Brain Fart

[Noyac]

I few weeks back we were discussing peri-operative MI's. I can't remember the thread or the person that was stating that most peri-operative MI's occur in the OR (hence the Brain fart) BUT in the May Issue of the ASA Newsletter there is an article, " The Conundrum of Care in Perioperative Stress Myocardial Ischemia," which references the VISION Trial (http://jama.jamanetwork.com/article.aspx?articleid=1172044). It states that 87% of these perioperative MI's occur by the end of POD#2. It doesn't say what percent occurred in day 1 or intraop. The trial itself states 74% by end of POD#1. So it leaves us kind of in the dark as to when these occur most frequently. But it appears that day 3 is less of a contributor. Reading the article though leads you to believe that the vast majority are occurring outside of the OR.

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[Hoya11]

I few weeks back we were discussing peri-operative MI's. I can't remember the thread or the person that was stating that most peri-operative MI's occur in the OR (hence the Brain fart) BUT in the May Issue of the ASA Newsletter there is an article, " The Conundrum of Care in Perioperative Stress Myocardial Ischemia," which references the VISION Trial (http://jama.jamanetwork.com/article.aspx?articleid=1172044). It states that 87% of these perioperative MI's occur by the end of POD#2. It doesn't say what percent occurred in day 1 or intraop. The trial itself states 74% by end of POD#1. So it leaves us kind of in the dark as to when these occur most frequently. But it appears that day 3 is less of a contributor. Reading the article though leads you to believe that the vast majority are occurring outside of the OR.

"outside the OR", but caused by intra-operative stress? probably not post-op stress.. maybe they actually occur IN the OR, but due to the patient being asleep, then awakening with narcotics on board and sleeping for an hour or so, then stress abates as they settle down post-op, complain of some twinge, check troponins (which are also a delayed sign) and boom diagnosed . Thats after pacu time, narcotic wash out, symptom recognition, test sending and results reviewed. So maybe thats why they happen on POD 1? Just that they are detected then but occur intraop... ? just a thought

 

[fakin' the funk]

I few weeks back we were discussing peri-operative MI's. I can't remember the thread or the person that was stating that most peri-operative MI's occur in the OR

Yeah, that's not true.

Nor is the old-school teaching that most perioperative MIs happen on POD#3 (from hypercoagulability, plaque rupture). This was true BEFORE the concept of NSTEMIs, when perioperative MIs were almost all what we would now call STEMIs and were massive, likely fatal events.

Nowadays, most perioperative MIs are of the NSTEMI, myocardial oxygen supply-demand mismatch, maybe-a-tiny-plaque-rupture variety, since we have high sensitivity cardiac enzyme assays (troponins) to detect such events. So it's an issue of detection and a change in the definition of the diagnosis. Because we have good troponin assays, we can detect and diagnose a lot more NSTEMIs and this changed the nature of perioperative MI's overall. So we are detecting these supply-demand mismatch events (ischemic events) that occur on POD#0, 1, 2 when there is hypovolemia, anemia, tachycardia from pain etc.

 

[urge]

"outside the OR", but caused by intra-operative stress? probably not post-op stress.. maybe they actually occur IN the OR, but due to the patient being asleep, then awakening with narcotics on board and sleeping for an hour or so, then stress abates as they settle down post-op, complain of some twinge, check troponins (which are also a delayed sign) and boom diagnosed . Thats after pacu time, narcotic wash out, symptom recognition, test sending and results reviewed. So maybe thats why they happen on POD 1? Just that they are detected then but occur intraop... ? just a thought

My guess is that the most of the stress comes from emergence and extubation. From many years of supervision at big centers I have noticed that most anesthetics are very stable until the beginning of emergence. From then on people lose focus on treating hemodynamics and rather focus on respiratory/neuro assessment. Uncontrolled tachycardia and hypertension are seen as normal during this period. By this point nobody is paying attention to the EKG tracing, plus the patient might start moving and the tracing not be readable. Sort of the same thing goes on in pacu.

By the time the patient gains full consciousness not feeling well, to someone getting concerned about ischemia, ordering an ekg, and troponins, troponin themselves going up, several hours if not a full day have gone by.

 

[urge]

Yeah, that's not true.

.

Really?

This is what Noyac's reference article says:

Among patients who experienced a TnT elevation 0.02 ng/mL or greater, this occurred at 6 to 12 hours after surgery, post operative day 1, postoperative day 2, and postoperative day 3 in 45.9%, 28.3%, 17.7%, and 8.2% of these patients, respectively.

I think it is foolish not think most of the MI's are intra op.

