Hyponatremia and surgery???

[Cadet133]

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I see it a lot in my patients as hospitalists. Anesthesiologists asking for medical clearance because a patient has chronic hyponatremia? I guess it risks their mortality??? How do you deal with patients with chronic hyponatremia?? Would you be ok with surgery

 

[deleted171991]

I see it a lot in my patients as hospitalists. Anesthesiologists asking for medical clearance because a patient has chronic hyponatremia? I guess it risks their mortality??? How do you deal with patients with chronic hyponatremia?? Would you be ok with surgery

Let me search for you, doctor:

Hyponatremia Institutional Guidelines

We are in the early phases of development of institutional guidelines (for our hospital) for electrolyte abnormalities and the conduct of anesthesia. We have many varying opinions regarding hyponatremia that are very confusing to surgeons and hospital staff alike, making it difficult to know if...

forums.studentdoctor.net

How low a Na+ for Elective Surgery?

Electrolyte Disorder Linked to Surgical Complications Hyponatremic patients with low sodium levels are at an increased risk of complications and death within a month of surgery, according to a study published online in the Archives of Internal Medicine. Of the nearly 1 million adult...

forums.studentdoctor.net

 

[Aether2000]

HYPONATREMIA
Definition– Plasma sodium less than 135 mEq/L. Mild is 130-134, Moderate 125-129, Severe is <125 mEq/L
Incidence– 14% of hospitalized patients, up to 30% of ICU patients
Pathology– Relative excessive free water, depletion of plasma sodium, or both. CHF, cirrhosis, SIADH, and excessive water consumption leads to excessive free water. Diabetes mellitus may lead to hyponatremia with or without hyperglycemia. Severe hyperglycemia may result in osmotic shifts of fluids into the vascular space and dilutional hyponatremia in occasional patients with hyperglycemia at a rate of 2.4 mEq/l sodium reduction per every 100mg/dl blood sugar over 100. However, hyponatremia may also result from diabetic nephropathy without hyperglycemia and several other mechanisms.
Salt wasting (most common iatrogenic form of hyponatremia) may occur due to excessive diuretics, SSRIs, SNRIs, opioids, NSAIDs, PPI, ACE inhibitors, antiepileptic drugs including gabapentin, and amiodarone. The combination of thiazide diuretics plus SSRIs are especially prone to hyponatremia. Hyponatremia may be associated with an increase in ICP.
Symptoms (Severe)– confusion, ataxia, seizures, obtundation, coma, respiratory depression. Mild to moderate– lethargy, headache, dizziness.
Effects of Hyponatremia on Anesthesia– None intraop, but can cause excessive sedation, seizures, coma, etc. that may be confused with anesthetic effects at the end of surgery or in the PACU. Avoid agents that further elevate ICP (Desflurane, succinylcholine, hypoventilation, unnecessary oropharyngeal suctioning, fentanyl).
Effects of Anesthesia on Hyponatremia– Anesthesia/surgery causes SIADH to occur afterwards over several days, causing hyponatremia days after anesthesia
Complications- 44% increased risk of death within 30 days of surgery, risk of major coronary event, pneumonia, and wound infections double
Treatment pre-op: Depends on the cause and determining this requires a full workup to divide hyponatremia into subtypes that respond to different and sometimes exactly the opposite treatment. Simply giving IV sodium chloride treating the serum Na without evaluating the urine sodium concentration and state of hydration can prove disastrous. Unless the surgery is emergent due to a life threatening situation, Na should be corrected to at least 125 for urgent surgery or 129 for elective surgery or until the hyponatremia associated severe symptoms of hyponatremia (confusion, ataxia, seizures, obtundation, coma, respiratory depression) have resolved. Serum osmolality may be helpful in differentiating causes and assisting in treatment.
Treatment intraop: If hypertonic sodium chloride is being given as an infusion preoperatively, continue this intraoperatively. In general, use 0.9% sodium chloride (normal saline) with 154 mEq/l sodium instead of LR (Lactated Ringers) with 130 mEq/l sodium.
Treatment postoperatively: Hyponatremia may worsen after surgery due to SIAD and the time course may be over several days. De novo hyponatremia may occur after surgery.

