Anesthesia for suction embolectomy of the pulmonary artery

[undalay]

I got called to give anesthesia in Intervention radiology lab for a elderly with saddle pulmonary embolism on high flow oxygen. These patients are sick and have multiple comorbidties including previous Stroke, hypertension and hemodynamically unstable. First I was told please give sedation and monitor the vitals while the procedure is being done. Do other institutions have any protocols as to how to navigate here. Do general anesthesiologist take care of such patients or is it cardiac anesthesiologist? What happens if there is tamponade or pulmonary artery injury and bleeding?

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[deleted875186]

Honestly, if there is a pulmonary artery injury with an interventional procedure there is no salvaging the situation. Tamponade may be less ominous, but also probably catastrophic. I’ve never done one of these procedures so maybe someone else can comment, but I would assume the majority are for unstable PEs that should already be mechanically ventilated.

 

[vector2]

I got called to give anesthesia in Intervention radiology lab for a elderly with saddle pulmonary embolism on high flow oxygen. These patients are sick and have multiple comorbidties including previous Stroke, hypertension and hemodynamically unstable. First I was told please give sedation and monitor the vitals while the procedure is being done. Do other institutions have any protocols as to how to navigate here. Do general anesthesiologist take care of such patients or is it cardiac anesthesiologist? What happens if there is tamponade or pulmonary artery injury and bleeding?

Honestly, if there is a pulmonary artery injury with an interventional procedure there is no salvaging the situation. Tamponade may be less ominous, but also probably catastrophic. I’ve never done one of these procedures so maybe someone else can comment, but I would assume the majority are for unstable PEs that should already be mechanically ventilated.

Unfortunately these patients are rarely ventilated. ED or ICU slaps on a NRB mask, starts peripheral norepi, and ships them to the procedure suite. These are extremely challenging cases which many times fall to general anesthesiologists because aspiration thrombectomy devices (such as the Inari) have become pretty common in many hospitals including community ones. If you do have cardiac anesthesia coverage, I would 100% recommend having them staff this case.

The mainstay of sedation here? Try not to sedate them at all, especially if we're talking about someone who is hemodynamically unstable / massive PE with acute right heart failure. Maintain spontaneous ventilation (+- 1-2mg versed, benadryl, baby dose of precedex), generous generous local in groin by IR, facemask with high O2 flows, a-line, have epi, norepi, and vaso GTTs inline plus pushes available. Inhaled flolan is great if you're able to easily get it. If you have to intubate, pretreat with epi+vaso before induction drugs and be extremely careful with positive pressure ventilation. Low Vt and no PEEP until some of the clot burden is relieved.

 

[vector2]

The procedure for those who are unfamiliar:



Houston Methodist video of them doing one:

 

[chessknt]

If someone is on pressors and getting this therapy instead of lytics there has been a major judgement error made prior to their arrival in IR. I'm not sure why they would need much sedation but if they require enough to have to compromise their hemodynamics that is another argument for lytics instead. So many patients get hurt with bad PE going to IR because people are unreasonably afraid of lytics.

 

[GravelRider]

These cases kind of suck. I prefer doing minimal to no sedation. However, often these are sick elderly patients in various stages of dementia and cooperativeness. Otherwise, I’ve done everything from some precedex to an LMA depending on hemodynamics. Be ready for catastrophe because it’s not uncommon for poop to hit the fan.

 

[Lecithin5]

We do a fair amount. These cases suck. Thankfully most of the time we end up giving nothing, or at most some small fentanyl pushes or some precedex. Lots or reassurance and hand-holding. It all obviously depends on comorbidities, anxiety levels, respiratory status, hemodynamics, etc. Most have an echo resulted in the system. Plus/minus aline. It gets hairy when the patient goes ape-**** during the procedure; can’t really sedate them too much, and you really don’t want to induce GA/ppv…

 

[T-burglar]

Should be done in a cardiac surgical suite or at least a place where VA ECMO can be instituted rapidly

Agreed that unstable PE shouldn’t just simply go to IR

 

[Arch Guillotti]

Should be done in a cardiac surgical suite or at least a place where VA ECMO can be instituted rapidly

Agreed that unstable PE shouldn’t just simply go to IR

What should be done and what actually happens in real life are two different things unfortunately.