 

[chocomorsel]

My guess is that the most of the stress comes from emergence and extubation. From many years of supervision at big centers I have noticed that most anesthetics are very stable until the beginning of emergence. From then on people lose focus on treating hemodynamics and rather focus on respiratory/neuro assessment. Uncontrolled tachycardia and hypertension are seen as normal during this period. By this point nobody is paying attention to the EKG tracing, plus the patient might start moving and the tracing not be readable. Sort of the same thing goes on in pacu.

By the time the patient gains full consciousness not feeling well, to someone getting concerned about ischemia, ordering an ekg, and troponins, troponin themselves going up, several hours if not a full day have gone by.

At my last job I had this one CRNA who would refuse to give BBlockers to old patients during emergence when they were tachying away with high B/Ps. Heck, half the time, the B/P cuff is off with the CRNAs before tube comes out. She would say, just wait, once we pull the tube the B/P and HR will be better. And I am like well, pull the ****ing tube already!!! So I would reach and push the esmolol myself. Idiot.
I also coded a patient during emergence when another CRNA was not paying attention to the monitor and I noticed deep ST depression in a tachycardic older patient. By the time I reached for the esmolol, it was too late and the patient went into VTach and became unstable. Thank God she hadn't pulled the tube as she said the patient just wasn't breathing correctly, sats low and she "didn't feel right" about pulling the tube. No ****. Maybe look at the monitor and put 2 and 2 together.
I now work alone (thankfully) and give esmolol, narcotics, propofol, and or turn gas back on as needed before pulling the tube to keep them as stable hemodynamically as possible.

 

[painstop]

At my last job I had this one CRNA who would refuse to give BBlockers to old patients during emergence when they were tachying away with high B/Ps. Heck, half the time, the B/P cuff is off with the CRNAs before tube comes out. She would say, just wait, once we pull the tube the B/P and HR will be better. And I am like well, pull the ****ing tube already!!! So I would reach and push the esmolol myself. Idiot.
I also coded a patient during emergence when another CRNA was not paying attention to the monitor and I noticed deep ST depression in a tachycardic older patient. By the time I reached for the esmolol, it was too late and the patient went into VTach and became unstable. Thank God she hadn't pulled the tube as she said the patient just wasn't breathing correctly, sats low and she "didn't feel right" about pulling the tube. No ****. Maybe look at the monitor and put 2 and 2 together.
I now work alone (thankfully) and give esmolol, narcotics, propofol, and or turn gas back on as needed before pulling the tube to keep them as stable hemodynamically as possible.

I know a few guys that take off the BP cuff and ECG leads to help speed up the emergence process and simply leave the pulse ox on when they transfer the pt to their recovery bed and then pull the tube. They tell me the pt will be bucking so much during extubation the ECG doesn't provide much actionable intelligence and missing one or two BP readings is negligible at that point and the recovery room BP which will be taken a couple minutes later will be the basis for determining whether the pt needs any meds or fluids. I'm like "hmmm, interesting". Anyone else routinely do this?

 

[chocomorsel]

I sometimes do this and if I immediately pull the tube, within a few seconds, I leave them off. If the B/P has been climbing I want to see what it is again before we leave the OR.
If I am waiting a little while I put them back on, especially when I am concerned about B/P and HR in an older, or sicker patient with comorbidities. Many times I keep everything on with transfer in those patients. Or I just tell the team to wait till tube is out before moving.
Today with the patient still asleep and gas at about 0.3 mac, the B/P was in the 200's and HR was in the 100s. I turned gas back on, gave more IV drugs, labetalol and versed (anxious patient) then woke them up.
Young, healthy patients can handle these swings in B/P and HR without problems. I don't really worry about them too much.

 

[fakin' the funk]

I think it is foolish not think most of the MI's are intra op.

So the 48% that AT EARLIEST happen at emergence or in the immediate postop period...those are intra-op right?
And the 52% that happen POD#1-3...those are intra-op right?

 

[Noyac]

I don't think we have good data on when these events are happening as of yet. I would lean towards post-op since monitoring is much less. TnT is difficult because it doesn't tell you when the event happened just that it happened. These pts are getting pain meds and are sedated somewhat post-op. They are not able to accurately feel or describe what they are feeling. The event then continues until something changes. In the OR we notice changes and we correct them. Therefore, I believe until proven wrong that the majority of these events are Post-op. And POD0-1 seems like a good time for this.

As far as removing monitors before extubation, I do it all the time, unless the pt warrants continued monitoring. Pulse ox remains on until we are headed for the door though.

 

[urge]

I know a few guys that take off the BP cuff and ECG leads to help speed up the emergence process and simply leave the pulse ox on when they transfer the pt to their recovery bed and then pull the tube. They tell me the pt will be bucking so much during extubation the ECG doesn't provide much actionable intelligence and missing one or two BP readings is negligible at that point and the recovery room BP which will be taken a couple minutes later will be the basis for determining whether the pt needs any meds or fluids. I'm like "hmmm, interesting". Anyone else routinely do this?

