Pre-op Cardiology Consult - Real World

[TexAnes]

Here's the situation. 80 y/o woman fractures her hip on Saturday at 3 pm. She has a significant cardiac history without a recent workup.

She's admitted to a community hospital at 5 pm. The surgeon puts her on the OR schedule for a hip arthroplasty the following morning at 8 am. The surgeon orders a cardiologist consult at 7 pm.

A cardiologist sees the patient at 10 pm. He writes a note summarizing her 2 MIs, AICD, a "reported EF of 28%", states her risk classification, and "clears" the patient for surgery. He also orders a stat echo for 7 am the following morning.

The echo is done the next morning, but has not been read by the cardiologist prior to the planned 8 am case start. When questioned about when he's going to read the echo, the cardiologist states that the echo wasn't needed to clear the patient for surgery. He states that he ordered the echo so that there would be a pre-op baseline and that he'll read it after the case.

1. As the anesthesiologist, do you proceed to the OR or wait for him to read the echo.
2. What advise would you have for the cardiologist or surgeon in the future.
3. What do you think about the idea of cardiac studies being ordered and/or performed pre-op, but not having the results available to the anesthesiologist prior to the surgery?
4. If the cardiologist refuses to read the echo until Monday, would you sit on a hip fracture until then?

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[caligas]

That's annoying but I'd just do the case, you already know her heart is ****ty.

 

[norwood]

Here's the situation. 80 y/o woman fractures her hip on Saturday at 3 pm. She has a significant cardiac history without a recent workup.

She's admitted to a community hospital at 5 pm. The surgeon puts her on the OR schedule for a hip arthroplasty the following morning at 8 am. The surgeon orders a cardiologist consult at 7 pm.

A cardiologist sees the patient at 10 pm. He writes a note summarizing her 2 MIs, AICD, a "reported EF of 28%", states her risk classification, and "clears" the patient for surgery. He also orders a stat echo for 7 am the following morning.

The echo is done the next morning, but has not been read by the cardiologist prior to the planned 8 am case start. When questioned about when he's going to read the echo, the cardiologist states that the echo wasn't needed to clear the patient for surgery. He states that he ordered the echo so that there would be a pre-op baseline and that he'll read it after the case.

1. As the anesthesiologist, do you proceed to the OR or wait for him to read the echo.
2. What advise would you have for the cardiologist or surgeon in the future.
3. What do you think about the idea of cardiac studies being ordered and/or performed pre-op, but not having the results available to the anesthesiologist prior to the surgery?
4. If the cardiologist refuses to read the echo until Monday, would you sit on a hip fracture until then?

1. OR, after detailed discussion with pt and family including a realistic picture of the risks. Chart, chart, chart. Unless someone secretly revascularized her and didn't tell anyone (don't we all wish!), she is high risk. But what's the alternative? She is not realistically going to get revascularized before having her ORIF. The alternative is that she will never get out of bed again, and will die shortly after from one of a short list of things. Now if her EF is so insanely bad that going to OR is just euthanizing her, then no, I wouldn't do that. I'd consult palliative care to control her pain. But if she was up-and-about enough to have broken her hip in the first place, she should have at least a bit of myocardium.

It comes down to a question of what the pt and family want. If they want to go for it, understanding the risks, I think it's a reasonable call for them to make. I'd take the bet if I were in her shoes.

2. Same advice I have for anyone else in medicine: live frugally, pay off debt, balance work and life, stay away from lawyers, and don't invest in anything too complicated for a 5th grader to understand.

3. Suboptimal. But you can compensate by getting her old records - if she has an AICD, she must have a sheaf of 'em. If it's well and truly a question of "does she have any meaningful chance of surviving a trip to the OR?," then I'd lean on the cardiologist to at least guesstimate the EF and Ao valve function without making her marinate for a day first. Otherwise, I'd go with what I have.

4. No.

 

[Mman]

I'm waiting for the Echo results before proceeding. It may change my management of the patient. Spinal vs GA? How I respond to hypotension intraop - fluid vs inotropes, etc.

The orthopod can do their next case on the list while we wait for 1-2 hours for the echo results. If the cardiologist says they are "clear" for surgery, I'll tell them I don't even know what that means.

 

[urge]

I would wait for the echo. There is no point in having a baseline if you are not going to take it into consideration for the case. Afterwards who cares?

 

[DrBeaker]

I would look at the echo myself. I would ask the cardiologist to read the echo before the OR, if he/she won't then at least I have looked myself. There is info in there that would affect my management.

 

[TexAnes]

So here's part 2: it's 7 am, the echo has been done and not read. The cardiologist says that he's not coming in to read it until 3 pm. But he says that the echo wasn't ordered as part of his pre-op eval. He was just ordering it as a baseline. He says the patient is cleared to go to the OR without the echo.

 

[Mman]

He says the patient is cleared to go to the OR without the echo.

I'll ask him to repeat that sentence since I don't know what it means. If he'd like to provide the anesthetic, I'm happy to let him. But when stuff hits the fan and the 20/20 hindsight wishes you knew their EF was barely detectable, the real world lawyer will ask you why you didn't have the results of the test that was already completed.

Not knowing the results of a completed test that could influence your intraop management doesn't look good in a deposition.

Now if the test had never been ordered and the cardiologist never felt the need to obtain one, that's a different story. But it got ordered and done and my hands are tied.

 

[Pooh & Annie]

If she's got an AICD and an EF that low, she's on Coumadin and she's not getting a spinal, which I wouldn't want to do anyway. Do a GA and you can throw in a TEE when needed. A line for induction. She'll survive surgery. Post-op is gonna be precarious.

 

[seinfeld]

A common problem in medicine, ordering a test and not knowing what you will do with the results. DONT order tests unless you prepare to act upon the results.

