Pre-op ECG

[Libertas]

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at all the hospitals in my system, as far as I've encountered, the EKGs are all read (eventually) by a cardiologist and officially 'signed off' on the machine read. I'm sure that results in some kind of 100$+ charge.

This guy doesn't even have any of the 'clinical risk factors' as defined by the aha/acc guidelines (known cad, known chf, CVA, dm, CKD) Low/moderate risk surgery (this could probably be done under local by surgeon with no anesthesiologist/anesthesia, technically) and good functional capacity. Don't see the reason to delay for an EKG if its not already done.

 

[sevoflurane]

at all the hospitals in my system, as far as I've encountered, the EKGs are all read (eventually) by a cardiologist and officially 'signed off' on the machine read. I'm sure that results in some kind of 100$+ charge.

This guy doesn't even have any of the 'clinical risk factors' as defined by the aha/acc guidelines (known cad, known chf, CVA, dm, CKD) Low/moderate risk surgery (this could probably be done under local by surgeon with no anesthesiologist/anesthesia, technically) and good functional capacity. Don't see the reason to delay for an EKG if its not already done.

Great. Now let's say he's going in for a lap chole. EKG shows new MI that wasn't on the old EKG from 2 years ago. EKG reads MI: "Age undetermined"

 

[BLADEMDA]

at all the hospitals in my system, as far as I've encountered, the EKGs are all read (eventually) by a cardiologist and officially 'signed off' on the machine read. I'm sure that results in some kind of 100$+ charge.

This guy doesn't even have any of the 'clinical risk factors' as defined by the aha/acc guidelines (known cad, known chf, CVA, dm, CKD) Low/moderate risk surgery (this could probably be done under local by surgeon with no anesthesiologist/anesthesia, technically) and good functional capacity. Don't see the reason to delay for an EKG if its not already done.

About ten years ago my department (anesthesiology) stopped the stupid practice of getting the EKG read by a Cardiologist. Instead, we refer/consult Cards on the 1% of EKGs when indicated

 

[Dwindlin]

About ten years ago my department (anesthesiology) stopped the stupid practice of getting the EKG read by a Cardiologist. Instead, we refer/consult Cards on the 1% of EKGs when indicated

We can't do that here. ECGs get uploaded to the EHR automatically from the machine (as well as a print out) and EVERY ECG done in the entire hospital (including ED) is eventually read by a cardiologist. Wasteful, but made for a nice high yield rotation as a med student (go in, read a 100+ ECGs with the Cardiologist and call it a day around lunch).

 

[BLADEMDA]

We can't do that here. ECGs get uploaded to the EHR automatically from the machine (as well as a print out) and EVERY ECG done in the entire hospital (including ED) is eventually read by a cardiologist. Wasteful, but made for a nice high yield rotation as a med student (go in, read a 100+ ECGs with the Cardiologist and call it a day around lunch).

Actually I disagree with you here. If the ordering Attending is an Anesthesiologist then nothing prevents the department from stating EKGs do not need to be read by a Cardiologist. Does a Pulmonary Specialist or CC doc need to read every ABG? Does a Hematologist need to evaluate every CBC?

Some HMOs have stopped letting Radiologists read every CXR and instead lets the Primary Doc look at it first. He/She can then ask for a Radiology read if abnormal.

 

[Libertas]

Great. Now let's say he's going in for a lap chole. EKG shows new MI that wasn't on the old EKG from 2 years ago. EKG reads MI: "Age undetermined"

I assume you mean a totally elective lap chole? Situation hasn't changed much. He is for a moderate cardiac risk surgery, but he has excellent functional capacity. In absence of active cardiac conditions, the guidelines state to proceed without further workup.

http://content.onlinejacc.org/data/journals/jac/23103/m_09001_gr1.jpeg

 

[dpmd]

You ask the orthopod not to order unnecessary EKG's again?

Eh, he probably trained or works somewhere where everyone above x age (50 where I trained) needs a preop cxr and EKG so that anesthesia won't delay the case.

 

[Dwindlin]

Actually I disagree with you here. If the ordering Attending is an Anesthesiologist then nothing prevents the department from stating EKGs do not need to be read by a Cardiologist. Does a Pulmonary Specialist or CC doc need to read every ABG? Does a Hematologist need to evaluate every CBC?

