Theoretical code under anesthesia

[deleted682700]

In a otherwise healthy patients that code and die on the operating table after all the usual suspects such as ett in the wrong place, bleeding, tension pneumo, cardiac tamponade? mi have been ruled out and treated for. Will it be appropriate to consider streptokinase to Lyse a suspected pulmonary embolism?
Will anybody here give it as a last ditch effort?

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[Urzuz]

Sure, I don't think there is anything wrong with considering it, but in the grand scheme of things the "usual suspects" are WAY more likely (wrong drug administered, hypovolemia, etc).

If an otherwise healthy patient codes though, the first thing I'm calling for in addition to extra hands and a crash cart is a TEE. With it you can quickly rule out and potentially rule in a lot of those things on your differential, including PE, tamponade, hypovolemia, etc). If you see right heart failure, then giving it makes a lot more sense.

 

[deleted682700]

Yes and if you don't have tee, right heart strain pattern in EKG, and clinical suspicion.
Yes first rule out hypovolemia, bleeding both overt and into any of the cavities,
Do they give 100 units to start with?

 

[Planktonmd]

If an otherwise healthy patient "codes and dies" on your OR table then the last thing you or the surgeon have done is what you need to undo!

 

[urge]

In a otherwise healthy patients that code and die on the operating table after all the usual suspects such as ett in the wrong place, bleeding, tension pneumo, cardiac tamponade? mi have been ruled out and treated for. Will it be appropriate to consider streptokinase to Lyse a suspected pulmonary embolism?
Will anybody here give it as a last ditch effort?

I would not do that. It takes a long time to break a clot. You don't have not than 5 min to have a good outcome. All it will do is cause more bleeding which might make things worse.

Everyone always thinks about PE when their pts code intraop but I have yet to see one.

 

[amyl]

I was just called to a code in the cath lab.... 87 year old pod 1 from gamma nailing hip. She coded on the floor that morning.... EKG changes in inferior leads, bradycardia, altered mental status rushed to cath lab for rca stent or Angio. She also there up at some point so they are trying to put an ng as well. They try without anesthesia. Doesn't go well so I'm emergency called to cath lab. She's sat-ing mid 80s but they are doing a ****ty job w Bmv. So sedate incubate ng. Something's not right. She's tight on the bag.... No lung history. Get the anes machine brought in.... Airway pressures high, no tv for a decent pressure, desating a little. I say I think she has a PE. Cards says no her inr is 2.4 (I say sure now... What was it last night) he argues trops positive but in acute renal failure (I ask the cards guy the ckmb percent and he doesn't know.... Blank looks why I'm talking). I say ok fine, fat embolism, PE whatever she's not right on the ventilator. I mess with the ventilator and get her Sats up as he's determined to cath and stent her. of course she had a PE - didn't need cath or stent.... It was all right heart demand ischemia d/t PE. Cards guy is an idiot.... And that's why I'm outta here

 

[urge]

Fibrinolysis is not recommended for undifferentiated cardiac arrest (III/B)

Circulation 2011;123:1788


/thread

 

[deleted171991]

I was just called to a code in the cath lab.... 87 year old pod 1 from gamma nailing hip. She coded on the floor that morning.... EKG changes in inferior leads, bradycardia, altered mental status rushed to cath lab for rca stent or Angio. She also there up at some point so they are trying to put an ng as well. They try without anesthesia. Doesn't go well so I'm emergency called to cath lab. She's sat-ing mid 80s but they are doing a ****ty job w Bmv. So sedate incubate ng. Something's not right. She's tight on the bag.... No lung history. Get the anes machine brought in.... Airway pressures high, no tv for a decent pressure, desating a little. I say I think she has a PE. Cards says no her inr is 2.4 (I say sure now... What was it last night) he argues trops positive but in acute renal failure (I ask the cards guy the ckmb percent and he doesn't know.... Blank looks why I'm talking). I say ok fine, fat embolism, PE whatever she's not right on the ventilator. I mess with the ventilator and get her Sats up as he's determined to cath and stent her. of course she had a PE - didn't need cath or stent.... It was all right heart demand ischemia d/t PE. Cards guy is an idiot.... And that's why I'm outta here

And these are the guys whose preop clearance we are supposed to follow religiously (according to some), even when contradicting their own guidelines.

