Surgeon Conflict

[diceksox]

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Doing an Avr/ cabg the other day on a guy with baseline creat 2. Surgeon instructs perfusion to give lasix on pump, we come off and urine output is sluggish with reasonable hemodynamics. Twenty five year vet cardiac surgeon wants more lasix (last dose1 hour ago), I suggest that might not be the best idea. He disagrees. I refuse to give it, he threatens me (I'm relatively new), I cave and give it but document it was surgeon decision. How have you senior guys dealt with combative outdated surgeons while not alienating yourself in the process. (No surprise, postoperative AKI)

 

[chessknt]

Doing an Avr/ cabg the other day on a guy with baseline creat 2. Surgeon instructs perfusion to give lasix on pump, we come off and urine output is sluggish with reasonable hemodynamics. Twenty five year vet cardiac surgeon wants more lasix (last dose1 hour ago), I suggest that might not be the best idea. He disagrees. I refuse to give it, he threatens me (I'm relatively new), I cave and give it but document it was surgeon decision. How have you senior guys dealt with combative outdated surgeons while not alienating yourself in the process. (No surprise, postoperative AKI)

I have never understood the use of lasix as a drug that targets UOP instead of volume status. Perhaps you could bring in an article to explain why you were against it (in a non-pompous way, ie hey sorry abt the pushback the other day but check out this article I looked in to the other night)?

http://ether.stanford.edu/urology/Furosemide.pdf

Second, it is tempting to administer repeated large
doses of furosemide (e.g. > 1000 mg) to improve the
urine output of patients with severe AKI. These patients
have the highest risk of ototoxicity from furosemide
because the clearance of furosemide is significantly
reduced in severe renal failure [17, 18, 60]. The risk of
ototoxicity is particularly high when the plasma furosemide
concentrations exceed 50 lg.ml)1 [61], with concurrent
aminoglycoside and vancomycin antibiotics [62],
and possibly in sedated patients who cannot report
symptoms of ototoxicity. Recent evidence suggests that
the use of large doses or prolonged furosemide infusion to
delay dialysis may in fact be associated with a higher
mortality in severe AKI than early dialysis [63, 64].

 

[Gasworks]

Give the lasix, chart it "As Per Surgeon". If I had to fight battles every time someone wanted protamine, pitocin, extra antibiotics, lasix, questionable transfusions, etc. where there was zero clinical indication I'd probably be looking for a new job real soon. I'm willing to bet that if you had won your little battle and the patient would have had any renal complications postop you'd be looking for a new job too.

 

[deleted126335]

Give the lasix, chart it "As Per Surgeon". If I had to fight battles every time someone wanted protamine, pitocin, extra antibiotics, lasix, questionable transfusions, etc. where there was zero clinical indication I'd probably be looking for a new job real soon. I'm willing to bet that if you had won your little battle and the patient would have had any renal complications postop you'd be looking for a new job too.

👍

 

[urge]

You can always say "ok" and not give it.

 

[chessknt]

Give the lasix, chart it "As Per Surgeon". If I had to fight battles every time someone wanted protamine, pitocin, extra antibiotics, lasix, questionable transfusions, etc. where there was zero clinical indication I'd probably be looking for a new job real soon. I'm willing to bet that if you had won your little battle and the patient would have had any renal complications postop you'd be looking for a new job too.

While I understand that this is probably what most of us end up doing, this really reinforces the notion that anesthesiologists are glorified nurses--this is exactly what they do on the wards. I have never seen a pt on the wards get a medication the primary team (ie order-writing team) did not agree with. Granted there is a much different power structure in the OR than the wards, but as a physician I dont think you should knowingly be giving a medication that can cause harm with no clinical benefit and put your name on it.

 

[ssmallz]

While I understand that this is probably what most of us end up doing, this really reinforces the notion that anesthesiologists are glorified nurses--this is exactly what they do on the wards. I have never seen a pt on the wards get a medication the primary team (ie order-writing team) did not agree with. Granted there is a much different power structure in the OR than the wards, but as a physician I dont think you should knowingly be giving a medication that can cause harm with no clinical benefit and put your name on it.

