Pre-Operative Testing

[militarymd]

Here's a question to you seasoned guys and to trainees. I'm curious as to what the seasoned guys are doing...and what is being taught in the Ivory towers.

60 year old male
HTN,CABG 8 years ago, chf, CVA 2 years ago, DM, CRI

ECG 6 months ago shows LBBB

meds: lopressor, plavix, asa, ramipril, dig, lasix, metformin, insulin, pravachol

physical activity: 2 flight of stairs...stops because of knee pain.

BMI: 26

scheduled for left knee arthroscopy with an ortho guy who will do the case in 15 minutes.

What pre-op testing would you order?

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[bullard]

Intern here.

I'd check a CBC, maybe a chem-7 if needed to assess his volume status given history of CHF and CRI.

Given that he's got moderate clinical predictors (prior CHF, old LBBB), decent exercise capacity, and going for low-risk surgery, he does not need a stress test. That's what they teach us in the ivory tower, anyway.

 

[dhb]

if you do a spinal you only need a coag... (my CA-1 2-cents)

 

[militarymd]

if you do a spinal you only need a coag... (my CA-1 2-cents)

You DIDN'T just say that.

 

[Xclamp]

if you do a spinal you only need a coag... (my CA-1 2-cents)

he's on plavix brother!!

Pre-op, Celebrex 200mg, Neurontin 600mg
CBC, CHEM 7, Fem Block with REMI gtt and a touch of Propofol in the background and have ortho boys squirt some IA PF Morphine

 

[2ndyear]

Ivory tower view and I'll drag it out for educational purposes as lots of CA-1's and interns read this:
Step 1: Need for surgery- Elective
Step 2: Coronary revasc. less than 5 years ago- No, it was 8
Step 3: Recent coronary eval- No, ekg that is 6 months old
Step 4: Clinical Predictors- Intermediate: Compensated or prior heart failure, DM, CRI. Minor: Abnormal EKG, prior CVA, possibly low functional capaciy.
Step 5: Intermediate clinical predictor, so goto Step 6.
Step 6: Functional capacity. 4 mets- climb a flight of stairs or walk up a hill, walk on level ground at 4 mph, do heavy work around the house, golf, bowl, or play doubles tennis. He can do 2 flights without SOB or CP.
Step 7: Surgical risk- Intermediate-Orthopaedic surgery, Low-Endoscopic surgery. Hmm, but it doesn't matter as they both lead to the same place- OR.

Let's back up to Step 6 and say that he has poor or moderate functional capacity. In that case, the diagram points to noninvasive testing prior to OR. Officially it words it this way "Patients without major but with intermediate predictors of clinical risk can generally undergo intermediate risk surgery with little likelihood of perioperative death or MI. Conversely, further noninvasive testing is often considered for patients with poor or moderate capacity but higher risk surgery and especially for patients with 2 or more intermediate clinical predictors."

Let's also go to Step 2 again to see what would happen if he had his CABG 5 years ago instead- Next box says recurrent symptoms or signs? No-to OR.

Also any major clinical predictor gets tested: Unstable or severe angina, decompensated CHF, significant arrythmia with uncontrolled rate or high grade AV block.

Longwinded, but in this Ivory Tower some would go ahead with a new EKG, chem panel, and am fingerstick provided he looks OK on exam and lungs sound clear, ie not having a CHF exacerbation. Most would want a visit to the cardiologist first, you know because they train us to be 'perioperative physicians' now but cancel the case so he can get cleared by an internist... All would go ahead if there were a recent stress test. Some might if there was a recent echo but no stress.

 

[militarymd]

he's on plavix brother!!

Pre-op, Celebrex 200mg, Neurontin 600mg
CBC, CHEM 7, Fem Block with REMI gtt and a touch of Propofol in the background and have ortho boys squirt some IA PF Morphine

For someone with renal insufficiency?

 

[TheSandMan]

he's on plavix brother!!

