Clinical case: pre-op EKG or no?

[urge]

Good discussion. I agree that pt reports >4 METS and is undergoing low risk procedure, no EKG is warranted. None was obtained. In OR large P waves and occasional PVCs noted, otherwise no significant arrhythmias. Gentle induction with Propofol, easy LMA placement. Pt noted to be quite pale, pulse ox tracing lost. Anesthetist asks surgeon to do pulse check, surgeon states feels carotid pulse. Pulse ox noted to be off, replaced and return of signal with 100% O2 sat. Pt hypotensive (MAP approx 50). Pulse low 40's. 0.2 glyco and 5mg ephedrine given. MAP raised to high50's/low 60's, pulse increased to 60's. No further problems, BP continued to rise to baseline, 10 mins, case is over. Pt to PACU, alert and conversing without complaints. Anesthetist asks for EKG and talks to family. Wife states, "well, he's been very fatigued the last few weeks. He's passed out a few times and when we left the ER the other day he said his chest felt really heavy and was having pain in his ribs". Pt admitted, serial troponins rising, EKG showed RBBB, inferior infarction age undetermined and ST depressions V3-6. Pt transferred to medical center. 2 days later, 4V CABG.

There was a severe deficit in the H&P.

The EKG discussion is academic.

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[urge]

Wait, an emergency is one of the highest predictors of increased complications. You're saying that it does not change the % risk in the calculator? This makes me doubt the integrity of the calculator.

I've done emergent stents, and they can get nasty very quickly. I've also cranked hundreds if not thousands of these lithos, stents, and stone extractions out in a urology outpatient center and never seen one MI.

That is what the fancy calculator says for this patient, not me.

Play with it.

This is with "elective case":

 

[urge]

Good discussion. I agree that pt reports >4 METS and is undergoing low risk procedure, no EKG is warranted. None was obtained. In OR large P waves and occasional PVCs noted, otherwise no significant arrhythmias. Gentle induction with Propofol, easy LMA placement. Pt noted to be quite pale, pulse ox tracing lost. Anesthetist asks surgeon to do pulse check, surgeon states feels carotid pulse. Pulse ox noted to be off, replaced and return of signal with 100% O2 sat. Pt hypotensive (MAP approx 50). Pulse low 40's. 0.2 glyco and 5mg ephedrine given. MAP raised to high50's/low 60's, pulse increased to 60's. No further problems, BP continued to rise to baseline, 10 mins, case is over. Pt to PACU, alert and conversing without complaints. Anesthetist asks for EKG and talks to family. Wife states, "well, he's been very fatigued the last few weeks. He's passed out a few times and when we left the ER the other day he said his chest felt really heavy and was having pain in his ribs". Pt admitted, serial troponins rising, EKG showed RBBB, inferior infarction age undetermined and ST depressions V3-6. Pt transferred to medical center. 2 days later, 4V CABG.

I have to point out that at the M&M, only FFP, Doctor4life, and me would have survived. All you guys would have been railroaded.

 

[deleted171991]

If I learned something in my fellowship is that there is no such thing as too much easily-obtainable data. Unless it's the kind that would not change management. And that's the precise question one should ask, before getting the EKG, or not.

 

[Ignatius J]

That is what the fancy calculator says for this patient, not me.

Play with it.

This is with "elective case":

View attachment 202243

With the numbers you put in, it should reflect less than 1% by the RCRI.

But seriously, you are in academics aren't you?

 

[Ignatius J]

If I learned something in my fellowship is that there is no such thing as too much easily-obtainable data. Unless it's the kind that would not change management.

The evidence shows that an EKG would not change management in this case.

 

[deleted171991]

The evidence shows that an EKG would not change management in this case.

Yes, it would. If you see new ST depression or RBBB, you cancel that surgery.

There is a difference between the EKG not being recommended, and me being lazy and not getting it when I have a suspicion, and it takes only 5 minutes and 5 dollars worth of paper.

