Question about proceeding w case.

[waterbottle10]

Just curious if you guys would proceed w the case or cancel.

Case is lap radical nephrectomy for cystic neoplasm. 60s years old avg sized, has mild copd , htn , smoker/drinker, had SOB 3 months ago found to have large anterior MI on EKG . tte per cardiologist note said 31% ef and lv aneurysm, etc and cleared him. According to patient he said he had stress test sometime after the MI and he thinks it was normal.. Labs today normal. Does get SOB w some exertion. Got a Aicd placed couple week ago.

Would you just proceed with the case or get more info?

---

Members don't see this ad.

 

[Noyac]

Well of course a TTE result of "normal" by the pt means nothing.
But if I got a feeling that this pt was as good as he will get for surgery then I will proceed.

 

[Arch Guillotti]

Just curious if you guys would proceed w the case or cancel.

Case is lap radical nephrectomy for cystic neoplasm. 60s years old avg sized, has mild copd , htn , smoker/drinker, had SOB 3 months ago found to have large anterior MI on EKG . tte per cardiologist note said 31% ef and lv aneurysm, etc and cleared him. According to patient he said he had stress test sometime after the MI and he thinks it was normal.. Labs today normal. Does get SOB w some exertion. Got a Aicd placed couple week ago.

Would you just proceed with the case or get more info?

Proceed.

 

[waterbottle10]

Thank you for opinions. My main concern was lack of formal stress report or at least a cath report but patient never received a cath I am guessing because the stress test was indeed ok

 

[sluggs]

Not to be such a technical bastard, but contrary to OP we no longer use the phrase "cleared for surgery". You risk stratify the patients and the the decision to proceed with surgery is really a "risk-benefit analysis", taking into account operative risk factors and how necessary the surgery is.
Sorry to be a dick, but this is an important point of verbiage.

 

[nimbus]

How would you guys proceed? To me this is a perfect non-cardiac case to use intraop TEE, Aline and CVP for vasoactive drips if necessary.

 

[Twiggidy]

A-line, CVP., drips ready, tell the surgeons to not dick around. Don't flood him with fluid and a king size suite in the ICU. TEE would be in the back of my mind but I probably wouldn't put it in unless drama occurred (ie, the kind of drama that pressors aren't fixing).

 

[vector2]

Thank you for opinions. My main concern was lack of formal stress report or at least a cath report but patient never received a cath I am guessing because the stress test was indeed ok

Same here. Regardless of stress testing I'm surprised this guy didn't get a cath or perfusion scanning given the aneurysm and how down his function is.

 

[waterbottle10]

Not to be such a technical bastard, but contrary to OP we no longer use the phrase "cleared for surgery". You risk stratify the patients and the the decision to proceed with surgery is really a "risk-benefit analysis", taking into account operative risk factors and how necessary the surgery is.
Sorry to be a dick, but this is an important point of verbiage.

Agreed but here most of charts still says cleared for surgery from surgeons to pulmonary to cards etc

 

[anbuitachi]

The trendelenburg position will stress that heart. Definitely minimize fluids.

 

[T-burglar]

There really needs to be a full coronary workup in the chart there. Angiogram +/- stress testing and clear reasoning by the cardiologist that his IHD is optimized, since the procedure he's scheduled for is not exactly low risk.

Additionally he has an infarct complication that is scary as hell. LV aneurysms rupture with stress just like a critically enlarged aorta. I don't know that I'd put a TEE in from the start, but I would probably have drug infusions and "reliable" access to keep the pressure DOWN as opposed to up (another reason I want to be sure there are no critically stenosed cors).

 

[GravelRider]

You need more info. Was he revascularized at the time of the MI 3 months ago? Stent, angio, medical management? Did he have a cath and what did it show? You should get the actual results of the most recent stress test. LV aneurysm means he had a large infarct scar, so I doubt the stress test was "normal." Is his SOB with exertion different than the SOB associated with the MI 3 months ago? Have his symptoms improved, worsened, or about the same? Any other signs/symptoms of heart failure? Why was the aicd placed? Primary or secondary prevention?

He may very well be optimized, but I don't have the full story based on what you posted. A note from the cardiologist saying "cleared" without a better understanding of why the cardiologist says "cleared" is useless to me.

