"A Single EGD that will only take 10min"

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At the military I would cancel. My civ hospital zu ze case.
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At my previous job, no problem. Current gig the nursing supervisor would be calling the ambulance/chopper to transport this guy out as soon as I read the chart!
 
Standing by for a proposed mechanism by which this patient crumps with a judiciously conducted MAC.

I will reiterate that the fenestrated aspect of this Fontan is crucial. If not fenestrated, my degree of concern goes way up.

Look I did fellowship in a place that did a ton of adult congenital cardiac, and I do a lot in my current private practice. I am more comfortable with these kinds of patients than probably most. I agree completely that a comprehensive understanding of the patient's physiology is mandatory before proceeding. And as usual *the patient in front of you is the most important data point.* You'll be able to tell from looking at this person whether they'll do ok. Since they walked into the facility on their own power, it seems highly likely that they will.

Doctor the f up, I say. You went through all that fancy schooling and went through all those hours of residency and became a consultant in acute care cardiopulmonary physiology for a reason. Not for the ASA 1 knee scope, for this.

Give me cases like this all day. This is why we're "physician anesthesiologists." Know the pertinent physiology, know what you can and can't do, and get the case done.

And while "crash onto CPB" might sound like a reasonable bailout plan to some, in real life this is just absurdly implausible.
 
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Hawaiian Bruin said:
Standing by for a proposed mechanism by which this patient crumps with a judiciously conducted MAC.

I will reiterate that the fenestrated aspect of this Fontan is crucial. If not fenestrated, my degree of concern goes way up.

Look I did fellowship in a place that did a ton of adult congenital cardiac, and I do a lot in my current private practice. I am more comfortable with these kinds of patients than probably most. I agree completely that a comprehensive understanding of the patient's physiology is mandatory before proceeding. And as usual *the patient in front of you is the most important data point.* You'll be able to tell from looking at this person whether they'll do ok. Since they walked into the facility on their own power, it seems highly likely that they will.

Doctor the f up, I say. You went through all that fancy schooling and went through all those hours of residency and became a consultant in acute care cardiopulmonary physiology for a reason. Not for the ASA 1 knee scope, for this.

Give me cases like this all day. This is why we're "physician anesthesiologists." Know the pertinent physiology, know what you can and can't do, and get the case done.

And while "crash onto CPB" might sound like a reasonable bailout plan to some, in real life this is just absurdly implausible.
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The same mechanism by which all other patients who have crumped while getting an EDG with propofol crump. Except there is no reserve left on this guy. Hypotension is a given with propofol. Worsened hypoxia is also a given from hypoventilation and from increased PVR causing more right to left shunt and from obstruction. Decreased cardiac output from decreased preload caused by the propofol is not unlikely either.

To summarize: no reserve yet hypoxia, hypotension, and decreased cardiac output are likely to occur. Still think a complication is far fetched?

Agree there is no reason to crash on bypass or ecmo. This guy has no surgical options which we already know. His only option is medical management.

I'm not saying the case can't be done. All I'm saying is you should have a lot of healthy respect for this "just an egd". I would only do it in house where icu care is available and his cardiologist is privileged to round on him if needed. Maybe the guy does just fine and can be discharged an hr after the egd which is fine by me. But in case he doesn't I'm prepared.

Also, saying the guy walked is quite a stretch. We were told he uses a walker to move around despite being a young man. How many 30 year olds who are "just fine" use a walker?
 
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Hawaiian Bruin said:
Standing by for a proposed mechanism by which this patient crumps with a judiciously conducted MAC.

I will reiterate that the fenestrated aspect of this Fontan is crucial. If not fenestrated, my degree of concern goes way up.

Look I did fellowship in a place that did a ton of adult congenital cardiac, and I do a lot in my current private practice. I am more comfortable with these kinds of patients than probably most. I agree completely that a comprehensive understanding of the patient's physiology is mandatory before proceeding. And as usual *the patient in front of you is the most important data point.* You'll be able to tell from looking at this person whether they'll do ok. Since they walked into the facility on their own power, it seems highly likely that they will.

Doctor the f up, I say. You went through all that fancy schooling and went through all those hours of residency and became a consultant in acute care cardiopulmonary physiology for a reason. Not for the ASA 1 knee scope, for this.

