cubs3canes

Senior Member
7+ Year Member
15+ Year Member
Oct 27, 2003
238
1
Visit site
Status
It happened yesterday during noon conference.

During my medicine internship, we had a lecture by an IM hospitalist on the ACC/AHA standards for pre-op clearance. I was sittiing there stating am I really listening to this? Especially because all of the hospital patients at my hospital are seen by anesthesia the night before surgery.

Also, he did the whole lecture without mentioning the work anesthesiologist. He said "if you have problems, the you can always consult cardiology." Cardiologists are not the experts in intra-operative cardiac complications.

Can the hospitalists bill a lot for this? I just do not understand why you would use an IM doc for pre-op clearance when the experts are down the hall. I ama also sure that you guys do not listen to their eval.
 

Noyac

10+ Year Member
Jun 20, 2005
7,958
2,676
Status
Attending Physician
cubs3canes said:
It happened yesterday during noon conference.

During my medicine internship, we had a lecture by an IM hospitalist on the ACC/AHA standards for pre-op clearance. I was sittiing there stating am I really listening to this? Especially because all of the hospital patients at my hospital are seen by anesthesia the night before surgery.

Also, he did the whole lecture without mentioning the work anesthesiologist. He said "if you have problems, the you can always consult cardiology." Cardiologists are not the experts in intra-operative cardiac complications.

Can the hospitalists bill a lot for this? I just do not understand why you would use an IM doc for pre-op clearance when the experts are down the hall. I ama also sure that you guys do not listen to their eval.

I'll listen to their eval. I'll let them do the pre-op but I'll do my own and I'll do the anesthesia my own way. I'll call them if they give me any bogus rec's or limit me in any way, and I guarantee they won't do it again. ;)

Most in house pre-ops are done by us at my hospital. The surgeons send pts to our pre-op clinic if they have any substantial medical problems. But I don't mind if a pts IM/FP sents me a note about the pts status. Hell they are the ones that know the pts history and have been following the pt.
 

Tenesma

Senior Member
10+ Year Member
15+ Year Member
Jun 11, 2002
5,332
127
Visit site
Status
Attending Physician
this thread reminds me of a story...

I was a CA-2 going for a pre-op on an inpatient, and when I walked into the room the Internist is still talking to the family. He says to them: "... and don't worry about her heart, it is a small operation without any real risks". Of course, I had looked at the chart prior to walking up and had seen her ECHO showing AS w/ an area=0.6 and a MEAN gradient in the high 60s... for an open chole.... thank you very much for that, because my conversation went down hill with the family when I told them that there are risks considering her AS and hx of poorly controlled CHF....

this also reminds me of another story....

As a CA-1, i had a patient whose cardiologist wrote in the chart as part of his pre-op note: "keep heart rate 60-65"... My attending blew a gasket when he saw this. Of course we did the anesthetic our way and everything went fine.... Then he paged the cardiologist and their conversation went like this
My attending: "hi, we just did Ms. So-and-so's case - it went pretty well. Thanks for your pre-op"
Cardiologist: "sure, thanks for taking care of her"
My attending: "oh... i should tell you we had to give her several small boluses of epinephrine, and then we put in an esophageal pacer"
Cardiologist: "YOU DID WHAT??? WHAT HAPPENED???"
My attending: "well her heart rate was in the mid 50s and your note clearly said to keep her HR between 60-65"
Cardiologist: "you gotta be kidding me"
My attending: "exactly mother f****er - don't ever write that **** in a note again".... he then hung up on the cardiologist... a bit extreme....

general rule of thumb:
1) FPs/Internists/Cardiologists pre-ops: are very useful as they know the patient pretty well and provide the surgeon and you some peace of mind
2) Anesthesia pre-op: is the most crucial... because it doesn't what every body else says, since you are the one ACTUALLY doing the anesthetic....
3) It is a LOT MORE common to cancel cases despite being cleared by cardiology/internal medicine.... It is very RARE to proceed with a case that has been cancelled by internist/FP/cards...
 
About the Ads

jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
111
level at FL210
Status
Tenesma said:
My attending: "exactly mother f****er - don't ever write that **** in a note again".... he then hung up on the cardiologist... a bit extreme....
...
MESSAGE:

Sometimes a dude hasta handle pushy consultants who document ludricrous recommendations in the chart

GANGSTA STYLE.

