Interesting case

[DocVapor]

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And what if the outcome of epi and 20 compressions isn't as rosy as that sounds and they'd rather just die, why not allow them that autonomy? What if the cause isn't that reversible and they don't want to go through that? I just don't understand why the unassailable position is that one cannot receive surgical care as a DNR patient

I agree that DNR's should not be automatically suspended in the periop period. When I have this discussion with my patients that have DNR's I usually let them know that sometimes the reason for the arrest is easily reversible as @nimbus said but sometimes it's not. The discussion can vary from there but it's rare for someone to completely suspend it, just like it's rare for someone to leave it completely in place, which I will honor. Usually what happens is they agree to some sort of airway for the procedure but don't want "heroic measures." They actually pretty much leave the decision about what to do or not do up to me, the physician that actually took the time to talk to them about it and understand their wishes.

Sadly at my place very few of the surgeons actually think about this until I tell them about it.

 

[chessknt]

We have three options on the DNR form: rescind and do everything possible, don’t do anything at all no matter what, or leave it up to the physicians to decide whether to resuscitate or not. 99% of my patients have chosen the last option.

I've literally never seen option #3 and agree that it sounds the most reasonable.

 

[secretasianman]

What a beautiful sequence of events. Kudos to the orthodoc.

Last week while I was board runner, I got a call from one of our orthopods who is not a cowboy. Patient was a 96 yo with a hip fracture. His initial question to me was how long the patient needed to be off eliquis for a spinal since that is what the IM doctor recommended. It had been 3 days so that was not an issue. But the patient had CHF/COPD and was DNR. She was on HFNC with O2 sat 85-90%, this was after a couple days diuresis. I told him it wasn’t a good idea to do surgery under spinal on somebody with no pulmonary reserve, that there was a real possibility that they would need ventilatory support intraop. I also added that while we would probably have no problem getting her through surgery under GA/ETT, she would need ICU monitoring postop and possibly require postop ventilation. The orthopedist relayed this to the patient and the family. The family said they’d be willing to accept postop ventilation for up to 24hrs, but not longer. The orthopedist told them he cannot guarantee that. At that point the patient and the family opted for comfort care.

 

[chessknt]

Shouldn't DNR and surgical intervention be mutually exclusive? DNR's are suspended for surgery for very good reason...putting anesthesiologists in a 'shoot, don't shoot' situation is criminal, IMHO. Everyone want's the patient to do 'well'. Allowing the patient to choose to be allowed to die does not include providing surgery and anesthesia to someone that wants it unless they don't...I have to look at myself in the mirror years after someone decides they want me to take them to surgery and then allow them to die in my hands....

I don't agree with that sentiment. If the surgical and perioperative risk are reasonable and felt to outweigh harm I don't see why it should be withheld or predicated on overriding reasonable decisions they have been held for themselves. I wouldn't view it as you killing eh patient but rather an unfortunately but known risk of a dangerous intervention which was delivered in the best way possible but luck wasn't on the patients side. It isn't a reflection of a bad anesthetist.

 

[nimbus]

And what if the outcome of epi and 20 compressions isn't as rosy as that sounds and they'd rather just die, why not allow them that autonomy? What if the cause isn't that reversible and they don't want to go through that? I just don't understand why the unassailable position is that one cannot receive surgical care as a DNR patient

I agree it should not be black and white. Resuscitation itself is on a spectrum, it’s not “on-off”. Whenever possible it’s important to have a nuanced discussion with the patient or their surrogate about what happens in the OR, what could happen in the OR, and how we respond in the moment. We don’t just put patients to sleep. Resuscitation is an integral part of anesthesia and we perform some form of resuscitation on a significant proportion of our patients, even healthy ones.

When I talk to patients and/or their families, I try explain that things happen in the operating room, that may or may not be simple and reversible, but that they need an immediate response. I ask for permission to keep them alive in that moment. If things don’t look hopeful after my initial response, I tell them we can have a discussion about discontinuing or withdrawing care. But the initial resuscitation buys us time to have that discussion. They have universally been agreeable to they approach.

I’m also a big proponent of preinduction Alines, preinduction inopressors, and gentle minimalistic inductions to reduce the necessity for resuscitation. But one could argue that the Aline and pressors are forms of resuscitation.

 

[Sleeplessbordernights]

Tbh the whole thing left me kind of depressed as this attending was a mentor to me. He didn’t straight up said lets kill this old lady, but still something as: if she desats just tube her, sent her to ICU and be done with that

 

[drmwvr]

I don't agree with that sentiment. If the surgical and perioperative risk are reasonable and felt to outweigh harm I don't see why it should be withheld or predicated on overriding reasonable decisions they have been held for themselves. I wouldn't view it as you killing eh patient but rather an unfortunately but known risk of a dangerous intervention which was delivered in the best way possible but luck wasn't on the patients side. It isn't a reflection of a bad anesthetist.

big difference the patient dying from the reason they were brought to surgery (like an ascending or ruptured AAA) and dying from not tolerating what we do to them for the anesthetic when we know with little uncertainty the risk for perioperative arrest. Where do we draw the lines when we simultaneously acknowledge the presence of a DNR and also run pressors, give fluids and mechanically ventilate a DNR patient? And then maybe pass the buck and let someone else declare her dead and let that person deal with the emotional fallout? Don't mean to get into theatrics here, but as someone going on 30 years of practice, that kind of thing adds up and denying it has a psychologic effect is delusional.

 

[vector2]

I don't agree with that sentiment. If the surgical and perioperative risk are reasonable and felt to outweigh harm I don't see why it should be withheld or predicated on overriding reasonable decisions they have been held for themselves. I wouldn't view it as you killing eh patient but rather an unfortunately but known risk of a dangerous intervention which was delivered in the best way possible but luck wasn't on the patients side. It isn't a reflection of a bad anesthetist.

Another nebulous aspect to the question of rescinded DNRs is how intraoperative deaths are perceived relative to ICU or ward deaths. At the end of the day it doesn't really make that much of a difference to the pt with a DNR where he dies, but the psychological impact (and possibly administrative/metric impact) of an intraoperative death just hits differently to all the people who work in the OR.