 

[chessknt]

What should be done and what actually happens in real life are two different things unfortunately.

I have noticed that facilities that do not use an intervening non-proceduralist (ICU/pulm/pert) to evaluate cases will tend to do a lot more of these. The IR/cardiology guys who do these really just look at the clot and say yes it can be done but don't look at the whole picture. The ER guys usually do not have the follow-up experience to know that this is frequently the wrong decision and are usually just looking for the most responsive person who can help them with disposition.

If you have had adverse outcomes at your facility keep filing quality reports because those are what prompts a facility to eventually look at this and re-tool their process.

 

[JiPo]

Do most people do Aline for these cases even when your plan is to give basically nothing?

 

[anaesthetic]

Do most people do Aline for these cases even when your plan is to give basically nothing?

Yes. PA rupture, clot dislodgement, vascular injury, etc. Things go south fast in those cases. Probably unwise to be digging around the wrist while the patient is massively hemorrhaging, but that’s just me.

 

[RemyMcswain]

I have been called to evaluate these patients countless times as both an Anesthesiologist and as an Intensivist. I’ve ordered tPA and I’ve argued against tPA and pushed for these to be done by the IR attending.

It is very likely that a patient shows up to a facility that has IR coverage but no CT surgery. It is completely impractical to expect these cases be done with a CT surgeon/“Cardiac Anesthesiologist”/VA ECMO stand by. One could argue it’s mal practice to transfer a patient on pressors with a massive/submassive PE to a facility that has ECMO. These patients just show up.

I have seen countless patients with submassive PE get this done and leave the hospital without major morbidity.

I’ve been part of a team decision to push tPA that was a complete disaster. It’s not so cut and dry

Just do the F-ing case. Stand by. Yes put in an a line if the IR attending won’t transduce beat to beat pressure monitoring. Just try and help the patient. Too much BS from anesthesia colleagues

 

[Shimmy8]

Vector nailed it. All of it.

Sometimes “just do the case” isn’t the answer when you have limited resources.

Everyone knows anesthesia ans PPV are about the worst thing for someone with massive PE and RV compromise. Most patients need generous local and a hand to hold or a whiff of sedation.

We instituted a policy where intensivist and IR have to agree on procedure and then they give us a heads up. If they’re super sick and the circulating nurse can’t handle their needs, we’ll be involved. Otherwise, IR nurses handle it.

 

[vector2]

I have noticed that facilities that do not use an intervening non-proceduralist (ICU/pulm/pert) to evaluate cases will tend to do a lot more of these. The IR/cardiology guys who do these really just look at the clot and say yes it can be done but don't look at the whole picture. The ER guys usually do not have the follow-up experience to know that this is frequently the wrong decision and are usually just looking for the most responsive person who can help them with disposition.

If you have had adverse outcomes at your facility keep filing quality reports because those are what prompts a facility to eventually look at this and re-tool their process.

I have been called to evaluate these patients countless times as both an Anesthesiologist and as an Intensivist. I’ve ordered tPA and I’ve argued against tPA and pushed for these to be done by the IR attending.

It is very likely that a patient shows up to a facility that has IR coverage but no CT surgery. It is completely impractical to expect these cases be done with a CT surgeon/“Cardiac Anesthesiologist”/VA ECMO stand by. One could argue it’s mal practice to transfer a patient on pressors with a massive/submassive PE to a facility that has ECMO. These patients just show up.

I have seen countless patients with submassive PE get this done and leave the hospital without major morbidity.

I’ve been part of a team decision to push tPA that was a complete disaster. It’s not so cut and dry

Just do the F-ing case. Stand by. Yes put in an a line if the IR attending won’t transduce beat to beat pressure monitoring. Just try and help the patient. Too much BS from anesthesia colleagues

Ultimately the evidence is controversial, and the way it's gone down at my hospital is before pulmcrit was involved we were doing too many, and now that they are involved they sometimes put on a hold on pts who do in fact need mechanical thrombectomy. I think that's as good as it's going to get for now, but I made all sides aware of the tremendous risk the pt faces if you bring them to the suite but they're someone who is unable to comply (either due to dementia, air hunger etc) with supine positioning and mild to no sedation.

