Pre-op ECG

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
I

izzygoer

Full Member
15+ Year Member
Joined
Apr 24, 2008
Messages
65
Reaction score
24
I would appreciate some help in understanding pre-op ecg indications.

According to Miller, patients with long standing, or poorly controlled hypertension need a preoperative ecg. Those with LVH on ecg should have a careful assessment of risk factors for CAD.

According to AHA guidelines preoperative ecg is indicated in patients undergoing intermediate/high risk surgeries with clinical risks factors based on Lee's Revised cardiac index.

The RCI does not list smoking or hypertension as significant risk factors to consider in preoperative cardiovascular mortality, although they are risk factors for cad.


Hypothetical board question
58 y/o male presents for open hernia repair with mesh. Chronic hypertension and smoker. Preop blood pressure 172/101. Takes lisinopril. Patient states his blood pressure is always high. He has not seen a pmd in a year. Had an ecg then, but it is unavailable. Exercise tolerance> 10 mets.

Their are 4 stat ecgs ahead of your elective case and there would be a delay of 3 hours before it is done. For hypothetical sake, doing an ecg yourself on the monitor is not an option. Surgeon says he will cancel if it does not go now. Patient is begging you not to cancel.

Do you proceed with the surgery or delay the case for an 12 lead ecg?

Are any of the responses below more correct/incorrect than another?

1) I would require a pre-op ecg. Patients with long standing hypertension should have one according to Miller.

2)I would get an ecg based on clinical suspicion that this patient has underlying cad based on risk factors of hypertension and smoking.

3) I would get an ecg because this patient needs a baseline ecg on record for future reference/comparison.

4) I would not delay the case for an ecg. According to AHA guidelines the patient has no risk factors based on RCI and is therefore low risk for per-operative event.

5) I would not order ecg. I am going to treat his hypertension anyway with a beta blocker so if the ecg findings show ischemia that would not change my management.
thanks for the input
Members don't see this ad.
 
Last edited:
I would go with 2&3. He has risks even though he can do 10 mets ( have you seen him do 10mets?). He hasn't seen his Dr in over a year and therefore any studies are >1 yr old. That's my board answer but it's been a while since I've taken the boards (MOCA doesn't really count, too easy).

If I were in the situation for real, well I guess I would have to analyze a few more things. Take him for a walk with stairs. How reliable is the surgeon as far as getting in trouble or taking a long time etc. Can I do this with a spinal? Remember spinal, MAC or GA with LMA are all equally stressful (or unstressful) even putting a tube in him can be minimal stress when done smoothly. At least with a MAC/spinal I can talk with the pt to see how he is doing. However, that won't protect me in court if something actually happens. So would I do this case, it depends but probably so. This isn't an abdominal hernia is it? Different story all together.
 
The at rest EKG will not offer any additional information necessary for you to make a decision about this patient's optimized status for surgery, and it is not going to alter your management.
He has > 10 mets exercise tolerance... that's the most relevant fact you have.
For the boards answer 3 would be the best.
 
Members don't see this ad :)
+1 what planktonmd said (if he is referring to the second option 3).

Learn the ACC/AHA guidelines for preoperative cardiovascular evaluation and apply them in your everyday practice.

In this case:
- Not an emergency surgery.
- No signs of active cardiac conditions.
- Hernia repair is ambulatory surgery, hence low-risk.
- Even if intermediate-risk, the patient has much more than 4 METs exercise tolerance. (That is maybe the most important indicator for intraop cardiovascular reserve).

No reason for ECG, unless you need it to diagnose an acute condition you have high suspicions of, based on the H&P (the patient has chest pain, you hear a new arrhythmia etc.).

BP 172/101 preop is nothing, nada, zilch; will go away with induction. If not, massage it with a touch of labetalol, once the surgery is on its way.

MAC vs GA/LMA depending on surgical local/regional block skills.

Do not delay surgeries for low-impact tests. If you are missing a piece of the puzzle, try to work around it, by planning your management as if the patient had that problem. Only do tests if they will impact your plan significantly, including a chance of postponing surgery for significant medical optimization.
 
Last edited by a moderator:
FFP said:
+1 what planktonmd said (if he is referring to the second option 3).

