How would you do this induction?

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  1. Attending Physician
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Here's the (actual) case:

93 year-old lady comes in with a broken hip and is booked for a TFN. She has an ICM, echo last month showed an EF of 15-20% (yes, really) with PASP estimated at 90 mmHg. Large RV, 2-3+ MR and wide open TR. Labs show an INR of 1.5, Cr of 1.9, normal platelets and moderate anemia (9 / 28). PSH includes a lumber fusion 20 years ago. Hospice was discussed with patient and family and refused. They desire to proceed...

Your move, doctor!
 
Given her INR and lumbar fusion, neuraxial is out. What's her airway like? Assuming non scary airway, preop A-line and CVC b/c I'm expecting to need to run some kind of drip during the case and it's always nice to have good IV access. +/- on a PAC to titrate your drip of choice (dobutamine, dopa, milranone, epi) and follow the cardiac parameters. The numbers are certainly nice to have but I don't think the evidence shows much differences in outcome so it's really your call. I would place one if doing the case but I'm sure others will disagree and I don't think its wrong to skip it.

Fent/Etomidate/Roc induction and a touch of sevo. This is the type of case I really like to have a BIS for because I plan on going as low as possible with sevo to maintain a decent pressure. Avoid the usual stuff like hypoxia/hypercarbia/acidosis as well as nitrous and ketamine b/c of her PA pressures. Limit the fluids you give if you can but she's gonna drop like a stone once the gas hits. Make sure to have syringes of your favorite pressor drawn up.
 
first i would have a discussion with the family re: wtf are you thinking, hospice time

if forced into general:
preop aline, gentle inhalation induction, 2 18g or larger pivs otherwise cvc (mac) - asleep, atracurium when >1.0 mac, phenyleph gtt in line, intubate smoothly, transduce cvp, have access to nitoglyc, levophed, milrinone on pumps

i also wouldnt rule out giving 2u FFP and rechecking INR, placing a lumbar epidural at a level unaffected by the prior sx (if poss), and an aline and gently bring up the epidural level while closely watching abp with a neo and levo gtt in line
 

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Pent/sux/tube?

OK, maybe not quite that simple. But really - 93 y/o hips are bread and butter cases in a lot of private practice places. We do them almost every day, and regardless of medical condition, I couldn't tell you the last one we would have even thought about an a-line or CVP or god-forbid a PAC. They get tuned up by IMS (correct coags, "optimized", etc) prior to coming to surgery (no such thing as an emergency hip despite what the orthopod wants) or we don't do them. However, tuned up admittedly means they probably still look like crap, but you do what you can and then move on. You pretty much have to do these cases - it's a palliative pain-control kinda thing. O/W grandma lies around in the bed hurting and dies from her PE in a few weeks. (granted, that's an option as well, but not always a good choice - my 92yr old mother still drives 😉 )

Good IV access, which probably means an 18ga. If you want to have your drips in the room, fine, just don't mix anything that you'll end up wasting. Judicious induction with a little fentanyl and etomidate or maybe just a wee bit of propofol if you don't like etomidate any more. LMA, position on fx table, breathe spontaneously with pressure assist if ya got it, BIS-guided sevo, fent as needed. Once positioned, prepped, and draped, these are 15-20 minute procedures for our surgeons. KISS in action. Obviously this isn't the academic way of doing them, but I think it's pretty common in the real world.
 
50mg of propofol + a little sevo, lma, titrate 25-50mcgs of fent, fascia iliaca with USD, hang some blood (don't slam it in). Avoid pain, hypoxia, hypercarbia, or anything else that would increae PA pressures.
 
sevoflurane said:
50mg of propofol + a little sevo, lma, titrate 25-50mcgs of fent, fascia iliaca with USD, hang some blood (don't slam it in). Avoid pain, hypoxia, hypercarbia, or anything else that would increae PA pressures.
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I'd do exactly that, though maybe 20 of propofol to start, 0.5-1mg of Versed, plus a phenylephrine gtt in line. I learned to do fascia iliacas by the pop-pop technique, guess I ought to get with the times and start using u/s for them. I think they're fantastic for old hips and they're the one block I'll routinely do even if the INR is >1.4, despite ASRA.

No central line if she had decent PIV access. I would put in an a-line.


I've tried to be enthusiastic about neuraxial (coags permitting) for these cases, but honestly I find a gentle GA + FI block is easy, safe, and low pain with minimal narcotics.
 
sevoflurane said:
50mg of propofol + a little sevo, lma, titrate 25-50mcgs of fent, fascia iliaca with USD, hang some blood (don't slam it in). Avoid pain, hypoxia, hypercarbia, or anything else that would increae PA pressures.
Click to expand...

I would do the same thing, but I am plus/minus on fascia iliaca. The surgeons are fast and use a fairly small incision -- they don't seem to hurt too much in PACU. Is fascia iliaca block allowing you guys to use no opioid whatsoever or are you just cutting it from fentanyl 200 to fentanyl 100 mcg?

Also, I've read about ultrasound-guided fascia iliaca on neuraxiom and usra.ca. Looks too hard for me. Any tips? Why can't I just do a USG femoral and use a really high volume of bupiv 0.25%? At least there I have a vascular landmark to find on ultrasound.