An important point for all sides to realize is that chronicity matters too, and that can be hard to establish. Clot turns into a slab of collagen with the texture of rubber cement when it's been sitting there long enough. You can throw all the tPA you want at those things but it's not going anywhere without a thrombectomy.

 

[Lecithin5]

Do most people do Aline for these cases even when your plan is to give basically nothing?

Not usually. Depends on situation. But obviously things can turn on a dime. And one never regrets placing an aline…

 

[chessknt]

I have been called to evaluate these patients countless times as both an Anesthesiologist and as an Intensivist. I’ve ordered tPA and I’ve argued against tPA and pushed for these to be done by the IR attending.

It is very likely that a patient shows up to a facility that has IR coverage but no CT surgery. It is completely impractical to expect these cases be done with a CT surgeon/“Cardiac Anesthesiologist”/VA ECMO stand by. One could argue it’s mal practice to transfer a patient on pressors with a massive/submassive PE to a facility that has ECMO. These patients just show up.

I have seen countless patients with submassive PE get this done and leave the hospital without major morbidity.

I’ve been part of a team decision to push tPA that was a complete disaster. It’s not so cut and dry

Just do the F-ing case. Stand by. Yes put in an a line if the IR attending won’t transduce beat to beat pressure monitoring. Just try and help the patient. Too much BS from anesthesia colleagues

The question in submassive isnt 'is there an adverse outcome' but rather 'was an adverse outcome avoided by doing this procedure.' There is truly no good data behind these procedures so it really is touch and go but I try to avoid IR intervention for most PE unless there is a specific scenario (contraindicated lytics, failed lytics etc). I would hazard a guess that any facility that is doing these frequently is not motivated by outcomes data. PEITHO shows that this was a viable strategy and HI-PEITHO will look at how well this compares to usual care.

And anyone on pressors is no longer submassive and should not be getting this done first line.

 

[chessknt]

Ultimately the evidence is controversial, and the way it's gone down at my hospital is before pulmcrit was involved we were doing too many, and now that they are involved they sometimes put on a hold on pts who do in fact need mechanical thrombectomy. I think that's as good as it's going to get for now, but I made all sides aware of the tremendous risk the pt faces if you bring them to the suite but they're someone who is unable to comply (either due to dementia, air hunger etc) with supine positioning and mild to no sedation.

An important point for all sides to realize is that chronicity matters too, and that can be hard to establish. Clot turns into a slab of collagen with the texture of rubber cement when it's been sitting there long enough. You can throw all the tPA you want at those things but it's not going anywhere without a thrombectomy.

In a chronic scenarion my understanding is that PEA is the standard of care not IR catheters.

 

[RemyMcswain]

The question in submassive isnt 'is there an adverse outcome' but rather 'was an adverse outcome avoided by doing this procedure.' There is truly no good data behind these procedures so it really is touch and go but I try to avoid IR intervention for most PE unless there is a specific scenario (contraindicated lytics, failed lytics etc). I would hazard a guess that any facility that is doing these frequently is not motivated by outcomes data. PEITHO shows that this was a viable strategy and HI-PEITHO will look at how well this compares to usual care.

And anyone on pressors is no longer submassive and should not be getting this done first line.

So the old lady who had a knee replacement 2 weeks ago now with SOB, Hypoxemia, PE on CTPE, tachypnea, RV dilation, new TR, HR 115, BP 92/45, on 3mcg/min NE. This patient is no longer a candidate for thrombectomy? You’re going to push tPA 100mg in this lady? Or the lady who just had a vascular fistula done 3 weeks ago or whatever whatever etc etc.

There is clinical equipoise. I find, remarkably, that IR is LESS likely to do this procedure at 2am and way more likely to do it at 10am. Shocking right? Must be departmental review of most recent meta analysis.

 

[vector2]

In a chronic scenarion my understanding is that PEA is the standard of care not IR catheters.

