aaa

[militarymd]

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This is one of my older cases....so some of the details are muddy.

60 something lady admitted for AAA repair (around 5 cm) which will require supra renal cross clamp.

med history includes:

htn
oxygen treated COPD.....with nc o2 at 4 l/m...sats in low 90's
dm
diabetic renal insufficiency cr 1.5

Patient went to cath lab on hospital day one to evaluate anatomy.

Scheduled on hospital day 2 for surgery....cancelled because of inability to cross match blood because of antibodies.

Took several days to get blood available....and in between... patient went back to cath lab again for some reason known only to the vascular surgeon ( He's not the sharpest tool in the shed).

Finally gets scheduled for surgery around hospital day 6 or 7.

I see the patient....the significant lab is Cr is not 3+...for which a nephrologist was consulted....and who has some nice recommendations written in the chart....NAC...Bicarb infusion...avoid hypotension..avoid hypovolemia. maintain urine output..etc.....

So how about some discussion about this case.

 

[urge]

Pent sux tube

dialysis.

 

[Noyac]

Pent sux tube

dialysis.

F*cking Hilarious! Thanks Urge, i laughed my ass off.

But seriously, THis pt's AAA is only 5cm and at that size the risk of rupture (unless it is growing rapidly) is less than 5% per year. That means it would be 10 yrs before she gets to a 50% chance of rupture assuming that it doesn't change. So the best treatment for this pt is no treatment. Follow it with serial US every 6 months and ten stent it when its time.

These guys that operate on things like this make no sense but they drive nice cars, really nice cars.

What does this jackhole drive, Mil?

 

[2win]

F*cking Hilarious! Thanks Urge, i laughed my ass off.

But seriously, THis pt's AAA is only 5cm and at that size the risk of rupture (unless it is growing rapidly) is less than 5% per year. That means it would be 10 yrs before she gets to a 50% chance of rupture assuming that it doesn't change. So the best treatment for this pt is no treatment. Follow it with serial US every 6 months and ten stent it when its time.

These guys that operate on things like this make no sense but they drive nice cars, really nice cars.

What does this jackhole drive, Mil?

👍👍👍

 

[IN2B8R]

How high/low does the aneurysm extend? Does it involve the renal vessels themselves? How has it changed over the past year? Is there any chance getting this done via endovascular approach, or is that out of the question?

This is one of my older cases....so some of the details are muddy.

60 something lady admitted for AAA repair (around 5 cm) which will require supra renal cross clamp.

med history includes:

htn
oxygen treated COPD.....with nc o2 at 4 l/m...sats in low 90's
dm
diabetic renal insufficiency cr 1.5

Patient went to cath lab on hospital day one to evaluate anatomy.

Scheduled on hospital day 2 for surgery....cancelled because of inability to cross match blood because of antibodies.

Took several days to get blood available....and in between... patient went back to cath lab again for some reason known only to the vascular surgeon ( He's not the sharpest tool in the shed).

Finally gets scheduled for surgery around hospital day 6 or 7.

I see the patient....the significant lab is Cr is not 3+...for which a nephrologist was consulted....and who has some nice recommendations written in the chart....NAC...Bicarb infusion...avoid hypotension..avoid hypovolemia. maintain urine output..etc.....

So how about some discussion about this case.

 

[IN2B8R]

LOL, why include the tube part? Just Pent and sux, that will save us the extra expenditure....

Pent sux tube

dialysis.

 

[militarymd]

How high/low does the aneurysm extend? Does it involve the renal vessels themselves? How has it changed over the past year? Is there any chance getting this done via endovascular approach, or is that out of the question?

- yes
- 1 cm
- no...I think that's why there was a second trip to the cath lab.

 

[Licoricestick]

the significant lab is Cr is not 3+...for which a nephrologist was consulted....and who has some nice recommendations written in the chart....NAC...Bicarb infusion...avoid hypotension..avoid hypovolemia. maintain urine output..etc.....

Did the renal guys miss the bit about AAA involving renal vessels, requiring supra renal x-clamp? Or do they have a magic way of mantaining urine output despite the absence of blood flow to the kidneys?

