Pre-Operative Testing

[militarymd]

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)

Depends on what type of surgery.

For a colectomy/ex-lap/AAA/ anything with a signficant blood loss (greater than 1 unit)...or where the procedure is prolonged with significant dissection...leading to 3rd spacing.....NO...because with the stress response...the K+ will go down significantly to the point where dysrhytmia is something to worry about.

For a surgery where...there is no blood loss, no 3rd spacing, minimal pain, short duration...where taking a dump after being constipated for 3 days is equalliy stressful....Absolutely...I would proceed.

If you can drive to the hospital, walk up a couple of flights of stairs to get to pre-op, you can have a 15 minute knee scope.

electrolyte abnormalites are a risk to patients because some of the dysrhythmias that can develop can be fatal.

Where in the world are you safer to develop these dysrhythmia than in the OR under the care of an anesthesia provider?

I will submit to anyone that you are LESS likely to develop dysrhymias under anesthesia (no stress) than while you are awake.

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[Noyac]

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.

I understand you. Now will you read my post #14. I said that this lab would be available (ortho dude ordered it) even though I don't need it ( I know you say nothing is available). Therefore, I would check it. Not that I would change anything due to the value is. My point is that if these labs are done you should at least look at them and be the perioperative physician that you are.

 

[Noyac]

Depends on what type of surgery.

For a colectomy/ex-lap/AAA/ anything with a signficant blood loss (greater than 1 unit)...or where the procedure is prolonged with significant dissection...leading to 3rd spacing.....NO...because with the stress response...the K+ will go down significantly to the point where dysrhytmia is something to worry about.

For a surgery where...there is no blood loss, no 3rd spacing, minimal pain, short duration...where taking a dump after being constipated for 3 days is equalliy stressful....Absolutely...I would proceed.

If you can drive to the hospital, walk up a couple of flights of stairs to get to pre-op, you can have a 15 minute knee scope.

electrolyte abnormalites are a risk to patients because some of the dysrhythmias that can develop can be fatal.

Where in the world are you safer to develop these dysrhythmia than in the OR under the care of an anesthesia provider?

I will submit to anyone that you are LESS likely to develop dysrhymias under anesthesia (no stress) than while you are awake.

Now the case is changing.

why do an elective knee scope on a cardiac pt on Dig with a low K+ (2.5 or less) when you don't need to? Now you get an arrhythmia. What next shock him and all is good? Replace the K+? Give Fab?

 

[VolatileAgent]

why do an elective knee scope on a cardiac pt on Dig with a low K+ (2.5 or less) when you don't need to? Now you get an arrhythmia. What next shock him and all is good? Replace the K+? Give Fab?

... who is also a diabetic.

i submit that you are committing malpractice if you give this patient a ga. prove me wrong, mil. just one source - any source - where it clearly states that it's standard, acceptable practice to take any patient electively to the OR with a k+ of 2.5

 

[jetproppilot]

... who is also a diabetic.

i submit that you are committing malpractice if you give this patient a ga. prove me wrong, mil. just one source - any source - where it clearly states that it's standard, acceptable practice to take any patient electively to the OR with a k+ of 2.5

MAN, ITS GETTIN' VOLATILE IN HERE!!!!!

Just waitin' for you dudes to break out a REAR NAKED CHOKE MATT_HUGHES STYLE!!!!!!

Ladies, calm down.

Its all good.

We're all colleagues here.

Albeit colleagues about to MIX IT UP with each other.

Heres how Jet sees it.

EVERYONE IS RIGHT.

Just a question on what you, the clinician, is comfortable with.

Yeah, I know. I can use the plethora of reasons posted by my colleagues to cancel this case. I respect your opinions.

Thats not how I practice. Lets look at this intuitively.

Call me simple minded, but the chance of having perioperative morbidity with this case is slim to none.

I've reviewed the chart. I know the data.

I'm preoxygenating and pushing the white stuff.

 

[jetproppilot]

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[jetproppilot]

..

 

[jetproppilot]

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[jetproppilot]

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.

Mike, you've violated THE CODE.

Mil is a prolific poster here.

He brings alotta good to this forum.

And you just called him an a hole.

Uhhhh, calling one of the rokkstars of this forum an expletive violates the code.

Retract.

Or I'm calling the Mets and having you sent down to double A.

(for you dudes in the blind, yep, Noy ussta play professional baseball for a living....and I'm sending his ass backta da minors....)

And VOLATILE,

Mil pushing your buttons now is only working in your favor.

You'll be better prepared for the oral examiners who love to breathe down a newbie's neck.

The Devils Advocate opinion is good for you to hear.

 

[jetproppilot]

Now the case is changing.

why do an elective knee scope on a cardiac pt on Dig with a low K+ (2.5 or less) when you don't need to? Now you get an arrhythmia. What next shock him and all is good? Replace the K+? Give Fab?

Man, Mike.

We're talkin' a 15 minute knee scope here.

How many CABGs have you done who have an EF of 15%, ESRD, pulmonary hypertension with a PAP of 80/40, who've done quite well post-CABG?

Sorry, I don't agree with you here.