Give me cases like this all day. This is why we're "physician anesthesiologists." Know the pertinent physiology, know what you can and can't do, and get the case done.

And while "crash onto CPB" might sound like a reasonable bailout plan to some, in real life this is just absurdly implausible.
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Hmm I mostly agree!
But saying you love this type of thing makes me wonder! If this guy kicks it in the endoscopy suite for some random reason despite a beautiful anaesthetic you're cooked...
Seriously why take the risk? Do you think the gi doc will come to court with you? This guy is why tertiary care exists.
By all means if the guy is ready to croak and need a tube or laparotomy give it a go but I don't know why youd take all the risk... And a jury of your peers(albeit not as educated as you) thinks differently to you...

Community hospitals ship us anyone over BMI 45 for even hernias. Sometimes I laugh at how trivial the issues are... But these guys in the community sleep soundly I imagine.
 
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somedumbDO said:
Done more pedi hearts than I care to remember, some of you seem pretty cavalier about how sick or how fast these cases can turn south. I am curious out of the people who have replied how many have done more than 10 fontains in their career? Understanding the physiology is one thing, but having a group of dedicated physicians/surgeons/intensivists that do this every day is another. We can all agree this case should be done at a tertiary care hospital? This isnt an emergency. I have had this happen to me, just a simple dental rehab on this hypoplast w central shunt.... glad there was bypass available
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Ok but a BT shunt patient isn’t the same as a completed Fontan sequence. Everyone knows the intermediate stage is the tenuous one. Also what happened during the case ? Sounds like he clotted his shunt if you had no way out but CPB, and if that’s the case it wasn’t the anesthesia.
 
I said I'd cancel it not because I can't handle this patient, but because the conditions as presented in the original post are terrible, and this is not an emergency (I am assuming this poster's hospital was not a tertiary care center). If you did take this guy in and he dies, that's a slam dunk lawsuit. I don't have anything to prove, and if this was my mom or dad I would want all doctors involved to maximize the conditions for his/her survival. There are plenty of hospitals that would be totally inappropriate to do this case at IMO. I also wouldn't trust a CRNA with this one.
This reminds me of surgeons over the years who have given my partners and I crap for putting in lines *they* don't think are necessary. I'd rather have more than I need than less on certain patients, and if it takes 5 or 10 extra minutes, oh well. I have thanked sweet baby Jesus plenty of times that I followed my instincts and over prepared.... I've never regretted covering my butt. Restraint and knowing limitations is not a sign of weakness and doesn't make one less doctorly.
 
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T-burglar said:
Ok but a BT shunt patient isn’t the same as a completed Fontan sequence. Everyone knows the intermediate stage is the tenuous one. Also what happened during the case ? Sounds like he clotted his shunt if you had no way out but CPB, and if that’s the case it wasn’t the anesthesia.
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Central shunt, not BT. Doubt it clotted. Don't understand why people start making up stuff.

When all you have is a hammer everything looks like a nail.
 
T-burglar said:
Ok but a BT shunt patient isn’t the same as a completed Fontan sequence. Everyone knows the intermediate stage is the tenuous one. Also what happened during the case ? Sounds like he clotted his shunt if you had no way out but CPB, and if that’s the case it wasn’t the anesthesia.
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Why can't anesthetic management contribute to shunts clotting off? Low CO can contribute to clot formation, are you saying nothing we do causes low CO?

Also, most things that I've read have recommended semi-elective procedures to occur after Stage 2 of the palliative sequence (post-Glenn, pre-Fontan), as it is the safest.

I agree it would best to do it at a tertiary care center (where the patient normally receives care, if at all stable.)
 
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urge said:
The same mechanism by which all other patients who have crumped while getting an EDG with propofol crump. Except there is no reserve left on this guy. Hypotension is a given with propofol. Worsened hypoxia is also a given from hypoventilation and from increased PVR causing more right to left shunt and from obstruction. Decreased cardiac output from decreased preload caused by the propofol is not unlikely either.

To summarize: no reserve yet hypoxia, hypotension, and decreased cardiac output are likely to occur. Still think a complication is far fetched?

