard of care"?????

Care to enlighten the rest of us on the secret data that you have?

And with regards to timing of a perioperative MI. The greatest likelihood of post-operative MI in orthopedic patients tends to occur 3 to 5 days post-op. Why? Probably a combination of hypercoagulability secondary to the surgery, aspirin withdrawal syndrome, and most importantly, overnarcosis with opiates causing respiratory depression, ergo low sats.

Sooooo, post TKA MI's tend to occur after the patients go home?

 

[jetproppilot]

statin.

In terms of type of anesthetic, yes, in my mind to withhold volatiles from someone with known CAD is potentially bad. I believe it's only a matter of 6 months to 1 year before it becomes standard of care to preferentially administer volatiles for patients with CAD.

.

So youre suggesting a general anesthetic trumps neuraxial technique for total-joint-replacement in terms of better outcome, huh?

Man, I'd love to see the literature on that.

Please enlighten me on the studies you used that suggest better-outcome-with-sevo, des, or iso , verses epidural anesthesia for total joint replacement.

 

[Noyac]

Yeah TIVA, I appreciate your input but I think you are taking this volatile agent cardiac preconditioning a little too far.

 

[TIVAphile]

HI all, just came over this hot topic
my 2cents
pre-op
targeted history for resp/cardiac symptoms
could argue for PFTs if inactive, just to know what dealing with, will look at chest xray
has pt been on statins/bblockers/ACEI since CABG, how many vessels?, evidence of PVD/carotid stenosis? if many "yes" will warant nuclear stress test
intraop
will prefer spinal, if not contraindicated , been shown to decrease risk of cardiovasc/DVTs. isobaric bupiv, or chlorprocaine for scope
wouldnt wanna comromize FRC/diffusion hypoxia while recovering from gas
femoral nerve cath/epidural would be great for TKR post-op

 

[TIVAphile]

Just to add
would probably start neo drip right away to avoid hypotention 2/2 spinal
I am not TIVA by the way, and I wonder if TIVA is truly TIVA, he seems to be into gas

 

[militarymd]

HI all, just came over this hot topic
my 2cents
pre-op
targeted history for resp/cardiac symptoms
could argue for PFTs if inactive, just to know what dealing with, will look at chest xray
has pt been on statins/bblockers/ACEI since CABG, how many vessels?, evidence of PVD/carotid stenosis? if many "yes" will warant nuclear stress test
intraop
will prefer spinal, if not contraindicated , been shown to decrease risk of cardiovasc/DVTs. isobaric bupiv, or chlorprocaine for scope
wouldnt wanna comromize FRC/diffusion hypoxia while recovering from gas
femoral nerve cath/epidural would be great for TKR post-op

OMG.....what are you guys learning in residency????

PFTs for non-thoracic surgery?????

CXR for non-thoracic surgery?????

Wanting details of "how many vessels".......are you planning on doing some PCI or CABG?????

OMG.....get that bazooka out and aim it at the flea on your dog!!!

 

[Noyac]

So this guy goes in for a knee scope and b/4 he can get scoped, he gets a stress test, PFT's, a gammut of blood work, ECG, two consults at least, and who knows what else. All these things take time and money. Money from a broken system that is already hemorrhaging more money than it currently has. You guys are right, all these things and even more not mentioned yet can be argued for but are they going to change your management. Not mine, I'm doing a spinal.
Also, the more you do the more chance of a complication. Say he gets a stress test and its inconclusive. Then he gets a cath and it shows nothing major. Then he goes home and the femoral artery puncture site breaks loose and he loses a liter of blood, I've seen it happen. Now he needs emergency surgery and is stressed more than he ever would have been. All b/c anesthesia wouldn't do his case without a cardiac evaluation.

 

[TIVAphile]

In fact, current cardiac work up shouve been a part of his routine cardiac care, and if it wasnt done, we have a good reason to do it. CABG last for about 10 years before graft re-stenosed, and its on a lucky patient. there is also a difference if he had one vessel with LIMA or a bunch of vein grafts. which would mean that he may not have good native collaterals to relay on.
while, I prefer spinal, should be ready for GA nonetheless, woudnt you want to know baseline PFT/TV before you reverse him and try pull ETT out.

 

[jetproppilot]

In fact, current cardiac work up shouve been a part of his routine cardiac care, and if it wasnt done, we have a good reason to do it. CABG last for about 10 years before graft re-stenosed, and its on a lucky patient. there is also a difference if he had one vessel with LIMA or a bunch of vein grafts. which would mean that he may not have good native collaterals to relay on.
while, I prefer spinal, should be ready for GA nonetheless, woudnt you want to know baseline PFT/TV before you reverse him and try pull ETT out.

