Hyponatremia

[militarymd]

Here's a case that came in last night....I want to hear everyone's opinion.

The patient is a 84 year old woman with PMHx significant for HTN and severe peripheral vascular disease. Her PShx includes CABG, AAA repair, L CEA, R Fem/distal bypass, open chole.

Med List: Lisinopril, metoprolol, omeprazole, percocet prn

She is added on by an orthopedic surgeon for a kyphoplasty for a 10 day old T-10 compression fracture. Patient has been in severe pain for the last week and has finally been referred to this orthopedic surgeon.

Recent chemical stress test is negative for inducible ischemia, and patient says that she is in her usual state of good health. She is alert and oriented to person, place, and time. Physical examination is unremarkable.

ECG is NSR with NSSTTW changes.

CHEM 7 is remarkable for Serum sodium of 124.

Would you do this case? and if not, why not?

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[MAC Man]

I'm certainly not taking her to the OR with that sodium. Despite her clean stress test, she is still a vascular nightmare, and who knows what might happen in the OR. How is she otherwise? Neurologically? What is her baseline activity? Also don't forget that an 84 year-old heart is a different bird. It's stiff and probably won't react very well to surgery. I'd hesitate to take this.

Don't get me wrong. I would have a long conversation with the patient about the risks, and if I really believed that she was willing to take the risks for what might be a much better QOL, I might be convinced. There are patients who are prepared to die on the table, and I think they deserve a lengthy discussion.

 

[Atropine]

I'm assuming by the title of your post that you're mainly concerned about the moderately low sodium. Given it is arguably elective and the patient has an extensive cardiac history, it certainly wouldn't hurt to determine the cause and correct the sodium to a more acceptable level. Given this woman is bedridden(and presumably hypovolemic) as well as taking an ace-inhibitor, I'd start there as potential causes. If the surgery was urgent for some unknown reason, I'd proceed but with caution. Just my two cents...

 

[UTSouthwestern]

Chip shot.

I would ask the surgeon to change the plan of care from kyphoplasty to vertebroplasty. The percutaneous, minimally invasive vertebroplasty does not require the two inch incision of the kyphoplasty and uses smaller instruments to achieve basically the same outcome (stabilization of the compression fracture with hopefully some reexpansion and probable destruction of the irritated nerves causing her pain).

She has a normal dobutamine stress echo and the sodium is likely her baseline 2/2 to the ACEI.

Rate control, judicious use of fluids, minimum level of anesthetic, adequate pain control, large bore IV, A line for kicks. Rescue meds available. Reverse T berg to prevent venous pooling from the waist up.

Kyphoplasties should only be at most 45 minutes to one hour per level.

Again, I would recommend they do a percutaneous vertebroplasty instead of a minimally invasive, but still open kyphoplasty. The vertebroplasty usually only requires local + sedation.

 

[Tenesma]

Pain in of itself does not make a case urgent or emergent... That pain can be treated on the floor. Unless the surgeon was able to document intelligently why this case needed to go - (ie: neurological involvement, etc.)

I would not do an elective case for a sodium that is under 129 (albeit a random number not based on any scientific evidence - other than the orthotopic liver transplant literature).... How long has the pt. been hyponatremic - if there is evidence that she has been living at 124 for the last year then no biggie. Otherwise she needs a work up for her hyponatremia.

Is she hyponatremic because she has 1) heart failure 2) cirrhosis 3) over-diuresed with a thiazide? 4) SIADH from a lung CA or a brain neoplasm? 5) undiagnosed adrenal insufficience or hypothyroidism 6) renal failure.... the list goes on... and most of these in some way not only will impact her anesthetic, but also her fluid management, her post-operative care etc...

 

[asdash]

From Miller (6th edition):

"Neither acute nor chronic hyponatremia necessitates the restoration of serum sodium to normal levels; brain swelling usually disappears at a serum sodium level of 130 mEq/L. This leaves us with the question of what levels of serum sodium make anesthesia more risky. Because no data exist to answer this question, to allow for some error in caring for patients, we have arbitrarily chosen a flexible concentration of 131 mEq/L as the lower sodium limit for elective surgery."

