New Jet Case

[jetproppilot]

I'm posting this case not because of its coolness, (very uncool case), but because this is a real life scenerio in a busy private practice that'll require you to make some decisions.

aside: theres probably not a RIGHT answer, but you're gonna haffta STEP UP TO THE MIKE WITH MICATIN.

73 year old dude in same day surgery...here for declot of AV graft. Supposed to get dialysis tomorrow.

MI 4 years ago, known angina relieved with NTG, HTN, renal failure secondary to HTN/DM, DM, blah blah blah.

Surgeon wants to do declot, and maybe a temporary subclav-dialysis cath under MAC.

Pt arrives, RN is checking him in, pt c/o chest pain.

RN calls surgeon.

Surgeon says "call pts primary call doc."

Primary doc called.

He orders (over the phone) STAT EKG, enzymes, NTG SL X3, 2" nitropaste, etc etc, consult cardiologist.

Cardiologist is consulted, at an other hospital and can't be here for a while.

I go see the dude. He's received the NTG X 3, nitropaste not on yet.

I see the orders for all this stuff, including the cardiology consult, in the doctor's orders, written as "voice orders", transcribed by the RN.

His chest pain is nearly gone. He's lying comfortably in bed, no distress, kinda hard of hearing, talking to me and his daughter.

EKG devoid of any acute ischemia.

Heart S1 S2 no S3 S4/M/G/R. Lungs clear.

So dude's primary care doc was consulted, didnt see the dude, but ordered all this sh it.

Cardiologist consulted, but can't come.

OR is ready, surgeon is here.

WHAT DO I DO NOW?

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[coprolalia]

Do the case. You're doing monitored care, right? Risk/benefit. You can get this guy's graft working, you're doing him a big favor. Talk to family, talk to patient, document, document, document. Besides, anesthesia is good for people. He's on the NTG, and you're going to give him stuff that's further going to relax his sympathetic tone. Move forward, brave soul. You have my blessing.

-copro

 

[huktonfonix]

Hes gonna need something for dialysis and this doesnt seem to fall under the category of acute coronary syndrome. This makes him a pt with 3 intermediate risk factors for a low risk procedure which he needs semi-urgently (either declotting the fistula or a dialysis cath for dialysis tommorow) I'd probably do the procedure under subclavian block or local with MAC as needed. In other words its easily justified to proceed with the procedure

 

[toughlife]

I'm posting this case not because of its coolness, (very uncool case), but because this is a real life scenerio in a busy private practice that'll require you to make some decisions.

aside: theres probably not a RIGHT answer, but you're gonna haffta STEP UP TO THE MIKE WITH MICATIN.

73 year old dude in same day surgery...here for declot of AV graft. Supposed to get dialysis tomorrow.

MI 4 years ago, known angina relieved with NTG, HTN, renal failure secondary to HTN/DM, DM, blah blah blah.

Surgeon wants to do declot, and maybe a temporary subclav-dialysis cath under MAC.

Pt arrives, RN is checking him in, pt c/o chest pain.

RN calls surgeon.

Surgeon says "call pts primary call doc."

Primary doc called.

He orders (over the phone) STAT EKG, enzymes, NTG SL X3, 2" nitropaste, etc etc, consult cardiologist.

Cardiologist is consulted, at an other hospital and can't be here for a while.

I go see the dude. He's received the NTG X 3, nitropaste not on yet.

I see the orders for all this stuff, including the cardiology consult, in the doctor's orders, written as "voice orders", transcribed by the RN.

His chest pain is nearly gone. He's lying comfortably in bed, no distress, kinda hard of hearing, talking to me and his daughter.

EKG devoid of any acute ischemia.

Heart S1 S2 no S3 S4/M/G/R. Lungs clear.

So dude's primary care doc was consulted, didnt see the dude, but ordered all this sh it.

Cardiologist consulted, but can't come.

OR is ready, surgeon is here.

WHAT DO I DO NOW?

Are we done yet?

 

[pd4emergence]

Take that order sheet and throw it out, tell the RN that she never saw it and that she does not want to consult the cardiologist using your Jedi mind control. The guy needs his access graft declotted. If he can make it through dialysis, he can make it through a declot.

