Anesthesia for suction embolectomy of the pulmonary artery

[medicine2wallstreet]

Obviously this is a different situation but I've benefited from thrombolysis and thrombectomy for a DVT years ago and it changed my life morbidity wise. No post thrombotic syndrome at all. If I had a ginormous PE I would want you to drag my dead body to the table and try to get that thing out mechanically like ol remi said. If I die on the table so what at least you gave me my shot. But I don't want to live with an RV that's smoked because some soft anesthesiologist felt afraid of trying to keep me alive for a proceduralist to do the definitive treatment.

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[okayplayer]

I’m sorry, what?!

 

[IMGASMD]

Obviously this is a different situation but I've benefited from thrombolysis and thrombectomy for a DVT years ago and it changed my life morbidity wise. No post thrombotic syndrome at all. If I had a ginormous PE I would want you to drag my dead body to the table and try to get that thing out mechanically like ol remi said. If I die on the table so what at least you gave me my shot. But I don't want to live with an RV that's smoked because some soft anesthesiologist felt afraid of trying to keep me alive for a proceduralist to do the definitive treatment.

Risks, benefits and alternatives.

When you’re an attending, making life and death decisions……. It’ll be your call, it’ll be your responsibility, maybe It’ll feel different.

Maybe not. Just don’t think you should be calling anyone soft, when you haven’t had that responsibility placed on you.

 

[anbuitachi]

Obviously this is a different situation but I've benefited from thrombolysis and thrombectomy for a DVT years ago and it changed my life morbidity wise. No post thrombotic syndrome at all. If I had a ginormous PE I would want you to drag my dead body to the table and try to get that thing out mechanically like ol remi said. If I die on the table so what at least you gave me my shot. But I don't want to live with an RV that's smoked because some soft anesthesiologist felt afraid of trying to keep me alive for a proceduralist to do the definitive treatment.

I’m sorry, what?!

Risks, benefits and alternatives.

When you’re an attending, making life and death decisions……. It’ll be your call, it’ll be your responsibility, maybe It’ll feel different.

Maybe not. Just don’t think you should be calling anyone soft, when you haven’t had that responsibility placed on you.

its wall street talk

 

[anaesthetic]

Risks, benefits and alternatives.

When you’re an attending, making life and death decisions……. It’ll be your call, it’ll be your responsibility, maybe It’ll feel different.

Maybe not. Just don’t think you should be calling anyone soft, when you haven’t had that responsibility placed on you.

I get what they’re saying though. I think the most important thing in these situations is to have a discussion with everybody involved and have a clear path forward. I’ve delayed cases to do just that, and it’s been worth it every time.

That being said, one of my colleagues cancelled a case for preoperative sinus tachycardia in a young, healthy patient undergoing an elective ortho procedure. That’s pretty soft, IMO. Many similar instances with usually the same 2-3 colleagues postponing cases for seemingly innocuous things.

All that is to say everyone has different tolerances and comfort levels, especially when taking care of the critically ill. I can’t imagine said colleagues doing a case like this, and I probably wouldn’t expect them to, to be honest—probably better for everyone involved that they don’t (if they can avoid it).

 

[medicine2wallstreet]

Risks, benefits and alternatives.

When you’re an attending, making life and death decisions……. It’ll be your call, it’ll be your responsibility, maybe It’ll feel different.

Maybe not. Just don’t think you should be calling anyone soft, when you haven’t had that responsibility placed on you.

Risks, benefits and alternatives.

When you’re an attending, making life and death decisions……. It’ll be your call, it’ll be your responsibility, maybe It’ll feel different.

Maybe not. Just don’t think you should be calling anyone soft, when you haven’t had that responsibility placed on you.

In my opinion there's nothing about this case that's my call. It's clearly an emergency and the proceduralist clearly feels like he can do something about it I'm not holding that case up for anything. That's what our job is designed for is to get patients safely through a procedure like this. Hell an aortic dissection that rolls in in extremis jacked on antihypertensives who is going to hold that up? Risk v benefit? This isn't remotely close to an elderly lady broken hip situation that has an unstable cardiac condition where some would roll and some wouldn't. This is the type of case that the specialty of anesthesia was designed for. This is the type of case where actual physicians are needed and we should be at our absolute best to try to get this patient through the case safely. If we shy away from this saying that it can't be done then we degrade the value of our specialty.

 

[vector2]

In my opinion there's nothing about this case that's my call. It's clearly an emergency and the proceduralist clearly feels like he can do something about it I'm not holding that case up for anything. That's what our job is designed for is to get patients safely through a procedure like this. Hell an aortic dissection that rolls in in extremis jacked on antihypertensives who is going to hold that up? Risk v benefit? This isn't remotely close to an elderly lady broken hip situation that has an unstable cardiac condition where some would roll and some wouldn't. This is the type of case that the specialty of anesthesia was designed for. This is the type of case where actual physicians are needed and we should be at our absolute best to try to get this patient through the case safely. If we shy away from this saying that it can't be done then we degrade the value of our specialty.

Not that the average anesthesiologist is necessarily aware of this, but the gap in level of evidence of benefit between surgery for a type A dissection and catheter based procedures for PE is as big as an ocean.

 

[DocVapor]

Not that the average anesthesiologist is necessarily aware of this, but the gap in level of evidence of benefit between surgery for a type A dissection and catheter based procedures for PE is as big as an ocean.