Agree there is no reason to crash on bypass or ecmo. This guy has no surgical options which we already know. His only option is medical management.

I'm not saying the case can't be done. All I'm saying is you should have a lot of healthy respect for this "just an egd". I would only do it in house where icu care is available and his cardiologist is privileged to round on him if needed. Maybe the guy does just fine and can be discharged an hr after the egd which is fine by me. But in case he doesn't I'm prepared.

Also, saying the guy walked is quite a stretch. We were told he uses a walker to move around despite being a young man. How many 30 year olds who are "just fine" use a walker?
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And while all of this is true, it comes down to knowing how to sedate a sick patient. Yes, when you give some propofol his pressure will go down and he will lose some drive to breath, but when that probe gives him stimulation his pressure will rise and he will be breathing again. Then it's just maintenance with touches of propofol, ie he squints give a bit more. Again, everything in your post is absolutely true.

I don't think anyone who is agreeing to do the case is walking in with a 20cc syringe of propofol and giving the entire thing. That's just wreckless. This EGD is either diagnostic or therapeutic and probably benefits him somewhat to have it done. To put it slightly more gently than Hawaiian Bruin, use your training and get the case done, or call a colleague who can get it done. I don't think there's anything "cavalier" about proceeding. I do think you can proceed and proceed with caution.

This case reminds me of when some of our surgeons get mad when one of my real sickies moves during a case while I'm running them light. My snarky response, "Moves = Not dead". Run the EGD light. A competent, vigilant anesthesiologist wont kill this guy with this case. But who knows, maybe I'm giving our field too much credit *shrug emoji*
 
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The patient is the same high risk at the tertiary center. They’re just more accustomed and more willing to biting the bullet and proceeding. We have docs who cancel 2 cases a week and others who cancel 2 cases a year. Apparently SDN does too.
 
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Do you do cardiac cases? Everyone repeats this because it’s in Miller but general anesthesia doesn’t actually drop cardiac output in any profound way. My lvad patients don’t go from compensated to suddenly in shock following induction.
Stroke volumes calculated by echo under GA are usually close to awake values.

Also urge you say central shunt not BT as if the physiology isn’t the same. A BT is just a subtype of a “central shunt”. Others being for example a sano modification. Could you explain the difference in physiology that invalidates my reasoning.
 
calvnandhobbs68 said:
You mean like a Sano (RV-PA) vs a modified BT? I don't think it's unheard of for Sanos to clot either.
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Anything and everything can clot. I had in mind a real central shunt, as in ascending aorta to main pulm artery. These have more flow and are much shorter that other shunts. I guess it's a matter of semantics across the country. When it was brought up I assumed the kid arrested from over shunting.

Only way we will know is if the person who had the case decides to talk about it.
 
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I find the arguments both ways very entertaining.

As a PICU person, had this patient been followed by the cards group where I did fellowship, they would have been all over this guy...admission a day prior to the Peds CICU, formal consults from adult congenital, heart failure/transplant team, cardiac anesthesia, and CT surgery, and because we had an extremely vocal EP group, they would have gotten involved too (because they always did, don't ask me what they added of value most times). Invariably with all those cooks in the kitchen, someone would have wanted to modulate something on him, and that "10 minute" EGD would end up being a 3-4 day CICU stay...if he was lucky and they elected not to just go straight to a Fontan reconstruction with a Maze procedure thrown in.
 
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Arch Guillotti said:
Posting for a long time member anonymously:
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Any updates on the case? Was he completed at the outside hospital? Did he get shipped off to another center that deals more with congenital cardiac patients?
 
It was a central shunt aorta to pa. Never seen a central shunt clot but I guess anything can happen. This kid was a sick puppy also had tapvr as well. Wanted to get rid of an abscess tooth before putting in anymore gortex. Over shunted, kiddies don't crash on to bypass well. Able to get him on pump for a revision after lots of sphincter puckering. Kid did well. Not many tapvr/Lhhs make it. Regardless obviously this isn't a prop/sux/tube case. Coming out of fellowship I thought I can do any case, you slowly (albeit after some near misses/bad outcomes) acknowledged that every hospital has its limitations (staff, equipment, etc), it's not always about the skill of the anesthesiologist. So to "doctor the F* up???!???" Just screams of arrogance to me. Especially when you have 4 university hospitals 20 min away from you, what is in the patients best interest??? Btw I am a rvu doc....
 