As I said, I would even do a TTE myself in all cardiac patients, if it were as easy as getting an EKG. I have never regretted investing 5 extra minutes in something important (for me) during my preop interview.

 

[urge]

The evidence shows that an EKG would not change management in this case.

It shows how you get managed at your yearly review with the chair.

 

[Ignatius J]

Yes, it would. If you see new ST depression or RBBB, you cancel that surgery.

There is a difference between the EKG not being recommended, and me being lazy and not getting it when I have a suspicion, and it takes only 5 minutes and 5 dollars worth of paper.

So, by your logic, would you get a EKG for everyone then? After all, it's quick and if there is ST depression you just cancel the surgery.

Also, it may be 5 dollars of paper to you, but curiously, you ever seen what the hospital bills for an EKG?

 

[Ignatius J]

It shows how you get managed at you yearly review withe the chair.

Confirmed. Academics.

 

[urge]

With the numbers you put in, it should reflect less than 1% by the RCRI.

With creatinine less than 2:

with creatinine more than 2:

0.9% to 6.6% risk. The patient has CKD, so chances are his cr is over 2.

The risk is not insignificant.

 

[urge]

Confirmed. Academics.

Your PP does not do a yearly review by the chair?

 

[deleted171991]

So, by your logic, would you get a EKG for everyone then? After all, it's quick and if there is ST depression you just cancel the surgery.

Also, it may be 5 dollars of paper to you, but curiously, you ever seen what the hospital bills for an EKG?

I am pretty selective. It depends on the surgery, patient and surgeon. The guidelines tell me when I must get an EKG. My gut tells me when I should (and it's frequently right). It's the same gut that lets me decide in less than 5 minutes whether a patient needs ICU or not, many times without even touching the patient, almost always right.

The reason the guidelines did not work in this patient was because he lied about his exercise tolerance.

 

[Ignatius J]

Your PP does not do a yearly review by the chair?

What's a chair?

 

[urge]

What's a chair?

The person that signs all your credentialing paperwork.

Did you not get credentialed for your hospital?

 

[Neogenesis]

There was a severe deficit in the H&P.

The EKG discussion is academic.

Exactly. Had that information been presented beforehand, COMPLETELY different ball game. I will point out that 3 individuals (surgeon and 2 anesthetists) each individually asked about cardiac signs/symptoms/functional capacity before hand and we're all given the same initial story. In reviewing the case as a non-participant, I would say that given the information that was presented initially and the procedure at hand I feel no EKG was a defensible call. Obviously the patient was way more compromised than presented and failed the impromptu stress test he was put under.

 

[Ignatius J]

The person that signs all your credentialing paperwork.

Did you not get credentialed for your hospital?

I go to about 30 different hospitals, including a urology outpatient surgery center where we to urethrolithotomies and send the patient home an hour later, not 3 days like that chart thingy of yours says is average. The only people I consistently see admitted after ureteroscopy stuff are ones in urosepsis that come in through the ER. A lot of times those just get perc drains in IR and I never see them.

To get back to your point, there is usually a medical director or anesthesia director at the facility that signs off on that stuff. Most QI stuff is done through our group. We have a very vigilant Clinical Review Committee.

 

[urge]

Exactly. Had that information been presented beforehand, COMPLETELY different ball game. I will point out that 3 individuals (surgeon and 2 anesthetists) each individually asked about cardiac signs/symptoms/functional capacity before hand and we're all given the same initial story. In reviewing the case as a non-participant, I would say that given the information that was presented initially and the procedure at hand I feel no EKG was a defensible call. Obviously the patient was way more compromised than presented and failed the impromptu stress test he was put under.

I understand that someone is giving you a hard time for not getting the EKG.

I would have liked one. It's just good medicine.

In the grand scheme of things, his outcome was not related to the EKG, but to the fact that he did not come through with his symptoms.

