Proceed with or cancel case?

[divinemsm]

Advertisement - Members don't see this ad

65 y/o male for elective laparoscopic umbilical hernia repair-slow surgeon.
Patient has afib diagnosed 6 years ago, asymptomatic, non compliant with anticoagulation and rate control pharmacotherapy greater than 5 years. Patient is very active, no echo on file, no other co morbidities. Thoughts ?

 

[aneftp]

Check INR. If it's less than X number (varies by different hospitals/centers). Than proceed. Medium risk patient having low to medium risk surgery (more on the lower risk surgery side) with no symptoms.

Proceed if INR is relatively normal.

Having slow surgeon has no baring on my decision whether to proceed unless it's a high risk patient.

 

[Noyac]

Continue with case.

 

[imfrankie]

65 y/o male for elective laparoscopic umbilical hernia repair-slow surgeon.
Patient has afib diagnosed 6 years ago, asymptomatic, non compliant with anticoagulation and rate control pharmacotherapy greater than 5 years. Patient is very active, no echo on file, no other co morbidities. Thoughts ?

My thought's are: if it is not the surgeon's habit to schedule poorly worked-up patients for elective cases, then GA; otherwise, let's talk Dr. Surgeon.

 

[PMPMD]

65 y/o male for elective laparoscopic umbilical hernia repair-slow surgeon.
Patient has afib diagnosed 6 years ago, asymptomatic, non compliant with anticoagulation and rate control pharmacotherapy greater than 5 years. Patient is very active, no echo on file, no other co morbidities. Thoughts ?

If HR < 100, then he doesn't meet "active cardiac condition" criteria for AF. Surgery is low-intermediate risk, so with exercise tolerance > 4 METs, he does not need further cardiac testing. If INR is OK, proceed.

 

[proman]

We tend to think of TTE as this magical test that tells everything. I will look at many of the TTE done in house as part of my preop. 95% are moderate to low quality and involve a lot of hedging and guesswork. It's not nearly as good a study as exercise tolerance. Sounds like this guy can do much more than 4 METs.

 

[docrower]

PMPMD, what is the citation for that paper? Looks like a good one to read. Thanks.

 

[pgg]

PMPMD, what is the citation for that paper? Looks like a good one to read. Thanks.

It's from the AHA/ACC guidelines for periop cardiovascular eval for noncardiac surgery.

Here's one source with figures

http://content.onlinejacc.org/cgi/content/full/50/17/e159

 

[pgg]

Having slow surgeon has no baring on my decision whether to proceed unless it's a high risk patient.

I agree and am always somewhat puzzled when people here bring up the surgeon's skill or lack thereof as a factor in doing or not doing a case. Unless that skill translates to an ability to alter the surgical plan/approach in a way that might reduce risk.

Seems like if I'm counting on a surgeon to be exceptional, even if he usually is, I'm setting myself up for a fall
- what if he has an off day?
- what if there's some equipment/tech problem and it takes longer?
- what is a jury going to think if I tell them "ya it was a soft call, but that surgeon is better than most"?

Granted, we're ALWAYS hitching our malpractice risk to what the surgeon does, but just because we go out on that limb for every case doesn't mean climbing further out than usual is such a great idea.

 

[Johnisit1234]

my concern would be his lack of anticoagulation and lack of rate control. What's his HR, is he rate controlled now?

 

[divinemsm]

My concern was primarily his lack of anti coagulation, as he was not in rapid a fib / no rapid ventricular response at time of presenting for his procedure. In all honesty, it was a matter of hedging bets on whether or not someone who chose not to be anti coagulated or rate controlled because " he doesn't believe in taking medicines", is to even be believed that he is as a symptomatic as he reports.

True- he had no other co morbidities as far as history- yet there is no guarantee that this guy does not have a grossly abnormal heart chambers or clot just waiting to embolize. Is it likely that he would spontaneously convert to sinus and throw a clot ? Unlikely yes, impossible -no.

I'm an admittedly new attending and had the original plan of doing the case-but conferring with others in my group scared me into not " risking " it. Maybe I'll get blasted for this- but I always have in the back of mind -if something catastrophic happened-" what will the lawyer say ? "
Thanks for the input, all.

 

[Planktonmd]

65 y/o male for elective laparoscopic umbilical hernia repair-slow surgeon.
Patient has afib diagnosed 6 years ago, asymptomatic, non compliant with anticoagulation and rate control pharmacotherapy greater than 5 years. Patient is very active, no echo on file, no other co morbidities. Thoughts ?