Patients almost never die in the OR. Even in level I trauma centers with busy cardiac, neuro, transplant, and major abdominal surgery services, it rarely happens. And I think most of the people who work in the OR, including anesthesiologists, probably have a deep-seated aversion to the idea that it's ok to "let" a patient die in the OR, even if he has a DNR.

It's totally irrational, but I find it's something that non-anesthesiologist intensivists have a hard time wrapping their heads around given how common terminal care is in the ICU.

 

[PTPoeny]

I am in the peds ICU and not the OR but I have had plenty of families ask us to do one minute of compressions while we make sure the code isn't from the trach popping out or hypoglycemia or some other easily fixable thing because they have seen their kid get 30 seconds of compressions plenty of times in the past but also realize if the code is from progression of their underlying disease then they are ready to let their child go.

I have always thought of reversing DNR in the OR as similar to the above. DNR isn't comfort care. DNR is recognizing the futility of CPR given whatever is going on with a patient. I have taken care of kids who lived for 15 years with a DNR the entire time. Probably some adult vs peds differences there too, but I don't see a conflict for most DNR only (ie not comfort care) kids to go to the OR with a temporary rescind to their DNR.

 

[Gern Blansten]

And what if the outcome of epi and 20 compressions isn't as rosy as that sounds and they'd rather just die, why not allow them that autonomy? What if the cause isn't that reversible and they don't want to go through that? I just don't understand why the unassailable position is that one cannot receive surgical care as a DNR patient

I explain that sometimes events that can be life threatening but easily reversible may occur during a normal anesthetic course. I always ask them if I can briefly resuscitate them for something I feel is easily reversible while we sort out what’s going on. If, after a couple of minutes, it feels like the event was more than initially thought and a meaningful recovery was unlikely, then I will respect their original DNR orders and halt efforts. Most patients and families are agreeable to that plan in my experience.

 

[chessknt]

I am in the peds ICU and not the OR but I have had plenty of families ask us to do one minute of compressions while we make sure the code isn't from the trach popping out or hypoglycemia or some other easily fixable thing because they have seen their kid get 30 seconds of compressions plenty of times in the past but also realize if the code is from progression of their underlying disease then they are ready to let their child go.

I have always thought of reversing DNR in the OR as similar to the above. DNR isn't comfort care. DNR is recognizing the futility of CPR given whatever is going on with a patient. I have taken care of kids who lived for 15 years with a DNR the entire time. Probably some adult vs peds differences there too, but I don't see a conflict for most DNR only (ie not comfort care) kids to go to the OR with a temporary rescind to their DNR.

80 year olds that are DNR tend not to bounce back from no circulation the same as kids I imagine. Even a few minutes can leave them pretty ****ed up and debilitated.

 

[Radetzky]

The compressions for “simple reversible things” argument doesn’t hold up to much scrutiny in my view. Simple reversible things are not exclusive to the OR. And by definition a simple reversible thing is short lived, so your 30 seconds of compressions aren’t gonna make much difference to the patient, but it might mean they have a prolonged death over the next week from rib #.

Now if your definition of brief compressions is “several minutes”, maybe you need to see more old folks who’ve had this done to them and how it ends up.

Kids are a different story

 

[Gern Blansten]

The compressions for “simple reversible things” argument doesn’t hold up to much scrutiny in my view. Simple reversible things are not exclusive to the OR. And by definition a simple reversible thing is short lived, so your 30 seconds of compressions aren’t gonna make much difference to the patient, but it might mean they have a prolonged death over the next week from rib #.

Now if your definition of brief compressions is “several minutes”, maybe you need to see more old folks who’ve had this done to them and how it ends up.

Kids are a different story

Things I consider to be potentially quickly reversible include an exaggerated response to induction dose of propofol, a vagal response or small venous gas embolism due to abdominal insufflation, or perhaps an anaphylactic response to a drug such as an antibiotic or NMB. Sometimes, those events turn into full blown unlikely to recover events, but sometimes, with brief and rapid treatment, they can recover completely. I feel like not acknowledging that sometimes things that we do can hasten death if we have our hands tied behind our back to address and undo what we caused is problematic. Full blown orthopedic surgeon rib crushing chest compressions for 15 minutes may not be the answer but a minute of 120 lb circulating nurse compressions may turn things around a bit for a quickly reversible event.
Therefore, I do think the “physician judgment” option has some value. Your point is well taken regarding “meaningful recovery” vs “prolonged death” over a week. It’s not always easy to know what the eventual outcome will be.

 

[deleted875186]

Things I consider to be potentially quickly reversible include an exaggerated response to induction dose of propofol, a vagal response or small venous gas embolism due to abdominal insufflation, or perhaps an anaphylactic response to a drug such as an antibiotic or NMB. Sometimes, those events turn into full blown unlikely to recover events, but sometimes, with brief and rapid treatment, they can recover completely. I feel like not acknowledging that sometimes things that we do can hasten death if we have our hands tied behind our back to address and undo what we caused is problematic. Full blown orthopedic surgeon rib crushing chest compressions for 15 minutes may not be the answer but a minute of 120 lb circulating nurse compressions may turn things around a bit for a quickly reversible event.
Therefore, I do think the “physician judgment” option has some value. Your point is well taken regarding “meaningful recovery” vs “prolonged death” over a week. It’s not always easy to know what the eventual outcome will be.

Not sure what you guys are talking about. I’ve seen plenty of old people post compressions, many have just mild discomfort from rib fracture, it’s not like a minute of chest compressions is going to kill them.

Agree with above, an intraoperative event leading to profound hypotension can be fully recoverable. In my mind it makes sense to rescind DNR for this, but have discussion that if etiology of the event is more ominous or hard to discern, and outcome will likely be poor, tk just stop chest compressions. Let’s face it, a recoverable event often only needs one round of compressions, more than that and it’s probably a bad outcome.

 

[The Duck Knows]

I personally have never understood the logic of reversing DNR for a procedure. If something about your value calculation has decided that all of the sequelae of cpr is not appropriate why does that magically have to change in the OR? Why not offer an intervention and if the unlikely scenario if death occurs accept it if the pt understands?