I'll bet, after the attending said the above, he continued:

"BY THE WAY, DO YOU KNOW LUCIFER?"

"CUZ YOU'RE ABOUT TO MEET'EM, MOTH#%FU$^&ER!!!!!" :laugh:

yes, HOOD anesthesia is efficacious sometimes....
 

jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
111
level at FL210
Status
supahfresh said:
hood anestheisa?
yes.

Hood Anesthesia (def): the act of a board-certified anesthesiologist taking command of a patients well-being during the perioperative period, through any measures deemed necessary, including, but not limited to, asking said stupid-ass-consultant if he personally knows Lucifer, and if not, inquiring if said-consultant would like to be introduced to Lucifer via a bullet-to-the-dome conduit.

HAHAHAHAHAHHAHHAHAHAHAHAHAHAHAHAHA...........man, thats funny.....I don't care who you are, thats some funny s h it.....HOOD ANESTHESIA......HAHHAHAHAHAHAHAHAHAHAH
 

SleepIsGood

Support the ASA !
10+ Year Member
5+ Year Member
Apr 16, 2006
1,965
2
Status
Fellow [Any Field]
jetproppilot said:
[...
yes, HOOD anesthesia is efficacious sometimes....
lol :laugh:
 

signomi

Amongst the Gravelings
10+ Year Member
May 4, 2006
247
2
Valley of the shadow of death
Status
Attending Physician
I am an internist and I do quite a few pre-ops at the request of surgeons. Usually it is the patients with complicated medical histories where they want someone to tell the patient what to do with their 10-15 meds and insulin. :eek: I have never once consulted on anesthesia...that is entirely up to the anesthesiologist. My recs are usually always directed to the surgeon. I have only suggested cancelling surgeries 3 times...one had an in-office EKG of CHB (doc, I feel weak these days... :scared: ), one had an EKG sent from the surgeons office unread with new-onset rapid a.fib and the last guy was using cocaine daily. Oh and the surgeon operated on cocaine boy against my advice (elective back surgery for "chronic pain") and the guy had an MI post-op and never came off the cocaine or narcotics.

I have always presumed anesthesiology just wanted to deal with the best anesthesia and intra-op fluids for each patient based on their history (pulm/cardiac status). Do you guys prefer to do more than that? Would you manage insulin and read pre-op EKGs?
 

jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
111
level at FL210
Status
cubs3canes said:
It happened yesterday during noon conference.

During my medicine internship, we had a lecture by an IM hospitalist on the ACC/AHA standards for pre-op clearance. I was sittiing there stating am I really listening to this? Especially because all of the hospital patients at my hospital are seen by anesthesia the night before surgery.

Also, he did the whole lecture without mentioning the work anesthesiologist. He said "if you have problems, the you can always consult cardiology." Cardiologists are not the experts in intra-operative cardiac complications.

Can the hospitalists bill a lot for this? I just do not understand why you would use an IM doc for pre-op clearance when the experts are down the hall. I ama also sure that you guys do not listen to their eval.
Nice post. Lemme break this down for you.

"Pre-op Clearance Consultants" can help you. They can elucidate knowledge/studies of a patient unknown to you. They can assure you patient's medical problems are "optimized".

Conversely, "Pre-op Clearance Consultants" can hurt you. Ya'll know the empirical-consultant drill: avoid hypotension and hypoxemia.....

.....or better yet, completely useless, non-applicable demands :

"62 year old WF well known to me. Documented MVCAD with EF 30%....needs lap chole... .....INTRAOPERATIVE SWAN REQUIRED...."

The latter is a consult I remember from a few years ago. Cardiologist DEMANDING an intra-op SWAN.....

now lets look at this from a board-certified anesthesiologist's perspective:

1) Once I pre-op the patient, this person is my patient, as well as yours.

2) Pulmonary artery catheterization is frought with risks, so said clinician has to remain assured that the benefits of placing a PAC outweigh the risks.