 

[Ignatius J]

Good discussion. I agree that pt reports >4 METS and is undergoing low risk procedure, no EKG is warranted. None was obtained. In OR large P waves and occasional PVCs noted, otherwise no significant arrhythmias. Gentle induction with Propofol, easy LMA placement. Pt noted to be quite pale, pulse ox tracing lost. Anesthetist asks surgeon to do pulse check, surgeon states feels carotid pulse. Pulse ox noted to be off, replaced and return of signal with 100% O2 sat. Pt hypotensive (MAP approx 50). Pulse low 40's. 0.2 glyco and 5mg ephedrine given. MAP raised to high50's/low 60's, pulse increased to 60's. No further problems, BP continued to rise to baseline, 10 mins, case is over. Pt to PACU, alert and conversing without complaints. Anesthetist asks for EKG and talks to family. Wife states, "well, he's been very fatigued the last few weeks. He's passed out a few times and when we left the ER the other day he said his chest felt really heavy and was having pain in his ribs". Pt admitted, serial troponins rising, EKG showed RBBB, inferior infarction age undetermined and ST depressions V3-6. Pt transferred to medical center. 2 days later, 4V CABG.

Interesting stuff. Thanks for sharing. Definitely a deficit in the H&P.

Question is: would a pre-op EKG have showed an MI? My guess is that didn't happen until you induced. But who knows.

 

[urge]

1 I go to about 30 different hospitals, including a urology outpatient surgery center where we to urethrolithotomies and send the patient home an hour later, not 3 days like that chart thingy of yours says is average. The only people I consistently see admitted after ureteroscopy stuff are ones in urosepsis that come in through the ER. A lot of times those just get perc drains in IR and I never see them.

2 To get back to your point, there is usually a medical director of anesthesia director at the facility that signs off on that stuff. Most QI stuff is done through our group. We have a very vigilant Clinical Review Committee.

1 Why so many hospitals? Do you have 30 IDs, 30 different scrubs, and 30 different setups, and 30 different teams? That's insane. Anyway, glad to hear that your outcomes are better than this calculator's. I tend to think that the people to visit the forum are on the upper quartile of the profession since they seem to care more.

2 That is your boss, however you call him.

 

[urge]

Interesting stuff. Thanks for sharing. Definitely a deficit in the H&P.

Question is: would a pre-op EKG have showed an MI? My guess is that didn't happen until you induced. But who knows.

The real question is, would you have worked him up for a cabg before doing the kidney stone? I think the answer is universally no.

 

[Ignatius J]

1 Why so many hospitals? Do you have 30 IDs, 30 different scrubs, and 30 different setups, and 30 different teams? That's insane. Anyway, glad to hear that your outcomes are better than this calculator's. I tend to think that the people to visit the forum are on the upper quartile of the profession since they seem to care more.

2 That is your boss, however you call him.

Just the way the market is here, I guess. I think it's pretty unique in both a good and bad way. This will likely change very soon, especially with bundling payments coming up and hospitals needing anesthesia "ownership" for quality metrics for reimbursement.

One universal badge that works at all facilities. Strange as it is, you meet pretty much everyone and get familiar with them. Usually it will be the same nurses working with the same surgeons working with the same anesthesiologists so you get to know them well.

Very well could be. We disagree, and that's okay.

I have to admit that I didn't think the RCRI/MACE predictor was used to classify procedural risk. Always thought they were different. Learned something this evening.

Thanks for the banter and have a good weekend.

 

[vector2]

Good discussion. I agree that pt reports >4 METS and is undergoing low risk procedure, no EKG is warranted. None was obtained. In OR large P waves and occasional PVCs noted, otherwise no significant arrhythmias. Gentle induction with Propofol, easy LMA placement. Pt noted to be quite pale, pulse ox tracing lost. Anesthetist asks surgeon to do pulse check, surgeon states feels carotid pulse. Pulse ox noted to be off, replaced and return of signal with 100% O2 sat. Pt hypotensive (MAP approx 50). Pulse low 40's. 0.2 glyco and 5mg ephedrine given. MAP raised to high50's/low 60's, pulse increased to 60's. No further problems, BP continued to rise to baseline, 10 mins, case is over. Pt to PACU, alert and conversing without complaints. Anesthetist asks for EKG and talks to family. Wife states, "well, he's been very fatigued the last few weeks. He's passed out a few times and when we left the ER the other day he said his chest felt really heavy and was having pain in his ribs". Pt admitted, serial troponins rising, EKG showed RBBB, inferior infarction age undetermined and ST depressions V3-6. Pt transferred to medical center. 2 days later, 4V CABG.

