A case that didn't go as planned

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pgg

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It's been a while since I've posted a case. This is from today.

The case first, later I'll tell you what I did ... let's give non-attendings some time to respond and/or heckle me first.


76 year old man scheduled for an elective total hip arthroplasty.

He sacrificed his spleen and the good health of a knee, femur, and hip to the motorcycle gods many years ago. 90 kg guy - not the usual morbidly obese joint patient.

He denies ever having heart problems, has excellent exercise tolerance doing strenuous yard work, all without symptoms. To hear this guy talk, if not for his hip he'd be jumping rope at the gym. An ECG was done at his preop visit a week ago because he's 76. Sinus rhythm, old MI, and per the AHA/ACC guidelines no further cardiac workup.

He is a former smoker, but only a few pack years, and he quit decades ago. CXR is a little hyperexpanded. For some reason somebody got PFTs, which show a minimal obstructive pattern and improvement with bronchodilators. He doesn't use or even have inhalers at home.

Remainder of ROS is negative.

Past surgical history includes a total knee (recent) and tonsils, appendectomy, inguinal hernia, and splenectomy (remote).


case-labs.jpg

(Not sure why coags didn't print out - PT 11.5, PTT 25.4, INR 1.1)

case-ecg.jpg



He doesn't want a spinal because he didn't like the one he got for his knee. Definitely wants to go to sleep. Preop nurses are very concerned because he was chewing gum on the way to the hospital.

Pent sux tube?
Make him wait 8 hours post-gum-spit-out?
Talk him into a spinal?
Postpone for repeat PFTs? ;)


Nothing exotic here, just typical old-person community-hospital B&B case.

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How recent was that "recent" total knee? And how hard has this guy been hittin the NSAIDs in the past few weeks?

The labs you've shown show some degree of renal impairment, which is by history new, and which is by the labs, evolving (i.e. resolving). The day of an elective surgery ain't a great time to work up this guy's renal failure, and with the gum-chewing on the way to preop you have another valid reason to postpone this case. I'd take a close history on his exposure to nephrotoxic stuff (NSAIDs being my #1 in this case) and refer him back to his PCP for renal workup (urine lytes, urine micro...uhh that's all I got).

It also catches my eye that this dude has
Calcium derangement
Renal impairment
Anemia
Bone pain (knee/hip)
and
Elevated globulin fraction of total protein
Which is, like, every classic feature of multiple myeloma, especially in an old guy

Nonetheless the title of this thread "A Case That Didn't Go As Planned" makes me think there was an acute intraoperative event totally unrelated to this internal medicine wankery above.
 
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I am not concerned with his chewing gum.

You may not be concerned about gum chewing but malpractice lawyers will be if the guy aspirates.

I know a pediatric study showed there increased gastric volume and lower PH with kids who chewed gum.

What if the guy's wife said he's gone through a "Costco wholesize pack of trident?" Would you be concerned than? I definitely would be.

Patient's lie a lot. I've personally seen patient's take a "sip" of water with their medicines....let's just say some people consider a sip of water like half a can of coke (6 ounces).

But getting back to the gum chewing....if they are believable, and it's only a brief gum chewing, I usually just wait an hour.
 
Just a med student here, but is that 3rd degree block on his preop EKG, +/- a bundle branch block (?LBB)? Is that concerning enough to want to put pads on this guy, just in case? Judging the by title of the thread, there's badness afoot...
 
Just a med student here, but is that 3rd degree block on his preop EKG, +/- a bundle branch block (?LBB)? Is that concerning enough to want to put pads on this guy, just in case? Judging the by title of the thread, there's badness afoot...

Where do you see a 3rd degree block on the EKG?
 
Someone needs to get their story straight. He denies ever having heart problems, yet he's had an MI in the past?
 
Just a med student here, but is that 3rd degree block on his preop EKG

Every QRS is preceded by a P so it's not a 3rd deg AV block.


ProRealDoc said:
Someone needs to get their story straight. He denies ever having heart problems, yet he's had an MI in the past?

The patient thought his heart was fine. It would be more complete to say the patient has never seen a cardiologist, been cathed, stress tested, or echo'd. The "old MI" bit came from the preop clinic's read of the ECG, and based on his functional status they did not refer him for any additional testing prior to surgery.


fakin' the funk said:
How recent was that "recent" total knee?