Because of the elevated PA pressures I probably wouldn't titrate in opioid during the case, probably just at end or when pt is awake. But LMA is definitely the way to go here. And I'd have ephedrine and epinephrine on hand, NOT phenylephrine. Pre-induction a-line is probably the biggest difference between this case and every other hip fracture.
 
jwk said:
Pent/sux/tube?

OK, maybe not quite that simple. But really - 93 y/o hips are bread and butter cases in a lot of private practice places. We do them almost every day, and regardless of medical condition, I couldn't tell you the last one we would have even thought about an a-line or CVP or god-forbid a PAC. They get tuned up by IMS (correct coags, "optimized", etc) prior to coming to surgery (no such thing as an emergency hip despite what the orthopod wants) or we don't do them. However, tuned up admittedly means they probably still look like crap, but you do what you can and then move on. You pretty much have to do these cases - it's a palliative pain-control kinda thing. O/W grandma lies around in the bed hurting and dies from her PE in a few weeks. (granted, that's an option as well, but not always a good choice - my 92yr old mother still drives 😉 )

Good IV access, which probably means an 18ga. If you want to have your drips in the room, fine, just don't mix anything that you'll end up wasting. Judicious induction with a little fentanyl and etomidate or maybe just a wee bit of propofol if you don't like etomidate any more. LMA, position on fx table, breathe spontaneously with pressure assist if ya got it, BIS-guided sevo, fent as needed. Once positioned, prepped, and draped, these are 15-20 minute procedures for our surgeons. KISS in action. Obviously this isn't the academic way of doing them, but I think it's pretty common in the real world.
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+1. Except that I would use an ETT and an Aline.
 
bullard said:
I would do the same thing, but I am plus/minus on fascia iliaca. The surgeons are fast and use a fairly small incision -- they don't seem to hurt too much in PACU. Is fascia iliaca block allowing you guys to use no opioid whatsoever or are you just cutting it from fentanyl 200 to fentanyl 100 mcg?

Also, I've read about ultrasound-guided fascia iliaca on neuraxiom and usra.ca. Looks too hard for me. Any tips? Why can't I just do a USG femoral and use a really high volume of bupiv 0.25%? At least there I have a vascular landmark to find on ultrasound.

Because of the elevated PA pressures I probably wouldn't titrate in opioid during the case, probably just at end or when pt is awake. But LMA is definitely the way to go here. And I'd have ephedrine and epinephrine on hand, NOT phenylephrine. Pre-induction a-line is probably the biggest difference between this case and every other hip fracture.
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Hello Bullard.

I like Fascia Iliacas for these patients. Especially when the INR is a little highish as pgg mentioned. You are far away from the artery although USD really helps. You can easily cover the lateral femoral cutaneous for the incision... as well as the osteotomal innervation of the femur. It is possible to do these cases w/o narcotics. However, a little background opiod may help keep her pain under control as the block sets up. My primary post op concern is that she is comfortable in PACU. These are easy blocks and if you can keep her pulm. htn. down by avoiding pain while at the same time avoiding acidosis/hypercarbia via limited to no post-op narcs 2/2 to the block, then it's a win-win situation, IMHO.

My pressor of choice would be small doses of norepinephrine to avoid tachy or brady and exacerbations of pulmonary hypertension while providing some good contractility in a low EF state. Small doses of Epi would be good as well but i wouldn't like the tachy that comes along with it = Increasing O2 demand in a patient with an EF of 15-20% and ischemic cardiomyopathy. As you mentioned a pure alpha (phenylephrine) could increase your afterload and regurgitant fraction thorough the MV making pulm. pressures worse (+ it's direct effects on the pulmonary vasculature) = not a great choice IMO, but I'm sure it's been done many times this way.
 
The effect of phenylephrine and norepinephrine in patients with chronic pulmonary hypertension*.

Abstract
In this study the effect of phenylephrine and norepinephrine for the treatment of systemic hypotension were evaluated in patients with chronic pulmonary hypertension. When systemic hypotension (systolic arterial pressure < 100 mmHg) occurred following induction of anaesthesia, either phenylephrine or norepinephrine were infused in a random manner to raise the systolic blood pressure by 30% and 50% above baseline values. Norepinephrine decreased the ratio of pulmonary arterial pressure to systemic blood pressure without a change in cardiac index. However, phenylephrine did not increase arterial blood pressure by more than 30% from baseline in one-third of patients and decreased cardiac index without a significant decrease in ratio of pulmonary arterial pressure to systemic blood pressure. These vasoconstrictors showed different systemic and pulmonary haemodynamic effects in patients with chronic pulmonary hypertension as compared to acute pulmonary hypertension. Norepinephrine was considered to be preferable to phenylephrine for the treatment of hypotension in patients with chronic pulmonary hypertension.

http://www.ncbi.nlm.nih.gov/pubmed/11843735
 
[YOUTUBE]http://www.youtube.com/watch?v=C08whkeYzPk[/YOUTUBE]

http://www.youtube.com/watch?v=C08whkeYzPk

What is nice about the USG FI block is that you do your traditional approach, see the fascial planes, FEEL THE TWO POPS, and then SEE THE HYDRODISSECTION, confirming correct placement of LA. I believe this improves the success rate significantly as you can FEEL and SEE what is going on. Try it out. I think you'll like it. 🙂
 