This x 100000000..........we work so hard to be PHYSICIANS not nurses....we go through medical school, not nursing school. We go through 4 years of tough residency, learning the subtle nuances of pt physiology so that when we on our own we are the ultimate decision maker, buck stop here person when it comes to anything on our side of the curtain. This is the single thing I hate most about anesthesia but unfortunately as long as you practice in an OR it's a part of your reality. The good news is that once you establish trust with the surgeons they will respect you and you will be able to to tell them what is an isn't appropriate from an anesthesia stand point... unfortunately, as the new guy it's best to avoid confrontation unless it directly affects patient safety

 

[mustang1]

How would the CT surgeon respond if you peaked over the curtain and critiqued how he did his anastomosis and demand he do it differently? This is what makes anesthesia tough. Surgeon feels like he can control whatever interests him but the moment you (inappropriately, just as he did) try to make recommendations all hell breaks loose.

 

[pgg]

Pick your battles.

When the orthopod asks me to redose the Ancef before he lets the tourniquet down and again at the end of the case, I internally 🙄 and do it.

When the orthopod asks me to lower the patient's BP because his sitting shoulder is bleeding a lot, I don't.

Some cardiac surgeons seem to be more "special" than most with their requests, especially the old ones. I haven't done cardiac cases in a while, but I always wore my extra thick skin to those cases. They treat all nurses / physicians like that. It's not a surgeon vs anesthesia thing, it's a narcissist vs inferior lifeform thing. You can take it personally if you want, but at the end of the day they'll still be arrogant jerks.


I think it's a bad habit to "pretend" to give drugs the surgeon asks for when you think they're not indicated, but I've done it. Just don't get caught.

 

[DreamMachine]

Doing an Avr/ cabg the other day on a guy with baseline creat 2. Surgeon instructs perfusion to give lasix on pump, we come off and urine output is sluggish with reasonable hemodynamics. Twenty five year vet cardiac surgeon wants more lasix (last dose1 hour ago), I suggest that might not be the best idea. He disagrees. I refuse to give it, he threatens me (I'm relatively new), I cave and give it but document it was surgeon decision. How have you senior guys dealt with combative outdated surgeons while not alienating yourself in the process. (No surprise, postoperative AKI)

How much Lasix did he want?

 

[bullard]

Not clear to me from the details posted that he's wrong and you're right.

AVR/CABG on a patient with baseline renal insufficiency is high risk for postop AKI, lasix or no lasix.

It's possible he was just trying to turn oliguric renal failure into nonoliguric renal failure using lasix. This is sometimes the goal in cardiac surgery when you're thinking you're going to have to dump in blood, FFP, and platelets in order to stop bleeding from a long pump run given that you're doing a combined valve/cabg. You're "making room" for the blood products.

Did you ask him his rationale for the lasix? You can learn from these vets.

Agree with others that this battle not worth picking. Disagree with lying about giving the drug. Credibility is too important.

 

[EdPierce]

did you have a swan? he may be associating urine output with cardiac output or index in order to justify his own surgery as a success. he doesnt care if the urine is actually pumped there by the heart or if it is just released into the nephron by giving lasix - he wants fluid in the foley so his numbers look better for CO and thus everyone thinks he did a great surgery and when the guy crumps in the unit because a PA only spent 2 minutes rounding on him the next day, its not his fault, surgery went well, it was an unforeseen complication.

 

[leaverus]

You can always say "ok" and not give it.

i agree with this. we're not nurses taking orders from them.

 

[bostonblaz]

I always have stood by the fact that in any given operating room I am by far the smartest doctor in the room. I have no problem when a stupid request is given asking why and I never ever accept " because I said so." If they can give me a medical reason and I agree with it I will do it. I always chart requested by surgeon if it is not something that I would give or an intervention I would do myself. Now as for this lasix. There are some out that believe that in low perfusion states the highest demand for ATP in the nephron is na+\k+\cl- pump that lasix inhibits and by giving a dose in the short term you are decreasing long term nephron damage. We used to give it a lot in supra renal cross clamping cases. I don't know if I have read a study that shows this actually works but I see some form of logic in it so I would
Do it if asked. I never give lasix to see more pee in a bag. Matter of fact I can't wait until they finally come up with markers for AKI that can be checked a lot like troponins so people will stop using intra and post op UOP as if it really ment something. Blaz

 

[gasattack3]

Give the lasix, chart it "As Per Surgeon". If I had to fight battles every time someone wanted protamine, pitocin, extra antibiotics, lasix, questionable transfusions, etc. where there was zero clinical indication I'd probably be looking for a new job real soon. I'm willing to bet that if you had won your little battle and the patient would have had any renal complications postop you'd be looking for a new job too.