3) According to OVERWHELMING literature, a PAC does nothing to affect patient outcome, SO, REALLY, its hard to justify putting in a PAC for intraoperative management IN ANY SCENERIO, let alone a 45 minute minimally-invasive operation with no blood loss and no fluid shifts.....

4)please read Jet's posts concerning Hood Anesthesia's Role in enforcement of dealing with unreasonable requests by physician consultants.... :laugh:
 

jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
111
level at FL210
Status
signomi said:
I am an internist and I do quite a few pre-ops at the request of surgeons. Usually it is the patients with complicated medical histories where they want someone to tell the patient what to do with their 10-15 meds and insulin. :eek: I have never once consulted on anesthesia...that is entirely up to the anesthesiologist. My recs are usually always directed to the surgeon. I have only suggested cancelling surgeries 3 times...one had an in-office EKG of CHB (doc, I feel weak these days... :scared: ), one had an EKG sent from the surgeons office unread with new-onset rapid a.fib and the last guy was using cocaine daily. Oh and the surgeon operated on cocaine boy against my advice (elective back surgery for "chronic pain") and the guy had an MI post-op and never came off the cocaine or narcotics.

I have always presumed anesthesiology just wanted to deal with the best anesthesia and intra-op fluids for each patient based on their history (pulm/cardiac status). Do you guys prefer to do more than that? Would you manage insulin and read pre-op EKGs?
With all the literature pointing towards decreased morbidity with tight glucose control we are managing intraop glucose tighter than before.

And yes, we look at pre-op EKGs. It is very rare that we cancel a case based on a pre-op EKG....they are utilized more for a baseline in case of a developing perioperative problem.

What we desire from you, Sir/Sirette, is a note testifying to the "optimization" of the patient's medical problems.

In other words,

"Ms Smith has a history of CHF. EF=30%. There is no clinical/laboratory evidence of exacerbation. Her lungs are clear. Her heart has a regular rate and rhythm. I cannot discern an S3. There is no JVD/pedal edema/orthopnea. Therefore, I deem her medically optimized for surgery."

ASIDE: I have never seen a consult like this, even though this would be the most useful to us.
 

toughlife

Resident
10+ Year Member
5+ Year Member
Sep 11, 2004
1,836
3
Status
Resident [Any Field]
Noyac said:
I'll listen to their eval. I'll let them do the pre-op but I'll do my own and I'll do the anesthesia my own way. I'll call them if they give me any bogus rec's or limit me in any way, and I guarantee they won't do it again. ;)

Most in house pre-ops are done by us at my hospital. The surgeons send pts to our pre-op clinic if they have any substantial medical problems. But I don't mind if a pts IM/FP sents me a note about the pts status. Hell they are the ones that know the pts history and have been following the pt.

Saw a pt in pre-op clinic this week who'd seen his internist earlier that day. Patient told internist of upcoming surgery and internist documents patient needs stress test as patient had c/o SOB and mild chest discomfort. Patient scheduled for cystoscopy and bladder bx the following day.

I see patient and he tells me he feels SOB and mild chest discomfort after walking 2-3 miles or going up several flight of stairs. EKG is unremarkable. My impression was patient did not need stress test and felt he was ready to go to OR.
However, since said internist had documented need for stress test, surgery was cancelled so pt could get the test. Patient was pissed since he'd traveled from out of state to have the surgery the following day.
 
About the Ads

jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
111
level at FL210
Status
toughlife said:
Saw a pt in pre-op clinic this week who'd seen his internist earlier that day. Patient told internist of upcoming surgery and internist documents patient needs stress test as patient had c/o SOB and mild chest discomfort. Patient scheduled for cystoscopy and bladder bx the following day.

I see patient and he tells me he feels SOB and mild chest discomfort after walking 2-3 miles or going up several flight of stairs. EKG is unremarkable. My impression was patient did not need stress test and felt he was ready to go to OR.
However, since said internist had documented need for stress test, surgery was cancelled so pt could get the test. Patient was pissed since he'd traveled from out of state to have the surgery the following day.
All for a MAC anesthetic.

A MAC can be confidently administered on a 95 year old with MVCAD, AS, MR, IDDM, brain tumor, HTN, CVA, etc etc.