Everywhere I’ve heard we just had a discussion clarifying goals of care with a specific form we both signed. I’ve never fully reversed DNAR status for a procedure, but I commonly get approval for “physician discretion” to treat any potentially reversible causes.

But I would guess that the traditional reason for “pausing DNAR” was so that we could intubate.

 

[Gern Blansten]

Everywhere I’ve heard we just had a discussion clarifying goals of care with a specific form we both signed. I’ve never fully reversed DNAR status for a procedure, but I commonly get approval for “physician discretion” to treat any potentially reversible causes.

But I would guess that the traditional reason for “pausing DNAR” was so that we could intubate.

I usually just tell them that intubation is part of the deal (when appropriate) and not considered resuscitation and that, if a devastating event occurs, we can still honor their wishes, within some degree of reason. In complex situations, I always specify the specifics of chest compressions, electricity, medication and ventilation to clarify what they will and will not allow. The physician discretion option makes it much easier to allow a couple of minutes to gain some clarity as to how bad of an event we are dealing with. It can be very complex, but I’ve had consent forms where I specify that patient will accept ventilation and drugs, but no shocks for example. I try to help them navigate the situation in a somewhat sensible way with the goal being to try to avoid a slow prolonged death in the ICU, which is the one thing almost everyone who is ever a DNR is actively trying to avoid.

 

[Urzuz]

Hold on a second. She should be in a hospice based on what? Being obese, with low sats and an abnormal cxr but no diagnosis of anything as yet other than dm?

Sure she may go that way, but good lord youre a bit of a grim reaper eh?

Meaningful recovery? Shes not had a stroke, and weve not been told anything of heart failure or renal failure? So far shes broken her arm. Shes 200lbs so likely nourished too.

When we talk about Meaningful recovery our patients likely have had multiple strokes on ecmo, crrt...

Did you read the same stem and see the same CXR that I did? Maybe I've taken care of this kind of patient one too many times and am reading between the lines, but this lady's morbidity/mortality is extremely high.

She is 79 years old. She has a BMI of 40+. She has been "around smokers all the time" and has a resting oxygen saturation of 80-83%. You truly think the only diagnosis she has is DM? Or do you think she is akin to the patient that has "no medical problems" but hasn't seen a doctor in four decades, and just happens to have a fasting blood sugar of 532? I'm thinking the latter. She also has a huge undiagnosed something pushing her trachea into last week, which she probably would have been diagnosed with years back had she been seeing a doctor regularly. I think it's safe to say her "only diagnosis" of DM is BS 🙂

All that being said, MAYBE she does just have DM. MAYBE she is just having a COPD exacerbation (oops just gave her another diagnosis) and just needs a neb treatment and she'll be back at a resting sat of 97%. MAYBE she just has a congenital deviation of her trachea and she doesn't have a huge mediastinal mass. MAYBE she just packed on a few pounds over Thanksgiving and is actually a BMI of 28 at baseline. If those criteria were met, maybe hospice would be a little aggressive, but palliative care would still be reasonable.

I feel like giving patients and their families unrealistic expectations for recovery is a huge disservice we do in this country (I'm assuming you're in the USA - sorry if you're not). You may call me the grim reaper, but I feel like I am realistic.

 

[PpfSuxTube]

Did you read the same stem and see the same CXR that I did? Maybe I've taken care of this kind of patient one too many times and am reading between the lines, but this lady's morbidity/mortality is extremely high.

She is 79 years old. She has a BMI of 40+. She has been "around smokers all the time" and has a resting oxygen saturation of 80-83%. You truly think the only diagnosis she has is DM? Or do you think she is akin to the patient that has "no medical problems" but hasn't seen a doctor in four decades, and just happens to have a fasting blood sugar of 532? I'm thinking the latter. She also has a huge undiagnosed something pushing her trachea into last week, which she probably would have been diagnosed with years back had she been seeing a doctor regularly. I think it's safe to say her "only diagnosis" of DM is BS 🙂

All that being said, MAYBE she does just have DM. MAYBE she is just having a COPD exacerbation (oops just gave her another diagnosis) and just needs a neb treatment and she'll be back at a resting sat of 97%. MAYBE she just has a congenital deviation of her trachea and she doesn't have a huge mediastinal mass. MAYBE she just packed on a few pounds over Thanksgiving and is actually a BMI of 28 at baseline. If those criteria were met, maybe hospice would be a little aggressive, but palliative care would still be reasonable.

I feel like giving patients and their families unrealistic expectations for recovery is a huge disservice we do in this country (I'm assuming you're in the USA - sorry if you're not). You may call me the grim reaper, but I feel like I am realistic.

Nonsense. Sloppy, lazy nonsense. If my grandma had wheels she would have been a bike.
You dont even have an abg...
Cxr is very rotated and not hyperinflated with round diaphragm.
She may have all those things you said, but we dont know yet

 

[vector2]

Im waiting on it. Medicine is still at it

Did you ever get the rest of the workup / results of the scan?

 

[Sleeplessbordernights]

Did you ever get the rest of the workup / results of the scan?

I asked ortho but they transferred her to another hospital after surgery (insurance oslt)

 

[Urzuz]

Nonsense. Sloppy, lazy nonsense. If my grandma had wheels she would have been a bike.
You dont even have an abg...
Cxr is very rotated and not hyperinflated with round diaphragm.
She may have all those things you said, but we dont know yet

Are you trolling me? You must be trolling me.

The CXR being rotated has nothing to do with her trachea going sideways and her having prominent interstitial markings.

And you want an ABG for what exactly?? Her resting saturation is 80% which improves to 90% with a face mask. You need an ABG to tell you that she’s hypoxemic??? Sorry but you sound like the kind of guy that looks over the drapes and sees blood pumping out of the aorta onto the field but insists on checking an H/H before transfusing.

 

[cincincyreds]

I would tell her to get a sling for her arm and send her to a medicine doctor for a further evaluation and I would tell the Ortho doc I fully understand there is a broken bone that needs to be fixed but the patient won't be alive if we were to fix her broken bone today.

 

[epidural man]

79 years old lady, 4’11, 200 lbs, recently diagnosed with DM, history of being around smokers all the time and using wood stove to cook. One week ago she fell from her height breaking her proximal humerus and is scheduled for humerus nail.

