Thanks for ruining a good thread Military by inevitably ticking people off. Your opinion is helpful as a datapoint, but you really need to work on your tact. In an academic setting, no way this case gets done. In a private setting, Zippy's route is the way to go. If no cardiac clearance by the cardiologist, case doesn't happen. It's ELECTIVE. It's not EMERGENT/URGENT. Anything happens, you're getting sued, and there's at least some chance you'll lose. You got to be smart about what you do. You don't want to piss your surgeon's off, but it's also their responsibility to send the patient's H&P to you to screen and send the patient off to the cardiologist, or if not, themselves send the patient off to the cardiologist. Most surgeon's do this. The ones that don't, may not be the best surgeons. Zippy's approach is the best way - as usual.
Further testing? Or proceed to OR?
- Thread starter TIVA
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This thread is like a bad car wreck.....
I dont really want to look but I do😎
I dont really want to look but I do😎
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I thought you were done with this thread?
You haven't come back to tell me that you PASSED your orals with your style.....what am I supposed to infer from that?
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Hey, I was doing a Jet imitation profiling.....If I'm off, let the Columbia frat boy tell me I'm wrong....
I'm willing to bet I'm almost 100% with his profile ......including the Dr.xxx THE THIRD...driving a fancy BMW...or other type car....etc. etc.
He can tell me I'm wrong if he wants....but I believe he is done with me.
I thought about profiling you....with your posts about masturbation...man boobs...and prostate stuff.....but that would be REALLY in bad taste.
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is that finally, as rediculous as both your posts were, he has proven his maturity over yours.....who knows, you could always track him down and challenge him to a throw down
or maybe, just mqaybe he does not have time all day on his hands to post rediculous posts.........
or maybe, just mqaybe he does not have time all day on his hands to post rediculous posts.........
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I'm super-surprised MilMD hasn't used the phrase "ivory tower" yet. Usually it's "you academics in your ivory tower, you'd never cut it in PP" with the typical emphasis of BLING & keeping the surgeons happy over safety & covering your medicolegal ass.
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and NO , that is not a compliment....why don't you give me the name of your hospital...I'll randomly call a few surgeons there, ask what they think of you, anbd post the responses here...my guess is very little....
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MS3 here. the OP seems to present a case where the anesthesia might be more dangerous than the procedure. why does a low risk procedure trump the possibility that this patient with many medical problems getting GA? thanks for any thoughts.
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I'm not here to make friends....I'm here for fun....and it IS fun to post here...especially how easy it is to get people pissed at me....
all I have to do is call a spade a spade.....tell things like I see it.....offer an opinion and people get SOOOOO upset....
I'm not mad at you for your opinions....why are you mad at me for mine?
Ask yourself that question.
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A general anesthetic is SAFE .....IF you are properly trained to administer it.
volatile anesthetics.......PROTECTS the heart......there are many here who know the data better than I do......it also PROTECTS the brain...etc. etc.
Mechanical Ventilation.....changes marginal spontaneous ventilation to BETTER ventilation.
When a patient gets sick (without surgery) and gets near dying....what do we do to them....we give them "general anesthesia" in the ICU with mechanical ventilation.....
I will give you that giving a general anesthetic to a sick patient is a PAIN IN THE ASS....because the side effect profiles of GA in sick patients are enormous, but that's what anesthesiologists get paid to do....
AND I will give you that the recovery profile from GA will be prolonged and again with more side effects than an ASA 1 , but, once again, that is what an anesthesiologist is paid to do.....
If someone can walk to the hospital, they can have a general anesthetic....because people who are sick and dying and get driven to the hospital in an ambulance GETS GA to save their lives.
Once you get someone to sleep, and manage the side effects from your GA.....a low risk procedure is nothing.
And remember ...no matter what you do....people will die...
If you follow a cohort of 65 year olds in the US....1 will die every 2 to 3 months...that is the death statistics in the US....
and if one of them just happens to be having surgery....well.....they will still try to die.....but because of our presence will probably live to try to die another day.
