another asc case

[thegasman]

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35 yo Male presents to asc for knee scope. Pt has history of TGA with mustard procedure. Pacemaker placed as teenager. Patient looks good 6'2 180 lb police officer says he regularly bikes 30-40 miles. ECG shows unusual p axis regular at 60 bpm. Says he hasn't seen his cards guy in "a year or 2". Is pacer working? "as far as i know, i don't have any problems". Surgeon is slick knee scope takes 10 minutes - anes is mac (versed/fent surgeon gives local then prop 50-100 mg when scope goes in and then case is over) I'm the new guy and senior partner has said case is good to go (but he isn't here). To the OR or not?

 

[Planktonmd]

35 yo Male presents to asc for knee scope. Pt has history of TGA with mustard procedure. Pacemaker placed as teenager. Patient looks good 6'2 180 lb police officer says he regularly bikes 30-40 miles. ECG shows unusual p axis regular at 60 bpm. Says he hasn't seen his cards guy in "a year or 2". Is pacer working? "as far as i know, i don't have any problems". Surgeon is slick knee scope takes 10 minutes - anes is mac (versed/fent surgeon gives local then prop 50-100 mg when scope goes in and then case is over) I'm the new guy and senior partner has said case is good to go (but he isn't here). To the OR or not?

what are you concerned about?

 

[zippy2u]

35 y/o, police officer, 6'2", 180. Dude prolly spends his days and nights runnin' after 'hood rats, gang bangers and other assorted misfits over fences and through streams with 30 lbs of gear on. 30-40 miles on a bike at a clip? Bang your drugs, dog, and drink your Wild Turkey with a clear conscience. Regards, ---Zip

 

[mille125]

35 yo Male presents to asc for knee scope. Pt has history of TGA with mustard procedure. Pacemaker placed as teenager. Patient looks good 6'2 180 lb police officer says he regularly bikes 30-40 miles. ECG shows unusual p axis regular at 60 bpm. Says he hasn't seen his cards guy in "a year or 2". Is pacer working? "as far as i know, i don't have any problems". Surgeon is slick knee scope takes 10 minutes - anes is mac (versed/fent surgeon gives local then prop 50-100 mg when scope goes in and then case is over) I'm the new guy and senior partner has said case is good to go (but he isn't here). To the OR or not?

are you consider cancelling this case?? why??

The surgeon can give an intraarticular injection. You can do a femoral block if so inclined. Will require very little MAC (this case can easily be done with a femoral block and intraarticular injection).

Stop worrying and do the case

 

[urge]

what are you concerned about?

I echo his question.

 

[Pooh & Annie]

Minor procedure + >> 4 METS. Doing the procedure would be going by the book.

 

[thegasman]

Patient has Transposition of Great Arteries repaired -sort of. Mustard procedure which is no longer performed inserts an intratrial baffle to preferentially redirect blood flow to the appropriate outflow tract via asd. These days the kids get a true repair - arterial switch procedure. Mustard kids all eventually end up with arrythmias and RV failure eventually when they grow up although it sounds like this guy is doing OK. Preop nurses are worried about it because they can't feel any peripheral pulses on the guy ( the surgeon said he didn't care) and the crna is nervous. My concern is that he vaguely says he hasn't seen a cardiologist in a couple of years. Anybody out there for getting a clearance?

 

[aredoubleyou]

Doesnt have any evidence of current RV failure, no symptoms of significant arrhythmia. No clue what the significance of a anbnormal p wave axis is after an atrial repair (ie may be a result of the surgery), but if the qrs axis is normal, cant really see why I would care that much about a minor ecg finding. If he bikes 30 miles, who cares about his peripheral pulses, cardiac output is increasing in proportion to oxygen demand. Probably higher risk than another 35 yo 180# biker.... but a whole lot less than your next patient, the 69 yo 250 lb fat guy who just finished a cigerette before coming to the lobby.