Learn the ACC/AHA guidelines for preoperative cardiovascular evaluation and apply them in your everyday practice.

In this case:
- Not an emergency surgery.
- No signs of active cardiac conditions.
- Hernia repair is ambulatory surgery, hence low-risk.
- Even if intermediate-risk, the patient has much more than 4 METs exercise tolerance. (That is maybe the most important indicator for intraop cardiovascular reserve).

No reason for ECG, unless you need it to diagnose an acute condition you have high suspicions of, based on the H&P (the patient has chest pain, you hear a new arrhythmia etc.).

BP 172/101 preop is nothing, nada, zilch; will go away with induction. If not, massage it with a touch of labetalol, once the surgery is on its way.

MAC vs GA/LMA depending on surgical local/regional block skills.

Do not delay surgeries for low-impact tests. If you are missing a piece of the puzzle, try to work around it, by planning your management as if the patient had that problem. Only do tests if they will impact your plan significantly, including a chance of postponing surgery for significant medical optimization.
Click to expand...

yes he was referring to the second number 3-following AHA guidelines for management (sorry I had two number 3s there) ...it has been corrected to number 4.. thanks for the help guys
 
Last edited:
I would proceed as follows:

1) Obtain resting ekg. This will invariably come back with "anterior infarct, age indeterminate."

So then you proceed to 2) treadmill echo. There are no inducible regional wall motion abnormalities, but the nonspecific anterior ST-T changes now look more nonspecifically nonspecific. So you decide he needs to go to

3) Cath. Unfortunately the cardiologist dissects his left main, he crashes in the cath lab, gets an emergent Impella followed by emergent CABG, and has yet to wake up.

Or you could skip all that and just fix his damn hernia.
 
I would get an EKG. I think a baseline EKG in patients at risk of Ischemia and/or arrhythmias is helpful postoperatively. More importantly, an EKG costs about a $1.00 a at my institution and is not read by anyone but an Anesthesiologist (no charge) prior to the surgery.

I've researched extensively on the subject and the book answer is that ASA 1 patients of any age don't need one prior to surgery. But, for the patient described in this thread I would order the EKG prior to his surgery. It may be a low yield test but it also a low cost one as well.

Here are some things I've seen on the EKG prior to surgery:

1. New onset A. Fib
2. PVCs, PACs
3. Second degree Heart block
4. Third degree heart block
5. Early ST repolarization
6. Non Specific ST/T changes
7. LVH (patient denies history of hypertension)
8. LBBB, LAFB, etc
9. Significant ST/T depression


The test costs about a $1.00 and I would require one in this example.
 
Last edited:
Other than the new afib and 3rd degree block, neither of which require a 12 lead to diagnose, how do any of the other findings change your management?
 
Hawaiian Bruin said:
Other than the new afib and 3rd degree block, neither of which require a 12 lead to diagnose, how do any of the other findings change your management?
Click to expand...


I was expecting that response. I don't like surprises in the O.R. as they tend not be good ones. I appreciate a preop baseline EKG for ST/T analysis in the PACU.
On patients that you view as at risk of postop ischemia (the patient in this thread clearly is) I require a preop EKG. My patient population is a high risk one so an EKG establishes a baseline for Physicians and Attorneys alike.
 
Hawaiian Bruin said:
Other than the new afib and 3rd degree block, neither of which require a 12 lead to diagnose, how do any of the other findings change your management?
Click to expand...


http://www.outpatientsurgery.net/su...ment/7-pre-op-tests-you-can-do-without--06-00


http://forums.studentdoctor.net/threads/pre-op-ekgs-worthless.953561/

I thought this would help make your argument for you. I've read all this stuff many times and there is no way I'm buying into it. I get the EKG which costs $1.00
 
If your EKG truly costs you a dollar, and doesn't delay the case, fine. I agree with you there is some value in knowing the baseline, but the real world cost of the EKG in most centers, plus the cost of delay, outweighs the benefit IMO.

What makes you think this guy is at a high risk of postop ischemia?
 
Hawaiian Bruin said:
If your EKG truly costs you a dollar, and doesn't delay the case, fine. I agree with you there is some value in knowing the baseline, but the real world cost of the EKG in most centers, plus the cost of delay, outweighs the benefit IMO.