If no echo was ordered i wouldn't have thought twice about prop/sux/tube but once a test is ordered I am obligated to wait for results especially if those results would/could affect my management. I see this often with EKGs, coags etc.

 

[deleted171991]

1. Let's play it by the guidelines:
- Not an emergency (though urgent).
- No active cardiac conditions.
- Intermediate risk surgery (if done properly).
- Find out the patient's exercise tolerance before the fracture. Highly functional, >4 METs? Go ahead. Sedentary, no stairs in the house, CHF symptoms on occasion? Wait for the echo, or at least look at it. If you must go ahead (ASA PS 4E), treat her as EF of 10-20% until proven otherwise, based on the functional capacity.Definitely no spinal, carefully titrated epidural might be fine though, depending on patient H&P. Otherwise GA +/- A-line.

Also, if the patient is very fragile, push the surgeon for the technique that results in the shortest possible surgery. If necessary, ask for a better surgeon.

2. I would report the cardiologist to the chief of staff. There is nothing such as a "baseline echo". If he orders it on the eve of the surgery, better move his/her butt, read it and put the note in the EHR before the patient is taken to OR, or sign it out to the overnight cardiologist on call. This is an urgent procedure, so what he did is unacceptable. I don't care about his cardiac eval as long as he felt the patient needed a preop echo.

I would advise every surgeon to avoid this cardiologist in the future, because I personally will disregard the cardiac preops from him/her.

3. See above. Ordering that echo is extremely dangerous from malpractice standpoint, even if the patient is highly functional. I would point this out to the medical leadership of the hospital and cardiology.

4. If the cardiologist refuses to do/read the echo urgently, I would ask him to write an addendum to his note where he specifies in writing that the echo is for his own fun, and he does not expect it to show anything different from the patient's previous baseline. I would also make a note that the cardiologist refused to make this echo urgent (let's see how calm he will be about the patient being ready for surgery THEN). Also, I would ask the surgeon to write a short note about the risks of waiting and the urgent nature of the surgery. I would have a serious discussion with the patient, surgeon and family about the risks/benefits of having the surgery vs waiting for echo. I would document the hell out of it, including what the hearts monkey said about the echo not being necessary for him to clear the patient.

 

[sleepallday]

The problem here is that the echo is already done. If AHA/ACC guidelines are applied and the patient has > 4 mets functional capacity, I would proceed to OR. No workup necessary. However, since the echo is already done, I would be forced to wait.

The bigger issue here is the complete lack of professionalism by the cardiologist.

 

[chocomorsel]

I would wait. And have in the past. Don't remember the details but it was ordered and I felt I needed to know the results before I proceeded. It was an elective knee or hip, I do remember that. And surgeon was reasonable. Flipped the schedule around for a couple of hours while waiting for the read.

So what's the update?

 

[cognitus]

I'm not a resident, but considering the patient's history described in this thread, what would the echo have to show that would cause a delay in the procedure that cannot be elicited by clinically evaluating the pt that morning? Seems like a resting echo and the LV function is not a consistent predictor of ischemic events during the procedure. Are you concerned about the echo picking up some valvular disease that may change anesthetic management?

 

[Hamhock]

I think the problem here is that anesthesiology continues to have internal medicine doctors (including the subspecialists of IM) "clear" patients for surgery. This should be the domain of anesthesiology -- especially for urgent or emergent cases.

HH

 

[TexAnes]

Here's the real-world follow-up. We held the case for a couple of hours (while the surgeons lost their minds yelling at us), the cardiologist came in and read the echo. He still insisted that the echo wasn't necessary for the surgery and that he and the internist has cleared the patient without the echo. EF 35-40%, valves fine. Did spinal.

The fallout has been that the surgeons feel that we should have accepted the cardiologists and internists "clearance" statements and should have accepted the echo-tech's prelim read (which stated that the EF was 45%).

I really like FFP's comments and wish I could follow them without repercussions, but...
No old records were available. Patient and family are poor historians. She was way less than "4 Mets". The Internist had written that she had a "major heart condition" and that she's lost "1/3 of her heart with the first MI and another 1/3 with the second MI." The cardiologist wrote the consult note but didn't put it on the chart until after surgery, so none of us knew what the cardiologist was thinking by ordering an echo. We couldn't even determine if he'd seen the patient until after we got him on the phone that morning. The internist refuses to use the good cardiologist and just uses other yahoos. We don't have an option of using another surgeon because this internist uses these surgeons. We are contracted with the hospital so we can't bring in other anesthesiologists. And there's no TEE accessible for the OR. But these are all political issues.

And the fallout is that we are being charged with being unprofessional for not getting doing the cardiologist's/internist's jobs of optimizing the patient pre-op and for not getting the cardiac results we needed prior to surgery.

I have since reviewed this case with another surgeon and two other cardiologists who completely back me up. There is another cardiologist who says that we didn't need the echo results, but I insist that they not order an echo or mention a pending echo in the consultation if it's not needed for their pre-op evaluation.

As another follow-up question, what do you think about a cardiologist who orders cardiac studies, but says they can be done after an upcoming surgery. We see this quite often on elective outpatient cases. Assuming that according to the guidelines, there's no indication for a cardiac study, but we know that one has either been done and the results are available to us, or there is a cardiac study pending to be done the following week. Whenever I call the cardiologist, they tell me to go ahead with surgery (because they don't want to piss off the surgeon), and the study is being done . . . just as a baseline, to line their pockets, or who knows why. I think that cardiologists who order studies should be forced to get us the results prior to elective procedures. If the studies aren't being done to prepare/risk-stratify a patient for a life-stressor (i.e. surgery), then what's the cardiac study for? What's wrong with cardiologists these days?!