 

[Planktonmd]

Patient has Transposition of Great Arteries repaired -sort of. Mustard procedure which is no longer performed inserts an intratrial baffle to preferentially redirect blood flow to the appropriate outflow tract via asd. These days the kids get a true repair - arterial switch procedure. Mustard kids all eventually end up with arrythmias and RV failure eventually when they grow up although it sounds like this guy is doing OK. Preop nurses are worried about it because they can't feel any peripheral pulses on the guy ( the surgeon said he didn't care) and the crna is nervous. My concern is that he vaguely says he hasn't seen a cardiologist in a couple of years. Anybody out there for getting a clearance?

You said he hikes 30- 40 miles and he works as a police man.
If the CRNA is nervous tell her that you are not nervous.
This is not the CRNA that gives Propofol + N2O for MAC is it?
If you are really worried do a femoral block and tell your CRNA not to do room air GA.

 

[zippy2u]

The 35-40 mile bike gigs are screamin' at ya, bro. Holy shiit Batman, this guy is pumpin' more blood throughout his body in one day than I pump in an entire month --ta hells with the peripheral pulses. For shiits and giggles, bang him with some amp/gent or vanco for SBE prophylaxis and call it a day. ASC, healthy cop with good insurance and a 10 minute knee scope surgeon--- you're about as close to heaven as you can get without dying. Ya can't walk on eggshells your whole life. Oh, heaven you ask? That's when the mofo bangs on the front door of the ASC at 6 AM pleading to have his scope done with an unlimited supply of cash, check or credit card and no insurance. Regards, ----Zippy

 

[Noyac]

 

[thegasman]

Well I agreed with you guys - 30-40 mi bike ride tells me he is good to go. We go to the OR and proceed with versed/fent prop, local, trochar goes in, everything looks good. I head out to do next preop. CRNA calls in - "hey I want to show you something" I come back and case is done. She points at ECG. Rate is 30-35, no p waves. Not regular either, some pretty Looong pauses. We gave some glyco and atropine and at least it got regular. Long QRS regular rate of 33 in the the pacu. But it didn't phase 30 mi bikin cop - he is alert with bp of 120/80. But at this point it is safe to say his pacer isn't working. One of the nurses said she saw a spike that didn't capture but I'm not seeing anything. So I try to call up his cards guy. Nurse says doc isn't in and this patient hasn't been seen since 2001!!! So I get in touch with cards guy covering for him and they want to admit him. This is same day as the other thread I posted with the aspirating pt. So I had the good fortune of having two admitted in the same day from asc. Not to mention I had a teenager get red man syndrome from vanc and that case got cancelled. My second day at the asc. I got to the house and had a few cold ones that night. A lot of this stuff is new to me and I am seeing there is a lot more to this biz than what you do in the or. The days of being a resident and doing one case in the or at a time was some easy s@it.

 

[zippy2u]

Well if the CRNA would have popped him with a little phenylephrine or ephedrine to keep his BP up prior to pushin' the prop, ya may not have had seen that strange arrhythymogenic juju. Good job, Pops. Regards, ---Zip

 

[Planktonmd]

Well I agreed with you guys - 30-40 mi bike ride tells me he is good to go. We go to the OR and proceed with versed/fent prop, local, trochar goes in, everything looks good. I head out to do next preop. CRNA calls in - "hey I want to show you something" I come back and case is done. She points at ECG. Rate is 30-35, no p waves. Not regular either, some pretty Looong pauses. We gave some glyco and atropine and at least it got regular. Long QRS regular rate of 33 in the the pacu. But it didn't phase 30 mi bikin cop - he is alert with bp of 120/80. But at this point it is safe to say his pacer isn't working. One of the nurses said she saw a spike that didn't capture but I'm not seeing anything. So I try to call up his cards guy. Nurse says doc isn't in and this patient hasn't been seen since 2001!!! So I get in touch with cards guy covering for him and they want to admit him. This is same day as the other thread I posted with the aspirating pt. So I had the good fortune of having two admitted in the same day from asc. Not to mention I had a teenager get red man syndrome from vanc and that case got cancelled. My second day at the asc. I got to the house and had a few cold ones that night. A lot of this stuff is new to me and I am seeing there is a lot more to this biz than what you do in the or. The days of being a resident and doing one case in the or at a time was some easy s@it.