Consultants have no ability to account for "severity of case".
 

signomi

Amongst the Gravelings
10+ Year Member
May 4, 2006
247
2
Valley of the shadow of death
Status
Attending Physician
ASIDE: I have never seen a consult like this, even though this would be the most useful to us.
That is interesting. I have been out of residency awhile now and I have always written my consults the way I was trained. I always conclude with, for example, "The Pt is a 65yof with intermediate clinical predictors (DM2, CRI) that are presently stable, moderate functional capacity and she is to undergo an intermediate risk procedure. No further cardiac testing is required at this time. Stress Echo from two years ago, as noted above was negative."
Then I list any recs I might have related to meds...usually not too much, I try to keep it to 1-4 things that I deem important. What is interesting to me is that I have never seen a pre-op written this way by any other doc or PA in the office. I swear, they all say "A/P: Okay for surgery."
I would say 8 times out of 10 I am not doing anything more than adjusting a BP med, lasix or insulin and reminding them the surgeon WAS serious about stopping the coumadin. :rolleyes: Most of the time I am just giving my blessing. It is so rare for me to add anything earth shattering, that I can remember those 3 specific patients.
 

signomi

Amongst the Gravelings
10+ Year Member
May 4, 2006
247
2
Valley of the shadow of death
Status
Attending Physician
Saw a pt in pre-op clinic this week who'd seen his internist earlier that day. Patient told internist of upcoming surgery and internist documents patient needs stress test as patient had c/o SOB and mild chest discomfort. Patient scheduled for cystoscopy and bladder bx the following day.
According to the ACC/AHA guidelines no further testing was needed and the guy was ok for the procedure. Maybe the doc was not up-to-date on his guidelines. Anyone that can walk 2-3 miles has at least moderate functional capacity!
 

jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
111
level at FL210
Status
signomi said:
That is interesting. I have been out of residency awhile now and I have always written my consults the way I was trained. I always conclude with, for example, "The Pt is a 65yof with intermediate clinical predictors (DM2, CRI) that are presently stable, moderate functional capacity and she is to undergo an intermediate risk procedure. No further cardiac testing is required at this time. Stress Echo from two years ago, as noted above was negative."
Then I list any recs I might have related to meds...usually not too much, I try to keep it to 1-4 things that I deem important. What is interesting to me is that I have never seen a pre-op written this way by any other doc or PA in the office. I swear, they all say "A/P: Okay for surgery."
I would say 8 times out of 10 I am not doing anything more than adjusting a BP med, lasix or insulin and reminding them the surgeon WAS serious about stopping the coumadin. :rolleyes: Most of the time I am just giving my blessing. It is so rare for me to add anything earth shattering, that I can remember those 3 specific patients.
Thank you for your post.

Which attests to the "false sense of security", and more importantly, the waste of time many anesthesiolgists endure for the "blessing" that its OK to do the surgery.

It is VERY RARE that I see a useful consult, i.e. something that would change my intraoperative management.
 

signomi

Amongst the Gravelings
10+ Year Member
May 4, 2006
247
2
Valley of the shadow of death
Status
Attending Physician
Which attests to the "false sense of security", and more importantly, the waste of time many anesthesiolgists endure for the "blessing" that its OK to do the surgery.

It is VERY RARE that I see a useful consult, i.e. something that would change my intraoperative management.
I have to agree. You would be stunned by the number of cataract pre-ops I get! At least one a day! I recommend: uhhhhh, you don't drive home?
The reality is, a lot of surgeons do it as a knee-jerk response that they learned in training...consult internal medicine. Plus, at our local hospitals my H&P counts for the admission H&P and the surgeon doesn't have to do one. TPTB (the powers that be) at my old group practice said that for private insurance the reimbursment for the average pre-op consult is pretty good. So we were never going to turn them down.
I was salaried there, so it didn't benefit me.
 