I see. So you decide where to place the needle by old-school landmark technique and just use the ultrasound to confirm that you are in the correct plane, yes? I'm gonna try it.
 
sevoflurane said:
The effect of phenylephrine and norepinephrine in patients with chronic pulmonary hypertension*.
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bullard said:
Because of the elevated PA pressures I probably wouldn't titrate in opioid during the case, probably just at end or when pt is awake. But LMA is definitely the way to go here. And I'd have ephedrine and epinephrine on hand, NOT phenylephrine. Pre-induction a-line is probably the biggest difference between this case and every other hip fracture.
Click to expand...

Above points are well taken on phenylephrine, but I think it's fine as a first drug, given a gentle slow induction and the fact that most of the hypotension is going to be from SVR dropping. This heart may need something else, though I don't think I'd go to epinephrine first, and ephedrine is slower and harder to titrate than I'd like.
 
Femtochemistry said:
Is ketamine an absolute no-no because of her PASP?
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I wouldn't say absolute. The reasons why I wouldn't use it on induction in this case: 1) renal failure and 2) she's 93 and I don't like giving old folks midazolam and I usually give midaz before ketamine. Maybe a touch of ketamine after induction to spare opioid would be OK.
 
pent sux tube...... m&m
 
Optimize the INR before surgery. This isn't an emergent procedure, so taking her back non-optimized is a disservice to both you and her. Epidural in place and bolused with 2% Lidocaine. Would run a low-dose remifentanil for sedation and tell her that postoperative hyperalgesia just comes along with the territory. If she needs a nasal trumpet, jaw thrust, or even bag-masking, who cares? Still better than dealing with inhalational agents and their myocardial depressant effects. Of course an arterial line. Would definitely have two large bore IVs and consider starting a central line. Once she inevitably heads up to the unit the intensivists would appreciate it.
 
Oh yeah, and go ahead and give her some PRBCs pre-operatively.
 
Ignatius J said:
Optimize the INR before surgery. This isn't an emergent procedure, so taking her back non-optimized is a disservice to both you and her. Epidural in place and bolused with 2% Lidocaine. Would run a low-dose remifentanil for sedation and tell her that postoperative hyperalgesia just comes along with the territory. If she needs a nasal trumpet, jaw thrust, or even bag-masking, who cares? Still better than dealing with inhalational agents and their myocardial depressant effects. Of course an arterial line. Would definitely have two large bore IVs and consider starting a central line. Once she inevitably heads up to the unit the intensivists would appreciate it.
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Good plan. But pumping this pt w/ FFP/PLT can not be a good idea...although I would do a regional approach if only her INR was less than 1.5
 
Ignatius J said:
Optimize the INR before surgery. This isn't an emergent procedure, so taking her back non-optimized is a disservice to both you and her. Epidural in place and bolused with 2% Lidocaine. Would run a low-dose remifentanil for sedation and tell her that postoperative hyperalgesia just comes along with the territory. If she needs a nasal trumpet, jaw thrust, or even bag-masking, who cares? Still better than dealing with inhalational agents and their myocardial depressant effects. Of course an arterial line. Would definitely have two large bore IVs and consider starting a central line. Once she inevitably heads up to the unit the intensivists would appreciate it.
Click to expand...


I think that hypoventilation/hypoxia (i.e. need for nasal trumpet/jaw thrust/etc, even LMA with spontaneous ventilation) could kill this pt with severe pulm htn and poor LV function. This chick sounds like she's right on the tipping point and any nudge up on her pulmonary pressures could cease all forward flow. If I couldn't do a regional technique, I'd go ETT/controlled ventilation/slow controlled wakeup in the OR vs ICU with little/no elevation of CO2. Pulmonary htn is one of the few disease processes that really tightens my sphincter, and if you don't respect it it will bite you in the ass someday.
 
Great discussion, and I appreciate the input very much. Here's how it went down...

I discussed in plain language the possibility of cardiac arrest / death during the operation and subsequently on the floor. They understood and realized this was a high-risk situation.

My first choice was a carefully titrated epidural, but for obvious reasons, this was not practical. I opted instead for a light GA with an LMA. I placed a pre-induction a-line (thank god) and induced using lidocaine, propofol and a smidge of fentanyl (12.5 mcg). I chose phenylephrine as my pressor because I reasoned it would adequately counteract the vasodilation of the propofol and with any luck, I'd keep her at baseline. I also use it a lot more on a daily basis. I did have epi (10 mcg/ml) immediately available. I gave the propofol in 10 mg boluses and waited knowing she had a slow circ time. At 40 mg of prop, she began to drop -- like a rock. I began pushing phenylephrine but with no effect. I emptied 1500 mcg and watched the pressure fall -- to ZERO. PEA arrest. As it became clear she was going to arrest I called for backup and when her a-line flattened out (no change in rhythm) we began compressions. By this time I had pushed a 50 mcg of epi and after about 30 seconds of vigorous compressions, we had a perfusing rhythm. We thought about it and decided to proceed with the case knowing her PA pressures and her heart were no going to improve, especially after her PEA arrest. We relaxed her, changed the LMA to an ETT, lined her up and did the case. As the case went on she developed significant ST depressions which we really couldn't do much about given she was now on a levophed gtt.