Her basal spo2 is 80-83% at best, which improves to 90% at best with simple facemask at 6 L. Lung auscultations gives us bilateral wheezing. She refers that over the last two months she is having trouble swallowing solids. Her labs are unremarkable other than glucose at 220. This is her chest x ray (which Im sharing with her permission).

What do you do?

OP,

Would you mind asking your attending a question or two for me?

Be very kind and humble, and say you are trying to understand your roll as a peri-operative expert and consultant.

Ask:
“Our patient had a resting SpO2 of 80% that wasn’t much corrected with supplemental, but that wasn’t low enough or severe enough to cancel the case. At what level would you need to see to cancel?

Also, the trachea looked very deviated but wasn’t deviated enough to cancel the case. What level of deviation would you need to see in order to cancel a case?

Her injury was not an emergency and some would argue didn’t even need surgery. Given her co-morbid states, how much less of a non-emergent state would the patient need to be in for you to decide that a further work up trumps the non-emergent surgical case?

Ya know, I was worried about diaphragmatic paralysis in this patient, but you weren’t. What scenario would you think would be worrisome?”

Ask with sincerity. Id love to know the answer to these questions.

 

[epidural man]

79 years old lady, 4’11, 200 lbs, recently diagnosed with DM, history of being around smokers all the time and using wood stove to cook. One week ago she fell from her height breaking her proximal humerus and is scheduled for humerus nail.

Her basal spo2 is 80-83% at best, which improves to 90% at best with simple facemask at 6 L. Lung auscultations gives us bilateral wheezing. She refers that over the last two months she is having trouble swallowing solids. Her labs are unremarkable other than glucose at 220. This is her chest x ray (which Im sharing with her permission).

What do you do?

I’ve heard of a renal pelvis, but never seen a kidney in the chest like this.

 

[GassYous]

Are you trolling me? You must be trolling me.

The CXR being rotated has nothing to do with her trachea going sideways and her having prominent interstitial markings.

And you want an ABG for what exactly?? Her resting saturation is 80% which improves to 90% with a face mask. You need an ABG to tell you that she’s hypoxemic??? Sorry but you sound like the kind of guy that looks over the drapes and sees blood pumping out of the aorta onto the field but insists on checking an H/H before transfusing.

"Did you label your ephedrine syringe with the date and time prior to administration?"

 

[Hoya11]

Well what actually happened was this:

I was pushing hard for my attending to postpone the case and actually work her up (other attendings passing by suggested the same), but he didn’t want to.

So we did a interescalene block (which I suggested was a bad idea) plus precedex.
The patient actually did well, her spo2 stayed around 85 all surgery. Still the whole thing left me kind of angry, the fact that everything went well doesn’t mean it was the right call and I didn’t like the attitude of my attending (kinda simping to orthobros).

Agree with others that I would postpone and get more info.

BUT, there may have been subtlety in your attendings technique, like a low volume, low plexus block.

For a case of a pain stimulus from lower in the shoulder/arm like a prox humerus fx - you can get a nice dense block from a low volume (15-20cc) SCB or ICB. I would argue minimal diaphragm paralysis.

So I am not SUPER surprised she did OK. As her (somewhat) optimized sat was 90, and now shes 85 post block.

 

[AKMD_1984]

Well what actually happened was this:

I was pushing hard for my attending to postpone the case and actually work her up (other attendings passing by suggested the same), but he didn’t want to.

So we did a interescalene block (which I suggested was a bad idea) plus precedex.
The patient actually did well, her spo2 stayed around 85 all surgery. Still the whole thing left me kind of angry, the fact that everything went well doesn’t mean it was the right call and I didn’t like the attitude of my attending (kinda simping to orthobros).

I would agree with your attending to proceed with the case and get the surgery done.

This is not an uncommon scenario in many rural and community hospitals by the way - if you wait for consults it would take 3 days to get the work up done and you’d still proceed with optimization. Consults and labs are nice to have but they shouldn’t obstruct in providing timely care.

Yeah shoulder surgery is not “urgent” but the patient cannot really function and may have to take pain meds for extended period of times - many times opioids. A fast surgeon and appropriate anesthetic is often sufficient to get the job done.

At the end of the day, it’s the anesthesiologist who’s responsible for the patient. Not the Pulm or cardiologist. They tend to comment on matters that they often have little knowledge on - for instance “avoid general anesthesia for this surgery”. I find it annoying actually. We both know that we often proceed with our plan without taking their recs into consideration.

So many anesthesiologists optimize as best as they can given the resources at hand and proceed. This is common in many community hospitals.

Let’s say this patient sees a pulmonologist and cardiologist and medicine. What will they do? Labs? Echo? CTA. Will they do cath? I mean are you concerned about cardiac ischemia? Heart failure? Even if she has a mediastinal mass - are you going to delay surgery for fracture and call cardio-thoracic surgery first to intervene? Are they going to operate? Assume she has an EF less than 20%…what are you going to do differently? What if she has pulmonary hypertension?

You see what I mean? It won’t change much as to how you do your anesthetic.

The purpose of diagnostic tests and consults is to help guide changes in treatment. You already know you’re going to do a block and avoid a heavy anesthetic on this patient and ideally keep the patient spontaneous.

You’ll of-course give her a breathing treatment, etc…make sure she stays within 20% of her hemodynamic range. Maybe you’ll do an art line and keep glide-scope in room…but are you really going to be able to fix her sats of 80-85% from chronic smoke exposure?

This lady was in routine health prior to coming to the hospital wasn’t she? Did she acutely decompensate?

Maybe your attending is experienced and upon his pre-op evaluation, although the patient may have appeared to disastrous on paper/labs/chart, but was close to her baseline and he felt that an expensive work up would just delay surgery and would not add anything of use. I’m suspecting that’s what happened.

If that’s the case - he did the right thing.

A good block and assessment of complete block before going to the OR with sedation would be my choice also in this situation if I was happy with my pre op interview about her general health.

But i would need to make sure that patient is at her baseline based on history and asking her and her family questions and essentially risk stratify.