What makes you think this guy is at a high risk of postop ischemia?
Click to expand...


High risk? No. He is simply a typical patient at my institution coming through for surgery. I'd put his risk of ischemia postop at around 5% or less. But, in a high volume practice 5% is a LOT of people over the course of a year who may need an EKG in the PACU. I prefer to have my $1.00 preop EKG available for comparison.

Cost of delay? That's because you don't explain to the nurses and surgeons you want an EKG preop. If you stress this simple $1.00 test then the number of delays will be minimal. I also have proceeded to surgery without my $1.00 EKG in order to make the surgeon happy.
 
Members don't see this ad :)
BLADEMDA said:
On patients that you view as at risk of postop ischemia (the patient in this thread clearly is) I require a preop EKG.
Click to expand...

Ok, but this is what you said.

I see the issue of baseline EKGs through a different lens. If I have a concern about postop ischemia, I can echo the patient myself to look for WMAs. Much more specific than the EKG.
 
Five guidelines address recommendations for preoperative ECG2–4,7,8; each is based primarily on low-level evidence and expert opinion. There is consensus among the guidelines that patients with active cardiovascular signs or symptoms should undergo ECG. The most widely accepted guideline in the United States advocates against ECG in patients undergoing low-risk surgery.4 The dilemma arises in how to define low perioperative cardiac risk, and what to do for patients who do not have active cardiovascular symptoms and who are not undergoing low-risk surgery. A recommendation based solely on age is an attractive solution because of its simplicity, but fails to address the question of who is at risk of perioperative cardiac morbidity and mortality.
Surgical cardiac risk is considered low if the risk of a perioperative cardiac event is less than 1 percent, intermediate if 1 to 5 percent, and high if greater than 5 percent 4,7 (Table 14). Patients should have preoperative ECG before undergoing a high-risk procedure. Two guidelines recommend using the Revised Cardiac Risk Index (RCRI) to assess the risk of cardiac complications after noncardiac surgery 4,7 (Table 210). The RCRI consists of five clinical risk factors and one procedural risk factor. The procedural risk factor utilized by Lee in the RCRI combines high- and intermediate-risk surgeries, which complicates modern risk stratification. As such, current guidelines primarily utilize the clinical risk factors from the RCRI but not the procedural risk factor. ECG is recommended before intermediate-risk procedures in patients with at least one clinical risk factor identified by the RCRI; those with two or more clinical risk factors are at significantly higher risk of a major cardiac event. ECG is not needed in patients undergoing low-risk procedures (Figure 1).
 
Hawaiian Bruin said:
Ok, but this is what you said.

I see the issue of baseline EKGs through a different lens. If I have a concern about postop ischemia, I can echo the patient myself to look for WMAs. More more specific than the EKG.
Click to expand...


Sorry but we must agree to disagree here. The bean counters want to cut out the EKG to save the $1.00 but I'm still ordering one here.
 
afp20130315p414-f1.jpg
 
I think this guy is a setup, possibly. He has HTN which usually doesn't get us excited. But he says that it is always high even with treatment and walking around with BP at 172/101 for a year will lead to changes. I want to know what has changed. He also smokes. Something tells me this guy needs an ECG. And I don't care how much that ECG costs.
 
I would get an EKG to cover my ass. No other reason.

30-40% of patients coming in for CABG have completely normal EKGs, including ones with high grade left main disease, and most of the rest have EKG that I wouldn't raise an eyebrow at.

Pretty useless for asymptomatic patients.
 
izzygoer said:
I would appreciate some help in understanding pre-op ecg indications.

According to Miller, patients with long standing, or poorly controlled hypertension need a preoperative ecg. Those with LVH on ecg should have a careful assessment of risk factors for CAD.

According to AHA guidelines preoperative ecg is indicated in patients undergoing intermediate/high risk surgeries with clinical risks factors based on Lee's Revised cardiac index.

The RCI does not list smoking or hypertension as significant risk factors to consider in preoperative cardiovascular mortality, although they are risk factors for cad.


Hypothetical board question
58 y/o male presents for open hernia repair with mesh. Chronic hypertension and smoker. Preop blood pressure 172/101. Takes lisinopril. Patient states his blood pressure is always high. He has not seen a pmd in a year. Had an ecg then, but it is unavailable. Exercise tolerance> 10 mets.

