Small case for the new attendings

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urge

urge

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You have been assigned to take care of the small procedures done in a closet in the PACU. Basically ECTs and cardioversions.

Your next patient is a 76 y/o male 5'9", 315 pounds, short neck, with a beard, mallampati 3, no teeth, DM2, htn, normal previous echo, satting 93 on 3L nasal cannula, visibly short of breath, and complaining of back pain from being in a gurney for too long.

Cardiology wants to do a tee under sedation before cardioverting. They usually do them in the echo lab ahead of time but they think he will not tolerate.

How would you handle it?
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I am not worried about his airway exam. I would be more worried about his shortness of breath. I would have the cardiologist evaluate the patient in order to ostensibly shift some risk.

If I had to do the case I would numb him up using whatever means I had to and do whatever I had to in order to keep his hemodynamics as close to baseline as possible.
 
Prop, no sux, ducer.
 
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Good, I mean good topical. Precedex for sedation, ( although in good hands prop,versed, ketamine could work), good preox and tell them to move with purpose. And for all of our cardiology buds avoid hypertension, hypodermic and tachycardia.
 
Precedex (takes quite a bit of time in my experience, and your institution may not be thrilled about its use...) and ketamine are your friends here, especially if there is a component of heart failure with preserved EF (for example) where boluses of propofol can be problematic. Infusions work well, but take patience. Topicalize, tropicalize, tropicalize.
 
Topicalize him, crank up the oxygen (sometimes in more tenuous patients I will have a face mask next to their face providing blowby during the procedure), and go slow with propofol. Keep him more on the lighter side. Know where your oral airways are.
 
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OK, so everybody wants to do some kind of light sedation. And only 1 person so far has raised the question whether it is a good idea to proceed.

Let's assume you go ahead with your favorite light sedation with plenty of topicalization.

Cardiology cannot pass the probe. The pt is coughing, choking, desatting intermittently to the low 80's and the highest it is coming back is 91. You try it yourself and it will still not go.

What next?
 
Ask cardiologist if he might possibly be satisfied with a TTE. What are they looking for, clot?

If not, GETA. If the TEE probe still won't pass easily, and the cardiologist is still hell bent on doing one, perhaps ask GI to do an upper on him to eval his esophagus. A perforation could be the end of him.
 
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Did a very similar case a couple weeks ago.

1) Big conversaiton with the patient prior with expectations, what to do, etc. Pre-op TEE for TAVR.
2) Lidocaine to toxic levels.
3) Homeopathic sedation. 50 mg total of propofol for a 10 minute TEE in a 350 lb patient... he was basically wide awake for the procedure and tolerated it very well.

If you can't get in by conventional means, then you can't get in for a reason. Don't force anything. Give GETA a try. Probably make it easier if the patient has a strong gag and very reactive to minimal stimulation despite adequate topicalization.
 
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urge said:
OK, so everybody wants to do some kind of light sedation. And only 1 person so far has raised the question whether it is a good idea to proceed.
Click to expand...

This comes with the huge caveat that I myself haven't seen the patient. No amount of words can replace physically seeing the patient myself. I am proceeding under the assumption that he passes MY eyeball test (this is implied in any answer as to how to proceed...this isn't actually oral boards all over again, is it?!?) But seriously, just being fat, difficult airway, and SOB doesn't necessarily pique my interest. But obviously there are different gradations of each of these things, and if he doesn't pass the eyeball test then I would reconsider my plan.

urge said:
Cardiology cannot pass the probe. The pt is coughing, choking, desatting intermittently to the low 80's and the highest it is coming back is 91. You try it yourself and it will still not go.

What next?
Click to expand...

Where is the probe getting hung up? Just inside the mouth or a bit deeper? Start by look in the guys mouth. Sometimes these patients can have osteophytes in the cervical vertebrae that make probe placement more difficult and make them more prone to perforation. If you can't get the probe to go easily by manipulating the head/neck without compromising the patient's airway and respiratory status, forcing it is the worst thing you can do. Delay the case until you can move into the OR and can tube him. Tubing him also gives you the ability to take a look at wtf is going on with a fiber.
 
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Avoid falling into the kill mistake of more and more sedation.
 
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The last thing this guy needs is a TEE!!!!
Tell them that the risk of a TEE outweighs the benefit and they need to do TTE and then proceed to cardioversion or just attempt medications to cardiovert or rate control since the prognosis is the same comparing cardioversion to rate control.
 
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Planktonmd said:
The last thing this guy needs is a TEE!!!!
Tell them that the risk of a TEE outweighs the benefit and they need to do TTE and then proceed to cardioversion or just attempt medications to cardiovert or rate control since the prognosis is the same comparing cardioversion to rate control.
Click to expand...