I would definitely get a good and detailed consent. But if I think she’s close to her baseline, I would just proceed to avoid delay. It is what it is. We cannot fix chronic problems acutely.

 

[Beeftenderloin]

I would agree with your attending to proceed with the case and get the surgery done.

This is not an uncommon scenario in many rural and community hospitals by the way - if you wait for consults it would take 3 days to get the work up done and you’d still proceed with optimization. Consults and labs are nice to have but they shouldn’t obstruct in providing timely care.

Yeah shoulder surgery is not “urgent” but the patient cannot really function and may have to take pain meds for extended period of times - many times opioids. A fast surgeon and appropriate anesthetic is often sufficient to get the job done.

At the end of the day, it’s the anesthesiologist who’s responsible for the patient. Not the Pulm or cardiologist. They tend to comment on matters that they often have little knowledge on - for instance “avoid general anesthesia for this surgery”. I find it annoying actually. We both know that we often proceed with our plan without taking their recs into consideration.

So many anesthesiologists optimize as best as they can given the resources at hand and proceed. This is common in many community hospitals.

Let’s say this patient sees a pulmonologist and cardiologist and medicine. What will they do? Labs? Echo? CTA. Will they do cath? I mean are you concerned about cardiac ischemia? Heart failure? Even if she has a mediastinal mass - are you going to delay surgery for fracture and call cardio-thoracic surgery first to intervene? Are they going to operate? Assume she has an EF less than 20%…what are you going to do differently? What if she has pulmonary hypertension?

You see what I mean? It won’t change much as to how you do your anesthetic.

The purpose of diagnostic tests and consults is to help guide changes in treatment. You already know you’re going to do a block and avoid a heavy anesthetic on this patient and ideally keep the patient spontaneous.

You’ll of-course give her a breathing treatment, etc…make sure she stays within 20% of her hemodynamic range. Maybe you’ll do an art line and keep glide-scope in room…but are you really going to be able to fix her sats of 80-85% from chronic smoke exposure?

This lady was in routine health prior to coming to the hospital wasn’t she? Did she acutely decompensate?

Maybe your attending is experienced and upon his pre-op evaluation, although the patient may have appeared to disastrous on paper/labs/chart, but was close to her baseline and he felt that an expensive work up would just delay surgery and would not add anything of use. I’m suspecting that’s what happened.

If that’s the case - he did the right thing.

A good block and assessment of complete block before going to the OR with sedation would be my choice also in this situation if I was happy with my pre op interview about her general health.

But i would need to make sure that patient is at her baseline based on history and asking her and her family questions and essentially risk stratify.

I would definitely get a good and detailed consent. But if I think she’s close to her baseline, I would just proceed to avoid delay. It is what it is. We cannot fix chronic problems acutely.

But not everyone NEEDS surgery.

Beks RB, Ochen Y, Frima H, Smeeing DPJ, van der Meijden O, Timmers TK, van der Velde D, van Heijl M, Leenen LPH, Groenwold RHH, Houwert RM. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J Shoulder Elbow Surg. 2018 Aug;27(8):1526-1534. doi: 10.1016/j.jse.2018.03.009. Epub 2018 May 4. PMID: 29735376.

TLDR: no difference in functional outcomes

Surgery may be preferred, but the good orthos know when surgery is truly necessary and when it’s not and often times they just need to be told that patients periop risk is sky high and suddenly non-op sounds reasonable.

And if she isn’t plugged into regular medical care it’s going to take more than 2-3 days to get her tuned up. It’s going to take weeks to months for inhaled steroids/LABAs to take meaningful effect, get her diuretics, left (and maybe right) sided after load reducers dialed in, which then takes months for reverse remodeling of the ventricles to occur.

Conservative fracture management. Get the heart/lungs worked up/tuned up, then she’ll be all ready for the OR in a couple months if her arm heals goofy. But per that paper it heals fine on its own and you saved this frail old women an unnecessary anesthetic and maybe an early death.

 

[AKMD_1984]

^ ok. Sure.

I will counter with a very basic argument - it’s not really upto anesthesia to decide who “needs” surgery or not and “when” (at least most of the time).

That’s upto the surgeon.

 

[AKMD_1984]

Secondly the OP is still under training. I mean no disrespect, but perhaps his board certified and experienced attending anesthesiologist viewed this patient differently on pre op than the OP and considered the patient good enough for surgery? We don’t know his perspective yet.

This whole discussion is based on information presented by the resident and how he understands it.

Unless one has clarity from the attending or see the patient themselves, it’s really not possible to comment and decide.

 

[drmwvr]

This is not an uncommon scenario in many rural and community hospitals by the way - if you wait for consults it would take 3 days to get the work up done and you’d still proceed with optimization. Consults and labs are nice to have but they shouldn’t obstruct in providing timely care.

Not even a chest CT? Takes less time than the pre-op nurses 'assessment'.

 

[AKMD_1984]

I would do whatever is available and necessary as long as it helps me optimize or change Mgt - I won’t do it just for diagnostic reasons. I would also not delay care.

If I were to get a chest CT it would only be if I’m suspecting PE and/ or PNA or something acute that needs to be addressed and can potentially be fixed before surgery.

otherwise I have moved away from extensive work ups for diagnostic reasons. If im suspecting something for instance, I just assume that it is the case and treat as such.

I would say that a periop echo or keeping a low threshold for intra-op TEE would be very useful in this situation

But what’s cardiology going to tell me? What’s pulmonary going to do?

 

[deleted875186]

I would agree with your attending to proceed with the case and get the surgery done.

This is not an uncommon scenario in many rural and community hospitals by the way - if you wait for consults it would take 3 days to get the work up done and you’d still proceed with optimization. Consults and labs are nice to have but they shouldn’t obstruct in providing timely care.

Yeah shoulder surgery is not “urgent” but the patient cannot really function and may have to take pain meds for extended period of times - many times opioids. A fast surgeon and appropriate anesthetic is often sufficient to get the job done.

At the end of the day, it’s the anesthesiologist who’s responsible for the patient. Not the Pulm or cardiologist. They tend to comment on matters that they often have little knowledge on - for instance “avoid general anesthesia for this surgery”. I find it annoying actually. We both know that we often proceed with our plan without taking their recs into consideration.