I agree with this. While only a CA2, I'll almost for sure take this stance into my own practice down the road. If it's a super rigid surgeon and the "treatment" is unlikely to do the patient harm (lower doses etc.) then there are bigger battles to fight.

 

[gasattack3]

This x 100000000..........we work so hard to be PHYSICIANS not nurses....we go through medical school, not nursing school. We go through 4 years of tough residency, learning the subtle nuances of pt physiology so that when we on our own we are the ultimate decision maker, buck stop here person when it comes to anything on our side of the curtain. This is the single thing I hate most about anesthesia but unfortunately as long as you practice in an OR it's a part of your reality. The good news is that once you establish trust with the surgeons they will respect you and you will be able to to tell them what is an isn't appropriate from an anesthesia stand point... unfortunately, as the new guy it's best to avoid confrontation unless it directly affects patient safety

What ssmallz said.

As the new guy, you probably do have to zip it for a while until you establish that trust which is key. I've seen it with a few of our new guys.

New guy earns some credibility early on with a neat little solution/way of doing things out of residency or fellowship, and senior surgical dude, from then on, is BIASED in favor of this guy.....hahaha Like, from then on the anes dude can do no wrong...... lol

So, there are nice little opportunities in this field also.

The key here is respect, which is earned over time (if at all).

 

[W222]

Worked with a famous cardiac anesthesiologist and he would regularly tell the surgeon "sure, done" then proceed to shoot the syringe on the floor. The older the surgeon I have noticed the more stuck in their outdated and ancient ways;a lot of their voodoo proven wrong a long time ago.

 

[OB1🤙]

In residency there was a surgeon who demanded a lasix gtt, 100mg/hr, if the UOP went low during the pump run. 😱

I think there's something to the theory of decreasing renal work with lasix, so long as the doses are reasonable and you know the beans are seeing adequate flow. It's a tough spot to be in as the new guy. I probably would have just repeated some small dose and waited for the next bigger battle to fight.

I'm so happy that the cardiac surgeons I work with now are normal, well-adjusted, friendly, reasonable people who trust me to do my job while they do theirs.

 

[BLADEMDA]

Furosemide did not appear to reduce the risk of
requiring renal replacement therapy (relative risk (RR)
1.02, 95% CI 0.90–1.16, p = 0.73) and hospital mortality
(RR 1.12, 95%CI 0.93–1.34, p = 0.23) when used as a
preventive or therapeutic drug in patients at risk of or
with established AKI, respectively (Figs 2 and 3). Using
all-cause mortality as an end-point, the funnel plot does
not suggest the presence of publication bias (Fig. 4).
These results confirmed the findings of our previous
meta-analysis [17].


First, it is important to emphasise that furosemide can
increase urine output without improving the creatinine
clearance and renal function. A transient increase in urine
output after furosemide may create a false sense of
security, as if the drug has ‘fixed the problem' or changed
the course of AKI. This has the potential to delay the
diagnostic and therapeutic process targeting the underlying
causes of AKI, such as hypovolaemia, urinary
outflow tract obstruction and sepsis. As such, the administration
of furosemide should only be considered after
close attention to the underlying causes of oliguria and the
haemodynamic status of the patient. Adequate hydration is
important in determining the diuretic and renovascular
protective response to furosemide [30, 37].


http://ether.stanford.edu/urology/Furosemide.pdf

 

[BLADEMDA]

