"My cardiologist says I can't have GA"

[militarymd]

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Last week, one of our OB nurses asked me to take care of her mother. Her mother was going to have a knee arthroscopy for a medial menisectomy, a 10 minute procedure here.

The OB nurse asked me to take care of her mother because she has observed me placing SABs, and in her opinion, I'm the best in our group, and her mother's cardiologist told her that her mother cannot have GA because of her pulmonary hypertension...cause of which is unclear to me.

When the lady shows up on day of surgery, she brings no medical records with her, and on questioning, is really unclear on her disease process.....very annoying, seeing how her daughter is a nurse.

Anyways, she either has primary pulmonary hypertension or chronic thromboembolic disease leading to secondary pulmonary hypertension. She is on coumadin and tracleer, and ventavis. She stopped her coumadin 5 days before dos and INR is normal.

Patient's function status is >4 METS.

What would you folks do? Do the SAB because the cardiologist says she can't have GA for a 10 minute case, or something else.

Ventavis can cause increased bleeding.

 

[Alpha_Male]

I'd give her some Versed, Propofol and Fentanyl.........let her breathe spontaneously while receiving Sevo/O2/N2O for this 10 minute procedure.

Screw the cardiologist, this lady will do fine.

 

[Noyac]

Let the Cardiologist do her anesthesia. It really pisses me off when they say things like that.
What I want from a cardiologist ( and IM doc for that mattter) is some knowledge about the pt. I'll make the anesthesia decisions. 😡

 

[jwk]

Ditto both of the above, BUT...

If the cardiologist has written a consult that goes on the medical record that this patient should not have general anesthesia, my group would probably insist on an amended consult prior to surgery. It's not convenient for the patient, but you don't want to let that opinion slide unchallenged in the chart.

We had a similar problem when our group took over at a new hospital a couple of years ago. Literally our first day there, an old guy was having bilateral carpal tunnels, with the surgeon telling us the patient's cardiologist said he needed bilateral axillary blocks only (DUH!!!), and that he would not do the case under general anesthesia because he didn't want to piss off the cardiologist. We settled on MAC with local that day.

It took a few months, but we let the cardiologists at that hospital know that all we wanted from them was a description of their current status and whether or not the patient was "optimized for surgery". No mention of technique - that's our problem, not theirs. It can be done professionally and tactfully, but it definitely should be addressed.

 

[jetproppilot]

Ditto both of the above, BUT...

If the cardiologist has written a consult that goes on the medical record that this patient should not have general anesthesia, my group would probably insist on an amended consult prior to surgery. It's not convenient for the patient, but you don't want to let that opinion slide unchallenged in the chart.

We had a similar problem when our group took over at a new hospital a couple of years ago. Literally our first day there, an old guy was having bilateral carpal tunnels, with the surgeon telling us the patient's cardiologist said he needed bilateral axillary blocks only (DUH!!!), and that he would not do the case under general anesthesia because he didn't want to piss off the cardiologist. We settled on MAC with local that day.

It took a few months, but we let the cardiologists at that hospital know that all we wanted from them was a description of their current status and whether or not the patient was "optimized for surgery". No mention of technique - that's our problem, not theirs. It can be done professionally and tactfully, but it definitely should be addressed.

Very, very good post, jwk. Your group handled the above situation the absolute best way if you wanna practice very, very defensive medicine. However, I have no tolerance for the kind of "consults" listed above. If everyone handled them that way, our health care system would turn into a muddy, paper-pushing mess resembling the VA.
We are the board certified anesthesiologists, right? Requesting a bilateral axillary block cancels out the usefulness of the consultation, both medically and legally.
We know what kind of anesthesia is best for the patient, so step up to the mike with Micatin! I am not intimidated by useless consults like that, and I do not let them interfere with what I deem the most appropriate anesthesia plan for the patient. Settling for anything less deleteriously affects the patient, the surgeon, the anesthesia team, and the operating room. Would I make a patient postpone a surgery because of an obviously useless consult? Absolutely not.

I have encountered many similar consults. One in particular was a request for a central line with CVP monitoring and PAC on a patient with CAD who was scheduled for a lap-chole with a deft surgeon, which equated to a thirty minute procedure requiring minimal volume, and undergoing no volume shifts. We did the case like any other lap chole on an ASA 3-4 patient.
The cardiologist called me after the uneventful case miffed. I eloquently explained my reasoning, and expressed concern about his needless requests for invasive procedures, which have literature-supported morbidity.
That was the end of the cardiologist trying to dictate our anesthetics.

The above was not a power play. It was simply using literature-supported common sense on how to deliver a safe anesthetic.

Sometimes you can educate our consulting physician colleagues on what a "useful" consult contains, and sometimes you can't. But even if you can't, giving into the consult when you would deliver a different anesthetic if the consult wasn't there is doing a disservice to the patient.

 

[jetproppilot]

Let the Cardiologist do her anesthesia. It really pisses me off when they say things like that.
What I want from a cardiologist ( and IM doc for that mattter) is some knowledge about the pt. I'll make the anesthesia decisions. 😡

👍 👍 👍

I second that.