Pre-op, Celebrex 200mg, Neurontin 600mg
CBC, CHEM 7, Fem Block with REMI gtt and a touch of Propofol in the background and have ortho boys squirt some IA PF Morphine

does anyone have any experience with neurontin for post-op pain control? never really heard of it, would like to know what u guys think.

 

[jetproppilot]

Here's a question to you seasoned guys and to trainees. I'm curious as to what the seasoned guys are doing...and what is being taught in the Ivory towers.

60 year old male
HTN,CABG 8 years ago, chf, CVA 2 years ago, DM, CRI

ECG 6 months ago shows LBBB

meds: lopressor, plavix, asa, ramipril, dig, lasix, metformin, insulin, pravachol

physical activity: 2 flight of stairs...stops because of knee pain.

BMI: 26

scheduled for left knee arthroscopy with an ortho guy who will do the case in 15 minutes.

What pre-op testing would you order?

I wouldnt order a thing......sorry.....the day surgery nurses automatically do a finger stick for blood sugar in DM pts. But that'd be the extent of it.

Two flights of stairs is better than most doctors can do.

Propofol 200 mg, LMA #4, crack the sevo, finish your chart, wake him up.

 

[militarymd]

I wouldnt order a thing......sorry.....the day surgery nurses automatically do a finger stick for blood sugar in DM pts. But that'd be the extent of it.

Two flights of stairs is better than most doctors can do.

Propofol 200 mg, LMA #4, crack the sevo, finish your chart, wake him up.

We NEED to be partners.

 

[Xclamp]

For someone with renal insufficiency?

One dose of a C0X II, ok so give him a 100mg...is the dude dialysis dependent or just runnin' high BUN/Cr's?

 

[EV-Stentor]

We NEED to be partners.

Hey Mil & Jet I agree the dude has a good exercise tolerance and will probably cruise on Prop, fent and tube followed by sevo but for the sake of academics I think it will be reasonable @ the least to repeat the EKG, finger stick glucose and induce with Etomidate...( Propofol is fine if titrated slowly) and careful hydration....I know he has CRI but remember the CHF history. Also the restenosis rate of his CABG keeps gnawing at me ...he probably had LIMA for his CABG given his age as oppose to a radial artery graft..better patency rate...okay he is on plavix and ASA but I am simply trying to stir things up a little for more discussion...hey UTSW can you please some of that superscience

 

[VolatileAgent]

15 minute arthroscopy? i'm with jet. except, i'd want to look at the echo (if available) and would want him off the plavix/asa for 7-10 days.

 

[Noyac]

Hey Mil & Jet I agree the dude has a good exercise tolerance and will probably cruise on Prop, fent and tube followed by sevo but for the sake of academics I think it will be reasonable @ the least to repeat the EKG, finger stick glucose and induce with Etomidate...( Propofol is fine if titrated slowly) and careful hydration....I know he has CRI but remember the CHF history. Also the restenosis rate of his CABG keeps gnawing at me ...he probably had LIMA for his CABG given his age as oppose to a radial artery graft..better patency rate...okay he is on plavix and ASA but I am simply trying to stir things up a little for more discussion...hey UTSW can you please some of that superscience

Unless he tells you that things have changed in the past 6 months since the ECG then why repeat it?

I wouldn't add anything either. He would most definitely come to the pre-op area with more than I would need (new ECG, chem 7, CBC) for this type of surgery. I would look at his K+ since it most likely will be available and he is on dig and lasix, not for the surgery but since it was done and it is good to follow.

 

[militarymd]

Hey Mil & Jet I agree the dude has a good exercise tolerance and will probably cruise on Prop, fent and tube followed by sevo but for the sake of academics I think it will be reasonable @ the least to repeat the EKG, finger stick glucose and induce with Etomidate...( Propofol is fine if titrated slowly) and careful hydration....I know he has CRI but remember the CHF history. Also the restenosis rate of his CABG keeps gnawing at me ...he probably had LIMA for his CABG given his age as oppose to a radial artery graft..better patency rate...okay he is on plavix and ASA but I am simply trying to stir things up a little for more discussion...hey UTSW can you please some of that superscience

He already has a LBBB....what's a repeat EKG going to tell you?...Asymptomatic L and R BBB?

