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I’m not sure I understand the condescending part. What do you mean?
Positive stress test for non cardiac surgery
Started by anes121508
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I think this is exactly what I was struggling with. I get the decision to forgo cath but Couldn’t understand why he was put on the schedule without the basic meds ahead of time.
Turns out he was refusing to go to the cardiologist at all. He also refused once in 2015 after having an nstemi. Went to ED, then refused cardiology visit and left ama.
This was exactly the problem here. Pretty significant wall motion abnormalities with minimal effort.
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this was exactly my sticking point too.
then in my head I asked myself how long does this guy need to be on meds to see a benefit?
patient and son were docs and adamant about immediately proceeding.Am I able to tell them that we have clear evidence that getting put on an asa, statin, and bb for 7 days will change his outcome? Is 7 days better than DOS? That was my real struggle.
This is very different from the picture I was seeing.
If he doesn't even give you the professional courtesy to tell you why he doesn't want to see the cardiologist to even try to mitigate your (also his own) risk, then it's pretty easy for me to say no.
I see it from their perspective. But they have to realize they are putting you in a bind here. Did they acknowledge that and try to see it from your perspective?
Not that it changes anything, but what does the surgeon think?
what you mentioned is exactly what happened...I wanted some type of documentation so we agreed upon the cardiologist writing a note that he is high risk and discussed with the patient and said he is optimized and we can’t change anything since the patient will not consent to office visit for medical management
I want to know the rationale for this. Not even optimal med management? Patient and son seem very unreasonable and a pain in the ass.
blade, what approach would save you from legal aspect if patient is refusing official cardiology visit and medical management?
yeah I know, really struggled with it.
their rationale was that if any medications would change outcome, 7 days wouldn’t be different than DOS
So here is what happened:
I wanted to know why no cath. Patient gave me his reasoning
I called cardiology. They wrote on chart about their phone convo with patient and risks explained and that they couldn’t help patient any more since he declined medical management and lch.
they wouldn’t comment on proceed or not to proceed with case.
I discussed risks with patients. We discussed the guidelines. Offered a different cardiologist. Documented convo.
gave aspirin DOS.
aline, neckline, swan ,controlled induction with full prep of meds on pump ready to control anything. Sort of overboard but felt I was already taking on enough risk. Tee.
slow insufflation With plan to open if looked lengthy.
hr <80, hgb was already 14, maps >70...index and swan numbers stay decent throughout so didn’t do much.
he was super stable.
2 hr case laparoscopic, extubated to pacu.
no events.
got lucky.
really just not sure the legal part. If cards won’t technically clear patient but says they have offered everything and patient refuses, then did I do the right thing going forward with case because of the patients wishes and informed decision?
I wanted to know why no cath. Patient gave me his reasoning
I called cardiology. They wrote on chart about their phone convo with patient and risks explained and that they couldn’t help patient any more since he declined medical management and lch.
they wouldn’t comment on proceed or not to proceed with case.
I discussed risks with patients. We discussed the guidelines. Offered a different cardiologist. Documented convo.
gave aspirin DOS.
aline, neckline, swan ,controlled induction with full prep of meds on pump ready to control anything. Sort of overboard but felt I was already taking on enough risk. Tee.
slow insufflation With plan to open if looked lengthy.
hr <80, hgb was already 14, maps >70...index and swan numbers stay decent throughout so didn’t do much.
he was super stable.
2 hr case laparoscopic, extubated to pacu.
no events.
got lucky.
really just not sure the legal part. If cards won’t technically clear patient but says they have offered everything and patient refuses, then did I do the right thing going forward with case because of the patients wishes and informed decision?
Got lucky, but his recovery is not over and he's not out of the woods. You should check up on him in a month. Guy seems like a giant PITA. Him saying DOS shouldn't make any difference, I'd respond with "let's let the cardiologist decide that."
Yes. Good job and I would have done the same but without the TEE/S-G cath. I may have used a Flo-Trac but I doubt it. Very wise to go with "slow Insufflation" as that can make a huge difference on hemodynamics.
I didn't have him pegged in my mind as the guy that was so cranky that he leaves AMA after having an NSTEMI, and never sees cardiology ever. No one is going to get anywhere with this kind of patient.
I'm not aware of any high quality literature that can answer this question (I'm open to being educated). The best rationale that I could probably come up with is that platelets have a lifespan of ~8 days or so in circulation, so the ASA will have time to hit most of the platelets he'll have in circulation on the DOS by then.
Can't really blame you for using all of the things on this patient. I probably would have done the case with a pre-induction art line, defib pads on, 2 good IV's in large veins, and vasoactive infusions ready to go. Slow abdominal insufflation really helps. I would have had a CVL kit and ultrasound in the room. Low threshold to place a CVL if his veins are crummy, or if he misbehaves at all at any time during the anesthetic. My hospital only has 1 TEE machine for the OR, and that's in the heart room, so that's not something that's generally available unless there's not a heart case going on.