About a year ago.


Arch Guilloti said:
I am not concerned with his chewing gum.

What if it wasn't sugar free? ;)
 
How recent was that "recent" total knee? And how hard has this guy been hittin the NSAIDs in the past few weeks?

The labs you've shown show some degree of renal impairment, which is by history new, and which is by the labs, evolving (i.e. resolving). The day of an elective surgery ain't a great time to work up this guy's renal failure, and with the gum-chewing on the way to preop you have another valid reason to postpone this case. I'd take a close history on his exposure to nephrotoxic stuff (NSAIDs being my #1 in this case) and refer him back to his PCP for renal workup (urine lytes, urine micro...uhh that's all I got).

It also catches my eye that this dude has
Calcium derangement
Renal impairment
Anemia
Bone pain (knee/hip)
and
Elevated globulin fraction of total protein
Which is, like, every classic feature of multiple myeloma, especially in an old guy

Nonetheless the title of this thread "A Case That Didn't Go As Planned" makes me think there was an acute intraoperative event totally unrelated to this internal medicine wankery above.

Figure out exactly why he didn't enjoy the spinal last time and see if you can address that - otherwise ETT with your choice of regional (Fascia iliacus or lumbar plexus catheter or single shot if the Orthopods aren't comfortable with catheters). Avoid any nephrotoxic drugs (ketorolac, etc) and provide adequate hydration.

I see the machine "read" the ECG. I am not that convinced there is a previous old MI. I see Q-waves in lead III, but not aVF or lead II. I wouldn't call those Q waves in leads V2 or V3 as there is an upslope. There is LAD around -30 and an interventricular conduction delay but I am not very excited about those things. If he truly gave the story that you typed then no further cardiac work-up.

I could care less about the gum chewing as long as he hasn't sucked down an entire pack, sugar free or not...don't care.

The hypocalcemia/hypophosphatemia makes me think of Vitamin D deficiency. I would suspect hypercalcemia with any kind of bony malignancy (MM, etc). I would also expect hyperphosphatemia with renal insufficiency or secondary to PTH issues, but these are issues for his PCP.

He needs his hip fixed so let's just fix while he is here. :xf:
 
The patient thought his heart was fine. It would be more complete to say the patient has never seen a cardiologist, been cathed, stress tested, or echo'd. The "old MI" bit came from the preop clinic's read of the ECG, and based on his functional status they did not refer him for any additional testing prior to surgery.


Classic VA patient, I guess. Meds?
 
Figure out exactly why he didn't enjoy the spinal last time and see if you can address that - otherwise ETT with your choice of regional (Fascia iliacus or lumbar plexus catheter or single shot if the Orthopods aren't comfortable with catheters). Avoid any nephrotoxic drugs (ketorolac, etc) and provide adequate hydration.

I see the machine "read" the ECG. I am not that convinced there is a previous old MI. I see Q-waves in lead III, but not aVF or lead II. I wouldn't call those Q waves in leads V2 or V3 as there is an upslope. There is LAD around -30 and an interventricular conduction delay but I am not very excited about those things. If he truly gave the story that you typed then no further cardiac work-up.

I could care less about the gum chewing as long as he hasn't sucked down an entire pack, sugar free or not...don't care.

The hypocalcemia/hypophosphatemia makes me think of Vitamin D deficiency. I would suspect hypercalcemia with any kind of bony malignancy (MM, etc). I would also expect hyperphosphatemia with renal insufficiency or secondary to PTH issues, but these are issues for his PCP.

He needs his hip fixed so let's just fix while he is here. :xf:

+1. I would not think twice about doing this case. Encourage spinal. If unwilling. Fentanyl/Propofol/Rocuronium/ETT/02/Desflurane. My money is on that is close to what was done +/- supplemental block. I suspect that it was well conducted and poorly tolerated. :)
 
D'oh forgot to put his meds in the OP. Nothing too exciting. PCN allergy. Takes Vicodin (up to 3/day) and spironolactone.

Fair enough. I am not satisfied about his cardiac hx. His ekg shows a LBBB and we don't know whether this is new or old unless i see prior EKGs. I appreciate the preop clinic's note but I ain't proceeding with this purely elective case. I trust them but need to verify.