Some HMOs have stopped letting Radiologists read every CXR and instead lets the Primary Doc look at it first. He/She can then ask for a Radiology read if abnormal.

No one asks for this to happen, It's automatic. ECGs are treated like imaging here. Every piece of imaging gets read by the Radiologist at some point (plain films for example do not get read on the weekend unless you call and ask, they all get read Monday), we can't get an x-ray and ask that it not be read by the Radiologist. Same goes with ECGs. Now this wouldn't add time, once I order it, I have it in hand and in the EHR in a few minutes, I don't have to wait on the Cardiologist to over read to make decisions, but it will be over read whether I want it or not.

 

[Dwindlin]

Eh, he probably trained or works somewhere where everyone above x age (50 where I trained) needs a preop cxr and EKG so that anesthesia won't delay the case.

Every case (and I do mean every case) at the VA here requires a CBC, BMP, Coags, ECG, and CXR within 30 days of surgery or it will automatically get canceled morning of. It's awful.

 

[dpmd]

Every case (and I do mean every case) at the VA here requires a CBC, BMP, Coags, ECG, and CXR within 30 days of surgery or it will automatically get canceled morning of. It's awful.

It wasn't that bad, but even for a local/MAC case on a young fairly healthy person we had to order at least an H/H. Of course, this was something we were taught by our seniors or attendings so maybe it was just urban legend. Regardless, it wasn't like I was going to be the one to not order it and get in trouble for causing a delay. Now that I am in private practice I try to not order still unless I think it makes a difference (in which case I want it before the day of surgery), and I guess I will figure out if it is a problem with any of the anesthesiologists (or maybe stuff will just get ordered per protocol like happens for my inpatients that I add on for the following day).

 

[Laryngophed]

Every case (and I do mean every case) at the VA here requires a CBC, BMP, Coags, ECG, and CXR within 30 days of surgery or it will automatically get canceled morning of. It's awful.

That sounds like an efficient use of resources. I'm sure there is a big chunk of patients who have underlying disease that would justify some of those exams, but I'm guessing that there are just as many that don't have any indication for preop testing.

 

[sevoflurane]

I assume you mean a totally elective lap chole? Situation hasn't changed much. He is for a moderate cardiac risk surgery, but he has excellent functional capacity. In absence of active cardiac conditions, the guidelines state to proceed without further workup.

http://content.onlinejacc.org/data/journals/jac/23103/m_09001_gr1.jpeg

Exactly. So many individuals out there that cancel cases... It can be frustrating. Very rarely do I cancel a case...but it does happen on occasion. The ones that I'm not sure of the day of surgery, I try and look at the heart myself.

My advise for some of you in training is to do some extra cardiology rotations. In particular, a couple of TTE rotations would be ideal. If your program doesn't have it... set it up! Echo lab all day long... untlil you are super sick of it. You'll carry that into your practice. Trust me.

It is very easy to assess global function with transthoracic echo if you need it. Very useful. You place the probe and after you've seen a couple hundered of them you'll get the big picture. You don't have to calculate a pisa, or a regurtitant oriface area, or a pressure half time or look at E/A ratios... or any of that advanced stuff. 99% of the time you can decide if the patient is ready to go if you are able to place color flow on valves and asses global function +H/P. Some are good to go, some have DCM and all sorts of regional wall abnormalities with 3+ MR. You can learn to see the big picture... just like when you first picked up the USD machine for USD guided nerve blocks.

You never know until you do it.... so do it.

I find this arena a great place for us as a proffesional organization to expand.

Imagine an anesthesia group with a pre-op clinic that does their own TTE/TEE and has an echo team ready for deployment. Do we really need to send them to cardiology? Most of the time, the answer is: NO.

Learn this stuff anesthesia peeps. It is worth it.

 

[sevoflurane]

 

[pgg]

Great. Now let's say he's going in for a lap chole. EKG shows new MI that wasn't on the old EKG from 2 years ago. EKG reads MI: "Age undetermined"

I assume you mean a totally elective lap chole? Situation hasn't changed much. He is for a moderate cardiac risk surgery, but he has excellent functional capacity. In absence of active cardiac conditions, the guidelines state to proceed without further workup.

http://content.onlinejacc.org/data/journals/jac/23103/m_09001_gr1.jpeg

A devil's advocate (or contrary oral board examiner) might argue that the "age undetermined" MI could've occurred in the last 30 days, which would be an active cardiac condition. How do you know the event wasn't 29 days ago?