 

[Gaseous Clay]

I see it a lot in my patients as hospitalists. Anesthesiologists asking for medical clearance because a patient has chronic hyponatremia? I guess it risks their mortality??? How do you deal with patients with chronic hyponatremia?? Would you be ok with surgery

You are confusing "medical clearance" with "medical optimization." Your job is to find out why the patient is hyponatremic and help correct the underlying issue. Most go by 130 and above for elective surgery. If the patient consistently lives in the mid 120s and their mental status is at baseline, I will proceed (assuming everything else stable from my standpoint). Hope that helps.

 

[hununuh]

HYPONATREMIA
Definition– Plasma sodium less than 135 mEq/L. Mild is 130-134, Moderate 125-129, Severe is <125 mEq/L
Incidence– 14% of hospitalized patients, up to 30% of ICU patients
Pathology– Relative excessive free water, depletion of plasma sodium, or both. CHF, cirrhosis, SIADH, and excessive water consumption leads to excessive free water. Diabetes mellitus may lead to hyponatremia with or without hyperglycemia. Severe hyperglycemia may result in osmotic shifts of fluids into the vascular space and dilutional hyponatremia in occasional patients with hyperglycemia at a rate of 2.4 mEq/l sodium reduction per every 100mg/dl blood sugar over 100. However, hyponatremia may also result from diabetic nephropathy without hyperglycemia and several other mechanisms.
Salt wasting (most common iatrogenic form of hyponatremia) may occur due to excessive diuretics, SSRIs, SNRIs, opioids, NSAIDs, PPI, ACE inhibitors, antiepileptic drugs including gabapentin, and amiodarone. The combination of thiazide diuretics plus SSRIs are especially prone to hyponatremia. Hyponatremia may be associated with an increase in ICP.
Symptoms (Severe)– confusion, ataxia, seizures, obtundation, coma, respiratory depression. Mild to moderate– lethargy, headache, dizziness.
Effects of Hyponatremia on Anesthesia– None intraop, but can cause excessive sedation, seizures, coma, etc. that may be confused with anesthetic effects at the end of surgery or in the PACU. Avoid agents that further elevate ICP (Desflurane, succinylcholine, hypoventilation, unnecessary oropharyngeal suctioning, fentanyl).
Effects of Anesthesia on Hyponatremia– Anesthesia/surgery causes SIADH to occur afterwards over several days, causing hyponatremia days after anesthesia
Complications- 44% increased risk of death within 30 days of surgery, risk of major coronary event, pneumonia, and wound infections double
Treatment pre-op: Depends on the cause and determining this requires a full workup to divide hyponatremia into subtypes that respond to different and sometimes exactly the opposite treatment. Simply giving IV sodium chloride treating the serum Na without evaluating the urine sodium concentration and state of hydration can prove disastrous. Unless the surgery is emergent due to a life threatening situation, Na should be corrected to at least 125 for urgent surgery or 129 for elective surgery or until the hyponatremia associated severe symptoms of hyponatremia (confusion, ataxia, seizures, obtundation, coma, respiratory depression) have resolved. Serum osmolality may be helpful in differentiating causes and assisting in treatment.
Treatment intraop: If hypertonic sodium chloride is being given as an infusion preoperatively, continue this intraoperatively. In general, use 0.9% sodium chloride (normal saline) with 154 mEq/l sodium instead of LR (Lactated Ringers) with 130 mEq/l sodium.
Treatment postoperatively: Hyponatremia may worsen after surgery due to SIAD and the time course may be over several days. De novo hyponatremia may occur after surgery.

Why would you use NS rather than LR? If Na is low, wouldn't you want crystalloid with as close Na serum concentration as possible so you don't correct Na too rapidly intra-op? For example, if Na is 130 pre-op, giving NS intra-op will undoubtedly increase serum Na, and if corrected too quickly, can cause pontine myelolinolysis, whereas, giving LR would keep the Na steady at 130.

