would you do this case

[toughlife]

This is my second case tomorrow: 56 y/o in for one level laminectomy. Preop note reads as follows:

Adenosine sestamibi c/w ef 36% and inferoapical ischemia, LHC in 2002 c/w severe dis prox and distal LAD. pt has CAD unamenable for PCI adn will be high risk for the surgery. PT NOT CLEARED FOR THE SURGERY

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[johankriek]

This is my second case tomorrow: 56 y/o in for one level laminectomy. Preop note reads as follows:

Adenosine sestamibi c/w ef 36% and inferoapical ischemia, LHC in 2002 c/w severe dis prox and distal LAD. pt has CAD unamenable for PCI adn will be high risk for the surgery. PT NOT CLEARED FOR THE SURGERY

if the patient is not cleared for surgery.. dont do the case.. Unless you dont care about getting sued.. and losing if anything bad happens. Its an elective case. Thats an easy one.

 

[Solidus]

Now, I'm just a senior in High school. But these words in particular:
"PT NOT CLEARED FOR THE SURGERY"
Raise a red flag.

 

[climbingdocs]

Is it actually scheduled? Who decided to schedule it? Wieerrrdd.....Can you NOT do the case?

 

[UTSouthwestern]

Is he symptomatic? Unstable anginal pattern? If he was cath'd in 2002 and they did nothing since, you need to find out why.

If he has been stable, no change in activity patterns, no unstable anginal pattern, etc., you could do him, however I would find out why they didn't set him up for bypass surgery first before doing this relatively mundane case.

If he has refused follow-up/surgery previously, this procedure is usually not an emergent one nor an absolutely necessary one, so don't feel compelled to push it through.

 

[Planktonmd]

This is my second case tomorrow: 56 y/o in for one level laminectomy. Preop note reads as follows:

Adenosine sestamibi c/w ef 36% and inferoapical ischemia, LHC in 2002 c/w severe dis prox and distal LAD. pt has CAD unamenable for PCI adn will be high risk for the surgery. PT NOT CLEARED FOR THE SURGERY

The final decision should be the patient's:
The cardiologist is obviously saying that there is nothing that can be offered to this patient to optimize him and that he thinks that the risk outweighs the benefit for this surgery.
Now the risk of perioperative MI should be weighed against the severity of this patient's back pain and associated neurological symptoms if any, and once the situation is explained in details to the patient including the real possibility of MI and death he should be able to make an informed decision with the help of all the physicians involved in his care including the anesthesiologist.
If he chooses to proceed then document everything and proceed.

 

[VentdependenT]

This is my second case tomorrow: 56 y/o in for one level laminectomy. Preop note reads as follows:

Adenosine sestamibi c/w ef 36% and inferoapical ischemia, LHC in 2002 c/w severe dis prox and distal LAD. pt has CAD unamenable for PCI adn will be high risk for the surgery. PT NOT CLEARED FOR THE SURGERY

Umm, so is this guy at high risk for being ALIVE?

Wtf.

Now that somebody wrote that note, they have to say the patient is optimized for surgery. Or have em say they need a CABG. First thing's first and now that Cards is on board they have to finish what was started. It doesn't even matter what the guys exercise tolerance is now. Medicolegaly its over.

Once you get that note then you can do the case. Crap, you can even do a hypObaric spinal with fentanyl and duramorph. Surgeon can squirt local in the epidural space if the spinal runs out which it shouldn't for a friggen one level lami.

Or just tube the dude. MRB (maximum resident benifit) put in an a-line if ya want.

One level lami is NOT a major surgery.

 

[militarymd]

1) cardiologists DO NOT clear patients for surgery....anesthesiologists do

2) cardiologists medically (both invasive and non-invasively) treat a patient's cardiac related diseases

Questions to be asked:

1) has this patient been adequately/maximally treated for his cardiac diseases

2) if not...why not.

3) if so...then does he understand the risks of being him

4) if he does, then tally ho.....put him to sleep.

 

[toughlife]

Case is scheduled for am since as I resident I can't pick or choose cases. Did talk to the attending and it sounds like cards decided that he pt is only amenable to medical therapy.

Pt does not appear to be symptomatic, and told he needed a cabg in 2002. He has not wanted to do it, has been medically managed and is currently on:

Isosorbide, plavix, lisinopril, toprol, vitoryn and HCTZ.

Further review of records shows he had cataract extraction OS in 2/06 under mac with no prob.

