Anesthesia Forum Memories

jetproppilot · Feb 27, 2006

Geez...

was bored so paged through Kold Case Clinical Files...some cool stuff. Interesting. Enjoyable.

guess peoples desire to talk clinical stuff is less important around match time.....

.

bummer.

Looking forward to mixing it up with attendings residents etc on a clinical level. This forum has sucked for the last month or two.

The Rock Stars Mil/Noyac/UT/Zip/Venty/JWK (jwk, where the f uck are you?), etc etc are posting less and less. Me too. Just havent been stimulated on this forum lately.

Whats the deal, folks?

Trisomy13 · Feb 27, 2006

jetproppilot said:
guess peoples desire to talk clinical stuff is less important around match time..... .

i think you hit the nail on the head here.

after match we'll all start getting scared again and trying to leech as much wisdom from the rockstars as we can.

Crash cart · Feb 27, 2006

jetproppilot said:
Geez...

was bored so paged through Kold Case Clinical Files...some cool stuff. Interesting. Enjoyable.

guess peoples desire to talk clinical stuff is less important around match time..... .

bummer.

Looking forward to mixing it up with attendings residents etc on a clinical level. This forum has sucked for the last month or two.

The Rock Stars Mil/Noyac/UT/Zip/Venty/JWK (jwk, where the f uck are you?), etc etc are posting less and less. Me too. Just havent been stimulated on this forum lately.

Whats the deal, folks?

Far too many of us pissy / competitive / insecure med students polluting this forum with our verbal diarrhea. I agree, and I am to blame as much as the others. It's sucked the last month or two. Although I'm afraid I don't have too much to contribute on a clinical level seeing as I'm just a student. But I'll bet some of these CRNA's and SRNA's will be happy to tell you what's what.

UTSouthwestern · Feb 27, 2006

Just busy dude. Took the TEE course in San Diego, but unfortunately, didn't learn that much more than I already knew. Met AC, aka Skrubz, and a couple of people from my medical school class.

Besides that, have been just very busy. Tomorrow, we're giving away another 11 private insurance cases.

Also have spent most of the time I'm on the board answering PM's about the match, schools, etc. so less time to post clinical material.

ThinkFast007 · Feb 27, 2006

yah i guess we're all just tooo bummed out from the match stuff JPP.

give me a year, then I'll start busting out some "Kool Cases" of my own to post on here (ok fine maybe 2 yrs, but I figure I'll have some knowledge base when I do my anesthesia rotation as a PGY1).

bullard · Feb 27, 2006

Yeah, I'm muddling through the rest of fourth year. Pretty sure nobody wants to hear about cases from my subinternship.

Although...here's a question that's been nagging at me for a while.

I had a ~58 yo female last month who we ended up diagnosing with severe mitral stenosis (0.8 cm2) and constrictive pericarditis secondary to mediastinal radiation for Hodgkins as a teenager. She'd already had a CABG and AVR 8 years ago for the same reason. Supposedly, she wasn't a candidate for surgery because it'd be way too risky. But we never had anybody from anesthesia come see her and I never spoke to her CT surgeon about what he thought about reoperating. Besides her heart, she's also got mild restrictive lung disease (probably fibrosis from radiation again).

What do you guys think? If this lady wanted surgery, could she make it through?

Skrubz · Feb 28, 2006

i don't normally post much anyways. but i do appreciate the clinical discussions because it's always nice to hear how other people would approach the same problem. unlike UT, my brain was hurting after the TEE course. hopefully it'll start to really click once i do my cardiac months.

on a random note, my attending (pedi trained) and i took a newborn in for a gastroschisis repair last week on call (my first). the kid was 37w, weighed 2kg and was all of 2 hours old (we'd provided the spinal for the mom's C/S too). i swear i haven't been that scared in the OR since i started back in july. definitely an experience.

Pooh & Annie · Feb 28, 2006

There's plenty of room here for clinical and training/residency stuff! I understand why the match threads would get pretty lame to the people who are done, but I personally can't get enough of it! It's like I need a fix all the time, and the cowbell ain't doin' it. I look forward to reading the clinical questions too, but right now I'm more concerned with where I'm going to end up for the next 4 years.

Annette · Feb 28, 2006

Ok, Jet, I've got a case for you . . .