Of course, they're called guidelines for a reason, we're allowed to use our judgment and do the right thing for the patient despite them.

 

[Dwindlin]

Exactly. So many individuals out there that cancel cases... It can be frustrating. Very rarely do I cancel a case...but it does happen on occasion. The ones that I'm not sure of the day of surgery, I try and look at the heart myself.

My advise for some of you in training is to do some extra cardiology rotations. In particular, a couple of TTE rotations would be ideal. If your program doesn't have it... set it up! Echo lab all day long... untlil you are super sick of it. You'll carry that into your practice. Trust me.

It is very easy to assess global function with transthoracic echo if you need it. Very useful. You place the probe and after you've seen a couple hundered of them you'll get the big picture. You don't have to calculate a pisa, or a regurtitant oriface area, or a pressure halt time or look at E/A ratios... or any of that advanced stuff. 99% of the time you can decide if the patient is ready to go if you are able to place color flow on valves and asses global function +H/P. Some are good to go, some have DCM and all sorts of regional wall abnormalities with 3+ MR. You can learn to see the big picture... just like when you first picked up the USD machine for USD guided nerve blocks.

You never know until you do it.... so do it.

I find this arena a great place for us as a proffesional organization to expand.

Imagine an anesthesia group with a pre-op clinic that does their own TTE/TEE and has an echo team ready for deployment. Do we really need to send them to cardiology? Most of the time, the answer is: NO.

Learn this stuff anesthesia peeps. It is worth it.

This is something I am very interested in, did you do this yourself? If so, when did you work it in? Coming to the end of internship, and unfortunately surgery interns here do not get elective time (thus I didn't get any electives this year).

 

[Random Anesthesiologist]

Exactly. So many individuals out there that cancel cases... It can be frustrating. Very rarely do I cancel a case...but it does happen on occasion. The ones that I'm not sure of the day of surgery, I try and look at the heart myself.

My advise for some of you in training is to do some extra cardiology rotations. In particular, a couple of TTE rotations would be ideal. If your program doesn't have it... set it up! Echo lab all day long... untlil you are super sick of it. You'll carry that into your practice. Trust me.

It is very easy to assess global function with transthoracic echo if you need it. Very useful. You place the probe and after you've seen a couple hundered of them you'll get the big picture. You don't have to calculate a pisa, or a regurtitant oriface area, or a pressure halt time or look at E/A ratios... or any of that advanced stuff. 99% of the time you can decide if the patient is ready to go if you are able to place color flow on valves and asses global function +H/P. Some are good to go, some have DCM and all sorts of regional wall abnormalities with 3+ MR. You can learn to see the big picture... just like when you first picked up the USD machine for USD guided nerve blocks.

You never know until you do it.... so do it.

I find this arena a great place for us as a proffesional organization to expand.

Imagine an anesthesia group with a pre-op clinic that does their own TTE/TEE and has an echo team ready for deployment. Do we really need to send them to cardiology? Most of the time, the answer is: NO.

Learn this stuff anesthesia peeps. It is worth it.

I had great exposure to critical care in my intern year this year and am really considering a fellowship. A lot of programs I've looked at allow you to get advanced training in TEE and TTE. And this goes without saying for a CV fellowship. I think this is an excellent area to expand those qualifications as well.

 

[Noyac]

Full steam ahead. For me this is a Bier block with a splash of propofol during the case.

Splash of propofol? He'll I didn't get any propofol for my ctr. Where were you when I needed you?

 

[sevoflurane]

Of course, they're called guidelines for a reason, we're allowed to use our judgment and do the right thing for the patient despite them.

That's it. 👍

We can use the tools we've been trained to use. Our experienced judgement goes a long ways. Guidelines are exactly that. You need to know them, but we also need to efficiently be able to use them. An EKG w/ a change w/in the last 2 years deserves attention. But that is not the be all and end all... as you know.

How much weight do you really give a moderate-high risk cardiac clearance? 🙄
It is only part of the puzzle. I rather see the data than hear it's high or low risk or whatever.
We posses the best knowledge as to how these cases can go intra-op as well. Unique to us and not the cardiologist.