So....I submit that for an old sick dude.....they are probably safer (and less likely to die) in the OR under GA..having a low risk procedure....then when they go about with their activities of daily living.....Assuming that you have a well-trained attending anesthesiologist ......of which I am apparently not according to the denizens of SDN Gasnet.
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The pt needs to be seen by a cardiologist before coming to my OR. He is having elective endoscopic surgery and seems to be poorly managed. Our surgeons would not bring this guy to the ORs...
I think beyond guidelines we need to use common sense and some clinical judgment based on our History and Physical findings of our patients. Does this man need endoscopic sinus surgery or 30 mins with a cardiologist?
Take Care
I think beyond guidelines we need to use common sense and some clinical judgment based on our History and Physical findings of our patients. Does this man need endoscopic sinus surgery or 30 mins with a cardiologist?
Take Care
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Am I the only one who sees the irony here?
How do you define a troll?
How on earth is that relevant to anything here? And why does it matter anyway?
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,
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I am curious how would a CRNA handle a case like this. Do CRNAs normally have higher threshold for canceling cases because they feel more obligated to listen to the surgeons? Would a CRNA agree to do MAC plus local anesthesia in this case? In a community private practice, how can a CRNA be expected to handle such a complicated case?
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Okay, so here is what we did and why ...
We cancelled the case. Postponed it actually. Sent the patient directly to our preop clinic. They hooked him up with a cardiologist. Cardiologist's eval pending.
With regards to doing it under MAC plus local ... no way. As a couple of you mentioned before, you've got secretions, drainage, blood in naso/oropharynx all ready to drip down into an unprotected airway. It's gonna make him cough, buck, gag, desaturate, or even aspirate. It's not worth it. Even good surgeons should be rewarded with a quiet operating field.
And with regards to doing it under local, the local anesthetic invariably has epinephrine in it. Even the surgeon said that injecting non-epi containing LA was not an option because he needed it to reduce swelling and secretions. Epi in someone with an old MI, inferior Q-waves, 2 pillow orthopnea, unknown EF, unknown status of coronaries, unknown status of meds (the patient wasn't clear on what meds he was on, nor did he bring a list), could be potentially harmful.
Clearly, we went down on the side of the algorithm that goes from intermediate clinical predictors plus poor functional status equals non-invasive testing. True, it's a relatively low risk procedure, but we felt the combination of multiple intermediate predictors and unknown current cardiac status warranted further testing.
And low risk procedure does not equate to low risk anesthesia. Nor does "lighter" anesthesia equate to less risky anesthesia. If anything, MAC in this patient is more risky than GA.
Personally, when I get into situations like these, and I'm not sure what to do, I think to myself, "if this were my wife, kid, father or grandfather, what would I want the anesthesiologist to do?" Sometimes, this helps to fend off lack of vigilance. Sometimes it helps me to see the bigger picture.
What do I mean by bigger picture? This: A lot of times patients get referred for further cardiac testing prior to undergoing low risk elective procedures. The counter argument invariably is what are you going to do with that information? What if the stress test is positive? Are you gonna send him to a cath with its own inherent risks prior to that lap chole/trigger finger/FESS surgery? And if the cath shows LM disease or triple vessel disease, are you gonna send him for a CABG before he can have that arthroscopic shoulder surgery? How can you justify sending someone to a high risk operation just to in order to do a low risk operation?
The problem with this argument is that the patient has priorities of their own. Maybe, that arthroscopic knee surgery isn't all of the sudden that important. Maybe they really should have that chest pain or SOB or orthopnea evaluated. Maybe there is something more important and insidious going on. Maybe that low risk, elective surgery can wait.
I believe information is power. It is not a bad thing to want more info, even if means having to rely on somebody's expertise (i.e. a cardiologist) or on technology (i.e. a stress test) in order to find where someone stands in terms of their cardiac competence when they are physically limited. Who knows, maybe that nighttime cough or orthopnea is really not due to post-nasal drip (for which the patient was presumably having sinus surgery) but low cardiac reserve.