Why would you want to cancel the case?

 

[Planktonmd]

The heart rate is not too high apparently and the patient chose not to take anticoagulants.
He made things easier for you.

 

[tucker27705]

Is he insured? Do the case.

 

[edelweiss]

Don't need an echo -- patient has >4 METS in functional capacity.

Who cares whether he's been compliant w/his anticoagulation for the past 5 years. Most surgeons take patients off their Coumadin and want a normal INR prior to surgery 😉 No one wants to operate on a fully anticoagulated patient!

 

[periopdoc]

Who cares whether he's been compliant w/his anticoagulation for the past 5 years. Most surgeons take patients off their Coumadin and want a normal INR prior to surgery 😉 No one wants to operate on a fully anticoagulated patient!

Taking a patient off their anticoag for a brief period of time for surgery is VASTLY different from a non-compliant x5 years patient and the risk of embolism in the second patient is significantly higher.

The reasoning for doing the case in both situations is different. In the first case, you appropriately held anticoagulation as the risk of bleeding during surgery is higher than the risk of clot formation and embolism over the short term.

The reasoning for doing the case in the second patient is that they are non-compliant and will never be compliant. If you cancel the case for medical optimization, they will just come back in a week or three weeks and will still be non-compliant. Document their willingness to accept the risk of their non-compliance and proceed.

You still do the case in both situations, but you need to be clear in your mind (and possibly your documentation) of your reasoning for doing the case.

- pod

 

[jetproppilot]

65 y/o male for elective laparoscopic umbilical hernia repair-slow surgeon.
Patient has afib diagnosed 6 years ago, asymptomatic, non compliant with anticoagulation and rate control pharmacotherapy greater than 5 years. Patient is very active, no echo on file, no other co morbidities. Thoughts ?

Uhhhhhhhhhhhhhhhhh....

That's what you've got concerning doing the case or not?

HAHAHAHAHAHAHAHA

Seriously Slim,

You've got

ALOT

to learn.

 

[cincincyreds]

65 y/o male for elective laparoscopic umbilical hernia repair-slow surgeon.
Patient has afib diagnosed 6 years ago, asymptomatic, non compliant with anticoagulation and rate control pharmacotherapy greater than 5 years. Patient is very active, no echo on file, no other co morbidities. Thoughts ?

Here's the most important question. Did this slow surgeon ride the short yellow bus when he was in school? Because maybe if he didn't, then he is not that slow.

 

[Magnus67]

They guy has been non-compliant for 5 years.......If you cancel and send him to a cardiologist, will he all of a sudden start to give a #@$! and take his beta blocker?

Give him an ETT and some metoprolol while he is asleep. Compliance is 100%. Problem solved.

 

[Idiopathic]

and so then he wakes up hemiplegic. how do you respond to inquiries? what is his CHADS2 score (probably 0-1, assume 3% risk per year of embolic event)? have you discussed with the patient his quantifiable risk of stroke unrelated to this procedure? i agree with doing the case, but absolutely discuss and document your concerns. i would say hes as likely to wake up tomorrow morning with a stroke as he is to wake up from anesthesia with a stroke, but that risk is always present.

 

[Bertelman]

Had a lady in residency stroke en route to the OR from pre-op for an eye case with MAC. 5 more minutes, that would have been our stroke.

 

[Idiopathic]

Had a lady in residency stroke en route to the OR from pre-op for an eye case with MAC. 5 more minutes, that would have been our stroke.

some would argue it still is...im unsure as to when the perioperative period ends and the postoperative period begins re: stroke and symptoms

edit: oh sorry i thought you said it happened after the case

 

[Bertelman]

some would argue it still is...im unsure as to when the perioperative period ends and the postoperative period begins re: stroke and symptoms

I can't think of a single reason how an unmedicated patient in a stretcher in pre-op suffering an embolic stroke could be attributed to the provider who happens to have his or her hands on the stretcher.

Guess one could make the argument that me lowering the head of the stretcher liberated a clot from the LAA.

 

[cincincyreds]

and so then he wakes up hemiplegic. how do you respond to inquiries? what is his CHADS2 score (probably 0-1, assume 3% risk per year of embolic event)? have you discussed with the patient his quantifiable risk of stroke unrelated to this procedure? i agree with doing the case, but absolutely discuss and document your concerns. i would say hes as likely to wake up tomorrow morning with a stroke as he is to wake up from anesthesia with a stroke, but that risk is always present.