 

[Aether2000]

LR would maximally correct to 130 if you exchanged their entire blood volume with LR, which is not very likely. Most surgeries use only 1-2 liters of IV fluids. If a hyponatremic person has a sodium of 125, then 1 liter of normal saline will raise their overall blood sodium level to approximately 129, a relatively small increase in overall sodium concentration. However is larger volumes are anticipated, ie. several liters, then LR would make a better choice. Of course the presence of symptoms should determine the rapidity of correction and chronic hyponatremia without symptoms may not need treatment at all since it may be a futile effort.

 

[vector2]

Why would you use NS rather than LR? If Na is low, wouldn't you want crystalloid with as close Na serum concentration as possible so you don't correct Na too rapidly intra-op? For example, if Na is 130 pre-op, giving NS intra-op will undoubtedly increase serum Na, and if corrected too quickly, can cause pontine myelolinolysis, whereas, giving LR would keep the Na steady at 130.

A 3% infusion usually has to be running at >70cc per hour before we start running into overcorrection rapidity problems. Normal saline is fine as long as you're not bolusing liters and liters intraop.

 

[Mman]

Why would you use NS rather than LR? If Na is low, wouldn't you want crystalloid with as close Na serum concentration as possible so you don't correct Na too rapidly intra-op? For example, if Na is 130 pre-op, giving NS intra-op will undoubtedly increase serum Na, and if corrected too quickly, can cause pontine myelolinolysis, whereas, giving LR would keep the Na steady at 130.

I gotta admit I chuckled at the thought hanging NS on a patient with a sodium of 130 was going to cause CPM. You worry about CPM when correcting a sodium of 110 or 115 too quickly, not 130. NS has 154 mEq of sodium per liter of fluid so spilling a little of that into a lake with a concentration of 130 mEq of sodium per liter is not going to cause much of a change.

 

[hununuh]

Thank you all. Im only a CA-1, so this is very helpful. Another question. Now i get that NS doesnt do harm, but what advantage does it have over LR?

 

[Planktonmd]

Hyponatremia is common and should not be a cause for cancelling a surgery unless it is acute, severe, and symptomatic.

 

[coffeebythelake]

Hyponatremia is common and should not be a cause for cancelling a surgery unless it is acute, severe, and symptomatic.

often times you don't know if it is acute
Na of 125? coming in for elective surgery? i would want to work it up

 

[Mman]

often times you don't know if it is acute
Na of 125? coming in for elective surgery? i would want to work it up

Yes you would because it increases their periop mortality. I have a hard time telling a patient that lots of people have hyponatremia and it increases your risk of dying, but we shouldn't really worry about it for this elective case.

 

[BLADEMDA]

The risk reward isn’t there for doing an elective case with a very low Sodium. That said, if you have a note from Renal or primary stating chronic low sodium of say 128 I would do the case.

Otherwise, I don’t do elective surgery if the sodium is less than 130. Is that too cautious? Perhaps, but it’s my malpractice policy and my license on the line with dozens of lawyers who advertise almost every hour on TV. We live in a highly litigious environment so some degree of caution is warranted.

 

[anbuitachi]

basically if patient shows up to your amb surg for a cataract, and there is only 1 lab value with a Na of 128. cancel time?

 

[Mman]

basically if patient shows up to your amb surg for a cataract, and there is only 1 lab value with a Na of 128. cancel time?

cataract? No. Obviously depends on the case and cataract is about the lowest risk possible. I almost don't even consider it surgery. As long as you aren't having chest pain in preop holding and can lay flat you are probably fine for having your cataract.