I'm not referring necessarily to CTEPH. For example, for one of these cases I had a 50 year old guy who had some disaster bilateral hip revisions way back, hadn't been moving in 6 months, nor taking A/C, and then had a massive PE. Both his DVTs and the clots in the PA were old. See:

Compared to acute thrombi, which are at high risk for fragmentation and embolization, residual chronic thrombi are stable and resistant to both anticoagulation and thrombolytic treatment (29,36,37). Several studies have described the hardening of chronic thrombi due in large part to the cross linking of fibrin and replacement of cellular material by collagen (29,36,38). By 1 week, thrombus collagen content may reach approximately 20%, and after three weeks it may be as high as 80% (25). While the process of thrombus maturation is variable, it is approximated that thrombi 15 days of age or older will undergo significant modification and can be considered chronic (29,39). These chronic thrombi become increasingly resistant to both anticoagulation and thrombolytic therapies (5).

Can thrombus age guide thrombolytic therapy?

Venous thrombosis (VT) is a common yet complex clinical condition that has shown minimal alteration in clinical management for decades. It is well known that thrombus evolves structurally over time, with complex changes resulting from the interplay between ...

www.ncbi.nlm.nih.gov

You can give all the heparin and tPA you want (IV or catheter directed) to these kind of clots, but they're not going anywhere. There are some subsets of PE which need aspiration (or open) thrombectomy, but the literature is yet to precisely delineate the decision making process.

 

[chessknt]

So the old lady who had a knee replacement 2 weeks ago now with SOB, Hypoxemia, PE on CTPE, tachypnea, RV dilation, new TR, HR 115, BP 92/45, on 3mcg/min NE. This patient is no longer a candidate for thrombectomy? You’re going to push tPA 100mg in this lady? Or the lady who just had a vascular fistula done 3 weeks ago or whatever whatever etc etc.

There is clinical equipoise. I find, remarkably, that IR is LESS likely to do this procedure at 2am and way more likely to do it at 10am. Shocking right? Must be departmental review of most recent meta analysis.

Half to full dose tpa sure, can talk to Ortho to see what the risk of bleeding is at their site but this is high risk of mortality, they can do a fasciotomy or something later if needed. If that old lady codes in the IR suite she is beyond ****ed. Going to screw around with catheters while she is actively dying makes no sense at all.

 

[RemyMcswain]

Half to full dose tpa sure, can talk to Ortho to see what the risk of bleeding is at their site but this is high risk of mortality, they can do a fasciotomy or something later if needed. If that old lady codes in the IR suite she is beyond ****ed. Going to screw around with catheters while she is actively dying makes no sense at all.

Man, I completely disagree with you. Have you seen the result of diffuse or even local catastrophic bleeding from tPA?

 

[chessknt]

Man, I completely disagree with you. Have you seen the result of diffuse or even local catastrophic bleeding from tPA?

I have--50 units of blood from a vaginal source the most memorable. Keep waiting for a head bleed but have yet to see one (and when I do it won't change my practice).

Doesn't change my mind at all because post arrest PE is dead for sure. Everyone I work with would recommend against IR in that case unless Ortho was adamant that bleeding would be catastrophic and unsalvageable.

 

[RemyMcswain]

I have seen people arrest and die in IR. Won’t change my practice. tPA is not a benign drug. Also, have you coded someone after they received tPA? That bloody disaster with central lines, pulmonary hemorrhage etc.

Also, have you noticed that it becomes “too dangerous”‘at 2am?

I have--50 units of blood from a vaginal source the most memorable. Keep waiting for a head bleed but have yet to see one (and when I do it won't change my practice).

Doesn't change my mind at all because post arrest PE is dead for sure. Everyone I work with would recommend against IR in that case unless Ortho was adamant that bleeding would be catastrophic and unsalvageable.

 

[chessknt]

I have seen people arrest and die in IR. Won’t change my practice. tPA is not a benign drug. Also, have you coded someone after they received tPA? That bloody disaster with central lines, pulmonary hemorrhage etc.

Also, have you noticed that it becomes “too dangerous”‘at 2am?

I have--50 units of blood from a vaginal source the most memorable. Keep waiting for a head bleed but have yet to see one (and when I do it won't change my practice).