Pd4

 

[Gern Blansten]

Take that order sheet and throw it out, tell the RN that she never saw it and that she does not want to consult the cardiologist using your Jedi mind control. The guy needs his access graft declotted. If he can make it through dialysis, he can make it through a declot.

Pd4

So true. How many times have we wished we could undo something after the cat was out of the bag.

 

[Planktonmd]

Jet, you said his chest pain was almost gone, this means he was still having chest pain?
I would not take him to the OR for anything untill his chest pain is completely gone, once he has no chest pain I wouldn't wait for anything else to be done.

 

[militarymd]

jet...you spelled it out pretty clear....

he could get his kidneys fixed now.....OR after he's had his MI and develops pulmonary edema cause ain't got no kidneys.

 

[Jeff05]

aca/aha guidelines 2007.



Table 2. Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery
(Class I, Level of Evidence: B)
Condition Examples
Unstable coronary syndromes Unstable or severe angina* (CCS class III or IV)†
Recent MI‡
Decompensated HF (NYHA functional
class IV; worsening or new-onset HF)
Significant arrhythmias High-grade atrioventricular block
Mobitz II atrioventricular block
Third-degree atrioventricular heart block
Symptomatic ventricular arrhythmias
Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled
ventricular rate (HR greater than 100 beats per minute at rest)
Symptomatic bradycardia
Newly recognized ventricular tachycardia
Severe valvular disease Severe aortic stenosis (mean pressure gradient greater than 40 mm Hg,
aortic valve area less than 1.0 cm2, or symptomatic)
Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional
presyncope, or HF)


doesn't seem to have any of these...

if he did, HD via a temporary catheter while patient is optimized is an option.

 

[deleted126335]

.

 

[drccw]

Is this consistent with his stable angina? because if it is (and sounds like it)...
then OR. afterwards then have a talk to the PCP about stable angina.....


renal failure
CAD
is he on insulin... 2 maybe 3 risk factors, low risk surgery....

please dont squirt his coronaries... please....

 

[Planktonmd]

Is this consistent with his stable angina? because if it is (and sounds like it)...
then OR. afterwards then have a talk to the PCP about stable angina.....


renal failure
CAD
is he on insulin... 2 maybe 3 risk factors, low risk surgery....

please dont squirt his coronaries... please....

It is stable angina but that doesn't mean you should take him to the OR while he is having chest pain (regardless of what the guidelines say)
Stable angina is not a contraindication for surgery but ongoing ischemia is.

 

[coprolalia]

please dont squirt his coronaries... please....

Well, you certainly aren't going to hurt his kidneys any worse with the dye...

-copro

 

[Noyac]

Is this consistent with his stable angina? because if it is (and sounds like it)...
then OR. afterwards then have a talk to the PCP about stable angina.....


renal failure
CAD
is he on insulin... 2 maybe 3 risk factors, low risk surgery....

please dont squirt his coronaries... please....

Is angina at rest "stable"?

 

[jetproppilot]

Thanks for all the intuitive, knowledgable replies.

I went ahead with the case.

I was frustrated by the chain of events that werent helping the patient.

The dude had chest pain, and what really happened was a buncha doctors were called, a buncha orders were voice-ordered, and nobody saw the dude, and nobody had any plans of seeing him in the near future.

If a doctor orders a stat EKG shouldnt they wanna read it when it comes? laugh

This was a big TERF GAME.

Surgeon says call primary guy.

Primary guy says call cardiologist.

Cardiologist can't come.

So I made a decision.

This guy needs dialysis. Yeah, the procedure could be done under local if I'm "scared" to go to the OR with him...

but whats really right for the patient?

Could I say we aint doin' it?

Easily.

Am I gonna contribute to his demise by giving a little sedation to him during what would otherwise be a local procedure, where he'd certainly be more uncomfortable?

I didn't think so.

Whats really the right thing to do for this kinda funny old dude here in day surgery?

I'm the only physician that examined the guy. And looked at his EKG, which showed no j point elevation/sinister ST segment-or-T wave changes. He was lying in bed, speaking in full sentences (read: no SOB), no distress, looking at his daughter alot for guidance since he was hard of hearing.