 

[Noyac]

I see it a lot in my patients as hospitalists. Anesthesiologists asking for medical clearance because a patient has chronic hyponatremia? I guess it risks their mortality??? How do you deal with patients with chronic hyponatremia?? Would you be ok with surgery

Your job is to determine if the hyponatremia is prerenal ( CHF for example), renal or postrenal.
if it is hypovolemic or normovolemic. Hypovolemic can be a real issue postop, leading to falls or confusion.
Is it caused by adrenal insufficiency or hypothyroidism.
Could it be caused by a diuretic (thiazides most commonly) and if so can we hold this for a few days?
Does the pt have pneumonia etc?
if there is a good explanation then I will usually proceed if it’s above 125. But most of these pts get seen preoperatively and it gets corrected or improved somewhat. Usually by holding the diuretic.
if it’s pediatric then it’s a entirely different beast.

 

[anbuitachi]

This is from the other thread years ago that was linked above. Blade posted this image but i didn't see anyone comment on it. If im not blind, mortality skyrockets after about 142. Here normal Na is ~136-145, the upper limit of normal is 145 for sodium, yet on that image, at 145, mortality is already about as high as low 130s... Reason? should the normal range undergo a change?

 

[Arch Guillotti]

if it’s pediatric then it’s a entirely different beast.

What kids are you checking labs on?

 

[sevoflurane]

I don’t work at a children’s hospital anymore, but severe hyponatrmia in syndromic/neuro-peds patients was quite high.

 

[BLADEMDA]

Mortality and Serum Sodium: Do Patients Die from or with Hyponatremia?

Background and objectives Severe hyponatremia (<120 mEq/L) in hospitalized patients has a high mortality rate. We hypothesized that underlying diseases causing hyponatremia attribute to mortality rather than hyponatremia itself. Design, setting, participants, & measurements The relationship...

cjasn.asnjournals.org

 

[BLADEMDA]

 

[BLADEMDA]

Mild chronic hyponatremia is not benign as previously thought and can directly contribute to increased morbidity and possibly, mortality (31,80). Although some of the above pathology is clearly related to hyponatremia, whether treating the disorder will reverse this sequence of events is not yet known. We are of the opinion that patients with mild chronic hyponatremia associated with unstable gait, recurrent unexplained falls, a high fracture risk, or severe osteoporosis might benefit from treatment.

Mild Chronic Hyponatremia in the Ambulatory Setting: Significance and Management - PMC

Mild chronic hyponatremia, as defined by a persistent (>72 hours) plasma sodium concentration between 125 and 135 mEq/L without apparent symptoms, is common in ambulatory patients and generally perceived as being inconsequential. The association ...

www.ncbi.nlm.nih.gov

 

[BLADEMDA]

The major finding of this meta-analysis is that across all groups of patients the relative risk of mortality in patients with hyponatremia vs patients without hyponatremia ranged between 2.47 and 3.34, thus indicating that this electrolyte disorder strongly predicts prognosis of all hospitalized patients. Another interesting result of our meta-analysis is that a moderate serum [Na+] reduction (i.e., 4.8 mmol/L) was associated with an increased risk of mortality, and a meta-regression analysis showed that the hyponatremia-related risk of overall mortality was inversely correlated with the serum [Na+]. Hence, the lower threshold considered, the higher the risk of mortality. This association was confirmed in a multiple regression model after adjusting for age, gender and diabetes mellitus.

Moderate Hyponatremia Is Associated with Increased Risk of Mortality: Evidence from a Meta-Analysis

Background Hyponatremia is the most common electrolyte disorder in clinical practice, and evidence to date indicates that severe hyponatremia is associated with increased morbidity and mortality. The aim of our study was to perform a meta-analysis that included the published studies that...

journals.plos.org

 

[BLADEMDA]

Also, elderly patients with unsteady gait and/or confusion should be checked for the presence of mild hyponatremia and if present it should not be ignored. Finally, elderly patients presenting with an orthopedic injury should have serum sodium checked and corrected if hyponatremia is present.

Is chronic hyponatremia a novel risk factor for hip fracture in the elderly?

Abstract. Hip fractures represent a serious health risk in the elderly, with significant associated morbidity and mortality. There is now an emerging literatur

academic.oup.com

 

[BLADEMDA]

Panopto

Capture, manage, and search all your video content.

nephrology.hosted.panopto.com

Watch this lecture then come back and post your "opinion" on doing ELECTIVE CASES with Na+ less than 130.