I'm not sure if you do ICU or not but one difference with anesthesia is that I follow these people to completion of their critical illness. Post arrest is a completely different animal whether tpa has been given or not and almost always portends the same outcome, avoiding that is my primary objective when stratifying risk.

Also yes IR universally avoids coming in overnight unless literally no other option exists. This is the way.

 

[RemyMcswain]

I do ICU. A lot of MICU. Many many PE cases. I see many patients to, as you put it, the completion of their critical illness. Stand by my comments that there is clinical uncertainty about what to do with these patients. Also that I have seen more complications from tPA than catheter therapies. Its often not so easy as just saying, "oh patient is on norepinephrine, so they are massive PE". What actually happens is this: A patient with multiple medical co morbidities presents with borderline massive/submassive. Risk associated with tPA, risk associated with catheter based procedure. IR team vacillates. Patient sits in ED. Either gets sick and requires something emergent or goes to the floor and gets discharged on oral AC +/- oxygen. This is the anesthesia forum. What triggered me is my colleagues who truly are removed from seeing these patients suffer inpatient or at home and make up excuses about how they are "too sick" to tolerate the procedure. Hence my comment of "just do the F-ing case."

What we dont see as anesthesiologists and intensivsts is the morbidity associated with being sent home with a PE so big its literally straining the right side of your heart. Not to mention the long term pulmonary hypertension from organizing clot. I always ask myself what I would want. I think I would want a catheter thrombectomy.

 

[vector2]

I posted these before but I love them so much I'm gonna post them again

 

[pgg]

An important point for all sides to realize is that chronicity matters too, and that can be hard to establish. Clot turns into a slab of collagen with the texture of rubber cement when it's been sitting there long enough. You can throw all the tPA you want at those things but it's not going anywhere without a thrombectomy.

I haven't done one since fellowship, but some of the circ arrest pulmonary embolectomies we'd do, they'd get these semi rigid tree things out that reminded me of those YouTube videos where someone pours molten aluminum into an ant nest and digs up the cast.

Frustrating part was that some would come off bypass with dramatically better PA pressures and some wouldn't be even a little bit different. Wonder if they have or will get better at predicting who'll benefit.

 

[nimbus]

I haven't done one since fellowship, but some of the circ arrest pulmonary embolectomies we'd do, they'd get these semi rigid tree things out that reminded me of those YouTube videos where someone pours molten aluminum into an ant nest and digs up the cast.

Frustrating part was that some would come off bypass with dramatically better PA pressures and some wouldn't be even a little bit different. Wonder if they have or will get better at predicting who'll benefit.

Yeah, chronicity matters. Can’t treat these with lytics.

 

[anbuitachi]

we do these patients since we have a IR suite and we have a ED. we dont have bypass/ecmo.

its usually just some MAC. theres no policy or guideline here since its just like any other case. anesthesiologist decides the plan. we have no cardiac here so no differentiation between cardiac vs generalist here.

if there is injury to surrounding structures, its just like any other case with injury to surrounding structures. you manage it. transfuse, supportive care, go to OR if possible, but the prognosis is pretty poor if already have large embolisms. we had a patient die on the table some months ago. it is what it is.

 

[jwk]

... but the prognosis is pretty poor if already have large embolisms. we had a patient die on the table some months ago. it is what it is.

Early in my career had a somewhat elderly lady that moved herself from stretcher to OR table, immediately arrested, and died in front of our eyes. I saw my first and only autopsy about 90 minutes later. It took the pathologist less than 10 minutes to get to the PAs, pull out a huge saddle embolus, and declare "there's your cause of death". It made quite an impression on a young anesthetist.

 

[anbuitachi]

Early in my career had a somewhat elderly lady that moved herself from stretcher to OR table, immediately arrested, and died in front of our eyes. I saw my first and only autopsy about 90 minutes later. It took the pathologist less than 10 minutes to get to the PAs, pull out a huge saddle embolus, and declare "there's your cause of death". It made quite an impression on a young anesthetist.

how? you didnt have to go to your next case after the patients arrest?

 

[anaesthetic]

how? you didnt have to go to your next case after the patients arrest?