We took her upstairs to the unit and the family withdrew on her the next day!!! WTF??!!

I think what happened is this: unbeknownst to me, my CRNA had slipped her 1 mg of midazolam in the HOLDING area. Holy **** was I pissed when I found out that. But because I'm the MD, the responsibility lays with me, not her -- and I wouldn't have that any other way. It was my fault for not controlling her more effectively. She undoubtedly hypoventilated from the versed. She also likely hypoventilated during the induction: given we were pushing the prop slowly and she was spontaneously breathing the whole time, we never effectively ventilated her. This caused her PaCO2 to increase and her PVR to follow suit, effectively stopping forward flow. This exacerbated the hypotension from the propofol and mitigated the effect of the pressors -- and presto - PEA!!

What really ended up helping her to maintain a perfusing rhythm (in addition to the compressions) was effective ventilation.

Lessons learned (for the residents reading this):

1) Respect pulmonary HTN. Hypercarbia, acidosis, hypotension and hypoxia can kill patients with severe pulmonary HTN.

2) Midazolam is not a benign drug that EVERYONE gets prior to surgery. Evaluate on a case-by-case basis. See above.

3) Control your CRNAs. Be a jerk if necessary. This can be tough to do, but it can be a matter of life and death.

4) Rule #1: The patient is the one with the disease (Read "House of God" if you don't know what I'm talking about)

5) Special thanks to the guys for discussion FI blocks. I've never done one, but they don't sound too tough with a little reading and watching video.

Cheers!
 
B-Bone said:
I think that hypoventilation/hypoxia (i.e. need for nasal trumpet/jaw thrust/etc, even LMA with spontaneous ventilation) could kill this pt with severe pulm htn and poor LV function. This chick sounds like she's right on the tipping point and any nudge up on her pulmonary pressures could cease all forward flow. If I couldn't do a regional technique, I'd go ETT/controlled ventilation/slow controlled wakeup in the OR vs ICU with little/no elevation of CO2. Pulmonary htn is one of the few disease processes that really tightens my sphincter, and if you don't respect it it will bite you in the ass someday.
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Couldn't have said it better myself. Very nice post.
 
yeah versed seems to drop an ICU patient's BP more than the books will admit.
 
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One thing not discussed. How about having Zall pads on the patient on induction. With an EF of 15% she is at risk for a malignant arrhythmia Vtach Vfib. At my institution it would have been pre induction aline no versed or fentanyl while she is awake, etomidate on induction, muscle relaxant of choice, cvc epi and levo ready to go on pumps, also have some amiodarone around somewhere. If she gave me trouble I might place an intraop TEE. Help me understand why placing an LMA in someone with severe pulmonary hypertension would be superior to placing an ET tube? A peripheral nerve block is smart as it may limit her narcotic use postop(less prone to hypoventilation/hypoxia).
 
sevoflurane said:
50mg of propofol + a little sevo, lma, titrate 25-50mcgs of fent
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That's a lot for 92 yo granma imho i would say 15mg and she's out.
👍 for those who went with an inhalation induction.

gasguy i think you forgot one point which is propofol is a powerful drug, we tend to forget it because you can slam it in ASA1-2 patients but when it comes to frail elderly patients you have to be very careful.

I wonder if anybody has ever done a case like this with FI block + local by the surgeon? no reason it couldn't work...
 
gasguy06 said:
1) Respect pulmonary HTN. Hypercarbia, acidosis, hypotension and hypoxia can kill patients with severe pulmonary HTN.

2) Midazolam is not a benign drug that EVERYONE gets prior to surgery. Evaluate on a case-by-case basis. See above.

3) Control your CRNAs. Be a jerk if necessary. This can be tough to do, but it can be a matter of life and death.

4) Rule #1: The patient is the one with the disease (Read "House of God" if you don't know what I'm talking about)

5) Special thanks to the guys for discussion FI blocks. I've never done one, but they don't sound too tough with a little reading and watching video.

Cheers!
Click to expand...

wow. thanks for the great teaching points. amazing how just ONE of versed can cause these physiological changes that most like compounded w/ the other anesthetics! :scared:

What I would have done:
1. GA w/ ETT (I have to have a secure airway)
2. Pre-induction a-line AND central line and SWAN
3. 50mg lido + 10mg ketamine + 25mcg fent + 10mg etomidate + 10mg ephedrine (HR up and, hopefully, BP) + 50mg roc.....wait patiently, as soon as pt is a sleep or BP starts to drift, I will stick that cold, metal MAC 3 in her mouth!
4. Levo, Neo, Dopa, Milrinone on pump

As a CA-2, I am very conservative. I am learning on utilizing multi-modal anesthesia...still have a lot to learn! Keep in mind I've had hours to think about this case.