 

[nimbus]

View attachment 284911

Mortality and Serum Sodium: Do Patients Die from or with Hyponatremia?

Background and objectives Severe hyponatremia (<120 mEq/L) in hospitalized patients has a high mortality rate. We hypothesized that underlying diseases causing hyponatremia attribute to mortality rather than hyponatremia itself. Design, setting, participants, & measurements The relationship...

cjasn.asnjournals.org

From the article:

“Conclusions The nature of underlying illness rather than the severity of hyponatremia best explains mortality associated with hyponatremia. Neurologic complications from hyponatremia are uncommon among patients who die with hyponatremia.”

We all know hyponatremia is a signal that the patient is ill and has a higher risk of mortality. What we don’t know is if correcting hyponatremia before surgery improves outcomes. We need a study comparing outcomes between those who have their sodium corrected preop vs those who did not. For all we know, the corrected patients could fare worse.

 

[Noyac]

What kids are you checking labs on?

None, other than the adrenally suppressed, chronic steroid dependent, CNS tumors, etc. But if a kid has hyponatremia then you’ve got issues.

 

[BLADEMDA]

From the article:

“Conclusions The nature of underlying illness rather than the severity of hyponatremia best explains mortality associated with hyponatremia. Neurologic complications from hyponatremia are uncommon among patients who die with hyponatremia.”

We all know hyponatremia is a signal that the patient is ill and has a higher risk of mortality. What we don’t know is if correcting hyponatremia before surgery improves outcomes. We need a study comparing outcomes between those who have their sodium corrected preop vs those who did not. For all we know, the corrected patients could fare worse.

Current evidence strongly suggests that proceeding with elective surgery on a patient with hyponatremia (Na+ less than 130) without a notation on the reason/cause for the hyponatremia is not recommended. Any bad outcome can easily be linked to the hyponatremia with an expert witness destroying you in a court of law based on our current peer reviewed evidence on hyponatremia.

 

[BLADEMDA]

 

[BLADEMDA]

Preoperative Hyponatremia Is Associated with Reoperation and Prolonged Length of Hospital Stay following Total Knee Arthroplasty

Thieme E-Journals - The Journal of Knee Surgery / Abstract

Thieme E-Books & E-Journals

www.thieme-connect.com

 

[Hork Bajir]

No one is denying that there is an association between hyponatremia and badness. But as other posters have pointed out, correlation does not equal causation... Ergo, at least to my knowledge “fixing” the Na has not been clearly shown to reduce risk (and I bet some of the expert witnesses on this forum would testify in that regard)

 

[BLADEMDA]

No one is denying that there is an association between hyponatremia and badness. But as other posters have pointed out, correlation does not equal causation... Ergo, at least to my knowledge “fixing” the Na has not been clearly shown to reduce risk (and I bet some of the expert witnesses on this forum would testify in that regard)

I disagree if the surgery is elective. Delay of surgery and correction of the sodium is indicated based upon the data we currently have on hyponatremia. Anyone who proceeds with purely electively surgery on a patient with a Na less than 130 should have a consult note on the chart explaining the reason for the hyponatremia. The decision to proceed with the elective surgery should be shared by all the team members (physicians) involved with the case.

 

[itwasalladream]

One of the large studies finding correlation between hyponatremia and periop mortality found that the correlation was particularly strong for ASA 1 and 2 patients. That's interesting to me, and I'm curious what others make of that detail. My own interpretation is that hyponatremia of unknown cause in a "healthy patient" is reason for concern in an elective case, and might reflect an undiagnosed serious condition. With an older, sicker, cardiac/renal disease patient, I'm less likely to worry about a low sodium (120-135), particularly if previous labs were similar, no neuro/CHF symptoms etc. You know their mortality is elevated anyway, and I agree that fixing it may not be beneficial.