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The closest University hospital is 2500 miles away from me. So there's that.

And it's confidence, not arrogance;)
 
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Hawaiian Bruin said:
The closest University hospital is 2500 miles away from me. So there's that.

And it's confidence, not arrogance;)
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New York to California is not even 3k miles. You must live in a special part of the country.
 
This case may be easy, but in my 80 bed community hospital, doing anything elective with this patient is unconsionable.

I have no useful specialists. I have an ICU that has tried to block post op admissions because they're "too sick". The blood bank has 2 units of FFP and 2 units of O negative. It takes 4 hours to get platelets.
I have endoscopists that routinely scope people that they have never met, and don't know why the NP referred them until 10 minutes before the start time.

There are several ways to do this guy reasonably safely. I dont think any of them are available to me. He should be sent down the road.
 
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urge said:
Anything and everything can clot. I had in mind a real central shunt, as in ascending aorta to main pulm artery. These have more flow and are much shorter that other shunts. I guess it's a matter of semantics across the country. When it was brought up I assumed the kid arrested from over shunting.

Only way we will know is if the person who had the case decides to talk about it.
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Central shunts are less common these days but one of our surgeons does them. Never heard of one clotting off, BT shunts on the other hand..
 
urge said:
The same mechanism by which all other patients who have crumped while getting an EDG with propofol crump. Except there is no reserve left on this guy. Hypotension is a given with propofol. Worsened hypoxia is also a given from hypoventilation and from increased PVR causing more right to left shunt and from obstruction. Decreased cardiac output from decreased preload caused by the propofol is not unlikely either.

To summarize: no reserve yet hypoxia, hypotension, and decreased cardiac output are likely to occur. Still think a complication is far fetched?
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I could be wrong, Wouldn't decrease in SVR help his Fontan physiology?
 
dchz said:
I could be wrong, Wouldn't decrease in SVR help his Fontan physiology?
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Had a 20-something year old patient with a Fontan for a hypoplastic left heart present in labor with a normal term pregnancy. Got all excited for a moment thinking about how we were going to handle her anesthetic, then thought ... oh. I guess it's ... just going to be ... an epidural. So exciting.
 
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That’s interesting (regional differences in terminology ) . I did a decent amount of congenital in residency and fellowship and I don’t think I did any ascending to main PA shunts. Almost all our single ventricle sequences got a sano
 
T-burglar said:
Do you do cardiac cases? Everyone repeats this because it’s in Miller but general anesthesia doesn’t actually drop cardiac output in any profound way. My lvad patients don’t go from compensated to suddenly in shock following induction.
Stroke volumes calculated by echo under GA are usually close to awake values.

Also urge you say central shunt not BT as if the physiology isn’t the same. A BT is just a subtype of a “central shunt”. Others being for example a sano modification. Could you explain the difference in physiology that invalidates my reasoning.
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Peds cardiac and adult congenital. Most of the studies I've read that say no change in CO add the caveat that it is in healthy volunteers, which this patient population certainly is not. But also, it is not global cardiac output we're concerned about, but flow specifically through the BT shunt, and you can certainly control flow through the shunt (easily determined by SpO2) with maneuvers like fluid boluses and increasing the MAP (but particularly the diastolic since that is when the shunt is perfused).

You could argue that other factors (like hypercoaguability 2/2 surgical insult) is more important, and I couldn't argue that one way or the other. I just don't think you can say that there is nothing we can do to prevent shunts from going down from an anesthetic standpoint.
 
dchz said:
I could be wrong, Wouldn't decrease in SVR help his Fontan physiology?
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Yes, over the long term. Akin to ACE inhibitors for heart failure. It’s not tolerated that well acutely. Most likely the pt is already on after load reducers and the bp will likely bottom out from anesthesia.
 
somedumbDO said:
Done more pedi hearts than I care to remember, some of you seem pretty cavalier about how sick or how fast these cases can turn south. I am curious out of the people who have replied how many have done more than 10 fontains in their career? Understanding the physiology is one thing, but having a group of dedicated physicians/surgeons/intensivists that do this every day is another. We can all agree this case should be done at a tertiary care hospital? This isnt an emergency. I have had this happen to me, just a simple dental rehab on this hypoplast w central shunt.... glad there was bypass available
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Physiology notwithstanding I think people here also need to recognize that the procedure itself is incredibly low risk. The patient is not in decompensated heart failure? Failing but not failed. He did come from home, not an ICU bed, so obviously something thought he was healthy enough to not need constant attention / life support.