Go easy on my flight plan 😳
 
dhb said:
That's a lot for 92 yo granma imho i would say 15mg and she's out.
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1.5cc's of prop and then she's out. Hmmm... 🙄 :laugh::laugh:

Everything we do is titrated. When I say 50 mg of prop it doesn't mean "slam it in". That is just not the way we treat this type of patient. It means give a little see what happens, then wait... then give a little more, until you get what you want. I'm going to guess that amount is about 50mg. 15mg is a nice safe starting point... but certainly not a dose that will "knock her out" enough to lie still and accept an LMA.

How you use the drug makes a big difference.

Depending on TV, RR, and etCO2, I can easily titrate in some fent while the block sets up. I know that from in room time, to prep and drape to pacu... we are talking a little over 30-40 minutes... maybe longer depending on the surgeon. Her pulmonary pressures are going to get better initially as she goes unconscious and is no longer in pain.

To say that 15mg will "knock her out", although possible, is not likely IMO. If she weighs 60kg, 15mg = .25mg/kg.

A 60kg healthy individuall can get 2.5 mg/kg = 150mg.

Let's keep it real bruh! 🙂
 
One thing to mention is that as you assist/take over ventilation while the prop wears off, it's important to keep an eye on delivered tidal volumes as these patients are usually not well volume resussitated and big TV's can decrease venous return making things worse.

Thanks for sharing your story gasguy06. Despite the sneaky CRNA and hypoventilation, do you think that pushing 1500mcg of phenylephrine may have made things worse? Things got better once you switched to epi right?

I'm thinking increased afterload, increased MR, increased PAP, decreased CO and then arrest. Epi being the rescue drug.

Just a thought.
 
Better get used to these types of patients. In Florida the average age is around 80 at my practice and typical EF is less than 30 (for these types of procedures).

I'd consider a 10 mg Isobaric Bup spinal on this patient if INR was less than 1.5. Considering her advanced age I'd discuss with the family giving 2 units of FFP then doing the SAB ( I don't need repeat labs as the INR is only 1.5 now).

I'm not sold in the fact that this block is essential as 90% of our patients don't get them and do just fine. I do agree adding the U/S to see the fascia planes helps immensely. As for doing a Femoral block with 40 mls of local (if U/S is unavailable) this works just fine for getting good pain relief.

Most of my partners would LMA this patient. Induction agent would be 30-40 mg of Propofol with the addition of Ketamine (20 mg IV if needed). Spont. Ventilation with avoidance of hypercarbia (this means keep the CRNA from giving too many opiods). I'd start with Phenyephrine for hypotension (mild) and add Vasopressin if needed (severe) as my second line agent then Norepi.
 
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CONCLUSIONS:

After hip arthroplasty, a continuous femoral nerve block is an acceptable analgesic alternative to a continuous posterior lumbar plexus block when using a stimulating perineural catheter. However, early ambulatory ability suffers with a femoral infusion



http://www.ncbi.nlm.nih.gov/pubmed/21467563?dopt=Abstract
 
http://www.ncbi.nlm.nih.gov/pubmed/15282985

For those who can't or don't do U/S but want to provide some analgesia to your post op hip patients consider a Femoral Block with added volume. I use 0.25% Ropivacaine and inject 40 mls for good spread. This provides decent post op pain relief.

If you have U/S then get the needle in the correct Fascial plane; without U/S avail you will need to see some Quadriceps stimulation before injection of the local.
 
narcusprince said:
One thing not discussed. How about having Zall pads on the patient on induction. With an EF of 15% she is at risk for a malignant arrhythmia Vtach Vfib. At my institution it would have been pre induction aline no versed or fentanyl while she is awake, etomidate on induction, muscle relaxant of choice, cvc epi and levo ready to go on pumps, also have some amiodarone around somewhere. If she gave me trouble I might place an intraop TEE. Help me understand why placing an LMA in someone with severe pulmonary hypertension would be superior to placing an ET tube? A peripheral nerve block is smart as it may limit her narcotic use postop(less prone to hypoventilation/hypoxia).
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I think the rationale must be that spontaneous ventilation through an LMA confers the benefit of avoiding positive intrathoracic pressure and so, off-loading the RV. In practice, however, I almost always see mild hypercarbia even with well-functioning LMAs and minimal opioid--resulting in my tendency to place an ETT in this type of patient. (thinking hypertensive crisis from hypercarbia to be more problematic than PP breaths with a low/normal CO2).

With Pa systolic pressures in the 90's and an EF of 15%, this is probably totally academic. As a famous youtube anesthesiologist well-put it, "she's not fit for a hair cut".
 
sevoflurane said:
One thing to mention is that as you assist/take over ventilation while the prop wears off, it's important to keep an eye on delivered tidal volumes as these patients are usually not well volume resussitated and big TV's can decrease venous return making things worse.

Thanks for sharing your story gasguy06. Despite the sneaky CRNA and hypoventilation, do you think that pushing 1500mcg of phenylephrine may have made things worse? Things got better once you switched to epi right?

I'm thinking increased afterload, increased MR, increased PAP, decreased CO and then arrest. Epi being the rescue drug.

