What would you tell the surgeon/Family

[seinfeld]

---

Members do not see this ad.

Recent case which i will paraphrase

79 year old with HX of multiple orthopedic implants, Moderate-severe plum HTN, previous Bilateral Aortio-ilio stents, and morbid obesity presents to ED with AMS, hypotension, fever, WBC 13 with left shift, reps failure. CXR shows no PNA (ETT in good position), Urine is clean. Day time ICU doc shot guns it and orders CT of Chest/ABD/Pelvis looking for occult process. Patient gets to ICU has Bp of 80/40 with Levophed at 15mcg/min. Rapid AFIB with rates of 130-150. Thoracic PA finds me to tell me that he was down in radiology looking to discuss case with radiologist as he oversaw a CT of chest which did not look good and it was an ICU patient, of course it was this one i am describing. I look at the non-contrast CT and it shows large aneurysm with moderate pericardial effusion. *&^%. My PA comes to tell me the same thing and that he has called the CT surgeon, the Echo tech. I go and see patient. Echo tech arrives does a TTE which shows moderate effusion, 1+ AI , ? dissection flap in descending aorta. I do TEE and sure enough Type A dissection started just above aortic valve, i see 3-4+ AI and the dissection extends further in the defending aorta than i can see. Patient is now on levophed at 20mcg/min, Vaso at 0.04 units/min, has received 3 liters of fluid since i arrived (all of this took about 1/2 hour from the time i knew of the issue). No urine output. Pt was a DNR . My colleague on call for Cardiac arrives in the ICU to look at the patient. Family is looking for your opinion as well as the surgeons about quality of life after the surgery.
What would you tell them as an anesthesiologist? Would you leave it up to surgeon to talk with family or would you be part of the conversation?
If you go to the OR what are your anesthetic concerns?

 

[urge]

Call a priest.

 

[gasorrad]

Would you cardiovert presurgery to restore the atrial kick? Low pressures on the vent will help preload. Milrinone in case of severe pulm HTN but will drop BP further. Could go up on levo/vaso. AMS and low urine output are a concern related to the dissection. Initiation of hypothermic protocol even before surgery might preserve neurological function? Emergent OR should still be the case. DNR doesnt apply in OR right?..my still in training thoughts..will wait for more experienced opinions.

 

[RxBoy]

Call a priest.

Agreed. This person will not make surgery. 99% will die either on OR table or in ICU by week's end. I would be blunt with the family.

If by miracle you can him keep alive through surgery, he will not tolerate the fluid shifts, stress, and acidosis post op. He will code. We can discuss the anesthetic techniques but we know what the ultimate end result will be. Obviously not a candidate for IABP either. This is the pt I dread admitting in the ICU.

 

[Idiopathic]

i dont have a problem with letting him go to the OR, since there is no medical management alternative here, but absolutely agree with a focused and honest discussion with family. i would hope they would defer the OR.

 

[proman]

What I'd want to do: Speak to the family and respect his DNR.

Realistically it's not my call, if the surgeon posts the case, I can do it. Patient will die either way.

 

[jwk]

Would you cardiovert presurgery to restore the atrial kick? Low pressures on the vent will help preload. Milrinone in case of severe pulm HTN but will drop BP further. Could go up on levo/vaso. AMS and low urine output are a concern related to the dissection. Initiation of hypothermic protocol even before surgery might preserve neurological function? Emergent OR should still be the case. DNR doesnt apply in OR right?..my still in training thoughts..will wait for more experienced opinions.

He's not in the OR yet, so the DNR remains in effect. There is also a lot of debate about whether or not a DNR remains in effect or not in surgery - and there is usually a hospital policy that addresses this issue.

 

[pretenda]

and this is why theres absolutely no way Im going to specialize in critical care medicine.

ridiculous.

 

[Idiopathic]

and this is why theres absolutely no way Im going to specialize in critical care medicine.

ridiculous.

i dont get what you mean. you dont have an interest in challenging cases, encompassing many layers of pathophysiology and dynamic personal interactions?

 

[Dwindlin]

He's not in the OR yet, so the DNR remains in effect. There is also a lot of debate about whether or not a DNR remains in effect or not in surgery - and there is usually a hospital policy that addresses this issue.

Where I am currently all DNRs get rescinded for the duration of the procedure and PACU stay.

 

[seinfeld]

i dont get what you mean. you dont have an interest in challenging cases, encompassing many layers of pathophysiology and dynamic personal interactions?