Tenesma

Senior Member
10+ Year Member
15+ Year Member
Jun 11, 2002
5,332
127
Visit site
Status
Attending Physician
first of all ACC/AHA guidelines are guidelines.... not standard of care... not rules.... all we ask is that pt is optimized to a decent degree
ie:
1) no 240/130 BP
2) no BS that run in the 340s
3) no CHF
4) thorough testing if they are poor protoplasm so that i don't push 400mg of propofol on a pt w/ unknown critical AS... ;)

pre-ops do generate money for internists/fps so no harm done... and generally their H&Ps are worth more than the surgeon's office notes (ie: foot looks infected - needs BKA)
 

signomi

Amongst the Gravelings
10+ Year Member
May 4, 2006
247
2
Valley of the shadow of death
Status
Attending Physician
We were trained to use the format of the guidelines for medical and legal reasons. It lets the surgeon and any lawyers know that you based your decision on a reasonably established national guideline. Now of course they are just a guide. There is some room for judgment, and experience may persuade you to alter the plan slightly (of course you have to document why you are doing this). The guy noted above was having a minor procedure and had only intermediate risk factors. Assuming no additional medical problems and his noted ability to walk 2-3 miles puts him at 4-6 mets depending on speed. He should be fine with MAC for a simple cystoscopy and f/u with the internist for the cardiac eval afterwards.

ETA:
generally their H&Ps are worth more than the surgeon's office notes (ie: foot looks infected - needs BKA)
That's assuming you can even read the surgeon's note. I usually can't, so half the time I am dependent upon the patient to tell me what procedure is planned. Hilarity frequently ensues.
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
18
Visit site
Status
Attending Physician
Tenesma said:
first of all ACC/AHA guidelines are guidelines.... not standard of care... not rules.... all we ask is that pt is optimized to a decent degree
ie:
1) no 240/130 BP
2) no BS that run in the 340s
3) no CHF
4) thorough testing if they are poor protoplasm so that i don't push 400mg of propofol on a pt w/ unknown critical AS... ;)

pre-ops do generate money for internists/fps so no harm done... and generally their H&Ps are worth more than the surgeon's office notes (ie: foot looks infected - needs BKA)
Interesting that you listed a very high blood pressure...

So here's the question to the IM guy and to you other gas passers.

IM guy: you see this guy for preop clearnace for hernia repair (op time 20 minutes)....patient has no other complaints.....is a mail man who carries his mail...does not drive a mail truck...EKG...LVH ony.....do you clear him for his surgery?

Gas passers: you see this guy in pre op hold...same history...do you send him to IM guy for clearance?
 

jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
111
level at FL210
Status
militarymd said:
Gas passers: you see this guy in pre op hold...same history...do you send him to IM guy for clearance?
HAHAHAHAHAHHAHAAHAHHAHAHAHHAHAHAHAHAHAHHAHAHAHAHAHAHAH

THATSA joke, right, Mil?

HAHAHAHAHAHAHAHHHAAHHAHAHHAHAHAHAHAHAHAHAHAHAHAH
 

jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
111
level at FL210
Status
militarymd said:
Interesting that you listed a very high blood pressure...

So here's the question to the IM guy and to you other gas passers.

IM guy: you see this guy for preop clearnace for hernia repair (op time 20 minutes)....patient has no other complaints.....is a mail man who carries his mail...does not drive a mail truck...EKG...LVH ony.....do you clear him for his surgery?

Gas passers: you see this guy in pre op hold...same history...do you send him to IM guy for clearance?

OK....so I jumped the gun a little....forgot about the listed BP of 230/130 or whatever.

If that isnt present, its a no brainer. I'm doing the case.

Additionally, I've established a personal diastolic cutoff. Probably means nothing in the grand scheme of things.....

.....but if Mr/Ms patient has a diastolic BP of 110 or greater I'm cancelling the case.

period.

Patient can pull out their IV and put their clothes on.
 
About the Ads

Noyac

10+ Year Member
Jun 20, 2005
7,958
2,676
Status
Attending Physician
signomi said:
I am an internist and I do quite a few pre-ops at the request of surgeons. Usually it is the patients with complicated medical histories where they want someone to tell the patient what to do with their 10-15 meds and insulin. :eek: I have never once consulted on anesthesia...that is entirely up to the anesthesiologist. My recs are usually always directed to the surgeon. I have only suggested cancelling surgeries 3 times...one had an in-office EKG of CHB (doc, I feel weak these days... :scared: ), one had an EKG sent from the surgeons office unread with new-onset rapid a.fib and the last guy was using cocaine daily. Oh and the surgeon operated on cocaine boy against my advice (elective back surgery for "chronic pain") and the guy had an MI post-op and never came off the cocaine or narcotics.