 

[toughlife]

1) cardiologists DO NOT clear patients for surgery....anesthesiologists do
2) cardiologists medically (both invasive and non-invasively) treat a patient's cardiac related diseases

Questions to be asked:

1) has this patient been adequately/maximally treated for his cardiac diseases

2) if not...why not.

3) if so...then does he understand the risks of being him

4) if he does, then tally ho.....put him to sleep.

I like it.

 

[toughlife]

Umm, so is this guy at high risk for being ALIVE?

Wtf.

Now that somebody wrote that note, they have to say the patient is optimized for surgery. Or have em say they need a CABG. First thing's first and now that Cards is on board they have to finish what was started. It doesn't even matter what the guys exercise tolerance is now. Medicolegaly its over.

Once you get that note then you can do the case. Crap, you can even do a hypObaric spinal with fentanyl and duramorph. Surgeon can squirt local in the epidural space if the spinal runs out which it shouldn't for a friggen one level lami.

Or just tube the dude. MRB (maximum resident benifit) put in an a-line if ya want.

One level lami is NOT a major surgery.

Agree. Done many single level lamis and there's nothing to them.


Did do a T2 costotransversectomy with C5-T6 fusion on friday on a 63 y/o with metastatic lung CA admitted with T2 compression and mets to T1-T3.
She was s/p posterior thoracotomy, chest wall resection and right upper and middle lobectomy 2/2 lung CA, 50 pack/yr hx of smoking sprinkled with COPD.

Hct dropped from 35 --> 23 very quickly and when asked, surgeons said "oh she's just oozing a bit" Yeah right.

On extubation she sounded like shizznit and had to bag her to the NICU and put her on CPAP. ****ty part is she was not able to move her lower extremities.

 

[toughlife]

1) cardiologists DO NOT clear patients for surgery....anesthesiologists do

2) cardiologists medically (both invasive and non-invasively) treat a patient's cardiac related diseases

Questions to be asked:

1) has this patient been adequately/maximally treated for his cardiac diseases

2) if not...why not.

3) if so...then does he understand the risks of being him

4) if he does, then tally ho.....put him to sleep.

So my question is, if the pt knows he is a great risk for dying on the table, has been explained the risk he is taking and how he would benefit from a CABG and he still wants to proceed AND cardiology says his medical treatment is maximized, can the anesthesiologist still be liable for an adverse outcome?

 

[August_Bier]

You raise an important question: Who would benefit from a pre-op intervention, be it a CABG or stent? Maybe there is no benefit:

Coronary-artery revascularization before elective major vascular surgery.N Engl J Med. 2004 Dec 30;351(27):2795-804.

 

[militarymd]

So my question is, if the pt knows he is a great risk for dying on the table, has been explained the risk he is taking and how he would benefit from a CABG and he still wants to proceed AND cardiology says his medical treatment is maximized, can the anesthesiologist still be liable for an adverse outcome?

Now that's almost a philosophical question.

Multiple factors in the equation.

If he dies, he won't sue, but will his family???? Does he have a lot of debt?

Where in the country are you? Some places are more pro-patient and others are pro-physician.

Will your cardiologist sell you out?

Will your surgeon sell you out?

I think yes...you're always liable for adverse outcomes, even if it is not your fault, but I don't think that should prevent you from doing what you think is the right thing to do.

 

[Planktonmd]

So my question is, if the pt knows he is a great risk for dying on the table, has been explained the risk he is taking and how he would benefit from a CABG and he still wants to proceed AND cardiology says his medical treatment is maximized, can the anesthesiologist still be liable for an adverse outcome?

You can still get sued but if you documented everything properly you should be OK.
You must clearly document that you have explained to the patient that his surgery could be fatal and that he understood and wanted to go ahead, also make sure to have the family involved.

 

[toughlife]

You raise an important question: Who would benefit from a pre-op intervention, be it a CABG or stent? Maybe there is no benefit:

Coronary-artery revascularization before elective major vascular surgery.N Engl J Med. 2004 Dec 30;351(27):2795-804.

thanks for the reference. I'll read it tonight.

 

[toughlife]

Now that's almost a philosophical question.

Multiple factors in the equation.

If he dies, he won't sue, but will his family???? Does he have a lot of debt?

Where in the country are you? Some places are more pro-patient and others are pro-physician.

Will your cardiologist sell you out?

Will your surgeon sell you out?

I think yes...you're always liable for adverse outcomes, even if it is not your fault, but I don't think that should prevent you from doing what you think is the right thing to do.