 

[TexAnes]

I think the problem here is that anesthesiology continues to have internal medicine doctors (including the subspecialists of IM) "clear" patients for surgery. This should be the domain of anesthesiology -- especially for urgent or emergent cases.

HH

I will concede this failure of our system in our city. Other than in the academic centers NO anesthesiologist sees a patient until immediately prior to the OR. If a surgeon calls us the night before with a specific concern, we'll make phone calls. Or if he tells me about her while we're together the previous day, I'll pre-op her the day before. But if you call me at 7 pm on a Saturday, there's no way that I or any other anesthesiologist would go in to see a patient who is scheduled for surgery the next morning. We do have an expectation that the admitting internist and cardiologist will prepare the patient for surgery. I'd like to hope that I'd call them to discuss critical cases and ask them to notify me if there are any holdups. But 99.9% of the time in this city, anesthesia just hopes that the PCP has done their job. But we see that when they haven't, we take the heat for delaying the case. In the situation I explained, it wouldn't have mattered if we'd seen the patient the night before; the echo still wasn't read by 8 am.

 

[TexAnes]

I'm not a resident, but considering the patient's history described in this thread, what would the echo have to show that would cause a delay in the procedure that cannot be elicited by clinically evaluating the pt that morning? Seems like a resting echo and the LV function is not a consistent predictor of ischemic events during the procedure. Are you concerned about the echo picking up some valvular disease that may change anesthetic management?

If the patient had significant AS, that would have precluded a spinal. Her functional status was so poor that AS couldn't be excluded clinically. Also, if her EF was very poor, it would have impacted what drips we needed and/or an arterial line. In our facility, these things are not done quickly. If the cardiologist would have stated that "no further testing was necessary" and would not have ordered the echo, we would have gone directly to the OR. But he ordered a "stat echo to be done in the am" to be done just one hour prior to surgery.

 

[cognitus]

If the patient had significant AS, that would have precluded a spinal. Her functional status was so poor that AS couldn't be excluded clinically. Also, if her EF was very poor, it would have impacted what drips we needed and/or an arterial line. In our facility, these things are not done quickly. If the cardiologist would have stated that "no further testing was necessary" and would not have ordered the echo, we would have gone directly to the OR. But he ordered a "stat echo to be done in the am" to be done just one hour prior to surgery.

So basically, by having the stat-echo, the anesthesiologist would have been liable by instituting management that may have been contraindicated by what was in the echo. Without the echo, you could have just read the cardiologist's note. If the patient ended up having AS, but crashed because you lowered the afterload with the spinal, then you wouldn't have been liable because you couldn't have known about this if there was no echo ordered AND it wasn't in the cardiologists note? Got it. So this is just a cover your a** situation.

 

[urge]

2. What advise would you have for the cardiologist or surgeon in the future.

I would tell the surgeon that cardiology consults for urgent procedures are useless. They always "clear" the patient unless they are in florid pulmonary edema, which is a no brainer.

3. What do you think about the idea of cardiac studies being ordered and/or performed pre-op, but not having the results available to the anesthesiologist prior to the surgery?

3rd world medicine.

4. If the cardiologist refuses to read the echo until Monday, would you sit on a hip fracture until then?

Write long note saying that all due diligence was done trying to get cardiology to complete work up but that awaiting for it is endangering the patient's life. Go ahead if you think it is adequate.

 

[Southpaw]

Sounds like your dbag ortho just views your work as that of a technician and not that of a fellow physician, and is treating you as such. Same should be said of your dbag cardiologist. Let me just give you couple scenarios of how your case could've played out in the 'real world':

1) patient survives OR after you delay a couple hours for results of echo - surgeon makes a big fuss to everyone willing to listen b/c you wasted an hour or two of his most precious time. In reality here, the surgeon just has no respect for your judgment.

2) patient survives OR with you proceeding without results of echo - no one says anything. We all know this is what happens most of the time in these situations, and why your dbag surgeon cried 'foul' when you actually cared about the results of a study that your dbag cardiologist ordered pre-op.

3) patient dies in OR without results of the study (which may or may not have affected your anesthetic plan) - dbag surgeon points the finger at your, saying you mentioned nothing about wanting the results of the echo and he'd have been happy to wait had you voiced your concerns. scumbag lawyer makes you look like a real idiot in court when your dbag anesthesiology 'colleague' testifying for the prosecution says 'no way should you have proceeded without results of the echo'.

4) patient dies in OR with results of the study - dbag surgeon still points fingers at you and doesn't trust you.

5) patient dies a few days after surgery while in the ICU/floor - dbag surgeon and dbag cardiologist claim patient was just 'really sick' and 'nothing more could be done'.

6) patient lives a while after getting hip fixed - dbag surgeon continues to walk on water.

We work in a f'd up environment, partially our own fault b/c over time, especially in private practice, surgeons trust the word of the internist/cardiologist over the word of the anesthesiologist, even though no internist or cardiologist would ever be willing to step foot in our OR and provide an anesthetic to a patient they've 'cleared' for anesthesia. Really, can that system by any more stupid?

 

[urge]

I will concede this failure of our system in our city. Other than in the academic centers NO anesthesiologist sees a patient until immediately prior to the OR.

Not really. Same thing happens in academia. Anesthesiologist don't get paid to see a patient pre op. Internists do.

 

[Hamhock]

I We do have an expectation that the admitting internist and cardiologist will prepare the patient for surgery...But 99.9% of the time in this city, anesthesia just hopes that the PCP has done their job.

Then you can't complain that the cardiologist or internist didn't "clear" the patient to your liking.

And you can't say that the cardiologist or internist is the one "clearing" the patient for the OR.

