Another ASC case

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Planktonmd

Planktonmd

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So here comes the story:
You are the anesthesiologist at the surgicenter, at the end of the day the nurse brings you a chart for review. It belongs to a 79 Y/O lady who is coming for sinus surgery in 2 days, she will require GA.
Her medical history from what you see in the chart is the following:
1- Ischemic cardiomyopathy with EF of 20 % (echo done last month).
2- History of Mitral valve and aortic valve replacement 2 years ago, on Coumadin that she has stopped 2 days ago and a pt + INR will be done tomorrow.
3- AICD placed after valve replacement and last year it shocked her 15 times for V tach during a 2 days period but no shocks since. Device working fine according to cardiologist.
4- COPD
5- DM type II
She has a note from a cardiologist saying she is "cleared" for surgery and that she is moderate risk.
EKG shows ventricular pacing.
Labs show Elevated AST and ALT in the 200-300 range.
Nurse is asking you if the patient is OK for surgery.
This is a free standing ASC where you will be the only anesthesiologist with 3 CRNA's.
What's the plan??
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Planktonmd said:
So here comes the story:
You are the anesthesiologist at the surgicenter, at the end of the day the nurse brings you a chart for review. It belongs to a 79 Y/O lady who is coming for sinus surgery in 2 days, she will require GA.
Her medical history from what you see in the chart is the following:
1- Ischemic cardiomyopathy with EF of 20 % (echo done last month).
2- History of Mitral valve and aortic valve replacement 2 years ago, on Coumadin that she has stopped 2 days ago and a pt + INR will be done tomorrow.
3- AICD placed after valve replacement and last year it shocked her 15 times for V tach during a 2 days period but no shocks since. Device working fine according to cardiologist.
4- COPD
5- DM type II
She has a note from a cardiologist saying she is "cleared" for surgery and that she is moderate risk.
EKG shows ventricular pacing.
Labs show Elevated AST and ALT in the 200-300 range.
Nurse is asking you if the patient is OK for surgery.
This is a free standing ASC where you will be the only anesthesiologist with 3 CRNA's.
What's the plan??
Click to expand...

How about "not an appropriate case for a free-standing ASC" ?
 
If all of her major medical issues are otherwise stable and unchanging then she would be an acceptable candidate pending her INR clearing. I would also like more information on her PACEMAKER (model, response to magnet, results of last interrogation would be nice) if possible since shes apparently got that on top of her ICD. The thing that bothers me is her elevation in LFTs. Whats causing this? I wouldnt be rushing into this surgery given the mortality associated with an acute hepatitis. Or is this liver congestion from acute CHF (ACC/AHA major risk factor)? Reaction to medication? Further workup may be needed. I would probably cancel pending further workup.

Oh, and if the surgery proceeds, I would caution the ENT about epi/coke use.
 
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Yes you can do this case in a free standing ASC but WHY?

This young lady will most likely have an uneventful perioperative experience. However the myriad of things that could go awry with her are not easily handled in a free standing ASC:

Pacer Problems
Bleeding Problems
Post op MI
Post op ventilation
Unknown Etiology of Elevated Liver enzymes

Is she as good as she will get medically? Prolly so....... but with all of the above potential complications not being best handled in a free standing ASC.


Im always curious about why a surgeon who has a financial interest in a ASC would bring a pt like this to his facility? Is the upside really worth all the downside in pts like this one?
 
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Looks to me like she's an ASA 4 (serious disease that is a constant threat to life). We don't do ASA 4s at the ASC. I didn't make up that rule but I follow it. Next!! ---Regards, ---Zip
 
The coumadin needs to be stopped earlier I think... You stated she's been on it for a while. Probably will require some sort of bridge therapy.

Why are the liver enz's so elevated? I agree, is CHF a concern?

Too much going on with her at this time in terms of CV status.

