[HSF] Pre op room air blood gases.

[erdinç naseri]

prasanna,
I personally examine the patients preoply and control their lab results ,see the angio and if any abnormality in the myocardial function or valves or any suspision of congenital anomaly I take the patient to echo room and see the warch  while the cardiologist does it.Having said this ,CXR was not abnormal and only in retrospect I could say that .In the 1.st discharge PO2 was around 60 on nasal O2 and in 2.nd discharge around 90 on nasal o2 but still he came back at both times.
erdinc> Date: Sun, 24 Jun 2007 16:43:22 +0530> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Pre op room air blood gases.> From: prasannasimha at gmail.com> CC: > > Erdinc,> There is something here - an abnormal preop CXR.> Was he discharged from the ICU with a normal ABG after extubation ?> Prasanna> erdinç naseri wrote:> > Ben,> > WRT your question let me share my experience with a patient of mine who underwent CABG 3 weeks ago:52 y/O male smoker( 20 pack-year) diabetic and athletic build up,CAD( 3 vessel disease),Nothing special on physical exam,CXR: aortic arch calcification, increased in bronchovascular marking.Forgot to take ABG preop.> > OP:CABG X 4 ( Lima,RA,RGEA),whole upper lobe and upper segments of the llower eft lung full of bullaes.decided not to touch the lung,Reoperation for bleeding in the 5.th hour and extubated the same day with PO2 60.s and transfered to the normal ward on postop 2.nd day.Air leak in the 3.rd day with falling PO2 and S%O2.Transfered to ICU and reintubated.(Tidal vol.ins 450 cc ,Tidal vol.exp 250 cc) taken to the operation room and repair one major leak in the upper lobe.uneventful day and night and extubated with no air leak, transfererd to normal ward.Postop 5.day massive facial emphysema ( left thoracic tube working properly),CXR:complete collapse of R lung,Tube thoracostomy with massive air leak and deteriorating hemodynamic and neurologic status,transfered to ICU reintubated ,TV ins 410 TV exp 280,PO2 50 mmHg, hemodynamic deterioration worsens ,BGL at 500.s despite daily 100 units of insulin).Taken to OR,Resternotomy and open R mediastinal pleura to see severe adhesion of> > the lung and bubbles coming deep from hemithorax.Release of the adhesions and complete inflation of the lungs but no air leak detected .Taken to ICU andverything normailzed. finally discharged at postop 10.th day.> > Retrospectively there was a minimal hyperaeration of the left lung on CXR corresponding to a big air sac in the upper lobe( missed by me)> > Had some trouble to explain to family about 4 times OR visit and lung problem.> > Lesson:ABG +/- thoracic CT preop if required .Explain accordingly about mortality and morbidity to the family.> > erdinc> > > >> Date: Sun, 24 Jun 2007 13:48:09 +1000> To: OpenHeart-L at lists.hsforum.com> From: benjamin.bidstrup at bigpond.com> Subject: Re: [HSF] Pre op room air blood gases.> CC: > > We should list the tests that get done preop and then rank them in > order of value for management.> e.g. My Sunday pm start of the list.> > EKG> CXR> ABG> RFTs (basic spirometry)> RFTs (lung volumes, DLCO)> CT Chest> Full blood count> Electrolytes> Liver Function> Cardiac Enzymes> Renal function (BUN, Cr)> > How many of these are defensive tests and how many really influence management?> What is the cost of these tests?> > > > >If it showed one or more lung tumors it would certainly change my > >plan for management. John Flege> >> >> >-----Original Message-----> >From: Michael Firstenberg <msfirst at gmail.com>> >To: OpenHeart-L at lists.hsforum.com> >Sent: Sat, 23 Jun 2007 11:05 am> >Subject: Re: [HSF] Pre op room air blood gases.> >> >> >> >> >> >> >I dont think anyone is arguing against a pre-op CXR. Although, > >> > > > >> >interestingly - how does that EVER change management. But, again - one of > >> >those "expensive tests" that is probably useless until the first post-op CXR > >> >is abnormal and you are quickly looking for the pre-op baseline. > >> >> >> >-michael > >> >> >> >On 6/23/07, Michael Firstenberg <msfirst at gmail.com> wrote: > >> >>> >> >>Actually, the real problem that we see is the opposite.> >> >>Patients get labeled as having COPD, bad lungs, etc as a function of> >their > >> >>smoking histories and so they get extubated (usually at the> >insistence of > >> >>the Fellows) with mariginal blood gases (i.e. some degree of hypoxia> >or > >> >>hypercarbia) and everyone then says: "oh, Sats in the mid 80's is> >fine, > >> >>they are smokers" - fine until they get obtunded,> >hypoxic/hypercarbic, and > >> >>need reintubation under sometimes less than idea clinical situations.