Their are 4 stat ecgs ahead of your elective case and there would be a delay of 3 hours before it is done. For hypothetical sake, doing an ecg yourself on the monitor is not an option. Surgeon says he will cancel if it does not go now. Patient is begging you not to cancel.

Do you proceed with the surgery or delay the case for an 12 lead ecg?

Are any of the responses below more correct/incorrect than another?

1) I would require a pre-op ecg. Patients with long standing hypertension should have one according to Miller.

2)I would get an ecg based on clinical suspicion that this patient has underlying cad based on risk factors of hypertension and smoking.

3) I would get an ecg because this patient needs a baseline ecg on record for future reference/comparison.

4) I would not delay the case for an ecg. According to AHA guidelines the patient has no risk factors based on RCI and is therefore low risk for per-operative event.

5) I would not order ecg. I am going to treat his hypertension anyway with a beta blocker so if the ecg findings show ischemia that would not change my management.
thanks for the input
Click to expand...


I agree with Miller et al about getting an EKG. My reason is number 3. That said, your patient has ZERO points based on the RCI and is undergoing a low risk surgery; as such, he does not need an EKG for this procedure.

I would still order one on him preop.
 
nimbus said:
I would get an EKG to cover my ass. No other reason.

30-40% of patients coming in for CABG have completely normal EKGs, including ones with high grade left main disease, and most of the rest have EKG that I wouldn't raise an eyebrow at.
Click to expand...
Which begs the question, what if this ECG comes back NSR?
 
The Board answer is to show you understand the RCI and the risk stratification of surgery (high, intermediate, low). After you explain this patient is undergoing a low risk surgery and has a zero score on the RCI you can then give your opinion about the EKG. Thus, you demonstrate that some experts wouldn't order the EKG based on best available opinion/evidence but you prefer to get one for postop comparison if needed.
 
Stumbled onto this thread because I am bored. Interesting that the hypertension doesn't bother you since as a surgeon I am accustomed to making patients go get their pressure under control prior to a truly elective case. I wonder if where I trained had more cautious anesthesiologists or if the surgeons were the ones instigating it. Also, our anesthesiologists would have wanted an ekg and cxr was part of the preop workup for a smoker so it would have already been done prior to date of surgery, so no delay.
 
dpmd said:
Stumbled onto this thread because I am bored. Interesting that the hypertension doesn't bother you since as a surgeon I am accustomed to making patients go get their pressure under control prior to a truly elective case. I wonder if where I trained had more cautious anesthesiologists or if the surgeons were the ones instigating it. Also, our anesthesiologists would have wanted an ekg and cxr was part of the preop workup for a smoker so it would have already been done prior to date of surgery, so no delay.
Click to expand...


I always appreciate the surgeons who understand that basic tests avoid delays before surgery. Patients should get their BP under control prior to surgery and quit smoking if possible a few months prior to the operation.
 
Based on my (extremely) limited knowledge (both generally and of the ACC/AHA guidelines) I wouldn't order a preop ECG for this patient. He has no risk factors considered by RCRI, has no active cardiac disease or complaints, and has a stated exercise tolerance of >10 METs. I think a baseline ECG adds nothing to optimization of his care prior to making his way to the OR table. I think the only preop cardiac test that may have value would be a stress echo, but again this guy has METs>10, which is a pretty sensitive indicator for CAD, IIRC. I think you stand the risk of seeing something that doesn't change your management but puts off the operation for a few days to weeks while the ticker doc states the patient is optimized for his operation. But my opinion and $0.49 will buy you a stamp.
 
Risk factors for perioperative pulmonary complications include chronic obstructive pulmonary disease, age older than 60 years, American Society of Anesthesiologists score of 2 or greater, functional dependence, hypoalbuminemia, congestive heart failure, emergency procedure, prolonged procedures, and certain surgical sites (e.g., upper abdomen, head, neck).5,12 However, there is no evidence that preoperative chest radiography in patients at risk of perioperative pulmonary complications alters outcomes more than findings from the history and physical examination.5 The American College of Physicians states that chest radiography should not be used routinely for predicting risk of postoperative pulmonary complications.5 Patients who should have chest radiography include those with new or unstable cardiopulmonary signs or symptoms, and patients at increased risk of postoperative pulmonary complications only if the results will alter perioperative management (i.e., inform decisions or postpone surgery).
 