Lassnig et al performed a placebo-controlled randomized
trial on the effect of dopamine and furosemide in 126 patients with normal preoperative
renal function undergoing cardiac surgery. Furosemide administration was
started at a rate of 0.5 mg/kg/minute at induction and continued until 48 hours postoperatively.
Compared with placebo, furosemide resulted in a significantly higher urine
output, but also in a more pronounced post-operative increase in serum creatinine.
The increased urine output was compensated with fluid administration and the groups
did not differ with regard to blood pressure or filling pressures.5 In summary, there is
little evidence from clinical trials that the prophylactic use of loop diuretics has a
beneficial effect on renal function and there is even evidence for the opposite.


http://www.sassit.co.za/Journals/Physiology/Nephrology/Voorkoming/diuretics in ARF.pdf

 

[BLADEMDA]

http://www.ncbi.nlm.nih.gov/pubmed/18243724

http://www.ncbi.nlm.nih.gov/pubmed/10616845


Thus, renal dose dopamine is ineffective and furosemide is even detrimental in the protection of renal dysfunction after cardiac surgery

 

[BLADEMDA]

Post-cardiac surgery acute kidney injury (AKI) is common and is associated with a significant increase in morbidity and mortality. We aimed to systematically review randomised trials that assessed the renoprotective utility of pharmacological agents in patients undergoing cardiac surgery. We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials for randomised controlled trials comparing renoprotective pharmacological interventions with control in adult patients undergoing cardiac surgery with cardiopulmonary bypass. We extracted data for mortality, need for renal replacement therapy (RRT), incidence of AKI, and creatinine clearance at 24-48 h. About 49 randomised controlled trials involving 4605 patients were included. Pharmacological interventions included dopamine, fenoldopam, calcium channel antagonists, natriuretic peptides, diuretics, and N-acetylcysteine. Most trials were of poor quality, with small sample sizes, under-reporting of randomisation procedure, allocation concealment and method of blinding. No pharmacological intervention significantly reduced mortality. Fenoldopam and Atrial Natriuretic Peptide (ANP) reduced the need for renal replacement therapy by 5% (NNT 20, 95% CI 11.3, 83.0) and 3.5% (NNT 29, 95% CI 17.1, 84.4), respectively. Brain Natriuretic Peptide resulted in a 10% reduction in the incidence of AKI (NNT 11, 95% CI 6.2, 32.0). Dopamine caused a significant reduction in creatinine clearance (-4.26 ml/min, 95% CI -7.14, -1.39). The quality of studies that have assessed pharmacological renoprotective agents in cardiac surgery is generally poor. Fenoldopam, ANP and BNP show evidence of renoprotection. Randomised studies evaluating the effect of novel renoprotective agents that are powered to detect clinically relevant differences in outcomes are required.


http://www.ncbi.nlm.nih.gov/pubmed/21400231

 

[BLADEMDA]

After the operation, the preservation of renal function was confirmed in the fenoldopam group by the preserved creatinine clearance; however, the major determinant of RRT-ARF after the operation is low cardiac output syndrome. This condition generally induces a compensatory vasoconstriction that results in reduced renal blood flow and consequent renal dysfunction. Moreover, this state is exacerbated by the use of exogenous catecholamines that further increase the peripheral and visceral arterial resistances. It is therefore not surprising that in our series, as well in other studies [7, 8, 10], a low output state requiring major and prolonged catecholamine support or even the need for IABP is associated with a severe risk of RRT-ARF.

In this setting of endogenous and exogenous vasoconstrictive pattern, fenoldopam is an independent protective factor against RRT-ARF. It is reasonable to hypothesize that the prerenal vasodilating effect of fenoldopam [11–14] may effectively counteract the splanchnic vasoconstriction generally considered as a major determinant of acute renal failure. In absence of this vasoconstrictive pattern, other factors may be advocated to induce a renal function impairment, namely, hemodilution during CPB, that has been recently claimed as a strong determinant of renal function impairment [8, 9], and that even in our series was significantly correlated with RRT-ARF at the univariate analysis in the overall population. As a matter of fact, in patients not having postoperative low cardiac output syndrome, fenoldopam treatment totally lost its protective effect.