And I don't think its cavalier at all to put this guy to sleep for FIFTEEN MINUTES.

The dude will experience more electrolyte imbalances drinking THREE CORONAS (the best beer known to mankind, bar none) than during this surgery.

"Deep breaths, sir...like you're gettin' ready to dive under water. You're goin' to sleep now...."

and this approach is coming from one of the biggest regional advocates on this forum.

Hear this:

Doing a fem-sci approach for this dude doesnt reduce morbidity/mortality. You can push the white stuff with confidence, followed by an LMA #4. And he'll do just as good.

Fifteen minutes. C'mon, green-resident-screamin'-I-think-I-know-everything types.

The ortho dude could almost do this in his office.

 

[jetproppilot]

i submit that you are committing malpractice

HAHAHHAHAHAHAHAHAHHAAHHAAHHHAHAHAHAHAHAHAHAH

Geez.

Mil ain't no anesthesia wanna-be.

He's the real deal, like all of us out here making our living doing what you are LEARNING.

His opinion ain't so far out in left field.

Azza matta of fact, I agree with him.

We do cases like this EVERY DAY, Slim.

So does that mean we're cowboys, putting our medical license on the fence with every case???

Or does it mean we've figured out when to hesitate, and when not to hesitate???? If we hesitated every time the Ivory Towers told us to hesitate we'd have a backlog of cases. And a buncha pissed off surgeons/patients.

More importantly, we'd be cancelling cases that didnt need to be cancelled.

Ten years of private practice has taught me to look at the whole picture.

A K+ of 2.5 isnt enough to cancel this case. For me.

And more importantly, for the patient.

 

[VentdependenT]

This has easily been one of the best clinical posts on the forum so kudos to all involved.

Anypoops just to lighten things up a bit I would like to present to you all the purchase I have made for halloween this year:

http://www.mr-s-leather.com/cgi-bin/mr-s/HT026.html

I also have a "bad ass" collar with chain to go with it. My fiance (female, you bastards) is going to be me dominatrix.

 

[militarymd]

... who is also a diabetic.

i submit that you are committing malpractice if you give this patient a ga. prove me wrong, mil. just one source - any source - where it clearly states that it's standard, acceptable practice to take any patient electively to the OR with a k+ of 2.5

I've always said this to my residents....Anesthesia is NOT the risk when you go to the OR...The risk to the patient in the OR comes from the fella holding the KNIFE.

The American College of Cardiology agrees with me on that one.

If I'm committing malpractice taking this patient to the OR and inducing GA, then someone else is also committing malpractice by stick a couple of needles in his groin and ass and injecting large amounts of equaling cardiotoxic drugs....albeit via a different mechanism.

Show me one source where it clealy states that it is not standard, acceptable practice to take any patient like this to the OR.

The reason that you think this is not acceptable is because you have anchored.

 

[Noyac]

Mike, you've violated THE CODE.

Mil is a prolific poster here.

He brings alotta good to this forum.

And you just called him an a hole.

Uhhhh, calling one of the rokkstars of this forum an expletive violates the code.

Retract.

Or I'm calling the Mets and having you sent down to double A.

(for you dudes in the blind, yep, Noy ussta play professional baseball for a living....and I'm sending his ass backta da minors....)

And VOLATILE,

Mil pushing your buttons now is only working in your favor.

You'll be better prepared for the oral examiners who love to breathe down a newbie's neck.

The Devils Advocate opinion is good for you to hear.

If I read his post wrong then I apologize. I was reading all the posts as he attacked everyone and then saw one directed at me. I stated in the first post I wrote that I wouldn't delay the case and then Mil decided to test me. I clearly stated why I would look at the K+ if it was available and that i wouldn't order one if it wasn't available.

About Double A, no ****ing way I'm going down to Double A. Double A sucks.

 

[militarymd]

If I read his post wrong then I apologize. I was reading all the posts as he attacked everyone and then saw one directed at me. I stated in the first post I wrote that I wouldn't delay the case and then Mil decided to test me. I clearly stated why I would look at the K+ if it was available and that i wouldn't order one if it wasn't available.

About Double A, no ****ing way I'm going down to Double A. Double A sucks.

Those weren't attacks...those were counterpoint questions to clarify why someone would want something.

 

[Noyac]

Man, Mike.

We're talkin' a 15 minute knee scope here.

How many CABGs have you done who have an EF of 15%, ESRD, pulmonary hypertension with a PAP of 80/40, who've done quite well post-CABG?

Sorry, I don't agree with you here.

And I don't think its cavalier at all to put this guy to sleep for FIFTEEN MINUTES.

The dude will experience more electrolyte imbalances drinking THREE CORONAS (the best beer known to mankind, bar none) than during this surgery.

"Deep breaths, sir...like you're gettin' ready to dive under water. You're goin' to sleep now...."

and this approach is coming from one of the biggest regional advocates on this forum.

Hear this:

Doing a fem-sci approach for this dude doesnt reduce morbidity/mortality. You can push the white stuff with confidence, followed by an LMA #4. And he'll do just as good.

Fifteen minutes. C'mon, green-resident-screamin'-I-think-I-know-everything types.