I'm curious: what kind of fluids would you have to use if you were to proceed with kyphoplasty as originally planned? Would you have to give demeclocycline before starting the case? What would actually happen if you were to ignore the 124 -- central pontine myelinolysis?

 

[militarymd]

Patient is ambulatory. She does her own activity of daily living...which is being impacted by the pain. She was an outpatient, coming in for surgery.

Physical examination shows absolutely no evidence of sodium/volume overload. CXR is normal....EF on stress test was greater than 70%. This lady has no heart failure. Serum creatinine is 0.5. Bun was 10.

As for cirrhosis....that particular cause did cross my mind, but I could find no stigmata of chronic liver disease on exam....ascites, caput medusa, asterisx, spider angiomas, etc...and she has no history of etoh abuse...although viral cause is certainly a possibility based on her surgical history......her PT/PTT was normal.....although albumin was a little low...I forget the number

She does not take diuretics. Her meds are what I listed.... I was under the impression that ACEI can cause hyponatremia only in overdoses, and this lady was underdosed....her BP was 150/90.

This particular orthopedic surgeon is an expert at kyphoplasties...one level is less than 30 minutes for him with negligible blood loss.

For those of you who would cancel....what are you concerned about happening in the perioperative period that would make you cancel the case?

As for the orthotopic liver transplantation literature...is cerebral edema and herniation the complication that can be avoided?

 

[jetproppilot]

Here's a case that came in last night....I want to hear everyone's opinion.

The patient is a 84 year old woman with PMHx significant for HTN and severe peripheral vascular disease. Her PShx includes CABG, AAA repair, L CEA, R Fem/distal bypass, open chole.

Med List: Lisinopril, metoprolol, omeprazole, percocet prn

She is added on by an orthopedic surgeon for a kyphoplasty for a 10 day old T-10 compression fracture. Patient has been in severe pain for the last week and has finally been referred to this orthopedic surgeon.

Recent chemical stress test is negative for inducible ischemia, and patient says that she is in her usual state of good health. She is alert and oriented to person, place, and time. Physical examination is unremarkable.

ECG is NSR with NSSTTW changes.

CHEM 7 is remarkable for Serum sodium of 124.

Would you do this case? and if not, why not?

Geez, Dude, thats a good one. Guess I'll have to turn into Flea Mode and think about this for a minute.

Lets see- hyponatremia can be hyper-, hypo-, or isovolemic. Does the patient look in any distress from hyper- or hypo- volemia? Tachypneic? Talking in short sentences? Mental status OK? Sounds like from your post nothing unusual, just another sick old lady.

Hearts OK...nothing dramatic from you pre-opping her other than her history (albeit somewhat significant)...

Is it a lab error?

I'd probably end up doing the case, bro. I'm pretty liberal, but even I would at this point talk with the surgeon about my concerns, and as Atropine mentioned, I'd talk with the patient as well. I'd tell surgeon and patient about my concerns, say theres abnormal lab value that might be of concern, the potential differential diagnoses, and the chances that the abnormal lab value reflects the differential diagnoses in question ( which is probably a low value).

Put it in their lap. Inform them. I'm willing to take the chance if they are, after careful documentation of same.

OK, lets say patient and surgeon are thoroughly informed, and agree to proceed. UT suggested talking to the surgeon and requesting he minimize the invasiveness of the procedure. Good call. Even if it doesnt work, I'd manage the patient like UT posted, but I'd definitely put in a central line; the possibility of transfusion is high, and if the patient requires any hemodynamic pharmacologic support, all infusions work better and faster if hooked up to a central, as opposed to a peripheral line, especially in the hypovolemia window where peripheral vasculature is vasoconstricted.. Lets do it. I'm ready.

 

[zippy2u]

No brainer, man. Your critical piece of info that the surgeon is an expert at kyphos with minimal blood loss and is quick is the key. Na is no problemo as neurologically she's intact. EF is approx 70% with nl. rhythm. Place an 18 gauge in her and let's rock and roll. Central line and A-line not needed as this is the real private world and not some resident operating on her. --Zippy2U

 

[militarymd]

Chip shot.