So his grafts are ALL closed....are you going to ask for stents or repeat CABG before his knee scope?

 

[militarymd]

15 minute arthroscopy? i'm with jet. except, i'd want to look at the echo (if available) and would want him off the plavix/asa for 7-10 days.

So, the echo shows an EF of 12%......and yes I've met my share of 2 digit %'ers who can climb stairs...albeit slowly.

Are you going to ask for a LVAD before his knee scope? I know you're not asking for the echo. I'm just asking for those who WOULD ask for an echo.

So, you would delay his knee scope 7 to 10 days even when your intellilectual Ortho guy says "I'd rather keep him on his cardio and cerebravascular protective meds"

 

[militarymd]

Unless he tells you that things have changed in the past 6 months since the ECG then why repeat it?

I wouldn't add anything either. He would most definitely come to the pre-op area with more than I would need (new ECG, chem 7, CBC) for this type of surgery. I would look at his K+ since it most likely will be available and he is on dig and lasix, not for the surgery but since it was done and it is good to follow.

So his K+ is 2.5....would you delay a 15 minute case where there is NO blood loss, no fluid shifts, no stress response, no chance for the K+ to go lower?

 

[militarymd]

One dose of a C0X II, ok so give him a 100mg...is the dude dialysis dependent or just runnin' high BUN/Cr's?

He just says that his kidney's aren't 100%...why take the chance to spare 1 percocet?

 

[militarymd]

does anyone have any experience with neurontin for post-op pain control? never really heard of it, would like to know what u guys think.

There are a number of studies looking at peri-operative neurontin, but they mostly look at surgeries that have significant post-op pain...and the end points of the studies are "morphine-sparing" effects.

do a quick search on pub med

 

[VolatileAgent]

So, the echo shows an EF of 12%......and yes I've met my share of 2 digit %'ers who can climb stairs...albeit slowly.

then he's definitely getting a neuraxial in my book, probably fem/sci single shots.

Are you going to ask for a LVAD before his knee scope? I know you're not asking for the echo. I'm just asking for those who WOULD ask for an echo.

okay, so doubtful his cardiac function would've improved over time, and no i'm not going to ask for an lvad (i hope this was nothing more than sarcasm).

So, you would delay his knee scope 7 to 10 days even when your intellilectual Ortho guy says "I'd rather keep him on his cardio and cerebravascular protective meds"

well, last time i checked there was no such thing as an emergency arthroscopy, and patients don't typically die from a torn meniscus. likewise you said cabg and didn't really tell us whether or not he was stented, which would change the management of the anti-plt drugs. iow, current practices states you could do a fem/sci on anti-plt meds, but i know a lot of attendings aren't that comfortable or practiced doing these. you just want to be sure you don't hit "big red" when you're dropping in the stimucath.

so, it all depends on how much of a cowboy you want to be. i'd be hesitant to give him a general with that lvef, and we didn't even mention valve function (ie., any AS or the like?).

so, my vote would be to proceed under spinal and or regional. downside of spinal is you have to stop the anti-plt meds, and the service is hesitant to do that. that's my plan, and i'd tell the ortho dude he could like it or lump it... or find another anesthesiologist willing to take the risk. no other pre-op testing needed (other than what's already stated), based on the way you've presented this case.

 

[VolatileAgent]

ah... just saw he's 100% blocked. no stents.

neuraxial or no dice.

 

[militarymd]

ah... just saw he's 100% blocked. no stents.

neuraxial or no dice.

Are you implying that regional anesthesia is "safer"?

 

[dhb]

skipped the part about plavix but if you d/c it (cf not an emergency case) you can do it...

 

[The_Sensei]

I wouldnt order a thing......sorry.....the day surgery nurses automatically do a finger stick for blood sugar in DM pts. But that'd be the extent of it.