How well can you see the LAA on TTE?
 
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What are his vitals? What is his rhythm? Why is he short of breath? Is he in rapid afib and acutely decompensating? Is he in chf? Is he having an MI?

We all know that we can do fancy techniques to guide any patient through an anesthetic. Sometimes we have to take a step back and find out why we are doing something. Obviously the cardiologist wants to do the echo and cardiovert, but is it the right thing to do here? Life is not always an oral board question where you make assumptions and just go ahead. Sometimes you need to get more information...especially if the patient appears to be sick.
 
GravelRider said:
What are his vitals? What is his rhythm? Why is he short of breath? Is he in rapid afib and acutely decompensating? Is he in chf? Is he having an MI?

We all know that we can do fancy techniques to guide any patient through an anesthetic. Sometimes we have to take a step back and find out why we are doing something. Obviously the cardiologist wants to do the echo and cardiovert, but is it the right thing to do here? Life is not always an oral board question where you make assumptions and just go ahead. Sometimes you need to get more information...especially if the patient appears to be sick.
Click to expand...
Agreed. the real issue here is that he is acutely SOB. without that it is no different from a fat, bad airway, and generally unhealthy guy coming for egd and you would proceed with you usual management (to each their own). Also I am a little shocked that people are suggesting that we try to place the probe ourselves. The cardiologist is the surgeon in this case; if a surgeon was having a difficult lap chole would you reach over the drapes and try to help?!!. Additionally, I am pretty sure that the surgical informed consent does not include the anesthesiologist trying to do the surgical procedure; if something happened the cardiologist would throw you under the bus and you would be fuc%ed. Lastly it is certainly a violation of ASA monitoring standards to be doing the procedure and providing anesthesia simultaneously.
 
dannyboy1 said:
Agreed. the real issue here is that he is acutely SOB. without that it is no different from a fat, bad airway, and generally unhealthy guy coming for egd and you would proceed with you usual management (to each their own). Also I am a little shocked that people are suggesting that we try to place the probe ourselves. The cardiologist is the surgeon in this case; if a surgeon was having a difficult lap chole would you reach over the drapes and try to help?!!. Additionally, I am pretty sure that the surgical informed consent does not include the anesthesiologist trying to do the surgical procedure; if something happened the cardiologist would throw you under the bus and you would be fuc%ed. Lastly it is certainly a violation of ASA monitoring standards to be doing the procedure and providing anesthesia simultaneously.
Click to expand...

Placing a TEE probe is well within an anesthesiologist's scope of practice, and many of us have placed MORE probes than cardiologists have. You will see that once you graduate and get outside of academia, the ones who succeed in ANY specialty are the ones who aren't too proud to ask for help. It is akin to having a difficult intubation and having an otolaryngologist attempt a laryngoscopy.

Regarding it being a violation of ASA monitoring standards, have you done your cardiac rotation? Did you place the TEE probe while delivering the anesthetic? It by no means violates any standards whatsoever.

Finally, something to consider -- especially as someone who is just entering into this specialty, you should be salivating at opportunities to show that you are more than a monkey who pushes propofol and puts endotracheal tubes into people. Go above and beyond, show your value, and show you can bring something different and unique to the table that a well-trained monkey can't.
 
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I did exactly this same guy 2 days ago. Except it was on the floor. Patient had recently gone into a fib and was starting to get sob. The cardiologist had difficulty passing the probe. After several attempts, I had to put on my gloves and do it for her. And then it was over in 5 seconds. There was no clot, she pulled the probe and we shocked the guy. He got a total of 100 mg of propofol in aliquots of 30, 30, 40. Sometimes you gotta help. I've done this several times for cards who couldn't find the subclavian vein for pacemaker. They know we are good at lines and we do a heck of a lot more TEE than they do.


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pgg said:
Ask cardiologist if he might possibly be satisfied with a TTE. What are they looking for, clot?
Click to expand...

Looking for clot. Refuse tte as tee is the standard of care.

They ask for the patient to be under deeper sedation.
 
Urzuz said:
Where is the probe getting hung up? Just inside the mouth or a bit deeper? .
Click to expand...

Past the tonge.

The guy has no neck so you start wondering whether he has cervical vertebra.
 
GravelRider said:
What are his vitals? What is his rhythm? Why is he short of breath? Is he in rapid afib and acutely decompensating? Is he in chf? Is he having an MI.
Click to expand...


This conversation was had before the start of the procedure.