57 year-old male smoker (3ppkx40 years), came to follow-up (resident) medicine clinic for an inguinal hernia. Always slightly dyspnic on exertion. Wants surgery ASAP because he is self employed and can't work secondary to hernia. Has not seen a physician since the 1970's. He has a nice machinery murmur. 2-D echo shows a nice VSD with mild to moderate L to R shunting. Nuclear stress shows no evidence of ischemia. Cholesterol levels are beautiful. Blood pressure was 115/68. No family history of cardiac issues. He can't cooperate with the PFT's because of the hernia. Surgeons want a cardiac cath before operating. "The anesthesiologist will want it" without further explination.

What pre-op labs/ tests would you want? What is a cardiac cath going to tell you that the 2-d Echo with bubble study didn't? What kind of monitoring would you want in this guy? Swan?

jetproppilot · Feb 28, 2006

Annette said:
Ok, Jet, I've got a case for you . . .

57 year-old male smoker (3ppkx40 years), came to follow-up (resident) medicine clinic for an inguinal hernia. Always slightly dyspnic on exertion. Wants surgery ASAP because he is self employed and can't work secondary to hernia. Has not seen a physician since the 1970's. He has a nice machinery murmur. 2-D echo shows a nice VSD with mild to moderate L to R shunting. Nuclear stress shows no evidence of ischemia. Cholesterol levels are beautiful. Blood pressure was 115/68. No family history of cardiac issues. He can't cooperate with the PFT's because of the hernia. Surgeons want a cardiac cath before operating. "The anesthesiologist will want it" without further explination.

What pre-op labs/ tests would you want? What is a cardiac cath going to tell you that the 2-d Echo with bubble study didn't? What kind of monitoring would you want in this guy? Swan?

WOW!! Anette throws me a bone!!! :laugh:

Chances are since the dude is 57, works, and nuclear stress shows no ischemia, that his VSD is small, i.e. pulm/aortic systemic pressure ratio <.3, Qp/Qs <1.4.

Yeah, you could cath him and all that, but the bottom line is he's gonna need the hernia repair, unless he wants to risk incarceration at a later date, which might be the end of him. And this case can be done very nicely under MAC with an 18" IV and standard monitors with the right surgeon.

Call cardiology before the case for a "consult", but preface the consult by telling them (assuming you have a good surgeon) that IV sedation and LA will be used with no volume shifts, and the procedure should be 30 minutes.

If the guy has a significant VSD...Qp/Qs > 2.0, PA systolic >50mmHg, evidence of volume overload (LV) or pressure overload (RV) then its a different story...but that doesnt fit the clinical picture you painted of this guy. Doesnt mean the guy needs heart surgery first, but certainly warrants medical intervention to get him in better shape before the hernia repair.

The problem with getting cardiology involved is they really dont differentiate between a relatively minor (IHR, lap chole) and a major (ELAP) surgery on their consults. So it would help your cause to call the cardiologist to tell him your plans. The less stuff you do to this guy during his operation the better. Definitely dont need a swan. I'd do it with a peripheral IV.

His biggest risk is endocarditis so make sure the Abx is given at the appropriate time.

jetproppilot · Feb 28, 2006

bullard said:
Yeah, I'm muddling through the rest of fourth year. Pretty sure nobody wants to hear about cases from my subinternship.

Although...here's a question that's been nagging at me for a while.

I had a ~58 yo female last month who we ended up diagnosing with severe mitral stenosis (0.8 cm2) and constrictive pericarditis secondary to mediastinal radiation for Hodgkins as a teenager. She'd already had a CABG and AVR 8 years ago for the same reason. Supposedly, she wasn't a candidate for surgery because it'd be way too risky. But we never had anybody from anesthesia come see her and I never spoke to her CT surgeon about what he thought about reoperating. Besides her heart, she's also got mild restrictive lung disease (probably fibrosis from radiation again).

What do you guys think? If this lady wanted surgery, could she make it through?

it'd be a mess in her chest from previous surgery/radiation. Surgeon might be able to have a clearer path through a thoracotomy incision...fem/fem bypass to ameliorate cannulation issues.

Best thing if she really needs intervention is MV annuloplasty in the cath lab and resorting to surgery only if the cardiologist mucks something up.

ecCA1 · Feb 28, 2006

nice stuff!

militarymd · Feb 28, 2006

jetproppilot said:
WOW!! Anette throws me a bone!!!

Chances are since the dude is 57, works, and nuclear stress shows no ischemia, that his VSD is small, i.e. pulm/aortic systemic pressure ratio <.3, Qp/Qs <1.4.

Yeah, you could cath him and all that, but the bottom line is he's gonna need the hernia repair, unless he wants to risk incarceration at a later date, which might be the end of him. And this case can be done very nicely under MAC with an 18" IV and standard monitors with the right surgeon.