I will take the conservative approach and refer this dude back and have him see a cardiologist.
 
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Just a med student here, but is that 3rd degree block on his preop EKG, +/- a bundle branch block (?LBB)? Is that concerning enough to want to put pads on this guy, just in case? Judging the by title of the thread, there's badness afoot...

I agree that there's something odd going on with the EKG. I'm about to end my medicine internship and start the real stuff, but something about that EKG makes me uncomfortable. The rate, for one thing, does not look 59 to me. Using the 300-150-100 etc trick, it looks to be about 40, which is confirmed when I count the number of QRS complexes I see in 6 seconds: 4 complexes, so a rate in the 40s. I agree that this is not 3rd degree block, but it looks like there may be a type two 2nd deg block going on. Those "bumps" following the T-waves look like they could be non-conducting P waves. I'd need more cardiac history, and possibly a cardiology consult re: PPM before proceeding with this case. Pads during this case might be a good idea. What were his vitals in the holding bay? I'm not sure what to induce with yet, but I may want to avoid sux in him because of his renal insufficiency and its effect on K. Possibly induce with etomidate, given its relatively favorable CV profile and low dose of fentanyl? Maintain with des and have phenylephrine at the ready. Would an a-line or central line be necessary in this case because of the blood loss and his anemia?
 
my first step would be repeat the EKG. i dont trust anything thats on that one. i also have a rule that reads if you see an asymptomatic patient with an EKG that says "ST elevation" then you should consider that maybe the EKG is flawed.
 
I don't see a LBBB i'm more in favor of inf Q waves with poor progression of R waves in V1-3.
In any case with good functional capacity there's no reason for futher workup.
I'm also more worried about the creatinine going from 2.4 to 1.5, something definitely happened there and the guy is left with less than 10% of functioning nephrons.
I guess you could imagine a silent MI with low flow state combined with NSAID causing the injury.
In this case i would follow gut feeling which is hard to perceive over the internet. You can't be faulted for proceeding or get a TTE and renal workup.
 
Would an a-line or central line be necessary in this case because of the blood loss and his anemia?

A-lines for these cases are unnecessary except in patients with major alteration of cardiac function. A central line is not the first choice for fluids/blood transfusion: a couple of good PIV will do a better job.
In any case with a good surgeon blood loss should be less than 500cc
 
It's been a while since I've posted a case. This is from today.

The case first, later I'll tell you what I did ... let's give non-attendings some time to respond and/or heckle me first.


76 year old man scheduled for an elective total hip arthroplasty.

He sacrificed his spleen and the good health of a knee, femur, and hip to the motorcycle gods many years ago. 90 kg guy - not the usual morbidly obese joint patient.

He denies ever having heart problems, has excellent exercise tolerance doing strenuous yard work, all without symptoms. To hear this guy talk, if not for his hip he'd be jumping rope at the gym. An ECG was done at his preop visit a week ago because he's 76. Sinus rhythm, old MI, and per the AHA/ACC guidelines no further cardiac workup.

He is a former smoker, but only a few pack years, and he quit decades ago. CXR is a little hyperexpanded. For some reason somebody got PFTs, which show a minimal obstructive pattern and improvement with bronchodilators. He doesn't use or even have inhalers at home.

Remainder of ROS is negative.

Past surgical history includes a total knee (recent) and tonsils, appendectomy, inguinal hernia, and splenectomy (remote).


case-labs.jpg

(Not sure why coags didn't print out - PT 11.5, PTT 25.4, INR 1.1)

case-ecg.jpg



He doesn't want a spinal because he didn't like the one he got for his knee. Definitely wants to go to sleep. Preop nurses are very concerned because he was chewing gum on the way to the hospital.

Pent sux tube?
Make him wait 8 hours post-gum-spit-out?
Talk him into a spinal?
Postpone for repeat PFTs? ;)


Nothing exotic here, just typical old-person community-hospital B&B case.

Soon to be CA-1 here that will put in my two cents. The crux of this case is it is an elective total hip arthroplasty. There is no need to move forward this case given all the data given it is an elective case. He isn't actively bleeding, crashing or dying. This guy needs his hip fixed which can wait until he has been properly evaluated.

