Most Insane Induction I've Ever Had

[shepardsun]

Middle aged male for enucleation of prostate. Has non-compaction cardiomyopathy with EF of 15% and an LVAD.

I'm not a cardiac guy so always treat these with kid gloves. Pre-induction art line and 16 g PIV placed in the forearm under ultrasound for vasoactives should I need them.

I've had similar patients crump before just by cracking a vial of propofol across the room, so after hooking up monitors and placing a Sedline I started with 0.5mg midaz and 10 mg prop. Waited thirty seconds, nothing happened, BP stable, great, another 10 mg of prop. Waited a minute, guy still responsive, gave him another 20mg, rinse and repeat.

By the time I almost got to the end of my first stick, and the guy would still open his eyes and give me a thumbs up, and his Sedline spectral edge was essentially unchanged, I started to sweat a little bit. Could the IV not be working? Skin felt great, carrier flew like a champ, he never complained once with the pushes, and I had been giving small bumps of phenylephrine throughout which would immediately bump his pressure.

Still, I went to the other arm and placed a new IV and started stick of propofol number 2. By the time 400 mg of propofol was in, he was sleepy and hypopneic, but still opening his eyes to his name. At this point I didn't really know what to think. Hemodynamics were fine, LVAD function great, he was clearly sleepier and there was a slow trend of the spectral edge downward. I thought about breathing him down on vapor but at this point we're literally like 25 minutes into the induction and I didn't want to go down the inhalation route if I didn't have to. I switched over to etomidate 2mg at a time, and it seemed like it was having a more pronounced effect on his mental status, so gave a total of 10mg at which point he became unresponsive.

I've never given this much for any patient, let alone one with severe LV dysfunction. I still don't really understand what happened. Maybe I was going so slow that I didn't even really build up a plasma concentration of propofol? The entire process from start to intubation was literally like 40 minutes. Totally crazy stuff.

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[Airway]

Marijuana? Etoh? Or just well compensated (and tolerated induction) heart failure due to lvad. Any weird drugs on his mar? I've never taken care of someone with non-xompaction cm, interesting story.

 

[IlDestriero]

The clinically useful half-life for a single propofol bolus is quite short just a few minutes. The prolonged induction wasn’t helping you.
You had an arterial line giving you beat to beat BPs, and an EEG monitor which your must trust or you wouldn’t be using it. I’m not sure why you dragged the induction out for 40 minutes? If you knew going in you were going to go glacially slow, it might have been easier to start a modest prop infusion, then bolus lido, fent, ketamine, prop, neo, etc every minute or so until well sedated. We would do graded stimulation all the time in cardiac patients. Do they tolerate a jaw thrust, no? More. Oral airway, no? more. Foley, no? More. Then finally the tube.
I like significant fentanyl blouses in cardiac cripples. It’s pretty CV stable in compromised patients when given as part of a balanced multi drug induction. I don’t take care of patients with LVADs, so I don’t know what happens with them and cardiac output during anesthesia. I imagine it supports it quite well, so I probably would have been a bit more aggressive knowing his native EF is only a part of his cardiac output.
I’m curious what the CV guys think, and how LVADs affect the plan.

 

[Hork Bajir]

I agree that it sounds like the problem was going too slowly- like running a prop infusion at 30 mcg/kg/min and wondering why the patient is never totally induced.

There is obviously a fair amount of complexity with LVADs if you want to do anything sophisticated or go down that particular rabbit hole, but in general with LVADs, it’s all about the RV. If his RV was sick, makes sense to be cautious… But by that same token, with a sick RV you’re not doing him any favors by letting him hypoventilate for 40 minutes. Better part of valor is just to give more midaz, prop, etomidate, ketamine, epi, or whatever else is within arms reach and just get off to sleep so that you can control ventilation.

If the RV is robust, then life is good. Give more prop and get on with it.

 

[deleted697535]

I agree that it sounds like the problem was going too slowly- like running a prop infusion at 30 mcg/kg/min and wondering why the patient is never totally induced.

There is obviously a fair amount of complexity with LVADs if you want to do anything sophisticated or go down that particular rabbit hole, but in general with LVADs, it’s all about the RV. If his RV was sick, makes sense to be cautious… But by that same token, with a sick RV you’re not doing him any favors by letting him hypoventilate for 40 minutes. Better part of valor is just to give more midaz, prop, etomidate, ketamine, epi, or whatever else is within arms reach and just get off to sleep so that you can control ventilation.

If the RV is robust, then life is good. Give more prop and get on with it.

what hork said. LVEF 15% means nothing with an LVAD unless its turned off

fent/midaz/ketamine/roc chair

 

[caligas]

Nothing wrong with breathing him down with some sevo especially with all that access you had.

 

[shepardsun]

Appreciate all the feedback- I don't do these often so I'm clearly a little gun-shy with them. This guy actually had a pretty good functional history so I should have known he'd be a little more robust. Good learning experience for me.

 

[deleted875186]

Did these in residency, we actually did quite a bit of LVADs.

have them hook up the monitor for the LVAD so you can see the flow, CO, and power.

place art line with ultrasound. If the noninvasive BP works then it’s fine to use, same with pulse ox, just means he has enough cardiac function left to make some pulsatility.