I've been in private practice for ten years now.

I was formerly in a practice that did many CABGs.

I'm currently in a practice that doesnt do as many hearts, but I still get my share of ASA 4 non-cardiac cases.

I've yet to order pre-op PFTs.

The only indication for PFTs is a total pnemonectomy or lung transplantation, neither of which I do.

Every PFT that is ordered pre-op that isnt a pre-op workup for the above two operations is a waste of time and money.

 

[Noyac]

I've been in private practice for ten years now.

I was formerly in a practice that did many CABGs.

I'm currently in a practice that doesnt do as many hearts, but I still get my share of ASA 4 non-cardiac cases.

I've yet to order pre-op PFTs.

The only indication for PFTs is a total pnemonectomy or lung transplantation, neither of which I do.

Every PFT that is ordered pre-op that isnt a pre-op workup for the above two operations is a waste of time and money.

I second that!

 

[jetproppilot]

OMG.....what are you guys learning in residency????

PFTs for non-thoracic surgery?????

CXR for non-thoracic surgery?????

Wanting details of "how many vessels".......are you planning on doing some PCI or CABG?????

OMG.....get that bazooka out and aim it at the flea on your dog!!!

I've been preaching the problems with the academic way ever since I've been posting here, Mil.

It's not their fault.

It's the Academic Anesthesia Milleau's fault for teaching residents the costly, time wasting, superfluous way of practicing anesthesia.

And people wonder why academic centers have money flow problems....efficiency problems...what wrought with over-diagnosis, over-ruling-s hit-out, over-testing...

and all the while NOT with better patient outcome than private practice centers....

yes, academic centers can do cases we cant....heart transplants, liver transplants, neonatal surgery, etc...with great results...

but on a case-for-case basis on lap choles, TKAs, hips, ELAPS, C-sections, etc,

academic centers need to look in the mirror and revise their archaic rituals.

 

[coccygodynia]

The only indication for PFTs is a total pnemonectomy or lung transplantation, neither of which I do.

Don't leave out the scoliosis patients! They have feelings too

 

[jetproppilot]

Don't leave out the scoliosis patients! They have feelings too

Ahhhhh....

so you've got a scoliosis patient scheduled for a total knee.

I've done literally hundreds.

How is ordering PFTs gonna change your management?

 

[jetproppilot]

Don't leave out the scoliosis patients! They have feelings too

I look at this mentality as many physicians look at putting in a SWAN....

If you do it, we're treating the patient better. We're doing the right thing.

 

[jetproppilot]

I look at this mentality as many physicians look at putting in a SWAN....

If you do it, we're treating the patient better. We're doing the right thing.

Unfortunately, it just isnt so.

 

[cowbell]

1. Cardiac evaluation in this guy would be necessary unless his functional status is better than 4 mets (i.e. able to ambulate up a flight of stairs without stopping in the middle due to shortness of breath).

Just because he can putter around in his garden is not enough information that he is cardiovascularly fit. Furthermore, if he is unable to to climb a flight of stairs because of his lumbar spinal stenosis, then a chemical stress echo would be in order (I'd choose adenosine assuming he's already on a betablocker). The results of the stress echo would dictate further evaluations.

this is hogwash. i echo millitarymd's and noyac's sentiments about this.

 

[cloud9]

You guys are right, all these things and even more not mentioned yet can be argued for but are they going to change your management. Not mine, I'm doing a spinal.

I think this is the most important message here about all of this. Will the test provide more information, yes, but change management? No.

 

[militarymd]

Testing is for 2 things.

1) managemetn strategy
2) whether to cancel or not....

 

[TIVA]

Good morning gentlemen,

Just walked into call today, no cases on the list yet, so here goes:

Regards to my seeming propensity for gas in spite of my name, I actually am extremely fond of total intravenous anesthetics because of their smooth emergences and euphoric wake ups. I truly believe anesthesia is an art and I hate the emergences with gas. At least in my hands, I have difficulty facilitating smooth and rapid wake ups, it's either one or the other, not both. But with TIVA, I can in fact more easily accomplish those two goals. Plus, I don't have to worry about the blunting of hypoxic vasoconstriction, but I'll talk about that later.

There was a thread not too long ago called "Des wake ups." For those who doubt my fondness of intravenous techniques, if you peruse that thread, you will find post #20 championing TIVA.

However, there are a studies that show significantly higher troponin levels (both statistically and clinically) post cardiac surgery with TIVA as opposed to with volatiles. I will post the names of the articles in the near future. And I cannot find one anesthesiologist who will agree to do cardiac surgery without the use of volatiles. Why? Because studies (also to be provided in the near future) show that volatiles potentiate ischemic preconditioning -- thereby lowering infarct size, improving EF, and reducing ventricular arrhythmias.

