RI Katz, JM Bernhart, G Ho, et al
A survey on the Intended Purposes and Perceived Utility of Preoperative Cardiology Consultation
Anesth Analg 87:830-836, 1998
Although surgeons and anesthesiologists often request cardiology consultations for patients with cardiovascular disease, no studies have documented the reasons behind these consultations or their effect on patient management. A study was designed to determine what surgeons, anesthesiologists and cardiologists think is important to obtain from a cardiology consultation and what effect any recommendations have on perioperative management.
A multiple-choice survey was developed from a focus group session conducted among 6 anesthesiologists and tested on groups of additional anesthesiologists, surgeons and cardiologists. The survey was sent to 1200 randomly selected physicians in these specialties [400 of each group]. Additional data were obtained from the charts of 55 consecutive patients who received preoperative cardiology consultations.
The overall response to the survey was 33.4% and opinions differed substantially about the importance and purposes of a cardiology consultation. Most cardiologists and surgeons, but not anesthesiologists, regarded intraoperative monitoring, clearing the patient for surgery and advising about the safest type of anesthesia as important. A majorityof surgeons [80.2%] but few anesthesiologists [16.6%], felt obligated to follow a cardiologist’s recommendations. Review of the 55 cardiology consultations found preoperative evaluation to be the most commonly stated purpose. Nearly 40% of the consultations contained no recommendation for changes in patient care or medication, and most advice offered about intraoperative management or cardiac drugs was ignored; of the 87 recommendations relating to preoperative management, however, 71 were followed [81.6%] There was disagreement among the specialists about which physician had primary authority to declare that an elective case may proceed.
Anesthesiologists, cardiologists and surgeons differ considerably in their opinions about the purpose and value of cardiology consultations. Many of these consultations appear to be requested for procedural reasons rather than to obtain responses to specific medical questions.
H.O. Myhre Department of Surgery, University Hospital of Trondbeim N-7006 Trondbeim
The ‘Failed’ Embolectomy
Br. J. Surg, Volume 87, Number 2, February, 2000, Pg. 136
This is an answer given by Professor H.O. Myhre of Trondbeim Norway to a question posed by the editors.
A patient has presented work severe ischaemia of the leg and a femoral embolectomy has been done. Excellent inflow has resulted and, although some material has been removed from the infrainguinal vessels, back bleeding has been poor. How should we proceed ?
a] If the patient has a known potential source of emboli, has sudden onset of symptoms, and the contralateral limb is free of occlusive disease.— -à EMBOLIC.
b] If symptoms are subacute with known atherosclerotic disease, & intermittent claudication – ACUTE THROMBOSIS superimposed on atherosclerosis.
c] Suspect a thrombosed popliteal aneurysm.
Preoperative angiography is not essential but optional especially if acute thrombosis is suspected. It may result in avoidable delay if attempted in all cases. He suggests intra-operative angiography if initial embolectomy fails.
A] If this shows residual embolic material – balloon extraction is tried.
B] If problem lies in the popliteal trifurcation area, —————– direct
embolectomy is advisable.
C] If thrombosis on pre-existing atheroma is suspected —à thrombolysis with recombinant tissues plasminogen activation is used. Clamp the vessel for 30 min. and follow up with arteriography. If lysis is incomplete, the step is repeated. If successful the underlying cause may be identified. This can be treated by balloon angioplasty or femoral popliteal bypass with fasciotomy.
D T Connelly – The Cardiothoracic Centre – Liverpool NHS Trust, UK
Heart 2001; 86: 221- 226
Drugs can review the incidence of malignant ventricular arrhythmias, amiodarone now being the drug of choice. However, it is preferable to use implantable cardioverter defibrillators. The implantable cardioverter defibrillators (ICDs) are very small and implanted to the chest wall (in pectoral muscle).
Ventricular arrhythmia can be detected. Antitachycardia pacing and cardioversion by defibrillation shocks can be administered.