Preop spiel about anesthesia risks

[codeb1ue]

What is your typical spiel you give to patients when you meet them in the preop holding? I find over time I have been saying less and less due to causing unnecessary anxiety but I realized I may be going too far the opposite direction. For GA I really only focus on N/V and sore throat and not so much about cardiovascular risk factors or even dental injury now and for MAC I still go back and forth about awareness but some patients get visibly nervous when I even bring up that word despite it being a sedation only case.

Obviously I am referring mainly to your average risk patients for average moderate risk elective surgery cases.

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[anbuitachi]

What is your typical spiel you give to patients when you meet them in the preop holding? I find over time I have been saying less and less due to causing unnecessary anxiety but I realized I may be going too far the opposite direction. For GA I really only focus on N/V and sore throat and not so much about cardiovascular risk factors or even dental injury now and for MAC I still go back and forth about awareness but some patients get visibly nervous when I even bring up that word despite it being a sedation only case.

Obviously I am referring mainly to your average risk patients for average moderate risk elective surgery cases.

Depends on how sick the patient is. If significant cardiopulmonary disease I let them know perhaps stay tubed and go to ICU or there's higher risk of cardiac issues.

Otherwise for elective somewhat healthy cases I just tell them sore throat. Sometimes mention nausea. For Mac cases I make sure they know they may be awake. I've had a number of patients tell me they had awareness in previous anesthetic and I look at chart and they were Mac cases.

A side note, when i was in residency i took over a case from CRNA that was just starting a case. she gave 2 midaz to some old guy and told me every MAC case needs to get midaz, because if the patient remembers, they will sue you.

 

[2Fast2Des]

Depends on how sick the patient is. If significant cardiopulmonary disease I let them know perhaps stay tubed and go to ICU or there's higher risk of cardiac issues.

Otherwise for elective somewhat healthy cases I just tell them sore throat. Sometimes mention nausea. For Mac cases I make sure they know they may be awake. I've had a number of patients tell me they had awareness in previous anesthetic and I look at chart and they were Mac cases.

A side note, when i was in residency i took over a case from CRNA that was just starting a case. she gave 2 midaz to some old guy and told me every MAC case needs to get midaz, because if the patient remembers, they will sue you.

I had a CRNA give me a break once and put a bis on, and she said she did it "because he's young"....

 

[TheLoneWolf]

I had a CRNA give me a break once and put a bis on, and she said she did it "because he's young"....

Haha I had an attending tell me that for a case I took over. I think it was a stable geriatric patient on et sevo of 1.6 or 1.7. Told her it wasn't necessary and that data says it's useless for intraop recall. She was like " I feel better using this and to document it, and the hospital payed for these and we should use it."

 

[codeb1ue]

For Mac cases I make sure they know they may be awake. I've had a number of patients tell me they had awareness in previous anesthetic and I look at chart and they were Mac cases.

That is precisely why I always mention awareness but many always seem so shocked by this . I typically say you may be a little awake BUT you will be comfortable. I always find this part the hardest for patients to digest.

 

[pgg]

I typically mention the benign stuff when talking about what we're doing. Then I cover the nasty stuff when going over our anesthesia consent form so I can add some context. Something like "this section lists many possible complications from anesthesia, including the common things we talked about like nausea and sore throat, but it also mentions serious things. I think the odds of you having a prolonged hospital stay, organ damage, disability, or dying is [insert very reassuring or less reassuring words depending on patient & surgery]. In any case my only job is to maximize your safety and comfort" etc and in this way I mention and draw attention to the YOU MIGHT DIE bit without freaking them out.

In terms of provoking or not provoking anxiety, delivery matters more than the substance of the words.

 

[T-burglar]

I usually just talk about nausea sore throat anaphylaxis and nerve injuries


And I handwave the rest “there is a long list of things that can complicate any medical procedure including an anesthetic blah blah “

 

[Iso4ane]

As a resident I had been emphasizing safety over comfort.

For sedation cases, I tell them the sedation medications can affect your breathing, so possibilities include, we are able to rise that line, or either you remember glimpses and breath on you own, or you remember nothing and wake up with a sore throat.