I would ask the surgeon to change the plan of care from kyphoplasty to vertebroplasty. The percutaneous, minimally invasive vertebroplasty does not require the two inch incision of the kyphoplasty and uses smaller instruments to achieve basically the same outcome (stabilization of the compression fracture with hopefully some reexpansion and probable destruction of the irritated nerves causing her pain).

She has a normal dobutamine stress echo and the sodium is likely her baseline 2/2 to the ACEI.

Rate control, judicious use of fluids, minimum level of anesthetic, adequate pain control, large bore IV, A line for kicks. Rescue meds available. Reverse T berg to prevent venous pooling from the waist up.

Kyphoplasties should only be at most 45 minutes to one hour per level.

Again, I would recommend they do a percutaneous vertebroplasty instead of a minimally invasive, but still open kyphoplasty. The vertebroplasty usually only requires local + sedation.

I think what you call a vertebroplasty is what we call a kyphoplasty....it is percutaneous under fluoro guidance with essentially zero blood loss.

 

[militarymd]

The lab is real. The surgeon got it at his office, then repeated it when she came it.

She is really asymptomatic....other than her severe pain from the compression fx.

So....for those who would cancel, what possible complication would be prevented by waiting until the sodium is corrected to say 130...which was the number that has been mentioned.

 

[Tenesma]

i think there are two sides for this

1) Oral Board Answer: cancel the case as it is elective and there are issues that need to be resolved

2) Real World Answer: you know the surgeon, you have a good feel for the patient and know your strengths and weaknesses... go for it.

3) (3rd point is extra) Court Answer: somewhere in between #1 and #2....

 

[jetproppilot]

The lab is real. The surgeon got it at his office, then repeated it when she came it.

She is really asymptomatic....other than her severe pain from the compression fx.

So....for those who would cancel, what possible complication would be prevented by waiting until the sodium is corrected to say 130...which was the number that has been mentioned.

I'm doin' the case, provided the surgeon and the patient are aware of the "attendant" risks. Yeah, a central line may be overkill, but hey, it makes me feel better, and it takes about five minutes extra. Lets rock.

 

[Tenesma]

yeah.... central access is overkill unless the patient has no access whatsoever... or if you really need to put in central drugs, you can always slip a long 18 through her AC

 

[militarymd]

Come on, you guys....I don't want to know how you would do it. I want to know what you would tell the surgeon is the reason for cancelling a case like this.

 

[jetproppilot]

Come on, you guys....I don't want to know how you would do it. I want to know what you would tell the surgeon is the reason for cancelling a case like this.

Dude, you're posting at 0359 and your brain needs sleep! Read the posts again- the answer to your question is I probably wouldnt cancel it.

 

[zippy2u]

militaryman, The point is that this case is not one that should be cancelled or even postponed.Your surgical colleagues will look upon you as weak and inept if you continue to cancel cases of this magnitude. You play that cancelling game and the orthopod will take his cases down the road where the cases wouldn't be cancelled. You can't walk on eggshells your whole working life. Again, only private world perspective ,not academic or government practice -- the only one that really counts. Regards --Zippy

 

[militarymd]

militaryman, The point is that this case is not one that should be cancelled or even postponed.Your surgical colleagues will look upon you as weak and inept if you continue to cancel cases of this magnitude. You play that cancelling game and the orthopod will take his cases down the road where the cases wouldn't be cancelled. You can't walk on eggshells your whole working life. Again, only private world perspective ,not academic or government practice -- the only one that really counts. Regards --Zippy

Actually, I didn't cancel it. My associate who was on call refused to do it, so at the request of the surgeon, I did the case, with a 20 gauge IV that a pre-op nurse placed for me. Propofol/sux/n2o/des and some LR.

Maybe you have your browser set to ignore, but a few people said they would cancel....so I'm asking....for those who would...what would your reason be??

My associate's answer was "I don't feel comfortable"...I'm not planning on having associates like that for long.

 

[militarymd]

Macman/Atropine/Tenesma

You guys initially said you wouldn't do the case. What would your arguments be for not doing the case??