HH

 

[deleted171991]

As another follow-up question, what do you think about a cardiologist who orders cardiac studies, but says they can be done after an upcoming surgery. We see this quite often on elective outpatient cases. Assuming that according to the guidelines, there's no indication for a cardiac study, but we know that one has either been done and the results are available to us, or there is a cardiac study pending to be done the following week. Whenever I call the cardiologist, they tell me to go ahead with surgery (because they don't want to piss off the surgeon), and the study is being done . . . just as a baseline, to line their pockets, or who knows why. I think that cardiologists who order studies should be forced to get us the results prior to elective procedures. If the studies aren't being done to prepare/risk-stratify a patient for a life-stressor (i.e. surgery), then what's the cardiac study for? What's wrong with cardiologists these days?!

First of all, it's my rule that I piss on cardiology clearances if something feels wrong (last year I had a hearts ***** clear a patient with a 4.5 cm aortic aneurysm which had not been checked for 3 years). The dumb orthopod lady kept repeating that the patient had been cleared by cardiology, in a "there is a fracture, I need to fix it" style. Talked to the patient, told him about the risks, including my 10+% risk estimate that he might burst his aneurysm and die on the table. Patient sided with me, surgery was postponed till after checkup. That's the way I prefer to do it, at least when I have a non-dumb patient.

I had the same problem as TexAnes, just a few weeks ago. Patient with cardiac history comes for plastic surgery after breast cancer; hearts monkey clearance says he asked for a stress test before surgery, but that the patient does not want to postpone surgery, because she has an opportunity window that will not come back for months (she had a sick mother she needed to take care of later, she was fighting depression, the stars were lined up etc.). I work in an ASC, so there is little room for being wrong with a sick patient, but our case numbers have been declining, so we are trying not to piss of the surgeons. Plus I do care about the patients; they have been NPO, taken days off work, arranged for a support system for post-op etc. One cannot just tell people that their surgery is cancelled on a hunch.

I interviewed this patient in detail, assessed the heck out of her exercise tolerance and symptoms. Thankfully she had pretty decent exercise tolerance and no severe non-cardiac comorbidities, so I went ahead with the surgery based on the ACC/AHA guidelines. I was careful with my GA until I saw that she had good functional reserve, like an ASA 2 patient. Everybody was happy in the end, but of course it might have gone the opposite way.

The main question for me is not necessarily "Will this change my management?" (if it will, I tend to just assume the worst about the test results and go ahead accordingly). The big question is: "Is there a high likelihood that this patient still has a lot of room for preop optimization?" and "Am I good enough and do I have the appropriate support to anesthetize this patient safely, the way she is right now, in this OR/PACU, with this surgeon?."

I use the cardiology clearance as just an extra piece of information; I don't really care about it, I care about the data in it, unless the patient has severe disease, or if she's well-known to the specialist. I have this luxury because I do outpatient surgery. I would never put a patient at risk, but things are rarely black or white.

To answer the question (finally!): the reality is that most cardiologists, and internists in general, don't know much about anesthesia. You can see that from assessments like "patient is cleared for MAC, but not for GA". They just imagine what anesthesia is like; most of them never rotated in it. I wouldn't be surprised if I knew more about real-life cardiac physiology than they do. They order studies not to risk-stratify the patient, but mostly to rule out an omission that might bite them back regardless of the surgery. Nobody will sue a cardiologist just because he cleared a patient for surgery and she died on the table, unless it was an obvious miss. It's not the cardiologist who takes care of the patient in the OR.

 

[Mman]

To answer the question (finally!): the reality is that most cardiologists, and internists in general, don't know much about anesthesia. You can see that from assessments like "patient is cleared for MAC, but not for GA". They just imagine what anesthesia is like; most of them never rotated in it. I wouldn't be surprised if I knew more about real-life cardiac physiology than they do. They order studies not to risk-stratify the patient, but mostly to rule out an omission that might bite them back regardless of the surgery.

Truer words were never spoken. I try to tell surgeons that when we ask for consults, don't go find somebody to "clear" the patient. That terms means nothing. I want optimization, or at least access to past study results they might have that I don't. Their office, for example, might have a copy of that echo from 8 months ago from somewhere else that I can't get my hands on.

But when they tell me that the patient with severe AS is cleared for a spinal but not for GA, I just chuckle. They don't understand the physiology of either the 1) spinal or 2) heart, but certainly not both. Modern cardiology is risk stratification and modification. You have x condition and if you take drugs y and z, your risk of MI will decrease from 8.1% to 5.7% in the next 5 years. They don't care about hemodynamics. They don't understand what happens to SVR and inotropy when I push my induction drugs. I make more adjustments to a patient's hemodynamic state in 60 minutes than they would make in 24 hours in the ICU.

S*** happens fast in the OR and if somebody got an echo on a sick patient preop, I'm damn sure going to see the results of it before proceeding with quasi elective or urgent surgery. A hip fracture isn't an emergency 16 hours after it happens. I've taken patients to the OR for their hip that had a TAVR done on admission for their hip fracture for their critical AS.

 

[sleepallday]

Not really. Same thing happens in academia. Anesthesiologist don't get paid to see a patient pre op. Internists do.

Not true. I've worked in both academics and private practice where we have been responsible for clearance.

 

[lane]

The anesthesiologist clears the patient for surgery.

The cardiologist assesses the patient to make sure they're medically optimized to proceed to the OR, or provides recommendations to improve their management.

 

[Colba55o]

If the patient had significant AS, that would have precluded a spinal. Her functional status was so poor that AS couldn't be excluded clinically. Also, if her EF was very poor, it would have impacted what drips we needed and/or an arterial line. In our facility, these things are not done quickly. If the cardiologist would have stated that "no further testing was necessary" and would not have ordered the echo, we would have gone directly to the OR. But he ordered a "stat echo to be done in the am" to be done just one hour prior to surgery.