I am in the midwest and yes it is a lawsuit happy state.

My CA-1 naivette wants to put every pt on the table and my morbid curiosity wants to see what happens when **** goes awry.

 

[climbingdocs]

Agree. Done many single level lamis and there's nothing to them.


Did do a T2 costotransversectomy with C5-T6 fusion on friday on a 63 y/o with metastatic lung CA admitted with T2 compression and mets to T1-T3.
She was s/p posterior thoracotomy, chest wall resection and right upper and middle lobectomy 2/2 lung CA, 50 pack/yr hx of smoking sprinkled with COPD.

Hct dropped from 35 --> 23 very quickly and when asked, surgeons said "oh she's just oozing a bit" Yeah right.

On extubation she sounded like shizznit and had to bag her to the NICU and put her on CPAP. ****ty part is she was not able to move her lower extremities.

did surgeon have SSEP and EMG monitoring during the case?

 

[InductionAgent]

In perusing the posts, I haven't seen what the specific surgical indication is for the procedure. That is a key element in determining under what conditions to proceed.

 

[toughlife]

did surgeon have SSEP and EMG monitoring during the case?

Nope. This case was an added as an emergency as the pt fell and her T2 vertebrae just crumbled from all the lytic lesions and imaging studies showed cord compression.

 

[toughlife]

In perusing the posts, I haven't seen what the specific surgical indication is for the procedure. That is a key element in determining under what conditions to proceed.

I am assuming you are asking about the laminectomy. Nothing pressing really except low back pain.

 

[toughlife]

So my attending and surgeon talked to the pt and convinced them he would be better off seeing our cardiologists before the surgery. Pt agreed and surgery was cancelled.

 

[Jeff05]

there is NO such thing as clearance for surgery. only risk stratification.
i love getting a photocopy of an internist's prescription pad with "pt. is cleared for surgery" scribbled on it.

new 2007 guidelines about cardiac workup before noncardiac surgery.
http://www.medscape.com/viewarticle/563640

clearly, this patient does NOT want a cardiac intervention. as long as a frank discussion and documentation of this discussion are performed - i would go ahead with the surgery.

1. good beta blockade
2. continue statin
3. preinduction a line
4. avoid hypotension/hypertension
5. don't let hct drop below 30.

 

[Jeff05]

Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. A report of the ACC/AHA Task Force on Practice Guidelines (writing committee to revise the 2002 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery). Circulation.

Study Highlights

Clinical trial evidence shows a protective effect of perioperative statin use on cardiac complications during noncardiac surgery, so statins should not be discontinued before surgery. Optimal dose, target or achieved levels of low-density lipoprotein cholesterol, and indications for therapy are still unclear.
For emergency noncardiac surgery, preoperative heart testing should not be done; rather, the patient should immediately undergo the emergency procedure.
Patients with severe or symptomatic cardiovascular disease and/or active cardiac conditions should undergo evaluation and treatment before noncardiac surgery. These conditions include unstable coronary syndromes, blockage of 2 or more coronary vessels, decompensated heart failure, significant cardiac arrhythmias, or severe valvular disease.
For high-risk cardiac patients undergoing noncardiac surgery, successful perioperative evaluation and management require multidisciplinary management and communication among the surgeon, anesthesiologist, primary caregiver, and cardiovascular consultant.
Noninvasive and invasive preoperative cardiac testing should not be done unless results will affect patient management.
Most patients with asymptomatic heart disease can safely undergo elective noncardiac surgery without first requiring angioplasty or coronary bypass grafting to lower the risk for surgery.
Angioplasty with stenting in patients who are asymptomatic may even increase the risk for perioperative cardiovascular complications, such as myocardial infarction, for which risk increases 4 to 6 weeks after stenting. For that reason, patients with stents should receive antiplatelet therapy for 4 to 6 weeks after stenting or for up to 1 year for coated or drug-eluting stents.
Patients who require cardiac intervention before elective noncardiac surgery should have angioplasty with use of a bare-metal stent followed by 4 to 6 weeks of thienopyridine plus aspirin.
Because of recent evidence suggesting that surgical outcomes in asymptomatic patients without active cardiac conditions is similar whether cardiovascular interventions are performed, preoperative cardiac screening is not recommended in these patients.
The previous guidelines advocated discontinuing antiplatelet agents before surgery to reduce risks for excessive bleeding associated with any surgical procedure. The updated guidelines recommend stopping antiplatelet medication for as short a time as possible after stent placement.
For patients who already have a drug-eluting coronary stent and require emergent noncardiac surgery, aspirin therapy should be continued if possible and prescription agents resumed as soon as possible.
Indications for further cardiac evaluation and therapy are the same in the noncardiac-surgery perioperative period as in the nonoperative setting, but timing of these interventions depends on several factors, such as the urgency of noncardiac surgery, patient-specific risk factors, and the degree of risk linked with the noncardiac procedure.
For many patients, noncardiac surgery is the first opportunity to evaluate short-term and long-term cardiac risk. Therefore, the cardiac consultant should make recommendations that should reduce immediate perioperative cardiac risk and to determine the need for subsequent postoperative risk stratification and interventions to modify cardiovascular risk factors.
Future research should address the value of routine prophylactic medical therapy vs more extensive diagnostic evaluation and interventions.

