Thoughts on case tomorrow

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sigrhoillusion

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Just wanted to get some people's opinions for a case I have later tomorrow afternoon. RElatively new attending at academic hospital.

Brief history...

26 yo M hx IVDA had some sort of trauma back in August with multiple facial and extremity fractures. Had hardware placed and eventually went to rehab.

He then came back to hospital about a week ago in septic shock and was in the ICU on pressors. AKI, Leukocytosis, thrombocytopenia, anemia and tranaminitis all linked to sepsis. So pretty much was seen by cards and ID initially and sepsis improved and was weaned off pressors and out of ICU.

However, they did a bedside ECHO which showed RV severly enlarged and hypokinetic. PFO via agitated saline, but no VSD. LVEF 45%. CXR back on the 4th showed increased bibasilar effusions and atelectasis, but no imaging since then. Cards recommended TEE, but because of his jaw fracutre and repair they were unable to do TEE so recommended cardiac MRI, however several notes say unable to perform due to "technical issues".

So tomorrow he's going for mandibular hardware removbal as a source of infection, but several notes also state possible RLE hardware and endocarditis as sources. His Hgb from the 5th was 7.6 and plt 87, none since then, but looks like they have CBC ordered. LFTs also elevated but imrpoving (they think from shock, but also Hep C Ab+ with no mention of chronic infection in chart). AKI improved Cr 3.1 --> 0.7

I figure I'm gonna talk to this kid and see what if any symptoms he's having. One cardiac note mentioned getting cardiac MRI as outpatient, so they don't seem overly concerned about his right heart fx despite elevated LFTS and effusions on CXR which were worsening but then not followed for a week...

Not sure what other workup I would do, besides check his morning labs to ensure his Hgb and Plts aren't completely in the toilet. Check for symptoms and if I'm really concerned have my goal to reduce PVR. Anything I'm missing? Outside of being a complete mess, the guy appeared to be otherwise healthy prior to his initial surgeries...

P.S. I'm very tired and going to bed soon, so preferably opinions with some constructive criticism. :rolleyes:

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If you can, do a bedside TTE tomorrow before you take him back and look at this RV for s/ of failure and his valves for endo (might as well put some color on them).
Is there flattening of the IVS? How dilated is the IVC? Whats the LV look like (underfilled)? Look for bidirectional or R>L flow across his pfo (unlikely). Pretty fast information to gather if you have the time and equipment. The important part of the exam is to look at biventricular function and lack of any major sources of endo. Good squeeze is good. No squeeze, not so much.


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If you don't have time then:

Check for signs of RHF when you see him and choose a balanced anesthetic based on the findings. Epi, Milrinone, sildenafil, etc.... if you get into trouble.

Honestly though... removal of mandibular hardware is a low risk procedure, so should be quick in and out. He's young, so he should make it through w/o major drama.
 
This can be endocarditis with a big time TR/PI plus/minus PE, this can be s/p inferior MI, this can be residual septic cardiomyopathy. Plus/minus fluid overload. What bothers me is that this guy has a shot RV without a clear diagnosis, and the hardware removal is not essential (except for maybe doing a TEE). You know the story: avoid hypoxia, hypercarbia, pain, sympathetic stimulation (including epi and catecholamines), avoid nitrous, use vasopressin/dobutamine/milrinone.

I think this could become both airway and cardiac fun. It's almost worth dropping in a Swan, or doing an intraop TEE once the hardware is out.
 
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Was the echo done when he was floridly septic? The RV could be enlarged depending on the size of the PFO and some degree of myocardial dysfunction isn't abnormal when someone is in septic shock. If the TTE didn't reveal any other structural heart disease, I wouldn't necessarily be overly concerned considering his other signs of multisystem organ dysfunction (lfts and cr) are improving. Likely his heart function is as well. That being said, floating a swan (if he doesn't have wide open TR) might be appropriate since you can't drop a probe.
 
I'm with Sevo in that I don't think this is gonna be a big deal. Prop sux tube. Keep his VS where they were before you put him to sleep. ETCO2 lowish. Next.
 
Intraop TEE
This. Either by a qualified anesthesiologist, or coordinate with the cards guys to come do it otherwise.

Can't have source control without knowing source.

Agree with the other management points already stated.
 
Epi, Milrinone, sildenafil, etc.... if you get into trouble.

Honestly though... removal of mandibular hardware is a low risk procedure, so should be quick in and out. He's young, so he should make it through w/o major drama.


Yep, load this young man up with sildenafil and see what happens...haha
 
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I would start a low dose epi infusion and proceed as usual, but I might be late to the party already.
 
Sooo...what happened ?

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So they ended up switching me into a pediatric room and I did a relatively healthy CDH repair. Co-worker took the dental room. From my knowledge he put a breathing tube into his trachea via his nose, turned on some gas, and then turned it off. Patient supposedly is still alive.

I think we all just assumed that he was a helathy patient, and although the floor interns stopped really trending anything besides his LFTs, his other labs were assumed to be improving/normalizing over the following 5-6 days. Mental masturbation at its finest.
 
So they ended up switching me into a pediatric room and I did a relatively healthy CDH repair. Co-worker took the dental room. From my knowledge he put a breathing tube into his trachea via his nose, turned on some gas, and then turned it off. Patient supposedly is still alive.

I think we all just assumed that he was a helathy patient, and although the floor interns stopped really trending anything besides his LFTs, his other labs were assumed to be improving/normalizing over the following 5-6 days. Mental masturbation at its finest.
That's a tough part, as an attending, to have the discipline and keep doing the mental masturbation. In the rare situation when it hits the fan, you will be sooooo happy that you have already considered all the scenarios, that you have a backup plan to the backup plan. Even if experienced, you should never rely on wishful thinking. Failing to prepare is preparing to fail. In time, this mental masturbation will take 2 minutes, not 20; the more you do it, the easier it becomes.

You already know all of this, I am just arguing that this time was definitely not wasted.
 
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So they ended up switching me into a pediatric room and I did a relatively healthy CDH repair. Co-worker took the dental room. From my knowledge he put a breathing tube into his trachea via his nose, turned on some gas, and then turned it off. Patient supposedly is still alive.

I think we all just assumed that he was a helathy patient, and although the floor interns stopped really trending anything besides his LFTs, his other labs were assumed to be improving/normalizing over the following 5-6 days. Mental masturbation at its finest.
I think your colleague's plan (prop,sux, tube) was the best plan for this patient and it's probably why he had a good outcome!
There is a reason why It's dangerous to have surgery at university hospitals!
 
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That's a tough part, as an attending, to have the discipline and keep doing the mental masturbation. In the rare situation when it hits the fan, you will be sooooo happy that you have already considered all the scenarios, that you have a backup plan to the backup plan. Even if experienced, you should never rely on wishful thinking. Failing to prepare is preparing to fail. In time, this mental masturbation will take 2 minutes, not 20; the more you do it, the easier it becomes.

You already know all of this, I am just arguing that this time was definitely not wasted.
That's true when the "mental masturbation" is done for the purpose of actually getting the case done with the least amount of problems and the simplest approach.
Unfortunately as you know in academia the mental masturbation is taken to a different level, and there are people who master the art of :"let's create some drama so we look smart"!
I think the more experienced you are the more likely that you will pick the simplest approach and avoid drama.
This is intended to be a general observation and not intended to criticize anyone's thought process, so no need for anyone to get their panties in a wad!
 
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