When do you cancel surgery?
I'm on call this week for our hospital's Critical Limb Care program. First thing Monday morning I had a call from a cardiologist who wanted to know whether to proceed or cancel an angioplasty (PCA). The case was an ablation of the right atrium. The problem was that the patient presented with a mid-shin wound that had been present for 3 weeks. The question at hand was whether the wound was infected and would contaminate the procedure. "What should I do? Cancel the case?"
This is a question that has no definitive answer. Could the cardiologist proceed with the case and complete it without a risk of infection? Maybe. But to really answer the question, you have to drill down a bit further. Start with the patient history. How old is the patient? What sort of comorbidities do they have? Are they a diabetic? What is their nutritional status? Are they a smoker? Drink alcohol? Are they active? Obese? The list goes on...
The cardiologist still wanted to proceed and sent me a text image of the wound. "What do you think? Is this OK?" The call was really a deferral of responsibility. If the case did get infected, he would have documented that he had spoken to me and I had given the green light to do the procedure. When in doubt, cancel the case. This was an elective procedure that could be performed once the patient was cleared of the infection. I canceled the case.
So what are some of the conditions that might result in a case being canceled? I'll often get calls from patients a day or two prior to their surgery saying that they have a cold or sore throat. I think it's great that our patients are comfortable with our office, checking in to be sure. Our policy is that when it comes to surgery, we're a team (doctor, staff, and patient). And there are no dumb questions. With a cold or sore throat (with the exception of strep throat) the case goes.
Eating food or liquids within 6 hours of performing the case? The case is canceled for sure. Every surgeon has seen a case where the stomach contents are aspirated, ultimately resulting in aspiration pneumonia. In elective surgeries, that's just a problem you can avoid.
High blood pressure? Maybe. How high is too high? First, you have to ask whether there is a history of hypertension. Transient hypertension or newly diagnosed hypertension can typically be managed in the OR if the patient is below 150/90. Anything higher and I start to worry about a cardiovascular event in surgery. No strokes, thank you. Chronic hypertension can result in cardiomegaly (enlarged heart) and would require cardiac clearance for surgery. Surgery causes physiological stress and in particular, stress to the heart. Why take a chance. Just cancel the surgery.
These examples are is just a few of the thousands of questions posed to surgeons on a daily basis. And it's a rare day that any of these questions are the same. On one hand, it's a heck of a challenge, but on the other hand, that's the art that is known as medicine.
Jeffrey A. Oster, DPM