Pearls for Practice

Patients with severe or symptomatic cardiovascular disease and/or active cardiac conditions should undergo evaluation and treatment before noncardiac surgery. Statins should not be discontinued before surgery. Patients who require cardiac intervention before elective noncardiac surgery should have angioplasty with use of a bare-metal stent followed by 4 to 6 weeks of thienopyridine plus aspirin.
Most patients with asymptomatic heart disease can safely undergo elective noncardiac surgery without first requiring angioplasty or coronary bypass grafting to lower the risk for surgery. Noninvasive and invasive preoperative cardiac testing should not be performed unless results will affect patient management.

 

[johankriek]

So my question is, if the pt knows he is a great risk for dying on the table, has been explained the risk he is taking and how he would benefit from a CABG and he still wants to proceed AND cardiology says his medical treatment is maximized, can the anesthesiologist still be liable for an adverse outcome?

My guess is yes. Anybody can be sued at any time. Family may and will sue you for the intra op periop death even though you explained the risks of dying to him explicitly. They will find a way to say, he didnt know. the lawyer for the plaintiff will convince anyone who is listening that you are the worst physician ever. You never talk to your patients and certainly you did not talk to his client. Your insurance company will settle.. because NOBODY will take it to trial. and guess what.. DR TOUGHLIFE is in the NPDB and you will have some 'splainin' to do every time you check off 'yes' next to Have you ever been involved in any malpractice lawsuit or is there any pending lawsuits against you to the best of your knowledge? That is after the are you board certified question? I personally wouldnt come near this case. I would excuse myself

 

[bubalus]

You raise an important question: Who would benefit from a pre-op intervention, be it a CABG or stent? Maybe there is no benefit:

Coronary-artery revascularization before elective major vascular surgery.N Engl J Med. 2004 Dec 30;351(27):2795-804.

See also the DECREASE V study

JACC Vol. 49, No. 17, 2007
Revascularization Before Noncardiac Surgery May 1, 2007:1763–9

FWIW, with that note in the chart, I wouldn't do the case. If something bad happened and the family sued, neither the surgeon nor the cardiologist is going to stand up for you. Not worth it to me.

 

[InductionAgent]

So my attending and surgeon talked to the pt and convinced them he would be better off seeing our cardiologists before the surgery. Pt agreed and surgery was cancelled.

certainly a good call for an elective case.

From JACC vol 50, no 17, 2007 1702-32 "Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary"

p. 1711-1712
Recommendations for Preoperative Coronary Revascularization with CABG or PCI.

Class I

3) Coronary revascularization before noncardiac surgery is useful in patients with stable angina who have 2-vessel disease with significant proximal LAD stenosis and either ejection fraction less than 0.50 or demonstrable ischemia on non-invasive testing (Level A)

This is the closest listed scenario to the patient in question. So the guy may or may not have angina symptoms (but if not, why the stress test?); maybe only LAD involvement instead of 2-vessel, but certainly significant proximal LAD stenosis AND EF < 50% AND ischemia. Seems like in this case evidence would support preoperative CABG. Or in any case, he could probably benefit from a CABG more than from spine surgery which might not help his back pain anyway.

 

[militarymd]

certainly a good call for an elective case.

From JACC vol 50, no 17, 2007 1702-32 "Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary"

p. 1711-1712
Recommendations for Preoperative Coronary Revascularization with CABG or PCI.