Would you do a cataract case for this patient? Yes I would. Would you do an EGD on this patient with the technique I described above? Yes I would.
 
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eikenhein said:
Agree that bad things can happen. But usually the complication is aspiration. Not decompensated heart failure.
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Oh is that all...with or without acute hypoxemia? And how does that bode for an already hypoxemic patient with a Fontan?
 
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Hawaiian Bruin said:
Standing by for a proposed mechanism by which this patient crumps with a judiciously conducted MAC.

I will reiterate that the fenestrated aspect of this Fontan is crucial. If not fenestrated, my degree of concern goes way up.

Look I did fellowship in a place that did a ton of adult congenital cardiac, and I do a lot in my current private practice. I am more comfortable with these kinds of patients than probably most. I agree completely that a comprehensive understanding of the patient's physiology is mandatory before proceeding. And as usual *the patient in front of you is the most important data point.* You'll be able to tell from looking at this person whether they'll do ok. Since they walked into the facility on their own power, it seems highly likely that they will.

Doctor the f up, I say. You went through all that fancy schooling and went through all those hours of residency and became a consultant in acute care cardiopulmonary physiology for a reason. Not for the ASA 1 knee scope, for this.

Give me cases like this all day. This is why we're "physician anesthesiologists." Know the pertinent physiology, know what you can and can't do, and get the case done.

And while "crash onto CPB" might sound like a reasonable bailout plan to some, in real life this is just absurdly implausible.
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If you do live in Hawaii then you at lease have a children's hospital in the state where I guarantee you they have a pediatric cardiologist who can give you a detailed report; not an adult cardiologist who is refusing to even give a prelim read like in this scenario. I still think it would be malpractice to put this guy to sleep without all of the available information in front of us unless the GI doc explicitly writes in the chart that his banding is an emergency and he cannot be shipped to the appropriate facility. These patients die of arrhythmias/sudden cardiac death all of the time due to their completely distorted conduction system, even at home where this guy came from. I also think that this guy is being lost to follow up and not completely optimized; which can happen once single ventricle patients reach adulthood and they are no longer pushed into doctor's visits by their parents. More than any propofol induced hypotension I would be worried about him having just enough hypoxia, hypercarbia, or surgical stimulation to push him into V-Fib or pulseless V-Tach. It then becomes very hard to resuscitate these patients because of their said distorted conduction system and their possible tricuspid regurgitation, making it harder for any Epi and CPR to perfuse their brain and coronary arteries rather than just pumping backwards. I would just want the best available specialists of all disciplines on hand if/when SHTF.
 
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urge said:
Yes, over the long term. Akin to ACE inhibitors for heart failure. It’s not tolerated that well acutely. Most likely the pt is already on after load reducers and the bp will likely bottom out from anesthesia.
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But unlike ACE inhibitors, the pharmacokinetics is much quicker.

If it bottoms too much, give it some alpha 1 agonism?? It's not gonna be the cardiac failure leading to hypotension from 40mg of propofol right?
 
This guy is a failing Fontan. Only a dope would want to perform a non emergency procedure on him in some place that doesn’t understand these patients. You get paid the big bucks because you know who not to operate on when you don’t have to. Based on the description neither the anesthesiologist, the GI dope, the patient, nor the adult cardiologist know what complex congenital cardiac defect this guy has or how it was repaired.
That alone would be a full stop and I’m a pediatric anesthesiologist. He needs a real history and/or at least a real exam by someone competent to opine on what he’s got going on in there and how it might have been palliated a few decades ago, and If anything can be done to optimize him for his “quick EGD with banding”. I bet the last adult echo consisted of “complex congenital cardiac disease, s/p Fontan, not in failure. F/u 12 months.”


