medical konsultasi

1. Medical Consultation: An Overview Lori A. Lemberg, MD Fall 2012

2. Yes, this is Medical Consult, How can I help you?

3. Learning Objectives • Function of the Medical Consultant • Goldman’s “Ten Commandments” • Surgical Considerations • Anesthesia Considerations • Appropriate History and Evaluation of Patient • ACC-AHA Guidelines

4. Function of the Medical Consultant to offer an opinion on diagnosis or management

5. 1. Determine the Question 2. Establish Urgency 3. Look for Yourself 4. Be as Brief as Appropriate 5. Be Specific 6. Provide Contingency Plans 7. Honor Thy Turf 8. Teach …With Tact 9. Talk is Cheap…and Effective 10. Follow Up Goldman’s Ten Commandments for Effective Consultation Goldman et al, Arch Int Med 1983; 143: 1753

6. 1. Determine the Question Ask the requesting service to be as specific as possible Clarify verbally if the question(s) are unclear

7. 2. Establish Urgency 3. Look for Yourself Emergency, Urgent, Elective See the patient within 24 hours • Review pertinent history and physical exam • Make an independent judgment

8. 4. Be as Brief as Appropriate 5. Be Specific • Do not recopy the history and physical • Highlight important points • The more detailed the suggestions the better • Spell out dosing, timing of meds • Less is more

9. 6. Provide Contingency Plans 7. Honor Thy Turf • Anticipate problems • Do not step on other’s toes • Remember your position as consultant

10. 8. Teach with Tact • Encourage collegial relations 9. Talk is Cheap and Effective • Talk with the primary physician or service about your findings and recommendations • Discuss disagreements • Bring the attendings to the table if necessary

11. 10. Follow-Up • Interval as appropriate to the case • Improves compliance with recommendations • Tell services you are signing off • Provide specific outpatient follow-up plan

12. Consult within 24 hours More than two follow-up notes Verbal contact with referring MD Limited number of recommendations (<5) Recommendations related to “central reason” of consult Factors Improving Compliance with Recommendations Kammerer, Gross, Medical Consultation

13. Factors Improving Compliance with Recommendations • Definitiveness of recommendation • “Crucial” recommendation • Details spelled out • Medication/treatment vs. diagnostic • Severely ill patient

14. Pre Operative Consultation

15. Pre Operative ConsultationWhy? • Elucidate patient’s risks and benefits of surgery • Improve risk by optimizing medical condition • Anticipate perioperative and postoperative complications

16. Risk of Surgery INHERENT RISKS OF PROCEDURE High:Emergency procedures, Major Vascular, Craniotomy Medium: Orthopedic, Prostate, Abdominal, Thoracic Low: Breast, Plastic Very Low: Cataract, Dental, Endoscopic

17. Surgeon Specific Risk Hospital Specific Risk

18. Anesthesia GENERAL • depresses cardiac function • airway control, but reduced lung volumes SPINAL or EPIDURAL • vasodilates • avoid with aortic stenosis No difference in CV events!

19. When do things go wrong? • Mortality Related to Surgery 10-15% during induction 30-40% during surgery 45-60% post-operative • Peak for Myocardial Infarction Day 0, 1, 2 days postoperatively

20. Induction Catecholamine surge Blood pressure lability

21. Post Operative State • Metabolic demands • Pain • Fluid Shifts • Catecholamine surges • CHF, Coronary ischemia • Atelectasis, VQ mismatch, Pneumonia • DVT • Immobilization

22. If the inherent risk of surgery is low, can I make an impact?

23. Medical Considerations for Surgery • Cardiovascular: CAD, CHF, HTN, Arrhythmias, Valvular heart disease • Hematologic: Bleeding, DVT risk • Pulmonary: COPD, Asthma, Smoking • Renal: Renal insufficiency • Endocrine: Diabetes, Thyroid, Adrenal

24. Medical Considerations for Surgery • Hepatic: Cirrhosis, Hepatitis • Habits: Alcohol, Drugs • Medications • Endocarditis prophylaxis • Pregnancy • Geriatric patients

25. History Include: • Previous surgery or complications • Bleeding • Functional capacity / Exercise tolerance • Medications • Allergies • Substance Use • Family History (bleeding, malignant hyperthermia)

26. Exam • Vitals • General Exam • Mental Status

27. Laboratories Controversial, Low predictive value CBC Anemia? Baseline? Chemistries K+? BUN/Cr? PT, PTT, Bleeding Time not predictive EKG for higher risk or older patients? CXR doubtful

28. Cardiovascular Risk Assessment

29. Higher Risk Features Goldman et al • Age > 70 5 pts • MI < 6 months 10 pts • S3 or JVD 11 pts • Important valvular AS 3 pts • Rhythm other than sinus 5 pts • > 5 PVCs per minute 5 pts NEJM 1977; 297:845

30. Goldmancontinued • Poor general medical status 3 pts • Intraperitoneal, 3 pts intrathoracic or aortic surgery • Emergency surgery 4 pts Total 53 pts Medium 13-25 pts 12% complications High Risk >25 pts 56% complications

31. Lee et alRisk Factors in Multivariate Analysis of 4315 Patients • High Risk Surgery • Ischemic Heart Disease • Congestive Heart Failure • History of TIA or Stroke • Insulin Therapy for Diabetes • Pre Op Creatinine > 2.0 Circulation 1999:100: 1043

32. Lee et al Circulation 1999:100: 1043

33. Table 1. Applying classification of recommendations and level of evidence. Fleisher L A et al. Circulation 2007;116:e418-e500 Copyright © American Heart Association

34. American College of Cardiology American Heart AssociationRevised 2002/2007 Guidelines MAJOR CLINICAL PREDICTORS • Unstable angina, Recent MI • Decompensated CHF • Significant Arrhythmias (high grade AV block, symptomatic ventricular arrhythmias, SVT uncontrolled • Severe valvular disease

35. ACC-AHA 2002/2007 Guidelines INTERMEDIATE CLINICAL PREDICTORS • Mild angina • Past history of CHF • Prior MI • Diabetes

36. ACC-AHA 2002/2007 Guidelines MINOR CLINICAL PREDICTORS • Age • ECG (LVH, LBBB, ST-T changes) • Low functional capacity (< 4 mets) • Rhythm other than sinus • Uncontrolled hypertension • Past history of stroke