The ortho dude could almost do this in his office.

Dude I never said I wasn't doing the case. I know the score. I have no problem doing this case.

 

[SexPanther]

This has easily been one of the best clinical posts on the forum so kudos to all involved.

Anypoops just to lighten things up a bit I would like to present to you all the purchase I have made for halloween this year:

http://www.mr-s-leather.com/cgi-bin/mr-s/HT026.html

I also have a "bad ass" collar with chain to go with it. My fiance (female, you bastards) is going to be me dominatrix.

That is a SICK costume!

 

[jetproppilot]

About Double A, no ****ing way I'm going down to Double A. Double A sucks.

 

[cfdavid]

The dude will experience more electrolyte imbalances drinking THREE CORONAS (the best beer known to mankind, bar none) than during this surgery.

.

In my professional opinion, I beg to differ!!

 

[zippy2u]

Throwing my 2 centavos into the circle... While youse hospital guys are mentally masturbating about the pt's EF and patency of his coronaries, yada, yada, yada, K+ and all that other rubbish we already did 3 scopes on 3 different pts. Quick game plan... 1 surgeon, 3 rooms with CRNAs with gas doc in holding area, 15 scopes, 0700-1100. Holding room nurse makes up my stick of numbing juice-- 40cc of 1:1 0.5% marcaine and 2% lidocaine. 20 gauge spinal needle. Bang guy with 100 of prop in holding area and place 25-30cc in lateral insertion site of knee under patella and place 5-10cc at the 2 trocar sites. Pt goes to OR and gets NC O2 MAC/GA with prop. Stays in RR 30 minutes and he gets booted out door. I hear it all the time, pts LOVE surgery centers and so do surgeons. Pts don't even know where the front door is on those 250 bed monstrosities. Then they spend 30 minutes just gettin' to the place they need to be with wheelchairs and phuckin' with elevators and asking 3 people where's the OR. For this particular pt., the nurses already have his ACCU check in HA and he walks in on his own 2 feet, looks pink and says he feels great, that's all I need. Surgeon already has him off plavix and ASA for 5 days because he wants no headaches. The bean counters at the hospitals always cringe when a new surgery center comes to town... ---Zippy

 

[VolatileAgent]

Throwing my 2 centavos into the circle... While youse hospital guys are mentally masturbating about the pt's EF and patency of his coronaries, yada, yada, yada, K+ and all that other rubbish we already did 3 scopes on 3 different pts. Quick game plan... 1 surgeon, 3 rooms with CRNAs with gas doc in holding area, 15 scopes, 0700-1100. Holding room nurse makes up my stick of numbing juice-- 40cc of 1:1 0.5% marcaine and 2% lidocaine. 20 gauge spinal needle. Bang guy with 100 of prop in holding area and place 25-30cc in lateral insertion site of knee under patella and place 5-10cc at the 2 trocar sites. Pt goes to OR and gets NC O2 MAC/GA with prop. Stays in RR 30 minutes and he gets booted out door. I hear it all the time, pts LOVE surgery centers and so do surgeons. Pts don't even know where the front door is on those 250 bed monstrosities. Then they spend 30 minutes just gettin' to the place they need to be with wheelchairs and phuckin' with elevators and asking 3 people where's the OR. For this particular pt., the nurses already have his ACCU check in HA and he walks in on his own 2 feet, looks pink and says he feels great, that's all I need. Surgeon already has him off plavix and ASA for 5 days because he wants no headaches. The bean counters at the hospitals always cringe when a new surgery center comes to town... ---Zippy

zip, i've finally made up my mind. you're a genius.

 

[militarymd]

zip, i've finally made up my mind. you're a genius.

I've made up my mind....Volatile...you are schizoprenic or bipolar.

Zippy says ...no labs...put them to sleep....he's a genius..

Mil says...no labs...put them to sleep....mil's committing malpractice.

 

[zippy2u]

More than likely, perhaps Volatile was being facetious. Zip ain't no genius, most of the time I just try to hang on. Regards, ---Zip

 

[EV-Stentor]

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?

Hey Mil like I said earlier this dude will probably fly without any further testing for this minor procedure...i just wanted to generate more discussion in a purely academic sense and btw if all his grafts are closed he will be symtomatic (angina) and will need angioplasty and stenting before a general anesthetic

 

[DenRock]

At our center we do tons of these, similar patient profiles, under local with propofol sedation, intra-articular Duramorph for post-op pain. Procedure takes about 15-30 min. Neuraxial technique seems to be losing favor, since the recovery period is prolonged over GA or MAC. I'd be interested to see differences between peripheral nerve block and intra-articular Duramorph with respect to post-op analgesia. I'd venture a guess and say they're similar. With that said, I'd proceed with only a quick check of the glucose, since he's on insulin.

 

[militarymd]

Hey Mil like I said earlier this dude will probably fly without any further testing for this minor procedure...i just wanted to generate more discussion in a purely academic sense and btw if all his grafts are closed he will be symtomatic (angina) and will need angioplasty and stenting before a general anesthetic

then he would need stenting regardless of having surgery or not.