Great thread Folks, especially for those of us preparing for oral boards!
I think this case turned out great since the patient did ok, so obviously you made the right choice TexAnes.

Few questions: Why do you think this patient was at risk for AS? Was there something in her hx that made you think she may have some valvular disease? Also when you think about it, how useful is a resting echo as opposed to a stress echo/nuclear stress test in a patient like this who has a hx of CAD? If she has an AICD, but is not paced, she clearly had reduced EF at some point.

In that situation, one could possible rely on clinical exam skills. I'm no cardiologist (ha!) but I am reasonably confident at identifying AS murmers by ausculation. A chest xray and clinical exam and medication hx would show if she was in a decompensated HF state. Also you say if her EF were "very poor" it would impact what drips you needed. Can you elaborate on this? If she became hypotensive, and assuming her EF was in the toilet, would you choose an epi gtt instead of neo? Why not just place the A-line anyway do a GA and proceed with the case? Just wondering if delaying the case so that you could await results of a resting echo would be better than proceeding with a slow careful induction, A line etc.

 

[deleted171991]

Great thread Folks, especially for those of us preparing for oral boards!
Why not just place the A-line anyway do a GA and proceed with the case?

As Hamlet would say: that is the oral boards question!

It's all about risks versus benefits. And unless one expects a high likelihood for the cardiac echo to show something critical, which needs to be fixed before any other surgery (e.g. severe AS or very low EF - and here's where the pertinent H&P becomes so important), one cannot argue postponing the surgery beyond a certain time point. There is a deadline (which I don't know for hip surgery) after which, pending echo results be damned, the patient will get the (by then) emergent surgery with the anesthesia plan assumption that she is as sick as an ASA PS 5 (NSA-level monitoring, gentle GA or masterful epidural/PNB and sedation).

 

[deleted171991]

Few questions: Why do you think this patient was at risk for AS? Was there something in her hx that made you think she may have some valvular disease?

I am no TexAnes, but I am bored and feel wiseguy-ish right now. Risk for AS? Age would be one, but that's never a reason to do an echo. You need pertinent H&P signs: angina (earth to earth), syncope (ashes to ashes), and in the end CHF (dust to dust without treatment). Only then can you argue for a high likelihood of a severe AS, at a level where proceeding might put the patient's life in danger, not only the joint.

Also when you think about it, how useful is a resting echo as opposed to a stress echo/nuclear stress test in a patient like this who has a hx of CAD? If she has an AICD, but is not paced, she clearly had reduced EF at some point.

You obviously want the stress echo (my precioussss!), but you need to prove first a high likelihood that it will show something that will make you not proceed with this urgent (definitely not elective) surgery. If she has an AICD, she might have just a history of arrythmias, and the EF might be normal.

In that situation, one could possible rely on clinical exam skills. I'm no cardiologist (ha!) but I am reasonably confident at identifying AS murmers by ausculation.

Congrats! I am not. But if I hear a crescendo-descrescendo (BS!) systolic murmur in the aortic area that radiates to the neck, I will whine about my need to rule out severe AS before any surgery. Which is again about risks versus benefits. (Who says one cannot have hip surgery with an aortic area of 0.5 cm2, with the right CRNA?)

A chest xray and clinical exam and medication hx would show if she was in a decompensated HF state.

No offense, says the wiseguy, but you cannot judge how decompensated that CHF is by the medications. Their role is exactly to compensate.

Also you say if her EF were "very poor" it would impact what drips you needed. Can you elaborate on this? If she became hypotensive, and assuming her EF was in the toilet, would you choose an epi gtt instead of neo?

Obvious solution to most of this echo conundrum: basic TTE performed by the anesthesiologist preop. Based on that, drip A+B versus C+D. However, a lot of phenylephrine is probably not a good idea; it will give a nice-looking blood pressure with a crappy end-organ perfusion and inotrope-negative effect. As long as the coronaries and the myocrapium tolerate it, an increase in cardiac output should be the primary source of the increase in the BP (unless you suspect a low SVR for some reason - *cough* spinal *cough*)

 

[TexAnes]

The anesthesiologist clears the patient for surgery.

The cardiologist assesses the patient to make sure they're medically optimized to proceed to the OR, or provides recommendations to improve their management.

"Clear" means that you allow the patient into the OR. Only the surgeon and anesthesia can clear the patient. The cardiologist can't put the patient in the OR nor can he stop it. He's not a gatekeeper, just a consultant.

 

[ssmallz]

This situation is a really more of a medicolegal mess then anything else. Cardiology "cleared" the pt, what this really means is that cardiology cannot optimize the pt any further so you're good to go. You already know her heart is crap so what does a new echo tell you? If you really wanna do a spinal put a stethascope over her heart and listen for a murmur, otherwise, just treat her like she does have AS, preop A-line, gentle induction and plenty of pressors in line. Titrate neo/epi to effect and keep the gas low. The echo isn't gonna change your plans much but since it was ordered you're going to look really bad in court if you don't check it. The cardiologist really screwed you over and it's such a shame that you get the blame for someone else's mistake. It's even worse that your surgeon doesn't see this either, sad sad world.

 

[nimbus]

Or just look at the echo yourself. AS is easy....really easy.. What's the peak velocity? gradient? Aortic valve area? You DON'T need a cardiologist to make the diagnosis. If you are not familiar with it, just ask the echo tech who did the study to show you. Do you ask radiologists to interpret every CXR before proceeding? Or a pathologist or internist to interpret every lab test? Read your own EKGs?

Sometimes board-certified consultant anesthesiologists, perioperative "experts" are worse than emergency medicine residents who come to the OR to intubate and leave. Relying on echos for years without ever digging deeper.

