[KsMICT]

How often does the situation arise that you look at a patient's chart and decide that, because of the patient's history, you are not comfortable proceeding with the surgery? Does the surgeon usually agree with you or can there be a lot of conflict? I realize that CRNAs, like any health care provider, must be a patient advocate first and foremost but in this era of get 'em in and get 'em out/restaurant-style health care (at least in busier areas) how much conflict arises between anesthesia providers and surgeons over opinions of potential patient instabilty during a surgery?

[stanman1968]

This happens from time to time. But you cannot cancel a case on a "feeling" you must remember that the most common place that a CRNA will have such autonomy is a rural hospital. There are usually only a few surgeons at these hospitals and they are often the biggest revenue generators so if you say no you need a reason.
Remember surgeons want to cut and hospitals want to make money so pick your battles cause if you do it to often no one will appreciate it.

[dfk]

just today we had a patient that was found to have undiagnosed/untreated HTN.
BP was around 180-200/80-90s. even though current literature states postponing elective surgery with diastolic >110, this pt was undiagnosed and untreated, so it was decided to consult primary care and cardiology, and postpone surgery.
some will argue why not tx BP and go ahead. even more current literature (not published yet) states that treating patients with beta blockers day of surgery (and never tx'd with BB before) actually poses a greater risk/outcome of morbidity and mortality.
so, moral of the story, as previously stated, the clinical picture needs to be your guide. and if it is a good enough argument, chances are the surgeon will go along with it, unless the surgeon says it's an emergent surgery, then you tighten your sphincter and proceed accordingly.

[wayunderpaid]

Originally Posted by dfk

just today we had a patient that was found to have undiagnosed/untreated HTN.
BP was around 180-200/80-90s. even though current literature states postponing elective surgery with diastolic >110, this pt was undiagnosed and untreated, so it was decided to consult primary care and cardiology, and postpone surgery.
some will argue why not tx BP and go ahead. even more current literature (not published yet) states that treating patients with beta blockers day of surgery (and never tx'd with BB before) actually poses a greater risk/outcome of morbidity and mortality.
so, moral of the story, as previously stated, the clinical picture needs to be your guide. and if it is a good enough argument, chances are the surgeon will go along with it, unless the surgeon says it's an emergent surgery, then you tighten your sphincter and proceed accordingly.

Great post, even though I am not a CRNA (ICU nurse for now), htn is absolutely a risk factor. Lowering bp to fast to what is considered "normal" levels can also cause end organ damage, especially for untreated high bp. It has to be done slowly and pt's renal/hepatic function watched closely too...
Lowering bp quickly just to do surgery might be a cause for concern. I am not saying that it can't be done, just that it needs to be monitored really closely. I had a patient whose "normal" was 210/120 (we were told not to call the provider with these values, believe me, it was really hard!! b/c they were always like this, even with 8-10 bp meds around the clock). Lowering bp to 120/80 would be a no-no in this circumstance. Perhaps 180/100 would be a realistic goal, and slowly taper down.
Wayunderpaid

[deepz]

Odd as it may seem, certain patients have their surgery cancelled or postponed -- not because we can't get them through the surgery itself (we can, with enough drips and interventions, get most any hunk of protoplasm to the PACU 'alive') -- but rather they get cancelled or postponed because the challenge is the immediate postop period ... when folks like UnderPaid will be saddled with the true heavy lifting. The quality of ICU care can be a concern (depends on the specific institution); some folks just need to be turfed to St Elsewhere.

Discretion is the better part of valor.
------ paraphrasing Falstaff

[TennRN2004]

Originally Posted by KsMICT

How often does the situation arise that you look at a patient's chart and decide that, because of the patient's history, you are not comfortable proceeding with the surgery? Does the surgeon usually agree with you or can there be a lot of conflict? I realize that CRNAs, like any health care provider, must be a patient advocate first and foremost but in this era of get 'em in and get 'em out/restaurant-style health care (at least in busier areas) how much conflict arises between anesthesia providers and surgeons over opinions of potential patient instabilty during a surgery?

I had a patient a few weeks ago whose case we canceled based on a low lab potassium value 2.7. I was the first to review the chart and pointed it out to the CRNA in the room with me, we called the floor to verify if it had been treated or rechecked, and the am nurse wasn't even aware of the k level. We notified the ologist who called the surgeon and talked the situation over with him. Basically, he said what someone else has mentioned, that if the case was an immediate emergency, then we could do it, but if not the patient should be rescheduled for another day.

The surgeon was fine with it, because he understood if we have a cardiac event from a low k in a case that could have waited a few days, it could be a big problem. Ultimately, if a bad outcome occurs with the patient intraop and anesthesia is trying to treat something that was recognized preop as a risk factor that was discussed with the surgeon, it leaves us and them open for liability issues. Of course, like someone else mentioned, you don't just go on your feeling about the possibility of something happening, anesthesia is expected to be prepared to treat a wide variety of acutely unstable scenarios in the OR. But, we do have evidence based practices that guide us on difficult situations. Provider experience and judgement is the bottom line. Surgeons may want fast turnover and lots of cases, but they don't want bad outcomes from doing a case that needs to be held off either.

[zrmorgan]

Originally Posted by stanman1968

This happens from time to time. But you cannot cancel a case on a "feeling" you must remember that the most common place that a CRNA will have such autonomy is a rural hospital. There are usually only a few surgeons at these hospitals and they are often the biggest revenue generators so if you say no you need a reason.
Remember surgeons want to cut and hospitals want to make money so pick your battles cause if you do it to often no one will appreciate it.

I practice in one of the rural settings as mentioned...our surgeons here understand that everyone in the room is responsible for the patients outcome in and outside of the OR. I have found that if you choose to postpone, or cancel cases judiciously, they will not have a problem, irregardless of the fact that you are a CRNA...most of them have been trained to respect the team members limits.

The key is before you make the decision, have your reasons for doing so straight...if you don't have the science to back up your decision, get some more anesthesia providers you work with to back you up...this can be your attending anesthesiologist, or another experienced CRNA if you dont have an ologist around.

Sometimes you can rely on an internist, or other consultant to make a recommendation to optimize the patient before proceeding...however, this can be tricky as I have often come accross the logic "well, cardiology cleared them, or they were "cleared by Internal medicine". The issue here is, only anesthesia should clear a patient for anesthesia.

As I said above (about being judicious), don't paint yourself as a person who cries wolf too much, as you may really need to advocate for a patient in the future.

Good luck.

Z