Just a thought.
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It's hard to answer that question as I didn't switch to epi until I was pretty sure she was going to code. Perhaps switching to epi earlier would have been prudent, and 1500 of pure alpha may well have hurt us. I will say that once we committed to proceeding with the case, I initially ran her on a minimal epi gtt (0.05 mcg/kg/min) and that produced such tachycardia we saw significant hypotension (decreased filling time) so we switched over to phenylephrine and were fine for the rest of the case (I initially said we ran her nor epi but that was a brain fart; we actually ran her on phenylephrine -- 0.5 mcg/kg/min). I really think the big issue was the hypercarbia.

Regarding another post, I chose to use an LMA over an ETT because I felt it would be less stimulating and thus I would have to give fewer drugs to blunt the laryngoscopy. Generally I have found an LMA to seat well and to be able to effectively ventilate through it.

If I had the ability to redo this case, I think I would have used etomidate as my induction agent and probably placed an ETT off the bat to control hypercarbia as it was an easy, grade 1 intubation. I'm still not convinced that etomidate would have preserved her SVR but it may have done so better than the propofol. I probably also would have done a FI block for post-op pain control and will definitely investigate this further.

All in all, this was an unsatisfying case and one I wish I could have done better with. That being said, she was a sick lady, arguably better off now. Nevertheless, I hate the be the hastener of death. It just doesn't feel good.
 
pgg said:
Above points are well taken on phenylephrine, but I think it's fine as a first drug, given a gentle slow induction and the fact that most of the hypotension is going to be from SVR dropping. This heart may need something else, though I don't think I'd go to epinephrine first, and ephedrine is slower and harder to titrate than I'd like.
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Agree. If you say the drop in pressure with induction is from dropping the SVR, then I don't see the harm in using vasoconstriction to bring it back to baseline. Obviously you wouldn't want to overshoot, but in this case phenylephrine isn't as evil as it is made out to be.
 
As a side note for the residents reading this post, this all happened at a level 2 community, private practice hospital (300 beds). Not to take anything away or pack a fight with our academic colleagues, because truly, I have nothing but respect for the guys doing academics. Really.

My point is simply this: wherever you go (academics or pp) you will encounter very sick patients. Resist the mindset in training that "I don't need to know this" because I'm going into private practice. That is a lie and you will endanger your patients by embracing it. Bad stuff and sick people are everywhere. Develop a plan to deal with critical AS (for example) and WRITE IT DOWN because you'll need it.

Again, not a knock on our academic colleagues, but having recently graduated from a well-respected, research-heavy training program, I feel like I was fed false reassurance about the acuity of private practice anesthesia from anesthesiologists who had never experienced it first hand ("get used to stuffing LMAs, buddy").

Just my humble advice.
 
gasguy06 said:
Generally I have found an LMA to seat well and to be able to effectively ventilate through it.
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Agreed, just because you use an LMA doesn't mean you have to put up with hypoventilation and an ETCO2 of 55.


gasguy06 said:
All in all, this was an unsatisfying case and one I wish I could have done better with.
Click to expand...

They're the best learning cases though. Thanks for sharing it.


gasguy06 said:
Bad stuff and sick people are everywhere.
Click to expand...

100% right on that
 
My induction for this case would've started with a long discussion with the family. Then I'd tell them about some choices. Definitely would've thrown an arterial line in preop if possible.

Could've tried a spinal catheter slowly titrated to effect. The INR doesn't really bother me that much as the risk of epidural hematoma would still be extremely small (certainly lower than her 30 day mortality) and a lumbar fusion doesn't preclude a spinal.

If I went GA, I'd probably just get her spontaneously breathing sevo until I could slip an LMA in. No IV drugs of any kind except little hits of vasopressors as needed until the LMA was in and I could back off the sevo. Then I'd just let her spontaneously breathe through the LMA on a little bit of sevo. If she wiggled too much, I'd suggest the orthopod hurry up.


Tough case with no good answer and an almost guaranteed bad outcome.
 
Mman said:
My induction for this case would've started with a long discussion with the family. Then I'd tell them about some choices. Definitely would've thrown an arterial line in preop if possible.

Could've tried a spinal catheter slowly titrated to effect. The INR doesn't really bother me that much as the risk of epidural hematoma would still be extremely small (certainly lower than her 30 day mortality) and a lumbar fusion doesn't preclude a spinal.

If I went GA, I'd probably just get her spontaneously breathing sevo until I could slip an LMA in. No IV drugs of any kind except little hits of vasopressors as needed until the LMA was in and I could back off the sevo. Then I'd just let her spontaneously breathe through the LMA on a little bit of sevo. If she wiggled too much, I'd suggest the orthopod hurry up.


Tough case with no good answer and an almost guaranteed bad outcome.
Click to expand...

It's doubtful her lumbar fusion was L2-S1. Most likely she had a 1 or 2 level lumbar fusion 20 years ago meaning a spinal is still an option.

That said, she won't be an easy spinal and my real world answer is give her 2 units of FFP over 2 hours then proceed with the case under Isobaric SAB. I would do a single shot technique. An arterial line sounds like a good idea in the holding area or prior to the SAB.

Of course, I'd make sure the family and surgeon know there is a significant chance (?50%) the patient won't survive the perioperative course. They need to be prepared for that outcome. This would follow along with my suggestion that the patient is too sick for General anesthesia and needs a Spinal after getting the FFP.

