Preop Testing for Endoscopy

[Aether2000]

Our hospital has a very busy endoscopy unit that includes bronch, cardioversions, US guided biopsies, colonoscopy, EGD, and TEE. Often these are the sickest patients we see for an anesthetic in the hospital and have multiple active and significant co-morbidies. Most are ASA III or IV patients that have been selected by the surgeons to not have these procedures in surgeon owned ambulatory surgery centers. Our surgeons frequently supply no lab studies, ECG, or cardiac workup on these patients, and expect no delays in the start time of their procedures for labs for these patients that are first seen by anesthesiology 10 minutes before the procedure as soon as the patients arrive. The surgeons refuse to send the patients to a preop clinic, and refuse to obtain labs from the PCPs to send to us with the patient or in advance, arguing they do their surgery center cases without any lab studies. Many patients are on renal dialysis where lab studies are obtained only once a month.

We are in the process of obtaining iStat cartridges to give us point of service lab testing on arrival as a solution to having lab tests available when needed (our hospital lab takes 45 min turnaround on lab studies). Should anesthesiologists have lower pre-op testing standards for these very sick patients or a much wider latitude in doing the anesthetic in cases of significant lab abnormalities since as the surgeons claim "they are only 10 minute cases" (but of course many times they are not)?

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[Planktonmd]

The question is what are you looking for in the pre-op visit that may alter the way you manage these patients for these minor procedures and can not be addressed on the day of the procedure?
What labs or tests do you need?

 

[caligas]

I think the primary issue is potassium...is there a reason that they make have a critically abnormal level such as renal insufficiency, taking supplemental, diuretics etc. The istat is a great solution, fast and reliable and need very little blood.

 

[pjl]

The question is what are you looking for in the pre-op visit that may alter the way you manage these patients for these minor procedures and can not be addressed on the day of the procedure?
What labs or tests do you need?

Also, are any of these tests going to stop you from sedating a patient for a colonoscopy, or change your plan in any way?
Remember, these patients have already done the prep.
Just be smart about what you actually need and how it will actually change anything, most of the time we are ordering testing that won’t affect management on these cases.

 

[Aether2000]

The aberrations in lab values that would cause cancellation of the anesthetic are indeed few, but for an elective colonoscopy would a potassium level of 6.0 be problematic? Or a sodium level of 125? Or previously undiagnosed atrial flutter? These were found within the past month on patients presenting without labs or ECG for endoscopy.

 

[nimbus]

The surgeons refuse to send the patients to a preop clinic, and refuse to obtain labs from the PCPs to send to us with the patient or in advance, arguing they do their surgery center cases without any lab studies. Many patients are on renal dialysis where lab studies are obtained only once a month.

In that case tell them they can go ahead and do the case at the surgicenter with no labs. Why did they even bring them to you if they don’t want your expert opinion?

 

[dannyboy1]

In that case tell them they can go ahead and do the case at the surgicenter with no labs. Why did they even bring them to you if they don’t want your expert opinion?

How sweet. You still think a surgeon wants your opinion. They want you to do the case with minimal delays. They bring them to the hospital because they are sick and want more help available if **** hits the fan

 

[nimbus]

How sweet. You still think a surgeon wants your opinion. They want you to do the case with minimal delays. They bring them to the hospital because they are sick and want more help available if **** hits the fan

Yes they actually ask my opinion. I’ve been working with many of them for 15 years. I rarely cancel cases but I never get pushback when I do.

Do your surgeons push back about checking potassium on dialysis patients? Ours never do. They know it would be useless and most of them actually care about avoiding unnessary complications.

Sorry you work in a sh**** environment where you get no respect.

 

[NightNight]

Should anesthesiologists have lower pre-op testing standards for these very sick patients or a much wider latitude in doing the anesthetic in cases of significant lab abnormalities since as the surgeons claim "they are only 10 minute cases" (but of course many times they are not)?

Not a question you want opposing counsel asking you in front of a jury....

 

[anbuitachi]

Our hospital has a very busy endoscopy unit that includes bronch, cardioversions, US guided biopsies, colonoscopy, EGD, and TEE. Often these are the sickest patients we see for an anesthetic in the hospital and have multiple active and significant co-morbidies. Most are ASA III or IV patients that have been selected by the surgeons to not have these procedures in surgeon owned ambulatory surgery centers. Our surgeons frequently supply no lab studies, ECG, or cardiac workup on these patients, and expect no delays in the start time of their procedures for labs for these patients that are first seen by anesthesiology 10 minutes before the procedure as soon as the patients arrive. The surgeons refuse to send the patients to a preop clinic, and refuse to obtain labs from the PCPs to send to us with the patient or in advance, arguing they do their surgery center cases without any lab studies. Many patients are on renal dialysis where lab studies are obtained only once a month.

We are in the process of obtaining iStat cartridges to give us point of service lab testing on arrival as a solution to having lab tests available when needed (our hospital lab takes 45 min turnaround on lab studies). Should anesthesiologists have lower pre-op testing standards for these very sick patients or a much wider latitude in doing the anesthetic in cases of significant lab abnormalities since as the surgeons claim "they are only 10 minute cases" (but of course many times they are not)?