So now you know that this guy is capable of a low junctional escape rhythm and that his pacer is not working.
Your CRNA managed with her "room air GA" to clarify the situation, and now the guy will get his PM fixed.
You actually did him a favor by exposing him to your CRNA's anesthetic stress test.

 

[urge]

You cancelled a case for red man syndrome? Are you serious? Wow!

My best bet is the pacer got deprogrammed during the procedure(assuming it was working earlier on during the day and someone bothered to check vital signs!). You could have tried a magnet to set it into asynchronus mode. Anyway, once it's malfunctioning you need someone to program it back. In an ASC cardiology will probably be your best bet.

ASC seem like a pain.

 

[thegasman]

You cancelled a case for red man syndrome? Are you serious? Wow!
.

I didn't cancel it. The podiatrist did and it was a good idea. The 16 yo girl was freakin out - but her mom has freakin out even more. The chick turned bright red and started saying she couldn't breath etc. But she was breathing fine SpO2 100 no wheezes, etc. They still gave her some low dose epi anyway. When I got there the best med for her was midaz and that (plus the benadryl) did the trick. The nurses were all convinced it was anaphylaxis and wanted me to admit the chick to the hospital. This was in the am though so I just observed her for several hours and sent her on her way. This is my first red man, but it can get pretty serious with angioedema hypotension and the like, so I don't think it is a bad idea to bring her back another day and let them chill out for a while.

 

[thegasman]

My best bet is the pacer got deprogrammed during the procedure(assuming it was working earlier on during the day and someone bothered to check vital signs!). You could have tried a magnet to set it into asynchronus mode. Anyway, once it's malfunctioning you need someone to program it back. In an ASC cardiology will probably be your best bet.

ASC seem like a pain.

Wrong. If you saw my post above, after the case we found out that this guy hadn't seen his cards guy in 7 years (pacer clinic should be every 6 mo). And he was in a sinus rhythm preop. The patient also let on afterwards (with the truth serum on board) that he knew the pacer hadn't been working for years. Looking back his story seemed a little vague and fishy preop.

 

[jetproppilot]

.

 

[radslooking]

Interesting case. It's amazing this guy can do all that biking using his RV to pump to his entire body.

What do you think caused him to go into a junctional rhythm?

From my limited experience, all the junctional rhythms i've ever seen maintain their pressures just fine.

And i agree with who cares about peripheral pulses. if those biking legs are getting enuf blood during those 30 mile bikes, that seems good enough.

 

[militarymd]

are you consider cancelling this case?? why??

The surgeon can give an intraarticular injection. You can do a femoral block if so inclined. Will require very little MAC (this case can easily be done with a femoral block and intraarticular injection).

Stop worrying and do the case

I 'm not kidding about this...

I reviewed a case just like this...except it was a shoulder arthroscopy......stroked out because there was shunting at the baffles that the patient didn't know about because he stopped going to his cardiologist 10 years ago........somehow during the case.....a little R to L developed....and probably a bubble or 2 got to his brain...

CANCEL this case....CYA.....don't do it without a cardiologist signing off on it.

 

[Planktonmd]

I 'm not kidding about this...

I reviewed a case just like this...except it was a shoulder arthroscopy......stroked out because there was shunting at the baffles that the patient didn't know about because he stopped going to his cardiologist 10 years ago........somehow during the case.....a little R to L developed....and probably a bubble or 2 got to his brain...

CANCEL this case....CYA.....don't do it without a cardiologist signing off on it.

🙄

 

[coprolalia]

CANCEL this case....CYA.....don't do it without a cardiologist signing off on it.

WOW!

I am stunned! MilMD canceling a case?!???! 😱

-copro