 

[Urzuz]

Circulation 2011;123:1788


/thread

"Undifferentiated" is the key word. If you drop a TEE and it showed R heart failure in an otherwise healthy person, PE shoots up on the differential.

Plus the level of evidence of that recommendation goes to show no one truly knows what to do.

 

[deleted547339]

I was just called to a code in the cath lab.... 87 year old pod 1 from gamma nailing hip. She coded on the floor that morning.... EKG changes in inferior leads, bradycardia, altered mental status rushed to cath lab for rca stent or Angio. She also there up at some point so they are trying to put an ng as well. They try without anesthesia. Doesn't go well so I'm emergency called to cath lab. She's sat-ing mid 80s but they are doing a ****ty job w Bmv. So sedate incubate ng. Something's not right. She's tight on the bag.... No lung history. Get the anes machine brought in.... Airway pressures high, no tv for a decent pressure, desating a little. I say I think she has a PE. Cards says no her inr is 2.4 (I say sure now... What was it last night) he argues trops positive but in acute renal failure (I ask the cards guy the ckmb percent and he doesn't know.... Blank looks why I'm talking). I say ok fine, fat embolism, PE whatever she's not right on the ventilator. I mess with the ventilator and get her Sats up as he's determined to cath and stent her. of course she had a PE - didn't need cath or stent.... It was all right heart demand ischemia d/t PE. Cards guy is an idiot.... And that's why I'm outta here

To be fair, a lot of EM and cards are moving away from routine use of CK-MB and PTE is a tough diagnosis to make.

We're there precordial EKG changes as well?

 

[amyl]

After a semi-code and a "rush" to the Cath lab for a stent and Cath she didn't need I think a ckmb is justified- exactly making my point... I don't listen to em or cards

 

[pgg]

Yes and if you don't have tee, right heart strain pattern in EKG, and clinical suspicion.

This patient was pulseless? (Sounds like it, if you were coding him and he died.) Right heart strain shows up as ischemia in V1-4/inferior leads and you've got to figure a guy getting compressions is going to be ischemic everywhere ... "get a 12 lead ECG" isn't part of the ACLS pulseless algorithms. I'm not sure I'd expect a a 12-lead in a pulseless patient to tell me anything that the strip on the defibrillator isn't already, and I don't think I'd halt CPR to get one.

 

[deleted547339]

After a semi-code and a "rush" to the Cath lab for a stent and Cath she didn't need I think a ckmb is justified- exactly making my point... I don't listen to em or cards

Not saying it isn't helpful in this situation. Just said it's becoming less common.

The "I don't listen to EM or cards" attitude is exactly what's wrong with medicine. That sort of thinking that "I'm the smartest doctor" is bad for patients.

 

[fakin' the funk]

The "I don't listen to EM or cards" attitude is exactly what's wrong with medicine. That sort of thinking that "I'm the smartest doctor" is bad for patients.

The attitude that a given physician is an expert on a given clinical question or topic based purely on their specialty is also incorrect. Like all opinions and "expertise," first consider the person giving it.

I.e., sometimes the cards consult is wrong. Just like sometimes we are wrong. The scenario that Amyl posted was a premature narrowing of the differential diagnosis. You know, that thing everyone in your training warned you not to do.

 

[urge]

I was just called to a code in the cath lab.... 87 year old pod 1 from gamma nailing hip. She coded on the floor that morning.... EKG changes in inferior leads, bradycardia, altered mental status rushed to cath lab for rca stent or Angio. She also there up at some point so they are trying to put an ng as well. They try without anesthesia. Doesn't go well so I'm emergency called to cath lab. She's sat-ing mid 80s but they are doing a ****ty job w Bmv. So sedate incubate ng. Something's not right. She's tight on the bag.... No lung history. Get the anes machine brought in.... Airway pressures high, no tv for a decent pressure, desating a little. I say I think she has a PE. Cards says no her inr is 2.4 (I say sure now... What was it last night) he argues trops positive but in acute renal failure (I ask the cards guy the ckmb percent and he doesn't know.... Blank looks why I'm talking). I say ok fine, fat embolism, PE whatever she's not right on the ventilator. I mess with the ventilator and get her Sats up as he's determined to cath and stent her. of course she had a PE - didn't need cath or stent.... It was all right heart demand ischemia d/t PE. Cards guy is an idiot.... And that's why I'm outta here

That's a good pick up. Aren't 80% of diagnosis based on history alone? There you go. Immobilized pt for a few days.