We are there every day in the OR. We know these cases and we know the surgeons.

 

[Noyac]

Of course, they're called guidelines for a reason, we're allowed to use our judgment and do the right thing for the patient despite them.

Precisely. This is the reason we have different views on this case. My take on this case as I stated before is that this guy presents to me as a setup. I have no doubts that I can get him through this hernia repair without incident however, he needs an ECG in my opinion. No, I will not delay the case for one. Yes, I will share it with his cardiologist either before or after the case. No, it will not change my management of the case 90% of the time. But to me he has serious risks of a major cardiac event, not during surgery but possibly during sex or yard work or whatever. He hasn't seen his cardiologist in over a year and essentially has untreated HTN with additional risk factors. I'm getting him an ECG for his record. And I'm calling his cardiologist to make him a follow up appt most likely.
I live and work in a fairly small medical community. I know every cardiologist by first name as well as they know mine. This is easy for me to do here. Maybe not in other communities.

 

[Libertas]

What do you mean he needs an EKG, but you would not delay the case for one?

 

[GaseousClay]

Precisely. This is the reason we have different views on this case. My take on this case as I stated before is that this guy presents to me as a setup. I have no doubts that I can get him through this hernia repair without incident however, he needs an ECG in my opinion. No, I will not delay the case for one. Yes, I will share it with his cardiologist either before or after the case. No, it will not change my management of the case 90% of the time. But to me he has serious risks of a major cardiac event, not during surgery but possibly during sex or yard work or whatever. He hasn't seen his cardiologist in over a year and essentially has untreated HTN with additional risk factors. I'm getting him an ECG for his record. And I'm calling his cardiologist to make him a follow up appt most likely.
I live and work in a fairly small medical community. I know every cardiologist by first name as well as they know mine. This is easy for me to do here. Maybe not in other communities.

why would he need to see a cardiologist for essential hypertension and a >10MET exercise tolerance. I think get a preop ekg and proceed but just go back to his regular pcp and get that htn better controlled.

 

[Noyac]

why would he need to see a cardiologist for essential hypertension and a >10MET exercise tolerance. I think get a preop ekg and proceed but just go back to his regular pcp and get that htn better controlled.

Sure a PCP physician may be fine but he has already seen a cardiologist so I'd recommend he see him/her again.

 

[sevoflurane]

This is something I am very interested in, did you do this yourself? If so, when did you work it in? Coming to the end of internship, and unfortunately surgery interns here do not get elective time (thus I didn't get any electives this year).

Def. doable. 4 year programs are probably easier to get it set up as they often include 2-3 months of electives. Transitional years also allow more flexibility w/ this regard, but doing a rotation as a CA-1 and then doing it again a couple of years later might be the way to go. There are other ways to get this experience.
As a senior on the acute pain service, I'd always make my way to the Cardiac ORs to pick up the TEE probe. By then, there wasn't much more to learn w/ regards to regional anesthesia. More knowledge could be had in the CT ORs. Furtherore, we convinced the CT staff to set up an evening TEE/TTE class for those of us willing to learn. Although sticking around voluntarily until 7pmish was challanging after a long day as a resident... the proagram was an immediate success. Very helpful.

 

[Dwindlin]

Def. doable. 4 year programs are probably easier to get it set up as they often include 2-3 months of electives. Transitional years also allow more flexibility w/ this regard, but doing a rotation as a CA-1 and then doing it again a couple of years later might be the way to go. There are other ways to get this experience.
As a senior on the acute pain service, I'd always make my way to the Cardiac ORs to pick up the TEE probe. By then, there wasn't much more to learn w/ regards to regional anesthesia. More knowledge could be had in the CT ORs. Furtherore, we convinced the CT staff to set up an evening TEE/TTE class for those of us willing to learn. Although sticking around voluntarily until 7pmish was challanging after a long day as a resident... the proagram was an immediate success. Very helpful.

Thanks. I'm planning on doing CC fellowship. One of my complaints has been since it's only a year there isn't a whole lot of time to spend some dedicated time to things like TTE/Bronchs/etc. Nice to hear it's not impossible to get a good handle on some of this as a resident.