> >> >>> >> >>-michael> >> >>> >> >>> >> >> On 6/23/07, Ani Anyanwu <anianyanwu at hotmail.com> wrote:> >> >> > > >> >> >> > Michael> >> >> >> >> >> > Surely you do not need an ABG to confirm, refute, or even elucidate> >> >> > severity of COPD? Also, in what way does a preop ABG help in> >getting you off > >> >> > the ventilator? What exactly are your criteria for extubating> >patients and > >> >> > where does the ABG come in the decision making? That a test is easy> >to get > >> >> > and easily accessible does not indicate its usage.> >> >> >> >> >> > Sounds like a real interesting population you have down there - are> >they > >> >> > just dumping the crap on the new guy or is it typical of your> >entire > >> >> > center's practice?> >> >> >> >> >> > Ani> >> >> >> >> >> >> >> >> >> >> >> > ----- Original Message -----> >> >> > From: Michael Firstenberg> >> >> > Sent: Saturday, June 23, 2007 10:38 AM> >> >> > To: OpenHeart-L at lists.hsforum.com> >> >> > Subject: Re: [HSF] Pre op room air blood gases.> >> >> >> >> >> > As this discussion hopefully continues.> >> >> > We have point of ca> > re ABGs - which means the RT on the floor can> >walk to > >> >> > the> >> >> > bedside, draw the gas, and walk to the lab 10 meters down the hall> >and > >> >> > get> >> >> > the results in 5 minutes.> >> >> >> >> >> > I advocate that many of our patients do have multiple risk factors> >- > >> >> > long smoking histories> >> >> > history of "COPD" - often never proven just assumed over the years.> >> >> > shortness of breath is often a major complaint> >> >> >> >> >> > large operations are planned - we do a lot of VADs (bridge, DT,> >salvage) > >> >> > and> >> >> > low EF's with valves.> >> >> > Even our simple CABGs these days have multiple medical problems> >> >> >> >> >> > In fact the healthiest patient I have operated on in the past> >couple of > >> >> > weeks was no medical problems other than bad multiple sclerosis for> >> >> > which> >> >> > she needed frequent interferon treatments (and now CAD and CHF due> >to > >> >> > her> >> >> > acute left main thrombosis)> >> >> > > >> >> >> > Many of our patients do not have cardiologists nor have the seen a> >> >> > doctor in> >> >> > years (if ever)> >> >> > Histories are unreliable -> >> >> > One patient I did, also for bad left main disease, already had a> >lung > >> >> > biopsy for IPF and still smoked, according to her 8 cigs/day -> >although > >> >> > the> >> >> > rest of her family (including her husband) all insisted it was more> >like > >> >> > 3> >> >> > packs a day! She did fine and when I saw her in follow-up and> >asked her > >> >> > about her smoking - she said she was down to 8 a day - her husband> >in > >> >> > the> >> >> > corner just rolled her eyes......> >> >> >> >> >> > I find that having a pre-op ABG is very helpful in it gives us some> >> >> > sense of> >> >> > what to shoot for in trying to get these patients off of the vent -> >> >> > particularly if they dont fly off right after surgery.> >> >> >> >> >> > In addition, granted not everyone needs them, but it is probably> >ea> > sier > >> >> > to> >> >> > have a pre-op protocol to get them in everyone rather than> >selectively > >> >> > pick> >> >> > and choose.> >> >> >> >> >> > -michael> >> >> >> >> >> >> >> >> >> >> >> > On 6/23/07, prasannasimha <prasannasimha at gmail.com> wrote:> >> >> > >> >> >> > > Something I wanted to ask too.> >> >> > > Prasanna> >> >> > >> >> >> > > Ani Anyanwu wrote:> >> >> > > > It is interesting as you move around different hospitals and> >speak > >> >> > to> >> >> > > different surgeons you get to realize how much of what you do is> >a > >> >> > waste of> >> >> > > time or unnecessary. I would actually go to the extreme of saying> >> >> > there is> >> >> > > no patient that NEEDS an ABG before elective heart surgery. It> >may be > >> >> > a> >> >> > > helpful guide in some patients but not a necessity. I trained in> >some > >> >> > > hospitals where we got PFTs, and sometimes room air ABG on every> >> >> > patient who> >> >> > > had ever smoked, was elderly or was high > > risk. However in my> >present > >> >> > > hospital, and we do much sicker patients and we have practically> >never > >> >> > got a> >> >> > > room air ABG and very rarely PFTs. The truth is somewhere in> >between > >> >> > but> >> >> > > either test is certainly not a necessity.