Would my outcome be any different? Would she survive the operation then die on POD 1 or POD 2? I just prefer that they don't die in the operating room if at all possible.
 
Severe pulmonary hypertension in my book gets an RSI with succ primarily to get on the vent ASAP to avoid hypercarbia. Even effective mask ventilation may result in hypercarbia. I think midazolam is the single most overutilized drug in anesthesia and usually entirely unnecessary.
 
gasguy06 said:
Great discussion, and I appreciate the input very much. Here's how it went down...

I discussed in plain language the possibility of cardiac arrest / death during the operation and subsequently on the floor. They understood and realized this was a high-risk situation.

My first choice was a carefully titrated epidural, but for obvious reasons, this was not practical. I opted instead for a light GA with an LMA. I placed a pre-induction a-line (thank god) and induced using lidocaine, propofol and a smidge of fentanyl (12.5 mcg). I chose phenylephrine as my pressor because I reasoned it would adequately counteract the vasodilation of the propofol and with any luck, I'd keep her at baseline. I also use it a lot more on a daily basis. I did have epi (10 mcg/ml) immediately available. I gave the propofol in 10 mg boluses and waited knowing she had a slow circ time. At 40 mg of prop, she began to drop -- like a rock. I began pushing phenylephrine but with no effect. I emptied 1500 mcg and watched the pressure fall -- to ZERO. PEA arrest. As it became clear she was going to arrest I called for backup and when her a-line flattened out (no change in rhythm) we began compressions. By this time I had pushed a 50 mcg of epi and after about 30 seconds of vigorous compressions, we had a perfusing rhythm. We thought about it and decided to proceed with the case knowing her PA pressures and her heart were no going to improve, especially after her PEA arrest. We relaxed her, changed the LMA to an ETT, lined her up and did the case. As the case went on she developed significant ST depressions which we really couldn't do much about given she was now on a levophed gtt.

We took her upstairs to the unit and the family withdrew on her the next day!!! WTF??!!

I think what happened is this: unbeknownst to me, my CRNA had slipped her 1 mg of midazolam in the HOLDING area. Holy **** was I pissed when I found out that. But because I'm the MD, the responsibility lays with me, not her -- and I wouldn't have that any other way. It was my fault for not controlling her more effectively. She undoubtedly hypoventilated from the versed. She also likely hypoventilated during the induction: given we were pushing the prop slowly and she was spontaneously breathing the whole time, we never effectively ventilated her. This caused her PaCO2 to increase and her PVR to follow suit, effectively stopping forward flow. This exacerbated the hypotension from the propofol and mitigated the effect of the pressors -- and presto - PEA!!

What really ended up helping her to maintain a perfusing rhythm (in addition to the compressions) was effective ventilation.

Lessons learned (for the residents reading this):

1) Respect pulmonary HTN. Hypercarbia, acidosis, hypotension and hypoxia can kill patients with severe pulmonary HTN.

2) Midazolam is not a benign drug that EVERYONE gets prior to surgery. Evaluate on a case-by-case basis. See above.

3) Control your CRNAs. Be a jerk if necessary. This can be tough to do, but it can be a matter of life and death.

4) Rule #1: The patient is the one with the disease (Read "House of God" if you don't know what I'm talking about)

5) Special thanks to the guys for discussion FI blocks. I've never done one, but they don't sound too tough with a little reading and watching video.

Cheers!
Click to expand...

First off, thank you very much for sharing this case as these are stressful to be be getting at 9pm at night when on late call. Yeah, as far as cRNAs, I work in a hospital that doesn't have them as I feel they are downright dangerous as they don't have any medical knowledge about how anything works. They only pretend to know what they are doing. I would assume with the low EF, it took a bit of time for that versed to kick in. I've induced cardiac patients with low EFs with 2mg of versed. Why did you pick propfol over etomidate? I've been doing this for about 5 years now, and I haven't had a problem with hypotension in these cases after giving etomidate. I could be wrong, but I don't think etomidate raises PAP. As another poster suggested, a central line after induction with a preop a line would have been useful to treat the hypotension with levophed as tachycardia could worsen the high PAP.

Thank you again for sharing the case.
 
Sorry forgot one more thing. I think I would've put in an ETT. With the high PAP, I would be concerned about hypoventilation and feel risk/benefit wise, an ETT is a better way to control the ventilation. Maybe if I had a pro-seal LMA where I work would I have gone that route.
 
I'm sure the propofol didn't help in this case. Def agree that Versed is very overused. Giving it to a 93 year old in the holding area is outright malpractice. I wonder what's your hospital's policy regarding M&M's and CRNA involvement? Are they required to attend?
 
sevoflurane said:
Let's keep it real bruh! 🙂
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Routinely induce old farts with 20-30mg of prop so yes i'm pretty sure 15mg would be enough. She got 40 (titrated) and arrested and i'm not surprised, i don't think the midaz was what tipped the scale.
 