I probably would have put on a BIS/sedline/"whatever anesthetic depth" monitor, done some TAP blocks, run some low dose background dexmedetomidine (no loading dose) if he wasn't requiring any pressors (sympathectomizes the patient, synergistic analgesia with any opioid given, spares volatile agent).
Regarding the Swan, they're not risk free devices. If this guy hasn't had a cath, we don't know the nature of his coronary circulation (left vs right vs codominant). If he were to have an ischemic event that resulted in LBBB and you have a swan in tickling the Right bundle branch, you could find yourself in the unenviable position of transcutaneously pacing. Just something to think about.
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deleted126335
Have somebody else do the case.
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My i
Post op his hgb dropped to 7.5 so he got a unit. Cards visited him and said call if needed. Interestingly someone ordered a troponin post op which was normal.
if I did it again, I probably wouldn’t place swan. I do like the tee though.
I like your point on the swan. Only reason for swan and tee was to make damn well sure I went the right direction if I did run into hemo issues. Just feel like you have one chance to pick a route and not much room for error. Turns out his numbers were great. Almost like he was tuned up by cardiology beforehand. I didn’t do much of anything.
Post op his hgb dropped to 7.5 so he got a unit. Cards visited him and said call if needed. Interestingly someone ordered a troponin post op which was normal.
if I did it again, I probably wouldn’t place swan. I do like the tee though.
What was the plan if he were to have had an intraop or PACU STEMI?
Raising my eyebrows at CVL, PAC, TEE, rack of drips... for what should be a quick lap colon case with minimal EBL. NONE of that stuff is without risk. Plus as another poster said, if you see ST changes, what are you gonna do differently? Flog his ischemic heart with inotropes to make the index more to your liking?
Many ways to skin a cat in anesthesia. I would have skinned this one with far fewer/simpler tools, but to each their own
Many ways to skin a cat in anesthesia. I would have skinned this one with far fewer/simpler tools, but to each their own
legit question and was my other sticking point. Someone mentioned a bind. The bind was worsened when I asked the surgeon and the cardiologist and the patient the same question.
Surgeon: that’s why you will be there
Patient: well I would want everything done (cath stent , iabp , Ecmo)
Cardiologist: I’m not bailing him out. You can’t tie my hands then do a salvage procedure or emergent Cath on an 85 yo that declined my help.
so I went back to patient and said plan was to admit him to cvicu if he had an event and we would do Medical management per cardiology and then intensivist would take it from there. Only way I could do the case is if patient agreed and he did. If patient didn’t agree to that I really Don’t know that I could do the case because I’d be stuck.
this was a big aspect of the case
Tee without contraindication and minimal manipulation of probe I don’t think has huge risk. Guides therapy and detects wall motion to help me anticipate.
central line with ultrasound sterile placement and removed post op I don’t think has super high risk. I wanted Central access and drips ready For two reasons:
I really wanted tight control of his Hemodynamics with what I’m comfortable using and because I’d rather not scramble around when he has an mi. This guy in my opinion based on his stress test really had minimal room for error.
swan, yes I agree. If the case went south and I was flying blind not knowing the exact cause of downfall I bet I would be happy to have the swan.
so I put in place what I wanted to have when things went really poor.
my beleif is that often times we fly blind without objective data and use our anesthesia senses. This wasn’t a case I wanted to do that. That being said tee plus swan is more than likely overkill for the OR however I place them nearly every day and am comfortable with it.
and the Swan was mainly for exactly the opposite Of flogging his heart with inotropic medications. I’m not sure who would do that or why you think id want to. Seems like not a productive comment.
I think we all agree that less wall stress would be best.
I think with the TEE any additional information you get from a swan will be limited at best. If the patient was crumping and they will go to the ICU after, and you won't have the TEE for guidance postop, than it makes sense to have one.
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Good that you had this discussion with all relevant parties. Yes the situation sucks and it puts you in a real bind. Very inconsiderate for your patient, who as a physician should know better.
Not surprised the surgeon said what you quoted. They don't really have a clue about what to do in that situation, they just step back and let someone else deal with it. As if YOU could be the one to do a cardiac cath in the OR as the patient is having a STEMI. And what about anticoagulation? I'm sure the surgeon would be PISSED off at YOU if it is needed when the patient has a cardiac event. I'm actually a bit upset at this whole situation. It shows an utter lack of care from the surgical team. The surgeon could have easily put their foot down and said, "hey until you get that cardiologist optimization i'm not going to do your surgery". I'm sure the patient would have followed those instructions.