Doesn't mean that everyone who codes in the OR out of the blue has a PE. I have yet to see one.

 

[urge]

"Undifferentiated" is the key word.

Plus the level of evidence of that recommendation goes to show no one truly knows what to do.

I think "undifferentiated" is exactly what the OP was talking about.

True, the level of evidence is opinion.

I agree with them though.

 

[deleted547339]

The attitude that a given physician is an expert on a given clinical question or topic based purely on their specialty is also incorrect. Like all opinions and "expertise," first consider the person giving it.

I.e., sometimes the cards consult is wrong. Just like sometimes we are wrong. The scenario that Amyl posted was a premature narrowing of the differential diagnosis. You know, that thing everyone in your training warned you not to do.

Agreed. It's also a phenomenal demonstration of anchoring bias.

That being said, saying "I don't listen to EM or cards" is a phenomenal demonstration of arrogance that can hurt patients.

 

[amyl]

Oh please. I mean I don't listen to them when my clinical judgement says completely otherwise. I listened at my last hospital bc they weren't idiots and knew what they were taking about - Here they stink, Sorry. Lots aren't BC -- One clears them for surgery and the other orders a Cath and an aicd -- experience here has taught me not to trust them. I listened and learned at Ccf bc there were good people there... Here not so much. Until you have seen what I've seen here you shouldn't be so quick to judge....

 

[deleted682700]

I was just called to a code in the cath lab.... 87 year old pod 1 from gamma nailing hip. She coded on the floor that morning.... EKG changes in inferior leads, bradycardia, altered mental status rushed to cath lab for rca stent or Angio. She also there up at some point so they are trying to put an ng as well. They try without anesthesia. Doesn't go well so I'm emergency called to cath lab. She's sat-ing mid 80s but they are doing a ****ty job w Bmv. So sedate incubate ng. Something's not right. She's tight on the bag.... No lung history. Get the anes machine brought in.... Airway pressures high, no tv for a decent pressure, desating a little. I say I think she has a PE. Cards says no her inr is 2.4 (I say sure now... What was it last night) he argues trops positive but in acute renal failure (I ask the cards guy the ckmb percent and he doesn't know.... Blank looks why I'm talking). I say ok fine, fat embolism, PE whatever she's not right on the ventilator. I mess with the ventilator and get her Sats up as he's determined to cath and stent her. of course she had a PE - didn't need cath or stent.... It was all right heart demand ischemia d/t PE. Cards guy is an idiot.... And that's why I'm outta here

Things happen don't take it personally, you tried. Every hospital has problems. Have not seen fat embolism yet. But did see air embolism with mill wheel murmur as soon as the 10 port of the laparoscope was going in. Immediately told the surgeon to get the scope out and deflate the peritoneum, turned off anesthesia, gave ephedrine. Put the head down. I will never forget that scenario. Patient turned around. No problems. I measure blood pressure every min when laparoscope is going in and will be watching the surgeon like a angry owl . But actually the surgeon thanked me for that and from that time does not inflate till after the scope is completely in. What he did was inflating as he was putting the visciport in and got into a blood vessel without realizing it

 

[deleted682700]

Anesthesiologists have to be assertive and sternly tell what to do in crisis. It doesn't mean I will not listen it the cardiologist, but I reserve my judgement and may not agree with the cardiologist, when all they say is cleared for surgery. I want to know how they came to the conclusion. Have seen cardiologists clear patients with positive stress test. Grey areas like this I will not touch in small hospitals with no cath lab facility.
In fact one time the cardiologist cleared a patient wit he ebsteins Anamoly for a planned csection. The cardiologist was clearly not aware, I am the only anesthesiologist/cardiologist/intensivist in town. He had cleared thinking that my hospital was like Stanford! I tell the patient very clearly, that I have no experience with such complexity and will let them know that the hospital is probably incapable of taking care go her if complications happen.
May be amyl can chime in

 

[SouthSideSteve]

That sort of thinking that "I'm the smartest doctor" is bad for patients.

Except when you are the smartest doctor on the case/in the room.

 

[Mman]

Something's not right. She's tight on the bag.... No lung history. Get the anes machine brought in.... Airway pressures high, no tv for a decent pressure, desating a little. I say I think she has a PE.

