Anesthesia is so much fun... Clinical thread.

[sevoflurane]

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So I've been resting up in the mountains for the last 10 days.
Good rest from the OR. But as always, I start missing the job at around day 5.





So here is my first case since I rejoined our OR team... and it's a case, like many cases, that make me appreciate what we do and truly excites my very existence in the OR (kinda like seinfields last thread). This thread will prolly be short, but either way, I think it will be fun and interesting. So here it goes. Med Studs, you guys start first.

65 y/o male presents to his primary care physician with CC of lower extremity edema, dyspnea and near syncope events that have been going on for several months.

Pmhx: Smoker, CAD, hyperlipidemia, HTN.

Pretty broad... but a good exercise to go through.

What are you guys thinking with the little info provided?

 

[Direct Laryngoscopy]

What's a good exercise tolerance. Pt can walk down the block to the bodega to get his Newports?

Med students will find out, getting a good history will really help you guide your management. I didn't appreciate it in meds school, but I really lean on it clinically.

 

[bobow98]

I'd ask what he's been doing when these fainting spells are about to happen.

This sounds like every other pt I saw in Intro to Clinical Medicine.

Without full history, the edema's got me thinking right heart failure from maybe left heart failure or, depending on his line of work + smoking, something pulmonary as well. CAD leans it toward CHF for now...but yeah need a history.

 

[2010rr]

yup, CHF

 

[sevoflurane]

What's a good exercise tolerance. Pt can walk down the block to the bodega to get his Newports?

Med students will find out, getting a good history will really help you guide your management. I didn't appreciate it in meds school, but I really lean on it clinically.

Golfer 3 years ago... progressively getting more symptomatic. Def. can go to the bodega and he is still > 4 mets. However, 5-10 times a day he gets a near syncope event.

 

[sevoflurane]

I'd ask what he's been doing when these fainting spells are about to happen.

This sounds like every other pt I saw in Intro to Clinical Medicine.

Without full history, the edema's got me thinking right heart failure from maybe left heart failure or, depending on his line of work + smoking, something pulmonary as well. CAD leans it toward CHF for now...but yeah need a history.

I like your thinking.

I'll give you another clue.

HEPATOMEGALY. 😉

What else do you want to know ?

 

[2010rr]

blood panel to check for hemachromatosis. test for hep

btw, how much does he drink? if you can get the history, alcoholism is more likely to account for fatty liver than the above...

 

[dhb]

AS? i'd get an echo

 

[Endee]

COPD, pulmonary hypertension, right sided heart failure.. What happens when you push on his RUQ for a few seconds? Does anyone still do that?

 

[Consigliere]

Prop, sux, tube. Peace!

 

[aalupatti]

More history about any past cardiac resp issues. Put the stethoscope on and then Ecg, cxr and echo

 

[BlackTalon]

Absent any history,

1. CHF (Hx of CAD, cardiac risk factors, dyspnea, signs of right heart failure)
2. Tricuspid regurgitation, perhaps due to pul HTN (?COPD) (signs of right heart failure, hepatomegaly)
3. Renal failure with fluid overload?

 

[loveoforganic2]

AS? i'd get an echo

This is what comes to mind for me as well. Ask about hx of angina and draw a CBC to check his H&H. Could do an EKG to check for LVH if echo referral would take some time. EKG would also be good to r/o cor pulmonale if this is a COPD-related deal (syncopal episodes could possibly be due to tamponade)

 

[sevoflurane]

Absent any history,

1. CHF (Hx of CAD, cardiac risk factors, dyspnea, signs of right heart failure)
2. Tricuspid regurgitation, perhaps due to pul HTN (?COPD) (signs of right heart failure, hepatomegaly)
3. Renal failure with fluid overload?

Good differential. I like the fact that you are focusing on the hepatomegaly as some of your peers have as well.

In general hepatomegaly can be broken down into 3 main causes:

1) Those intrinsic to the liver (Hepatitis, Cirrhosis, Hemochromotosis, Amyloidosis, NASH, gallbladder disease, etc)

2) Tumors (Hemangiomas, Primary and secondary liver CA)

3) CV related: CHF, Vena Cava thrombosis, Tricuspid regurg, Chronic temponade, Budd Chiarri syndrome, etc.

So this guy had JVD, Hepatomegaly, and bilateral LE edema. The syncope thing was VERY strange...

So he was worked up.... and found to have occlusive CAD. But that doens't explain the syncope like events (late AS could explain this but he didn't have that).

He did have a strange looking CVP trace intra-op.



The patient did not have CHF and his function was actually pretty decent despite his 2 vessel disease.