1) "Old MI" - 76 year old with old MI on EKG with no previous hx of chest pain or cardiac hx. That sounds sketchy to me and leads me to not trust the patient at their word because he is probably a guy that disregarded chest pain in the past due to not wanting to go to hospital. Get the guy a stress test or stress echo. His EKG doesn't look like a LBBB to me. He has a LAD but with LBBB you have negative last segment of the QRS in V1 and positive last segment in V6 which he doesn't have. He has a widened QRS though and shortened PR interval. WPW might fit the bill and I think I see delta waves in aVL and aVF.
2) Elevated Cr - What is this guy's baseline Cr? This guy has an unknown elevated Cr at 2.4 one week ago and now is resolving at 1.5. Resolving ARF would not cause delay of case but given the other information I would be hesitant. I don't see anything in his hx to suggest renal dysfunction with the exception being he has been popping NSAIDs like they are going out of style.
3)Spironolactone - Why is he taking spironolactone? Has he had leg edema before in the past for unknown reason and been receiving spironolactone for diuresis.
4)Anemia - He has an unexplained anemia. It could go along with popping NSAIDs and ARF. What is his baseline Hb?

I probably have been lead by the title of this thread but given all the information, I postpone the case until a later day. Good case and I appreciate you taking the time to scan the data and EKG.

RedAnesthesia
 
I'm not sure what to induce with yet, but I may want to avoid sux in him because of his renal insufficiency and its effect on K.

Only if you knew his K+ was already high. CKD'ers have the same rise in K+ as do people with normal renal function after sux, assuming all else is equal

Would an a-line or central line be necessary in this case because of the blood loss and his anemia?

That depends -- what are the indications for arterial and central line placement? Does this patient or surgery meet any of them? If they are for "monitoring," how is that monitoring going to guide your treatment?
 
RS on V1 lead and I do see rabbit ears on V4 zooming into it unless my eyes are deceiving me. Either way something is going on and it needs to be explored.
 
RS on V1 lead and I do see rabbit ears on V4 zooming into it unless my eyes are deceiving me. Either way something is going on and it needs to be explored.

The way i recognize a LBBB is that R and T wave must be in opposite directions in all leads which is not the case.
 
RS on V1 lead and I do see rabbit ears on V4 zooming into it unless my eyes are deceiving me. Either way something is going on and it needs to be explored.

Rabbit ears are indicative of RBBB no?
 
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Are you saying that because the word rabbit starts with the letter "r" and so does "rbbb"? :D

Heh, I guess with RBBB the bunny ears would be present in the other septal/anterior V leads?
 
Rabbit ears are an indication of RBBB no?

Are you saying that because the word rabbit starts with the letter "r" and so does "rbbb"? :D

No, rabbit ears or RSR' which often people refer to in V1 and V2 is seen with RBBB and not LBBB. I think you have it backwards. Either way, I don't think it is a LBBB or a RBBB.

-RedAnesthesia
 
Undifferientiated renal insufficiency means hasn't been optimized. I also don't know what to make of his high osmals. He needs to see a nephrologist. I don't think much of his alledged cardiac history, but if he suffers worse renal function post op, it's your fault.
 
Rising CA1 here. This is my read of the ECG:

He has a new onset bifascicular block.
* There is a 2:1 block at the AV Node. Those little bumps after the T waves are P waves. Note how each of the bumps has the same direction and magnitude of the P wave in each corresponding lead. Each of the bumps is halfway between the P waves as well. 2:1 AV nodal block cannot be further characterized as Type 1 Mobitz or Type 2 Wenkibach (sp) as we'll leave it at that.
* He also shows a left fascicular block. It doesn't meet LBBB criteria because of the lack of T wave inversion in V5 or V6.

What does this mean for the day's case?
This guy has no prior cardiac evaluation. Does this bifascicular block have an ischemic etiology? For this elective case I would delay pending a cardiology evaluation. If it was an emergency I suppose you could slap on some pads and get ready for some external pacing, and place a central line for possible transvenous pacing. Place art line as well.
 