Two flights of stairs is better than most doctors can do.

Propofol 200 mg, LMA #4, crack the sevo, finish your chart, wake him up.

Damn, dude! That's EXACTLY what I'd do.....scary

 

[VentdependenT]

I wouldnt order a thing......sorry.....the day surgery nurses automatically do a finger stick for blood sugar in DM pts. But that'd be the extent of it.

Two flights of stairs is better than most doctors can do.

Propofol 200 mg, LMA #4, crack the sevo, finish your chart, wake him up.

Agreed.

I'd check if the guy had some kind of lab work in the past 3 months. If there wasn't anything then too late. I'm not going to cancel this LOW RISK procedure (min blood loss, zero fluid shift, minimal pain etc). I'd go ahead with the case based on his functional capacity AND the fact that somebody (pcp or cards) has been following this guy and has him on all the right meds.

I would accucheck the guy however.

It would be a different story IF he was symptomatic OR was going for a larger procedure. If the guy was going for a total knee then I would like to see stress test on him. Anyone differ in that opinion?

The fact that he has a "new" BBB may warrant a myocardial scan with a stress test or an angio sometime in the near future HOWEVER this is a LOW RISK procedure and that work up is not needed in this case.

LMA.

VICODIN post op pain

git yo self back on the plavix tonight sucka

laters

 

[VentdependenT]

Ivory tower view and I'll drag it out for educational purposes as lots of CA-1's and interns read this:
Step 1: Need for surgery- Elective
Step 2: Coronary revasc. less than 5 years ago- No, it was 8
Step 3: Recent coronary eval- No, ekg that is 6 months old
Step 4: Clinical Predictors- Intermediate: Compensated or prior heart failure, DM, CRI. Minor: Abnormal EKG, prior CVA, possibly low functional capaciy.
Step 5: Intermediate clinical predictor, so goto Step 6.
Step 6: Functional capacity. 4 mets- climb a flight of stairs or walk up a hill, walk on level ground at 4 mph, do heavy work around the house, golf, bowl, or play doubles tennis. He can do 2 flights without SOB or CP.
Step 7: Surgical risk- Intermediate-Orthopaedic surgery, Low-Endoscopic surgery. Hmm, but it doesn't matter as they both lead to the same place- OR.

Let's back up to Step 6 and say that he has poor or moderate functional capacity. In that case, the diagram points to noninvasive testing prior to OR. Officially it words it this way "Patients without major but with intermediate predictors of clinical risk can generally undergo intermediate risk surgery with little likelihood of perioperative death or MI. Conversely, further noninvasive testing is often considered for patients with poor or moderate capacity but higher risk surgery and especially for patients with 2 or more intermediate clinical predictors."

Let's also go to Step 2 again to see what would happen if he had his CABG 5 years ago instead- Next box says recurrent symptoms or signs? No-to OR.

Also any major clinical predictor gets tested: Unstable or severe angina, decompensated CHF, significant arrythmia with uncontrolled rate or high grade AV block.

Longwinded, but in this Ivory Tower some would go ahead with a new EKG, chem panel, and am fingerstick provided he looks OK on exam and lungs sound clear, ie not having a CHF exacerbation. Most would want a visit to the cardiologist first, you know because they train us to be 'perioperative physicians' now but cancel the case so he can get cleared by an internist... All would go ahead if there were a recent stress test. Some might if there was a recent echo but no stress.

excellent run down of the algorithm.

 

[VentdependenT]

So, the echo shows an EF of 12%......and yes I've met my share of 2 digit %'ers who can climb stairs...albeit slowly.

Are you going to ask for a LVAD before his knee scope? I know you're not asking for the echo. I'm just asking for those who WOULD ask for an echo.

So, you would delay his knee scope 7 to 10 days even when your intellilectual Ortho guy says "I'd rather keep him on his cardio and cerebravascular protective meds"

Lets say this guy had drug eluting stents placed one year ago for a postive angio after equivocal stress test (no infarct) and we are going for this same procedure.