Call cardiology before the case for a "consult", but preface the consult by telling them (assuming you have a good surgeon) that IV sedation and LA will be used with no volume shifts, and the procedure should be 30 minutes.

If the guy has a significant VSD...Qp/Qs > 2.0, PA systolic >50mmHg, evidence of volume overload (LV) or pressure overload (RV) then its a different story...but that doesnt fit the clinical picture you painted of this guy. Doesnt mean the guy needs heart surgery first, but certainly warrants medical intervention to get him in better shape before the hernia repair.

The problem with getting cardiology involved is they really dont differentiate between a relatively minor (IHR, lap chole) and a major (ELAP) surgery on their consults. So it would help your cause to call the cardiologist to tell him your plans. The less stuff you do to this guy during his operation the better. Definitely dont need a swan. I'd do it with a peripheral IV.

His biggest risk is endocarditis so make sure the Abx is given at the appropriate time.

I've been kind of busy too....my ORs having been ramping up...while staffing is less.

Anyways, cool case.

From what's been posted, I would not order any other studies. The guy WORKS, AND inguinal hernia repairs are LOW RISK surgeries.

I would have to disagree with Jet with regards to SBE prophylaxis. The patient certainly does have a cardiac lesion that is "at risk" for developing SBE, however, the procedure is a non-bacteremia inducing procedure. Only abx indicated would be a first or second generation cephalosporin used to prevent would infections.

The AHA SBE prophylaxis guidelines published in JAMA in 1997 would support my approach with regards to abx therapy in the perioperative period.

militarymd · Feb 28, 2006

bullard said:
Yeah, I'm muddling through the rest of fourth year. Pretty sure nobody wants to hear about cases from my subinternship.

Although...here's a question that's been nagging at me for a while.

I had a ~58 yo female last month who we ended up diagnosing with severe mitral stenosis (0.8 cm2) and constrictive pericarditis secondary to mediastinal radiation for Hodgkins as a teenager. She'd already had a CABG and AVR 8 years ago for the same reason. Supposedly, she wasn't a candidate for surgery because it'd be way too risky. But we never had anybody from anesthesia come see her and I never spoke to her CT surgeon about what he thought about reoperating. Besides her heart, she's also got mild restrictive lung disease (probably fibrosis from radiation again).

What do you guys think? If this lady wanted surgery, could she make it through?

It depends on what type of surgery....low risk surgery...no problem....high risk surgery....likely to have issues post-op, but that's what intensivists are paid to take care of.

jetproppilot · Feb 28, 2006

militarymd said:
I've been kind of busy too....my ORs having been ramping up...while staffing is less.

Anyways, cool case.

From what's been posted, I would not order any other studies. The guy WORKS, AND inguinal hernia repairs are LOW RISK surgeries.

I would have to disagree with Jet with regards to SBE prophylaxis. The patient certainly does have a cardiac lesion that is "at risk" for developing SBE, however, the procedure is a non-bacteremia inducing procedure. Only abx indicated would be a first or second generation cephalosporin used to prevent would infections.

The AHA SBE prophylaxis guidelines published in JAMA in 1997 would support my approach with regards to abx therapy in the perioperative period.

Yeah youre right Mil.

I stand corrected.

bullard · Mar 1, 2006

militarymd said:
It depends on what type of surgery....low risk surgery...no problem....high risk surgery....likely to have issues post-op, but that's what intensivists are paid to take care of.

By surgery I meant MVR and pericardiectomy...annuloplasty is a no go because of MVA 0.8.

militarymd · Mar 1, 2006

bullard said:
By surgery I meant MVR and pericardiectomy...annuloplasty is a no go because of MVA 0.8.

This would be a multi-displinary call....cardiologist/pulmonary/ICU/CT surgery combined conference kind of thing.

I would have to say that anesthesia is kind of out of the loop in this one.

You can safely anesthetize this person.

Most likely they will come off bypass ...if the run isn't too long....so they will make it to the ICU, but the BLEEDING and DIC and MODS, and all the other stuff that is going to happen....well...all those other docs will need to be involved....the OR part is the easy part.

Anesthesia Forum Memories

jetproppilot

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Trisomy13

ultra

Crash cart

Nothing good ever happens past midnight

UTSouthwestern

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ThinkFast007

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bullard

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Skrubz

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Pooh & Annie

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Annette

gainfully employed

jetproppilot

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jetproppilot

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ecCA1

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militarymd

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militarymd

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jetproppilot

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bullard

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militarymd

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