"Screw the orders", I thought.

The right thing to do is to get him in the OR right now while the surgeon is here. That way he won't be absorbed by The System and rot in his bed for another twelve hours, waiting on doctors and labs, delaying the dialysis he REALLY NEEDS even more.

We went to the OR, gave the dude some midaz and propofol, surgeon ballooned the graft and placed temporary subclavian access for dialysis.

You may consider that cowboy-like.

I don't.

I made a decision based on my evaluation of the patient and his data, and his need to have this procedure done.

Regardless of what was ordered by people who weren't there.

 

[TIVA]

Hey Jet,

I know you gave midaz and propofol, but did you leave him spontaneously breathing? Or intubate? LMA? ... Just curious.

 

[Planktonmd]

Thanks for all the intuitive, knowledgable replies.

I went ahead with the case.

I was frustrated by the chain of events that werent helping the patient.

The dude had chest pain, and what really happened was a buncha doctors were called, a buncha orders were voice-ordered, and nobody saw the dude, and nobody had any plans of seeing him in the near future.

If a doctor orders a stat EKG shouldnt they wanna read it when it comes? laugh

This was a big TERF GAME.

Surgeon says call primary guy.

Primary guy says call cardiologist.

Cardiologist can't come.

So I made a decision.

This guy needs dialysis. Yeah, the procedure could be done under local if I'm "scared" to go to the OR with him...

but whats really right for the patient?

Could I say we aint doin' it?

Easily.

Am I gonna contribute to his demise by giving a little sedation to him during what would otherwise be a local procedure, where he'd certainly be more uncomfortable?

I didn't think so.

Whats really the right thing to do for this kinda funny old dude here in day surgery?

I'm the only physician that examined the guy. And looked at his EKG, which showed no j point elevation/sinister ST segment-or-T wave changes. He was lying in bed, speaking in full sentences (read: no SOB), no distress, looking at his daughter alot for guidance since he was hard of hearing.

"Screw the orders", I thought.

The right thing to do is to get him in the OR right now while the surgeon is here. That way he won't be absorbed by The System and rot in his bed for another twelve hours, waiting on doctors and labs, delaying the dialysis he REALLY NEEDS even more.

We went to the OR, gave the dude some midaz and propofol, surgeon ballooned the graft and placed temporary subclavian access for dialysis.

You may consider that cowboy-like.

I don't.

I made a decision based on my evaluation of the patient and his data, and his need to have this procedure done.

Regardless of what was ordered by people who weren't there.

Was the chest pain completely gone?

 

[coprolalia]

Is angina at rest "stable"?

No. But, I don't think he was necessarily describing unstable angina in this case.

Was the chest pain completely gone?

That's what the man said. And, no ECG changes to indicated AMI.

-copro

 

[Noyac]

My problem with this case is that the nurse and the surgeon didn't call you first, Jet. Here at my facility, I would have been the first Dr. called. And I would have done exactly what you did.

 

[2win]

Yep - the first one to be called is YOU. Otherwise you're right.

 

[joncmarkley]

could get a shiley for his dialysis

does not need to go to the or with unstasble angina

dw cardio see if he has had a cath latley

might need an intervention in the lab or an opcab

peace

 

[jetproppilot]

could get a shiley for his dialysis

does not need to go to the or with unstasble angina

dw cardio see if he has had a cath latley

might need an intervention in the lab or an opcab

peace

peace back, Dude.

"ERE!"

 

[Apollyon]

Is angina at rest "stable"?

No. But, I don't think he was necessarily describing unstable angina in this case.

Actually, I have always thought (and never, ever been challenged by cardiology) that "unstable angina" is a change in character from other episodes (like a first episode, which is a change from never having had anginal chest pain).

So, yes, angina at rest could be stable - by definition, you're a cardiac cripple, but, if it's the same pain, every day, it's stable angina.

Now, anginal pain is indicative of cardiac ischemia, and any activity will increase the myocardial oxygen demand, swinging you towards injury and infarct, but, if you can get someone to wait on you hand and foot (and take stool softeners to the point that the stool just falls out), theoretically, you could do it.