I don't know... I feel that a properly placed LMA in these little old 92 y/o's gives you some of the easiest lungs to ventilate... great complience. Put some of these patients on PS or PC ventilation set at 12 cmH20 and you can get some gigantic TV's and chest wall excursion...so much so that sometimes you need to further adjust your settings down so you don't get them too hypocarbic.
If you are afraid of getting them hypecarbic on induction, just place them on PS from the begining with a low trigger and get them well oxygenated with an ETCO2 of 28-30 before you put in the LMA. Keeping patients from going hypercarbic does require some vigilance, but it's a basic anesthesia task that shouldn' take much effort. Put them on a back up rate and adjust your ETCO2 alarms if you are concerned.

Personally, if I can avoid paralytics, reversal and the pressor response to laryngoscopy in someone who has pulm htn and is to undergo what should be a very quick procedure, then I do it... fully respecting the effects of hypercarbia.
That being said, when these patients are on their way down... a little laryngophed can be helpful.

Re: phenylephrine:

Phenylephrine caused a significant (p less than .01) increase in mean aortic pressure (84 to 108 mm Hg) and right ventricular coronary driving pressure (46 to 69 mm Hg). In response, there was a significant (p less than .01) rise in mean pulmonary artery pressure (58 to 67 mm Hg), right ventricular end-diastolic pressure (10 to 16 mm Hg) and wedge pressure (5 to 9 mm Hg), and an insignificant fall in cardiac output (3.26 to 3.09 L/min) and pulmonary artery O2 saturation (57 to 49 percent). Although phenylephrine increased right ventricular coronary driving pressure, it worsened right ventricular function as manifest by a rise in end-diastolic pressure and fall in cardiac output. Any benefit of raising right ventricular coronary driving pressure may have been offset by alpha vasoconstriction of right ventricular coronary blood flow and/or pulmonary arterial vasoconstriction. Phenylephrine does not appear to be a useful therapy of right ventricular failure from pulmonary hypertension in patients who fail vasodilators.

http://chestjournal.chestpubs.org/content/98/5/1102.full.pdf+html

Dont' get me wrong... We all have a special place for phenylephrine... we use it every day. In a patient with a large hypertrophied RV and high pulm pressues, I'd rather take 1cc of Norepi and place it in a 100cc bag to get me some 10mcg/ml alpha + beta action. IMO, patients who have problems getting blood from the right heart to to the left will benefit more from an agent that provides contractility (beta-1) + small amount of beta-2 (epi is better at this). It can also act like phenyleprhine and give you a nice reflex bradycardia. Just my 2 cents.


+1 to gasguy 06 for sharing his case. It has stimulated a good discussion and is certainly something we will all see again and again as our patient population gets older and sicker.
 
I"ve had several really sick patients bottom out after Etomidate; you need to be ready and not let your guard down just because etomidate is being used as the induction agent.

I really like Vasopressin the past few years. I dilute up 20 mg in a 20 ml syring with LR/NS in order to make 1 unit per ml. It's gotten me out of more than a few jams.
 
sevoflurane said:
Re: phenylephrine:

Phenylephrine caused a significant (p less than .01) increase in mean aortic pressure (84 to 108 mm Hg) and right ventricular coronary driving pressure (46 to 69 mm Hg). In response, there was a significant (p less than .01) rise in mean pulmonary artery pressure (58 to 67 mm Hg), right ventricular end-diastolic pressure (10 to 16 mm Hg) and wedge pressure (5 to 9 mm Hg), and an insignificant fall in cardiac output (3.26 to 3.09 L/min) and pulmonary artery O2 saturation (57 to 49 percent). Although phenylephrine increased right ventricular coronary driving pressure, it worsened right ventricular function as manifest by a rise in end-diastolic pressure and fall in cardiac output. Any benefit of raising right ventricular coronary driving pressure may have been offset by alpha vasoconstriction of right ventricular coronary blood flow and/or pulmonary arterial vasoconstriction. Phenylephrine does not appear to be a useful therapy of right ventricular failure from pulmonary hypertension in patients who fail vasodilators.

http://chestjournal.chestpubs.org/content/98/5/1102.full.pdf+html

Dont' get me wrong... We all have a special place for phenylephrine... we use it every day. In a patient with a large hypertrophied RV and high pulm pressues, I'd rather take 1cc of Norepi and place it in a 100cc bag to get me some 10mcg/ml alpha + beta action. IMO, patients who have problems getting blood from the right heart to to the left will benefit more from an agent that provides contractility (beta-1) + small amount of beta-2 (epi is better at this). It can also act like phenyleprhine and give you a nice reflex bradycardia. Just my 2 cents.
Click to expand...

Thanks - I'm reconsidering what I'll reach for first next time I see someone with bad pulm HTN. These threads are great.
 
BLADEMDA said:
I"ve had several really sick patients bottom out after Etomidate; you need to be ready and not let your guard down just because etomidate is being used as the induction agent.

I really like Vasopressin the past few years. I dilute up 20 mg in a 20 ml syring with LR/NS in order to make 1 unit per ml. It's gotten me out of more than a few jams.
Click to expand...

Absolutely. It's good powerful stuff. I double dilute it to get .5unit per ml.

Correct me if I'm wrong but I believe it can raise your systemic pressure while lowering your pulmonary pressures. Would be a great choice for this case as well. 👍
 
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