 

[coffeebythelake]

One of the large studies finding correlation between hyponatremia and periop mortality found that the correlation was particularly strong for ASA 1 and 2 patients. That's interesting to me, and I'm curious what others make of that detail. My own interpretation is that hyponatremia of unknown cause in a "healthy patient" is reason for concern in an elective case, and might reflect an undiagnosed serious condition. With an older, sicker, cardiac/renal disease patient, I'm less likely to worry about a low sodium (120-135), particularly if previous labs were similar, no neuro/CHF symptoms etc. You know their mortality is elevated anyway, and I agree that fixing it may not be beneficial.

Yes interesting thought. I agree with your conclusion.
Nobody "normal" comes in with a Na of 125. Normal bodily homeostasis wouldn't allow that.
Ergo that patient isn't really normal, and they aren't really ASA 1 or 2. It means they have some undiagnosed condition.

 

[nimbus]

Current evidence strongly suggests that proceeding with elective surgery on a patient with hyponatremia (Na+ less than 130) without a notation on the reason/cause for the hyponatremia is not recommended. Any bad outcome can easily be linked to the hyponatremia with an expert witness destroying you in a court of law based on our current peer reviewed evidence on hyponatremia.

I agree. The preop note should address hyponatremia if it is present and at least a theory about why the patient is hyponatremic. However I don’t know of any studies showing that preoperative correction of hyponatremia reduces postoperative complications. Is it really beneficial for the patient to delay a case for 2 days to correct the sodium from 125 to 130? I have no idea.

 

[deleted171991]

I agree. The preop note should address hyponatremia if it is present and at least a theory about why the patient is hyponatremic. However I don’t know of any studies showing that preoperative correction of hyponatremia reduces postoperative complications. Is it really beneficial for the patient to delay a case for 2 days to correct the sodium from 125 to 130? I have no idea.

This is easy. It's the risks vs benefits of waiting to correct the asymptomatic hyponatremia vs proceeding. I.e. one won't correct hyponatremia before an emergent CABG, but will definitely do so for a port-a-cath.

 

[nimbus]

This is easy. It's the risks vs benefits of waiting to correct the hyponatremia vs proceeding. I.e. one won't correct hyponatremia before an emergent CABG, but will definitely do so for a port-a-cath.

What is the benefit?

 

[deleted171991]

What is the benefit?

The benefit is avoiding the bad outcomes Blade's studies have mentioned.

Until somebody proves that there is no difference in outcomes between 125 and 130, one can always be accused of having caused a bad outcome by not fixing the sodium, despite having had the time to.

 

[nimbus]

The benefit is avoiding the bad outcomes Blade's studies have mentioned.

Until somebody proves that there is no difference in outcomes between 125 and 130, one can always be accused of having caused a bad outcome by not fixing the sodium, despite having had the time to.

Say an 88yo nursing home patient presents to the hospital with a hip fracture and a sodium of 125. They have a higher risk of 30 day mortality, delirium, etc. Does correcting the sodium to 130 modify that risk? Maybe I’m missing something but I haven’t seen any studies showing that correcting the sodium does anything but correct the sodium. We do it because everybody likes normal numbers. Even the lecture posted by Blade shows some of the cognitive tests got worse after correction of sodium.

 

[Mman]

Say an 88yo nursing home patient presents to the hospital with a hip fracture and a sodium of 125. They have a higher risk of 30 day mortality, delirium, etc. Does correcting the sodium to 130 modify that risk? Maybe I’m missing something but I haven’t seen any studies showing that correcting the sodium does anything but correct the sodium. We do it because everybody likes normal numbers. Even the lecture posted by Blade shows some of the cognitive tests got worse after correction of sodium.

a hip fracture in an old person is definitely not an elective surgery

 

[deleted171991]

Say an 88yo nursing home patient presents to the hospital with a hip fracture and a sodium of 125. They have a higher risk of 30 day mortality, delirium, etc. Does correcting the sodium to 130 modify that risk? Maybe I’m missing something but I haven’t seen any studies showing that correcting the sodium does anything but correct the sodium. We do it because everybody likes normal numbers. Even the lecture posted by Blade shows some of the cognitive tests got worse after correction of sodium.