> >> >> > > >> >> >> > > > What I would ask those who do or rely on these tests is to> >think > >> >> > back as> >> >> > > to how many times the results of this test has changed management> >and > >> >> > how?> >> >> > > >> >> >> > > > Ani> >> >> > > >> >> >> > > > ----- Original Message -----> >> >> > > > From: prasannasimha> >> >> > > > Sent: Saturday, June 23, 2007 7:46 AM> >> >> > > > To: OpenHeart-L at lists.hsforum.com> >> >> > > > Subject: Re: [HSF] Pre op room air blood gases.> >> >> > > >> >> >> > > > Michael , if the patient has an OK pulse oximetry value on room> >air > >> >> > he> >> >> > > > doesn't need a preop ABG. If he has an abnormal one he needs a> >PFT > >> >> > etc> >> >> > > > etc e> > tcand not just an ABG.> >> >> > > > We do a preop ABG selectively.> >> >> > > > Incidentally PFT's ABG's etc etc will all have a confounding> >value > >> >> > if> >> >> > > > the patients lungs are full of water eg MS or MR. or even an> >ASD. > >> >> > > > Prasanna> >> >> > > > Michael Firstenberg wrote:> >> >> > > >> >> >> > > >> We are in the midst of a heated discussion. I agrue that like> >> >> > basic> >> >> > > labs and chest xray a room air abg is needed before heart> >surgery. My > >> >> > > partners advocae that it is a waste of money unless clearly> >> >> > indicated. But> >> >> > > no one gives indications.> >> >> > > >>> >> >> > > >> Thoughts?> >> >> > > >> Practice patterns?> >> >> > > >> Bob - i am sure you wrote a few papers on this.> >> >> > > >>> >> >> > > >>> >> >> > > >> Michael Firstenberg <msfirst at gmail.com>> >> >> > > >>> >> >> > > >> -----Original Message-----> >> >> > > >> From: "John Schor" < johnschor at mac.com>> >> >> > > >> To: OpenHeart-L at lists.hsf> > orum.com> >> >> > > >> Sent: 6/22/2007 9:00 PM> >> >> > > >> Subject: Re: [HSF] CABG in Patient with HIT Antibodies> >> >> > > >>> >> >> > > >> Hal:> >> >> > > >> One dose of heparin for CPB is usually OK....believe it or> >not. The > >> >> > > >> prolonged administration of heparin, ie the flush in an> >Arterial > >> >> > > >> line, is much worse.> >> >> > > >> John> >> >> > > >>> >> >> > > >> John Schor, MD> >> >> > > >> PO Box 4445> >> >> > > >> Cottonwood, AZ 86326> >> >> > > >>> >> >> > > >>> >> >> > > >> On Jun 22, 2007, at 4:50 PM, Hgrmd at aol.com wrote:> >> >> > > >>> >> >> > > >>> >> >> > > >>> >> >> > > >>> Dear Members,> >> >> > > >>> I need a little advice. My group was consulted on a 53 yo> >man > >> >> > > >>> with SEMI> >> >> > > >>> who was found to have 3VD with an EF of 25%. His past> >history is > >> >> > > >>> significant> >> >> > > >>> for severe thrombocytopenia after a PCI in '02. During this> >> >> > > >>> admission, he> >> >> > > >>> received Lovenox. > > Angiomax was used during the cath. He> >has HIT > >> >> > > >>> antibodies.> >> >> > > >>> I suggested an OPCAB with Angiomax to my partner.> >Supposedly, it > >> >> > > >>> has the> >> >> > > >>> shortest half life and is hepatically excreted. Does> >anybody > >> >> > have> >> >> > > >>> a specific> >> >> > > >>> protocol for Angiomax and CABG? Are other agents better?> >> >> > > >>> Claudia, where are> >> >> > > >>> you?> >> >> > > >>> Hal> >> >> > > >>>> >> >> > > >>>> >> >> > > >>>> >> >> > > >>> ************************************** See what's free at> >http:// > >> >> > > >>> www.aol.com.> >> >> > > >>> _______________________________________________> >> >> > > >>> OpenHeart-L mailing list> >> >> > > >>>> >> >> > > >>> Send postings to:> >> >> > > >>> OpenHeart-L at lists.hsforum.com> >> >> > > >>>> >> >> > > >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:> >> >> > > >>> http://mmp.cjp.com/mailman/listinfo/openheart-l> >> >> > > >>>> >> >> > > >>> All m> > essages transmitted by the OpenHeart-L are subject to> >the > >> >> > > >>> policies and> >> >> > > >>> disclaimers posted at:> >> >> > > >>> http://www.hsforum.com/listdisclaim> >> >> > > >>> -----------------------------------------> >> >> > > >>>> >> >> > > >>>> >> >> > > >> _______________________________________________> >> >> > > >> OpenHeart-L 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>> >> > > and> >> >> > > >> disclaimers posted