Exactly my thought too. Its these types of cases where a CRNA will never be able to cut into your turf and it is these cases where being a physician matters most.

But to digress back to the original premise of my post. myself, the cardiac surgeon, and the my Cardiac Call colleague discussed deeply with family and they decided not to proceed with surgery. Not a life saved but a meaningful, and fulfilling human interaction and a great case of diagnostics and pathophysiology.

 

[TrustMe]

Seems like the appropriate choice. I like realistic families that understand that there is something to be said for quality of life. The other thing that I may have done while you have an ultrasound/echo machine handy is put a vascular probe on his neck to see if he has dissected his carotids (given his altered mental status). Just more potential information that you can give the family. If he has dissected his carotid then his outcome is even more confirmed.

 

[pgg]

But to digress back to the original premise of my post. myself, the cardiac surgeon, and the my Cardiac Call colleague discussed deeply with family and they decided not to proceed with surgery. Not a life saved but a meaningful, and fulfilling human interaction and a great case of diagnostics and pathophysiology.

👍 Helping the patient and family reach a no-surgery decision without feeling guilty about "giving up" is every bit the victory as getting him through the OR would've been. If not more so.

 

[pretenda]

👍 Helping the patient and family reach a no-surgery decision without feeling guilty about "giving up" is every bit the victory as getting him through the OR would've been. If not more so.

I would not want to have to accepted taking care of this man if he had gone to the OR. Day in and day out attempting to wean an unweanable patient. Destroying any quality of life he may have left.

Everyone knows how this story would have ended had this man had the operation. Maybe you guys have seen someone like this recover but in my limited experience I certainly have not.

 

[cincincyreds]

Recent case which i will paraphrase

79 year old with HX of multiple orthopedic implants, Moderate-severe plum HTN, previous Bilateral Aortio-ilio stents, and morbid obesity presents to ED with AMS, hypotension, fever, WBC 13 with left shift, reps failure. CXR shows no PNA (ETT in good position), Urine is clean. Day time ICU doc shot guns it and orders CT of Chest/ABD/Pelvis looking for occult process. Patient gets to ICU has Bp of 80/40 with Levophed at 15mcg/min. Rapid AFIB with rates of 130-150. Thoracic PA finds me to tell me that he was down in radiology looking to discuss case with radiologist as he oversaw a CT of chest which did not look good and it was an ICU patient, of course it was this one i am describing. I look at the non-contrast CT and it shows large aneurysm with moderate pericardial effusion. *&^%. My PA comes to tell me the same thing and that he has called the CT surgeon, the Echo tech. I go and see patient. Echo tech arrives does a TTE which shows moderate effusion, 1+ AI , ? dissection flap in descending aorta. I do TEE and sure enough Type A dissection started just above aortic valve, i see 3-4+ AI and the dissection extends further in the defending aorta than i can see. Patient is now on levophed at 20mcg/min, Vaso at 0.04 units/min, has received 3 liters of fluid since i arrived (all of this took about 1/2 hour from the time i knew of the issue). No urine output. Pt was a DNR . My colleague on call for Cardiac arrives in the ICU to look at the patient. Family is looking for your opinion as well as the surgeons about quality of life after the surgery.
What would you tell them as an anesthesiologist? Would you leave it up to surgeon to talk with family or would you be part of the conversation?
If you go to the OR what are your anesthetic concerns?

I would call the cRNA to do the case who has a doctor of nursing/critical care/ TEE degree. If that doesn't work, then I call ghostbusters because there will be a ghost in this situation no matter what happens. I'm not sure if I would be able to get this patient off the table to the ICU.

 

[RemyMcswain]

And this is why I probably WILL specialize in critical care medicine.

 

[OB1🤙]

Bravo!

I think Gloria in White Men Can't Jump said it best when she said "Sometimes when you win, you really lose. And sometimes when you lose, you really win."

Exactly my thought too. Its these types of cases where a CRNA will never be able to cut into your turf and it is these cases where being a physician matters most.

But to digress back to the original premise of my post. myself, the cardiac surgeon, and the my Cardiac Call colleague discussed deeply with family and they decided not to proceed with surgery. Not a life saved but a meaningful, and fulfilling human interaction and a great case of diagnostics and pathophysiology.

 

[Idiopathic]

I would not want to have to accepted taking care of this man if he had gone to the OR. Day in and day out attempting to wean an unweanable patient. Destroying any quality of life he may have left.