Would it be advisable to contiue plavix (risk of intra-articular hematoma) OR d/c it in favor of a bridge therapy (lovenox or low dose aspirin, neither of which are equivalent to plavix but at least its something) prior to case? What is OUR role in this decision making?

 

[2ndyear]

Lets say this guy had drug eluting stents placed one year ago for a postive angio after equivocal stress test (no infarct) and we are going for this same procedure.

Would it be advisable to contiue plavix (risk of intra-articular hematoma) OR d/c it in favor of a bridge therapy (lovenox or low dose aspirin, neither of which are equivalent to plavix but at least its something) prior to case? What is OUR role in this decision making?

Vent, this is big news out here right now in the home of Boston Scientific and I read about it in the paper every day. Boston scientific really leapt forward in 2004 with the Taxus stent increasing sales by $2 billion. Let me again recap so everyone is on the same page:
In March 2 studies were reported at the ACC meeting. The BASKET trial looked at 18 month data of bare vs coated stents and the Camenzind study was a meta-anaylsis of 3 year data. BASKET showed an increase in death not significant with coated stents, the meta-analysis showed a significant increase in death at 3 years. These are late restenoses when people are off of Plavix, as they would normally stop it after 3-6 months, or up to a year if no increased bleeding risk with an eluting stent. Now the FDA is involved and just announced a meeting in December with the 2 stent makers, so this is still up in the air.

So now we've got a guy that a year ago would come to us and we (or someone) could say "let's just stop the plavix, you've been on it for a year and have an eluting stent, no reason to continue". Now it would seem prudent for this guy to be on prolonged, maybe lifelong Plavix.
Here is a link: http://heartdisease.about.com/od/angioplastystents/a/drgstnt4.htm
Apparently in light of all of this, some cardiologists are saying the the Plavix can never be stopped under any circumstances for any procedure.

As far as our role, I would think that ortho has to decide if they can operate and risk intra-articular hematoma on plavix. It will change what we do if they think they can obviously if we considered a spinal. I think the cardiologist has to call the shots on this one after a frank discussion of the risks and current controversies with the patient.

Now for some fun stuff and where to put your money:
On July 18, 2006, the New York Times, reported that Bristol-Myers had already seen a double-digit sales increase for Plavix in the US this year, up 26% to $850 million.

 

[militarymd]

Interesting replies.

Let's start a poll on regional vs general on this patient.

 

[VolatileAgent]

Are you implying that regional anesthesia is "safer"?

yes, in this patient.

 

[militarymd]

yes, in this patient.

Who told you that?

 

[VentdependenT]

MMD throw up some studies holmes.

I have been told and at read (at least as it pertains to vascular surgery) that there is no outcome difference between the two regimens as long as you:

1)Have appropriate monitoring

2)Decide upon and Maintain appropriate goals. i.e. "I aint letten this dude's systolic get higher than 150 or lower than 120 dag nabbit"

3)Are aware of the tricky areas of the case (induction, clamping/unclamping of crud, extubation) and have the appropriate interventions available to achieve your anesthetic plan.

For example: On extubation of a vascular case you can have dexmetatomidine runnen and have NTG drip and esmolol bolus' available for ANTICIPATED HTN in order to maintain appropriate CPP AND MAP for the patient.

same crap goes for your epidural/spinal/regional block. Have pressors/downers/whatever available to maintain your anesthetic plan.

 

[militarymd]

MMD throw up some studies holmes.

I wish I could.

There are those that support regional....recently in BMJ...but the patient population is wrong ...2% death rate in both groups.

Others....inherent bias because of lack of randomization.

I just know what the ACC says.