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Il Destriero
 
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Let me try to break this down so i can avoid the Dunning-Kruger:

His only ventricle pumps to systemic circulation and the venous drainage mixes with pulm artery passively drains into lungs then to drain into the atrium for the systemic ventricle.

There may or may not be a pop off on the venous side that allows venous overflow to the systemic circulation. (+/- fenestrations on conflicting TTEs)

All human physiology still applies after that. And pt is compensated enough to not need home O2 and able to walk around with walker.

The planned procedure is to band veins from varices, with potential blood loss. After talking it out it just feels like an EGD with any other cause of varices. Our job is to let him tolerate a EGD scope going down his oral pharynx for "10 mins".

Correct me, or paint a more complete picture on what i'm missing please.

I also don't understand why OP said he wouldn't use phenylephrine. It sounds like the perfect drug to counteract the SVR drop from propofol here.
 
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dchz said:
But unlike ACE inhibitors, the pharmacokinetics is much quicker.

If it bottoms too much, give it some alpha 1 agonism?? It's not gonna be the cardiac failure leading to hypotension from 40mg of propofol right?
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Correct, assuming you don't over do it both on the way down or the way up. It's a very fine line to walk with very bad outcome if not done properly. Basically the key is not to disturb him too much. Easier said than done some times.

PS: I think we have gone deeper than SDN can handle. I will excuse myself from this thread since I don't want to keep arguing stuff that is not factually correct.

Until then I bid you Pent Sux Tube, which, BTW, happens to be the way I would have handled it.
 
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To quote myself, "I agree completely that a comprehensive understanding of the patient's physiology is mandatory before proceeding."

Also:

LAW 13: THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.
 
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IlDestriero said:
This guy is a failing Fontan. Only a dope would want to perform a non emergency procedure on him in some place that doesn’t understand these patients. You get paid the big bucks because you know who not to operate on when you don’t have to. Based on the description neither the anesthesiologist, the GI dope, the patient, nor the adult cardiologist know what complex congenital cardiac defect this guy has or how it was repaired.
That alone would be a full stop and I’m a pediatric anesthesiologist. He needs a real history and/or at least a real exam by someone competent to opine on what he’s got going on in there and how it might have been palliated a few decades ago, and If anything can be done to optimize him for his “quick EGD with banding”. I bet the last adult echo consisted of “complex congenital cardiac disease, s/p Fontan, not in failure. F/u 12 months.”


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Il Destriero
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After his real history and his real exam they will take him to the endo suite, provide supplemental O2, and carefully titrate propofol while maintaining spontaneous ventilation. Also how are they gonna get a good quality echo on this 40bmi patient? Maybe they can TEE him stone cold sober, then give the okay for EGD with sedation.;)
 
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Like dchz said, he still obeys the laws of human physiology. Saying that a mild transient hypercarbia or hypoxia or transient swings in blood pressure will suddenly "push" this patient into VT or VF just says to me that you don't really ever take care of sick cardiac patients, because this is not reality. Again, this is a palliated walking talking fontan who stresses himself every time he sleeps or naps and still has not had an episode of SCD or ICU admission for cardiogenic shock. It's not one of the handful of sick neonatal or toddler conditions that's much scarier.

And as nimbus said, what would you do when this guy shows up on your schedule for TEE prior to revision cardiac surgery?
 
T-burglar said:
Like dchz said, he still obeys the laws of human physiology. Saying that a mild transient hypercarbia or hypoxia or transient swings in blood pressure will suddenly "push" this patient into VT or VF just says to me that you don't really ever take care of sick cardiac patients, because this is not reality. Again, this is a palliated walking talking fontan who stresses himself every time he sleeps or naps and still has not had an episode of SCD or ICU admission for cardiogenic shock. It's not one of the handful of sick neonatal or toddler conditions that's much scarier.