Physio Doc 2 Be said:
Based on my (extremely) limited knowledge (both generally and of the ACC/AHA guidelines) I wouldn't order a preop ECG for this patient. He has no risk factors considered by RCRI, has no active cardiac disease or complaints, and has a stated exercise tolerance of >10 METs. I think a baseline ECG adds nothing to optimization of his care prior to making his way to the OR table. I think the only preop cardiac test that may have value would be a stress echo, but again this guy has METs>10, which is a pretty sensitive indicator for CAD, IIRC. I think you stand the risk of seeing something that doesn't change your management but puts off the operation for a few days to weeks while the ticker doc states the patient is optimized for his operation. But my opinion and $0.49 will buy you a stamp.
Click to expand...


The practice of medicine sometimes involves more than the book answer. Best available evidence should be based on research and clinical data not just opinion. In my experience a preop EKG is occasionally helpful but never harmful or costly so I order one frequently.
 
BLADEMDA said:
I always appreciate the surgeons who understand that basic tests avoid delays before surgery. Patients should get their BP under control prior to surgery and quit smoking if possible a few months prior to the operation.
Click to expand...
Yeah, I think I "grew up" with the idea of protocols for stuff like that. Maybe it is a waste of time and money but at least it won't be my time or money. Now let's say the hernia is incarcerated but not strangulated and it would be 3 hrs before the ekg would be done. In that case I might plead my case not to have to hang out waiting for 3 hrs (depending on if I thought waiting till the next day was an option or not).
 
The reason I posted this is because it seemed like a chicken and egg scenario.

AHA states that given lee's RCI,.. a hx of stable CAD and intermediate risk surgery is a good reason for preop ECG.

But doesn't one need an ECG to Dx CAD?
This guy could have silent ischemia and walking around with an old q wave and inverted t waves.

Just because his pmd did not Dx him with cad last year does not mean it could not have developed since.

Given the high clinical suspicion ( age, smoking, hypertension), isn't it our important role as perioperative specialists to make or refute a possibly important and life saving diagnosis at a critical time such as this?

If you did wait for the ECG and it showed t wave inversions in lateral leads wouldn't that change management?

Maybe an a line, beta blocker, etomidate instead of prop, more aggressive intraoperative Bp control, and starting post op beta blockers/ statins along with an immediate appointment with pmd post op?
 
Last edited:
Anesth Analg. 2013 Dec;117(6):1329-37. doi: 10.1213/ANE.0b013e318299a516.
Anesthetic induction with etomidate, rather than propofol, is associated with increased 30-day mortality and cardiovascular morbidity after noncardiac surgery.
Komatsu R1, You J, Mascha EJ, Sessler DI, Kasuya Y, Turan A.
Author information
  • 1From the *Anesthesiology Institute, †Department of Quantitative Health Sciences, and ‡Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; and §Department of Anesthesiology, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan.
Abstract
BACKGROUND:
Because etomidate impairs adrenal function and blunts the cortisol release associated with surgical stimulus, we hypothesized that patients induced with etomidate suffer greater mortality and morbidity than comparable patients induced with propofol.
METHODS:
We evaluated the electronic records of 31,148 ASA physical status III and IV patients who had noncardiac surgery at the Cleveland Clinic. Among these, anesthesia was induced with etomidate and maintained with volatile anesthetics in 2616 patients whereas 28,532 were given propofol for induction and maintained with volatile anesthetics. Two thousand one hundred forty-four patients given etomidate were propensity matched with 5233 patients given propofol and the groups compared on 30-day postoperative mortality, length of hospital stay, cardiovascular and infectious morbidities, vasopressor requirement, and intraoperative hemodynamics.
RESULTS:
Patients given etomidate had 2.5 (98% confidence interval [CI], 1.9-3.4) times the odds of dying than those given propofol. Etomidate patients also had significantly greater odds of having cardiovascular morbidity (odds ratio [OR] [98% CI]: 1.5 [1.2-2.0]), and significantly longer hospital stay (hazard ratio [95% CI]: 0.82 [0.78-0.87]). However, infectious morbidity (OR [98% CI]: 1.0 [0.8-1.2]) and intraoperative vasopressor use (OR [95% CI] 0.92: [0.82-1.0]) did not differ between the agents.
CONCLUSION:
Etomidate was associated with a substantially increased risk for 30-day mortality, cardiovascular morbidity, and prolonged hospital stay. Our conclusions, especially on 30-day mortality, are robust to a strong unmeasured binary confounding variable. Although our study showed only an association between etomidate use and worse patients' outcomes but not causal relationship, clinicians should use etomidate judiciously, considering that improved hemodynamic stability at induction may be accompanied by substantially worse longer-term outcomes.
Comment in
PMID:
24257383
[PubMed - indexed for MEDLINE]
 