I have always presumed anesthesiology just wanted to deal with the best anesthesia and intra-op fluids for each patient based on their history (pulm/cardiac status). Do you guys prefer to do more than that? Would you manage insulin and read pre-op EKGs?
Not sure I understand your question here. But yes I would like rather manage the insulin as well as their other meds and read ECG's. I would also rather decide which anesthetic is appropriate for each pt, how much fluids to give, how fast/slow the heart rate should be and everything else. When I read the IM consult, I look for/want pt's current status. :thumbup:

Oh, did the anesthesiologist know the pt was using coke daily? :eek:
 

md2k

Member
10+ Year Member
5+ Year Member
Nov 28, 2005
78
1
Texas
Status
Attending Physician
jetproppilot said:
Thank you for your post.

Which attests to the "false sense of security", and more importantly, the waste of time many anesthesiolgists endure for the "blessing" that its OK to do the surgery.

It is VERY RARE that I see a useful consult, i.e. something that would change my intraoperative management.
I agree. A consult is usually a waste of time. What does the cardiologist tell you?? Keep the BP b/w 170/90 and 120/75 and give the pt BB to keep the HR less than 90. No **** sherlock, thanks for the consult. Another thing, surgeons and other specialties are under the impression that we need cardilogy or IM clearance. Thats crap, they cant clear a pt for surgery only we can. They can give thier recomendations which are often useless.
:cool:
 

Noyac

10+ Year Member
Jun 20, 2005
7,958
2,676
Status
Attending Physician
jetproppilot said:
OK....so I jumped the gun a little....forgot about the listed BP of 230/130 or whatever.

If that isnt present, its a no brainer. I'm doing the case.

Additionally, I've established a personal diastolic cutoff. Probably means nothing in the grand scheme of things.....

.....but if Mr/Ms patient has a diastolic BP of 110 or greater I'm cancelling the case.

period.

Patient can pull out their IV and put their clothes on.
I have the same basic cutoff, Jet. but if this guy can carry the mail daily without symptoms and I see him with a BP that high, I try to get it down. I'll give some versed to treat anxiety, labetolol for BP if versed not working. If I can easily get it down , I proceed. If it takes more work then he's cancelled and now I gotta figure out what to do with him next. Do I send him to the ER, his primary, or continue to treat his HTN b/4 sending him home. I'm not sending him home with a BP like that.
 

Noyac

10+ Year Member
Jun 20, 2005
7,958
2,676
Status
Attending Physician
md2k said:
I agree. A consult is usually a waste of time. What does the cardiologist tell you?? Keep the BP b/w 170/90 and 120/75 and give the pt BB to keep the HR less than 90. No **** sherlock, thanks for the consult. Another thing, surgeons and other specialties are under the impression that we need cardilogy or IM clearance. Thats crap, they cant clear a pt for surgery only we can. They can give thier recomendations which are often useless.
:cool:

Not useless, just often misguided.
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
18
Visit site
Status
Attending Physician
Noyac said:
I have the same basic cutoff, Jet. but if this guy can carry the mail daily without symptoms and I see him with a BP that high, I try to get it down. I'll give some versed to treat anxiety, labetolol for BP if versed not working. If I can easily get it down , I proceed. If it takes more work then he's cancelled and now I gotta figure out what to do with him next. Do I send him to the ER, his primary, or continue to treat his HTN b/4 sending him home. I'm not sending him home with a BP like that.
Why would you do anything at all? Obviously he's been walking around with that BP for a while....no symptoms.

I would do the case after checking a couple of labs to make sure this is not accelerated/malignant hypertension. Putting him to sleep will almost guarantee that you will lower the BP.

After the hernia repair (20 minutes later)....call an IM guy to come and start him on antihypertensivies
 

VentdependenT

You didnt build thaT
Moderator Emeritus
15+ Year Member
Oct 3, 2003
4,010
24
44
Louisville
www.somethingawful.com
Status
Fellow [Any Field]
jetproppilot said:
Nice post. Lemme break this down for you.