I'll let you guys know what the cardiologist ends up saying on our patient.
We cancelled the case. Postponed it actually. Sent the patient directly to our preop clinic. They hooked him up with a cardiologist. Cardiologist's eval pending.
With regards to doing it under MAC plus local ... no way. As a couple of you mentioned before, you've got secretions, drainage, blood in naso/oropharynx all ready to drip down into an unprotected airway. It's gonna make him cough, buck, gag, desaturate, or even aspirate. It's not worth it. Even good surgeons should be rewarded with a quiet operating field.
And with regards to doing it under local, the local anesthetic invariably has epinephrine in it. Even the surgeon said that injecting non-epi containing LA was not an option because he needed it to reduce swelling and secretions. Epi in someone with an old MI, inferior Q-waves, 2 pillow orthopnea, unknown EF, unknown status of coronaries, unknown status of meds (the patient wasn't clear on what meds he was on, nor did he bring a list), could be potentially harmful.
Clearly, we went down on the side of the algorithm that goes from intermediate clinical predictors plus poor functional status equals non-invasive testing. True, it's a relatively low risk procedure, but we felt the combination of multiple intermediate predictors and unknown current cardiac status warranted further testing.
And low risk procedure does not equate to low risk anesthesia. Nor does "lighter" anesthesia equate to less risky anesthesia. If anything, MAC in this patient is more risky than GA.
Personally, when I get into situations like these, and I'm not sure what to do, I think to myself, "if this were my wife, kid, father or grandfather, what would I want the anesthesiologist to do?" Sometimes, this helps to fend off lack of vigilance. Sometimes it helps me to see the bigger picture.
What do I mean by bigger picture? This: A lot of times patients get referred for further cardiac testing prior to undergoing low risk elective procedures. The counter argument invariably is what are you going to do with that information? What if the stress test is positive? Are you gonna send him to a cath with its own inherent risks prior to that lap chole/trigger finger/FESS surgery? And if the cath shows LM disease or triple vessel disease, are you gonna send him for a CABG before he can have that arthroscopic shoulder surgery? How can you justify sending someone to a high risk operation just to in order to do a low risk operation?
The problem with this argument is that the patient has priorities of their own. Maybe, that arthroscopic knee surgery isn't all of the sudden that important. Maybe they really should have that chest pain or SOB or orthopnea evaluated. Maybe there is something more important and insidious going on. Maybe that low risk, elective surgery can wait.
I believe information is power. It is not a bad thing to want more info, even if means having to rely on somebody's expertise (i.e. a cardiologist) or on technology (i.e. a stress test) in order to find where someone stands in terms of their cardiac competence when they are physically limited. Who knows, maybe that nighttime cough or orthopnea is really not due to post-nasal drip (for which the patient was presumably having sinus surgery) but low cardiac reserve.
I'll let you guys know what the cardiologist ends up saying on our patient.
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God, no wonder our profession is the laughing stock of the medical community. Seeing what could have turned into an opportunity for discussion and [shudder] learning devolve into grade-school name calling is an embarassment. My most optimistic take on this whole charade is that most people "assume" a persona when they come here and this isn't REALLY how they are. Oh please let this be so......please let it be so........😳
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the acc/aha guidelines are a consensus from a panel of experts incorporating observational and retrospective data into an expert opinion on the the subject...in studies that have examined its efficacy, it seems to do well identifying patients at the highest and lowest risks--in one study, those patients with intermediate risk factors, despite indicated stress testing, still had a significant event rate, meaning that we are still unable to better identify patient at increased risk in this cohort (like this particular patient).
BESIDES: the lee index score (see circulation, 1999) is a prospectively derived and validated composite of six independent clinical predictors of perioperative cardiac events (high-risk surgery, h/o ischemic heart dz, chf, cerebrovascular disease, IDDM, Cr > 2)...the presence of 2 or more risk factors is ominous for perioperative events, with rates being just over 5% for patients with 2 RF and almost 11% for >2 RF in the original paper. insofar as the acc/aha guidelines predict risk, it is because they are somewhat similar in content to the lee index.