 

[Aether2000]

Sometimes it is possible to obtain a verbal report by simply calling the center where tests were performed or cardiologist about the patient and document that conversation. The surgery is not an emergency but is a time dependent elective surgery with cardiac risk potentially decreasing with time after a MI but risk of death due to malignancy increasing with time. Documenting the patient understands these issues and wishes to proceed even if the cardiac metrics are not available would be the minimum requirement. I would also consult with the most adept anesthesiologist in my group for guidance about intrinsic details about conduct of the case, and ask for help if I needed it.

 

[Planktonmd]

The ischemic cardiomyopathy has probably a higher long term mortality in this patient than the renal cancer.
So ultimately I don't think it matters if we rush into surgery, or if we wait a few more days to get confirmation of all the studies that have been done and to decide if further intervention (unlikely) is needed before the surgery.

 

[waterbottle10]

You need more info. Was he revascularized at the time of the MI 3 months ago? Stent, angio, medical management? Did he have a cath and what did it show? You should get the actual results of the most recent stress test. LV aneurysm means he had a large infarct scar, so I doubt the stress test was "normal." Is his SOB with exertion different than the SOB associated with the MI 3 months ago? Have his symptoms improved, worsened, or about the same? Any other signs/symptoms of heart failure? Why was the aicd placed? Primary or secondary prevention?

He may very well be optimized, but I don't have the full story based on what you posted. A note from the cardiologist saying "cleared" without a better understanding of why the cardiologist says "cleared" is useless to me.

No revasc no cath. Not sure why. Tried calling but no pickup unfortunately. Pt says he feels fine.

 

[Fajardo04]

The burning question: Is this patient optimized for surgery? I can't answer that with the info presented. You say he had an MI 3 months ago - was this an acute STEMI? Did his troponins bump? If he had a STEMI/NSTEMI, and he did not have a cath, then he had a poorly managed ACS and is not optimized. But if he didn't have a STEMI/NSTEMI? You still shouldn't trust a patient's story of a "normal" stress test or a cardiologist's "clearance." Only the anesthesiologist has all the tools and information to "clear" a patient for surgery.

 

[pgg]

The ischemic cardiomyopathy has probably a higher long term mortality in this patient than the renal cancer.
So ultimately I don't think it matters if we rush into surgery, or if we wait a few more days to get confirmation of all the studies that have been done and to decide if further intervention (unlikely) is needed before the surgery.

I agree you're probably right about the ICM killing him soonest.

But we have documented "clearance" from his cardiologist for the surgery. We're not going to send him back, asking "are you sure you don't want to do something?"

In the absence of stents and antiplatelet regimen issues, there's not much to do here except do the case.

I'd probably do a TEE but I've been swinging that hammer a lot lately and so everybody sort of looks like a nail to me. Not totally necessary. A line, central line, blood ready, vasoactive drips, judicious fluids. The usual periop ICD management.

 

[epidural man]

Use this.

ACS Risk Calculator - Home Page

Get the risk. Explain it to the patient. Give them the options.

 

[GravelRider]

Use this.

ACS Risk Calculator - Home Page

Get the risk. Explain it to the patient. Give them the options.

This. He might very well be optimized and "cleared" for surgery and we all know how to get a sick patient like this through a surgery. However, we need to be able to communicate the real risks of the procedure to both the patient and the surgeon. You don't have quite enough information to do that yet.

Hopefully this case was brought to the attention of your department with a little more warning than 20 minutes before the case is supposed to start.

 

[BLADEMDA]

I agree that a frank discussion with the patient and his family is required before proceeding with the case. He is clearly at increased risk of a major coronary event in the perioperative period. This could result in his death. While the surgeon may not appreciate this discussion with the patient and family IMHO, it should take place prior to proceeding with the case. I doubt there is much more Cardiology can do for him at this point. I would also reach out to his cardiologist for any available data (stress test, etc) prior to the case.

Unfortunately for me, this is a typical case at my institution and the vast majority survive the perioperative period (ASA4 with AICD) but more than a few never leave the hospital alive.