What about poor compliance in the lungs makes you think PE? It's a vascular phenomenon. All the patients with PEs I've taken care of in the OR had unremarkable compliance in their lungs. They can't oxygenate, but the gas moves in and out of their alveoli just fine.

 

[Planktonmd]

After a semi-code and a "rush" to the Cath lab for a stent and Cath she didn't need I think a ckmb is justified- exactly making my point... I don't listen to em or cards

You know what was the problem here? "Rushing the patient to the cath lab" people have become so focused on "rushing" that they frequently forget their common sense and the basics of medicine.
As soon as someone suspects coronary symptoms a bunch of people suddenly appear and start "rushing" like idiots without any rational thinking and without even considering the basic ABCs.
That's why your patient was not breathing well and why she was vomiting and about to die while all the *****s in the cath lab were "rushing".

 

[pgg]

What about poor compliance in the lungs makes you think PE? It's a vascular phenomenon. All the patients with PEs I've taken care of in the OR had unremarkable compliance in their lungs. They can't oxygenate, but the gas moves in and out of their alveoli just fine.

The theory goes that severe PEs can cause bad pulmonary congestion/edema which could affect compliance.

Though I can't say I've ever really observed this firsthand, and I wouldn't use my subjective evaluation of compliance as a point either for or against PE on my differential.

 

[deleted171991]

You know what was the problem here? "Rushing the patient to the cath lab" people have become so focused on "rushing" that they frequently forget their common sense and the basics of medicine.
As soon as someone suspects coronary symptoms a bunch of people suddenly appear and start "rushing" like idiots without any rational thinking and without even considering the basic ABCs.
That's why your patient was not breathing well and why she was vomiting and about to die while all the *****s in the cath lab were "rushing".

Exactly. In an emergency situation, the most important thing is proper diagnosis. If the diagnosis is not correct, the patient can die. One must see the forest, not just the trees, even in that split second.

If the patient is difficult to ventilate, the patient might have pulmonary edema. Instead of scrambling for cath, somebody get a TTE and look at that heart. It takes 5 minutes, and it doesn't require a genius.

 

[Planktonmd]

The theory goes that severe PEs can cause bad pulmonary congestion/edema which could affect compliance.

Though I can't say I've ever really observed this firsthand, and I wouldn't use my subjective evaluation of compliance as a point either for or against PE on my differential.

It's BS, I have never seen a PE that presented as decreased compliance!

 

[fakin' the funk]

The theory goes that severe PEs can cause bad pulmonary congestion/edema which could affect compliance.

And in fat embolism or amniotic fluid "embolism" there is an intense inflammatory/ALI/ARDS-type deal going on causing capillary leak, alveolar collapse, etc. Kind of like you just said

 

[Mman]

And in fat embolism or amniotic fluid "embolism" there is an intense inflammatory/ALI/ARDS-type deal going on causing capillary leak, alveolar collapse, etc. Kind of like you just said

I think that is a distinctly different physiology than a classic PE where a thrombus dislodges from a vein and travels through the right heart and occludes a pulmonary artery. In a PE, there is less blood flowing to the lung so I can't really see a mechanism for edema to form within the alveoli, at least acutely.

 

[Arch Guillotti]

What about poor compliance in the lungs makes you think PE? It's a vascular phenomenon. All the patients with PEs I've taken care of in the OR had unremarkable compliance in their lungs. They can't oxygenate, but the gas moves in and out of their alveoli just fine.

I don't get it either.

 

[urge]

I think that is a distinctly different physiology than a classic PE where a thrombus dislodges from a vein and travels through the right heart and occludes a pulmonary artery. In a PE, there is less blood flowing to the lung so I can't really see a mechanism for edema to form within the alveoli, at least acutely.

If we call a PE on every arrest/pseudo arrest in which we are involved, eventually we will be right, I guess.

You know what they say about broken clocks.

 

[pgg]

It's BS, I have never seen a PE that presented as decreased compliance!

Well yeah, a PE that big is going to present with ... a code.

And like I said, I've never seen/experienced it either, but I'm not going to write it off as impossible.

 

[RxBoy]

http://www.ncbi.nlm.nih.gov/pubmed/16717302

http://www.ncbi.nlm.nih.gov/pubmed/24426880

 

[deleted171991]

And in fat embolism or amniotic fluid "embolism" there is an intense inflammatory/ALI/ARDS-type deal going on causing capillary leak, alveolar collapse, etc. Kind of like you just said

It doesn't even need to cause capillary leak. It can cause bronchospasm. That's where the increase in airway resistance comes from.