Which ocean, though? If it's smaller than the Indian ocean, I'm unimpressed.

 

[zizzer]

I think it's notable that the patient likely doesn't need the large doses of thrombolytics given for stroke since an IV dose will all go 100% straight to a saddle PE, as opposed to somewhere in the distal systemic arterial system.

 

[Radetzky]

I agree with the posters saying to thrombolyse first. The evidence for systemic thrombolysis for massive PE is clear as day, catheter procedures not so much. Yes there are many complications from TPA but that doesn’t mean it’s not the right move. More inclined to try IR if it’s submassive or the bleeding risk truly is huge.

Also sometimes just intubating someone and controlling their agitation, CO2, hypoxia, oxygen demand and recruiting lung is better for them than “trying to avoid PPV”

The point about chronic clot is kind of not relevant as that’s not the situation the OP is describing

 

[abolt18]

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.

Never done one of these cases. What in the whole picture that you're referring to makes this intervention the right or wrong decision?

 

[SpacemanSpifff]

I think it's notable that the patient likely doesn't need the large doses of thrombolytics given for stroke since an IV dose will all go 100% straight to a saddle PE, as opposed to somewhere in the distal systemic arterial system.

Interestingly, the recommended doses for both alteplase and tenecteplase are higher for massive PE than stroke. Perhaps due to the size of the clot in each situation, but it has always puzzled me a bit.

 

[2Fast2Des]

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.

Not in my job, on to the next! You think the surgeon or the following cases' surgeon gives a damn what happened? One time I had to go intubate a coding patient, the surgeon was pissed that he had to wait an extra 5 minutes for his case to go back because I inconvenienced him by trying to save someone's life despite him knowing the situation. Really showed me the true colors of these people, they don't care.

Next!

 

[Aether2000]

We use minimal sedation- 1-2 mg midazolam, no a-line, have a single lumen ETT on the cart. The results from embolectomy are immediate and dramatic with increase in SpO2 from 65 to 92%.

 

[chessknt]

Never done one of these cases. What in the whole picture that you're referring to makes this intervention the right or wrong decision?

The biggest concern I have that the proceduralist doesn't even consider is that this person has to be moved to a different location/bed in a remote area, laid down flat where their breathing is mechanically disadvantaged, given some form of sedation which will impair their hemodynamics further, and if they start to get worse instead of giving them high flow and holding their hand they get (more often than not) intubated which is frequently a fatal act (and if it isn't then they are much less stable than before). Anesthesiology is about minimizing risk, you guys aren't used to watching someone breathe 40 times per minute with a sat of 88 and just sitting on it.

None of that happens in an ICU where they are settled in and left alone. It is also important to realize that no intervention is going to magically reduce their RV afterload back to normal levels immediately. That flogged blown RV is still going to be flogged after the procedure but if they had a brief cardiac arrest and a ton of pressors on board now then they are in a far worse place than before even if the clot is 'out'.

 

[psychbender]

The biggest concern I have that the proceduralist doesn't even consider is that this person has to be moved to a different location/bed in a remote area, laid down flat where their breathing is mechanically disadvantaged, given some form of sedation which will impair their hemodynamics further, and if they start to get worse instead of giving them high flow and holding their hand they get (more often than not) intubated which is frequently a fatal act (and if it isn't then they are much less stable than before). Anesthesiology is about minimizing risk, you guys aren't used to watching someone breathe 40 times per minute with a sat of 88 and just sitting on it.

None of that happens in an ICU where they are settled in and left alone. It is also important to realize that no intervention is going to magically reduce their RV afterload back to normal levels immediately. That flogged blown RV is still going to be flogged after the procedure but if they had a brief cardiac arrest and a ton of pressors on board now then they are in a far worse place than before even if the clot is 'out'.

That sounds like education for the proceduralists and others involved is in order. If they are going to be offering the procedure, then they need to understand how they're going to need to handle the patient. Or, if they're going to involve our services, then the responding anesthesiologists need to understand how these are often "ok anesthesia" cases, as you're mostly handling hemodynamics, rather than sedation. It's a big undertaking, and the entirety of the process need to be addressed by all stake-holders during the creation of a PERT protocol.

 

[chessknt]

That sounds like education for the proceduralists and others involved is in order. If they are going to be offering the procedure, then they need to understand how they're going to need to handle the patient. Or, if they're going to involve our services, then the responding anesthesiologists need to understand how these are often "ok anesthesia" cases, as you're mostly handling hemodynamics, rather than sedation. It's a big undertaking, and the entirety of the process need to be addressed by all stake-holders during the creation of a PERT protocol.

Educating IR on critically ill PE management seems out of scope, that is why having a non-proceduralist as a screener and involved in the discussion is important. The proceduralist needs to have realistic expectation about what the proximal clot burden is with respect to distal clot burden and can offer that perspective during the discussion rather than just looking at what can be removed in isolation.

 

[psychbender]

Educating IR on critically ill PE management seems out of scope, that is why having a non-proceduralist as a screener and involved in the discussion is important. The proceduralist needs to have realistic expectation about what the proximal clot burden is with respect to distal clot burden and can offer that perspective during the discussion rather than just looking at what can be removed in isolation.

I'm saying, educate them that they can't just go, "hey, give 2 of versed and 2 of fentanyl, like we always do, so this guy will hold still." They don't need to know exactly how to manage everything (that's what the rest of the people involved are for), but they need to know how NOT to manage everything.