How can we identify the high-risk patient? : Current Opinion in Critical Care


This patient would get an arterial line, large bore IV and Central venous access as part of my anesthetic plan; in addition, epi, norepi and vasopressin would be ready in the room at the start of the case. I'd maintain the HGb level above 9 and have the appropriate blood products available (no last minute calls from the blood bank telling us there are any issues).

 

[deleted162650]

Here's a guy with a known cancer that needs to come out, and a note from cards (however lacking it may be) that says he's good to have it out. Let's pretend you postpone it now 'cuz you want some kind of stress test. Comes back positive - then what?? I doubt a CT surgeon would want to bypass him with a known cancer. DES and you just bought him 6-12mo. to sit there and let this CA grown/possibly metastasize. Balloon angioplasty has been shown to increase risk of plaque rupture. BMS (probably the best option), but that still delays the case and lets the CA grow for a handful of weeks.

I say you proceed. I love TEE for this case for a few reasons - keep an eye on the cardiac scar, evaluate fluid status and inotropy in real time on this sick heart, keep an eye out for new RWMA's, and (assuming this is an RCC) look for tumor crawling it's way up the IVC which can have significant surgical implications as well as embolic risk. RCC's can grow quick so just because the vessels were clean on CT doesn't mean they are clear now.

At least this is a total nephrectomy which are usually fairly benign assuming the surgeon isn't a total donkey. The partial nephrectomies carry a much higher pucker factor.

 

[BLADEMDA]

Here's a guy with a known cancer that needs to come out, and a note from cards (however lacking it may be) that says he's good to have it out. Let's pretend you postpone it now 'cuz you want some kind of stress test. Comes back positive - then what?? I doubt a CT surgeon would want to bypass him with a known cancer. DES and you just bought him 6-12mo. to sit there and let this CA grown/possibly metastasize. Balloon angioplasty has been shown to increase risk of plaque rupture. BMS (probably the best option), but that still delays the case and lets the CA grow for a handful of weeks.

I say you proceed. I love TEE for this case for a few reasons - keep an eye on the cardiac scar, evaluate fluid status and inotropy in real time on this sick heart, keep an eye out for new RWMA's, and (assuming this is an RCC) look for tumor crawling it's way up the IVC which can have significant surgical implications as well as embolic risk. RCC's can grow quick so just because the vessels were clean on CT doesn't mean they are clear now.

At least this is a total nephrectomy which are usually fairly benign assuming the surgeon isn't a total donkey. The partial nephrectomies carry a much higher pucker factor.

I like your post. But, let me ask you a question: How many of these patients have gone South on you in the O.R.? How many of them have you coded? How many have you talked to preoperatively as the last person they will ever see again?

I have an ethical obligation to make sure the patient and family are aware of the risks that this operation poses on his immediate health. I respect their decision to proceed with the case after an informed consent has been obtained. That's the key here: Informed consent.

 

[deleted162650]

I like your post. But, let me ask you a question: How many of these patients have gone South on you in the O.R.? How many of them have you coded? How many have you talked to preoperatively as the last person they will ever see again?

I have an ethical obligation to make sure the patient and family are aware of the risks that this operation poses on his immediate health. I respect their decision to proceed with the case after an informed consent has been obtained. That's the key here: Informed consent.

Agree 100%. Informed consent first and foremost. This pt needs to know what he's getting himself into upfront. I wasn't trying to be a cowboy, just wanted to point out that I don't think there's a strong anesthetic/medical reason to significantly delay this case. If you feel there isn't enough information right this second to have an informed consent discussion with the patient I support the gathering of more info before proceeding.

 

[BLADEMDA]

Agree 100%. Informed consent first and foremost. This pt needs to know what he's getting himself into upfront. I wasn't trying to be a cowboy, just wanted to point out that I don't think there's a strong anesthetic/medical reason to significantly delay this case. If you feel there isn't enough information right this second to have an informed consent discussion with the patient I support the gathering of more info before proceeding.

Your approach to the case is sound. As a more senior Anesthesiologist I was just posting that these cases typically go well but if you do enough then a bad outcome is all but inevitable. One of the things I have learned over the decades is that these deaths perioperatively have taken a toll on me; I'm not the same Anesthesiologist or person I was when I started this gig decades ago. The patients are much sicker (even at the community level) and the expectations for a good outcome much greater than in the past. Somewhere along the way a dose of "reality" needs to be provided to the patients and their families. Sad to say but the surgeons seems to "understate" the risks to this patient population which we have a moral duty to correct prior to initiation of an anesthetic.