So, if you're willing to believe the cardiac anesthesia literature, which I am, then if volatiles are good for patients with heart disease undergoing heart surgery, then those very same volatiles are probably good for patients with heart disease undergoing non cardiac surgery.

Can I fault anyone for not choosing a volatile over another anesthetic plan such as spinal or regional block? Absolutely not. It depends on the individual, their comorbidities, the anesthesiologist, and the surgery they're about to have. But given the case that Trinity presented, with all the info he gave on his dad-in-law and all the comorbidities he has, then I feel a pre-op epidural (tested, not dosed), GA with volatile and intraop fentanyl would be good. Can a spinal or epidural or regional technique get the person through a TKA safely? Sure. But consider the following ...

Which brings me to the topic of hypoxic vasoconstriction and the obliteration of that effect by volatiles.

Yes, volatiles do blunt this effect. But in someone with pre-existing lung disease, be it restrictive (which the dad-in-law has with pulm fibrosis) or obstructive (such as with COPD), their lungs are resistant to this effect. Yes, let me repeat that ... Volatiles are not able to blunt the hypoxic vasoconstriction of pulmonary vasculature in sick lungs as compared to healthy lungs. Why? Because sick lungs, with all there intrapulmonary shunts and increased vascular thickening lead directly to pulmonary hypertension. PH is resistant to volatile-related blunting of hypoxic vasoconstriction, which works to our advantage in the OR cuz then we're not chasing the cause of low sats or what have you. In fact, have you not noticed this in your own patient population? COPD'ers satting 100% all day long on less than 40% O2.

Oh, yeah, also, the problem with spinals in CAD patients is that you have to keep a very, very close eye on their diastolic pressure lest you drop their coronary perfusion pressure. So I agree with the neo drip being nearby. And you also have to keep a close eye on MAP's cuz in a vasculopath, the heart and the kidneys love pressure. Remember, we are perioperative physicians, not just sleep doctors.

Anyways, moving on ...

With regards to PFT's? Agree with those who say "nah."

With regards to what to do with that additional info that further cardiac eval will provide? Now that is probably the heart of the issue (no pun intended ... well, okay, intended). Excellent point. Would the father-in-law be a candidate for PCI or redo bypass?

Let's say the stress test shows something minor or stupid like possible inferior attenuation ... then no, no further workup warranted. But if there is a significant reversible perfusion deficit (such as moderate size, moderate area in territory of LAD, or a significant reversible wall motion abnormality), then if I was the patient, I think I would be interested in knowing that information ... some potentially life threatening, rate-limiting flow lesion vs blindly going into a totally elective procedure that requires me to withhold my aspirin which is keeping that one platelet from unleashing that pack of ravaging wolves in an unstable plaque. I think I would want to know, if I were the patient.

We as anesthesiologists are not the patient's primary care doctor. But we are more than technicians in some assembly line that just put patients to sleep and keep them from moving under the surgeon's knife. We teeter them along on the line between not feeling pain ... and death. For those who are healthy, that line is broad. For those who are not, that line is thin.

So, in Trinity's case, I think at the very minimum a chemical stress test is warranted. After all, as someone mentioned previously, the life of graft patency is about 10 years and the father-in-law is 15 years post CABG.

Which stress test? According to my cardiology buddy, if you want it to be positive, go with the adenosine thallium, if you want it to be negative, go with the dobutatmine stress echo.

 

[TIVA]

One other point:

I will not hold a case up in the hopes of finding some remote chance of some obscure and insignificant pathology. And I will not just refer someone to cardiology for the hell of it. But this is a guy who has a significant cardiac history and has nothing to show for it's current status in terms of symptoms or functional status (limited due to spinal stenosis).

Anesthesia, for the most part, is pretty safe for a large variety of patients and comorbidities. Geez, sometimes the cardiac history amounts to changing our anesthetic plan by doing nothing more than just looking at the BP and HR a little more frequently during induction and emergence.

But I genuinely believe in exercise as an indicator of overall health and wellbeing. And if you can exercise, then you can safely undergo not just the anesthetic but the very surgery as well, which is a form of stress test unto itself. That's why your high school athlete recovers from the surgery faster than the 48 y.o. obese diabetic. So for those who say that exercise tolerance or METS are irrelevant to the anesthetic workup, I kindly beg to differ.