izzygoer said:
The reason I posted this is because it seemed like a chicken and egg scenario.

AHA states that given lee's RCI,.. a hx of stable CAD and intermediate risk surgery is a good reason for preop ECG.

But doesn't one need an ECG to Dx CAD?
This guy could have silent ischemia and walking around with an old q wave and inverted t waves.

Just because his pmd did not Dx him with cad last year does not mean it could not have developed since.

Given the high clinical suspicion ( age, smoking, hypertension), isn't it our important role as perioperative specialists to make or refute a possibly important and life saving diagnosis at a critical time such as this?

If you did wait for the ECG and it showed t wave inversions in lateral leads wouldn't that change management?

Maybe an a line, beta blocker, etomidate instead of prop, more aggressive intraoperative Bp control, and starting post op beta blockers/ statins along with an immediate appointment with pmd post op?
Click to expand...


Slim,

I'm not a believer in Etomidate where it can be avoided. I'd rather use lower dose propofol with SEVO mask induction or Keatmine/Propofol over Etomidate.

Don't be so dramatic as this guy is my routine, average case these days. In fact, I would consider him below average for my typical day.
 
izzygoer said:
The reason I posted this is because it seemed like a chicken and egg scenario.

AHA states that given lee's RCI,.. a hx of stable CAD and intermediate risk surgery is a good reason for preop ECG.

But doesn't one need an ECG to Dx CAD?
This guy could have silent ischemia and walking around with an old q wave and inverted t waves.

Just because his pmd did not Dx him with cad last year does not mean it could not have developed since.

Given the high clinical suspicion ( age, smoking, hypertension), isn't it our important role as perioperative specialists to make or refute a possibly important and life saving diagnosis at a critical time such as this?

If you did wait for the ECG and it showed t wave inversions in lateral leads wouldn't that change management?

Maybe an a line, beta blocker, etomidate instead of prop, more aggressive intraoperative Bp control, and starting post op beta blockers/ statins along with an immediate appointment with pmd post op?
Click to expand...
Dude, just follow the ACC/AHA guidelines for preop evaluation (that's what you'll be expected to do at the orals, too). Read the darn paper. And think about probabilities. The entire medical science is about probabilities and odds ratios.

Suspicion of silent ischemia at rest (that's how he'll be during the ECG) in a guy who does 10 METs? You must be kiddin' me. What's the probability for that?

Everything you do, ask yourself: (how) would the results change your management? If the ECG showed chronic ischemic lesions, including old MI, I would proceed with the low-risk surgery. I already had my risk stratification at 10 METs.

For me this guy is an almost healthy surgicenter patient, even with the poorly controlled hypertension. (You have to deduct 20 mm Hg from those numbers on account of preop anxiety. Would 150/80 scare you that much?) Wait till you see the BMI 45, OSA, asthma, DM, HTN, CAD, pulmonary hypertension, couch potato etc. patients for one-day surgery. I especially love the crappy 75 year-old cardiac patients for laparoscopic hernia repair.
BLADEMDA said:
Anesth Analg. 2013 Dec;117(6):1329-37. doi: 10.1213/ANE.0b013e318299a516.
Anesthetic induction with etomidate, rather than propofol, is associated with increased 30-day mortality and cardiovascular morbidity after noncardiac surgery.
Click to expand...
I would treat that study with a grain of salt (like I do with all of them, the bigger the study the bigger the grain), because it's still not clear whether those patients die because of etomidate or whether they get etomidate just because they are so sick in the first place.
 