Talk about swiss cheese. He was in the ER a few days ago, he has a known history of CAD/stents, and he didn't get an EKG and/or echo as part of a syncope workup at that time? He really didn't tell you guys that he was just in the ER for syncope "the other day" and had chest heaviness afterwards when you asked about CP/SOB/functional status? I can't tell if he was being macho or just being a ****** considering that many people could ask him about sxs without getting a straight answer ...

I'm also curious about his volume status (diuretics?), preop BP (he take an ace-i?) and intraop BP management. Many times after induction we wait out relative hypotension in anticipation of a bump after surgical stimulation...might've just taken a couple minutes of bad diastology, mildly depressed right heart, hypovolemia, and coronary hypoperfusion to crunk this guy

 

[Doctor4Life1769]

Exactly. Had that information been presented beforehand, COMPLETELY different ball game. I will point out that 3 individuals (surgeon and 2 anesthetists) each individually asked about cardiac signs/symptoms/functional capacity before hand and we're all given the same initial story. In reviewing the case as a non-participant, I would say that given the information that was presented initially and the procedure at hand I feel no EKG was a defensible call. Obviously the patient was way more compromised than presented and failed the impromptu stress test he was put under.

I dunno.

After hours case for what appears to be urosepsis requiring stent due to stones. He has "stable" CAD with stent 8 years ago and CKD, what was the Cr?

In my brief time in residency, the one thing I learned was that simple "after hours" cases are never all that simple. He's possibly a sick guy (without knowing his most recent decline in functional capacity as was later revealed). I would like to have an updated EKG in the chart if there wasn't one in the past 12 months.

 

[Chloroform4Life]

Interesting case. Either the people involved were not specific enough with their H&P or the patient flat out lied. The M&M should focus on why the H&P was so deficient and not the fact that the patient didn't get a pre-op EKG. A lot of reasonable anesthesiologist would not get a pre-op EKG based on the original description of the patient.

If I knew his actual physical status, I would have gotten an EKG. Chances are though that it would have shown non-specific stuffs like T wave inversion, non-specific ST abnormalities, poor R wave progression, etc. I don't really care much about RBBB (Should I? I've always noted it, but not do anything about it).

His ST depression probably happened after induction and hypotension induced ischemia. Same with the troponin rising post-op. He might have still needed the urinary stent before CABG to prevent infection.

 

[Neogenesis]

Yeah, my feeling is that the sequelae was due to the induction/post induction hypotension in a pt that was already teetering. I'll bet that a preop EKG wouldn't have shown much more that the RBBB and inferior q waves. But history, history, history (at least when they give you an accurate one )

 

[Doctor4Life1769]

Yeah, my feeling is that the sequelae was due to the induction/post induction hypotension in a pt that was already teetering. I'll bet that a preop EKG wouldn't have shown much more that the RBBB and inferior q waves. But history, history, history (at least when they give you an accurate one )

Was he admitted to the same hospital's ER?
If so, that's on y'all for not looking up historicals in the hospital EMR. If he was at some other random ER, that's on him the patient.

 

[OB1🤙]

I would not have ordered an EKG on the patient as originally presented. Not getting an accurate exercise tolerance at first is wtf.