 

[jetproppilot]

Last week, one of our OB nurses asked me to take care of her mother. Her mother was going to have a knee arthroscopy for a medial menisectomy, a 10 minute procedure here.

The OB nurse asked me to take care of her mother because she has observed me placing SABs, and in her opinion, I'm the best in our group, and her mother's cardiologist told her that her mother cannot have GA because of her pulmonary hypertension...cause of which is unclear to me.

When the lady shows up on day of surgery, she brings no medical records with her, and on questioning, is really unclear on her disease process.....very annoying, seeing how her daughter is a nurse.

Anyways, she either has primary pulmonary hypertension or chronic thromboembolic disease leading to secondary pulmonary hypertension. She is on coumadin and tracleer, and ventavis. She stopped her coumadin 5 days before dos and INR is normal.

Patient's function status is >4 METS.

What would you folks do? Do the SAB because the cardiologist says she can't have GA for a 10 minute case, or something else.

Ventavis can cause increased bleeding.

I'd use an appropriate dose of etomidate or propofol, fentanyl 100ug, LMA #4, and a dash of sevo/des.

 

[jetproppilot]

.

Patient's function status is >4 METS.

Ventavis can cause increased bleeding.

READ THESE 2 FACTS. THERES YOUR ANSWER.

 

[jwk]

Very, very good post, jwk. Your group handled the above situation the absolute best way if you wanna practice very, very defensive medicine. However, I have no tolerance for the kind of "consults" listed above. If everyone handled them that way, our health care system would turn into a muddy, paper-pushing mess resembling the VA.
We are the board certified anesthesiologists, right? Requesting a bilateral axillary block cancels out the usefulness of the consultation, both medically and legally.
We know what kind of anesthesia is best for the patient, so step up to the mike with Micatin! I am not intimidated by useless consults like that, and I do not let them interfere with what I deem the most appropriate anesthesia plan for the patient. Settling for anything less deleteriously affects the patient, the surgeon, the anesthesia team, and the operating room. Would I make a patient postpone a surgery because of an obviously useless consult? Absolutely not.

Sometimes you can educate our consulting physician colleagues on what a "useful" consult contains, and sometimes you can't. But even if you can't, giving into the consult when you would deliver a different anesthetic if the consult wasn't there is doing a disservice to the patient.

We were trying to be polite going into a new facility with surgeons and cardiologists who didn't know us yet. This surgeon was going to cancel the case if we wanted to do a general, and obviously we refused the bilateral blocks. It was tempting to have a review of local anesthetic toxicity with him, but we passed. 😉 The MAC + local worked well as you might imagine.

We won't hesitate to do cases the way we think they should be done, or to not do the case if the surgeon wants something we consider inappropriate. My point was the concern about having a written consult on the chart even when the consultant's conclusion was obviously incorrect. We're always going to do what we think is best for the patient. And you're right, it is defensive medicine, for better or worse.

 

[jetproppilot]

We were trying to be polite going into a new facility with surgeons and cardiologists who didn't know us yet. This surgeon was going to cancel the case if we wanted to do a general, and obviously we refused the bilateral blocks. It was tempting to have a review of local anesthetic toxicity with him, but we passed. 😉 The MAC + local worked well as you might imagine.

We won't hesitate to do cases the way we think they should be done, or to not do the case if the surgeon wants something we consider inappropriate. My point was the concern about having a written consult on the chart even when the consultant's conclusion was obviously incorrect. We're always going to do what we think is best for the patient. And you're right, it is defensive medicine, for better or worse.

well done.

 

[Tenesma]

my favorite story is with one of my old attendings when i was a CA-1 way back when...

Cards wrote in the note to keep HR between 60 and 80, and some other useless stuff like PAOP<20 etc... on some guy w/ CAD for a straightforward case. The guy's heart rate was 45-50 throughout the whole case, so my attending called the cards attending and the conversation went like this
"hi, just wanted you to know that we did Mr. SO-and-so today and everything went well"
"oh good..."
"but we did have to give him several boluses of epinephrine and start a dopamine drip"
"WHAT!!!! oh my god... what happened"
"nothing really... we were just trying to bring his heart rate up to the heart range you dictated in your consult"
"well i didn't mean for you guys to use epi..."

that was the last time that that cardiologist would write anything other than 1) optimized from his point of view 2) cardiac management as per anesthesia 🙂

 

[militarymd]

I spoke with the patient. I told her my recommendations were that she should have a general anesthetic...that she had no reason that I could identify why she would have problems with GA.

I also explained to her that the risks of surgery are just that...mainly the type of surgery she is having...a big one or a little one....how she is anesthetized is of little consequence in her particular situation.

She said "do what you think is best"

200 mg of propofol (my standard dose)...size 4 flex lma (my usual lma)...oxygen and sevo..no narcs. for the case...she got 4 mg of morphine in the PACU...went home 30 minutes after end of surgery.

She told me she was going to talk to her cardiologist again.