 

[Mman]

sore throat, dental injury, and nausea are the common things I warn them about. I also mention the rare possibility of serious things like heart attack, stroke, or death but that we will all do our best to prevent anything bad from happening to them. If someone really pushes me on that, I tell them that there are people walking around right now that will have a heart attack today. I don't know who they are. One of them might even be scheduled to have surgery today. And if they happen to have a heart attack during or after surgery, we will do everything to treat it.

 

[nimbus]

For cataracts, I tell them “I will give you something to take the edge off but you will be awake. We need you to be aware of your surroundings and be able follow directions.”

If it’s a higher risk procedure (pump case) or a higher risk patient, then I will tell them they are at higher risk than average for things like stroke and heart attack. If it’s a knee scope or gallbladder on a healthy patient, I don’t mention it.

 

[MTGas2B]

“Are you nervous?”
“Yes.”
“Me too.”


Sent from my iPhone using SDN

 

[2Fast2Des]

“Are you nervous?”
“Yes.”
“Me too.”


Sent from my iPhone using SDN

"The needle won't hurt me a bit"

 

[Drwine]

We have a preprinted consent form. After going over the most common risks such as sore throat and nausea and that we don't anticipate causing dental damage, I then say that I need to repeat the equivalent of the last 5 seconds of a television drug commercial. I also mention that this is the same consent that I have families of 90 year olds who have broken their hip. Even the most anxious patients get it.

 

[BobLoblaw78]

I am not sure if the dental damage needs to be part of it unless they are a difficult airway. I think perioperative MI is more likely and more pertinent. Although, I don't mention that to every patient. For those with elevated risk, I tell them "there is risk with every case and with their condition it is elevated slightly but nothing that we don't know how to handle well."

For those that I talk about awareness, I tell them "you won't ever be awake enough to tell me you are starting to get uncomfortable" (except cataracts and others that get minimal sedation). That seems to put them at ease.

 

[Mman]

I am not sure if the dental damage needs to be part of it unless they are a difficult airway. I think perioperative MI is more likely and more pertinent.

While an MI is obviously worse, dental injury is the most common injury.

 

[BobLoblaw78]

While an MI is obviously worse, dental injury is the most common injury.

Is it though? I have followed up on more perioperative MI's in the past 2 years than I have dental damage. Maybe it is the difference between intraop MI and 30 day postop period for MI's. And, I think videolaryngoscopes has really come close to eliminating dental damage (I would appreciate you avoiding the jokes about my anesthetic technique and MI's.....I think 19 perioperative MI's is reasonable over 2 years)

 

[nimbus]

While an MI is obviously worse, dental injury is the most common injury.

Depends how hard you are looking for those MI’s.

Postoperative troponin surveillance: A diagnostic dilemma

Postoperative Troponin T and Mortality and Myocardial Injury After Noncardiac Surgery

The Enigma of Postoperative Troponin Elevation : Anesthesia & Analgesia

 

[Mman]

Is it though? I have followed up on more perioperative MI's in the past 2 years than I have dental damage. Maybe it is the difference between intraop MI and 30 day postop period for MI's. And, I think videolaryngoscopes has really come close to eliminating dental damage (I would appreciate you avoiding the jokes about my anesthetic technique and MI's.....I think 19 perioperative MI's is reasonable over 2 years)

From lawsuit data at the Closed Claims project...


I agree dental injuries are not that big of a deal, but they are the most likely thing to get sued for.

 

[pgg]

I agree dental injuries are not that big of a deal, but they are the most likely thing to get sued for.

Don't most people/practices handle any dental damage simply by saying "sorry" to the patient in PACU and then paying the $1000 or $2000 or whatever to get the patient's teeth fixed? If for no other reason, as part of good customer service and good will?

What's the typical scenario where one of these actually ends up ballooning into a lawsuit?

 

[drmwvr]

...She was like " I feel better using this and to document it, and the hospital payed for these and we should use it."

I was in a group that, on advice of counsel, got rid of their BIS monitors because the mere availability in the department would increase liability in the event the group was sued for a case of awareness/recall and one were not used. This was 15+ years ago...