So many anesthesiologists optimize as best as they can given the resources at hand and proceed. This is common in many community hospitals.

Let’s say this patient sees a pulmonologist and cardiologist and medicine. What will they do? Labs? Echo? CTA. Will they do cath? I mean are you concerned about cardiac ischemia? Heart failure? Even if she has a mediastinal mass - are you going to delay surgery for fracture and call cardio-thoracic surgery first to intervene? Are they going to operate? Assume she has an EF less than 20%…what are you going to do differently? What if she has pulmonary hypertension?

You see what I mean? It won’t change much as to how you do your anesthetic.

The purpose of diagnostic tests and consults is to help guide changes in treatment. You already know you’re going to do a block and avoid a heavy anesthetic on this patient and ideally keep the patient spontaneous.

You’ll of-course give her a breathing treatment, etc…make sure she stays within 20% of her hemodynamic range. Maybe you’ll do an art line and keep glide-scope in room…but are you really going to be able to fix her sats of 80-85% from chronic smoke exposure?

This lady was in routine health prior to coming to the hospital wasn’t she? Did she acutely decompensate?

Maybe your attending is experienced and upon his pre-op evaluation, although the patient may have appeared to disastrous on paper/labs/chart, but was close to her baseline and he felt that an expensive work up would just delay surgery and would not add anything of use. I’m suspecting that’s what happened.

If that’s the case - he did the right thing.

A good block and assessment of complete block before going to the OR with sedation would be my choice also in this situation if I was happy with my pre op interview about her general health.

But i would need to make sure that patient is at her baseline based on history and asking her and her family questions and essentially risk stratify.

I would definitely get a good and detailed consent. But if I think she’s close to her baseline, I would just proceed to avoid delay. It is what it is. We cannot fix chronic problems acutely.

I would have to disagree with a lot of what you said.

I agree you can consider doing the case, but not before some basic workup. All you have is crappy sats, a rotated portable CXR, and a crappy history. Putting this person to sleep with only this info is reckless. Doing a block and going to surgery is reckless because at any minute the case could turn into general anesthesia in the operating room. There is no emergency here.

And “keeping people near baseline” is not always the correct answer.

 

[epidural man]

I would agree with your attending to proceed with the case and get the surgery done.

This is not an uncommon scenario in many rural and community hospitals by the way - if you wait for consults it would take 3 days to get the work up done and you’d still proceed with optimization. Consults and labs are nice to have but they shouldn’t obstruct in providing timely care.

Yeah shoulder surgery is not “urgent” but the patient cannot really function and may have to take pain meds for extended period of times - many times opioids. A fast surgeon and appropriate anesthetic is often sufficient to get the job done.

At the end of the day, it’s the anesthesiologist who’s responsible for the patient. Not the Pulm or cardiologist. They tend to comment on matters that they often have little knowledge on - for instance “avoid general anesthesia for this surgery”. I find it annoying actually. We both know that we often proceed with our plan without taking their recs into consideration.

So many anesthesiologists optimize as best as they can given the resources at hand and proceed. This is common in many community hospitals.

Let’s say this patient sees a pulmonologist and cardiologist and medicine. What will they do? Labs? Echo? CTA. Will they do cath? I mean are you concerned about cardiac ischemia? Heart failure? Even if she has a mediastinal mass - are you going to delay surgery for fracture and call cardio-thoracic surgery first to intervene? Are they going to operate? Assume she has an EF less than 20%…what are you going to do differently? What if she has pulmonary hypertension?

You see what I mean? It won’t change much as to how you do your anesthetic.

The purpose of diagnostic tests and consults is to help guide changes in treatment. You already know you’re going to do a block and avoid a heavy anesthetic on this patient and ideally keep the patient spontaneous.

You’ll of-course give her a breathing treatment, etc…make sure she stays within 20% of her hemodynamic range. Maybe you’ll do an art line and keep glide-scope in room…but are you really going to be able to fix her sats of 80-85% from chronic smoke exposure?

This lady was in routine health prior to coming to the hospital wasn’t she? Did she acutely decompensate?

Maybe your attending is experienced and upon his pre-op evaluation, although the patient may have appeared to disastrous on paper/labs/chart, but was close to her baseline and he felt that an expensive work up would just delay surgery and would not add anything of use. I’m suspecting that’s what happened.

If that’s the case - he did the right thing.

A good block and assessment of complete block before going to the OR with sedation would be my choice also in this situation if I was happy with my pre op interview about her general health.

But i would need to make sure that patient is at her baseline based on history and asking her and her family questions and essentially risk stratify.

I would definitely get a good and detailed consent. But if I think she’s close to her baseline, I would just proceed to avoid delay. It is what it is. We cannot fix chronic problems acutely.

This is an interesting perspective.

I have some questions for you (remembering this surgery is non-urgent and as some have pointed out, not even required, and also as presented, we have no idea what underlying pathology is responsible for current abnormalities.)

If this baseline PulseOx doesn’t bother you; what baseline would?

If this deviated trachea of unknown cause doesn’t bother you, can you give me some examples of some airway pathology or lung disease that would bother you? If this degree of deviation is non-concerning, what degree of deviation would make you question your decision to proceed or not?

You aren’t worried about loss of diaphragm function in this patient. What scenario would you be worried about it?

 

[Beeftenderloin]

I would have to disagree with a lot of what you said.

I agree you can consider doing the case, but not before some basic workup. All you have is crappy sats, a rotated portable CXR, and a crappy history. Putting this person to sleep with only this info is reckless. Doing a block and going to surgery is reckless because at any minute the case could turn into general anesthesia in the operating room. There is no emergency here.

And “keeping people near baseline” is not always the correct answer.

People get way too bogged down on this part: “BuT sHeS aT hEr BaSeLiNe”. There are plenty of people out there living in the world who are so chronically ill “at their baseline” that they wouldn’t tolerate a particularly violent sneeze, let along anesthesia and surgery. Baseline is frankly irrelevant. Either the patient is well enough for surgery/anesthesia or she isn’t. Based on the data presented you absolutely cannot make the determination that this patient is safe to anesthetize in any fashion, regardless of her baseline. She needs more work up.