I would like to hear the other side of the arguement....something other than what my associate said.

 

[militarymd]

Dude, you're posting at 0359 and your brain needs sleep! Read the posts again- the answer to your question is I probably wouldnt cancel it.

Must be something wrong with the internet clock. If I'm up at 0359, it's going to be something ugly in the OR

 

[zippy2u]

chances are that your associate is recently out of residency and a little green. Whip him in shape but don't get rid of him. There ain't nothin' worse than runnin' an anesthesia group with little manpower.

 

[militarymd]

chances are that your associate is recently out of residency and a little green. Whip him in shape but don't get rid of him. There ain't nothin' worse than runnin' an anesthesia group with little manpower.

Ohhh...don't get me started with lack of manpower....I'm in the midst of a very bad drought.

I wish the guy was green and trainable......This guy is old and a bizillion years out of residency. I'm embarrassed to have him in my group.

 

[Atropine]

Macman/Atropine/Tenesma

You guys initially said you wouldn't do the case. What would your arguments be for not doing the case??

I would like to hear the other side of the arguement....something other than what my associate said.

Actually, I never said I wouldn't proceed at all--just preferably delay it unless there was some outstanding reason to proceed urgently. Since it's an elective case, you benefit the patient by figuring out some things beforehand--acuity of its decline, its progression(is it trending downward?), its cause, and initiation of treatment. If it's acute and progressively declining, I'd worry about cerebral edema and other neurological complications and wouldn't do the case. If it was chronic and not trending downward, I'd still factor in the time needed for correction to an acceptable--albeit arbitrary--level of 130. With overly rapid correction of the hyponatremia, demyelination becomes a concern.

What possible complication can arise by delaying the surgery--besides the surgeon yelling at you? Not much in my opinion. Obviously quite a few complications can occur if the sodium declines below 120 perioperatively because the surgeon decided to be a cowboy and rushed into surgery.

Having said that, I understand that real world practice and academics are entirely different. Since you asked for opposing viewpoints, I obliged.

 

[Tenesma]

militarymd... like i said earlier, if this is a board question we all would know better than to start that case!!!!
In private practice, most good surgeons would be worried about this in their patient and would probably get a medicine consult involved, and wouldn't pressure you to do a case like this.... Unfortunately we have to work with some surgeons who have forgotten their medicine and don't have the insight needed

In private practice, this case is pretty much a no brainer... primarily because she has a normal mental status... and it will be a quick case with no fluid shifts.

 

[militarymd]

militarymd... like i said earlier, if this is a board question we all would know better than to start that case!!!!

Why??? Can you elaborate?

In private practice, most good surgeons would be worried about this in their patient and would probably get a medicine consult involved, and wouldn't pressure you to do a case like this....

The surgeon was very collegial. He asked me if it was safe to do the case. I told him yes, but please have the patient seen by IM afterwards. (My wife is IM, so I'm getting her business.)

 

[Tenesma]

militarymd.... i hate to say this, but i already answered why on a board question I wouldn't answer it... I would want to know the underlying reason for the hyponatremia and rule out certain issues that would be concerning. Is there any literature that providing anesthesia to a hyponatremic (other than the liver transplant literature) patient is frought with bad outcomes? NO... But there is also no literature that can show bad outcomes for patients who are hypokalemic (other than Cardiac Surgery)... would you start a case with a K=2.3??? board answer is no....

 

[zippy2u]

The surgeon has just created a division in your group. You sided with the surgeon and said the case can be done and your partner didn't want to do the case. muy malo. Rule # 1 in group practice is that all anesthesia members must be on the same side of the fence when dealing with the surgeons. Your partner had 1st dibs on case and was reluctant to proceed as he is conservative in providing anesthesia. Militaryman, your numero uno job when the surgeon came whining to you was to support and respect your partner's decision and postpone the case until IM could quickly evaluate and make recs. Likewise, if you had 1st dibs on case and you wanted to proceed, your partner has your back. Lucky for you, you're not in the prison system or you'd have a nice steel shank in your back when you least expect it. Regards, --Zippy

 

[Alpha_Male]

would you start a case with a K=2.3??? board answer is no....