I guess you would need a pretty good lawyer if this were to happen.

 

[divinemsm]

You've been an attending for how long ? Yeah, I've been one for six months. No need to be so extra in your laughing at me type of response. I specifically stated earlier that I felt the case should be done- listening to others' opinions as the new kid led me to question my decision-hence-I asked the general opinion on this forum. Maybe you know the correct way to consider every single clinical situation, but I don't.-in response to jetproppilot-as the quoting feature failed me here.

 

[michigangirl]

You've been an attending for how long ? Yeah, I've been one for six months. No need to be so extra in your laughing at me type of response. I specifically stated earlier that I felt the case should be done- listening to others' opinions as the new kid led me to question my decision-hence-I asked the general opinion on this forum. Maybe you know the correct way to consider every single clinical situation, but I don't.-in response to jetproppilot-as the quoting feature failed me here.

divinemsm-- it's been a bit of a trend around these parts. Check out a recent thread on academics vs. private practice workups. it's getting old. people know it. Don't take it personally. have no idea what the condescension is all about. I worry it just drives away many young/inexperienced trainees who just want to ask their questions/concerns in a non-intimidating environment. It's annoying and childish. If you want to be an internet role model self-proclaimed "ROKKSTAR" 🙄....act like one. Don't know what exactly that entails, but its certainly not what we're seeing. Back in the "good old days" his posts actually used to be helpful.

 

[Idiopathic]

I can't think of a single reason how an unmedicated patient in a stretcher in pre-op suffering an embolic stroke could be attributed to the provider who happens to have his or her hands on the stretcher.

Guess one could make the argument that me lowering the head of the stretcher liberated a clot from the LAA.

please see my edit so you dont think im a complete idiot 😉

 

[urge]

I could do the case. Pent sux tube, of course. But first I want to see a TEE from today documenting no clot in the left atrium, and he would have to be admitted for post op anticoagulation and cardiology follow up. I would document the pt does not care about anticoagulation or stroke risk. In fact I would make him sign the progress note stating such. If there is a clot I would not do it.
Plus I would make sure he knows about new drugs that don't require routine labs.

I would also make sure the surgeon understands the 200 bucks he is going to make is not worth the hassle.

You know you are getting sued if he strokes out.

 

[urge]

My concern was primarily his lack of anti coagulation, as he was not in rapid a fib / no rapid ventricular response at time of presenting for his procedure. In all honesty, it was a matter of hedging bets on whether or not someone who chose not to be anti coagulated or rate controlled because " he doesn't believe in taking medicines", is to even be believed that he is as a symptomatic as he reports.

True- he had no other co morbidities as far as history- yet there is no guarantee that this guy does not have a grossly abnormal heart chambers or clot just waiting to embolize. Is it likely that he would spontaneously convert to sinus and throw a clot ? Unlikely yes, impossible -no.

I'm an admittedly new attending and had the original plan of doing the case-but conferring with others in my group scared me into not " risking " it. Maybe I'll get blasted for this- but I always have in the back of mind -if something catastrophic happened-" what will the lawyer say ? "
Thanks for the input, all.

Sounds like you work in a good group. You should consider yourself lucky.

The easiest path would be to push propofol without asking questions. It's not worth it for me.

 

[Bertelman]

please see my edit so you dont think im a complete idiot 😉

I suspected that's where you were coming from.

 

[Planktonmd]

divinemsm-- it's been a bit of a trend around these parts. Check out a recent thread on academics vs. private practice workups. it's getting old. people know it. Don't take it personally. have no idea what the condescension is all about. I worry it just drives away many young/inexperienced trainees who just want to ask their questions/concerns in a non-intimidating environment. It's annoying and childish. If you want to be an internet role model self-proclaimed "ROKKSTAR" 🙄....act like one. Don't know what exactly that entails, but its certainly not what we're seeing. Back in the "good old days" his posts actually used to be helpful.

Well, I don't see where Jet referred to academic anesthesia!
He was basically telling the OP (in a colorful challenging way) that he did not have a good argument in wanting to cancel a straight forward case, and I agree with him!
If you felt that this was an anti-academic argument then that's your right but I am not sure I see the reasoning.
And It is not a secret that academic anesthesia is completely different from what happens in the real world of private practice where it is about money, time, and customer service. You don't have to like it but that's how it is.