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100% agree with this post.
our ct surgeons request swans for all cases for exactly what you said. Post op. Not a huge fan of that. I was 50/50 Swan prior to case. Not sure I’d place it again if I was in same position.
glad you brought this up. I didn’t really want to go down this path But since you mentioned it...yes I felt like the surgeon passed the buck and put me in a ****ty positionfrom the get go. She wanted to play good guy and let me be bad guy why case either wasn’t done or why patient had an event. The surgeon should have taken more ownership and she dropped the ball from the beginning. “Ok fine you don’t want cath, please go visit cardiologist to make sure medical management is straight”...then come to me an say “hey I have a guy and I did some basic stuff and I think it’s a tough position but it’s as good as we can get”.
if the patient agreed to delay the case and go see cardiology to explore asa bb statin I bet surgeon would have come complaining to me.
also glad you brought up the anticoagulation issue... before I went back to the cardiologist to tell them that patient wanted us to do everything I told the surgeon that patient wanted salvage cath and or Ecmo or iabp which would mean anticoagulated and she didn’t look happy and Said “well let’s see what cards says”. I think we can all infer the motive here.
this is a surgeon who will have no qualms about throwing you under the bus when something happens. seen it many times before. the attitude. their patients think they are wonderful but they are sociopaths. you and the cardiologist are seen as a hinderance to the surgeon making their RVUs.
A few points...
Coronary ct is going to be non-diagnostic in this patient. Too old, too calcified to determine actual stenosis, high pretest prob it is abnl... Iagree a great option for your younger patients.
Why do a stress if no cath? It helps you assess risk. Even if it doesn't change cath or not, it will help the discussion with the patient. It also helps you cover your ass
Stenting perioperatively, does not reduce risk for a surgery. Multiple trials showing this. Only time is possibly lm. Nowadays we will place a des even for urgentish surgeries and stop dapt in 4-6 weeks. Cant tell you the last time I saw anyone place a bms...
If case set up in 36 hours- I'd say start beta blocker and delay a few more days until a week. Worse outcomes if bb started < 7 days prior to surgery. Agree with statin. Doesn't matter when statin started.
This case is kinda a no brainer- it is an absolutely needed surgery. He wants no further workup. Put him on the right meds. Document the hell out of the fact he wants no further testing, doesn't want to see a cardiologist, and understands the risk better than most patients because he himself is an internist.
Coronary ct is going to be non-diagnostic in this patient. Too old, too calcified to determine actual stenosis, high pretest prob it is abnl... Iagree a great option for your younger patients.
Why do a stress if no cath? It helps you assess risk. Even if it doesn't change cath or not, it will help the discussion with the patient. It also helps you cover your ass
Stenting perioperatively, does not reduce risk for a surgery. Multiple trials showing this. Only time is possibly lm. Nowadays we will place a des even for urgentish surgeries and stop dapt in 4-6 weeks. Cant tell you the last time I saw anyone place a bms...
If case set up in 36 hours- I'd say start beta blocker and delay a few more days until a week. Worse outcomes if bb started < 7 days prior to surgery. Agree with statin. Doesn't matter when statin started.
This case is kinda a no brainer- it is an absolutely needed surgery. He wants no further workup. Put him on the right meds. Document the hell out of the fact he wants no further testing, doesn't want to see a cardiologist, and understands the risk better than most patients because he himself is an internist.
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DES stopped after 4 to 6 weeks? Seriously? What guidelines say that js appropriate
Depends on the generation of des and the urgency of why it is being stopped. Must be 2 most recent DES generations.
last ESC guidelines on management of NSTE-ACS allow P2Y12 inhibitor administration for a shorter duration of 3–6 months after DES (not the 1 year). The us guidelines are like 4 years old.
Some stents get the CE mark from the europeans (Conformité Européenne) which gets labeled for dapt for 1–3 months.
There is good data as well. Some brands of des actually show superiority to bare metal stents both in terms of safety and efficacy after a mandatory DAPT duration period of only 1 month (a polymer-free biolimus-eluting DES). This is why bms are basically never used.
So for non urgent surgery that can be delayed, using the older data and delaying is best. For urgent/emergent cases, leaning on your friendly neighborhood cardiologist would be helpful, especially if the surgery comes with high bleeding risk (neurosurgery and the like)
I dispute the premise that this surgery is urgent. He is 85 even if his colon cancer is aggressive it could take 5+ years to get to the point where it could kill him as opposed to this surgery which could kill/debilitate him much sooner. Several months of appropriate therapy (whether medical or stenting) to give him his best shot at making it out of the hospital at the small risk of his cancer getting worse is not only reasonable but really the only viable option.
Also again he is 85....
Also again he is 85....
You with your logic and reason...
What, you're not comfortable robbing St. Peter for RVUs?