Rising CA1 here. This is my read of the ECG:

He has a new onset bifascicular block.
* There is a 2:1 block at the AV Node. Those little bumps after the T waves are P waves. Note how each of the bumps has the same direction and magnitude of the P wave in each corresponding lead. Each of the bumps is halfway between the P waves as well. 2:1 AV nodal block cannot be further characterized as Type 1 Mobitz or Type 2 Wenkibach (sp) as we'll leave it at that.
* He also shows a left fascicular block. It doesn't meet LBBB criteria because of the lack of T wave inversion in V5 or V6.

Hmm. You might be right. Initially I thought the P-P intervals were different, but closer look they are the same, which supports a second degree AVB. Also, I just noticed that his neutrophil % is 95, which is high. Elevated neutrophil count was the first test used to diagnose MI (before enzymes were available).
 
I'd like to know about this gum issue- What is the concern? Saliva in the stomach? Seems like it would be pretty minimal, and pass through quickly. Fill me in, cause it seems silly to me.
 
Here's what happened.

I didn't care about the gum chewing. It does increase gastric volume a small amount (at least in nonsmokers), but I think it's most reasonable to treat it as a clear liquid. There was a 2 hour gap between chewing and OR arrival time.

The renal insufficiency was concerning to me. Creatinine 2.4 a week ago, 1.5 day of surgery. But, it appeared more pre-renal / dehydration to me, and if I cancelled every old person with a bit of renal insufficiency, I'd be out of a job. So I decided to proceed but avoid nephrotoxic drugs, hydrate him a bit, watch urine output, etc. This surgeon does THAs fast and well, every time, so I wasn't too worried about excessive blood loss and a kidney hit from that.

I completely missed the important finding in the 12-lead, being over-reassured by his exercise tolerance. The eventual cardiologist read was a 2nd deg AVB and LBBB. I didn't catch that the actual ventricular rate was about 40 (not 59 as the machine read), and I didn't look at the Ts closely enough to see that there were were actually extra Ps and not just lumpy Ts or T+U waves. Reassured by his exercise tolerance, I took him to the OR.

He was anxious, so I gave him 2 mg of midazolam; his hip hurt, so I gave him 50 mcg of fentanyl. He got comfortable and his HR decreased a bit. While preoxygenating him, this was his rhythm

case-strip.jpg

HR of around 30, sometimes in the 20s, clearly a 2nd deg AVB. Occasionally he'd get two PQRS complexes in a row with a constant PR interval (didn't get a strip of that unfortunately) so to be more specfic he had a type 2 second degree block. BP was normal for him 150-170/40-60, he was wide awake, alert, responsive.

At this point I cancelled the case. In an effort to at least get his HR out of the 20s before leaving the OR, I gave him 0.2 mg of glycopyrrolate, got nothing, then 0.4 mg of atropine, also nothing - HR still about 30. This is of course not surprising for a high grade AV block; there's a reason the ACLS algorithm for bradydysrhythmias says atropine for unstable patients with 1st deg & 2nd deg type 1 blocks, and transcutaneous pacing for 2nd deg type 2 & 3rd deg blocks.

I took him to the PACU, and consulted cardiology. He was admitted overnight to telemetry and the next morning (today) he had a pacer implanted. His hip is rescheduled for sometime in the future.


I had tunnel vision on his excercise capacity and lack of symptoms - he never should've made it past his preop appointment or the holding area with me. The preop ECG showed a LBBB and 2:1 2nd degree AV block. It's possible the preop clinic had an old ECG to compare it to and knew the LBBB was old. I didn't have an old ECG to look at, but so many patients show up with a single ECG and a LBBB that unless I have any hint that it might be new (recent symptoms, change in functional status, other admissions/surgeries/stressors) I'd have a hard time justifying cancelling all of those patients. Even though that's what the book says you should do ...

Regardless, a Mobitz II 2nd deg AV block is an active cardiac condition per the 2007 AHA/ACC guidelines, and exercise tolerance shouldn't exempt this patient from a preop cardiac evaluation of some kind. We can't really tell from the 12-lead if this is a type 1 or 2 second degree block but I think that doesn't matter.


A few reasons I posted this case
- ECGs still make me feel dumb sometimes.
- ">4 METs" exercise tolerance isn't a magical cardiac clearance talisman.
- Pressure to not cancel cases is very real and although I try not to let it affect my judgment, it has. I do cases now that would've been cancelled during residency.
- Even if you're in the OR, propofol in hand, waiting for the cuff to cycle so you can induce, it's not too late to cancel.
 