The lee index is the better tool, this patient had at least two RF placing his event rate around 5%, irregardless of type of surgery--would you do this case knowing this percentage without further evaluation (or at least better CYA)?
BESIDES: the lee index score (see circulation, 1999) is a prospectively derived and validated composite of six independent clinical predictors of perioperative cardiac events (high-risk surgery, h/o ischemic heart dz, chf, cerebrovascular disease, IDDM, Cr > 2)...the presence of 2 or more risk factors is ominous for perioperative events, with rates being just over 5% for patients with 2 RF and almost 11% for >2 RF in the original paper. insofar as the acc/aha guidelines predict risk, it is because they are somewhat similar in content to the lee index.
The lee index is the better tool, this patient had at least two RF placing his event rate around 5%, irregardless of type of surgery--would you do this case knowing this percentage without further evaluation (or at least better CYA)?
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Even if you go ahead and do the case, information is power......
Most people who posted here, including military, who claim to have read the paper, in fact misinterpret one diagram....that step 6= low risk go to OR....that is NOT at all what is stated in the paper, nor in table 5.....
table 5 is what i call the "stupid man's" graft, or as the paper calls it, the short-cut approach to the algorithm....intermediate risk, poor MET=further testing....and military goes on and on and tells people to read the paper.....the papers behind that statement can be viewed over and over, and debated, and cases made for each..fact is, the paper clearly writes that this pt deserves further non invasive workup...
For the most part, this argument between two complete dweebs was over what the paper stated...and MILITARY is clearly wrong...then tells others they do not know how to read...well, that other stiff posts this wording ver batum, and military goes on to try and attack a guy he knows nothing about like a two year old..such an embarrassing post......
one of my favorite quotes..
"Sometimes it is better to keep your mouth shut and let people think you are an idiot, than to open it and prove it."-try living by it military, you'll have a lot more friends here, and come off as a little bit more intelligent.
kudos to you TIVA...I think you did the right thing.....If you really provide quality anesthetic care, and the surgeons appreciate the service you provide them, this will not happen often...everyone wants cases to go smoothly, and to get the hell home....
If you are someone who would simply rush this case in, my guess is you are a nobody..just some schmuck sitting behind a screen the surgeon doesn't know, and doesn't even care to know....always seen as a mere hinderance to surgery.......
Most people who posted here, including military, who claim to have read the paper, in fact misinterpret one diagram....that step 6= low risk go to OR....that is NOT at all what is stated in the paper, nor in table 5.....
table 5 is what i call the "stupid man's" graft, or as the paper calls it, the short-cut approach to the algorithm....intermediate risk, poor MET=further testing....and military goes on and on and tells people to read the paper.....the papers behind that statement can be viewed over and over, and debated, and cases made for each..fact is, the paper clearly writes that this pt deserves further non invasive workup...
For the most part, this argument between two complete dweebs was over what the paper stated...and MILITARY is clearly wrong...then tells others they do not know how to read...well, that other stiff posts this wording ver batum, and military goes on to try and attack a guy he knows nothing about like a two year old..such an embarrassing post......
one of my favorite quotes..
"Sometimes it is better to keep your mouth shut and let people think you are an idiot, than to open it and prove it."-try living by it military, you'll have a lot more friends here, and come off as a little bit more intelligent.
kudos to you TIVA...I think you did the right thing.....If you really provide quality anesthetic care, and the surgeons appreciate the service you provide them, this will not happen often...everyone wants cases to go smoothly, and to get the hell home....
If you are someone who would simply rush this case in, my guess is you are a nobody..just some schmuck sitting behind a screen the surgeon doesn't know, and doesn't even care to know....always seen as a mere hinderance to surgery.......
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Do you mean posts like this?
I have friends in the real world....I don't need them here.🙂
ICUDOC said:
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1. I would do this pt (very representative of the several thousand V.A. patients I've anesthetized) with a common-sense and gentle general anesthetic. No cookbook 2 ccs of X, 20 ccs of Y, 6 ccs of Z, but gently titrating everything to desired effect based on surgeon actions and estimated finishing time, constantly monitoring calculated MAP, and staying a step ahead of the surgeon at all times.