Preop questions: any cardiac Ix available - specifically recent ECG, angio, echo? Is her COPD as good as it gets? Airway (I assume as you haven't mentioned anything it was unremarkable)? Check with surgeon if they really want to proceed with Cr 2x baseline


Plan:
Consent to include risk of irreversible renal failure and dialysis dependence
Double check blood is available
14-16G IV
Midaz
Artline + standard monitors
Epidural, low thoracic
GA - Fentanyl, thio or propofol, cisatracurium
ETT
CVC
2nd large bore IV (if CVC isn't a MAC line)
FAWD, fluid warmer
Maintenance: Sevo + Epidural
Renal protection: Attempt to maintain MAP with fluids in preference to vasopressors prior to clamping, ensure adequately loaded prior to clamp coming off. Not sure there is much else that is going to make much difference, given that there is no way to do the operation without cutting of RBF.
Extubate
High dependency post op

 

[Frank Rizzo]

for access, place a vascath, that way she avoids anymore sticks when she needs dialysis on POD #2. Hell, if the vasc surgeon wants to make three payments on that nice car, instead of two, have him do an A-V fistula before you wake up!

 

[Fastrach]

Did the renal guys miss the bit about AAA involving renal vessels, requiring supra renal x-clamp? Or do they have a magic way of mantaining urine output despite the absence of blood flow to the kidneys?

Preop questions: any cardiac Ix available - specifically recent ECG, angio, echo? Is her COPD as good as it gets? Airway (I assume as you haven't mentioned anything it was unremarkable)? Check with surgeon if they really want to proceed with Cr 2x baseline


Plan:
Consent to include risk of irreversible renal failure and dialysis dependence
Double check blood is available
14-16G IV
Midaz
Artline + standard monitors
Epidural, low thoracic
GA - Fentanyl, thio or propofol, cisatracurium
ETT
CVC
2nd large bore IV (if CVC isn't a MAC line)
FAWD, fluid warmer
Maintenance: Sevo + Epidural
Renal protection: Attempt to maintain MAP with fluids in preference to vasopressors prior to clamping, ensure adequately loaded prior to clamp coming off. Not sure there is much else that is going to make much difference, given that there is no way to do the operation without cutting of RBF.
Extubate
High dependency post op

Would nix the epidural if it's a suprarenal aneurysm out of concerns for hypotension/compromised renal perfusion postop; infrarenal maybe.
Don't forget some mannitol +/- lasix before clamping, for what it's worth.

 

[ProRealDoc]

This is one of my older cases....so some of the details are muddy.

60 something lady admitted for AAA repair (around 5 cm) which will require supra renal cross clamp.

med history includes:

htn
oxygen treated COPD.....with nc o2 at 4 l/m...sats in low 90's
dm
diabetic renal insufficiency cr 1.5

Patient went to cath lab on hospital day one to evaluate anatomy.

Scheduled on hospital day 2 for surgery....cancelled because of inability to cross match blood because of antibodies.

Took several days to get blood available....and in between... patient went back to cath lab again for some reason known only to the vascular surgeon ( He's not the sharpest tool in the shed).

Finally gets scheduled for surgery around hospital day 6 or 7.

I see the patient....the significant lab is Cr is not 3+...for which a nephrologist was consulted....and who has some nice recommendations written in the chart....NAC...Bicarb infusion...avoid hypotension..avoid hypovolemia. maintain urine output..etc.....

So how about some discussion about this case.

Mil: I am concerned about the fact a pt with chronic renal insufficiency was given contrast x 2 in a week. Did you mean to say her creat. is 3+? Is she on any inhalers/current steroids for COPD? Any cardiac workup available? If not then goold old H&P would have to suffice. At DA U, she'd get an echo/heart cath but this is the real world. Is the surgeon fast?


1) pre-induction aline
2) smooth induction with agent of choice
3)MAC/swan and quinton (she'll need it post op)
4) nipride/nitro gtt (whatever you prefer) ready
5) keep her peeing
6) Drop off intubated in ICU

 

[militarymd]

The learning point about this case is not how you do it.....it's about whether the case should be done at all.....at least that day.

I did the case.....when I should have NOT done the case.

Here are the things I learned from this case:

Just because a "specialist" gives the OK doesn't mean that it is OK. I learned that the nephrologists around where I practice are a bunch of idiots when it comes to perioperative care/critically ill patients.

This patient had base line renal insufficiency....and had 2 separate insults in 1 week....(contrast nephropathy)....and her creatinine clearance is on its wane RIGHT on the day of surgery from the second exposure.....

One SHOULD NOT take someone like that to the OR electively when the operative case has a known post op renal failure rate that is significant.

The right thing to do is to wait for the contrast nephropathy to resolve before going to the OR despite what the fricking pee doctor says.

