Positive stress test for non cardiac surgery

[anes121508]

It’s a pet peeve of mine when people make these sorts of condescending counterproductive comments. What if the stress test was negative? Would be nice reassurance, no? Risk stratification has value for making an informed decision. I would like the information as a competent anesthesiologist whether or not he goes through with the cath as recommended. Patients have the right to make informed decisions. They don’t have to agree with everything you recommend.

We as physicians constantly whine about how patients and families want too much end of life care and then throw a fit when the rare one actually wants to take ownership of their decision making and informed consent.

I’m not sure I understand the condescending part. What do you mean?

 

[anes121508]

If he's not on appropriate medical therapy for his CAD, he's not having surgery in 2 days. He will go to the cardiologist, and will take indicated medical therapy prior to this time sensitive operation if he wants to be anesthetized by me. He is always welcome to seek care elsewhere if he prefers substandard treatment.

According to the AHA guidelines for secondary prevention for patients with CAD (here):
-he should be on aspirin, class 1 indication, level of evidence A
-he should be on a statin, class 1 indication, level of evidence A
-he probably should be on a beta blocker. If his NSTEMI was w/i 3 years that's also a class 1 indication, level of evidence A. If >3 yrs ago, its a class IIa indication, level of evidence B.

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.

 

[anes121508]

I think it's worth mentioning that not all MACE is created equal; it's one thing to have a small apical reversible defect at 10 METS. It's quite another to have a large anterior wall defect with the equivalent level of exertion needed to saunter up a flight of stairs.

This was exactly the problem here. Pretty significant wall motion abnormalities with minimal effort.

 

[anes121508]

For case originally presented, the sticking point for me is the patient not being on appropriate medical therapy. That means he's not optimized. Furthermore, cancer patients are hypercoagulable, and furthermore surgery is a pro-thrombotic and pro-inflammatory insult. None of those things are great news for someone with hemodynamically significant CAD.

He needs to go home and take his ASA/BB/statin for a week and come back for his operation. His cancer has probably been there for a year, this operation can wait a week for his coronary plaques to marinade in some statin for plaque stabilization, and for his platelets to get a little less sticky from some aspirin. If he's cranky about taking meds, he can stop taking them after surgery for all I care, he's just gotta take them a few days leading up to the operation to get past me as his roadblock. He's an internist, he's supposed to be smarter than me surely he can figure all this out.

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.

 

[dchz]

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 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.

 

[dchz]

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.

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?

 

[anes121508]

I would definitely get a "cardiologist clearance" for this case. Just something that said "I've seen the patient. He's the best I can get him despite him not wanting further cardiology evaluation". I would have a good discussion with the patient about his risks. If he agrees to proceed there are definitely ways to do the case and get him through safely. I would 100% place an arterial line so I can tightly control his BP and I would 100% place a CVP more so in case I need a cocktail of drips to go directly to his heart.

Another big factor in the case which I can't remember if I've read above or not is SURGEON SKILL. Is this the type of surgeon who plays around with the laparoscope or is this a surgeon who will be "in and out" before you can even finish charting. I would argue that's just as big of a factor as any anesthetic technique.

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

 

[coffeebythelake]

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.

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.

 

[anes121508]

Some of you people are just naive. Plain and simple. A review of the case by the plaintiff’s expert will destroy you. Your Analysis is flawed as seen by a jury of your peers. That’s who is going to determine your fate. So, for those who don’t get the cardiology note on high risk patients your defense won’t hold up and the case will be settled quickly. You are not viewed as equal to an expert in cardiology by the public. We all take calculated risks each and every day in our practice. I highly recommend good care along with appropriate consults with our colleagues regardless of whether it changes outcome. I guarantee the one outcome it does change is whether you get sued or not.

blade, what approach would save you from legal aspect if patient is refusing official cardiology visit and medical management?

 

[anes121508]

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.

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

 

[anes121508]

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?

 

[abolt18]

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 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."

 

[BLADEMDA]

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?

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.

 

[UnbentLaryngoscope]

He also refused once in 2015 after having an nstemi. Went to ED, then refused cardiology visit and left ama

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.

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.

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.

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.

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.

 

[dr doze]

blade, what approach would save you from legal aspect if patient is refusing official cardiology visit and medical management?

Have somebody else do the case.

 

[anes121508]

My i

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.

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.

 

[vector2]

My i

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?

 

[DrZzZz]

What was the plan if he were to have had an intraop or PACU STEMI?

 

[Hork Bajir]

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

 

[anes121508]

What was the plan if he were to have had an intraop or PACU STEMI?

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

 

[anes121508]

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

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.

 

[anes121508]

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

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.

 

[coffeebythelake]

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.

 

[coffeebythelake]

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

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.

 

[anes121508]

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.

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.

 

[anes121508]

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.

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.

 

[anes121508]

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.

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.

 

[coffeebythelake]

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

For BB it should not be initiated DOS
ASA probably ok, statin maybe ok

 

[coffeebythelake]

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.