2. I always listen to surgeons. Part of OR etiquette is being a diplomat even when you wish to shout out loud something to the contrary. When they cross the obviously-ridiculous line, I politely say "sorry, wish I could, but I can't and here's why" -->> objective explanation given and 99.9% of the time accepted.
2a. If it's the pt's time to go, you can do the world's most perfect anesthetic and they'll still kick the bucket. On the other hand, if it's not yet their time, you can give the sorriest anesthetic ever and the pt will still sail through.
3. I wouldn't do this via MAC. Umm, no, sorry. Perhaps an LMA.
4. In private practice, a CRNA can be expected to handle this case as so eloquently said by Dr. Michael Bookallil, elder statesman on GASnet (run by Dr. Keith Ruskin at Yale): "GA, if you know how." This case really isn't complicated. He's had his AAA and carotid stenosis repaired, and assuming his DM and other co-morbidities are under reasonable control and he can walk from the parking lot to the check-in desk without needing a wheelchair then why waste time and $$$$ for more work-up? You know what the IM consult will say:
a. avoid hypoxia
b. avoid hypotension
c. (my personal favorite) monitor BP interoperatively.
5. I trained at Charity Hospital in New Orleans. This case is a chip-shot compared to the pathology which sometimes came to those magnificient ORs.
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Now in the lead for the funniest post ever.
I'm sure you are the greatest anesthesiologist to ever live and that Columbia is the best place to train, period. THe rest of us struggle everyday with the bread and butter cases.😴
Anyone that thinks this much of themselves is truely misguided and not someone I'm interested in working with. But that doesn't matter since I don't work with you.
Oh, those cases you mentioned. They don't mean shiite. Almost everyone hear has done those or at least something like it.
If your ego is this big then you will find partners hard to come by. If I am off base about your ego then you are the most insecure person I have met in some time now. I don't believe that any of this that you claim is true b/c the name calling and bragging is not a quality of someone with those qualifications.
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Thanks for that. That is what I was really wondering. What does getting the non-invasive testing really going to tell you and how will it affect your managment? Are you really going to stent him or CABG him before he can get a FESS? The other question I had based on your intial post is, with all the symptoms, is this his baseline? ie has the orthopnea or functional status worsened? If not, then is he optimized enough where you would just consider doing a GA with periop beta blockade?
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Sorry, I had to chime in. I love the "liveliness" of this thread. Great stuff! It's like a movie or something, everything gets totally out of control but in the end there's an important take home message.
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This is the internet.
It's all in good fun....especially my profile of my arch nemesis on this thread..
In real life, I'll bet we would be good colleagues.....that is if we didn't find out who the other person was and shoot each other first.
It's all in good fun....especially my profile of my arch nemesis on this thread..
In real life, I'll bet we would be good colleagues.....that is if we didn't find out who the other person was and shoot each other first.
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way more embarrassing. Whoever military is, he is always calling himself a senior...hinting at just how good he is......calling others "junior" when he resorts to a two year old antic...just read this......can you believe this was written by someone older than 7?
You obviously come from a family of wealth and influence....I'll bet you're probably Dr. s2353456365 "THE THIRD" or something like that....
Got school all paid for by daddy and drove some fancy BMW during school and residency while everyone else scrapped by with debt.
I'll even bet your daddy is disappointed with you for not being a REAL doctor like a cardiologist or surgeon....so you take it out here by calling people names when someone who doesn't agree with you give a little sarcasm.........typical rich kid behavior.
Tell us....did you do this at your orals???? and did they let you pass your orals with this behavior?
I won't post again if you don't.....
and I'll ride your ass any chance I get...because you insulted me for no reason.
You obviously come from a family of wealth and influence....I'll bet you're probably Dr. s2353456365 "THE THIRD" or something like that....
Got school all paid for by daddy and drove some fancy BMW during school and residency while everyone else scrapped by with debt.