Everyone knows how this story would have ended had this man had the operation. Maybe you guys have seen someone like this recover but in my limited experience I certainly have not.

well, then, i agree with your decision not to be an intensivist.

 

[BCM]

👍 Helping the patient and family reach a no-surgery decision without feeling guilty about "giving up" is every bit the victory as getting him through the OR would've been. If not more so.

I agree. Furthermore, as an Anesthesiologist, it is critical to stay engaged in this conversation and give the patient, family, and surgeon a realistic picture what the intra-op and post-op picture will look like. Most important, respect the patient's wishes.

 

[IlDestriero]

It was a fatal event. Hopefully the surgeon is onboard.
His DNR, while not necessarily in effect at this moment, clearly indicates that the patient wanted to avoid heroic and futile efforts to extend his life. Proceeding with this surgery would be just that. In fact, it would guarantee him him exactly the kind of prolonged demise he was trying to avoid.
-
"The truth is incontrovertible, malice may attack it, ignorance may deride it, but in the end; there it is."

 

[dhb]

All i have to say is DN f**kin R

Its these types of cases where a CRNA will never be able to cut into your turf and it is these cases where being a physician matters most.

I disagree with this: in this instance the type of provider will make no impact on the outcome.

 

[dhb]

i dont get what you mean. you dont have an interest in challenging cases, encompassing many layers of pathophysiology and dynamic personal interactions?

I think he means no interest in futile care for dying patients

 

[seinfeld]

All i have to say is DN f**kin R



I disagree with this: in this instance the type of provider will make no impact on the outcome.

No i agree that the overall outcome would not have changed if i had the janitor do the case , but indeed being physician and being involved in end of life discussions with a family will have an impact of the process of care.

 

[BLADEMDA]

Exactly my thought too. Its these types of cases where a CRNA will never be able to cut into your turf and it is these cases where being a physician matters most.

But to digress back to the original premise of my post. myself, the cardiac surgeon, and the my Cardiac Call colleague discussed deeply with family and they decided not to proceed with surgery. Not a life saved but a meaningful, and fulfilling human interaction and a great case of diagnostics and pathophysiology.

This is exactly why ObamaCare will want you heavily involved in all surgical decisions. Imagine how much money and resources would have been wasted on this patient who has a less than 1 percent chance of survival? Imagine how many cases like this go on across the country every day? We are taking hundreds of millions if not billions of Medicare dollars spent in the last 30 days of life.

 

[BCM]

The intensity and variation of surgical care at the end of life: a retrospective cohort study

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61268-3/fulltext

 

[pgg]

I disagree with this: in this instance the type of provider will make no impact on the outcome.

I disagree with this: time and again I've seen CRNAs fail to be good advocates for what's best for patients, because they are nurses and many of them are either content to be subordinates to the surgeons, or unable to step out of that subordinate role when needed.

This is exactly the kind of case where an anesthesiologist can make a real difference, even if it's presenting an argument for doing nothing.

 

[pretenda]

This is exactly why ObamaCare will want you heavily involved in all surgical decisions. Imagine how much money and resources would have been wasted on this patient who has a less than 1 percent chance of survival? Imagine how many cases like this go on across the country every day? We are taking hundreds of millions if not billions of Medicare dollars spent in the last 30 days of life.

Is this a bad thing?

 

[dhb]

This is exactly the kind of case where an anesthesiologist can make a real difference, even if it's presenting an argument for doing nothing.

Ok, i meant if the case was to be done.

 

[pretenda]

I disagree with this: time and again I've seen CRNAs fail to be good advocates for what's best for patients, because they are nurses and many of them are either content to be subordinates to the surgeons, or unable to step out of that subordinate role when needed.

This is exactly the kind of case where an anesthesiologist can make a real difference, even if it's presenting an argument for doing nothing.

very real statement

 

[BLADEMDA]

Is this a bad thing?

My point was Critical Care Physicians like Seinfed will be essential to Obamacare, CMS, IPAB and the entire health care system in the upcoming years. The real role for Seinfeld is cost effective care for the last year of life. Like it or not Seinfeld will be the gatekeeper of the future for many patients.