No.

They just don't want to see/document how bad the hemodynamics are during emergence. Takes 20 seconds to remove monitors.

 

[urge]

So the 48% that AT EARLIEST happen at emergence or in the immediate postop period...those are intra-op right?
And the 52% that happen POD#1-3...those are intra-op right?

There is no question in my mind that the intra op period is the worst offender in terms of MI's.

Did you read the paper? 45.9% already tested positive on the first set of troponin. It tapered off from then.

Considering Troponin T takes a while to peak, a good number of those troponins in POD1 were also due to intra op events.

I repeat: I think it is foolish not think most of the MI's are intra op.

 

[deleted171991]

It's normal that most ischemic injuries (as measured by a troponin leak) will happen at the time of the highest demand-supply imbalance. Which is usually intraop, especially for high-risk surgeries.

 

[propadope]

I know a few guys that take off the BP cuff and ECG leads to help speed up the emergence process and simply leave the pulse ox on when they transfer the pt to their recovery bed and then pull the tube. They tell me the pt will be bucking so much during extubation the ECG doesn't provide much actionable intelligence and missing one or two BP readings is negligible at that point and the recovery room BP which will be taken a couple minutes later will be the basis for determining whether the pt needs any meds or fluids. I'm like "hmmm, interesting". Anyone else routinely do this?

Why take them off before a very stimulating time period? Why have the patient wake up bucking like crazy? A lot can happen between emergence and arriving at the PACU. Im all for speed and efficicency but not at the patient's expense.
Would you want your pilot to land a plane using only altitude and not air speed, pitch, roll, angle of attack etc...

 

[urge]

Why take them off before a very stimulating time period? Why have the patient wake up bucking like crazy? A lot can happen between emergence and arriving at the PACU. Im all for speed and efficicency but not at the patient's expense.
Would you want your pilot to land a plane using only altitude and not air speed, pitch, roll, angle of attack etc...

It doesn't make sense that removing a bp cuff and ekg's would slow us down, considering that we all here are known for placing central lines, a lines, epidurals, etc., before you can finish saying "piece of cake".

That, or we are all full of $hit.

Don't know.

 

[propadope]

It doesn't make sense that removing a bp cuff and ekg's would slow us down, considering that we all here are known for placing central lines, a lines, epidurals, etc., before you can finish saying "piece of cake".

That, or we are all full of $hit.

Don't know.

+1
Pulling 5 wires and undoing velcro should not be too time consuming

 

[pgg]

I know a few guys that take off the BP cuff and ECG leads to help speed up the emergence process and simply leave the pulse ox on when they transfer the pt to their recovery bed and then pull the tube. They tell me the pt will be bucking so much during extubation the ECG doesn't provide much actionable intelligence and missing one or two BP readings is negligible at that point and the recovery room BP which will be taken a couple minutes later will be the basis for determining whether the pt needs any meds or fluids. I'm like "hmmm, interesting". Anyone else routinely do this?

If they're expecting every patient to buck so much that the ECG will quit working, the problem is them.

I'm not saying my patients never cough or buck during emergence, but it's not common, and it's certainly not so long in duration that it interferes with monitoring. In a case where it's critically important for the patient to not buck or cough at all, I handle the emergence differently. I'd like to think every competent anesthesiologist does the same.

Maybe those guys are just incompetent.

At my last job I had this one CRNA who would refuse to give BBlockers to old patients during emergence when they were tachying away with high B/Ps. Heck, half the time, the B/P cuff is off with the CRNAs before tube comes out. She would say, just wait, once we pull the tube the B/P and HR will be better. And I am like well, pull the ****ing tube already!!! So I would reach and push the esmolol myself. Idiot.

Those are the same people who do hamfisted inductions on brittle patients, and then just put up with hypotension reasoning that their brutally hamfisted DL and intubation will restore the patient's sympathetic tone.

 

[chocomorsel]

Yes PGG, I know. We had a locums old CRNA who gave all 200mg of propofol to a 90 year old. Seriously. Thank God he didn't become unstable and recovered. I just saw it in the chart after the fact, wasn't my case.

And another one, (one of the best according to the boss) when I was still new induced an elderly patient with a crapload of propofol and the patient went into a narrow complex unstable tachycardia with B/P in the 50's and I had to cancel the case. And he was wondering what the heck happened. He totally didn't understand. An another time I walk in on him bagging another old lady. I ask what the deal is and he says he gave Versed. Really? Does an 85+ old lady need versed? They don't seem to get that these old people don't metabolize these drugs the same way and their cognitive function declines with all these unnecessary drugs.

Glad I work alone now. More difficult physically, but at least I don't have to deal with other people's crap.