On the flip side, what sort of 'sinus surgery' is it? I know nowadays, some ENTs will do Endoscopic sinus surgery on patients via MAC. However, in her case, why even risk it....Sinus surgery is typically elective.
 
doing the case while liver enzymes are elevated could be problematic first off.

secondly, having a aicd renders her asa 4 and these cases are best done in the hospital.

so i would not rubber stamp her, i would say "not a candidate for surgery at the asc at this time"
 
This would not affect my decision NOT to do this case in an ASC (due to the likelihood of the peri/postop complications others have mentioned), but I'm curious, what is her exercise tolerance?

The transaminitis could be many things, but I'm putting my money on CHF, unless you tell me she can climb stairs with a full bag of groceries on each arm!

Planktonmd said:
So here comes the story:
You are the anesthesiologist at the surgicenter, at the end of the day the nurse brings you a chart for review. It belongs to a 79 Y/O lady who is coming for sinus surgery in 2 days, she will require GA.
Her medical history from what you see in the chart is the following:
1- Ischemic cardiomyopathy with EF of 20 % (echo done last month).
2- History of Mitral valve and aortic valve replacement 2 years ago, on Coumadin that she has stopped 2 days ago and a pt + INR will be done tomorrow.
3- AICD placed after valve replacement and last year it shocked her 15 times for V tach during a 2 days period but no shocks since. Device working fine according to cardiologist.
4- COPD
5- DM type II
She has a note from a cardiologist saying she is "cleared" for surgery and that she is moderate risk.
EKG shows ventricular pacing.
Labs show Elevated AST and ALT in the 200-300 range.
Nurse is asking you if the patient is OK for surgery.
This is a free standing ASC where you will be the only anesthesiologist with 3 CRNA's.
What's the plan??
Click to expand...
 
I don't care what additional workup she gets. If she wants surgery, it's gonna be at the big house.
 
zippy2u said:
Looks to me like she's an ASA 4 (serious disease that is a constant threat to life). We don't do ASA 4s at the ASC. I didn't make up that rule but I follow it. Next!! ---Regards, ---Zip
Click to expand...

Zippy you are on the money again. Clearly an ASA 4 case that doesn't belong at an ASC.
I would want an A-line for the case and she may need an overnight stay depending on how she does.
 
So let's say we decided to do it at the hospital.
She shows up 2 day later at the hospital.
Her INR is 1.5
Liver enzymes were rechecked and they are the same (AST and ALT 200-300) with mild elevation of Alk-phos and Total bili = 2.
She says that she feels OK and that she is able to walk 1 block slowly before she has to stop to catch her breath.
She has mild edema of her ankles.
Her lungs sound clear.
Her SPO2 on room air is 95%.
The airway looks OK.
Can we proceed now?
 
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Hospital is where she belongs

Is the one block exercise tolerance her baseline? I'm assuming it is, as long she wasn't walking a mile a day and something has changed recently that's fine.

If the ENT is okay with an INR of 1.5 I'd say go for it.

Elevated liver enzymes? Minimal impact on anesthetic management, obvious concern for why, I would fear the medicolegal consequences more than the clinical consequences

I would want the AICD switched over to a back up rate with the defib function turned off, and pacer pads placed on her until the defib is turned back on. Who does that at your institution? We get the EP fellows to come do it. I've gotten a sense the device reps are less inclined to come in for things like that.
 
Planktonmd said:
So let's say we decided to do it at the hospital.
She shows up 2 day later at the hospital.
Her INR is 1.5
Liver enzymes were rechecked and they are the same (AST and ALT 200-300) with mild elevation of Alk-phos and Total bili = 2.
She says that she feels OK and that she is able to walk 1 block slowly before she has to stop to catch her breath.
She has mild edema of her ankles.
Her lungs sound clear.
Her SPO2 on room air is 95%.
The airway looks OK.
Can we proceed now?
Click to expand...

It looks like she's good to go, a-line before induction. I'm far from a remi fan but you could make a good case for it in this scenario.
 
maceo said:
secondly, having a aicd renders her asa 4 and these cases are best done in the hospital.
Click to expand...

