An interesting case

[Sleeplessbordernights]

52 yo male scheduled for right thoracoscopy for tumor vs empiema (tough surgery was sure It was on the cancer side) with a history of heavy smoking over 20 years, HBP with no treatment, dilated miocardiopath, heart failure with FEV1 20%, recent onset AF. Current meds are digoxine, furosemide, enalapril and metoprolol. At the OR the patien was unstable with AF all over the place, my attending cancelled the case, but what would be your plan for this patient?

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[PainDrain]

Rate control his AF and bring him back in 24-48hrs for his surgery. If his AF is truly new onset he should have an updated echo to r/o clot and determine if his EF has dropped any. Also would like to ensure he isn’t currently in failure prior to proceeding so a BNP and CXR would be nice.

As for the case, it’s pretty basic. Thoracic epidural, arterial line and 18G IV in holding. Prop, roc and DLT. Another IV intraop depending on the skill of your surgeon. Keep fluids less than 500mls, avoid narcotics and begin using the epidural during the last 45 minutes of the case.

 

[Lidolover]

Rate control his AF and bring him back in 24-48hrs for his surgery. If his AF is truly new onset he should have an updated echo to r/o clot and determine if his EF has dropped any. Also would like to ensure he isn’t currently in failure prior to proceeding so a BNP and CXR would be nice.

As for the case, it’s pretty basic. Thoracic epidural, arterial line and 18G IV in holding. Prop, roc and DLT. Another IV intraop depending on the skill of your surgeon. Keep fluids less than 500mls, avoid narcotics and begin using the epidural during the last 45 minutes of the case.

It drives me crazy when ppl comment with confidence on the EXACT amount of fluids a thoracic surgery pt should receive. That DRY theory is so relative but ppl still believe DRY = < 500 cc.

 

[GassYous]

Why does he have new af? Probably it's due to the infection vs inflammation since I'm guessing that the ef is not new. I agree with the attending, I want the rate controlled and etiology explored. I'd like the hr to stay below 110 if possible. I'm not sure that the bnp matters much as long as the patient doesn't have 3+ pitting edema and wet lungs. Would seeing a cxr change anything? I would want a new echo as well though.

I just do thoracoscopies with a dlt and one iv now. I don't place an epidural, a line or 2nd iv because placing that would probably double the time we're in the or. I don't give more than a liter but I'm not sure that I believe in that dry lung wet lung stuff.

 

[PainDrain]

It drives me crazy when ppl comment with confidence on the EXACT amount of fluids a thoracic surgery pt should receive. That DRY theory is so relative but ppl still believe DRY = < 500 cc.

That <500mls isn’t for lung protection; hint it’s for his ticker.

 

[FiO2@21]

It drives me crazy when ppl comment with confidence on the EXACT amount of fluids a thoracic surgery pt should receive. That DRY theory is so relative but ppl still believe DRY = < 500 cc.

The figure I read was to aim for 6 cc/hr or less.

 

[PainDrain]

Why does he have new af? Probably it's due to the infection vs inflammation since I'm guessing that the ef is not new. I agree with the attending, I want the rate controlled and etiology explored. I'd like the hr to stay below 110 if possible. I'm not sure that the bnp matters much as long as the patient doesn't have 3+ pitting edema and wet lungs. Would seeing a cxr change anything? I would want a new echo as well though.

I just do thoracoscopies with a dlt and one iv now. I don't place an epidural, a line or 2nd iv because placing that would probably double the time we're in the or. I don't give more than a liter but I'm not sure that I believe in that dry lung wet lung stuff.

I didn’t read thoroughly, yes the epidural is overkill if it’s just thorascopic. I thought it was open. As for the arterial line, I do them for anyone with a low EF with the recent hx of arrhythmia.

 

[Lidolover]

The digoxin in his Med Rec indicates chronic afib more or less. It is a common choice in pt that have both HF and arrhythmias. Apparently, he has an acute exacerbation (either from rate controlled afib or a flip in his rhythm altogether. Given that afib is a common finding post thoracic surgery, I would not cancel the case as long as the pt was not getting into the field of unstable afib

 

[MirrorTodd]

Anyone use any of the continuous noninvasive arterial pressure products? The reps have been hanging around the hospital I'm currently rotating at. Easy enough to use, puts out more numbers than I need since I'd only really use it for arterial pressure monitoring in place of an A line.

 

[deleted171991]

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52 yo male scheduled for right thoracoscopy for tumor vs empiema (tough surgery was sure It was on the cancer side) with a history of heavy smoking over 20 years, HBP with no treatment, dilated miocardiopath, heart failure with FEV1 20%, recent onset AF. Current meds are digoxine, furosemide, enalapril and metoprolol. At the OR the patien was unstable with AF all over the place, my attending cancelled the case, but what would be your plan for this patient?

What was the HR? How did the patient compare his current status to his baseline? What did he tell you about the history and evolution of his disease during the last few months?

 

[FiO2@21]

52 yo male scheduled for right thoracoscopy for tumor vs empiema (tough surgery was sure It was on the cancer side) with a history of heavy smoking over 20 years, HBP with no treatment, dilated miocardiopath, heart failure with FEV1 20%, recent onset AF. Current meds are digoxine, furosemide, enalapril and metoprolol. At the OR the patien was unstable with AF all over the place, my attending cancelled the case, but what would be your plan for this patient?

I’m a little confused by the timeline. The case was started and they cancelled intra-operatively?

Or they were hypotensive with RVR in pre-op?

To me this would be sepsis secondary to empyema until proven otherwise. My question would be if the patient can be optimized in the unit or if this is “as good as they’re going to get”.

I would place an art line, central line if I foresee pressors in their future. Would avoid placing an epidural in a hypotensive patient.