 

[AKMD_1984]

I would have to disagree with a lot of what you said.

I agree you can consider doing the case, but not before some basic workup. All you have is crappy sats, a rotated portable CXR, and a crappy history. Putting this person to sleep with only this info is reckless. Doing a block and going to surgery is reckless because at any minute the case could turn into general anesthesia in the operating room. There is no emergency here.

And “keeping people near baseline” is not always the correct answer.

Patient did fine didn’t they?

Me and you weren’t there.

You’re commenting based on a resident report.

 

[AKMD_1984]

People get way too bogged down on this part: “BuT sHeS aT hEr BaSeLiNe”. There are plenty of people out there living in the world who are so chronically ill “at their baseline” that they wouldn’t tolerate a particularly violent sneeze, let along anesthesia and surgery. Baseline is frankly irrelevant. Either the patient is well enough for surgery/anesthesia or she isn’t. Based on the data presented you absolutely cannot make the determination that this patient is safe to anesthetize in any fashion, regardless of her baseline. She needs more work up.

Again. My question is:

How much work up is needed to make YOU comfortable to proceed?

That’s the issue. The attending anesthesiologist based on his pre op eval just went with it. He’s the one who’s seeing the patient not us.

It would be a different issue if he actually neglected the patient and provided Sun-standard care. But he did what was needed…block plus keep the patient spontaneous.

I don’t see anything wrong with it.

 

[Radetzky]

Where did the assumption come from that optimization in a short time period is not possible? You literally know nothing about the pt. It is likely she has come in with a decompensation of some hitherto undiagnosed chronic disease, with the potential for some acute infectious component. This is not the patients “baseline”. There is potentially a lot that can be achieved in a week with things like bronchodilators, antibiotics, NIV, diuresis depending on what the cause is. Meanwhile her fracture will still be fixable in a week.

And yea if there truly was a mediastinal mass (which I doubt) you would absolutely address that first.

 

[MirrorTodd]

Secondly the OP is still under training. I mean no disrespect, but perhaps his board certified and experienced attending anesthesiologist viewed this patient differently on pre op than the OP and considered the patient good enough for surgery? We don’t know his perspective yet.

This whole discussion is based on information presented by the resident and how he understands it.

Unless one has clarity from the attending or see the patient themselves, it’s really not possible to comment and decide.

I almost want to believe you except that the MAJORITY of board certified anesthesiologists commenting on this thread have said that she needed a workup and optimization prior to fixing the arm. Just because one narrowly avoided an accident on the freeway doesn't mean one is driving safely.

 

[chessknt]

I would agree with your attending to proceed with the case and get the surgery done.

This is not an uncommon scenario in many rural and community hospitals by the way - if you wait for consults it would take 3 days to get the work up done and you’d still proceed with optimization. Consults and labs are nice to have but they shouldn’t obstruct in providing timely care.

Yeah shoulder surgery is not “urgent” but the patient cannot really function and may have to take pain meds for extended period of times - many times opioids. A fast surgeon and appropriate anesthetic is often sufficient to get the job done.

At the end of the day, it’s the anesthesiologist who’s responsible for the patient. Not the Pulm or cardiologist. They tend to comment on matters that they often have little knowledge on - for instance “avoid general anesthesia for this surgery”. I find it annoying actually. We both know that we often proceed with our plan without taking their recs into consideration.

So many anesthesiologists optimize as best as they can given the resources at hand and proceed. This is common in many community hospitals.

Let’s say this patient sees a pulmonologist and cardiologist and medicine. What will they do? Labs? Echo? CTA. Will they do cath? I mean are you concerned about cardiac ischemia? Heart failure? Even if she has a mediastinal mass - are you going to delay surgery for fracture and call cardio-thoracic surgery first to intervene? Are they going to operate? Assume she has an EF less than 20%…what are you going to do differently? What if she has pulmonary hypertension?

You see what I mean? It won’t change much as to how you do your anesthetic.

The purpose of diagnostic tests and consults is to help guide changes in treatment. You already know you’re going to do a block and avoid a heavy anesthetic on this patient and ideally keep the patient spontaneous.

You’ll of-course give her a breathing treatment, etc…make sure she stays within 20% of her hemodynamic range. Maybe you’ll do an art line and keep glide-scope in room…but are you really going to be able to fix her sats of 80-85% from chronic smoke exposure?

This lady was in routine health prior to coming to the hospital wasn’t she? Did she acutely decompensate?

Maybe your attending is experienced and upon his pre-op evaluation, although the patient may have appeared to disastrous on paper/labs/chart, but was close to her baseline and he felt that an expensive work up would just delay surgery and would not add anything of use. I’m suspecting that’s what happened.

If that’s the case - he did the right thing.

A good block and assessment of complete block before going to the OR with sedation would be my choice also in this situation if I was happy with my pre op interview about her general health.

But i would need to make sure that patient is at her baseline based on history and asking her and her family questions and essentially risk stratify.

I would definitely get a good and detailed consent. But if I think she’s close to her baseline, I would just proceed to avoid delay. It is what it is. We cannot fix chronic problems acutely.

If she has a mediastinal mass causing tracheal deviation maybe she wants to get it biopsied under the same general anesthetic risk and now you know about it and can prepare for an airway emergency. Maybe she has metastatic disease or severe pulmonary fibrosis and wants to go comfort care instead? I think barrelling ahead in ignorance based on the assumption that no information from workup can change your plan is profoundly stupid.

 

[Urzuz]

^ ok. Sure.

I will counter with a very basic argument - it’s not really upto anesthesia to decide who “needs” surgery or not and “when” (at least most of the time).

That’s upto the surgeon.

I agree with some of what you said in your previous posts, disagree with a lot of what you said, but the bolded part is not only wrong and dangerous, but I’ll go as far as to say you cannot be a good anesthesiologist worth their salt without knowing some basic indications for emergent/urgent/elective surgery. The surgeon may be the ‘expert,’ but it is up to you to synthesize the entire picture and have a frank discussion with the surgeon regarding the risks/benefits of surgery, timing, etc.