Sounds like a ****ty work environment and you are getting pushed around by the surgeons. Like the surgeons said, if they argue that they do teh cases in their surgery centers without labs then go back to the surgery center to do it. Why even do it here.
People die from these procedures because surgeon/proceduralist says it's a quick/small case, its no big deal. Look at what happened to Joan rivers. Imagine having a ASA4 patient coming to you going for bronch or EGD with no labs, or any sort of workup but has bad cardiac history. I bet seeing an echo that says Severe AS, severe pHTN, RV/LV systolic function 10%, would change your management for your bronch. And when the lawyers ask you in court after you get sued for the arrest why you didn't get any work up, what are you going to say? The surgeon didn't let you? The surgeon will say the anesthesiologist absolutely should have gotten workups and it's the anesthesiologists fault this happened

 

[Twiggidy]

Yes they actually ask my opinion. I’ve been working with many of them for 15 years. I rarely cancel cases but I never get pushback when I do.

Do your surgeons push back about checking potassium on dialysis patients? Ours never do. They know it would be useless and most of them actually care about avoiding unnessary complications.

Sorry you work in a sh**** environment where you get no respect.

Agree. Even our crankiest surgeon at least has the sense enough to let us evaluate patients and make sure they’re optimized. This is whwre your leadership has to take a stand and make it clear that these tests aren’t needed just so you can cancel cases, but to make sure the patient is the best they can be for an anesthetic.

 

[Twiggidy]

. And when the lawyers ask you in court after you get sued for the arrest why you didn't get any work up, what are you going to say? The surgeon didn't let you? The surgeon will say the anesthesiologist absolutely should have gotten workups and it's the anesthesiologists fault this happened

this right here

 

[Psai]

Don't take that bull**** from the surgeons. Either they want to do it in the hospital with the anesthesiologist or they don't. I've only been doing this for a year and I've already seen some crazy happenings in the endo suites.

 

[DrOwnage]

How is a potassium level going to cancel a MAC case? It will be a little low from the prep, but its not general anesthesia which involves induction/stress response/fluid shifts/myocardial demand/blood loss. Only thing I could see is if the patient is on a large dose of diuretics and happened to take them with the prep. Would you even cancel a MAC case for a potassium of around 3 or even 6?

 

[Arch Guillotti]

How is a potassium level going to cancel a MAC case?

Arrhythmia.

 

[Consigliere]

Here are all the labs and tests I order for endo procedures:










Thank you

 

[DrOwnage]

Chronic renal failure patients will often tolerate a higher than normal serum potassium without detrimental effects due to adaptation. But I don't see a low potassium causing an arrhythmia without a very acute change, and a low stress MAC shouldn't throw someone into one. Why not just get an EKG to look for changes instead if really worried.

 

[T-burglar]

I would only want a workup if there is clear suspicion for something that may arrest with light sedation .

 

[nimbus]

Ok so most of you do not check potassium on dialysis patients before an endoscopy? What about a glucose on diabetics? Where I work they are both required before getting anesthesia of any sort and are part of our standing preop orders.

 

[anbuitachi]

Ok so most of you do not check potassium on dialysis patients before an endoscopy? What about a glucose on diabetics? Where I work they are both required before getting anesthesia of any sort and are part of our standing preop orders.

We do but it is departmental policy so it's not like we have much of a choice.

 

[Aether2000]

Potassium is not constant during endoscopy due to hypercarbia and lack of practical airway access...It is elevation of K from 6.5 to 6.9 that is our concern.

 

[Twiggidy]

Ok so most of you do not check potassium on dialysis patients before an endoscopy? What about a glucose on diabetics? Where I work they are both required before getting anesthesia of any sort and are part of our standing preop orders.

Im less concerned about Glucose than I am about Potassium for reason said above. With dialysis patients I’d like to know what I’m getting into and if for some strange reason there is an arrest I’ll have a good idea where to start. With dialysis patients, you gotta give me something.

 

[nimbus]

We do but it is departmental policy so it's not like we have much of a choice.

Potassium is not constant during endoscopy due to hypercarbia and lack of practical airway access...It is elevation of K from 6.9 to 6.5 that is our concern.

Im less concerned about Glucose than I am about Potassium for reason said above. With dialysis patients I’d like to know what I’m getting into and if for some strange reason there is an arrest I’ll have a good idea where to start. With dialysis patients, you gotta give me something.

Thanks for replies. I was surprised by some of the earlier responses and wanted to know what people actually do in the real world and not hypothetical Internet forum world.

 

[BeatriZZ]

At our ASC we do Conscious Sedation as well as MAC endos. One of their CS stroked out in the pre-procedure area before undergoing his colonoscopy. Could have easily happened post-procedure and if it was a MAC, anesthesia would be blamed.

A little versed and propofol probably won't hurt even the sickest patient, but if someone has a K of 6.5 and they arrest in PACU, best believe you will be blamed. Bad stuff happens to sick poorly optimized patients and even if you didn't cause the stuff if your name is on the chart you will be held responsible just by nature of being involved in the peri-operative period.

I wonder if all the cowboys who scoff at testing for "minor procedures" think the same holds true if it's their family member. Do what's best for the patient, they are depending on you

 

[sigrhoillusion]

At our ASC we do Conscious Sedation as well as MAC endos. One of their CS stroked out in the pre-procedure area before undergoing his colonoscopy. Could have easily happened post-procedure and if it was a MAC, anesthesia would be blamed.

A little versed and propofol probably won't hurt even the sickest patient, but if someone has a K of 6.5 and they arrest in PACU, best believe you will be blamed. Bad stuff happens to sick poorly optimized patients and even if you didn't cause the stuff if your name is on the chart you will be held responsible just by nature of being involved in the peri-operative period.

I wonder if all the cowboys who scoff at testing for "minor procedures" think the same holds true if it's their family member. Do what's best for the patient, they are depending on you

"CS stroked out in the pre-procedure"

So the GI doc asked for anesthesia due to now being an ASA3 and asked for light sedation, right? 🙄