 

[Noyac]

Well, I don't see where Jet referred to academic anesthesia!
He was basically telling the OP (in a colorful challenging way) that he did not have a good argument in wanting to cancel a straight forward case, and I agree with him!
If you felt that this was an anti-academic argument then that's your right but I am not sure I see the reasoning.
And It is not a secret that academic anesthesia is completely different from what happens in the real world of private practice where it is about money, time, and customer service. You don't have to like it but that's how it is.

Academics and PP don't have to be practiced differently.

Academics could consider the customer more.

 

[michigangirl]

Well, I don't see where Jet referred to academic anesthesia!
He was basically telling the OP (in a colorful challenging way) that he did not have a good argument in wanting to cancel a straight forward case, and I agree with him!
If you felt that this was an anti-academic argument then that's your right but I am not sure I see the reasoning.
And It is not a secret that academic anesthesia is completely different from what happens in the real world of private practice where it is about money, time, and customer service. You don't have to like it but that's how it is.

Completely not where I was going. i know he didn't say anything about academics in this thread. I was commenting on this: http://forums.studentdoctor.net/showthread.php?t=897113

 

[michigangirl]

Well, I don't see where Jet referred to academic anesthesia!
He was basically telling the OP (in a colorful challenging way) that he did not have a good argument in wanting to cancel a straight forward case, and I agree with him!
If you felt that this was an anti-academic argument then that's your right but I am not sure I see the reasoning.
And It is not a secret that academic anesthesia is completely different from what happens in the real world of private practice where it is about money, time, and customer service. You don't have to like it but that's how it is.

Also, to be clear, there is no question in my mind that the majority of academic anesthesia is completely different than private practice in how anesthesia is practiced and delivered. PP in general is much more efficient and customer friendly than academics. But there is a need for both, and its a good thing that certain people love one or the other. Makes the anesthesia world go round! 🙂

 

[Noyac]

Why is he/she an "inhonest dude?" What's his MO have to do with it? He/she was just asking a question because he's a resident and wants to know the bigger picture!

Everyone freeze!

This is the police!

You make one f*cking move and I'll blow your cocks off.

 

[pd4emergence]

My concern was primarily his lack of anti coagulation, as he was not in rapid a fib / no rapid ventricular response at time of presenting for his procedure. In all honesty, it was a matter of hedging bets on whether or not someone who chose not to be anti coagulated or rate controlled because " he doesn't believe in taking medicines", is to even be believed that he is as a symptomatic as he reports.

True- he had no other co morbidities as far as history- yet there is no guarantee that this guy does not have a grossly abnormal heart chambers or clot just waiting to embolize. Is it likely that he would spontaneously convert to sinus and throw a clot ? Unlikely yes, impossible -no.

I'm an admittedly new attending and had the original plan of doing the case-but conferring with others in my group scared me into not " risking " it. Maybe I'll get blasted for this- but I always have in the back of mind -if something catastrophic happened-" what will the lawyer say ? "
Thanks for the input, all.

Nothing wrong with what you did here. I am not quite sure where some of the blow back is coming from. This case doesnt exist in a vacuum. You saw the pt, got a feeling, went to the more experienced members of your group and they said to not do it. Are you gonna still do it after most of your group said they wouldn't? To last past the new guy stage, err on the conservative side and listen to the partners who know the game.

I had a guy not too long ago, one level spinal fusion, thin, smoker, no other risk factors 50 yr old with lbb block on ekg, he seemed kind of evasive, didn't wanna answer questions, just wanted to get his back fixed. Got that feeling that something wasn't right, sent him for an echo and he had an ef of 15% and was found to have severe cad. Following the aha guidelines above, no further testing was warranted, Anybody can blindly follow guidelines.

 

[Noyac]

I had a guy not too long ago, one level spinal fusion, thin, smoker, no other risk factors 50 yr old with lbb block on ekg, he seemed kind of evasive, didn't wanna answer questions, just wanted to get his back fixed. Got that feeling that something wasn't right, sent him for an echo and he had an ef of 15% and was found to have severe cad. Following the aha guidelines above, no further testing was warranted, Anybody can blindly follow guidelines.

seriously?
I can see some people slipping through the cracks but someone with a 15% EF isn't easy to ignore.
Not even in academics.....😉. I had to say it!
I think the echo is mistaken. People don't just walk around with a EF that low without having seen someone for something.