I'll even bet your daddy is disappointed with you for not being a REAL doctor like a cardiologist or surgeon....so you take it out here by calling people names when someone who doesn't agree with you give a little sarcasm.........typical rich kid behavior.
Tell us....did you do this at your orals???? and did they let you pass your orals with this behavior?
I won't post again if you don't.....
and I'll ride your ass any chance I get...because you insulted me for no reason.
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come on now....do you really think i would write those up...those were done by two women i trained with, who first got my stuff one night on call when the computer in the lounge did not log me out...you should have seen the ones I deleted, I simply did not get them all.......
I got em back good though, if you have ever scoured the likes of craigslist..............
it is funny though, resorting to childish behavior by trying to dig up dirt on others....
just out of curiosity though...will you concede that the paper does indeed state in clear writing...intermediate risk and MET<4 consider further diagnostic work up?? It is right on page 19...in clear english.... That is after all what the original post asked. Not who would do it, who wouldn't..What is academic what isn't. It was a simple question...the answer is now sitting right in front of me as i read the paper once again.....
I'm trying to figure out who that other butthead was.....got the crawelers out....also work with a ex navy doc up here in NY, so digging for you, and will certainly post pics of both if i find em.....it is pretty easy these days through IP addresses to find someone on these forums....just not sure if I care to committ the time.....though in your case it would be funny....you've pissed off a lot, and as i read the posts a lot of people over the past two years....ha
I got em back good though, if you have ever scoured the likes of craigslist..............
it is funny though, resorting to childish behavior by trying to dig up dirt on others....
just out of curiosity though...will you concede that the paper does indeed state in clear writing...intermediate risk and MET<4 consider further diagnostic work up?? It is right on page 19...in clear english.... That is after all what the original post asked. Not who would do it, who wouldn't..What is academic what isn't. It was a simple question...the answer is now sitting right in front of me as i read the paper once again.....
I'm trying to figure out who that other butthead was.....got the crawelers out....also work with a ex navy doc up here in NY, so digging for you, and will certainly post pics of both if i find em.....it is pretty easy these days through IP addresses to find someone on these forums....just not sure if I care to committ the time.....though in your case it would be funny....you've pissed off a lot, and as i read the posts a lot of people over the past two years....ha
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Just cause the kid was at my alma mater..columbia, don't think he had a silver spoon in his mouth....hardly any did....one guy in my class drove a truck cross coutry for 3 years after high school...went to some crappy college in LA someplace, then northwestern medschool then here......It is in no way an academic program like it use to be in the 70s, when the majority of teh literature in the field came out of it....it is one beat down...no CRNAs, days to 8pm not on call with very little attending backup, having to deal with primadonna(sp?) surgeons....you can not finish that program without being very clinically good, no matter how thick headed you are.......
the rich boy BMW thing though, i did find offensive...i hate chris bangal
the rich boy BMW thing though, i did find offensive...i hate chris bangal
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You're right...on page 19 it does clearly state what you state about further testing....but I do believe the word used is "suggest".
However, it doesn't address that arrow on the right side of step 6....no where in the article does it SPECIFICALLY address that arrow on the right side of step 6......but there are several references in various places addressing LOW RISK surgery....not all in one place but in several ...that kind of addresses that arrow...ie low risk surgery is no worse then ADL.
That's what I mean about "reading" it....meaning it is not in exactly one spot like the paragraph for going to testing.
Reading these long articles are interesting...ie they really don't flow very well....like multiple people writing it...which clearly it was....and you really have to know ALL the people (which I don't) who were together to get the gist of it....I'm sure there were many disagreements amongst the authors.
I guess the "shave my johnson" post didn't really flow right with the rest of your posts....but I just couldn't help myself.....
There are multiple pics of me in various places around the internet...though none show my face...if you post one...and it is me....I'll admit to it.
I'm pretty sure on the profile of your alum....although I don't have access to IP addresses like the mods.
AND I just use "junior" to piss people off.....
