Authors

  • Mitch Keamy Photo Mitch Keamy is an anesthesiologist in Las Vegas Nevada Andy Kofke Photo Andy Kofke is a Professor of Neuro-anesthesiology and Critical Care at the University of Pennslvania Mike O'Connor Mike O'Connor is Professor of Anesthesiology and Critical Care at the University of Chicago Rob Dean Photo Rob Dean is a cardiac anesthesiologist in Grand Rapids Michigan, with extensive experience in O.R. administration.

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Comments

andrew kofke

whack a mole
good description of evidence based medicine where the evidence just wont stay still. after 25 yrs of seeing steroids on off on off on off as just one example it is dificult to put much faith in ebm, esp if the evidence runs counter to good well based physiology.

much of it is simple design flaws. take a drug found to be brain protective given right after a brain insult then do a clinical trial where you can wait 6 hours to give it and....surprise...ebm is quoted as saying the therapy is no good!

ak

Sid Schwab

One of my favorite cardiologists, an extraordinarily good guy with whom I loved to have jaw to jaw political debates, was given to hyperbole. "This patient is has the worst coronaries of any who's walking around." "This patient has the most brittle hypertension I've ever seen." It took me a couple of years to add the grain of salt, having done a few operations differently than I'd have preferred, in the name of a brief anesthetic, and having the patient -- tip of hat to excellent anesthesia -- sail through. I've seen pretty fair cardiologists "clear" or "not clear" in puzzling ways. Armed with appropriate data, I trust the anesthesiologists view more than the cardiologist, vis a vis surgical risk (whatever that is) for non cardiac surgery. Best of all worlds: a gas passer who does lots of cardiac.

mkeamy

hey Sid! thanks for dropping by. There are a couple of things I know from the literature and experience that would interest you about all this. First, length of surgical time is almost certainly not an independent predictor of peri-operative MI. But complexity of surgery probably is, with really major cavity surgery having some small risk, and simple surgery (i.e.hernia) almost none. So length of surgery and incidence of MI are vaguely related as both being dependent on extent of surgery.In my experience, likewise hypertension, if carefully managed is not an intra-operative risk at all; the exception being cocaine/amphetamine induced acute hypertension, which can be scary and risky for bleed. THis assumes that the anestehsiologist doesn't try to "fix" severe pre-op hypertension but lets it ride high. That may be a nuisance for you, but is usually manageable with diligent application of sparks and clips...

Peri-up MI's come in two categories theoretically; intra/immediate postop, which are non-q wave (used to be called subendocardial, or non-transmural) related to tachycardia and or hypo/hyper-tension, and transmural MI's (acute coronary syndrome, acute coronary occlusion, plaque rupture etc) related to the hypercoagulable state that is a consequence of the inflammation and stress of surgery. These can (and usually do) occur days post-op, when those platelets are really revved up. Revved up platelets are like whipped up dogs; they'll go after anything; they like stents (high incidence of post-op stent occlusion) DVT (not sure if this is platelet mediated or not; platelets are more active on the arterial side, but the hypercoagulable state is not limited to platelet activation.) So once the patient is induced, no need to hurry through the operation unless A) your anesthesiologist is a "gas passer" or B) the hospital is on fire.
I liked your last post a lot, but didn't have anything intelligent to add.

Cheers!

Mitch

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