RRT= Renal Replacement Therapy


http://ats.ctsnetjournals.org/cgi/content/full/78/4/1332

 

[Oggg]

1. CT surgeons actually care about the pts cardiovascular performance, and they have to manage/follow their patients into the ICU, so they care a lot about what their patients get in terms of drugs and drips. That is why they are always in "our business", and that's why I hate most CT surgeons, but at the same time I give them some slack. If you don't give lasix in the OR, they'll just give it in the ICU, so you might as well give it. Worse case they can ban you from the cardiac room and that's really bad for you.
2. One of my CT surgeons has been asking for a bicarbonate drip on all patients with elevated Cr and all major cases (in addition to renal dopamine). Anyone else doing bicarbonate drips?

 

[urge]

1. CT surgeons actually care about the pts cardiovascular performance, and they have to manage/follow their patients into the ICU, so they care a lot about what their patients get in terms of drugs and drips. That is why they are always in "our business", and that's why I hate most CT surgeons, but at the same time I give them some slack. If you don't give lasix in the OR, they'll just give it in the ICU, so you might as well give it. Worse case they can ban you from the cardiac room and that's really bad for you.
2. One of my CT surgeons has been asking for a bicarbonate drip on all patients with elevated Cr and all major cases (in addition to renal dopamine). Anyone else doing bicarbonate drips?

Other surgeons don't care? Doubt it.

The reason is they think they know better than anyone else.

 

[W222]

One of my CT surgeons has been asking for a bicarbonate drip on all patients with elevated Cr and all major cases (in addition to renal dopamine). Anyone else doing bicarbonate drips?

Bicarbonate drips? What's the reasoning behind this voodoo?

Renal dopamine? Hasn't he read a journal article in the last decade? I can't see giving an arrhythmogenic drug to a patient (in a population prone to arrhythmia mind you) for the soul purpose of making a little more urine. I can't believe you would follow this stuff.

 

[BLADEMDA]

 

[BLADEMDA]

Go buy him a beer after work

 

[BLADEMDA]

At my Residency Program when a CT Surgeon would ask for a drug to be given the usual response was "Do yo have any evidence that medication actually works or helps the patient?" The answer was the following: "I'm the CT surgeon. I think it helps. You are Anesthesia. Just give it."

Most Attendings were not receptive to that type of answer including the Chairman and Chief of Cardiac Anesthesia. I was taught to practice Evidence Based Medicine at my Medical School and Top ten residency. Despite the bullying by ignorant CT Surgeons (they are the worst) the younger CT surgeons (under age 50) are more receptive to peer reviewed articles showing that some drugs are of no benefit to the patient and may in fact be quite harmful.

 

[BLADEMDA]

http://www.youtube.com/watch?v=LqeC3BPYTmE

I have met more than a few of these types of "CT Surgeons" in my career. They are the worst example of what our system produces and I hope a thing of the past.

 

[BLADEMDA]

You have a moral obligation to the patient to do not harm.

 

[dhb]

I have never understood the use of lasix as a drug that targets UOP instead of volume status.

This...

 

[FrankWhite]

At my Residency Program when a CT Surgeon would ask for a drug to be given the usual response was "Do yo have any evidence that medication actually works or helps the patient?" The answer was the following: "I'm the CT surgeon. I think it helps. You are Anesthesia. Just give it."

As a resident I am faced with this situation a lot but I just defer to my attending who most of the time will cave in and please the surgeon. How would you handle these situations when you were a resident Blade?

I'm assuming in private practice you don't want to be the anesthesiologist who argues with a surgeon set in his ways because you may end up without a job.

I always chart requested by surgeon if it is not something that I would give or an intervention I would do myself.

If there was an adverse outcome, how much would this actually protect you in court?

 

[45408]

did you have a swan? he may be associating urine output with cardiac output or index in order to justify his own surgery as a success. he doesnt care if the urine is actually pumped there by the heart or if it is just released into the nephron by giving lasix - he wants fluid in the foley so his numbers look better for CO and thus everyone thinks he did a great surgery and when the guy crumps in the unit because a PA only spent 2 minutes rounding on him the next day, its not his fault, surgery went well, it was an unforeseen complication.

Hmmm, I missed that part of the story in the original post.

i agree with this. we're not nurses taking orders from them.

I agree, but lying about giving a med is a passive-aggressive move that physicians shouldn't do. I can see good arguments throughout this thread about giving it or not giving it, but lying about giving it seems like the worst idea.