The tricuspid valve however, was hard to examine. Here is a nice systolic view of the ME AV SAX: What's going on here??? 😀

 

[Idiopathic]

.

 

[periopdoc]

Nice. Video clip would be awesome.

- pod

 

[Stank811]

Right sided atrial Myxoma essentially causing right sided congestion with occasional syncopal episodes when it prevents adequate preload to RV?

 

[sevoflurane]

Right sided atrial Myxoma essentially causing right sided congestion with occasional syncopal episodes when it prevents adequate preload to RV?

Right sided? I thought atrial myxomas were left sided. 😉

 

[bobow98]

I think he meant the OTHER right. 🙂

 

[VentdependenT]

big fat RV thrombus extending into RVOT? Im just a TTE dude now. havent done a TEE in 5 years...

CVP tracing...cant make out anything in systole from the C to the V. looks like a flat line? Dunno. what did his EKG show?

 

[Idiopathic]

whatever it is, its bizarre. and the discussion in the OR will invariably be "how was this guy walking around with this"

my money is on renal cell CA with tumor/clot extending up the IVC into the RA

 

[Stank811]

Right sided? I thought atrial myxomas were left sided. 😉

Most of the time but they can also be right sided...although not as common

 

[sevoflurane]

Nice. Video clip would be awesome.

- pod

Hope this works...



Try clicking on it from a laptop or desktop. Doesn't work on my iphone.

 

[Stank811]

Agree with Vent...CVP also seems to have an absent x descent which could be from the big mass preventing the normal transmissions of pressures from RV

 

[sevoflurane]

my money is on renal cell CA with tumor/clot extending up the IVC into the RA

That is a good guess, cuz I've seen renal CA go up the IVC numerous times over the years.

 

[sevoflurane]

....and the discussion in the OR will invariably be "how was this guy walking around with this"

Exactly. This guy was @ super high risk for sudden cardiac death... either from acute obstruction or emboli. Syncope spells were a sentinel event for sure.

 

[loveoforganic2]

Hope this works...



Try clicking on it from a laptop or desktop. Doesn't work on my iphone.

It works, thanks. Is that tricuspid valve prolapse? I've only had ~30 minutes of formal education on US, so that may be way off

Edit: Take that back, I was thinking from this view, you could see the valve movement like that, but I expect it would cut off and you wouldn't be seeing the whole thing, so must be some kind of mass, back to thinking in a bit

 

[Stank811]

The video works and that is a problem

 

[Idiopathic]

amazing. probably every time preload was transiently dropped (rise from sitting, valsalva, etc.) this guy would be on the verge of blacking out. had to be so preload dependent

 

[lushmd]

my money is on renal cell CA with tumor/clot extending up the IVC into the RA

Agreed. Had an echo similar to this today (known hx renal cell CA, thought to be infrahepatic).

 

[VentdependenT]

Where is the cancer... muhahah

That big fat bastard of a clot/tumor was causing complete intermittent RVOT obstruction and causing him to pass out. I cant believe preop echo didnt show this.

 

[Stank811]

Thanks for taking the time to post the pics and vid...great case

 

[sevoflurane]

Thanks for taking the time to post the pics and vid...great case

Yeah man... no prob. I hope it was fun.

Stank...

That hits at the very point of this thread. This thread is really not about clinical anesthesia. It's about anesthesia being awesome!

We are privilaged in that we can see and participate in some amazing pathology out there. Participate in life changing maneuvers that are ultimately life or death.
From the little gramers to the bi-vad, to the simple appy or the occasional zebra that walks through the door. We meet new people everyday. We get to be there pre-op, intra-op and round on them post-op. It's a good feeling I must say. We all have some of those days where we get home and think to ourselves...

Wow... that was a little crazy

or

did that really just happen...?

Regardless of what comes down the line with obamacare, I truly can't imagine a better specialty. Working hard isn't working hard when you love what you do.

These types of cases makes me super happy cuz they are special.

I'm thankful to be part of it.

Here is an echo picture after coming off bypass:





Anesthesia is awesome.

and amazing...

all at the same time.

If you guys are on here... you know what I'm talking 'bout.

 

[sevoflurane]

Right sided atrial Myxoma essentially causing right sided congestion with occasional syncopal episodes when it prevents adequate preload to RV?

Well done buddy. You got it.

90% are left sided and 10% are right sided.

Inccidence range is somewhere between .5-30 per million for atrial myxomas... so the right sided ones are pretty rare.

"Introduction
Myxoma is the most common primary cardiac tumour. This case report illustrates the case of a probable right atrial myxoma prolapsing through the tricuspid valve into the right ventricle, and the fatal outcome if such a mass is not promptly detected and excised.