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I agree...if the patient is at his baseline, and as good as he gets, i go right ahead with it....However, those who have not taken their orals yet.....might want to think differently....though that is another game altogether....In my opinion, it is all about poise and damage control....damage control for the one yanker that throws out a porphyria question..
another question for you. all this chatter about pay for performance. For instance, where I work, anytime a pt comes in with a diagnosis of CHF, the case gets reviewed, and predetermined guidelines(ie cookbook) are checked off or not....the hospital gets an overall grade for their treatment of heart failure basically determined by their compliance.
where do you see this affecting anesthesia....obviously beta blocking, perhaps intraop insulin drips, but do you see it changing the way in which you would manage this case?? Often times with these sick buggers, I find less is better, keep it simple. Start getting too fancy on a 20 minute case, and you wind up i trouble....any thoughts or insight as to where this will lead to....
another question for you. all this chatter about pay for performance. For instance, where I work, anytime a pt comes in with a diagnosis of CHF, the case gets reviewed, and predetermined guidelines(ie cookbook) are checked off or not....the hospital gets an overall grade for their treatment of heart failure basically determined by their compliance.
where do you see this affecting anesthesia....obviously beta blocking, perhaps intraop insulin drips, but do you see it changing the way in which you would manage this case?? Often times with these sick buggers, I find less is better, keep it simple. Start getting too fancy on a 20 minute case, and you wind up i trouble....any thoughts or insight as to where this will lead to....
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One thing that wasn't brought up...and which I also did not bring up because of the ensuing online ******ed battle that I got into and which I so enjoy...but really shouldn't partake in ...like too much bourbon....is that although I feel that this patient is ready for surgery.....the location of the surgery (ASC) is not really appropriate......
If someone had said.......move the case immediately to a hospital before inducing GA...then I would have said...that was a better answer than mine.
As for Pay for Performance...we are trying to develop a program within our group to head in this direction.
The "performance" aspect of P for P is much more difficult to measure in our specialty than say in IM or cardiology.
I don't know where we are headed in all this....but I have a feeling it's not going to be good for our wallets.
If someone had said.......move the case immediately to a hospital before inducing GA...then I would have said...that was a better answer than mine.
As for Pay for Performance...we are trying to develop a program within our group to head in this direction.
The "performance" aspect of P for P is much more difficult to measure in our specialty than say in IM or cardiology.
I don't know where we are headed in all this....but I have a feeling it's not going to be good for our wallets.
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Friggen awsome thread.
TIVA you gotta let us know what eventually happened to this guy. I bet it was "betablocker, keep intra-op SBP below 150 and greater than 120. No further invasive testing in the near future."
Anyways this was a good brain romp for most of us here.
TIVA you gotta let us know what eventually happened to this guy. I bet it was "betablocker, keep intra-op SBP below 150 and greater than 120. No further invasive testing in the near future."
Anyways this was a good brain romp for most of us here.
That's up to the patient to decide and is called informed consent. With a little more info, the physician can hopefully give the patient a better idea of the risks and benefits of proceeding in any direction.
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Multinational study....randomized 770 patients with intermediate clinical predictors scheduled for vascular surgery (ie...high risk....not low risk surgery)...to 1 of 2 arms...
testing or no testing.
In the testing group...patients with ischemia underwent preoperative revascularization prior to their HIGH risk surgery...
Guess what?
at 30 days postop, the incidence of primary outcome (cardiac death or MI) was not significantly differernt in the 2 arms....the no testing arm actually had a lower incidence of adverse outcome ...1.8% vs 2.3%.
And remember...this is HIGH risk surgery
So...what should we tell the patient.? We'll delay your surgery....get more information....maybe do more invasive things to you....but in the end....there will probably be no difference in safety for you.....is that what we should tell the patients.....at least based the latest data available?
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True, but remember, the ones who were not tested were aggressively beta-blocked to keep HR in 60's. Our patient had COPD, on home oxygen, 2 pillow orthopnea, could only get into hospital in wheelchair due to limited functional status, and PFT's showing severe obstructive ventilatory pattern. Beta blockers may help his heart, but it ain't gonna help him off the vent when it comes time to extubate.