 

[OneFellSwoop]

Great discussion! I'll add my 2 pennies:
I would not have gotten an EKG. Based on RCRI (which I can do at bedside as I'm doing HP, that other one is pretty long and arduous and I doubt its validity when it talks about staying in the hospital for 3 days for this... Come on). If Cr was greater than 2 I would have probably insisted a little more on ekg. But given the urgency of case, impending urosepsis, there isn't time for the appropriate work up and certainly not the definitive treatment CABG or stent anyway. So if no EKG I would do gentle induction planning for potential CAD badness. If I got an ekg (Cr>2) and there was badness I would consider A line and ICU admission and May intubate instead and have a come to Jesus talk with patient and urologist. But above all else this seems urgent to emergent to me and needs to get done. The ekg doesn't change whether I'd do the case or not just what I would do intraoperatively.


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[pgg]

1 In the rare instance that you find something pathologic, like a 3rd degree block, LBBB, etc, what do you do? Abort when you are already in the room?

I had a patient with a type 2 second degree AV block that I picked up in the OR just before pushing his propofol (elective joint replacement). I cancelled. He got a pacemaker the next day.

Of course, the only reason we got that far was because everyone (including me) missed the high grade block on his preop 12 lead. It wasn't the easiest ECG to read, but still, oops.

 

[pgg]

Many times after induction we wait out relative hypotension in anticipation of a bump after surgical stimulation...

I never do that and I think it's bad practice, a bad habit, even in young healthy people who can surely tolerate it.

 

[Planktonmd]

What is the EKG going to show that would make you not take the patient to the OR to relieve his acute hydronephrosis???
And what EKG finding would make you change your management in this urgent case???
I think that as physicians sometimes we need to skip the ACC f*cking protocol and use our brains!

 

[dannyboy1]

I never do that and I think it's bad practice, a bad habit, even in young healthy people who can surely tolerate it.

agreed. never understood why people wait to treat bp. is it really that hard to give a squirt of neosynephrine or ephedrine ?

 

[Chloroform4Life]

What is the EKG going to show that would make you not take the patient to the OR to relieve his acute hydronephrosis???
And what EKG finding would make you change your management in this urgent case???
I think that as physicians sometimes we need to skip the ACC f*cking protocol and use our brains!

STEMI.....
Stenting coronaries trump stenting ureters.

But yeah, based on OP's original description, no way he could be having an MI...unless he is lying about his symptoms.....

Going to be hard to pretend everything is groovy when you're having a STEMI though.

 

[vector2]

agreed. never understood why people wait to treat bp. is it really that hard to give a squirt of neosynephrine or ephedrine ?

It's a matter of timeframe. If the nurses and surgeons are taking their sweet ass time prepping and scrubbing, of course you're going to treat it. If the MAP is 61 in a healthy young person and the first assist is ready to cut in t-minus 2 minutes, are you really gonna push neo right before incision?

 

[pgg]

It's a matter of timeframe. If the nurses and surgeons are taking their sweet ass time prepping and scrubbing, of course you're going to treat it. If the MAP is 61 in a healthy young person and the first assist is ready to cut in t-minus 2 minutes, are you really gonna push neo right before incision?

Yes.

I've always felt that if you need the physiologic stress and catecholamine response from a surgical assault to move the patient's vitals to where you want them, the patient needs more anesthesia. We're trying to avoid more than just movement and recall with anesthesia.

We own the anesthetized patient's physiology, so let's own it. Routinely exercising careful control of a patient's hemodynamics in cases when it doesn't matter very much makes us more skilled at doing it in patients when it does matter. I think it's just good habit and good style.

 

[dannyboy1]

It's a matter of timeframe. If the nurses and surgeons are taking their sweet ass time prepping and scrubbing, of course you're going to treat it. If the MAP is 61 in a healthy young person and the first assist is ready to cut in t-minus 2 minutes, are you really gonna push neo right before incision?

MAP of 61 in a young healthy pt is fine and i wouldn't treat it. Dont usually push neo right before incision but i do push it on induction for anyone with CAD, CAD risk factors, or pretty much anyone over 60. you know the BP will go down so why wait ?

 

[vector2]

Yes.

