pre op EKGs: worthless?

[caligas]

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I've now been practicing almost 10 years and I can't think of a single time that an EKG affected the ultimate management of a patient. I take a good history and exam, and this info quite frequently affects management. I think we should reconsider the frequency that EKGs are used pre op.

 

[BLADEMDA]

I've now been practicing almost 10 years and I can't think of a single time that an EKG affected the ultimate management of a patient. I take a good history and exam, and this info quite frequently affects management. I think we should reconsider the frequency that EKGs are used pre op.

EKGs are valuable tools for a small Group of patients. In particular, higher risk patients benefit from a preop EKG because this establishes a baseline for an MD to compare with later in the perioperative course (e.g. PACU).

In addition, I have caught new onset A. Fib from an EKG in the holding area. What about third degree heart block or other issues?

The complete elimination of a preop EKG is a bad idea based upon my extensive experience taking care of an elderly population.

 

[sevoflurane]

EKGs are valuable tools for a small Group of patients. In particular, higher risk patients benefit from a preop EKG because this establishes a baseline for an MD to compare with later in the perioperative course (e.g. PACU).

In addition, I have caught new onset A. Fib from an EKG in the holding area. What about third degree heart block or other issues?

The complete elimination of a preop EKG is a bad idea based upon my extensive experience taking care of an elderly population.

+1

or... what about new Q waves that were not there before in the diabetic female undergoing a fem-pop....?

 

[sevoflurane]

That being said, we don't get EKG's on all comers over 40 y/o. That's overkill.

You need to take into consideration the procedure (mainly vascular and big cases) AND the patients medical condition.

 

[Mman]

I've now been practicing almost 10 years and I can't think of a single time that an EKG affected the ultimate management of a patient. I take a good history and exam, and this info quite frequently affects management. I think we should reconsider the frequency that EKGs are used pre op.

I've had many times in PACU that I was glad I had a preop EKG to compare to when a patient was complaining of chest pain. I don't think the point of an EKG preop is to change your management. It's to provide a baseline.

then again you do sometimes catch new a-fib or flipped t waves that weren't there 6 months ago,etc.

 

[Endee]

In the last two days, we had 2 patients that had their surgeries postponed because of ECGs taken in the holding area. One was a 2 minute run of VT and another was new Afib @ 140bpm, both in ~80 year olds.

 

[Planktonmd]

The problem is: we don't really know if getting an EKG pre-op actually improves outcome!
I like EKG's and used to order them left and right... but one day we converted to electronic records and it became a pain in the arse to see an EKG, so for about a month, until we learned the system, I hardly looked at one EKG (I know... It's wrong)...
Anyway... no one died during that month... no one had any problems that I did not anticipate!
So... is it really life saving to discover a new Afib pre-op and cancel the surgery?
Is a q wave in an asymptomatic patient important?
I don't know!

 

[OB1🤙]

I can think of a much cheaper way than an ekg to detect afib in preop. Unfortunately it involves examining the patient, so it's a little old school.

 

[Planktonmd]

I can think of a much cheaper way than an ekg to detect afib in preop. Unfortunately it involves examining the patient, so it's a little old school.

👍

 

[Mman]

I can think of a much cheaper way than an ekg to detect afib in preop. Unfortunately it involves examining the patient, so it's a little old school.

It's also far cheaper to have a preop EKG than having a full cardiac workup in PACU on a patient with some EKG abnormalities that were present preop but you didn't know it.

EKGs aren't for everybody. But for moderate to high risk patients, they can be valuable. Would you request an EKG on a 70 year old man for a carotid that was diabetic and hypertensive and had a Crt of 1.5 if he hadn't had one in the last 5 years? Or would you proceed without?

 

[Planktonmd]

It's also far cheaper to have a preop EKG than having a full cardiac workup in PACU on a patient with some EKG abnormalities that were present preop but you didn't know it.

EKGs aren't for everybody. But for moderate to high risk patients, they can be valuable. Would you request an EKG on a 70 year old man for a carotid that was diabetic and hypertensive and had a Crt of 1.5 if he hadn't had one in the last 5 years? Or would you proceed without?