The case doesn’t end until you hit “Anesthesia Stop.”

 

[pgg]

how? you didnt have to go to your next case after the patients arrest?

I think every place I've ever worked pulled all staff from the affected OR for at least the rest of the day if there was an unexpected intraop death.

You can't really expect people to be on top of their game and focused on the next patient after something like that.

 

[pgg]

Early in my career had a somewhat elderly lady that moved herself from stretcher to OR table, immediately arrested, and died in front of our eyes. I saw my first and only autopsy about 90 minutes later. It took the pathologist less than 10 minutes to get to the PAs, pull out a huge saddle embolus, and declare "there's your cause of death". It made quite an impression on a young anesthetist.

Maybe 10 years ago something similar happened to me. It was a 50-something yo F who was getting a port placed. I thin she had metastatic ovarian cancer or something awful and was due to start chemo. Sedation case, nothing special about it, except the surgeon struggled to get a wire in the IJ for a long time. Eventually succeeds. Case is over, patient moves herself back to the gurney, abruptly stops talking to us.

DRT

Family declined an autopsy but I can't imagine what else it could've been, but a massive PE.

 

[RemyMcswain]

Maybe 10 years ago something similar happened to me. It was a 50-something yo F who was getting a port placed. I thin she had metastatic ovarian cancer or something awful and was due to start chemo. Sedation case, nothing special about it, except the surgeon struggled to get a wire in the IJ for a long time. Eventually succeeds. Case is over, patient moves herself back to the gurney, abruptly stops talking to us.

DRT

Family declined an autopsy but I can't imagine what else it could've been, but a massive PE.

RA tear/tamponade?

 

[anbuitachi]

I think every place I've ever worked pulled all staff from the affected OR for at least the rest of the day if there was an unexpected intraop death.

You can't really expect people to be on top of their game and focused on the next patient after something like that.

case hasnt even started! she died from moving to OR table!

 

[jwk]

how? you didnt have to go to your next case after the patients arrest?

Last case of the day. Hung around just to see the post. I was fascinated - never saw one before or since.

 

[pgg]

RA tear/tamponade?

We considered it, and pneumo/hemothorax, ruled out with bedside echo and CXR.

It was abrupt. Lights out. She was talking, then nothing.

 

[medicine2wallstreet]

I have been called to evaluate these patients countless times as both an Anesthesiologist and as an Intensivist. I’ve ordered tPA and I’ve argued against tPA and pushed for these to be done by the IR attending.

It is very likely that a patient shows up to a facility that has IR coverage but no CT surgery. It is completely impractical to expect these cases be done with a CT surgeon/“Cardiac Anesthesiologist”/VA ECMO stand by. One could argue it’s mal practice to transfer a patient on pressors with a massive/submassive PE to a facility that has ECMO. These patients just show up.

I have seen countless patients with submassive PE get this done and leave the hospital without major morbidity.

I’ve been part of a team decision to push tPA that was a complete disaster. It’s not so cut and dry

Just do the F-ing case. Stand by. Yes put in an a line if the IR attending won’t transduce beat to beat pressure monitoring. Just try and help the patient. Too much BS from anesthesia colleagues

This guy GETS IT. Has that ENERGY.

 

[Southpaw]

I do ICU. A lot of MICU. Many many PE cases. I see many patients to, as you put it, the completion of their critical illness. Stand by my comments that there is clinical uncertainty about what to do with these patients. Also that I have seen more complications from tPA than catheter therapies. Its often not so easy as just saying, "oh patient is on norepinephrine, so they are massive PE". What actually happens is this: A patient with multiple medical co morbidities presents with borderline massive/submassive. Risk associated with tPA, risk associated with catheter based procedure. IR team vacillates. Patient sits in ED. Either gets sick and requires something emergent or goes to the floor and gets discharged on oral AC +/- oxygen. This is the anesthesia forum. What triggered me is my colleagues who truly are removed from seeing these patients suffer inpatient or at home and make up excuses about how they are "too sick" to tolerate the procedure. Hence my comment of "just do the F-ing case."