Last edited by a moderator:
izzygoer said:
Maybe an a line, beta blocker, etomidate instead of prop, more aggressive intraoperative Bp control, and starting post op beta blockers/ statins along with an immediate appointment with pmd post op?
Click to expand...

This is a hernia (you never said what kind so I'm assuming its not an interesting one) in a guy who can do >10 METs. He doesn't need an a-line. Nobody needs etomidate, that goes double for this guy. Good intra-op BP control should be a part of every anesthetic. I'm not a flea so he's not getting started on a beta blocker or statin postop - that's insane, I'm not his PCM, I'm not going to follow him.

Sure, get an ECG. He's a 58 yo hypertensive smoker, he deserves one. The real question is what are you going to do differently if it's abnormal in a non-acute way? Delay for workup? That's what I'd tell the oral board examiner. In real life, I'd just do the case and tell him he ought to see his PCM to talk about his blood pressure, smoking, and cardiac risks.


izzygoer said:
For hypothetical sake, doing an ecg yourself on the monitor is not an option.
Click to expand...

That's a little too far off into the hypothetical. If it's not an option, that's because there's no monitor. If there's no monitor, we aren't doing the surgery anyway.
 
izzygoer said:
The reason I posted this is because it seemed like a chicken and egg scenario.

AHA states that given lee's RCI,.. a hx of stable CAD and intermediate risk surgery is a good reason for preop ECG.
Click to expand...

This is neither a hx of stable CAD, and while it's technically intermediate risk surgery, it's a frigging hernia.

But doesn't one need an ECG to Dx CAD?
Click to expand...
No, you need a cath to diagnose CAD. An EKG is not specific for CAD. Yes, in the setting of an active STEMI, an EKG is specific for infarction. But a resting EKG absent cardiac symptoms is not specific for CAD. As stated earlier, about half of the people we take for CABG have rock solid normal resting EKGs.
This guy could have silent ischemia and walking around with an old q wave and inverted t waves.
Click to expand...
And doing 10 METS while he's at it. Guidelines say go do your hernia.
Just because his pmd did not Dx him with cad last year does not mean it could not have developed since.
Click to expand...
Refer to the guidelines.
Given the high clinical suspicion ( age, smoking, hypertension), isn't it our important role as perioperative specialists to make or refute a possibly important and life saving diagnosis at a critical time such as this?
Click to expand...
An abnormal EKG does not rule in CAD, and a normal EKG does not rule it out. A resting EKG is neither sensitive nor specific for CAD. The patient does 10 METS of exercise without symptoms, and you have clear guidelines to tell you to proceed.
If you did wait for the ECG and it showed t wave inversions in lateral leads wouldn't that change management?
Click to expand...
Without symptoms? Nope. Propofol, LMA, maybe a TAP block, local by surgeon, case gets done, to PACU, get a sandwich, pour a Macallan.
Maybe an a line, beta blocker, etomidate instead of prop, more aggressive intraoperative Bp control, and starting post op beta blockers/ statins along with an immediate appointment with pmd post op?
Click to expand...
Nuh uh. This is a hernia in an active dude.

If you get an EKG in this guy, it'll show LVH, and if you echo him, it'll show the same. He'll be the volume sensitive type, which might matter if this was a Whipple. But it's a frigging hernia. In an active dude.

Just do the case.

And I will say again that if you want an EKG simply for postop comparison AND it doesn't cost you anything as in Blade's shop, fine. But in my shop, it costs money, nontrivial money. So I don't get it. And I don't worry about covering my ass, because I have a whole bunch of literature and guidelines that backs up that decision.
 
And to those who agree the guidelines say it isn't necessary but still want this EKG, answer the question as posed- would you delay the case 3 hours for it, when the surgeon and patient are both begging to go?
 
chmd said:
Lbbb is one he listed. Wouldn't a new lbbb be an indication to delay elective case?
Click to expand...
A bundle block (right or left) should be easily visible on the monitor, so if you see wide QRS on the monitor in a patient who is not known to have a bundle block then by all means order an EKG.
All the other discoveries that Blade stated do not require a 12 lead EKG, this is why we have monitors.
 