 

[VolatileAgent]

Who told you that?

my experience.

listen, if you don't know how to do a fem/sci block, or just don't want to spend the extra time setting-up for it, just say so. no one seems to care, except you - who apparently has some sort of point (not sure exactly what that is) to prove here. so, go ahead and give an unnecessary GA to a dude with a 12% lvef. just know that i'm not gonna be the one who'll be sitting in court trying to defend myself if the **** hits the fan.

no one here is going to argue that there isn't more than one way to skin a cat. you're trying to dig something up or defend your preference in a roundabout sort of way, or you just don't know what you're talking about. i'm not really sure, except that you just seem to want to get into a pissing contest on an internet forum.

i'm not the jury. others can decide what's right. you might induce, drop an lma in, and not have anything go wrong. you might do the same thing, and have the guy die 24 hours later... and who are they going to depose when the word gets out that there's a non-general technique that wouldn't have put the stress of a GA on this guy?

so, i'm not telling you how to practice. i don't care how you practice. what i am telling you is that it safer to block that leg than do a GA on this particular patient. if you don't/can't understand that intuitively, you need more training. (aren't you the same guy who does awake colectomies? jeezus, man, what kind of anesthesia do you practice?!?!?)

 

[militarymd]

my experience.

listen, if you don't know how to do a fem/sci block, or just don't want to spend the extra time setting-up for it, just say so. no one seems to care, except you - who apparently has some sort of point (not sure exactly what that is) to prove here. so, go ahead and give an unnecessary GA to a dude with a 12% lvef. just know that i'm not gonna be the one who'll be sitting in court trying to defend myself if the **** hits the fan.

no one here is going to argue that there isn't more than one way to skin a cat. you're trying to dig something up or defend your preference in a roundabout sort of way, or you just don't know what you're talking about. i'm not really sure, except that you just seem to want to get into a pissing contest on an internet forum.

i'm not the jury. others can decide what's right. you might induce, drop an lma in, and not have anything go wrong. you might do the same thing, and have the guy die 24 hours later... and who are they going to depose when the word gets out that there's a non-general technique that wouldn't have put the stress of a GA on this guy?

so, i'm not telling you how to practice. i don't care how you practice. what i am telling you is that it safer to block that leg than do a GA on this particular patient. if you don't/can't understand that intuitively, you need more training. (aren't you the same guy who does awake colectomies? jeezus, man, what kind of anesthesia do you practice?!?!?)

Yep, just as I thought....

I knew the insults would start soon.....

the expected insults from a RESIDENT with LOTS of EXPERIENCE in anesthesia.......let me count...a whopping ....CA1 + CA2 + half of CA3.....hmmmmm...sounds like a lot.

 

[militarymd]

my experience.

It is not experience that you are speaking from....it is anchoring.

I was listening to a speaker on Monday speaking on LMA vs ETT in airway protection...and he brought up the concept of anchoring...which is VERY true ...and unfortunately is holding back advances in anesthesia (among other things)

And the one of the other posters in the military medicine forum also brought it up.....I thought how serendipitous.....so I'm going to bring it up here.

 

[militarymd]

Vent, this is big news out here right now in the home of Boston Scientific and I read about it in the paper every day. Boston scientific really leapt forward in 2004 with the Taxus stent increasing sales by $2 billion. Let me again recap so everyone is on the same page:
In March 2 studies were reported at the ACC meeting. The BASKET trial looked at 18 month data of bare vs coated stents and the Camenzind study was a meta-anaylsis of 3 year data. BASKET showed an increase in death not significant with coated stents, the meta-analysis showed a significant increase in death at 3 years. These are late restenoses when people are off of Plavix, as they would normally stop it after 3-6 months, or up to a year if no increased bleeding risk with an eluting stent. Now the FDA is involved and just announced a meeting in December with the 2 stent makers, so this is still up in the air.

So now we've got a guy that a year ago would come to us and we (or someone) could say "let's just stop the plavix, you've been on it for a year and have an eluting stent, no reason to continue". Now it would seem prudent for this guy to be on prolonged, maybe lifelong Plavix.
Here is a link: http://heartdisease.about.com/od/angioplastystents/a/drgstnt4.htm
Apparently in light of all of this, some cardiologists are saying the the Plavix can never be stopped under any circumstances for any procedure.

