I Don’t Care What Your Cardiologist Says


 
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By Stephen Freiberg, MD

Yeah.

I said it.

As an anesthesiologist, especially as a cardiothoracic anesthesiologist, there are few things I am more interested in than how well or how poorly your heart functions and why. And a cardiologist can help me obtain a lot of vital information in that regard. But there several things a cardiologist cannot, and I argue, should not do, when it comes to the perioperative care of patients.

First, a cardiologist’s assessment of anesthetic risk or prediction of perioperative complication, means nothing to me. Or rather, it is no different than the risk level that I can determine for myself. I will receive cardiologist letters that say, “This patient is at moderate risk for perioperative complication.” In fact, it usually says the patient is at moderate risk.

How does a cardiologist determine risk? Typically, or at least hopefully, by using a validated risk calculator such as the Revised Cardiac Risk Index (RCRI) or the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator.

You know who is intimately familiar with these calculators and the data they are based on?

This guy.

You know who is perfectly capable of using the online calculators if I’m genuinely interested in knowing a numerical prediction of a patient’s potential complication?

This guy.

You know who else has also developed something of a Spidey-Sense for patients I’m concerned about, no matter what they look like on paper, or what a risk calculator might say?

You get the idea.

I don’t need to be told about risk. I know and understand it. You know who does need to be told? The patient! And the surgeon! That way, when I tell either party about my assessment of the risk, it doesn’t seem like the first time they’ve ever been told.

Second, please do not recommend a type of anesthesia.

Respectfully, you have no idea what you’re talking about.

People tend to assume that sedation or “twilight anesthesia” is safer than general anesthesia. That’s not necessarily true. I’ve even had cardiologists recommend spinal anesthesia. I guarantee that a cardiologist has very little insight into the potential and complex hemodynamic effects of spinal anesthesia. Or at least, a cardiologist does not know them as well as I do. Especially when in the same recommendation, he or she has insisted that the patient not stop their clopidogrel. Active use of this medication is an absolute contraindication to spinal anesthesia. So forgive me for not following your recommendation that could leave the patient neurologically devastated and me pleading for mercy before the board of medicine or civil court.

Anesthesiologists spend the entirety of our training learning how to develop the best and safest anesthetic plans for our patients. Please spare us your best guess recommendation on anesthesia type. We will typically ignore it, and it only leads to confusion when we have to explain to a patient why we are going to do something different than what his or her cardiologist (who they may have known for 20 years) recommends.

Lastly, please DO NOT make recommendations about which anesthetic medications to give.

I know propofol can cause hypotension. I know it has negative inotropic effects. I’ve answered more test questions about propofol than questions about my own personal demographics. And I’ve probably even gotten more of them right.

Also ask yourself, how many times have you held a syringe of propofol, connected it to an IV, and personally administered it. Even if that number is more than zero, I am confident that it is fewer than the number of times that I personally did just that in my first year of residency alone. Probably less than I did in my first month. And as such, in addition to knowing exact weight-based dosing, I have a certain gestalt for the effect that 1, 2, or 10 cc’s of that drug will produce.

But what I really suspect many cardiologists don’t understand is the fundamental logistical difference in how anesthesia care is delivered.

I don’t blame them. The way anesthesiologists deliver care is completely different than how people who train via the route of internal medicine do. Which is the route cardiologists go by definition.

On the wards, and even to a certain, albeit slightly lesser extent in the ICU, it goes like this: the physician gets called to evaluate the patient for hypotension. The physician has to come to the bedside. Then, conduct a physical exam and analyze the vital signs, and make a management decision. They might decide to administer a vasopressor medication, such as norepinephrine. Typically this will be by starting an infusion. Then, the team has to wait for the pharmacy to prepare and deliver the medication. Then, the nursing staff prime the medication into tubing, load it onto a pump, program the pump, and start an infusion. A few minutes after the infusion is started, hopefully an improvement in blood pressure is seen. If not, and the clinician wants to deliver another intervention, many of the same steps will need to be repeated.

Now let’s move to the operating room.

The patient is suddenly hypotensive. I open my drawer, draw up a medication (in the unlikely event I don’t already have it prepared), and deliver it as a bolus into an IV line. I will see a clinical effect in seconds, and in those seconds, I am already further analyzing why the patient was hypotensive. I’m also already planning my subsequent second, third, and fourth interventions if the first didn’t work. This is a cornerstone and catchphrase of anesthesiology: “Simultaneously diagnose and treat.”

Do you see the difference?

It’s not that I’m smarter or better … just wired and trained to think and act differently. As such, the way I choose to deliver certain medications in various dosages, and the way I choose to augment or offset the effects of a given drug, cannot be understood from reading a textbook.

Telling me what drugs to give, would be little different than if I told you what stent to put in the coronary artery.

Now, I’ve bashed on you cardiologists enough.

There are ways that you are invaluable. Among them being obtaining and interpreting the diagnostic tests that are crucial in my being able to deliver safe anesthesia. And the role that you play that is most critical, specific to the perioperative period, is optimizing your patients’ chronic medical conditions. Making sure their blood pressure is at goal. Fine-tuning their heart failure or pulmonary hypertension medications to maximize their functional capacity. Recommending and performing coronary revascularization if it is, in fact, indicated. That is what makes you all the superstars.

I know your hearts are in the right place (pun intended). And I strongly believe the team-based approach to care is the best approach.

So please, bring all of your expertise. But I’ll bring the propofol.

 
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