"Pre-op Clearance Consultants" can help you. They can elucidate knowledge/studies of a patient unknown to you. They can assure you patient's medical problems are "optimized".

Conversely, "Pre-op Clearance Consultants" can hurt you. Ya'll know the empirical-consultant drill: avoid hypotension and hypoxemia.....

.....or better yet, completely useless, non-applicable demands :

"62 year old WF well known to me. Documented MVCAD with EF 30%....needs lap chole... .....INTRAOPERATIVE SWAN REQUIRED...."

The latter is a consult I remember from a few years ago. Cardiologist DEMANDING an intra-op SWAN.....

now lets look at this from a board-certified anesthesiologist's perspective:

1) Once I pre-op the patient, this person is my patient, as well as yours.

2) Pulmonary artery catheterization is frought with risks, so said clinician has to remain assured that the benefits of placing a PAC outweigh the risks.

3) According to OVERWHELMING literature, a PAC does nothing to affect patient outcome, SO, REALLY, its hard to justify putting in a PAC for intraoperative management IN ANY SCENERIO, let alone a 45 minute minimally-invasive operation with no blood loss and no fluid shifts.....

4)please read Jet's posts concerning Hood Anesthesia's Role in enforcement of dealing with unreasonable requests by physician consultants.... :laugh:
I think I read an article about the need for a swan in that case in the NEW HAMPSHIRE JOURNAL OF POOPY MEDICINE.
 

Noyac

10+ Year Member
Jun 20, 2005
7,958
2,676
Status
Attending Physician
militarymd said:
Why would you do anything at all? Obviously he's been walking around with that BP for a while....no symptoms.
I would do the case after checking a couple of labs to make sure this is not accelerated/malignant hypertension. Putting him to sleep will almost guarantee that you will lower the BP.

After the hernia repair (20 minutes later)....call an IM guy to come and start him on antihypertensivies

Are you sure about that?
 
About the Ads

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
18
Visit site
Status
Attending Physician
Noyac said:
I'm not.
haven't you seen them come to you nervous as hell and with BP's in this range? Then give a touch of versed and they come right down.
sometimes they don't come down....but induction of GA almost always gets it down.
 

toughlife

Resident
10+ Year Member
5+ Year Member
Sep 11, 2004
1,836
3
Status
Resident [Any Field]
Saw this case today..83 y/o female in for right TKR, hx of thoracic AA @
5.4cm per MRI 2 years ago and moderate aortic regurgitation. Last TTE in 2003 shows EF >50%. Denies any symptoms. Vitals normal. Underwent right THR 6 months ago.

Would you order MRI/ echo on this lady or just take her to the OR? I said take her to OR since she tolerated TRH well. Powers that be wanted MRI to check TAA status and thinking echo for AR.

WWJD?
 

Noyac

10+ Year Member
Jun 20, 2005
7,958
2,676
Status
Attending Physician
militarymd said:
sometimes they don't come down....but induction of GA almost always gets it down.
Of course. But isn't this just a little too high for a hernia repair? I am not worried about intraop, I'm more worried about post-op, when the GA is over. Plus I don't know of any surgeons that want to operate on a pt with this high of a BP anyway.
 

Noyac

10+ Year Member
Jun 20, 2005
7,958
2,676
Status
Attending Physician
toughlife said:
Saw this case today..83 y/o female in for right TKR, hx of thoracic AA @
5.4cm per MRI 2 years ago and moderate aortic regurgitation. Last TTE in 2003 shows EF >50%. Denies any symptoms. Vitals normal. Underwent right THR 6 months ago.

Would you order MRI/ echo on this lady or just take her to the OR? I said take her to OR since she tolerated TRH well. Powers that be wanted MRI to check TAA status and thinking echo for AR.

WWJD?

I would probably want some more info, like physical exam with regards to recent changes in exercise tolerance, dizziness, SOB etc etc. If no changes then fine. If she gives you the usual response, "I can't do anything and i get real SOB now days b/c of my hip." Then you gotta decide how you are going to proceed.
 

toughlife

Resident
10+ Year Member
5+ Year Member
Sep 11, 2004
1,836
3
Status
Resident [Any Field]
Noyac said:
I would probably want some more info, like physical exam with regards to recent changes in exercise tolerance, dizziness, SOB etc etc. If no changes then fine. If she gives you the usual response, "I can't do anything and i get real SOB now days b/c of my hip." Then you gotta decide how you are going to proceed.

pt only limited by use of cane. No exercise intolerance otherwise.
 