Class I

3) Coronary revascularization before noncardiac surgery is useful in patients with stable angina who have 2-vessel disease with significant proximal LAD stenosis and either ejection fraction less than 0.50 or demonstrable ischemia on non-invasive testing (Level A)

This is the closest listed scenario to the patient in question. So the guy may or may not have angina symptoms (but if not, why the stress test?); maybe only LAD involvement instead of 2-vessel, but certainly significant proximal LAD stenosis AND EF < 50% AND ischemia. Seems like in this case evidence would support preoperative CABG. Or in any case, he could probably benefit from a CABG more than from spine surgery which might not help his back pain anyway.

I believe they are referring to vascular surgery....not lum lam...2 different balls of wax.

 

[gas87]

Johan,
So how do you "excuse" yourself from a case if you are a resident? What if you already told your attending that your plan would involve further cardiology consult before the case, but your attending disagreed?

 

[Laurel123]

Well, the attending is liable. Part of residency is learning different approaches, even things you wouldnt do.

Personally, I think it is a low risk procedure for a patient that probably is as good as he gets. or at least as good as he is willing to get. However, I would still NOT do the case and I dont know why the surgeon even bothered booking a case that has the words 'not cleared for surgery' written on the chart. It is elective.

 

[militarymd]

Well, the attending is liable. Part of residency is learning different approaches, even things you wouldnt do.

Personally, I think it is a low risk procedure for a patient that probably is as good as he gets. or at least as good as he is willing to get. However, I would still NOT do the case and I dont know why the surgeon even bothered booking a case that has the words 'not cleared for surgery' written on the chart. It is elective.

Because...He has payments on:

1) airplane
2) boat
3) carribean home
4) ex-wives
5) trophy wife
6) kids college tuition
7) ferrari in the garage
8) rolex on the wrist
9) I can go on and on and on.....

It's just about the almighty $$$ sister....has always been and always will be.

We can either be:

1) getting on the gravy train
2) riding the gravy train

or

3) being told to get off the gravy train.

 

[johankriek]

Johan,
So how do you "excuse" yourself from a case if you are a resident? What if you already told your attending that your plan would involve further cardiology consult before the case, but your attending disagreed?

as a resident you HAVE to do what your told or find yourself another career or another residency. As an attending I would phone the attending and say,"ehem, listen shorty I aint doing it, Look at the time Ive got to get home before the beginning of oprah!!"

 

[InductionAgent]

I believe they are referring to vascular surgery....not lum lam...2 different balls of wax.

This particular section and the article as a whole is referring simply to noncardiac surgery of any type. Parts of the article refer specifically to vascular surgery, but not the article in its entirety.

 

[militarymd]

This particular section and the article as a whole is referring simply to noncardiac surgery of any type. Parts of the article refer specifically to vascular surgery, but not the article in its entirety.

are you sure...look at the references that are cited....the patient populations in the references are all vascular surgery patients.

 

[InductionAgent]

are you sure...look at the references that are cited....the patient populations in the references are all vascular surgery patients.

There are some citations that are not limited to vascular surgery only.
For instance #48 Leibowitz D, Cohen M, Planer D, et al. Comparison of cardiovascular risk of noncardiac surgery following coronary angioplasty with versus without stenting. Am J Cardiol 2006;97:1188 –91

contains this text:
The most common surgical procedures
performed were vascular (n = 75), abdominal/gastrointestinal
(n= 39), genitourinary (n = 20), and orthopedic
(n = 15) surgery.

The ACC/AHA Guidelines for noncardiac surgery have indicated that one of the reasons that vascular surgery is such high risk is the high incidence of significant CAD in its patient population. When dealing with a patient with known significant CAD, the fact that the surgical procedure is not vascular is less reassuring.

 

[militarymd]

There are some citations that are not limited to vascular surgery only.
For instance #48 Leibowitz D, Cohen M, Planer D, et al. Comparison of cardiovascular risk of noncardiac surgery following coronary angioplasty with versus without stenting. Am J Cardiol 2006;97:1188 –91

contains this text:
The most common surgical procedures
performed were vascular (n = 75), abdominal/gastrointestinal
(n= 39), genitourinary (n = 20), and orthopedic
(n = 15) surgery.

The ACC/AHA Guidelines for noncardiac surgery have indicated that one of the reasons that vascular surgery is such high risk is the high incidence of significant CAD in its patient population. When dealing with a patient with known significant CAD, the fact that the surgical procedure is not vascular is less reassuring.

from a different section of the guidelines, but OK.

But the findings don't support the table that was printed....

They should make ONE person write these things.