Peri-operative echo is OUR purview. It should be part of every anesthesia residency. This is one way to distinguish ourselves from CRNAs. By knowing our s***.

 

[Mman]

If you are not familiar with it, just ask the echo tech who did the study to show you.

That's all well and good til the tech has inappropriately set the nyquist limits on the view you are looking at and suddenly that regurgitant jet looks a lot worse or better than it actually is.

While we don't ask every radiologist for a read on a CXR, we tend to not make much in the way of clinical decision making based on a CXR these days anyways. If the Echo is possibly showing something abnormal that could change how you manage the patient, probably best to let somebody board certified in reading TTE do it themselves.


The 2 real problems with the OPs case are that 1) TTE probably shouldn't have been ordered in the first place and 2) if it's ordered preop we need the result preop since it could change management. I see some mention of just pretending they have bad AS and treating as if. Well what if it's severe MR? What if it's severe pulmonary hypertension? Unless our therapy for every single cardiac condition is the same, we can't just treat them in 1 "cardiac" way and be done with it.

 

[Bostonredsox]

I think the problem here is that anesthesiology continues to have internal medicine doctors (including the subspecialists of IM) "clear" patients for surgery. This should be the domain of anesthesiology -- especially for urgent or emergent cases.

HH

This.

I don't clear pts for surgery. I risk stratify them and make sure they, their family and the consulting surgeon understand where the pt stands in terms of their individual risk as a pt and e risk of that particular surgery. if there is work to be done to better optimize them for surgery I do that as well. However i never, under any circumstances write a pt is cleared for surgery. That is the anesthesiologists job. I will write mr smith has a significant history of cad, afib and cvd including past mi and stroke though both events are remote and he is optimized from a medical standpoint on his current medication regimen. I will write orders for holding of his anti platelet and anticoagulants and when to resume them providing he has no post op bleeding and surgery is ok with resumption. And I will state pt is low, medium, high risk for this low, medium or high risk procedure. Pt and family are aware of risks. If he needs a preop test I will order it and ensure it is interpreted prior to the case beginning. However, all this really says is that I have achieved the best preoperative state this pt is capable of and he still stands in this particular risk stratification group.

Whether or not he goes to the or is up to you, not me.

 

[nimbus]

That's all well and good til the tech has inappropriately set the nyquist limits on the view you are looking at and suddenly that regurgitant jet looks a lot worse or better than it actually is.

While we don't ask every radiologist for a read on a CXR, we tend to not make much in the way of clinical decision making based on a CXR these days anyways. If the Echo is possibly showing something abnormal that could change how you manage the patient, probably best to let somebody board certified in reading TTE do it themselves.


The 2 real problems with the OPs case are that 1) TTE probably shouldn't have been ordered in the first place and 2) if it's ordered preop we need the result preop since it could change management. I see some mention of just pretending they have bad AS and treating as if. Well what if it's severe MR? What if it's severe pulmonary hypertension? Unless our therapy for every single cardiac condition is the same, we can't just treat them in 1 "cardiac" way and be done with it.

1. TTE is fundamentally the same as TEE. You just have to get used to the pie being inverted.

2. I learned echo mid-career and one of the best resources for me were the cardiac sonographers in my hospital echo lab. They do these all day every day. I would argue they know echo better than many of the cardiologists who sign off on the reports.

3. Techs know how to set Nyquist limits. The cardiologists depend on it. And you can just look at the scale on the right of the screen to confirm.

4. It is easier to get accurate Doppler velocities through the aortic valve by TTE than TEE.

I'm just advocating that we take a greater interest in echo so that a passive-aggressive uncooperative consulting cardiologist can't put you in a bad spot. You take the power away from a power tripper. That is priceless

 

[TexAnes]

You'll never believe this. I have ANOTHER real life scenario that is playing out right now. Here it is...

Morbidly obese 50 y/o man with diabetes, CRF, and new chest pain. Scheduled for a laparoscopic peritoneal dialysis catheter placement tomorrow. The cardiologist got a stress test today which is "grossly positive". He has ordered a cath to be done, but he says that we can do it after surgery. When we questioned why not do the cath today, he said that he'd cancel the order and then just do it as an outpatient after we do the surgery tomorrow. What in the world is going on?! This is actually happening!

If the cath is not needed after a positive stress test, then it's not needed, regardless of whether the patient is having surgery or not. So if it's not needed pre-op, then it's not needed at all, right? Someone please help me understand what this cardiologist is saying when he says that a cath can be done after surgery.

 

[Scumlee13]

He can get the cath when he's intubated in the ICU, I guess. Or he could get it after his CABG. No biggie.

 

[Idiopathic]

.

 

[norwood]

The cardiologist got a stress test today which is "grossly positive". He has ordered a cath to be done, but he says that we can do it after surgery.
...
What in the world is going on?! This is actually happening!

Joking aside, a lot of cardiologists don't really "get" what happens in the OR. I've had preop "clearances" say everything from "avoid hypotension and hypoxia" (shucks, I guess I should put the tube in the trachea on this one?) to "run continuous NTG infusion" (on a pt with a negative stress test and excellent exercise tolerance). But my absolute favorite came on a preop sheet that, for whatever reason, asked for an ASA status to be assigned: "No ASA - pt is about to have surgery!"

Sounds like you might have run into an "anesthesia is like taking a nap, and I'd clear him to take a nap, so..." type of cardiologist.

 

[Mman]

You'll never believe this. I have ANOTHER real life scenario that is playing out right now. Here it is...