I said no...and the surgeon (who is ALSO NOT the sharpest tool in the shed) declares it an emergency...even after I told him that he was guaranteeing post-op renal failure and dialysis for this patient...with all the attributable mortality that goes with periop renal failure and dialysis.

The patient died about a week after surgery.....

This case was in my first months in PP at my current gig....I had NO POLITICAL CAPITAL....the loser nephrologist HAD a fair amount...and the surgeon listened to the pee doctor and not me.

I'm not saying that waiting for renal function to recover would have altered the outcome, but at least the odds would have been a little better.

Currently I have built up my political capital to the point where this won't happen again.....sometimes, based on your situation, you may not be able to make the right call even if you're right............oh, and btw....refusing to do a case because of clear liquids is NOT a good way to build your political capital.

 

[ProRealDoc]

The learning point about this case is not how you do it.....it's about whether the case should be done at all.....at least that day.

I did the case.....when I should have NOT done the case.

Here are the things I learned from this case:

Just because a "specialist" gives the OK doesn't mean that it is OK. I learned that the nephrologists around where I practice are a bunch of idiots when it comes to perioperative care/critically ill patients.

This patient had base line renal insufficiency....and had 2 separate insults in 1 week....(contrast nephropathy)....and her creatinine clearance is on its wane RIGHT on the day of surgery from the second exposure.....

One SHOULD NOT take someone like that to the OR electively when the operative case has a known post op renal failure rate that is significant.

The right thing to do is to wait for the contrast nephropathy to resolve before going to the OR despite what the fricking pee doctor says.

I said no...and the surgeon (who is ALSO NOT the sharpest tool in the shed) declares it an emergency...even after I told him that he was guaranteeing post-op renal failure and dialysis for this patient...with all the attributable mortality that goes with periop renal failure and dialysis.

The patient died about a week after surgery.....

This case was in my first months in PP at my current gig....I had NO POLITICAL CAPITAL....the loser nephrologist HAD a fair amount...and the surgeon listened to the pee doctor and not me.

I'm not saying that waiting for renal function to recover would have altered the outcome, but at least the odds would have been a little better.

Currently I have built up my political capital to the point where this won't happen again.....sometimes, based on your situation, you may not be able to make the right call even if you're right............oh, and btw....refusing to do a case because of clear liquids is NOT a good way to build your political capital.

Sucks for the pt and her family. What was her cause of death? Is the ICU care ****ty at your hospital? I know you're not running the ICU so who does?

 

[militarymd]

Sucks for the pt and her family. What was her cause of death? Is the ICU care ****ty at your hospital? I know you're not running the ICU so who does?

everybody.


sirs/mods after starting hd

 

[IN2B8R]

Yep. F*ck with the kidney long enough, be that from contrast nephropathy or intra-op insults from clamping/hypotension, then you get what you got. It all goes back to surgery 101: what's the best predictor of a successful surgical outcome? Patient selection.

Nice post, Mil.👍

The learning point about this case is not how you do it.....it's about whether the case should be done at all.....at least that day.

I did the case.....when I should have NOT done the case.

Here are the things I learned from this case:

Just because a "specialist" gives the OK doesn't mean that it is OK. I learned that the nephrologists around where I practice are a bunch of idiots when it comes to perioperative care/critically ill patients.

This patient had base line renal insufficiency....and had 2 separate insults in 1 week....(contrast nephropathy)....and her creatinine clearance is on its wane RIGHT on the day of surgery from the second exposure.....

One SHOULD NOT take someone like that to the OR electively when the operative case has a known post op renal failure rate that is significant.

The right thing to do is to wait for the contrast nephropathy to resolve before going to the OR despite what the fricking pee doctor says.

I said no...and the surgeon (who is ALSO NOT the sharpest tool in the shed) declares it an emergency...even after I told him that he was guaranteeing post-op renal failure and dialysis for this patient...with all the attributable mortality that goes with periop renal failure and dialysis.

The patient died about a week after surgery.....

This case was in my first months in PP at my current gig....I had NO POLITICAL CAPITAL....the loser nephrologist HAD a fair amount...and the surgeon listened to the pee doctor and not me.

I'm not saying that waiting for renal function to recover would have altered the outcome, but at least the odds would have been a little better.

Currently I have built up my political capital to the point where this won't happen again.....sometimes, based on your situation, you may not be able to make the right call even if you're right............oh, and btw....refusing to do a case because of clear liquids is NOT a good way to build your political capital.