As far as our role, I would think that ortho has to decide if they can operate and risk intra-articular hematoma on plavix. It will change what we do if they think they can obviously if we considered a spinal. I think the cardiologist has to call the shots on this one after a frank discussion of the risks and current controversies with the patient.

Now for some fun stuff and where to put your money:
On July 18, 2006, the New York Times, reported that Bristol-Myers had already seen a double-digit sales increase for Plavix in the US this year, up 26% to $850 million.

Thank you for bring these points out...I was too lazy to type all that.

 

[VolatileAgent]

Yep, just as I thought....

I knew the insults would start soon.....

the expected insults from a RESIDENT with LOTS of EXPERIENCE in anesthesia.......let me count...a whopping ....CA1 + CA2 + half of CA3.....hmmmmm...sounds like a lot.

maybe it's your talking-down-to-people, know-it-all arrogance that could be construed as the first insult on this thread...

It is not experience that you are speaking from....it is anchoring.

I was listening to a speaker on Monday speaking on LMA vs ETT in airway protection...and he brought up the concept of anchoring...which is VERY true ...and unfortunately is holding back advances in anesthesia (among other things)

And the one of the other posters in the military medicine forum also brought it up.....I thought how serendipitous.....so I'm going to bring it up here.

yeah, and what's the price of tea in china?

i tell you what, why don't you contact your boy, greensmith, and ask him what he'd do in the scenario you present? he is the director of our regional and acute pain management service.

call him up and present the case exactly as you've described it here. i'll pm his phone number to you if you want.

i'll tell you in advance, though, that he's going to agree exactly with what i said here.

 

[VolatileAgent]

Thank you for bring these points out...I was too lazy to type all that.

maybe to lazy to put in a fem/sci block too? our patient doesn't have a drug eluting stent, does he? i addressed that point already.

 

[militarymd]

maybe it's your talking-down-to-people, know-it-all arrogance that could be construed as the first insult on this thread...



yeah, and what's the price of tea in china?

i tell you what, why don't you contact your boy, greensmith, and ask him what he'd do in the scenario you present? he is the director of our regional and acute pain management service.

call him up and present the case exactly as you've described it here. i'll pm his phone number to you if you want.

i'll tell you in advance, though, that he's going to agree exactly with what i said here.

You are confusing CHOICE of technique with SAFETY of a technique.

You said that regional is SAFER....whereas I'm saying there is no difference.

The recovery profile...the intraoperative course are different for the two techniques....

The intraoperative course is much easier for the regional technique....allows the anesthetist to read the newspaper....

Whereas general would probably require attention to the patient.

I never met Greensmith...so I will take your word that he would choose regional, but regional is NOT SAFER...which is what I am saying.

 

[militarymd]

maybe it's your talking-down-to-people, know-it-all arrogance that could be construed as the first insult on this thread...

Hmmmm....I was asking for opinions and practice patterns.....what's being taught...etc....

Please link me my post where I talk down to someone....other than in response to you...after you started insulting me.

 

[Noyac]

So his K+ is 2.5....would you delay a 15 minute case where there is NO blood loss, no fluid shifts, no stress response, no chance for the K+ to go lower?

Its called good medicine and we are peri-operative physicians, a-hole.

I said I would LOOK at the K+ since it would be available and he is on Dig and lasix. I also said NOT for surgery and that I wouldn't add anything. So no I wouldn't delay.

Damn, you really like pushing peoples buttons.

 

[VolatileAgent]

Damn, you really like pushing peoples buttons.

THANK YOU!

 

[Noyac]

then he's definitely getting a neuraxial in my book, probably fem/sci single shots.

Not in mine. This is a 15 min case. Blocks are overkill for these cases.

I'm using Jet's book.

 

[militarymd]

Its called good medicine and we are peri-operative physicians, a-hole.