An 88 yo nursing patient, while in the hospital, is scheduled for a port-a-cath. Will you proceed with an asymptomatic sodium of 125, knowing that there are studies that show worsened outcomes under 130? Or will you at least attempt to improve it?

Humans are not machines, so what may "statistically" work for most may not work for the individual, but would you proceed with surgery?

I'll make it easier: we would all proceed with a cataract surgery and a good surgeon, right?

 

[nimbus]

An 88 yo nursing patient, while in the hospital, is scheduled for a port-a-cath. Will you proceed with an asymptomatic sodium of 125, knowing that there are studies that show worsened outcomes under 130? Or will you at least attempt to improve it?

Humans are not machines, so what may "statistically" work for most may not work for the individual, but would you proceed with surgery?

I'll make it easier: we would all proceed with a cataract surgery and a good surgeon, right?

In real life I’d proceed with the portacath because I haven’t seen anything that shows that correcting the sodium to 130 will improve outcomes. Also in real life I would not check a sodium on a patient presenting for cataract surgery. I’ve probably done cataracts on scores of patients with hyponatremia.

 

[deleted171991]

In real life I’d proceed with the portacath because I haven’t seen anything that shows that correcting the sodium to 130 will improve outcomes. Also in real life I would not check a sodium on a patient presenting for cataract surgery. I’ve probably done cataracts on scores of patients with hyponatremia.

I would also proceed with the cataract, and probably with the port-a-cath. Definitely not with a TKR, but then I am not PP.

 

[BLADEMDA]

I would also proceed with the cataract, and probably with the port-a-cath. Definitely not with a TKR, but then I am not PP.

I am PP and would cancel an elective TKR case with a Na+ of less than 130 unless there is consultant note on the chart from Nephrology or another Physician stating that the hyponatremia is well known in this patient and elective surgery may proceed.

HbA1c over 9.5 or 10? Cancel
Na+ less than 130? Cancel

Now, what you do in your neck of the woods is up to you but in my shop there is no way in h@ll I am proceeding with a real elective surgery on an unaddressed hyponatremic patient (Na+ less than 130).

Again, as practicing physicians the decision to proceed is yours.

 

[deleted171991]

I am PP and would cancel an elective TKR case with a Na+ of less than 130 unless there is consultant note on the chart from Nephrology or another Physician stating that the hyponatremia is well known in this patient and elective surgery may proceed.

HbA1c over 9.5 or 10? Cancel
Na+ less than 130? Cancel

Now, what you do in your neck of the woods is up to you but in my shop there is no way in h@ll I am proceeding with a real elective surgery on an unaddressed hyponatremic patient (Na+ less than 130).

Again, as practicing physicians the decision to proceed is yours.

If I were to cancel all cases with a high A1c, my surgeons would KILL me. Actually, they would get my boss to do it.

 

[BLADEMDA]

If I were to cancel all cases with a high A1c, my surgeons would KILL me. Actually, they would get my boss to do it.

Total Joint Replacements
Penile Surgery

These are some types of surgeries where a high A1c likely matters.

Error - Cookies Turned Off

onlinelibrary.wiley.com

Is hemoglobin A1c and perioperative hyperglycemia predictive of periprosthetic joint infection following total joint arthroplasty? A systematic review and meta-analysis - PMC

This meta-analysis aims to determine whether hemoglobin A1c (HbA1c) and perioperative hyperglycemia are associated with the increased risk of periprosthetic joint infection following total knee and hip arthroplasty. A systematic search is performed ...

www.ncbi.nlm.nih.gov

 

[BLADEMDA]

A man who elected to have a penile implant in a Florida hospital is now suing his doctor after a post-surgical infection resulted in the amputation of his organ.
Enrique Milla, 65, who was reportedly deported from the United States last year back to his native Peru, has been testifying in court via Skype that the medical procedure robbed him of his dignity and manhood.
In a medical malpractice trial that began this week, Milla claims that his doctors should have known that he was not a good candidate for the procedure because of his diabetes and high blood pressure.
"This has been devastating, painful and embarrassing," said Milla's attorney, Spencer Aronfeld of Coral Gables, according to ABC's affiliate WPLG.