I don't mean to preach to much here but aside from the professional aspects of this case, which you really have down, I want to encourage you to think about the expectations of patients and family members.

 

[GravelRider]

In addition to the family, the surgeon needs to know what he's getting into with this patient. The surgeon might not fully appreciate the severity of this patient's cardiac risk since he got the "all clear" sign from cardiology. This is the problem with these "clear for surgery" notes. It gives the patient and surgeon a false sense of security.

No one is really advocating postponement. This is not a case that can come to the attention of the anesthesiologist assigned to it 20 minutes before it is scheduled to start. Worse comes to worse, you delay it by an hour gathering the appropriate information to have that frank discussion with surgeon/patient/family.

 

[deleted59964]

Not to be such a technical bastard, but contrary to OP we no longer use the phrase "cleared for surgery". You risk stratify the patients and the the decision to proceed with surgery is really a "risk-benefit analysis", taking into account operative risk factors and how necessary the surgery is.
Sorry to be a dick, but this is an important point of verbiage.

most of us here just let the "cleared for surgery" statement slide with an internal groan.
what we want from physicians is an opinion that the patient is as medically optimised as possible.
helpful suggestions from physicians to avoid hypoxia and hypercapnia in patients with pulmonary hypertension cause further internal groaning.

 

[fakin' the funk]

How good is your surgeon?

 

[deleted682700]

Is the surgeon any good? Or is his judgement poor? Why laparoscopy? What is the surgeons outcome. Does he and the institution do such cases routinely. Not being confrontational but objective

 

[waterbottle10]

Arnet most laparoscopic these days when possible?

 

[Ignatius J]

Interesting to me is the "cystic neoplasm" which I believe caries a good prognosis. Does that change anything for anyone if the urologist says "we don't need to do this today"?

 

[Noyac]

Your approach to the case is sound. As a more senior Anesthesiologist I was just posting that these cases typically go well but if you do enough then a bad outcome is all but inevitable. One of the things I have learned over the decades is that these deaths perioperatively have taken a toll on me; I'm not the same Anesthesiologist or person I was when I started this gig decades ago. The patients are much sicker (even at the community level) and the expectations for a good outcome much greater than in the past. Somewhere along the way a dose of "reality" needs to be provided to the patients and their families. Sad to say but the surgeons seems to "understate" the risks to this patient population which we have a moral duty to correct prior to initiation of an anesthetic.

I don't mean to preach to much here but aside from the professional aspects of this case, which you really have down, I want to encourage you to think about the expectations of patients and family members.

One of the best posts in a long long while.

 

[DrBeaker]

I agree with salty. No point in more work up being done. He has cancer. He's sick. His heart stinks. He might die. Consent the patient and get in the OR. I would drop a TEE on this guy.

Blade, thanks for your perspective. I agree that a realistic informed consent and realistic expectations need to be discussed. I have had the experience of things not go well in the operating room quite a bit. From residency on through. It definitely wears on you, as you said. And I'm not the same as I was a few years ago. I'm still fairly fresh out, and I love what I do. I think we as a specialty don't do enough to help each other when we experience badness. Whether the person shows it or not, that experience in the operating room has had an impact. When something happens during a case with residents, I try and have a debrief with them, talk things through. What could we have done differently? How do you feel?

Blade when you have these conversations, what's your approach? I use the ACS risk data base. Give them the numbers. Explain things in great detail. Seems like sometimes they just stare at you and nothing sinks in.

 

[deleted171991]

Blade when you have these conversations, what's your approach? I use the ACS risk data base. Give them the numbers. Explain things in great detail. Seems like sometimes they just stare at you and nothing sinks in.

50% of people have an IQ under 100. That's really stupid. You can't fix stupid.

 

[Noyac]

Another thing to think about in this case is the LV aneurysm. How would you approach hypotension? How about large blood loss? Would you use anything (drips or tools) that you would not have used if he didn't have the aneurysm?