 

[Drwine]

Don't most people/practices handle any dental damage simply by saying "sorry" to the patient in PACU and then paying the $1000 or $2000 or whatever to get the patient's teeth fixed? If for no other reason, as part of good customer service and good will?

What's the typical scenario where one of these actually ends up ballooning into a lawsuit?

We have been advised that as long as we disclose the risk that we should not and do not pay for dental damage.

 

[cchoukal]

A consensus statement on post-operative delirium published in AnA a couple months ago recommends that all patients over 65 should be informed about the risk of "perioperative neurocognitive disorder" (e.g., confusion, in attention, memory problems) after an operation. Anyone doing this?

 

[Mman]

we have a local dentist in town we send people to and we just directly pay

 

[pgg]

A consensus statement on post-operative delirium published in AnA a couple months ago recommends that all patients over 65 should be informed about the risk of "perioperative neurocognitive disorder" (e.g., confusion, in attention, memory problems) after an operation. Anyone doing this?

I wasn't aware of the statement.

I don't routinely talk about postop cognitive function. I usually mention delirium as a side effect of anesthesia when I'm talking to family members of very elderly patients. I guess I should be more consistent about it.

 

[jthedestroyr]

For cataracts, I tell them “I will give you something to take the edge off but you will be awake. We need you to be aware of your surroundings and be able follow directions.”

If it’s a higher risk procedure (pump case) or a higher risk patient, then I will tell them they are at higher risk than average for things like stroke and heart attack. If it’s a knee scope or gallbladder on a healthy patient, I don’t mention it.

I wish more people did this. I cant tell you how many people I hear tell me, "they woke up for anesthesia, so they wanted the university now." When we inquire more, 99.9% it was MAC case for colon/EGD.

 

[sigrhoillusion]

For normal general cases with generally healthy ASA1-3 patients with normal-ish airways, I mention N/V, sorethroat, low risk of dental/lip/gum damage, headaches, muscle soreness and soreness at the procedure site (albeit that's more surgical issue). I then tell them I don't expect any of the more serious complications (which are further in the consent) but someone will be present at all times and we have everything needed if something arises. "Feel free to read the consent, ask me any questions and when your're ready sign at the bottom." They usually sign right away.

For sedation/"MAC" cases I will mention low risk of hearing things/remembering but we tend to run them so deep it's probably not likely...

Obviously I cater consent to sicker patients or those with tough airways differently. Typical history, consent, plus physical exam takes me like 3-5 minutes. Of course I try to gather as much info about the patient from the EMR as possible before talking to them, so as not to have them waste 15 minutes trying to think of the little white pill they took that morning with a sip of water.

I've been debating about adding nerve injury/corneal abrasion to my schtick, since we've had an uptick in both of those in our department in the last few months...

 

[drmwvr]

Since the advent of the pre-procedure time out, my hospital has recently mandated "fire risk". Doesn't take much to score "high" fire risk and that is noted at that time. We're going to bring that to the attention of the OR management to demand it's part of the surgical/anesthesia consent.

https://www.ormanager.com/wp-content/uploads/pdfx/ORMVol22No1scoringFireRisk.pdf

 

[sigrhoillusion]

You may experience nausea, vomiting, sore throat and burning up in a pillar of flames...

 

[Iso4ane]

‘You may need a large central line and arterial line in case we have to transfuse large amounts of blood.’

“For an ingrown toenail?!”

‘You never know what may happen.’

 

[Psai]

‘You may need a large central line and arterial line in case we have to transfuse large amounts of blood.’

“For an ingrown toenail?!”

‘You never know what may happen.’

There's no such thing as a routine case. Some of our worst complications are in cases you'd never expect

 

[coffeebythelake]

A consensus statement on post-operative delirium published in AnA a couple months ago recommends that all patients over 65 should be informed about the risk of "perioperative neurocognitive disorder" (e.g., confusion, in attention, memory problems) after an operation. Anyone doing this?

are surgeons doing this? there is strong evidence that it isn't just the anesthetic, it also involves the stress and inflammation involved with the surgery

 

[Mman]

are surgeons doing this? there is strong evidence that it isn't just the anesthetic, it also involves the stress and inflammation involved with the surgery

simply being admitted to the hospital is a risk factor even in nonsurgical elderly patients. The older you get, being in an unfamiliar environment contributes to confusion. Throw in altered sleep cycles (or total lack thereof), polypharmacy, pain, etc. and it's what happens.

