Heartfelt with Dr Melissa Walton-ShirleyView all posts »
Is (pre-op) "clearance" just a code word for "Vindication"?Mar 30, 2009 11:43 EDT
I ran over to the Preoperative Cardiac Evaluation talk at 8 am this Monday morning, chaired by Kim A Eagle, Ann Arbor Michigan. It was an excellent presentation by Drs. Eagle, Frochlich of Ann Arbor as well, Fleisher of Philadelphia, Leppo of MA, Santiago Garcia of Minneapolis and Thadani of Oklahoma City. There were no disagreements there so why is it so difficult to get clinicians onto the same page ?
The first speaker suggested that cardiac clearance "granted" by the cardiologist reassures the surgeon that they "should have operated" and will serve to vendicate them if there is a poor outcome. It's like making your little brother or sister help you break into the cookie jar just so you can have someone else "in trouble" with you. Don't get me wrong, there are many reasonable requests for assistance, but there are by far too many "clearance requests" in our country. (I also take issue with the term "clearance" which lead me to write a "form" letter that explains that I NEVER "clear" anyone for anything. I offer my assistance to reduce risk and provide guidance including the utilization of perioperative monitoring and the correction of over or under hydration, etc.)
The next hour was spent highlighting some excellent points: Utilizing higher thoracic epidural anesthesia (as opposed to lumbar) can lower periop MI risk by 40% when used for abdominal surgery. (caution, a meta analysis). Perioperative development of anemia to a hematocrit of <28% on the first post op day is very bad. We need to keep our hemoglobins in these patients around 9-10 in contrast to fear and loathing of transfusions in the cardiology world. In a prior trial, a change in hemoglobin of >30% in conjunction with BB utilization was actually associated with an INcrease in ischemia. (that was not a typo-but i THINK it just means that lower volume with lower BP=lower perfusion which can't be good) . Which brings me back to POISE: none of us should give elderly people with low heart rates and low BP's high dose beta blockers. I think that's what POISE told us, which is what most of us already learned in our junior year of medical school or even before we ever went to medical school. However, point well taken.
If we utilize the Revised Cardiac Risk Index, the Eagle criteria, even some of the old Goldman criteria for pre op assessment, any of them are better than nothing. However, We learned today that the addition of creatinine clearance as a risk factor seems to be the best NEW tool for pre op risk assessment. As cardiologists, we must learn to reign in our infatuation with stress testing for low risk surgeries in low risk patients. In one publication, even when a positive stress exam yielded an event rate of 23%, having done something about it like medical therapy or intervention or surgery did nothing to lower perioperative risks. (Can we say COURAGE TRIAL boys and girls?) In one trial, revascualarizing two patients cost them their lives because of the wait incurred for their AAA surgery.
If what we do as cardiologists in the way of pre-op testing in low risk patients undergoing low risk surgery doesn't really help lower cardiac risk, and if when we do something about what we find , i.e revascularize the patient/medicate the patient .....and it still doesn't help,.......... then why are we invited to the Pre-op assessment party anyway? More of us need to have frank conversations with our colleagues and friends about extracing ourselves from the "cover your butt" mutual admiration society.
Instead what should happen is this: Anesthesiologists and surgeons are doctors too. They can read and write and utilize graphs/tables and algorithims as well or better than most. There is really NO NEED to get the cardiologist involved UNLESS there is poor fuctional capacity, recent MI, progressive symptoms, ACS, active heart failure, uncontrolled arrhythmias , complicated valve issues or low creatinine clearance. I'm grateful that most of my surgeons and anethesiologists figured this out a long time ago. Hiring a nurse to do risk assessment screening was the best thing our hospital ever did. However, I fear that in so many places the surgeons insist upon hand- holding just in case they have to take a walk to the witness stand. When cardiologists get the engraved invitation (consult request), we just can't resist the urge to get all dressed up with an echo and a stress exam, just in case. The entire ridiculous, costly and in some cases, down right dangerous cycle, just continues unchecked.
Bottom line: To our friends the Surgeons and anesthesiologists: Stop inviting cardiologists to the Pre-op assessment party unless you really need us. If you just can't resist, we'll do our best to treat tachycardia, maintain beta blockers (if the patient is already on them), medicate for post op rhythm issues and advise about whether or not pressors or fluid resuscitation is best to bolster the HOTN induced by afterload and pre load reduction intra op. We'll handle the IV lopressor. We might even start a statin. If you'll let us, we'll give them aspirin. We'll even nudge you to transfuse in the early hours following surgery, And we'll be most happy to get all dressed up in that brand new beautiful echo or stress exam suit and come to the party for those of you who really really need us .
Other than that, I'd like to keep my pre-op assessment dance card as free as possible.