Last edited:
I wouldn't delay the case more than 15 minutes for an EKG. If it takes 3 hours or was an emergency (incarcerated hernia) I would proceed without an EKG.

I would like an EKG preop for a baseline. As for the monitor in the room they don't always have paper in them and I'd prefer to avoid the pressure of being forced into doing the case once he gets all hooked up to the monitors.

FYI, I've seen second degree heart block, new onset A. Fib, etc on the monitor in the room prior to induction. I've also seen significant ST depression (new onset) just prior to induction and cancelled the case. That patient got a CABG 48 hours later.

This discussion is getting old already. If you don't want an EKG then the recommendations support that decision. If however you want a preop EKG for comparison purposes later then get one as that is my routine.
 
Hawaiian Bruin said:
This is neither a hx of stable CAD, and while it's technically intermediate risk surgery, it's a frigging hernia.


No, you need a cath to diagnose CAD. An EKG is not specific for CAD. Yes, in the setting of an active STEMI, an EKG is specific for infarction. But a resting EKG absent cardiac symptoms is not specific for CAD. As stated earlier, about half of the people we take for CABG have rock solid normal resting EKGs.

And doing 10 METS while he's at it. Guidelines say go do your hernia.

Refer to the guidelines.

An abnormal EKG does not rule in CAD, and a normal EKG does not rule it out. A resting EKG is neither sensitive nor specific for CAD. The patient does 10 METS of exercise without symptoms, and you have clear guidelines to tell you to proceed.

Without symptoms? Nope. Propofol, LMA, maybe a TAP block, local by surgeon, case gets done, to PACU, get a sandwich, pour a Macallan.

Nuh uh. This is a hernia in an active dude.

If you get an EKG in this guy, it'll show LVH, and if you echo him, it'll show the same. He'll be the volume sensitive type, which might matter if this was a Whipple. But it's a frigging hernia. In an active dude.

Just do the case.

And I will say again that if you want an EKG simply for postop comparison AND it doesn't cost you anything as in Blade's shop, fine. But in my shop, it costs money, nontrivial money. So I don't get it. And I don't worry about covering my ass, because I have a whole bunch of literature and guidelines that backs up that decision.
Click to expand...


What does an EKG cost in your area? An EKG tech makes $15 per hour and the machine is needed anyway for other patients. Actual costs of an EKG in your area is "non trivial money"? Simply delete the routine Cardiologist review of the EKG (is anyone still getting Cards to look at them?) and I don't see how an EKG costs more than $10.
 
Got it thanks Thanks for the advice and links guys ...very helpful.
 
MAC for CTR. 67 y/o asymptomatic, 6Mets, h/o htn and hyperlipidemia. Orthopod orders EKG the morning of surgery.
NSR w/ what appears to be an old infarct. No previous EKG or history of CAD.
How do you proceed?
 
sevoflurane said:
MAC for CTR. 67 y/o asymptomatic, 6Mets, h/o htn and hyperlipidemia. Orthopod orders EKG the morning of surgery.
NSR w/ what appears to be an old infarct. No previous EKG or history of CAD.
How do you proceed?
Click to expand...
You ask the orthopod not to order unnecessary EKG's again?
 
CTR = carpal tunnel release, I guess.

In my practice, that is a clear OK for surgery, after pertinent negative H&P.
 
sevoflurane said:
MAC for CTR. 67 y/o asymptomatic, 6Mets, h/o htn and hyperlipidemia. Orthopod orders EKG the morning of surgery.
NSR w/ what appears to be an old infarct. No previous EKG or history of CAD.
How do you proceed?
Click to expand...

Full steam ahead. For me this is a Bier block with a splash of propofol during the case.
 
You must log in or register to reply here.

Similar threads

P
Remaining intubated post op
Replies
20
Views
2K
zizzer
Z
C
Post op note, MD vs CRNA
Replies
24
Views
2K
chessknt
chessknt
E
New onset aflutter pre op... Cancel?
2 3
Replies
127
Views
8K
BLADEMDA
BLADEMDA
Aether2000
  • Locked
Surgeon Documentation for Post Op Pain Block Necessity
Replies
6
Views
1K
Aether2000
Aether2000
C
Nerve block pre existing deficit
Replies
31
Views
2K
DirtDocMD
D
Top