Milla alleges that his anesthesiologist Dr. Laurentiu Boeru "failed to evaluate properly the risks of this procedure." He first filed the lawsuit in 2009, naming Boeru and Dr. Paul Perito, the urologist who performed the surgery.

Diabetic Sues Doctor After His Infected Penis Is Amputated

Enrique Milla testifies from Peru that his Miami doctor ignored his diabetes and unsafely implanted a penile prosthesis.

abcnews.go.com

 

[nimbus]

A man who elected to have a penile implant in a Florida hospital is now suing his doctor after a post-surgical infection resulted in the amputation of his organ.
Enrique Milla, 65, who was reportedly deported from the United States last year back to his native Peru, has been testifying in court via Skype that the medical procedure robbed him of his dignity and manhood.
In a medical malpractice trial that began this week, Milla claims that his doctors should have known that he was not a good candidate for the procedure because of his diabetes and high blood pressure.
"This has been devastating, painful and embarrassing," said Milla's attorney, Spencer Aronfeld of Coral Gables, according to ABC's affiliate WPLG.

Milla alleges that his anesthesiologist Dr. Laurentiu Boeru "failed to evaluate properly the risks of this procedure." He first filed the lawsuit in 2009, naming Boeru and Dr. Paul Perito, the urologist who performed the surgery.

Diabetic Sues Doctor After His Infected Penis Is Amputated

Enrique Milla testifies from Peru that his Miami doctor ignored his diabetes and unsafely implanted a penile prosthesis.

abcnews.go.com

Still a hassle and I feel bad for the guy but FWIW....

Doctor cleared of negligence in penis-amputation case of patient who developed gangrene after implant surgery went wrong

A jury in Miami have cleared Dr. Laurentiu Boeru of negligence after he was sued by Enrique Milla for penile implant surgery that went wrong when his penis had to be amputated due to a post-operative infection.

www.google.com

Jury reaches verdict in penis amputation case

A jury has reached a verdict in the case against a South Florida anesthesiologist who was sued after a patient's penis had to be amputated due to a post-operative infection.

www.local10.com

 

[BLADEMDA]

“Further research is needed into the tools used to measure blood sugar levels and into the conditions associated with diabetes that place these patients at a higher risk for infection,” Cancienne says. “Patients with diabetes and HbA1c levels of 8.0 and higher should be counseled that proceeding with surgery may place them at higher risk for prosthetic joint infection.”

After Shoulder Replacement Surgery A1c Levels May Affect Complications and Infection Risk

Patients with diabetes may be at an increased risk for complications and infection following shoulder replacement surgery, researchers warn in a new study published in the Journal of the American Academy of Orthopaedic Surgeons.

www.rehabpub.com

 

[BLADEMDA]

Still a hassle and I feel bad for the guy but FWIW....

Doctor cleared of negligence in penis-amputation case of patient who developed gangrene after implant surgery went wrong

A jury in Miami have cleared Dr. Laurentiu Boeru of negligence after he was sued by Enrique Milla for penile implant surgery that went wrong when his penis had to be amputated due to a post-operative infection.

www.google.com

Jury reaches verdict in penis amputation case

A jury has reached a verdict in the case against a South Florida anesthesiologist who was sued after a patient's penis had to be amputated due to a post-operative infection.

www.local10.com

I saw that he won his case. Great. Those of you who decide to proceed with Na+ of 125, or an HgbA1c of 10 I hope you win your cases as well. For the rest of us, let's try to not get sued in the first place by following reasonable evidence as presented by the literature. We should error on the side of caution when possible for truly elective surgery. I am referring to test results which are way off from the "norm" where there is data suggesting caution is warranted.

One last comment is that Plaintiff's attorneys will seek an extremely large award against you in court. The pressure will mount for you to settle the case even when the literature is inconclusive. The jury award can easily exceed your malpractice policy limit leaving you personally responsible to the plaintiff for the remainder.