I'd like to know about this gum issue- What is the concern? Saliva in the stomach? Seems like it would be pretty minimal, and pass through quickly. Fill me in, cause it seems silly to me.

We had a thread about it a while ago here.

In short, chewing gum appears to increase gastric secretions, raising volumes without changing pH. How much? Probably not much, IIRC one study showed a difference of 20 mL vs 30 mL in an otherwise fasted patient.

For medicolegal reasons I treat it as a clear liquid and wait 2 hours. I don't fault the people who say it's all a bunch of crap and just go straight to the OR though.
 
Rising CA1 here. This is my read of the ECG:

He has a new onset bifascicular block.
* There is a 2:1 block at the AV Node. Those little bumps after the T waves are P waves. Note how each of the bumps has the same direction and magnitude of the P wave in each corresponding lead. Each of the bumps is halfway between the P waves as well. 2:1 AV nodal block cannot be further characterized as Type 1 Mobitz or Type 2 Wenkibach (sp) as we'll leave it at that.
* He also shows a left fascicular block. It doesn't meet LBBB criteria because of the lack of T wave inversion in V5 or V6.

What does this mean for the day's case?
This guy has no prior cardiac evaluation. Does this bifascicular block have an ischemic etiology? For this elective case I would delay pending a cardiology evaluation. If it was an emergency I suppose you could slap on some pads and get ready for some external pacing, and place a central line for possible transvenous pacing. Place art line as well.

I agree with you Darko upon further review. That is a good pick-up if that is in fact what it is but I believe it makes sense. The patient likely had an ischemic event leading his now bifascicular block. I am anxiously awaiting the story from pgg.

-RedAnesthesia
 
* He also shows a left fascicular block. It doesn't meet LBBB criteria because of the lack of T wave inversion in V5 or V6.

Interesting, I'll try to remember to ask the cardiologist about that next time I see him. So maybe NOT a LBBB?

Again, ECGs make me feel dumb sometimes.

Still, the high grade AV block should've bought him a ticket to see cardiology preop.
 
good catch to the newbie on the extra p waves. i think we all missed that, except for whoever suggested 3rd degree block. so just counting boxes, the ventricular rate looks to be 20. is this a standardized EKG? this is really a great lesson and kind of why i suggested repeating the EKG. the computerized assessment seems to be totally wrong, and i think its counting T waves as QRS complexes, resulting in an artifically increased HR (59?) and suggesting ST elevation, which is unlikely to be present.

great case, you very likely dodged a bullet.
 
Here's what happened.

I didn't care about the gum chewing. It does increase gastric volume a small amount (at least in nonsmokers), but I think it's most reasonable to treat it as a clear liquid. There was a 2 hour gap between chewing and OR arrival time.

The renal insufficiency was concerning to me. Creatinine 2.4 a week ago, 1.5 day of surgery. But, it appeared more pre-renal / dehydration to me, and if I cancelled every old person with a bit of renal insufficiency, I'd be out of a job. So I decided to proceed but avoid nephrotoxic drugs, hydrate him a bit, watch urine output, etc. This surgeon does THAs fast and well, every time, so I wasn't too worried about excessive blood loss and a kidney hit from that.

I completely missed the important finding in the 12-lead, being over-reassured by his exercise tolerance. The eventual cardiologist read was a 2nd deg AVB and LBBB. I didn't catch that the actual ventricular rate was about 40 (not 59 as the machine read), and I didn't look at the Ts closely enough to see that there were were actually extra Ps and not just lumpy Ts or T+U waves. Reassured by his exercise tolerance, I took him to the OR.

He was anxious, so I gave him 2 mg of midazolam; his hip hurt, so I gave him 50 mcg of fentanyl. He got comfortable and his HR decreased a bit. While preoxygenating him, this was his rhythm

case-strip.jpg

HR of around 30, sometimes in the 20s, clearly a 2nd deg AVB. Occasionally he'd get two PQRS complexes in a row with a constant PR interval (didn't get a strip of that unfortunately) so to be more specfic he had a type 2 second degree block. BP was normal for him 150-170/40-60, he was wide awake, alert, responsive.