What we dont see as anesthesiologists and intensivsts is the morbidity associated with being sent home with a PE so big its literally straining the right side of your heart. Not to mention the long term pulmonary hypertension from organizing clot. I always ask myself what I would want. I think I would want a catheter thrombectomy.

As always we must weigh risk of the procedure against the morbidity/mortality associated with doing nothing. Where are we with evidence? I say this as an anesthesiologist not currently doing these cases. I’m just an interested observer in the discussion.

 

[RemyMcswain]

As always we must weigh risk of the procedure against the morbidity/mortality associated with doing nothing. Where are we with evidence? I say this as an anesthesiologist not currently doing these cases. I’m just an interested observer in the discussion.

Conflicting evidence on this stuff. Think about all the variables that come in to play that affect you’re interpretation of these studies:

Dose of tPA. Infusion vs bolus. Repeat doses

Heparin bolus or not. Heparin + tPA or tPA alone. PTT goals. During of heparin infusion

Type of device. How many done per year at the hospital.

Is patient on pressors. How much pressor. Baseline Cardiac dysfunction?

Morbidity at discharge. Oxygen vs no oxygen vs long term pulm HTN.

I mean, the list goes on. There is a lack of clear statistical evidence that is one size fits all. That’s why most hospital PE protocols end with something like “discussion between IR and ICU attendings. Weigh risk vs benefit”. Like I said in a previous post, for a doctor to say “oh this is ‘massive PE’, needs emergent tPA and no procedure” is probably not the best medicine. Really need to take many factors into account. We all know that a patient with a HR of 110 BP 92/55 on 4 NE who is talking to you but dyspneic is different than the diaphoretic 80/50 on 15 NE who probably won’t tolerate being moved and flat. According to another poster they are BOTH “Massive” PE.

 

[RemyMcswain]

This guy GETS IT. Has that ENERGY.

😘😘

 

[anbuitachi]

Conflicting evidence on this stuff. Think about all the variables that come in to play that affect you’re interpretation of these studies:

Dose of tPA. Infusion vs bolus. Repeat doses

Heparin bolus or not. Heparin + tPA or tPA alone. PTT goals. During of heparin infusion

Type of device. How many done per year at the hospital.

Is patient on pressors. How much pressor. Baseline Cardiac dysfunction?

Morbidity at discharge. Oxygen vs no oxygen vs long term pulm HTN.

I mean, the list goes on. There is a lack of clear statistical evidence that is one size fits all. That’s why most hospital PE protocols end with something like “discussion between IR and ICU attendings. Weigh risk vs benefit”. Like I said in a previous post, for a doctor to say “oh this is ‘massive PE’, needs emergent tPA and no procedure” is probably not the best medicine. Really need to take many factors into account. We all know that a patient with a HR of 110 BP 92/55 on 4 NE who is talking to you but dyspneic is different than the diaphoretic 80/50 on 15 NE who probably won’t tolerate being moved and flat. According to another poster they are BOTH “Massive” PE.

where is the anesthesiology attending in that discussion. risk of anesthesia?

 

[vector2]

where is the anesthesiology attending in that discussion. risk of anesthesia?

don't worry, pulm wrote "avoid hypotension and hypoxia" in their stratification note so you're good

 

[anbuitachi]

don't worry, pulm wrote "avoid hypotension and hypoxia" in their stratification note so you're good

cardiology writes cleared for GA, recommend avoiding agents that depress cardiac function or preload, or afterload

 

[IMGASMD]

cardiology writes cleared for GA, recommend avoiding agents that depress cardiac function or preload, or afterload

I did get one just the other day for a hip or knee

Recommendation: regional anesthesia.

 

[T-burglar]

If you’re worried you can do a spinal

 

[T-burglar]

when I was a very new attending in a small community hospital I had a surgeon bring a patient from the ED to the OR after hours in the middle of a major anaphylactic reaction for a gall bladder.

And I swear to god he told me if I was worried I could do a spinal.

 

[Beeftenderloin]

when I was a very new attending in a small community hospital I had a surgeon bring a patient from the ED to the OR after hours in the middle of a major anaphylactic reaction for a gall bladder.

And I swear to god he told me if I was worried I could do a spinal.

To be fair, the SVR prob can’t get much lower.