I said I would LOOK at the K+ since it would be available and he is on Dig and lasix. I also said NOT for surgery and that I wouldn't add anything. So no I wouldn't delay.

Damn, you really like pushing peoples buttons.

the original question was "would you order any tests?" at all.

so the K would not be available unless you asked for it.

My answer as a perioperative physician for K is the following:

This is a procedure where the potassium level (whether high or low) is not expected to change during or after the procedure.

In light of that, there is no need to check the level because whether it is high, normal, or low, it is a parameter that the perioperative physician has no control over.

Abnormal potassium levels are best addressed over days/weeks by the primary care physician.

 

[Noyac]

So, you would delay his knee scope 7 to 10 days even when your intellilectual Ortho guy says "I'd rather keep him on his cardio and cerebravascular protective meds"

The plavix can be a problem. I did my second fasciotomy in my 5 yrs on a pt who had a knee scope while on plavix and got a compartment syndrome post-op. Not a whole lot of cases but how many knee scopes have you done while continuing the plavix. Now the guy gets 1-2 more generals.

I'd want the plavix stopped for 7 days.

 

[militarymd]

The plavix can be a problem. I did my second fasciotomy in my 5 yrs on a pt who had a knee scope while on plavix and got a compartment syndrome post-op. Not a whole lot of cases but how many knee scopes have you done while continuing the plavix. Now the guy gets 1-2 more generals.

I'd want the plavix stopped for 7 days.

Your ortho guys keep your patients on Plavix?

 

[Noyac]

Vent, this is big news out here right now in the home of Boston Scientific and I read about it in the paper every day. Boston scientific really leapt forward in 2004 with the Taxus stent increasing sales by $2 billion. Let me again recap so everyone is on the same page:
In March 2 studies were reported at the ACC meeting. The BASKET trial looked at 18 month data of bare vs coated stents and the Camenzind study was a meta-anaylsis of 3 year data. BASKET showed an increase in death not significant with coated stents, the meta-analysis showed a significant increase in death at 3 years. These are late restenoses when people are off of Plavix, as they would normally stop it after 3-6 months, or up to a year if no increased bleeding risk with an eluting stent. Now the FDA is involved and just announced a meeting in December with the 2 stent makers, so this is still up in the air.

So now we've got a guy that a year ago would come to us and we (or someone) could say "let's just stop the plavix, you've been on it for a year and have an eluting stent, no reason to continue". Now it would seem prudent for this guy to be on prolonged, maybe lifelong Plavix.
Here is a link: http://heartdisease.about.com/od/angioplastystents/a/drgstnt4.htm
Apparently in light of all of this, some cardiologists are saying the the Plavix can never be stopped under any circumstances for any procedure.

As far as our role, I would think that ortho has to decide if they can operate and risk intra-articular hematoma on plavix. It will change what we do if they think they can obviously if we considered a spinal. I think the cardiologist has to call the shots on this one after a frank discussion of the risks and current controversies with the patient.

Now for some fun stuff and where to put your money:
On July 18, 2006, the New York Times, reported that Bristol-Myers had already seen a double-digit sales increase for Plavix in the US this year, up 26% to $850 million.

What have I been saying in this forum for over 3 months now? Exactly this. Well close enough.

very Nice post 2nd year

 

[VolatileAgent]

the original question was "would you order any tests?" at all.

so the K would not be available unless you asked for it.

My answer as a perioperative physician for K is the following:

This is a procedure where the potassium level (whether high or low) is not expected to change during or after the procedure.

In light of that, there is no need to check the level because whether it is high, normal, or low, it is a parameter that the perioperative physician has no control over.

Abnormal potassium levels are best addressed over days/weeks by the primary care physician.

you're going to take a guy with a 2.5 K+ to the OR? with this heart history? and, you're going to give him a general anesthetic? ummm.... okay. (see previous statements)

 

[Noyac]

Your ortho guys keep your patients on Plavix?

Not usually. I wasn't involved in the initial case though.