Term 4 Week 4 (w/c 24/10/2012)
It’s been a great month on #Gasclass. We have had our best month ever for hits on the case histories. We have brought out some new polls and The Experts says. So hopefully it will be another good week.
This week we are back in theatre. You are the first anaesthetist on call for advice during a week day. The pre-assessment nurse from General Surgery calls you to say she has an elective male patient with a blood pressure of 184/106.
What do you want to know and what will you ask for?
The preop nurse has repeated the BP in clinic. It remains at 179/104. The ECG is reported as normal. The patient is on no medication currently. The patient returns to the GP and the practice nurse repeats the BP three times with a maximum blood pressure of 139/86 on the third reading.
The preop nurse is now back on the phone with this information. She is asking:
Is there anything further you want done before operation?
Lots of people reading the posting.
It’s pretty clear to all of us in this kind of case that there is no need for general practice to get involved in treatment. The patient comes into hospital and the admission unit nurse records a BP of 190/110.
Procedure is Lapraoscopic Inguinal Hernia Repair.
Will you do anything differently? Do you want more information?
The ECG is now shown to you.
Time to make decision. The patient is in hospital.
As the patient is actually in the building we have arranged for an echo to further inform the preop status.
There is very mild concentric left ventricular hypertrophy and a small jet of mitral regurgitation. LVEF is 67%. All other measurements are within normal limits.
Question for all groups:
Should the anaesthetist just get on with it?
This has been a fairly tame week for our classroom chat. However it has been a topic that gets a lot of others exercised and is rarely discussed between the two specialties of General Practice and Anaesthesia. Cardiologists may wax lyrical on the topic whilst we deal with it.
As a summary it seems that most anaesthetists are fairly happy to proceed. A labile blood pressure preoperatively predicts a labile blood pressure intraoperatively. This is not necessarily a predictor of disaster although it wrecks a beautiful anaesthetic chart. It may be a risk for intraoperative stroke. It is difficult to find a connection to postoperative cardiac sequelae. This is more related to pump function and perfusion.
Management of Blood pressure in this case has led us to invite our second contributor to The EXPERT says:
If all his BP readings, in the Primary care setting, were normal, then I would not necessarily have requested an ECHO on this man, (assuming her is otherwise fit and healthy, with no other concerning history or signs).
Many clinicians are aware of the R and S wave criteria in the precordial (chest) leads, but this can be dependent on body habitus. The chest leads placed on a tall, thin man, with little adipose tissue, are in close proximity to the heart so naturally, the waveform amplitude in the chest leads will be large. The limb leads, being less affected by body habitus,
are often more reliable in these individuals.
Voltage criteria for LVH in V1-V6 alone, in a tall thin person, without other cause for concern, is not necessarily an indication for an ECHO.
If a patient with LVH criteria on ECG is hypertensive, then arguably, an ECHO is only helpful if it will alter your threshold for treatment. If you plan to treat anyway, an ECHO is of dubious further value.Likewise, an ECG suggestive of LVH in a normotensive person, would only be indicated if a) Body habitus didn’t explain the amplitude, or b) There was other signs/symptoms of concern (Possible HOCM? or Aortic Stenosis?).
As far as the ECHO report goes, mild concentric LVH can often be seen in healthy individuals (even athletes); and mild/trivial MR may also be present, and of no significance, in a large proportion of healthy population.
In short, we need to know more about his risk factors, physique and generalhea lth to decide if this ECG is significant or not.
Thanks to Heather for this contribution.
Please only Tweet one point and wait until someone else has tweeted.
There are no trick questions in #gasclass. It is an educational tool only. Everyone’s opinion is as valid as the next person. Follow the conversation by using (or searching for) the hashtag #gasclass on twitter. We welcome input from all specialties and you can send us a direct message if you would prefer to remain anonymous.