How do you figure that? Yes, I realize AICD placement implies a significant ongoing risk of sudden death but there are lots of similar conditions (e.g. 7cm AAA) that don't make you an ASA4.
 
thegasman said:
No on the asc, yes at the hospital, and I probably wouldn't place an aline.
Click to expand...

Until something goes wrong and your auto BP cuff stops working. Then, who knows whether all that Phenylephrine will do any good.

Plus, is a Midlevel provider doing the case? Are you relying on someone else's judgement to actual deliver the anesthetic?

You won't know that you need the A-line until you need it. The same reason you buy insurance.
 
Is it OK to do elective surgery on a patient with liver enzymes 6-7 times the normal?
Is this liver dysfunction secondary to heart failure or is it something else? Does it matter??
 
Planktonmd said:
Is it OK to do elective surgery on a patient with liver enzymes 6-7 times the normal?
Is this liver dysfunction secondary to heart failure or is it something else? Does it matter??
Click to expand...

She has a lot more problems to worry about than bad sinuses. I would get a GI consult to CYA on this patient but yes, I bet the elevated LFT's are due to her heart.

Assuming you keep her three hearts cell contracting during the case the LFT's should hopefully stay the same.

By the way, what is her renal function like? Does she has renal insufficiency as well?

Her increased LFT's could also be due to a medication like a statin. You didn't list her twenty meds.
 
Last edited:
. Nouel1, J. Henrion1, J. Bernuau1, C. Degott1, B. Rueff1 and J. -P. Benhamou1
contact.gif
(1) Unité de Recherches de Physiopathologie Hépatique (INSERM), 92118 Clichy, France(2) Service d'Anatomie et de Cytologie Pathologiques, Hôpital Beaujon, 92118 Clichy, France
Received: 7 May 1979 Revised: 19 June 1979 Accepted: 29 June 1979
Abstract Heart failure is a recognized, although uncommon, cause of massive liver cell necrosis, the clinical consequences of which are intermingled with those of cardiac insufficiency in most cases. We report the cases of six patients suffering from chronic heart failure in whom an episode of acute circulatory failure resulted in massive liver cell necrosis and fulminant hepatic failure. The manifestations of fulminant hepatic failure, ie, hepatic encephalology, jaundice, and marked increase in prothrombin time, developed after an interval of one to three days, after the episode of acute circulatory failure, while the patients' hemodynamic condition had returned to the previous basal status.
 
Cardiomyopathy unrecognized as a cause of hepatic failure.

Hoffman BJ, Pate MB, Marsh WH, Lee WM.
Department of Medicine, Medical University of South Carolina, Charleston 29425.
Two patients with similar symptoms referred for diagnosis and treatment of hepatic failure subsequently proved to have cardiomyopathy as the cause of their hepatic decompensation. Except for fatigue and edema, symptoms of congestive heart failure were absent and no history of dyspnea, orthopnea, or paroxysmal nocturnal dyspnea could be elicited. Hepatomegaly was present in both patients, but neck venous distension and hypotension were not apparent, and both patients were able to lie flat. The diagnosis of cardiomyopathy was made by echocardiogram showing global hypokinesis and low ejection fractions; right atrial pressures were markedly increased. Liver biopsies demonstrated centrilobular necrosis and congestion. Treatment for heart failure led to a prompt response in both patients with rapid return of all hepatic parameters toward normal. Paradoxically, our patients had striking evidence of hepatic failure and a notable absence of symptoms and signs of congestive heart failure. An awareness of this unique presentation may avoid prolonged evaluations in such critically ill patients.
 
Pilot Doc said:
How do you figure that? Yes, I realize AICD placement implies a significant ongoing risk of sudden death but there are lots of similar conditions (e.g. 7cm AAA) that don't make you an ASA4.
Click to expand...


Yes. If you work at an ASC there are NO ASA 4 patients.;)

But, seriously you are correct. The presence of an AICD alone does not make one an ASA 4.
In PP, there are patients who get AICD's with EF=35% and no history of actual V. tach (they may have INDUCIBLE V. Tach). In fact, the vast majority that I have seen tell me the device has never shocked them even once.
 