Morbidly obese 50 y/o man with diabetes, CRF, and new chest pain. Scheduled for a laparoscopic peritoneal dialysis catheter placement tomorrow. The cardiologist got a stress test today which is "grossly positive". He has ordered a cath to be done, but he says that we can do it after surgery. When we questioned why not do the cath today, he said that he'd cancel the order and then just do it as an outpatient after we do the surgery tomorrow. What in the world is going on?! This is actually happening!

If the cath is not needed after a positive stress test, then it's not needed, regardless of whether the patient is having surgery or not. So if it's not needed pre-op, then it's not needed at all, right? Someone please help me understand what this cardiologist is saying when he says that a cath can be done after surgery.

Tell the cardiologist that if the patient needs a CABG, that takes precedence over his PD catheter since he won't be doing PD in the cardiac ICU post CABG.

 

[nap$ter]

we

I would wait. And have in the past. Don't remember the details but it was ordered and I felt I needed to know the results before I proceeded. It was an elective knee or hip, I do remember that. And surgeon was reasonable. Flipped the schedule around for a couple of hours while waiting for the read.

So what's the update?

we as perioperative physicians have no mandate to wait for the results of tests ordered by consultants when the test is not indicated. we are not liable in this instance regardless of outcome. plentiful data and the aha guidelines would support this in this case.

if the cardiologist had ordered a pregnancy test in this patient would you have delayed until he read the result for fear of liability?

i would have proceeded. if her ef was less than 20% there would likely be clinical or historical data to suggest this. if she appeared optimized by my exam i would have proceeded to treat her as if her ef was somewhere between 20 and 40%, which in my hands is a fascia iliacus block and LMA.

 

[Hamhock]

we


we as perioperative physicians have no mandate to wait for the results of tests ordered by consultants when the test is not indicated. we are not liable in this instance regardless of outcome. plentiful data and the aha guidelines would support this in this case.

if the cardiologist had ordered a pregnancy test in this patient would you have delayed until he read the result for fear of liability?

i would have proceeded. if her ef was less than 20% there would likely be clinical or historical data to suggest this. if she appeared optimized by my exam i would have proceeded to treat her as if her ef was somewhere between 20 and 40%, which in my hands is a fascia iliacus block and LMA.

Finally, someone posting something that makes sense (from my outside of anesthesiology perspective).

Why do you folks care what some other doc says in her pre-op "clearance" note? Aren't you guys the one's who "clear" patients for the OR? Just put in a little note describing why you think that the testing was not indicated and therefore the results should no effect the current course of action.

The pregnancy test for males that salvin used is good, but a bit hyperbolic.

When I worked in EM more frequently, I would often get sign-out of chest pain patients with a d-dimer sent by the previous doc. Often these would return elevated. All this required from me was a quick note in the chart describing why the d-dimer was not indicated and that given the pre-test probability for thromboembolism, the d-dimer of 600 is meaningless. I would then discharge the patient.

This was even easier when the d-dimer was sent by the triage nurse, who knows almost nothing about the emergent medical evaluation of chest pain...kinda like how you guys are saying reminding us that the IM docs know almost nothing about anesthesiology and that the anesthesiologists are the "peri-op" docs.

Take care of the "pre-op clearance" yourself.

HH

 

[urge]

You'll never believe this. I have ANOTHER real life scenario that is playing out right now. Here it is...

Morbidly obese 50 y/o man with diabetes, CRF, and new chest pain. Scheduled for a laparoscopic peritoneal dialysis catheter placement tomorrow. The cardiologist got a stress test today which is "grossly positive". He has ordered a cath to be done, but he says that we can do it after surgery. When we questioned why not do the cath today, he said that he'd cancel the order and then just do it as an outpatient after we do the surgery tomorrow. What in the world is going on?! This is actually happening!

If the cath is not needed after a positive stress test, then it's not needed, regardless of whether the patient is having surgery or not. So if it's not needed pre-op, then it's not needed at all, right? Someone please help me understand what this cardiologist is saying when he says that a cath can be done after surgery.

Is the patient currently being reliably dialysed by another method? Why is he getting PD? No access?

The patient needs to get dialysed. If he doesn't have an access dialysis take priority. If he does, then the work up takes priority.

 

[deleted171991]

That is all very nice, Hamhock. Let me put it this way: "Doctor, why did you discharge this patient when her d-dimer was high?" "Because the pre-test probability for PE was low." "Yes, but isn't there a chance she could have had PE? Why did the first doctor order the d-dimer then?" "There is a very small chance that she could have had PE. There are many other causes of elevated d-dimer." "Even with her chest pain, doctor? Isn't it true that you sent home the patient, and then she died a day later, when a simple, but expensive for the hospital, CT scan could have saved her life?" "Yes, but when I sent her home she was fine, and her chest pain was typical of costochondritis." "That might be true but why did you ignore that d-dimer, doctor?" "Because there was a high chance if was a false positive." "Would you have sent your mother home, doctor, without ruling out PE?"... In this particular situation, the guidelines might save your butt. However, there are no guidelines about waiting for an already-ordered significant preop test.

I love to be the internist in the OR and in the periop period, but if the surgeon , he will have to wait for the full results of it, too. I have zero incentive to risk liability for not doing so, unless it's an emergency. (I am sorry, this is not Europe, it's the United States of Attorneys.) I should not go by the low probability of the test coming back positive. If it's an elective surgery, and there is a chance the test might come back positive for something meaningful that might cancel this surgery at this time, one should wait for the test. Again, I am talking about a test that I probably would not have ordered, but somebody else did.

Even in a big hospital, if they really cared, surgeons could develop a meaningful relationship with a few anesthesiologists, who would be a phone call away for all these periop questions. But then they would actually have to treat us with respect...