 

[pd4emergence]

seriously?
I can see some people slipping through the cracks but someone with a 15% EF isn't easy to ignore.
Not even in academics.....😉. I had to say it!
I think the echo is mistaken. People don't just walk around with a EF that low without having seen someone for something.

Guy said he hadn't been doing much lately because of his back. I had to drag any info out of him, kept changing his story, just didn't seem right. Echo was off a little bit, ef was 20% on his cath. It just doesn't take a whole lot to sit at home and smoke on the couch while watching daytime tv.

 

[Noyac]

Guy said he hadn't been doing much lately because of his back. I had to drag any info out of him, kept changing his story, just didn't seem right. Echo was off a little bit, ef was 20% on his cath. It just doesn't take a whole lot to sit at home and smoke on the couch while watching daytime tv.

What does " not doing much lately" mean? Are we talking 5 yrs? Because you don't just go from 50% to 20% in 6 months without knowing something ain't right.

 

[pd4emergence]

What does " not doing much lately" mean? Are we talking 5 yrs? Because you don't just go from 50% to 20% in 6 months without knowing something ain't right.

I think the only true statement this guy told me was his name.

 

[periopdoc]

I had a guy not too long ago, one level spinal fusion, thin, smoker, no other risk factors 50 yr old with lbb block on ekg, he seemed kind of evasive, didn't wanna answer questions, just wanted to get his back fixed. Got that feeling that something wasn't right, sent him for an echo and he had an ef of 15% and was found to have severe cad. Following the aha guidelines above, no further testing was warranted, Anybody can blindly follow guidelines.

I disagree. If you want to go by the language of the guidelines, he has a ventricular dysrhythmia and is not active enough to be symptomatic. Therefore he qualifies for preoperative formal cardiac evaluation per my interpretation of the guidelines.

The guidelines were careful to mention that activity level should be considered in defining asymptomatic vs symptomatic even going so far as to say that unstable angina

May include "stable" angina in patients who are unusually sedentary.

I will let a RBBB slide, but just about any unexplained LBBB gets booted to the cardiologists even if the patient has >4mets and is asymptomatic.

- pod

 

[pd4emergence]

I disagree. If you want to go by the language of the guidelines, he has a ventricular dysrhythmia and is not active enough to be symptomatic. Therefore he qualifies for preoperative formal cardiac evaluation per my interpretation of the guidelines.

The guidelines were careful to mention that activity level should be considered in defining asymptomatic vs symptomatic even going so far as to say that unstable angina


I will let a RBBB slide, but just about any unexplained LBBB gets booted to the cardiologists even if the patient has >4mets and is asymptomatic.

- pod

I am with you here, I usually do the same with lbbb. But, if you look in section 2.7 in the guidelines, it mentions lbbb as a minor predictor that has not been shown to increase perioperative mortality. So according to the above you don't have to workup every lbbb. This guy had an unknown activity level, no major known clinical predictors, I would have been well within the guidelines to let him get to the or. Sorry I would paste the paragraph in here but I can't figure out how to do it on my iPad.

 

[Planktonmd]

I disagree. If you want to go by the language of the guidelines, he has a ventricular dysrhythmia and
- pod

I am not sure that a LBBB is "ventricular dysrhythmia".
Are conduction abnormalities dysrhythmias?

 

[periopdoc]

I am not sure that a LBBB is "ventricular dysrhythmia".
Are conduction abnormalities dysrhythmias?

Yeah you are right. I was definitely stretching the definition for the hell of it.

If the LBBB is old, I don't work it up and I think that is what the guidelines mean when they refer to it as a minor predictor. If it has not been previously appreciated, it gets a workup.

- pod

 

[Noyac]

Periopdoc, you are right about the LBBB being more ominous. But if he case is minor and the exercise tolerance is great then I don't fret it much. If it is new, I refer to a cardiologist postoperatively and I inform the surgeon that they pt needs to see cards as well. It all depends on the case. One thing for sure, I induce gently and watch closely.

 

[dhb]

One thing for sure, I induce gently and watch closely.

You must be great with ladies 😉

 

[Noyac]

You must be great with ladies 😉

You have no idea!

Wait, actually you do.

Never mind!

 

[sevoflurane]

McDreamy...!

Mcdreamy...!

Is that you?

 

[sevoflurane]

I couldn't resist...🙄

 

[Noyac]

I couldn't resist...🙄

I bet you couldn't.