Clinical Case of the Month: You’re medical director for a busy outpatient surgery center. An RN routinely does the preoperative screening by telephoning each patient two days prior to surgery. The RN pages you with this question: A 48-year-old patient scheduled for anterior cruciate ligament (ACL) reconstruction surgery takes hydrochlorothiazide for hypertension, and has not had electrolytes checked for six months. His last potassium was 3.6 mEq/L. The patient is asymptomatic except for knee pain. The nurse asks you whether this patient needs to have his potassium rechecked now, before surgery. What do you do?
Discussion: Pre-op evaluation will never be the topic of a Hollywood thriller — you’ll never see Tom Cruise or Brad Pitt rubbing their temples worrying about whether they need to recheck the electrolytes. But for you and me, it’s a question worth discussing. How important is it to diagnose hypokalemia in this asymptomatic patient on chronic diuretic therapy? If the K=3.0 mEq/L, will you cancel the surgery? What about if the K=2.9 mEq/L? Experienced anesthesiologists know standards of care for their specialty, and also develop a gut impression about which patients are prepared for surgery, and which ones are not. Do you sense this patient is at risk for sudden death or a cardiac arrhythmia? Let’s examine this question.
First off, why didn’t you see this patient in your pre-op clinic? The answer is because you won’t find the Stanford model of a well-staffed Pre-Anesthesia Clinic in the private practice community. The Pre-Anesthesia Clinic is important at Stanford because many patients suffer from significant medical comorbidities, and because of the invasive nature of many of the inpatient surgeries. In a community practice with healthier patients and less invasive procedures, there is neither the money nor the need to physically meet and examine every patient several days prior to surgery. Adam Smith’s economic dictum of the invisible hand pertains to clinical medicine as well — anesthesiologists are paid to give anesthetics. Neither insurers nor Medicare will reimburse you for routine pre-operative clinic encounters with patients.
In 2002, the American Society of Anesthesia published Practice Advisory for Preanesthesia Evaluation: A Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. This publication is available on the ASA website at http://www.asahq.org/publicationsAndServices/practiceparam.htm. Their recommendations for the timing of preanesthesia evaluation differ, depending on the severity of disease and also on the surgical invasiveness. Our patient’s surgery involves a non-severe comorbidity (well-controlled hypertension) and a non-invasive surgery (knee arthroscopy). For patients such as this, the ASA Practice Advisory states, “preoperative assessment may be done on or before the day of surgery. “ In our community outpatient practice in Palo Alto, a surgery-center RN calls the patient two days prior to surgery to ask pertinent questions. This telephone call helps avoid day-of-surgery surprises (e.g. patients still on aspirin, patients with undiagnosed chest pain or dyspnea). The physical evaluation by the anesthesia attending occurs on the day of surgery.
Outpatient surgery centers rarely have the ability to do lab tests other than blood glucose measurements or a 12-lead ECG. Tests such as the measurement of electrolyte concentrations need to be done at an outside lab, at least one day prior to surgery. Regarding preanesthesia serum chemistries (i.e., potassium, glucose, sodium, renal and liver function studies), the ASA Practice Advisory gives no specific recommendation to check preoperative electrolytes during chronic diuretic therapy. The recommendation on checking pre-op electrolytes states “Clinical characteristics to consider before ordering such tests include likely perioperative therapies, endocrine disorders, risk of renal and liver dysfunction, and use of certain medications or alternative therapies.”
Might “perioperative therapies” include potassium replacement? Consider this: potassium is predominantly an intracellular ion. Per Miller’s Anesthesia, “Only 2% of total-body potassium is stored in plasma. . . . a 20% to 25% change in potassium levels in plasma could represent a change in total-body potassium of 1000 mEq or more if the change were chronic or as little as 10 to 20 mEq if the change were acute. . . . Chronic changes are relatively well tolerated because of the equilibration of serum and intracellular stores that takes place over time to return the resting membrane potential of excitable cells to nearly normal levels.” (Miller’s Anesthesia, 2005, pp.1105-6)
The same textbook states, “Retrospective epidemiologic studies attribute significant risk to the administration of potassium (even chronic oral administration). In one study, 1910 of 16,048 consecutive hospitalized patients were given oral potassium supplements. Of these 1910 patients, hyperkalemia contributed to death in 7, and the incidence of complications of potassium therapy was 1 in 250.” (Miller’s Anesthesia, 2005, p. 1107).
Given this information, what should we do?
Here’s the answer: Per Miller’s Anesthesia, p. 1107, “As a rule, all patients undergoing elective surgery should have normal serum potassium levels. However, we do not recommend delaying surgery if the serum potassium level is above 2.8 mEq/L or below 5.9 mEq/L, if the cause of the potassium imbalance is known, and if the patient is in otherwise optimal condition.”
The same textbook points out an additional problem in ordering lab tests: “the failure to pursue an abnormality appropriately poses a greater risk of medicolegal liability than does failure to detect that abnormality. In this way, extra testing increases the medicolegal risk to physicians.” (Miller’s Anesthesia, 2005, p. 945)
Regarding the timing of lab testing, the ASA Practice Advisory on Preanesthesia Evaluation states “test results obtained from the medical record within 6 months of surgery are generally acceptable if the patient’s medical history has not changed substantially. More recent test results may be desirable when the medical history has changed, or when test results may play a role in the selection of a specific anesthetic technique (e.g., regional anesthesia in the setting of anticoagulation therapy.)”
For all the reasons stated above, you tell the RN that you won’t recheck the potassium lab value for this patient, and you won’t delay or cancel the ACL surgery. The surgery is completed two days later, without complication. Your two clients, the patient and the surgeon, are both happy, and you’ve practiced sound, evidence-based medicine.
Introducing …, THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel. Publication date August 31, 2014 by Pegasus Books. Available on all major online book vendors. THE DOCTOR AND MR. DYLAN can be ordered in print or ebook from Amazon.com. The first four chapters are available for free at Amazon. Read them and you’ll be hooked! To reach the Amazon webpage, click on the book cover image below:
Brief description: Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.
Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.
Amazon Review: 5.0 out of 5 stars I thoroughly enjoyed reading this September 5, 2014
This book gives you some insight as to the life of a physician.
Many of us wind up in hospitals to undergo some procedure or another and our life is in their hands. It was so interesting to read about their side of the story and the effects it all has on them. The influence of friends and family plays a part in all our lives and so often we forget how much help that can be, too. Dr. Novak follows the path that Carol Cassella blazed in the genre of Anesthesiologist authors.
I thoroughly enjoyed reading this book.
By Mark in Manhattan on September 24, 2014
Format: Kindle Edition
Great beginning. Terrific ending. I’m a junkie for courtroom drama, and this book reminds me of John Grisham’s best. Hard to believe it was written by a doctor. The Dylan character is a hoot. A top-notch novel.
A real page turner!
By Maddiepup on October 1, 2014
Format: Kindle Edition
This book get your attention from the first page — a real page turner. A great mystery with humor intertwined. A great read!!
Learn more about Rick Novak’s fiction writing at