 

[Hamhock]

FFP -

I could go through each of your "lawyer" questions about the emergent medical evaluation of chest pain and the use of the d-dimer and easily answer them, but that is not the point here, is it? [And I work in the USAttorneys, not the EU]

The point is, again: Anesthesiologists repeatedly claim -- rightly so, I would say -- that they are the peri-op specialists and they are the ones who provide pre-op clearance, which is "all very nice"...but all too frequently, the "pre-op" clearance is requested of IM docs or IM-based specialists and then the anesthesiologists complains the next day that it was not performed correctly.

Perform the "pre-op clearance" yourself (if you are an anesthesiologist/peri-op specialist).

HH

 

[deleted171991]

I think the reason we don't do those pre-op consults is that we are probably not paid for it (especially not for optimizing the patient for days), while the internists are. The smart surgeons know to call about a sicker patient and ask for advice way ahead of the surgery; we are more than happy to provide these curbside consults, if needed. Many times I tell the surgeon to skip a bunch of tests and just bring the patient.

 

[ssmallz]

Finally, someone posting something that makes sense (from my outside of anesthesiology perspective).

Why do you folks care what some other doc says in her pre-op "clearance" note? Aren't you guys the one's who "clear" patients for the OR? Just put in a little note describing why you think that the testing was not indicated and therefore the results should no effect the current course of action.

The pregnancy test for males that salvin used is good, but a bit hyperbolic.

When I worked in EM more frequently, I would often get sign-out of chest pain patients with a d-dimer sent by the previous doc. Often these would return elevated. All this required from me was a quick note in the chart describing why the d-dimer was not indicated and that given the pre-test probability for thromboembolism, the d-dimer of 600 is meaningless. I would then discharge the patient.

This was even easier when the d-dimer was sent by the triage nurse, who knows almost nothing about the emergent medical evaluation of chest pain...kinda like how you guys are saying reminding us that the IM docs know almost nothing about anesthesiology and that the anesthesiologists are the "peri-op" docs.

Take care of the "pre-op clearance" yourself.

HH

This isn't a question of preop clearence but rather a question of cardiac optimization. We have a grossly positive stress test but we don't know what the cardiologist wants to do about it or what that even means. Is this patient optimized from a cardiac perspective? What is cards plan for the information gained from the stress test? Is there potential for the pt to get a stent? How bout a CABG? If so would they do it now or 6 months from now? What are the alternatives for dialysis fro this patient if we delay the case? These are all things we need to know before we can make a decision of whether or not this case should proceed.

Knowing that there is a + stress test, I would want cards to say that the pt is optimized for surgery at this point and that we will consider other interventions in the future. If he can't say that, I would look at the risks and benefits of doing this case. Can we place a temporary catheter and maybe do an AVF awake w/a regoinal block for a more permanent solution? Might be less stressful on the heart then a lap catheter. Most likely we do this case. Assuming "grossly positive stress test" means reversible area of ischemia we make sure cards documents that the "pt doesn't need further interventions prior to surgery." This is the single most important sentence a cardiologist can write because that's the whole reason we care about what he thinks and it frees us from whatever medicolegal bs will come later if the S hits the F. W/out that sentence or something similar there is no reason to get a cardiac consult or proceed with the case. Preop a-line and induce w/your cocktail of choice.

 

[Hamhock]

I think the reason we don't do those pre-op consults is that we are probably not paid for it (especially not for optimizing the patient for days),

Bingo.

Anesthesiologists have declared themselves masters of peri-op and the only ones who "clear" patients for the OR, but don't want to do to the work. Pre-op evaluation must be part of the pay for anesthetic, right? Maybe this is a piecemeal business, but I suspect that in order to safely provide an anesthetic, pre-op evaluation, including cardiac risk is part of the deal.

I agree that optimization (especially over days) is not part of the anesthesiologists job...but that is not what these threads are about. They are about "urgent" or "emergent" cases of hospitalized patients and "clearance" for the OR. Neither the OP or anyone else has said: "I think this lady needs an ECHO and perhaps a stress test (whatever is meant by that) and pending those results we will either go to the OR or send the patient to the cardiologist for optimization."

Rather, the pre-op clearance was provided by the cardiologist and the anesthesiologists have complained about how it was performed. The cardiologist said the ECHO wasn't necesssary to "clear" the patient. If you disagree, and feel form your pre-op assesment that the patient can't be "cleared" without an ECHO, then order the ECHO. If you feel an ECHO isn't necessary to clear the patient, then proceed to the OR and let the cardiologist order whatever nonsense she wants...ECHO, BNP, lipid panel, A1C, hogwart level, etc...

You can't have it both ways.

HH

 

[nap$ter]

Bingo.

Anesthesiologists have declared themselves masters of peri-op and the only ones who "clear" patients for the OR, but don't want to do to the work. Pre-op evaluation must be part of the pay for anesthetic, right? Maybe this is a piecemeal business, but I suspect that in order to safely provide an anesthetic, pre-op evaluation, including cardiac risk is part of the deal.

I agree that optimization (especially over days) is not part of the anesthesiologists job...but that is not what these threads are about. They are about "urgent" or "emergent" cases of hospitalized patients and "clearance" for the OR. Neither the OP or anyone else has said: "I think this lady needs an ECHO and perhaps a stress test (whatever is meant by that) and pending those results we will either go to the OR or send the patient to the cardiologist for optimization."

Rather, the pre-op clearance was provided by the cardiologist and the anesthesiologists have complained about how it was performed. The cardiologist said the ECHO wasn't necesssary to "clear" the patient. If you disagree, and feel form your pre-op assesment that the patient can't be "cleared" without an ECHO, then order the ECHO. If you feel an ECHO isn't necessary to clear the patient, then proceed to the OR and let the cardiologist order whatever nonsense she wants...ECHO, BNP, lipid panel, A1C, hogwart level, etc...

You can't have it both ways.

HH

well put.