I've always felt that if you need the physiologic stress and catecholamine response from a surgical assault to move the patient's vitals to where you want them, the patient needs more anesthesia. We're trying to avoid more than just movement and recall with anesthesia.

We own the anesthetized patient's physiology, so let's own it. Routinely exercising careful control of a patient's hemodynamics in cases when it doesn't matter very much makes us more skilled at doing it in patients when it does matter. I think it's just good habit and good style.

I don't think anyone is disagreeing with your overarching platitudes, but let's look at some nitty gritty. This is a case I did a couple days ago...whipple with vascular resection, 60yo lady, 54kg, stable CAD with 2 stents in 2011, negative stress echo last week, DM.

Probably could've gotten away with less propofol, pushed neo sooner after induction, and run the iso a little lighter post induction, but she was responsive to some phenylephrine and getting some stimulation during central line placement. Notice between 735 and 745 after anesthesia ready mark I attempted to treat her hypotension , turned the vapor down, opened some fluid (not shown). Now, look at the period between 745-750. Case is ready go, chloraprep is drying on the skin... is anyone in their right mind going to push more phenylephrine before the knife hits at 750?

I'm trying to make sense of what you're saying with "the patient needs more anesthesia"...it's as if you're implying that we should have high dose prop/vapor >2 MAC/fentanyl 5mcg/kg onboard along with pressor infusion before incision...cause that's pretty much the only way you're gonna have a patient maintain a normal-high MAP under minimal stimulation 'and' not have a hemodynamic response of any sort after the big cut. I mean, hell, even folks who have a dense spinal have some sympathetic outflow with incision.

I run a pretty tight ship, man, but the implication of what you're saying sounds kind of unreasonable short of supernaturally fast acting uppers and downers. This is essentially how the rest of her case looked, even with a 700cc EBL in a pt whose starting crit was 28 (obviously the dip at 1215 is when the CRNA gave me lunch )

 

[pgg]

Nicely done, I'm really not trying to be critical, just my personal preference.

Just a pet peeve of mine to see people put up with hypotension while waiting for the surgeon to squeeze loose some catecholamines. Maybe it's just because the people I see do it tend to do other things I don't like.

 

[Ronin786]

On a somewhat related note, I would love to see some similar records for a lot of the members on here. I find that snapshot above fascinating.

 

[Planktonmd]

I don't think anyone is disagreeing with your overarching platitudes, but let's look at some nitty gritty. This is a case I did a couple days ago...whipple with vascular resection, 60yo lady, 54kg, stable CAD with 2 stents in 2011, negative stress echo last week, DM.

So, the A line systolic is overshooting by 30 to 40 compared to NIBP, and you seem to try to fix that with hits of Propofol, but then you give phenylephrine and even run a phenylephrine infusion at some point as if now you are looking at the low cuff pressure and ignoring the Aline.
Are you using a BIS monitor that is making you give the Propofol hits to achieve some magical number?
It's a pretty schizophrenic chart IMHO!

 

[deleted59964]

ffs I thought physicians were into mental masturbation.

get the ekg - it has zero risk, and takes only a couple of minutes... or don't - who cares

 

[sigrhoillusion]

So, the A line systolic is overshooting by 30 to 40 compared to NIBP, and you seem to try to fix that with hits of Propofol, but then you give phenylephrine and even run a phenylephrine infusion at some point as if now you are looking at the low cuff pressure and ignoring the Aline.
Are you using a BIS monitor that is making you give the Propofol hits to achieve some magical number?
It's a pretty schizophrenic chart IMHO!

I don't understand the use of gas with so much frequent use of propofol/fentanyl... and then neo boluses between them.
Also, if there's that much variation in BP the patient was probably intravascularly dry.

 

[Mman]

No? I thought that's why we still use the stethoscope. Or the bedside echo. Or whatever is easy to do, has very little risk, and possibly a lot of benefits, at low cost.

If I had a Vscan, you bet that almost every cardiac patient would get a 2-minute focused tte before a general anesthetic. It's all a matter of risks x costs / benefits.