Noyac

10+ Year Member
Jun 20, 2005
7,958
2,676
Status
Attending Physician
toughlife said:
pt only limited by use of cane. No exercise intolerance otherwise.
If thats the case, I'd most likely proceed unless I could ellicit more pertanent information.
 

jetproppilot

Turboprop Driver
10+ Year Member
Mar 12, 2005
5,858
111
level at FL210
Status
toughlife said:
Saw this case today..83 y/o female in for right TKR, hx of thoracic AA @
5.4cm per MRI 2 years ago and moderate aortic regurgitation. Last TTE in 2003 shows EF >50%. Denies any symptoms. Vitals normal. Underwent right THR 6 months ago.

Would you order MRI/ echo on this lady or just take her to the OR? I said take her to OR since she tolerated TRH well. Powers that be wanted MRI to check TAA status and thinking echo for AR.

WWJD?
Plant an epidural in her back.

And dose it up.

BP wont get above 120 so the aneurysm'll never blow. :D
 

cloud9

King of my realm
10+ Year Member
5+ Year Member
Feb 9, 2005
185
0
42
Northeastern South Texas
Status
Resident [Any Field]

Annette

gainfully employed
Lifetime Donor
10+ Year Member
15+ Year Member
Aug 24, 1999
1,446
3
The Land of Lincoln
Visit site
Status
Attending Physician
I never understood why I was doing pre-ops either. :rolleyes: One thing though, is trying to get the patients to stop smoking 8 weeks prior to surgery. Apparently there is a small study that showed patients who stopped closer to surgery than 8 weeks had a poorer outcome than those patients who never stopped prior to surgery. Do you guys have any thoughts on why?

Oh, and that guy with the super high BP? Please don't stroke him out by taking him too low . . . :scared: :cool:
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
18
Visit site
Status
Attending Physician
Annette said:
I never understood why I was doing pre-ops either. :rolleyes: One thing though, is trying to get the patients to stop smoking 8 weeks prior to surgery. Apparently there is a small study that showed patients who stopped closer to surgery than 8 weeks had a poorer outcome than those patients who never stopped prior to surgery. Do you guys have any thoughts on why?

Oh, and that guy with the super high BP? Please don't stroke him out by taking him too low . . . :scared: :cool:
There is more than one study....the much quoted one is the one referenced in Stoelting's Co-Existing disease....patient population is those undergoing CABG.

There are others....including one from Japan...looking a lung resection surgery.

When you read these, remember your patient population.....ie pre-intervention pulmonary complications are high already....so some interventions (stop smoking) resulted in surrogate endpoint improvements.

I doubt it makes any difference in lower risk surgeries....

As for why....I think chronic smoke exposure actually suppresses some secretions.....during the 6 to 8 weeks after stopping smoking....coughing and secretions actually increase.....I know...it happened to me when I quit.
 

toughlife

Resident
10+ Year Member
5+ Year Member
Sep 11, 2004
1,836
3
Status
Resident [Any Field]
Annette said:
I never understood why I was doing pre-ops either. :rolleyes: One thing though, is trying to get the patients to stop smoking 8 weeks prior to surgery. Apparently there is a small study that showed patients who stopped closer to surgery than 8 weeks had a poorer outcome than those patients who never stopped prior to surgery. Do you guys have any thoughts on why?

Oh, and that guy with the super high BP? Please don't stroke him out by taking him too low . . . :scared: :cool:
Smoking causes ciliary paralysis from toxic and obstructive byproducts of tobacco. For this function to return to baseline, it requires about 4-6 weeks of smoking cessation. So short term smoking cessation does nothing to increase secretions and patient's ability to maintain a mucus free airway. How this translates into poorer outcomes is beyond me.
 

nimbus

Member
10+ Year Member
Jan 14, 2006
5,016
5,292
Status
"Healthy" smokers, even some with early COPD, often do better in my hands. They wake up faster and crisper with less nausea.
 
About the Ads