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Oh yeah ...
And he had Q-waves in II, III, and aVF, indicating prior inferior MI. Beta blockers are good for the left side of the heart (decrease diastolic dysfunction, decrease myocardial oxygen demand, increase coronary perfusion pressure), but not as beneficial for the right side of the heart. If his right heart is blown, beta blockers might further exacerbate his cardiac status.
And he had Q-waves in II, III, and aVF, indicating prior inferior MI. Beta blockers are good for the left side of the heart (decrease diastolic dysfunction, decrease myocardial oxygen demand, increase coronary perfusion pressure), but not as beneficial for the right side of the heart. If his right heart is blown, beta blockers might further exacerbate his cardiac status.
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I thought everyone was beta blocked.....
the take home point....testing doesn't decrease risk....appropriate MEDICAL therapy per 21st century practice parameters decrease risk.
Couple of points..
1) I already yielded that ASC is not the appropriate venue for him for GA...ie high likelihood of post anesthesia side effects that will require prolonged care....although ASC's do have overnight capabilities...but probably not prolonged vent capabilities.
2) How many patients have you given beta blockers (beta 1 selective ones) to that worsened their respiratory parameters aftwards....COPD patients that is.....5 years worth of attending in a micu with patients admitted with COPD exacerbations...and I remember 1 patient where I really thought the lopressor was causing problems
3)....if not beta blockers...you still have diltiazem per DAVIT trials.
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Just curious: do you mean sufentanil, or remi? This is a very short and unstimulating case, if all goes according to plan.
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1) This guy would not have been done at our ASC even though we are connected to the hospital.
2) absolutely! I have not seen any problems with Beta blockers an COPD. If I remember right, SDN1977 commented on the newer Beta blockers not having as much respiratory effects and that the risks was almost nil.
3) Yes, Dilt.
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I have just about stopped using etomidate all together. I just cut the propofol dose down, way down at times. If I am really concerned about hypotension with even the smallest dose of propofol (50mg for induction) i'll give some neo right b/4 the propofol.
I have seen steroid depletion to the point of not responding to anything short of NE with one dose. Trust me, you can accomplish an extremely stable induction in just about anyone with propofol.
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Damn, with just a single dose? Fortunatley I haven't seen that yet.
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Mil,
I just remembered another thing. The study you mention above raises some interesting points. And I do believe it is a valid study. However, it is a difficult study to read.
What they call intermediate risk, is not what we call intermediate clinical predictors. According to the ASA, a patient who has one, any, or all of the following classifies as having intermediate clinical predictors:
mild angina
prior MI
compensated CHF
prior CHF
DM
renal insufficiency
In the article you mention, they call anyone low risk if they have none of these predictors. They call them intermediate risk if they have 1 or 2 of these predictors. And they call them high risk if they have 3 or more of these predictors. Anyone who was "intermediate risk" was randomized between the study and the control groups. Anyone who was "high risk" automatically was shunted into further testing.
And thus, it's difficult to directly apply this study to our patient, because our patient would have been classified as high risk if he had been in their study and would have automatically gotten a stress test +/- proceed (stress test, cath, stent, or CABG).
Nevertheless, I do think you bring up a valid point. However, I just can't get over the symptomatic and poor functional status, which to me (not the ASA) is yet another clinical predictor unto itself.
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Yes, it is difficult to interpret international data....other thing of note is the rate of endpoint....in the 1 to 2 % range.....pretty darn low for all patients undergoing vascular surgery...
I consider 1 to 5 % range to be probably what we accept in the states.
Lot's of data....lot's of opinion....unfortunately no "standard of care".
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i'm sensing a recurring theme....... continually pointing a finger with three pointed back at himself...... maybe......
(this is a great thread, by the way, and everyone should go back 30-40 posts and read for their enjoyment.)
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The fat, balding, big eared, doubled chinned guy...who feels entitled to titles not yet earned weighs in again.