At this point I cancelled the case. In an effort to at least get his HR out of the 20s before leaving the OR, I gave him 0.2 mg of glycopyrrolate, got nothing, then 0.4 mg of atropine, also nothing - HR still about 30. This is of course not surprising for a high grade AV block; there's a reason the ACLS algorithm for bradydysrhythmias says atropine for unstable patients with 1st deg & 2nd deg type 1 blocks, and transcutaneous pacing for 2nd deg type 2 & 3rd deg blocks.

I took him to the PACU, and consulted cardiology. He was admitted overnight to telemetry and the next morning (today) he had a pacer implanted. His hip is rescheduled for sometime in the future.


I had tunnel vision on his excercise capacity and lack of symptoms - he never should've made it past his preop appointment or the holding area with me. The preop ECG showed a LBBB and 2:1 2nd degree AV block. It's possible the preop clinic had an old ECG to compare it to and knew the LBBB was old. I didn't have an old ECG to look at, but so many patients show up with a single ECG and a LBBB that unless I have any hint that it might be new (recent symptoms, change in functional status, other admissions/surgeries/stressors) I'd have a hard time justifying cancelling all of those patients. Even though that's what the book says you should do ...

Regardless, a Mobitz II 2nd deg AV block is an active cardiac condition per the 2007 AHA/ACC guidelines, and exercise tolerance shouldn't exempt this patient from a preop cardiac evaluation of some kind. We can't really tell from the 12-lead if this is a type 1 or 2 second degree block but I think that doesn't matter.


A few reasons I posted this case
- ECGs still make me feel dumb sometimes.
- ">4 METs" exercise tolerance isn't a magical cardiac clearance talisman.
- Pressure to not cancel cases is very real and although I try not to let it affect my judgment, it has. I do cases now that would've been cancelled during residency.
- Even if you're in the OR, propofol in hand, waiting for the cuff to cycle so you can induce, it's not too late to cancel.


Like I said. He did have a LBBB and I am not a cardiologist.

I am editing this post to provide a more complete answer. PGG, you clearly have achieved a high level of comfort dealing with patients presenting with conditions in which there's evidence that underlying cardiac pathology may be present. I agree with your comment about the exercise tolerance not being a 'magical clearance talisman' as you eloquently describe it. The problem I see with guidelines is that many of us take them at their word and forget they are just guidelines not rules.

One of my favorite attendings always says that when you are in doubt, all guidelines go out the window and you go with your clinical judgement. It's hard for me to do that but I think there's some truth to it. In the end, I am glad you managed the case well and the patient received the care they needed. No one can fault you for wanting to proceed and do what you felt was best for the patient (in this case get his hip fixed).

Great case.
 
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+1. I would not think twice about doing this case. Encourage spinal. If unwilling. Fentanyl/Propofol/Rocuronium/ETT/02/Desflurane. My money is on that is close to what was done +/- supplemental block. I suspect that it was well conducted and poorly tolerated. :)

U sure about that?
 
2:1 block. I saw it when reading this case, but that is because I was looking for the twist. I would hope that I would have seen it in actual practice. It is obvious when you know it is there. Kinda like that open pelvis fracture that none of us saw on the pelvic x-ray (when I was a student and had never seen anything like that before), until someone pointed it out. Oooooh, you mean that large, very obvious gap where the pubic symphasis usually is?

I have had an attending who canceled a case for an adult chewing gum, but then I came across this in a recent pediatric textbook and I think she may have been overreacting. But, I guess it is her license on the line.

"Children who have been chewing gum must dispose of the gum by throwing it out, not swallowing it. Recent evidence suggests that chewing gum increases the gastric fluid volume, but tends to increase pH in children, leaving no clear evidence for an increased risk of regurgitation. Consequently, we recommend that if the gum is discarded, then elective anesthesia can proceed without additional delay. If, however, the child swallows the gum, then surgery is canceled because aspirated gum may be nearly impossible to extract from a bronchus of trachea."

2009 4th Edition of A PRACTICE OF ANESTHESIA FOR INFANTS AND CHILDREN, Cote, Lerman, Todres. pg 28
 
Here's what happened.

I didn't care about the gum chewing. It does increase gastric volume a small amount (at least in nonsmokers), but I think it's most reasonable to treat it as a clear liquid. There was a 2 hour gap between chewing and OR arrival time.