Case presentation
A 51-year old man presented with a 1-year history of recurrent pedal and abdominal swelling, and 6-month history of progressive dyspnoea on exertion. Transthoracic echocardiography showed a large right atrial mass prolapsing through the tricuspid valve into the right ventricle. Patient discharged himself against medical advice and died about one hour after getting home while trying to stand up from the sitting position.

Conclusion
Cardiac myxomas should always be considered when the cause of heart failure is not obvious. Transthoracic echocardiography remains an invaluable tool in the diagnosis, and prompt treatment is necessary to avoid fatal outcomes."

http://www.casesjournal.com/content/1/1/386

 

[VentdependenT]

Well I obviously cant read a TEE fer $hit! Awesome case dude! Thank the lord for good anesthesiologists. Im still learnin TONS from you dudes/dudettes.

Glad everything turned out well for this guy. He was LUCKY that he needed a CABG.

 

[BlackTalon]

Great case, sevo. Thanks for sharing! And yes, anaesthesia is AWESOME! I'm starting my intern year next month, and can't wait to get started on anaesthesia proper. Not too enthusiastic about the exams though (25-30% pass rate here).

BTW, how would you anesthetize this patient while keeping preload up? The usual cardiac (balanced anaesthesia) induction? I'm guessing if you are getting that CVP trace while the patient is awake, there is significant RVOT obstruction even before induction.

 

[aalupatti]

Wow that PA dint kick the ball down into the RVOT......

 

[sevoflurane]

Wow that PA dint kick the ball down into the RVOT......

PA was the easy part (took 2 tries to float it past the tumor).

The tough part was placing the SVC cannula. TEE was very helpful for this part. Careful placement. Literally lifting the tumor up from the base of the atrium.

 

[sevoflurane]

Great case, sevo. Thanks for sharing! And yes, anaesthesia is AWESOME! I'm starting my intern year next month, and can't wait to get started on anaesthesia proper.

Great choice. I felt the same way starting out. 👍

Learning anesthesia will be a blast. The first time your attending leaves you in the room by yourself is a right of passage. Then the tough cases will follow (transplants, neuro, trauma, cardiac, complex pedi). Before you know it, you will be in PP or academia having the time of your life.

 

[sevoflurane]

BTW, how would you anesthetize this patient while keeping preload up? The usual cardiac (balanced anaesthesia) induction? I'm guessing if you are getting that CVP trace while the patient is awake, there is significant RVOT obstruction even before induction.

Try to keep him at his baseline and keep flow going forward (good preload, limit the pure alpha stuff and things that cause increased pulm pressures. Be ready to crash onto bypass if you need to as this is a pure mechanical problem).

 

[aalupatti]

PA was the easy part (took 2 tries to float it past the tumor).

The tough part was placing the SVC cannula. TEE was very helpful for this part. Careful placement. Literally lifting the tumor up from the base of the atrium.

If I knew ahead I would no way put a PA in. But ignorance is a bliss too...
Great case

 

[sevoflurane]

I knew ahead of time. I also saw the stalk it was hanging from. Like all procedures... don't force it or you may break it/cause some harm. PA was easy.

SVC cannula was way bigger and consequently a little bit more challenging... but we did it slowly and safely.



SVC cannula squeezing in behind the tumor.... carefully. 🙂

 

[periopdoc]

Cool. I would have guessed renal cell as well given the location.

Sure that avoiding things that will increase pulm pressure is necessary? I would think that anything that keeps RVDP up would be beneficial.

- pod

 

[urge]

Cool case.

I wouldn't have placed a PA catheter. But then, I don't place many PA catheters nowadays.

 

[sevoflurane]

Cool. I would have guessed renal cell as well given the location.

Sure that avoiding things that will increase pulm pressure is necessary? I would think that anything that keeps RVDP up would be beneficial.

- pod

Well... I think it depends on the degree of obstruction. I hear you on raising diastolic pressure. In a dynamic obstruction a raise in diastolic pressures could help keep the mass from completely obstructing forward blood flow. On the other hand, you want to help all the blood that actually makes it past the tumor out the RVOT and into the systemic circulation. Increasing pulmonary vasoconstriction or increasing afterload may impede this process in a situation where CO is already compromised. Venodilation and reduction in afterload is def. a bad thing. I think you enter a slippery slope if you go too hard in either direction.

My goal was to keep him at baseline. He had been living with this giant in his heart for some time so I really didn't want to make any major changes to his hemodynamics. I used a little diluted vaso and a couple hundred mcgs of neo before bypass... in aliquots that were just enough to keep him right around baseline.

Interestingly, his CVP went from 25mmhg to 6mmhg after bypass and his CI went from 1.5ish to 5.5ish. Pretty satisfying case.