Afib HR 132. BP 165/80 RR 28. Sat 93 on 3 L. Rapid shallow breaths with pursed lips. Arms on both side rails of the gurney. No limitation in complaining activity.

Cardiology says he will feel much better once he is in NSR. No chest pain.

Of note he walked into the room.
 
Ok, let's continue.

Further attempts at passing the probe have been halted. Cardiology requests a 2nd anesthesia attending.

What now?
 
GETA - video scope handy.
placing the TEE probe = not my problem
 
JobsFan said:
GETA - video scope handy.
placing the TEE probe = not my problem
Click to expand...

At this point, GETA would be much more simplistic. Then, using a DL technique to pass the probe, or to evaluate if there is something obstructing at the esophageal inlet.
 
How many attempts at TEE insertion now? Call it a day before somebody perfs this guy's esophgus. One of our cardiologists did this a few months ago on a similar patient, necessitating GI involvement for a stent. Anticoagulate, control rate, and come back for cardioversion after he's therapeutic and the possible clot has dissolved.

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urge said:
Looking for clot. Refuse tte as tee is the standard of care.

They ask for the patient to be under deeper sedation.
Click to expand...
OK then as I said, he can get GETA. That TEE probe can get inserted gently or not at all, it's all the same to me.

More sedation is a setup for a kill. Jamming the probe in past resistance is too.
 
Normal prior echo? Why's he SOB? Why can't they do a TTE first?
psychbender said:
How many attempts at TEE insertion now? Call it a day before somebody perfs this guy's esophgus. One of our cardiologists did this a few months ago on a similar patient, necessitating GI involvement for a stent. Anticoagulate, control rate, and come back for cardioversion after he's therapeutic and the possible clot has dissolved.

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Click to expand...


I like this strategy. Dude is acutely decompensated, sob can be simply blamed on his HR, and obesity/work of breathing etc but he could also be in acute heart failure/Pulm edema (your physical exam helps here and as we weren't given anything that screams he's wet he likely isn't in this case but it's obviously something you'd look for). I'd argue for TTE first, accepting that it's not sensitive for LA thrombus but I'd like to know how bad his heart looks before I do any sedation on him, his past echo doesn't console me.

If this guys in acute heart failure you can argue cardioversion is exactly what he needs if he's sans clot, but if acquiring the images is too risky and may kill him im not sure you're helping him. If all looks good and I thought we could give it a go, like everyone else says I'd topicalize well, and he'd get very little actual sedation from me, precedex may be perfect here but I agree in the doses we'd be giving its not exactly rapid acting. Over sedation kills this guy so we try once or twice and if no luck passing probe I'd argue for delay while the guy gets rate control and anticoagulation, better assessment of resp status and hopefully better oxygenation etc prior to repeat attempt vs GETA today.
 
Planktonmd said:
The last thing this guy needs is a TEE!!!!
Tell them that the risk of a TEE outweighs the benefit and they need to do TTE and then proceed to cardioversion or just attempt medications to cardiovert or rate control since the prognosis is the same comparing cardioversion to rate control.
Click to expand...
You can't rule out clots with TTE in a 315 pounder (or even in most normal BMI people). You also can't cardiovert chemically (it's the same embolic risk according to our cardiologists).

But I do agree that the risks of anesthesia for TEE outweigh the benefits. What's the extra embolic risk, like 4%? Minimal propofol, zap, done.
 
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FFP said:
You can't rule out clots with TTE in a 315 pounder (or even in most normal BMI people). You also can't cardiovert chemically (it's the same embolic risk according to our cardiologists).

But I do agree that the risks of anesthesia for TEE outweigh the benefits. What's the extra embolic risk, like 4%? Minimal propofol, zap, done.
Click to expand...
What I was trying to say is that leaving this guy in Afib and just doing rate control is not too bad and possibly better for him than the risk of TEE and crdioversion.
We now know that restoring sinus rhythm does not improve the prognosis:
http://www.medscape.com/viewarticle/584780
 
urge said:

This conversation was had before the start of the procedure.

Afib HR 132. BP 165/80 RR 28. Sat 93 on 3 L. Rapid shallow breaths with pursed lips. Arms on both side rails of the gurney. No limitation in complaining activity.

Cardiology says he will feel much better once he is in NSR. No chest pain.

Of note he walked into the room.
Click to expand...

I'm not convinced yet that he needs the DCCV. How long has he been in afib? Did he fail rate control? Was that even attempted? His blood pressure is stable. Does he have signs of myocardial ischemia due to the rapid rate? He's likely short of breath because of the rapid rate. Rate control him and anticoagulate him. Put him on a diltiazem drip and bridge him to Coumadin.
 