If you request an EKG on this above mentioned patient and it shows let's say q waves in the inferior leads and you don't have a previous EKG to compare with.
You have already spoke to the patient and he told you that he runs 5 miles every day and is training for a marathon, what would you do next?

 

[Mman]

If you request an EKG on this above mentioned patient and it shows let's say q waves in the inferior leads and you don't have a previous EKG to compare with.
You have already spoke to the patient and he told you that he runs 5 miles every day and is training for a marathon, what would you do next?

I'd do the case. Why? Cardiology would suggest the same if you got a consult. Asymptomatic active patient for a low to intermediate risk procedure.

 

[seinfeld]

I would guess that the NNT would be extremely high but because its a cheap, non-invasive test it makes sense to CYA in the high risk patient. Most old timers, and those who would assist the plaintiff, would argue along those lines.

I do a lot of cardiac, most do not have EKGs that "scare" me (except those coming direct from the cath lab and then who gives a flying monkey about the ECG) . The history often times is worse that the EKG. A corollary is that those that do have significant events rarely have a history...until they have a history....

My last patient in the ICU with Cardiogenic shock from coronary disease (95% acute occlusion of LAD) was in a 38 y/o (Tox screen neg).

 

[Mman]

I would guess that the NNT would be extremely high but because its a cheap, non-invasive test it makes sense to CYA in the high risk patient. Most old timers, and those who would assist the plaintiff, would argue along those lines.

I don't think it's CYA. I think it's that we have a consensus guideline from the American Heart Association and American College of Cardiology that describes which patients should get a preop EKG, including class 1 recommendations for some patients and IIa and IIb for others. It's evidence based.

Need a pretty strong reason to forgo a preop EKG in a patient that experts and evidence both suggest should get one. It's completely noninvasive and carries no risk to the patient.

 

[ssmallz]

The history often times is worse that the EKG. A corollary is that those that do have significant events rarely have a history...until they have a history....

Great quote......I definatly agree. I feel like there are too many EKGs ordered and I look at them because they are there but they very rarely change my management. Most the real cardiac assessment is done by a good solid H&P. If I have any questions an echo or stress is often needed anyway regardless of what the EKG looks like

 

[Planktonmd]

I'd do the case. Why? Cardiology would suggest the same if you got a consult. Asymptomatic active patient for a low to intermediate risk procedure.

So, the presence of an EKG abnormality did not change your plan and you based your decision on the clinical exam and the history.
Did you really need the EKG?

 

[cincincyreds]

I think those preop EKGs are useful. I picked up a new LBBB for a podiatry case. I canceled the case, and was yelled and cursed at by the podiatrist.

I followed up and saw the patient next week on the CABG schedule.

I love being treated like dirt. It makes me feel good about myself.

 

[caligas]

So, the presence of an EKG abnormality did not change your plan and you based your decision on the clinical exam and the history.
Did you really need the EKG?

Glad it worked out ok, that said, I would not cancel a podiatry case for a LBBB in the absence of other findings on history and physical.

 

[Mman]

So, the presence of an EKG abnormality did not change your plan and you based your decision on the clinical exam and the history.
Did you really need the EKG?

As I said previously, the preop EKG is often useful in the postop period. It isn't a test that changes intraop management much at all.

Do you not believe a test is worth getting if it will only help postop? I mean in PACU you can't go back and get a pre-op EKG if you didn't have it in the first place when the patient has some abnormalities.

It's harmless and provides useful information to compare to in the periop period. And if you ask your cardiologist for a consult at any point in the first 48-72 hours postop, they are really going to be disappointed if there wasn't a preop EKG to compare to.

 

[Mman]

I think those preop EKGs are useful. I picked up a new LBBB for a podiatry case. I canceled the case, and was yelled and cursed at by the podiatrist.

I followed up and saw the patient next week on the CABG schedule.

I love being treated like dirt. It makes me feel good about myself.

We have a handful of patients every year that end up getting a CABG because of abnormalities picked up on their preop EKG. It's not common, but it's not unheard of either.