And as nimbus said, what would you do when this guy shows up on your schedule for TEE prior to revision cardiac surgery?
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Don't tell me what I do or don't do in my practice. I take care of plenty of sick cardiac patients as an attending pediatric anesthesiologist unlike many of the posters here who have "been exposed" to congenital cardiac as residents or adult cardiac fellows, which might mean 1-2 months at a children's hospital Max and a handful of Fontan and intermediate operations under the supervision of their attending. I have done plenty of fontan completions, their intermediary procedures, fontan re-operations, and more interventional cath lab cases and non-cardiac surgeries than I can count. I have also had plenty of these patients arrest in front of me. The fact that you don't understand that they are at high risk of SCD and that this patient is in failure and not just part of his "natural progression" shows to me that you lack a basic understanding of single ventricle physiology. I never said that this was a complicated anesthetic. To quote myself earlier, I also said that most competent anesthesiologists can get him through the procedure. I merely contend that it is malpractice to anesthetize him at a facility that lacks the appropriate available resources such as in this scenario unless the GI doc declares it an emergency. I feel that anyone who chooses to proceed with this case in this given scenario will be toast in the court of law. To answer your question about what I would do if he presents for a TEE prior to a fontan revision I have several answers: 1. I would have no problem sedating him for a TEE at the appropriate facility where I have a cardiologist who actually knows what to look for 2. I have never almost never seen a TEE performed as a part of a work up for pediatric cardiac surgery (almost always TTEs as well as catheterizations for calculations of right sided pressures) and 3. There is no revision cardiac surgery for this patient. He is in end stage heart failure based on several indices which I don't think that you comprehend (cyanosis, decline in functional status, and liver failure). His next step is a heart transplant.
 
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HalO'Thane said:
...I never said that this was a complicated anesthetic. To quote myself earlier, I also said that most competent anesthesiologists can get him through the procedure. I merely contend that it is malpractice to anesthetize him at a facility that lacks the appropriate available resources such as in this scenario unless the GI doc declares it an emergency...
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A couple of things have emerged from this discussion that stand out and one is the way people blithely throw around the term "compensated". CHF is a compensatory response that ultimately ends in the patient's death. That he's compensated for laying around his house and light housework isn't grounds for a sense of well being for his doctors here. The second is the implied assumption that everything is going to go well. It isn't an anesthetic, it's a procedure. Aspiration/hypoxic insult? Esophageal tear? Significant or uncontrolled variceal bleeding? I can deal with these issues to the extent that I can get the patient to the ICU, but then what? Who looks after him when I leave for my next case?
 
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ok so we all teleport ourselves to CHOP......

Same patient same scenario

What’s the plan?
 
Twiggidy said:
ok so we all teleport ourselves to CHOP......

Same patient same scenario

What’s the plan?
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Lidocaine spray and versed. My plan never changed.

I' m not a pediatric cardiac anesthesiologist but I've dealt with more than a fair share of sick ass, tettering on death patients in the GI suite.
 
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T-burglar said:
Like dchz said, he still obeys the laws of human physiology. Saying that a mild transient hypercarbia or hypoxia or transient swings in blood pressure will suddenly "push" this patient into VT or VF just says to me that you don't really ever take care of sick cardiac patients, because this is not reality. Again, this is a palliated walking talking fontan who stresses himself every time he sleeps or naps and still has not had an episode of SCD or ICU admission for cardiogenic shock. It's not one of the handful of sick neonatal or toddler conditions that's much scarier.

And as nimbus said, what would you do when this guy shows up on your schedule for TEE prior to revision cardiac surgery?
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I’m more worried about a little hypoxia or hypercarbia increasing his PVR, worsening his Rt to Lt shunt through is already in use pop off valve fenestration, decreased cardiac output, etc. Then you’re in the profound hypoxia, hypotension, arrhythmia death spiral. I’ve been there, you don’t want to be there. This guy’s 2/3 of the way there already.


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Il Destriero
 
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Twiggidy said:
ok so we all teleport ourselves to CHOP......

Same patient same scenario

What’s the plan?
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First figure out what this dude has going on in his chest. Then good topicalization, precedex, +/- ketamine and spontaneous ventilation. And hopefully a quick GI guy who can do a “quick band”. That actually may not exist there. :(


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Il Destriero
 
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This would be a good oral boards scenario.
 
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With enough topical, and very judicious sedation (I’d use midazolam) I think he’ll do fine.

Since aspiration is disastrous for him, and I’m going to carefully topicalise anyway I might as well do an afoi as well. Once the ett is in, if the case drags on he can have a little sevo
 
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