Physicians often use the word "protoplasm" to mean a patient's overall health and fragility. Protoplasm makes a big difference. A 70 year old with hypertension, hyperlipidemia, coronary artery disease, aortic stenosis, COPD, end stage renal disease, peptic ulcer disease, diabetes, and Parkinson's fares a lot worse from a flu than a 70 year old who walks his dog five miles a day and has no other significant medical problems. Someone who is bedbound, wheelchair-bound, or limited in mobility has a higher risk for complications than someone who ambulates on his own. A patient who is cachectic, who has little reserve, has a higher likelihood of dying from any physiologic perturbation.
All this is obvious, but some experiences in the CVICU really place a spotlight on "protoplasm." I was shocked to hear that one of our surgeons did a "triple valve" on an eighty-year-old. She had an aortic valve replacement, a mitral valve replacement, and a tricuspid ring. The surgeon was extremely skilled and the bypass time was fairly reasonable. But the patient's age, pre-existing pulmonary hypertension, baseline kidney disease, and frailty made the post-operative course a nightmare. We spent days weaning our inhaled epoprostenol and pressors. We had to be ginger not to provoke the right heart as she teetered on right heart failure. We managed to extubate her, but her poor pulmonary reserve required reintubation the following day. We struggled to get adequate nutrition for her. We could not salvage the kidneys and had to start continuous renal replacement therapy. In retrospect, she was not an appropriate surgical candidate. Although you may be able to operate on anyone, you shouldn't.
The problem in our current system is that pre-operative decision making doesn't include all the players. It is up to the surgeon to realistically set expectations on the recovery course and an anesthesiologist often ensures that things are as optimized as possible. They ensure that the surgery is feasible and that the patient will make it through, but don't always assess how rocky the post-operative course might be. As a critical care physician, I only meet these patients after the fact. And the truth is, for some patients and some surgeries, the stay in the ICU is harder than the surgery or anesthetic, and a patient ought to know what that might look like before committing to it.
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2 comments:
Sorry if this is an ignorant question, but as a medical student, would you say "protoplasm" correlates with ASA status? Thanks!
That's a great question and like most questions, the answer is yes and no. ASA status is an extremely imprecise measure of a patient's comorbid conditions. (for those who don't know, ASA 1 signifies a healthy person, ASA 2 signifies someone with well-controlled chronic disease, ASA 3 signifies poorly controlled chronic disease, ASA 4 signifies significant disease that is a threat to life, and ASA 5 signifies someone whose life expectancy is <24 hours).
The problem with the ASA classification system is that it is used to assess risk but nearly all patients fall into ASA 2 and 3. If I see an ASA 4 (or 5) patient, I have a good sense that they may not survive the perioperative period or are high risk for complications and morbidity. But an ASA 2 could be hypertension or chronic kidney disease; CKD is a lot more worrisome perioperatively. An ASA 3 could be diabetes with an A1c of 10% and sugars in the 200s or it could be severe aortic stenosis. As an anesthesiologist, the latter scares me much more than the former.
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