Okay, but dude..........I think what militarymd is getting at is WHY. It would be a good learning point to discuss WHY you would cancel a case with the aforementioned NA+ level. The first thing a surgeon is gonna' say is "why are you going to cancel this case? What are the risks and potential complications?" Saying "Uh.......Ummmmmmmm.........I'm just not comfortable doing this case" is a bull**** cop-out branding you immediately as an incompetent.

 

[mdmccallum]

I had a case this year that just brings up a reason not to do this case. A very good spine surgeon was doing a vertebroplasty. He managed to get some spread of the cement in the vertebral canal and the pt woke up ( yes he wants his patients asleep for these) with a tremor and some neuro deficits. I don't know the mechanism of the tremor but when this was occuring we tried to think of everything that could cause it. The surgeon first blamed the anesthetic. Electrolyte imbalance (low Na+) could be one of the causes. This would really confuse the issue and delay the accurate diagnosis. An MRI revealed the true cause finally. Don't think that even your best friend won't blame you for something going wrong.
I also would not be to fond of doing something that my colleage had already said he would not do. That breeds Dr. shopping and bad relationships among colleagues. I would have been pissed if my partner agreed to do something that I said needed to be worked up first. We all know we can do this case but do we really need to do it before an IM consult. Its not a new injury that is life threatening. Put her on the floor with a PCA and do her in the am. Why be a cowboy? Just my $.02 I know there are other ways.

 

[militarymd]

I thought this was an interesting case, in that a lawyer would never fault you for cancelling it, but a surgical colleague and an internist(my wife) would wonder why you would cancel.....

so I thought I would get everyone's oral board rationale for not doing it ie...explaining to a surgical colleague what the potential complications of doing such a case would be. I think the simple answer of "there is a higher risk of complication" is an unacceptable answer.

As it stands right now, I have received only answers that simply say stuff like I want to know why she has a low sodium. Anyone with an answer to what the risks of having a low risk, no blood loss procedure is? What could potentially happen that can be avoided by correcting the sodium first or finding out why the sodium is low?

As for zippyman's remark on the divide in the group, well it exists already. The divide is between partner's (myself and a few others), and those who want to be partner's but who we are not offering partnership to.

The case was actually scheduled earlier in the day, when I OKed her for surgery, but as everyone knows, OR schedules sometimes run late, and the call dude shows up and says that the patient is not ready for surgery and refuses to do it....now zippyman...what am I supposed to do?

Change my medical evaluation now and agree with the call dude? or back up my initial assessment, suck it up, stay and do the case?

 

[militarymd]

Here's my rationale for why it is OK to do the case:

1) patient is asymptomatic. Medical evaluation would be done on an outpatient basis with blood tests and perhaps free water restriction to see if SIADH from her pain is the cause.

2) The dreaded CPM occurs only with rapid correction of very low serum sodium. This is a rare complication that is reported but unlikely to occur in someone with this level of hyponatremia

3) The anesthetic is not going to correct her sodium. There is no need for fluid resuscitation, and even if there is LR has a sodium content of 130, so a correction would at most be somewhere between 124 and 130....say 127...not going to cause a problem

There is absolutely NO reason to cancel this case.

The flip side argument would be this:

1) There is a surgical mishap, and the surgeon perforates the thoracic aorta while placing his needls and you have to crack the chest

well if you worry about stuff like that, perhaps a change of profession is in order

 

[Tenesma]

major reported consequence of doing a patient with hyponatremia is high risk for CPM - that is the only documented (in the literature) reason and was initially described in the liver transplant literature.... argh... how many times do i have to write this??? nobody reads my posts....

The board answer is not to do this case because of the risk of CPM is high in the possible setting of this tiny case turning into a volume/fluid resuscitation case.... ooops the trochar slipped past or through the vertebral body into the aortic graft... now she is bleeding intra-peritoneally and is prone and doesn't have her airway secured etc..... those are the boards for you... now she is resuscitate but is a vegetable from the CPM... great...