 

[FiO2@21]

Anyone use any of the continuous noninvasive arterial pressure products? The reps have been hanging around the hospital I'm currently rotating at. Easy enough to use, puts out more numbers than I need since I'd only really use it for arterial pressure monitoring in place of an A line.

My preference for them is for SVV. There aren’t many patients out there who warrant those finger cuffs vs an art line.

For fun we placed an art line and that EV-1000 on the same patient, MAPs kind of agreed.

 

[T-burglar]

AF is common after thoracic surgery. Is the infection a proximate cause of his AF? If the infection is in the site of previous surgery then source control will be pretty important to getting his AF into durable sinus rhythm. I would bring him to the table, TEE for clot, defibrillate the atria, sleep tube and do the surgery.

 

[Guillemot]

So to reference a prior response, how reliable would a BNP be in this situation for determining volume status? The patient was apparently in afib with RVR, ? sepsis.

My recollection is that multiple factors aside from volume status can effect the BNP. So I would think it would be difficult to interpret even if one had a prior baseline for this individual.

 

[Sleeplessbordernights]

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What was the HR? How did the patient compare his current status to his baseline? What did he tell you about the history and evolution of his disease during the last few months?

The HR was 115-125, he says he is fine but his wife says he is deteriorating and less functional than 6 months ago, also lost a lot of weight in these past months

 

[Guillemot]

Additionally, I agree that it would be prudent to get a TTE to assess any change in heart function.

For those that wanted a TEE for clot --> cardioversion if no clot, I am less clear about the line of reasoning. Is there a definite benefit to cardioversion pre-op if the patient is stable with just rate control in afib?

 

[Sleeplessbordernights]

I’m a little confused by the timeline. The case was started and they cancelled intra-operatively?

Or they were hypotensive with RVR in pre-op?

To me this would be sepsis secondary to empyema until proven otherwise. My question would be if the patient can be optimized in the unit or if this is “as good as they’re going to get”.

I would place an art line, central line if I foresee pressors in their future. Would avoid placing an epidural in a hypotensive patient.

The case never starte, tough we had the pt in the OR and ready to go, We never went trough with induction

 

[FiO2@21]

The case never starte, tough we had the pt in the OR and ready to go, We never went trough with induction

When you said they were unstable, did you mean hypotensive? Or just that they were in afib?

I wouldn’t expect 115-125 to be the primary cause of hypotension. I would think septic —> afib.

In those patients I feel that rate controlling them aggressively only leads to doom.

 

[Sleeplessbordernights]

When you said they were unstable, did you mean hypotensive? Or just that they were in afib?

I wouldn’t expect 115-125 to be the primary cause of hypotension. I would think septic —> afib.

In those patients I feel that rate controlling them aggressively only leads to doom.

He was ranging from 90/60-80/40

 

[FiO2@21]

He was ranging from 90/60-80/40

Cool.

I have attendings who’d go either way. I would communicate with both surgery and ICU. If the consensus is that surgery is vital for source control I would do the case.

My only extra thought would be that I wouldn’t do a DLT but rather a big single lumen and a bronchial blocker. It’s not completely clear to me that this guy would be immediately extubatable.

Otherwise awake art line, CVL after induction, bronchial blocker. Would have my epi diluted and drawn already.

 

[vector2]

What's the guy's white count? Febrile? It matters whether this is a septic picture or not, but since you say surgeon has high index of suspicion for cancer we'll assume cancer.

Regarding the AF, we don't need to go searching out relative zebras to find the etiology. He's got dilated cardiomyopathy (ischemic or non-ischemic?) which presumably means significant left atrial enlargement and possibly valvular disease (big AF risk factors). He's also got a long smoking history (another AF risk factor) which means he could have mixed pre and post-cap PH (another AF risk factor) and right heart dysfunction.

Make no mistake, poorly controlled AF in HFrEF is bad. These people may already suffer from low cardiac output at baseline so the CO reduction from AF RvR may just put them into frank decompensated failure. There is also a growing body of evidence that catheter ablation +- CRT is the superior strategy for AF in HFrEF, which gels with my pre-existing suspicion that being in sinus with HFrEF is the way to go. But, barring that, at the minimum he needs good rate control.

I think you're right to cancel this case because 1. he already appears decompensated, 2. Your induction and the hemodynamic changes from OLV, positioning, and capnothorax would probably put him over the edge.

Get cards on board. Start with TTE (need to see valvular and right heart fnx), BNP, and check a dig level. I assume he already has recent films of the chest to assess pulmonary edema. You didnt discuss what kind of symptoms the guy has, but if he's SOB you need to make a further clinical differentiation between heart and lung pathology if it's not clear from your exam and findings, and an SVO2 or even a RHC may actually be helpful here. Discuss with cards starting amiodarone (risk vs benefit given his lungs) and TEE/DCV. May need to temporarily hold BB and ace if he's symptomatically hypotensive. See what he looks like in a couple days after rhythm control or rate control and then go from there.

 

[coffeebythelake]

My recollection is that multiple factors aside from volume status can effect the BNP. So I would think it would be difficult to interpret even if one had a prior baseline for this individual.

Noncardiac conditions that change BNP levels

Increase BNP

Increasing age

Female gender

Lung disease

High blood pressure

Overactive thyroid

Excessive cortisol levels

Kidney failure

Advanced liver disease

Certain rare tumors

Brain hemorrhages



Decrease BNP

Obesity

Medications

Ace inhibitors

Spironolactone

Diuretics

Beta blockers




Although I am not sure to what magnitude an effect they have on BNP...

 

[dhb]

Given the clinical picture it's highly unlikely you'll defib him to SR.
Barring urgent need for source control i agree that it's a good idea to postpone to optimize.