 

[nimbus]

Anecdote time.

My dad was admitted to the hospital for pneumonia 6 years ago at age 74. When I got there he was incontinent and didn’t recognize me. I honestly thought I would have to move him in me and hire a caregiver when he was discharged. Fortunately his delirium cleared up as his pneumonia was treated. He still lives independently and is very active but it was scary to see how tenuous we are.

 

[coffeebythelake]

I think also we need to distinguish delirium and postop cognitive dysfunction. They aren't the same thing.

 

[nimbus]

I think also we need to distinguish delirium and postop cognitive dysfunction. They aren't the same thing.

Yes but it would be hard to distinguish the two in the first few days postop. Cognitive dysfunction is a part of delirium. Is it postop, postanesthesia, drug induced, infectious, sleep deprivation, or just being in unfamiliar surroundings? Or a combination of any or all of these?

 

[bcat85]

My standard consent is sore throat, dental damage, and PONV plus “rare things” like heart/lung problems, medication reactions. I do a lot of cardiac, so I also provide more or less reassurance on those risks depending on how sick the patient is.

 

[Impromptu]

Many patients have the impression that the anesthesiologist is the man/woman who jumps in for 30 seconds before the surgery, and I think that impression is somewhat on reality. I have a bit of a longer talk with the patients, but I have found they really appreciate this. I have found that as you explain the type of anesthesia you are going to use, the risks naturally come out.

Sometimes I use a straightforward list, such as, "The risks of anesthesia include, but not limited to, death, disability, brain, breathing and heart problems of all different kinds, other organ problems, nerve problems, drug reactions. Then the smaller ones include nausea, sore throat, teeth damage, dry scratchy eyes, awareness during the procedure, forgetfulness afterward, and many other smaller ones."

That does not take too long to say, but may not convey the gravity of the situation properly. This is all patient specific. If I feel like expounding on any of the risks to make sure that understanding has happened, here are some transitions I use depending on the patient and situation.

"Any time we give powerful medications, bad things are possible. They are rare, but like with all statistics, if they happen to you, you are the one that has to deal with it. The most common one is nausea. Do you get nauseous easily? Other problems can include..."

"Part of the consent process is to tell you about risks that can happen. There are some more minor ones, like nausea, a sore throat, teeth damage, or scratchy eyes. Then there are the big bad ones, like not breathing, heart or brain problems of many different kinds..."

"There is a long list of bad things that can happen, but they are rare. For your COPD I am going to be watching your breathing very well, as low oxygen levels can cause very bad things to happen. Other things I will be watching for are..."

"Did you eat any breakfast today? No? Good, we do not want bacon and eggs and stomach acid to come into your lungs. Then we might have to leave you on a ventilator in the ICU. Not letting you eat breakfast was not meant as torture, but as a way to minimize risks. Other risks of anesthesia include..."

"For your child we are going to be giving general anesthesia. That means he/she will be all the way asleep and we will be breathing for them. No parent really wants to hear about all of the bad things that can happen under anesthesia. So if you do not want to hear them all, I will just say that bad things are possible, and that I will be paying especially close attention to your child's breathing and oxygen levels."

"While you are sleeping I am going to put a breathing tube in to breathe for you, as anesthesia can stop your breathing. Do you have any loose or chipped teeth? Any crowns or implants, especially in the front that I should especially worry about? I haven't knocked any teeth out yet, and I do not want you to be the first. It is a soft rubber breathing tube, but if you bite down hard while waking up, there is a chance of tooth damage, and I do not pay for new teeth."

"We will have you take out your dentures as we do not pay for new ones if they are broken."

"After anesthesia it may seem that your mom/dad has taken a step back in their dementia or forgetfulness. Pre-existing forgetfulness is one of the bigger risk factors. If this happens, it can last for the rest of the day, a few days, or even weeks. There is still ongoing research into the exact causes, because it can happen with different types of anesthetics, like spinals, sedation, general, even nerve blocks. I will try and give them as few medications as necessary, but it still may occur."