The private practice answer is twofold because zippy brought up an excellent point.... 1) i would do the case if i knew the surgeon well and his skills.... trust me, i have been stuck in 8 hour vertebroplasties before where i had to intubate a patient while he was prone
2) if a colleague cancels a case for a reasonable cause, and then you proceed with the case you put yourself at huge risk from a legal point of view.... lawyer in court: "why did you do the case when another board certified anesthesiologist felt it prudent not to?" and trust me there would be a line of expert witnesses who would support the first anesthesiologist... but you also make the surgeons lose confidence in your group while caressing your ego... the surgeons will quickly learn that they can split the group to their advantage....

 

[militarymd]

"why did you do the case when another board certified anesthesiologist felt it prudent not to?" and trust me there would be a line of expert witnesses who would support the first anesthesiologist.......

Just to be clear, I'm BC in anesthesia and ccm, the other person is not BE.

 

[militarymd]

militaryman, The point is that this case is not one that should be cancelled or even postponed.Your surgical colleagues will look upon you as weak and inept if you continue to cancel cases of this magnitude. You play that cancelling game and the orthopod will take his cases down the road where the cases wouldn't be cancelled. You can't walk on eggshells your whole working life. Again, only private world perspective ,not academic or government practice -- the only one that really counts. Regards --Zippy

Zman,

I agree with you conceptually in that you need to support your colleagues in their decisions, but what if they consistently "walk on eggshells"....then what would you do?

Continue to support their "wrong" decisions and make the "right" ones when they are not there?

Do I tell surgeons when they come to me to just go to the On-Call guy when I know that there is a high likelihood that their case will be cancelled?

A few months ago, I had a situation where the surgeon had to transfer his patient to another hospital to do his case because one of my colleagues refused to do a case, and the surgeon "did not want to impose on me"...he did not know me that well at the time.

What would you do?

 

[militarymd]

Lucky for you, you're not in the prison system or you'd have a nice steel shank in your back when you least expect it. Regards, --Zippy

I get lots of metaphorical shanks in my back

The hospital staff always tell me about it afterwards.

 

[zippy2u]

Well then you apparently saw the pt. first and ok'd the surgery. When the on call guy comes in , discuss the case with him and if he's unwilling to do the case, you must suck it up and do the case despite you not being on call. The disagreement between you and your colleague must never be conveyed to the surgeon. If the surgeon asks why you are doing the case rather than the on call gasdoc, you say he is busy doing other stuff in hospital or needed a couple hours to take care of family matters, something benign. ---Zippy

 

[militarymd]

If the surgeon asks why you are doing the case rather than the on call gasdoc, you say he is busy doing other stuff in hospital or needed a couple hours to take care of family matters, something benign. ---Zippy

Our surgeons are not dummies.

 

[blocks]

Don't mean to interrupt, but this thread is a great read. If any other attendings or residents can post real-life cases that are applicable to board prep, private practice, etc. that would be great. Maybe even posted as a sticky.

I am just starting intern year, but reading about the real-life decision making on cases has a lot of value as I proceed in anesthesia residency next year.

 

[misfit]

I know this question is a complete aside from the original topic and it falls within Primary Care, not Anesthesia or Surgery, but...

WHY IS THIS WOMAN NOT ON A STATIN?

With the sh*tty vasculopathy she has, I just have to wonder why?

Sorry for the interruption, continue the GAS WARS!

misfit

 

[militarymd]

I know this question is a complete aside from the original topic and it falls within Primary Care, not Anesthesia or Surgery, but...

WHY IS THIS WOMAN NOT ON A STATIN?

With the sh*tty vasculopathy she has, I just have to wonder why?

Sorry for the interruption, continue the GAS WARS!

misfit

Talk to her outpatient doc.

 

[Gator05]

Fascinating read; may thanks to all who have contributed. If this keeps up, I might start counting these topics towards my daily reading!

MilitaryMD, my apologies if I missed it/these questions are absurdly simple, but would you mind letting us know what her post-op sodium was?

Also, was a urinary sodium obtained? If so, did this make you more/less comfy with the decision to move forward? How about a lipid panel?