 

[AKMD_1984]

I agree with some of what you said in your previous posts, disagree with a lot of what you said, but the bolded part is not only wrong and dangerous, but I’ll go as far as to say you cannot be a good anesthesiologist worth their salt without knowing some basic indications for emergent/urgent/elective surgery. The surgeon may be the ‘expert,’ but it is up to you to synthesize the entire picture and have a frank discussion with the surgeon regarding the risks/benefits of surgery, timing, etc.

Thank you for the feedback.

But you’re wrongly extrapolating and misconstruing what I said.

Of course we don’t proceed when it’s unsafe or ridiculous.

But customer service is a thing where I practice - customers being surgeons, patients and the hospital.

Anyways, no one actually knows how this particular attending anesthesiologist evaluated the patient and proceeded.

I’m giving him benefit of the doubt as he evaluated the patient and as per the resident “patient did well”.

You don’t want to give him credit - that’s fine.

I’m actually not sure if the report by resident has any merit or it’s written to sway the peanut gallery - which it seems to have accomplished.

I would trust a boarded experienced anesthesiologist and their choice of proceeding Vs not proceeding over a trainee. They have more experience and of course they may view things differently than a resident. For them an ASA 2 maybe an ASA4 for the resident…

 

[vector2]

Patient did fine didn’t they?

One of the most dangerous phrases in anesthesia...

 

[AKMD_1984]

If she has a mediastinal mass causing tracheal deviation maybe she wants to get it biopsied under the same general anesthetic risk and now you know about it and can prepare for an airway emergency. Maybe she has metastatic disease or severe pulmonary fibrosis and wants to go comfort care instead? I think barrelling ahead in ignorance based on the assumption that no information from workup can change your plan is profoundly stupid.

Is the patient able to lay flat? Does the patient have any symptoms? Are there any signs and symptoms of airway obstruction? What’s the chronicity of all this? Etc etc…

Let’s start there before we start ordering a million dollar work up…

Calling someone else’s work up and management stupid while you didn’t see the patient yourself makes you irrational…

 

[AKMD_1984]

Lol that’s what the resident said….not me…

 

[chessknt]

Is the patient able to lay flat? Does the patient have any symptoms? Are there any signs and symptoms of airway obstruction? What’s the chronicity of all this? Etc etc…

Let’s start there before we start ordering a million dollar work up…

Calling someone else’s work up and management stupid while you didn’t see the patient yourself makes you irrational…

You are the one who extrapolated the what ifs to conclude that there was unlikely to be anything that could be done to optimize so why even look, but yes I guess I am the irrational one?

Also how does getting a TTE and CT chest cost a million dollars? What?? This surgery is going to cost more than all possible medical workup combined turbo.

 

[Urzuz]

I’m giving him benefit of the doubt as he evaluated the patient and as per the resident “patient did well”.

You don’t want to give him credit - that’s fine.

I’m actually not sure if the report by resident has any merit or it’s written to sway the peanut gallery - which it seems to have accomplished.

OK, but don’t you see the problem? You’re arguing a hypothetical scenario that wasn’t presented. Sure, the patient may not have looked as bad as the resident presented it. Maybe the patient wasn’t satting 80% with wheezes but was clear and satting 92% on room air. Maybe that was some random CXR image that the poster pulled off the Internet. Then yes, I agree that proceeding may have been reasonable. But on an anonymous Internet forum where we don’t know what actually happened, we don’t know the resident, we don’t know the attending, etc, we can all only discuss the case as it was written in the original post. To argue that the patient may not have looked as bad as the resident presented in the original post is discussing a completely different case altogether.

Stick to what was presented and frame your discussion based on that, not what the patient “may” have actually looked like.

 

[AKMD_1984]

^ I am being realistic. Me commenting on this case is no different than your comment. It’s just a matter of perspective. We are presented with information by a resident. Neither you or I actually evaluated the patient clinically.

Any experienced anesthesiologist deals with this everyday where CRNAs and midlevels (and residents) present and discuss cases which may be complex and disastrous on paper for them - but clinically, with appropriate anesthetic technique and risk stratification - the outcomes are good and within norms of one’s routine Anesthesia practice.

I’m suspecting that’s what happened here.

It would be inappropriate and unfair to comment on intelligence or balls or courage of the attending without getting his perspective on the situation in addition to the residents.

 

[AKMD_1984]

Where did the assumption come from that optimization in a short time period is not possible? You literally know nothing about the pt. It is likely she has come in with a decompensation of some hitherto undiagnosed chronic disease, with the potential for some acute infectious component. This is not the patients “baseline”. There is potentially a lot that can be achieved in a week with things like bronchodilators, antibiotics, NIV, diuresis depending on what the cause is. Meanwhile her fracture will still be fixable in a week.

And yea if there truly was a mediastinal mass (which I doubt) you would absolutely address that first.

Neither do you though. The difference is you’re assuming the worst and have already made up your mind that this is poor care.

You will find out your answers you posted above if you talk to the patient. You know, do your job as a physician. Your questions in your post will be answered by a pre op HP as ASA and most experienced anesthesiologists recommend.

Then get labs. Get a lot of them. Get consults.

Don’t blindly order workups if on your clinical evaluation and what you’re planning to do as an anesthesiologist it’s not going to change management

 

[AKMD_1984]

OP,

Would you mind asking your attending a question or two for me?

Be very kind and humble, and say you are trying to understand your roll as a peri-operative expert and consultant.

Ask:
“Our patient had a resting SpO2 of 80% that wasn’t much corrected with supplemental, but that wasn’t low enough or severe enough to cancel the case. At what level would you need to see to cancel?

Also, the trachea looked very deviated but wasn’t deviated enough to cancel the case. What level of deviation would you need to see in order to cancel a case?

Her injury was not an emergency and some would argue didn’t even need surgery. Given her co-morbid states, how much less of a non-emergent state would the patient need to be in for you to decide that a further work up trumps the non-emergent surgical case?

Ya know, I was worried about diaphragmatic paralysis in this patient, but you weren’t. What scenario would you think would be worrisome?”

Ask with sincerity. Id love to know the answer to these questions.

I like this. I would be interested in learning his approach as well.