 

[BLADEMDA]

Just about every discussion on the Hill about "saving Medicare" these days is talk about decreasing reimbursements to providers and health plans.* There's also a lot of talk about preventive care — and yes, I'll say it — prevention has*little potential of saving money in Medicare.* You can't prevent away heart disease or diabetes in elderly patients;*you might postpone it but you will eventually pay.* Medicare is still, fundamentally, an end of life program — 1 out of 4 Medicare dollars are spent in the last 6 months of life.* And it's unsustainable in its current form.* So there's only two*real solutions: to talk to*beneficiaries about their*wishes for their end of life care; and to stop spending money on things that don't work.*


Last week in The Lancet Harvard researchers found that among 1.8 million Medicare beneficiaries who died in 2008:

nearly 1 out of 3 had surgery in the last year of life;
nearly 1 out of 5 had surgery in the last month of life;
nearly 1 out of 10 had surgery in the last week of life.
Those are astounding numbers, and controversial.* Of course many of those procedures were performed to relieve suffering or to prolong life.* But the researchers said they know from experience — as all of us do in eldercare — that doctors often operate to fix something but that will not save a dying patient — to avoid the difficult conversations with patients and caregivers about their prognosis and what they want.* So often*it's "cut to cure" fix-it docs and adult children, with too much drama and way too little information, driving these decisions — not the patient, long in advance of the care episode.*

 

[BLADEMDA]

Just about every discussion on the Hill about “saving Medicare” these days is talk about decreasing reimbursements to providers and health plans.* There’s also a lot of talk about preventive care — and yes, I’ll say it — prevention has*little potential of saving money in Medicare.* You can’t prevent away heart disease or diabetes in elderly patients;*you might postpone it but you will eventually pay.* Medicare is still, fundamentally, an end of life program — 1 out of 4 Medicare dollars are spent in the last 6 months of life.* And it’s unsustainable in its current form.* So there’s only two*real solutions: to talk to*beneficiaries about their*wishes for their end of life care; and to stop spending money on things that don’t work.*


Last week in The Lancet Harvard researchers found that among 1.8 million Medicare beneficiaries who died in 2008:

nearly 1 out of 3 had surgery in the last year of life;
nearly 1 out of 5 had surgery in the last month of life;
nearly 1 out of 10 had surgery in the last week of life.
Those are astounding numbers, and controversial.* Of course many of those procedures were performed to relieve suffering or to prolong life.* But the researchers said they know from experience — as all of us do in eldercare — that doctors often operate to fix something but that will not save a dying patient — to avoid the difficult conversations with patients and caregivers about their prognosis and what they want.* So often*it’s “cut to cure” fix-it docs and adult children, with too much drama and way too little information, driving these decisions — not the patient, long in advance of the care episode.*

We all have our own experiences and anecdotes.* Medicare routinely pays for hip replacements for Alzheimer’s patients, even though most couldn’t complete physical therapy for rehab and resume activities of daily living.**Last year*my 96-year-old grandfather suffered through a $120,000 back fusion surgery he didn’t want or need (he hasn’t been out of his motorized scooter in 5 years) but his doctor and local community hospital insisted he have.* What did he want? “A lethal dose paid for by Medicare Part D.” Last month he failed his second suicide attempt.* We just want him to find some peace — and he’ll never find it at the end of a surgeon’s blade.

We don’t talk enough about how we want to die in this country.*I think we honor one’s life by allowing them to die with dignity, the way they want to go.**These are not conversations most doctors like to have, but they must occur if we’re to*bring any sense to Medicare expenditures.*We no longer have the luxury of a wide-open entitlement program.


John Gorman

 

[seinfeld]

The basis for my posting this scenario is to show that anesthesiologists can and should be involved in discussions with families and surgeons about appropriateness of surgery. Too often we do what is brought before us, sometimes complaining all the way.

We all need to be gatekeepers of care. Think about how an add on case of this degree would effect OR resource for a day. How it would complicate others getting care. I am part of problem that confounds this whole problem. In the day when the family doc new the patient and family and took care of them whether it was the office or the ICU end of life discussions were easier to have. Sometimes i meet families for a the first time and then have to tell them that i recommend no further treatment.

A decent example of resource utilization was a couple of months ago. I had a 30+y/o with severe resp failure who i put on VAV ECMO. On day 2 a cardiac surgery patient was having issues with right heart failure post op (had hx of mod Pulm HTN, CKD underwent a rather long pump run for CABG AVR MVR). Surgeon wanted to put RVAD in but i was using the pump for ECMO. In the end both did great and both left ICU with realistic hopes of going to home or Rehab. Luckily in this case everyone understood the difference and who deserved extraordinary means of support more. Problem these day is that Dialysis , long term ventilation etc are no longer extraordinary means of support.