Again, thanks for posting the topic. Perhaps we could try to start a rotating series of anesthesia dilemmas?

 

[militarymd]

Postop was unchanged. Her workup is going to be on an outpatient basis.

Urinary sodium was not done preop.

 

[jetproppilot]

Macman/Atropine/Tenesma

You guys initially said you wouldn't do the case. What would your arguments be for not doing the case??

I would like to hear the other side of the arguement....something other than what my associate said.

Military,

I feel for you- working with colleagues that throw up road blocks for insignificant issues will make your life and your surgeon's lives miserable. Were the "road blockers" in the group before you?

It'd be great to figure out how you can accomplish "out with the bad, in with the good" so your group doesnt suffer mediocrity forever.

 

[militarymd]

Military,

I feel for you- working with colleagues that throw up road blocks for insignificant issues will make your life and your surgeon's lives miserable. Were the "road blockers" in the group before you?

It'd be great to figure out how you can accomplish "out with the bad, in with the good" so your group doesnt suffer mediocrity forever.

Yes, the problem(s) existed prior to my joining. We're currently expanding right now....hopefully diluting the blocks, or cause blocks to become less blocked.

 

[undecided05]

Two quick questions... why was there no urinary Na+ done as part of pre-op after the low serum Na+? You said that EF was 70%... do you know that she didn't have a diastolic dysfunction CHF that lead to low Na+?

Just curious. Thanks.

 

[militarymd]

Two quick questions... why was there no urinary Na+ done as part of pre-op after the low serum Na+? You said that EF was 70%... do you know that she didn't have a diastolic dysfunction CHF that lead to low Na+?

Just curious. Thanks.

Same day preop labs....Patient never saw an internist.

Patient has no clinical evidence of CHF....She was not fluid overloaded per my exam, so that rules out CHF as a diagnosis, although at her age, I'm sure she has diastolic dysfunction.

 

[Justin4563]

I thought this was an interesting case, in that a lawyer would never fault you for cancelling it, but a surgical colleague and an internist(my wife) would wonder why you would cancel.....

so I thought I would get everyone's oral board rationale for not doing it ie...explaining to a surgical colleague what the potential complications of doing such a case would be. I think the simple answer of "there is a higher risk of complication" is an unacceptable answer.

As it stands right now, I have received only answers that simply say stuff like I want to know why she has a low sodium. Anyone with an answer to what the risks of having a low risk, no blood loss procedure is? What could potentially happen that can be avoided by correcting the sodium first or finding out why the sodium is low?

As for zippyman's remark on the divide in the group, well it exists already. The divide is between partner's (myself and a few others), and those who want to be partner's but who we are not offering partnership to.

The case was actually scheduled earlier in the day, when I OKed her for surgery, but as everyone knows, OR schedules sometimes run late, and the call dude shows up and says that the patient is not ready for surgery and refuses to do it....now zippyman...what am I supposed to do?

Change my medical evaluation now and agree with the call dude? or back up my initial assessment, suck it up, stay and do the case?

Why arent you offering partnerships to dem guys military out of curiosity? because he wouldnt do a case with a sodium of 124.. Thats good medicine wanting to know the reason for a sodium of 124 before doing the case. THats a pretty involved workup as you know already. WHy risk it if it is an elective case. Patient may have a malignancy that you are not aware of.. THat would be important information. Just offer dem guys partnership military.. and dont hold the delay of the case against the poor guy.. man.. talk about a divisive group.. Tell me wehre you are so i dont apply there..

 

[Justin4563]

Just to be clear, I'm BC in anesthesia and ccm, the other person is not BE.

Then you must be right..

 

[jetproppilot]

Then you must be right..

Alright Justin, you're obviously a smart dude, but I've about haddit with your negative, verbal-brawl-taunting posts.
LETS GO DUDE! I'm 5'11, 210 lbs, gym-rat extraordinairre. Tell me where you are. I'm ready to settle this gangsta style.
Oh, and its OK to say youre scared.

 

[jetproppilot]

Then you must be right..

HEY VENT, I'm nominating Justin for a by each of his posts. He's officially earned the title, taunting UT, Military, and just about everyone else.