Planktonmd said:
You see what you can see and then either Zap him or do rate control with anticoagulation.
Click to expand...

I've never done a r/o clot for cardioversion this way. I use both TTE/TEE. A TTE in a 315lb patient will like give you crappy windows, even worse actually trying to interrogate the LAA. TEE is da bomb when it comes to LAA.

11785_gr1.jpeg
 
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Planktonmd said:
The last thing this guy needs is a TEE!!!!
Tell them that the risk of a TEE outweighs the benefit and they need to do TTE and then proceed to cardioversion or just attempt medications to cardiovert or rate control since the prognosis is the same comparing cardioversion to rate control.
Click to expand...

May be true that the risk outweighs benefits. So lets go further.. How do you convey this message to the cardiologist who is set on doing a TEE? Guaranteed he/she is going to have a problem with the anesthesiologist saying that.
 
Furthermore... Say that you do suboptimal TTE and immediately after cardioversion the guy strokes out?
Then you do a TEE and find a mobile clot in the LAA and a partially embolized clot bouncing around in the LA.
Lawyers would have a hay day with that one.
 
gasp said:
May be true that the risk outweighs benefits. So lets go further.. How do you convey this message to the cardiologist who is set on doing a TEE? Guaranteed he/she is going to have a problem with the anesthesiologist saying that.
Click to expand...
You write a statement in the chart that in your opinion the anesthetic risk of this procedure outweighs the benefit in this morbidly obese patient who appears to be in acute respiratory failure and that he will require GETA to do the procedure safely.
If the cardiologist still insists on the TEE after that you ask him to put it in writing and proceed with GETA.
 
sevoflurane said:
Furthermore... Say that you do suboptimal TTE and immediately after cardioversion the guy strokes out?
Then you do a TEE and find a mobile clot in the LAA and a partially embolized clot bouncing around in the LA.
Lawyers would have a hay day with that one.
Click to expand...
The decision to proceed with TTE is not yours, it should be the cardiologist's based on your assessment that the risk of anesthesia is too high as a consultant anesthesiologist.
 
Planktonmd said:
The decision to proceed with TTE is not yours, it should be the cardiologist's based on your assessment that the risk of anesthesia is too high as a consultant anesthesiologist.
Click to expand...

I'm not saying it is. You are suggesting to stop the procudre and tell the cardiologists to do a TTE instead (he probably would quitely chuckle).
I am saying that a TTE while fine and dandy, is likely not going to show much in this patient. You are way better off suggesting a contrast enhanced CMR.
 
sevoflurane said:
Furthermore... Say that you do suboptimal TTE and immediately after cardioversion the guy strokes out?
Then you do a TEE and find a mobile clot in the LAA and a partially embolized clot bouncing around in the LA.
Lawyers would have a hay day with that one.
Click to expand...

Lawyers will also have a field day if the esophagus get perfed or there was some other complication during a potentially unnecessary TEE. Rate control and anticoagulation for afib is something you learn during intern year. Just because the cardiologist says so, does not get you off the hook.
 
GravelRider said:
Lawyers will also have a field day if the esophagus get perfed or there was some other complication during a potentially unnecessary TEE. Rate control and anticoagulation for afib is something you learn during intern year. Just because the cardiologist says so, does not get you off the hook.
Click to expand...

Not arguing for a TEE if you can't pass it easily. That's anesthesia 101... if it doens't go easily, don't force it. Applies to every single procedure we do.

I have no problem with rate control and anticoagulation and come back to fight another day.

What I am saying is that to do a TTE on a 315 lb patient is not exactly a good way to cardiovert someone who may have a LAA clot.
 
Ok. Fascinating. Nobody has asked for a 2nd pair of hands.

Cardiology still wants to proceed. You have the discussion about further sedation leading to a catastrophe. They are not thrilled with intubating the guy for the procedure but they want it done.

Let's assume you are preparing to intubate.

What do you set up? What is your back up?
 
Video laryngoscopy here is your best friend, and while you are there you can see if anything is obstructing the esophageal inlet. Use whichever device you are most comfortable with (i.e. GlideScope vs C-MAC). For rescue, I'd have a Bougie handy as well as Airtraq (this CERTAINLY isn't for everyone but I've had a lot of exposure and use with it) with a Parker (curved tip ETT).
 
Inhalation induction with Sevo to keep pt spontaneously breathing and then gentle DL with cmac/glidecscope to see if you can visualize the cords. If you see the cords, sux then tube


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i hate making assessments of these kinds of patients without seeing them. does he tingle my spidey sense? or do i think i can ventilate/intubate? i would probably ask for a second set of hands.
 
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