at:> >> >> > > >> http://www.hsforum.com/listdisclaim> >> >> > > >> -----------------------------------------> >> >> > > >>> >> >> > > >>> >> >> > > >>> >> >> > > >>> >> >> > > >> >> >> > > > _______________________________________________> >> >> > > > OpenHeart-L mailing list> >> >> > > >> >> >> > > > Send postings to:> >> >> > > > OpenHeart-L at lists.hsforum.com> >> >> > > >> >> >> > > > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> >> >> > > > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> >> > > >> >> >> > > > All messages transmitted by the OpenHeart-L are s> > ubject to the> >> >> > policies> >> >> > > and> >> >> > > > disclaimers posted at:> >> >> > > > http://www.hsforum.com/listdisclaim> >> >> > > > -----------------------------------------> >> >> > > > _______________________________________________> >> >> > > > OpenHeart-L mailing list> >> >> > > >> >> >> > > > Send postings to:> >> >> > > > OpenHeart-L at lists.hsforum.com> >> >> > > >> >> >> > > > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> >> >> > > > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> >> > > >> >> >> > > > All messages transmitted by the OpenHeart-L are subject to the> >> >> > policies> >> >> > > and> >> >> > > > disclaimers posted at:> >> >> > > > http://www.hsforum.com/listdisclaim> >> >> > > > -----------------------------------------> >> >> > > >> >> >> > > >> >> >> > > _______________________________________________> >> >> > > OpenHeart-L mailing list> >> >> > >> >> >> > > Send postings to:> >> >> > > OpenHeart-L at lists.hsforum.com> >>> > >> > >> >> >> > > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> >> >> > > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> >> > >> >> >> > > All messages transmitted by the OpenHeart-L are subject to the> >> >> > policies> >> >> > > and> >> >> > > disclaimers posted at:> >> >> > > http://www.hsforum.com/listdisclaim> >> >> > > -----------------------------------------> >> >> > >> >> >> > _______________________________________________> >> >> > OpenHeart-L mailing list> >> >> >> >> >> > Send postings to:> >> >> > OpenHeart-L at lists.hsforum.com> >> >> >> >> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> >> >> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> >> >> >> >> > All messages transmitted by the OpenHeart-L are subject to the> >policies > >> >> > and> >> >> > disclaimers posted at:> >> >> > http://www.hsforum.com/listdisclaim> >> >> > -----------------------------------------> >> >> > ________________________________________> > _______> >> >> > OpenHeart-L mailing list> >> >> >> >> >> > Send postings to:> >> >> > OpenHeart-L at lists.hsforum.com> >> >> >> >> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> >> >> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> >> >> >> >> > All messages transmitted by the OpenHeart-L are subject to the> >policies > >> >> > and> >> >> > disclaimers posted at:> >> >> > http://www.hsforum.com/listdisclaim> >> >> > -----------------------------------------> >> >> >> >> >>> >> >>> >> >_______________________________________________ > >> >OpenHeart-L mailing list > >> >> >Send postings to: > >> >OpenHeart-L at lists.hsforum.com > >> >> >To UNSUBSCRIBE, to CHANGE email address, or to view archives: > >> >http://mmp.cjp.com/mailman/listinfo/openheart-l > >> >> >All messages transmitted by the OpenHeart-L are subject to the policies and> >disclaimers posted at: > >> >http://www.hsforum.com/listdisclaim > >> >----------------------------------------- > >> >> > > >> >> >> >> >________________________________________________________________________> >AOL now offers free email to everyone. Find out more about what's > >free from AOL at AOL.com.> >=0> >_______________________________________________> >OpenHeart-L mailing list> >> >Send postings to:> >OpenHeart-L at lists.hsforum.com> >> >To UNSUBSCRIBE, to CHANGE email address, or to view archives:> >http://mmp.cjp.com/mailman/listinfo/openheart-l> >> >All messages transmitted by the OpenHeart-L are subject to the policies and> >disclaimers posted at:> >http://www.hsforum.com/listdisclaim> >-----------------------------------------> > > -- > Ben Bidstrup FRACS FRCSEd FEBCTS> Consultant Cardiothoracic Surgeon> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHear> > t-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the policies and > > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> >> >> > > > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------