 

[militarymd]

........
However, there are a studies that show significantly higher troponin levels (both statistically and clinically) post cardiac surgery with TIVA as opposed to with volatiles. I will post the names of the articles in the near future. And I cannot find one anesthesiologist who will agree to do cardiac surgery without the use of volatiles. Why? Because studies (also to be provided in the near future) show that volatiles potentiate ischemic preconditioning -- thereby lowering infarct size, improving EF, and reducing ventricular arrhythmias.

So, if you're willing to believe the cardiac anesthesia literature,.......

One of the most common mistakes in interpreting literature committed by my residents....applying data from one patient population to another.

Another very common error committed by anesthesiologists ..... confusing SURROGATE ENDPOINTS with real endpoints. The above post is filled with surrogate endpoints that don't mean diddlely at the end of the day.

 

[TIVA]

And with regards to demands for literature showing outcomes:

Let's please be reasonable. We don't need literature to show us how to micromanage our skill, our science, and our art that we call Anesthesia. I believe each of your experiences is just as valid as the literature. Having said that, I will be providing some articles in the near future for your perusals as soon as I dig them out.

And besides, I know of no double blind, randomized, controlled trial that shows parachutes work. But if they do do such a study. I want to the be in the arm that has the parachutes.

 

[militarymd]

Let's say the stress test shows something minor or stupid like possible inferior attenuation ... then no, no further workup warranted. But if there is a significant reversible perfusion deficit (such as moderate size, moderate area in territory of LAD, or a significant reversible wall motion abnormality), then if I was the patient, I think I would be interested in knowing that information ... some potentially life threatening, rate-limiting flow lesion vs blindly going into a totally elective procedure that requires me to withhold my aspirin which is keeping that one platelet from unleashing that pack of ravaging wolves in an unstable plaque. I think I would want to know, if I were the patient.

Being 80 years old is life threatening.

Undergoing PCI/CABG is life threatening.

Elective TKA is life threatening before or after revascularization.

I propose skipping one of the 3 possible life threatening events on his way to a better lifestyle.

 

[cowbell]

And with regards to demands for literature showing outcomes:

Let's please be reasonable. We don't need literature to show us how to micromanage our skill, our science, and our art that we call Anesthesia. I believe each of your experiences is just as valid as the literature. Having said that, I will be providing some articles in the near future for your perusals as soon as I dig them out.

And besides, I know of no double blind, randomized, controlled trial that shows parachutes work. But if they do do such a study. I want to the be in the arm that has the parachutes.

poor analogy

 

[DenRock]

Wow - haven't been on the forum in a while, and this post really got my attention. I will add what is my understanding about the volatiles' benefit. I understand that volatile anesthetics (and opioids to some degree) improve cardiac ISCHEMIC preconditioning, as demonstrated for OHS. So for there to be some benefit for non-cardiac surgery, you must presume there will be myocardial ischemia. I don't think we can say with confidence that there will be in this case. I believe that subarachnoid block with intrathecal opioid is STILL the gold standard for total joint replacement. My $0.02.

Vacationing/Studying 'til I start my new job at AGH Pittsburgh!

 

[Noyac]

Wow - haven't been on the forum in a while, and this post really got my attention. I will add what is my understanding about the volatiles' benefit. I understand that volatile anesthetics (and opioids to some degree) improve cardiac ISCHEMIC preconditioning, as demonstrated for OHS. So for there to be some benefit for non-cardiac surgery, you must presume there will be myocardial ischemia. I don't think we can say with confidence that there will be in this case. I believe that subarachnoid block with intrathecal opioid is STILL the gold standard for total joint replacement. My $0.02.

Vacationing/Studying 'til I start my new job at AGH Pittsburgh!

Not true.
The studies show protection for future ischemic events and don't require ischemia during the pre-conditioning period. Its been called a "genomic response".
Now I am not discounting the volatiles benefits but I think TIVA is reading too much into this.

By the way, why does the guy need to stop taking his aspirin. It arguable for TKA but not for a knee scope.

 

[coccygodynia]

Ahhhhh....

so you've got a scoliosis patient scheduled for a total knee.

I've done literally hundreds.

How is ordering PFTs gonna change your management?

Sorry - guess I should have been more specific - I'm talking about the actual repair/fusion in a scoliosis patient (to add to your list of procedures that benefit from PFTs). I agree with your point about unnecessary testing for a knee.

 

[jetproppilot]

Sorry - guess I should have been more specific - I'm talking about the actual repair/fusion in a scoliosis patient (to add to your list of procedures that benefit from PFTs). I agree with your point about unnecessary testing for a knee.

gotcha.

I agree....youre speaking of those huge (mostly pediatric) scoliosis repairs.

Add that one to the list.