The renal insufficiency was concerning to me. Creatinine 2.4 a week ago, 1.5 day of surgery. But, it appeared more pre-renal / dehydration to me, and if I cancelled every old person with a bit of renal insufficiency, I'd be out of a job. So I decided to proceed but avoid nephrotoxic drugs, hydrate him a bit, watch urine output, etc. This surgeon does THAs fast and well, every time, so I wasn't too worried about excessive blood loss and a kidney hit from that.

I completely missed the important finding in the 12-lead, being over-reassured by his exercise tolerance. The eventual cardiologist read was a 2nd deg AVB and LBBB. I didn't catch that the actual ventricular rate was about 40 (not 59 as the machine read), and I didn't look at the Ts closely enough to see that there were were actually extra Ps and not just lumpy Ts or T+U waves. Reassured by his exercise tolerance, I took him to the OR.

He was anxious, so I gave him 2 mg of midazolam; his hip hurt, so I gave him 50 mcg of fentanyl. He got comfortable and his HR decreased a bit. While preoxygenating him, this was his rhythm

case-strip.jpg

HR of around 30, sometimes in the 20s, clearly a 2nd deg AVB. Occasionally he'd get two PQRS complexes in a row with a constant PR interval (didn't get a strip of that unfortunately) so to be more specfic he had a type 2 second degree block. BP was normal for him 150-170/40-60, he was wide awake, alert, responsive.

At this point I cancelled the case. In an effort to at least get his HR out of the 20s before leaving the OR, I gave him 0.2 mg of glycopyrrolate, got nothing, then 0.4 mg of atropine, also nothing - HR still about 30. This is of course not surprising for a high grade AV block; there's a reason the ACLS algorithm for bradydysrhythmias says atropine for unstable patients with 1st deg & 2nd deg type 1 blocks, and transcutaneous pacing for 2nd deg type 2 & 3rd deg blocks.

I took him to the PACU, and consulted cardiology. He was admitted overnight to telemetry and the next morning (today) he had a pacer implanted. His hip is rescheduled for sometime in the future.


I had tunnel vision on his excercise capacity and lack of symptoms - he never should've made it past his preop appointment or the holding area with me. The preop ECG showed a LBBB and 2:1 2nd degree AV block. It's possible the preop clinic had an old ECG to compare it to and knew the LBBB was old. I didn't have an old ECG to look at, but so many patients show up with a single ECG and a LBBB that unless I have any hint that it might be new (recent symptoms, change in functional status, other admissions/surgeries/stressors) I'd have a hard time justifying cancelling all of those patients. Even though that's what the book says you should do ...

Regardless, a Mobitz II 2nd deg AV block is an active cardiac condition per the 2007 AHA/ACC guidelines, and exercise tolerance shouldn't exempt this patient from a preop cardiac evaluation of some kind. We can't really tell from the 12-lead if this is a type 1 or 2 second degree block but I think that doesn't matter.


A few reasons I posted this case
- ECGs still make me feel dumb sometimes.
- ">4 METs" exercise tolerance isn't a magical cardiac clearance talisman.
- Pressure to not cancel cases is very real and although I try not to let it affect my judgment, it has. I do cases now that would've been cancelled during residency.
- Even if you're in the OR, propofol in hand, waiting for the cuff to cycle so you can induce, it's not too late to cancel.

Great case.

Nice job.:thumbup:
 
You may not be concerned about gum chewing but malpractice lawyers will be if the guy aspirates.

I know a pediatric study showed there increased gastric volume and lower PH with kids who chewed gum.

What if the guy's wife said he's gone through a "Costco wholesize pack of trident?" Would you be concerned than? I definitely would be.

Patient's lie a lot. I've personally seen patient's take a "sip" of water with their medicines....let's just say some people consider a sip of water like half a can of coke (6 ounces).

But getting back to the gum chewing....if they are believable, and it's only a brief gum chewing, I usually just wait an hour.

An hour? How brief is brief?

Where is PlanktonMD when I need him?????? We have had this discussion before on this forum.
 
Also, for undifferentiated second degree block, pretty sure that widened qrs suggests mobitz II. A cardiologist told me that 2:1 block with a narrow qrs is almost never mobitz II. If you have mobitz I with a wide qrs, it implies additional pathology.
 
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