 

[DrDrummer]

Not in anesthesia but once when looking into this I found a couple abstracts from conferences and papers (from anesthesia lit.) describing intra-operative or perioperative dx of PE from calculation of dead space using the mixed expiratory PCO2 or end tidal. I would be interested in your thoughts on why this would or wouldn't work in an environment as described here.

 

[deleted171991]

Not in anesthesia but once when looking into this I found a couple abstracts from conferences and papers (from anesthesia lit.) describing intra-operative or perioperative dx of PE from calculation of dead space using the mixed expiratory PCO2 or end tidal. I would be interested in your thoughts on why this would or wouldn't work in an environment as described here.

The Bohr formula for dead space is calculated with mixed expiratory pCO2. End-tidal does not work for this purpose, AFAIK.

 

[DrDrummer]

The Bohr formula for dead space is calculated with mixed expiratory pCO2. End-tidal does not work for this purpose, AFAIK.

Yeah, the Bohr equation is calculated as such and requires some special equipment or modifications to a standard anesthesia rig as I understand it. These authors used EtCO2 and ABGs: http://journal.publications.chestnet.org/article.aspx?articleID=1215585 & http://www.amc.edu/academic/gme/pro...gnosis_intraoperative_pulm_embolism_-_neu.pdf -- definitely less definitive, but still interesting.

 

[deleted171991]

It's probably neither sensitive nor specific enough, but it can be used as another piece in the diagnostic puzzle.

If there is high suspicion for embolism for other reasons, one doesn't even need that difference. If one sees unexplainable suddenly dropping EtCO2, one will suspect some kind of pulmonary embolus (and other causes of dead space ventilation and decreased cardiac output).

 

[Planktonmd]

Not in anesthesia but once when looking into this I found a couple abstracts from conferences and papers (from anesthesia lit.) describing intra-operative or perioperative dx of PE from calculation of dead space using the mixed expiratory PCO2 or end tidal. I would be interested in your thoughts on why this would or wouldn't work in an environment as described here.

the anesthesia literature is unfortunately full of similar crap!

 

[Urzuz]

Yeah, the Bohr equation is calculated as such and requires some special equipment or modifications to a standard anesthesia rig as I understand it. These authors used EtCO2 and ABGs: http://journal.publications.chestnet.org/article.aspx?articleID=1215585 & http://www.amc.edu/academic/gme/pro...gnosis_intraoperative_pulm_embolism_-_neu.pdf -- definitely less definitive, but still interesting.

It's probably neither sensitive nor specific enough, but it can be used as another piece in the diagnostic puzzle.

If there is high suspicion for embolism for other reasons, one doesn't even need that difference. If one sees unexplainable suddenly dropping EtCO2, one will suspect some kind of pulmonary embolus (and other causes of dead space ventilation and decreased cardiac output).

But of course, if we are going off of the OP's original question, the ETCO2 isn't exactly going to be accurate (or present!) if the patient is coding

 

[deleted682700]

Anesthesia has improved leaps and bounds in improving patient safety particularly with the mandatory use of pulse-ox and ETCO2. Most of us agree that unexplained deaths are particularly rare in otherwise healthy individuals. What is the risk vs benefit of giving streptokinase in an unexplainable code early on once bleeding has been ruled out? The clot may be Lysed and you can potentially have micro emboli to the heart and brain. With the micro emboli in the heart can have arrhythmia that u can now shock vs pea before?
With the emboli in the brain, well the patient survived , but was not the same as before surgery?
This is all conjecture. But I do believe that PE is probably the culprit in unexplained codes under anesthesia after having ruled out all the common causes.

 

[pgg]

How are emboli from a lysed PE going to reach the brain?

 

[Noyac]

How are we gonna get streptokinase to any emboli when they are in PEA? Chest compressions? Good luck.

The streptokinase is a cleave thought, I just don't see how it's gonna change anything.

 

[deleted682700]

Yes pgg, you are correct. And noyac, you too may be. But I want to go down trying?

 

[Noyac]

How are emboli from a lysed PE going to reach the brain?

Actually, I think he may be thinking of lysed DVT (not PE). This can make its way to the brain since a large portion of the population has a PFO.