We use a stethoscope because we are required to do a preoperative physical exam of the patient. As for a TTE, you surely would not want to do one before every general anesthetic even if you easily could as the risk would greatly outweigh the benefit in healthy patients. It's like getting a full body CT scan on a rich guy just because you can. The problem is your false positive rate is high enough with certain things that if you routinely get it you get a lot of false positives and unnecessary and costly delays and further workups.

Doing a test because we easily can is never a good idea IMHO

 

[deleted171991]

We use a stethoscope because we are required to do a preoperative physical exam of the patient. As for a TTE, you surely would not want to do one before every general anesthetic even if you easily could as the risk would greatly outweigh the benefit in healthy patients. It's like getting a full body CT scan on a rich guy just because you can. The problem is your false positive rate is high enough with certain things that if you routinely get it you get a lot of false positives and unnecessary and costly delays and further workups.

Doing a test because we easily can is never a good idea IMHO

I was not talking about anything like MRI for breast cancer, or full body CT, in healthy general population, with very low positive predictive value. Not even about a formal full TTE.

I was talking about looking for significant pathology (because I wouldn't see anything else on the 3.5 inch screen of a pocket device) with a rapid focused exam in patients with pre-existing cardiac disease. If I see valve disease on that screen, it will be most likely a significant one. Same goes for wall motion abnormalities, or low EF. I could get the same information from a good H&P except that, as in this case, patients lie. The echo doesn't. If anything, it will make a lesion look better, because the heart is not under the same load as intraop.

I use my stethoscope to rule out severe lung or heart disease and to have a baseline, not just because I have to, or to look for an excuse to cancel a case. That's another example of a cheap rapid focused exam with much more upsides than downsides.

 

[vector2]

So, the A line systolic is overshooting by 30 to 40 compared to NIBP, and you seem to try to fix that with hits of Propofol, but then you give phenylephrine and even run a phenylephrine infusion at some point as if now you are looking at the low cuff pressure and ignoring the Aline.
Are you using a BIS monitor that is making you give the Propofol hits to achieve some magical number?
It's a pretty schizophrenic chart IMHO!

I don't understand the use of gas with so much frequent use of propofol/fentanyl... and then neo boluses between them.
Also, if there's that much variation in BP the patient was probably intravascularly dry.

I should've turned the cuff off. This lady had bilateral mastectomy so didn't put cuff on UE's. She had a slightly overized cuff on a calf that was probably full of diseased vessels, not to mention changes between T and reverse T position.

The use of propofol and phenylephrine looks frenetic if you weren't in the room watching the BP beat by beat (instead of a 15m time interval chart as shown above). Her chart would've been undulating waves of sbp > 150 then <100 without some strategic upper and downer boluses. Would I liked to have been able to set the iso, give her a fluid bolus, occasional fentanyl, and just sit there on my ass and watch a railroad? Sure, but that's not the way whipple/vascular resections in anemic people with CAD/HTN go. Same goes for carotids- I'm constantly bolusing cardene or phenylephrine in anticipation of wild swings up and down. Changing your neo infusion from 0.25 to 0.5 then back to 0.25 is not fast or effective enough for my taste. By all means, though, feel free to share some charts from your whipple/big belly/significant fluid shift cases so I can learn how to do it.

I doubt she was intravascularly dry early in the case, but she probably was later as blood loss was ongoing. She got about 2.5L of crystalloid early and then I used PPV % to work in 100-200cc 5% albumin boluses when it creeped above 10-12%. Granted, I wasn't running her with 8cc/kg tidal volumes and pressors throw off the accuracy, but if anything I probably gave her too much crystalloid/colloid because I'm pretty (sometimes to my detriment) transfusion averse.

 

[vector2]

For fun, let's look at the last 5 (not mine) whipples I could find in epic. some of these were with our opioid-free protocol (lido/dex infusions, ketamine, decadron, tylenol, nsaid), but no epidurals per our two whipple surgeons' bizarre preference