Vasopressors like you did, or rapid fluid bolus like you were ready for if there’s a suction event.

RV function as noted above. Cardiac level stuff, way above my knowledge.

sounds like this guy was a drinker or something. You gave enough to match a prop infusion somewhere between 100-150 mcg/kg/min, would have expected him to be asleep. Probably after the first prop stick I would have given more midaz, or just turned on the gas, and pushed a bunch of roc.

 

[dannyboy1]

40 minutes????
What happened to good old etomidate roc tube.

 

[DoctwoB]

HOLEP in an EF of 15? Why no spinal?

 

[nimbus]

HOLEP in an EF of 15? Why no spinal?

Anticoagulation?

 

[GassYous]

I think the change in ef matters a lot more than the actual number itself. Functional status as well as you noted. And the lvad makes it irrelevant/rv more important like everyone said.

 

[TheLoneWolf]

Maybe

 

[Hork Bajir]

I don’t think you need an ACTA fellowship to safely provide anesthesia for patients with LVADs, but you should have a basic understanding of the device, how it works, hemodynamic goals under anesthesia, the limitations of various monitors (NIBP, Doppler pressures, pulse ox), and troubleshooting common problems (mostly low flow alarms, suction events, changes in pulsatility, and hypertension/hypotension). There are a number of good free lectures out there on VADs for the non-cardiac anesthesiologist; I believe the most recent episode of the ACCRAC podcast covers these things in a fair amount of detail.

 

[deleted697535]

HOLEP in an EF of 15? Why no spinal?

Yes. 22g needle works best

 

[Tony C anesthesia]

what hork said. LVEF 15% means nothing with an LVAD unless its turned off

fent/midaz/ketamine/roc chair

That's a good point. He has LVAD because he HAD poor cardiac output but now with LVAD you worry on the right heart more.

 

[caveat87]

Why not consider a generous dose of versed (middle aged) and 50-75mcg of sufentanil? We used this combo at my residency program and it was amazing how rock solid stable vital signs were during induction and laryngoscopy. The sufenta bolus will tail off nicely if procedure is >1 hour.

agree with pre-induction A-line and prepare for suction events etc.

 

[dabears505]

I have just one upped you. I've been inducing for a 730 start this morning til now. Partner got me out for a lunch break, so not sure how he will proceed. Thoughtless surgeon is going insane, not sure what his problem is.

 

[Gern Blansten]

I like significant fentanyl blouses in cardiac cripples.

That is a very specific proclivity. I had a friend who was really into feet.

 

[GassYous]

That is a very specific proclivity. I had a friend who was really into feet.

We just call em podiatrists over here

 

[vsl5]

Aside from RV function, the other really important thing to maintain in LVAD patients is afterload. Ideally you'd have a tech there who is managing the LVAD and able to tell you the baseline settings (RPM / calculated flow / pulsatility index) and how they are changing with induction. One potential disaster during induction is dropping the afterload too much, which means the LVAD will flow higher and shift the interventricular septum towards the LV which distorts the mechanics of RV freewall contraction. At the extreme end, this can result in suck down and loss of LVAD output (which the LVAD tech should be able to detect easily). So in this case, I'd run background phenylephrine or norepi during the induction (or at least have it in line) and have bolus doses of pressors (vasopressin 0.5-1 unit at a time works well for this) and make a note of the baseline MAP - try to keep it there during induction. Keeping the MAP there also helps the RV.
For you POCUS savvy folks, you can monitor this in real time with periinduction TTE - with apical 4C view looking at the position of the IVS - ideally it's in the neutral position. After induction, TEE can be used.

 

[Hork Bajir]

Aside from RV function, the other really important thing to maintain in LVAD patients is afterload. Ideally you'd have a tech there who is managing the LVAD and able to tell you the baseline settings (RPM / calculated flow / pulsatility index) and how they are changing with induction. One potential disaster during induction is dropping the afterload too much, which means the LVAD will flow higher and shift the interventricular septum towards the LV which distorts the mechanics of RV freewall contraction. At the extreme end, this can result in suck down and loss of LVAD output (which the LVAD tech should be able to detect easily). So in this case, I'd run background phenylephrine or norepi during the induction (or at least have it in line) and have bolus doses of pressors (vasopressin 0.5-1 unit at a time works well for this) and make a note of the baseline MAP - try to keep it there during induction. Keeping the MAP there also helps the RV.
For you POCUS savvy folks, you can monitor this in real time with periinduction TTE - with apical 4C view looking at the position of the IVS - ideally it's in the neutral position. After induction, TEE can be used.

Yes- just don’t let the map get too far above 80, as the VAD is afterload sensitive and high MAP will also cause VAD flow to drop

 

[woopedazz]

Reminds me of a 20 minute propofol induction for ECT i witnessed in training.

... **** seizure obviously.

 

[anbuitachi]

He was opening eyes because you didn't give a paralytic

 

[T-burglar]

Lmao that rules . Did the surgeon have a stroke ?