BLADEMDA said:
Yes. If you work at an ASC there are NO ASA 4 patients.;)

But, seriously you are correct. The presence of an AICD alone does not make one an ASA 4.
In PP, there are patients who get AICD's with EF=35% and no history of actual V. tach (they may have INDUCIBLE V. Tach). In fact, the vast majority that I have seen tell me the device has never shocked them even once.
Click to expand...

I would disagree that the presence of an AICD does not automatically make one an ASA 4. The definition of an ASA 4 is a patient with a medical condition which is a constant threat to life. If someone has a severe enough risk of having a fatal arrhythmia ( a constant threat to life) that their cardiologist believes it is in the patient's best interest to undergo an invasive and expensive medical procedure to mitigate that risk, I think they are the very definition of an ASA 4.

Furthermore, even if I could accept that they are an ASA 3, I still would not do one in an ASC. 2007 ACC/AHA guidelines say that these should be interogated after surgery. Having a rep meet the patient post-op to interogate the AICD will significantly increase PACU time, which is frowned upon in most ASCs.
 
9french said:
I would disagree that the presence of an AICD does not automatically make one an ASA 4. The definition of an ASA 4 is a patient with a medical condition which is a constant threat to life. If someone has a severe enough risk of having a fatal arrhythmia ( a constant threat to life) that their cardiologist believes it is in the patient's best interest to undergo an invasive and expensive medical procedure to mitigate that risk, I think they are the very definition of an ASA 4.

Furthermore, even if I could accept that they are an ASA 3, I still would not do one in an ASC. 2007 ACC/AHA guidelines say that these should be interogated after surgery. Having a rep meet the patient post-op to interogate the AICD will significantly increase PACU time, which is frowned upon in most ASCs.
Click to expand...

We disagree then. In my part of the woods Cardiologists place a LOT of AICD's. Some of these patients are in decent shape despite the fact they have an AICD. In fact, the middle aged fat guy with OSA may be just as likely to keel over as the patient with an AICD. Both can be ASA 3's.

As for automatically not doing a patient with an AICD at an ASC that is one opinion. I have personally done some of those cases. For example, a cataract, colonoscopy, knee arthroscopy, etc. can safely be performed on a subset of AICD patients at an ASC.

As for waiting for the AICD rep we do the AICD patient EARLY in the morning. This means the rep shows up around 10:00 and checks the device. Since the Surgeons OWN the ASC they don't mind the patient sticking around an extra hour.

However, if you don't want to deal with the AICD and keeping the patient for an extra hour is a big deal then don't do the case at the ASC.
 
Prophylactic Implantation of a Defibrillator in Patients with Myocardial Infarction and Reduced Ejection Fraction (MADIT II Trial). NEJM 3/21/02, v346, n12.

This trial was designed to assess the mortality difference between having a implantable defibrillator vs standard medical therapy for patients with heart failure. There were 1232 patients enrolled with prior MI and a LVEF of 30% or less. Patients were randomly assigned in a 3:2 ratio (742 in the defibrillator group vs. 490 in the standard medical therapy group). Results showed an average follow-up time of 20 months with mortality rates being 19.8 % in the standard medical therapy group vs. 14.2% in the defibrillator group (the difference was significant). There was a subgroup analysis done also, which showed similar results regardless of age, sex, EF, NYHA class, and QRS interval. Basically, the study showed to put AICDs in patients with prior MI and an EF of 30% or less. Note that this trial only is for patients with ischemic cardiomyopathy.

​
 
Statins and elevated liver tests: what's the fuss? Even when liver function tests are moderately elevated, statins are safe for most patients

Journal of Family Practice, July, 2008 by Edward Onusko

Practice recommendations
* Order liver function tests before starting statin therapy, 12 weeks after initiation, with any dose increase, and periodically for long-term maintenance therapy (C).
* Mild elevations of alanine aminotransferase (ALT) or aspartate aminotransferase (AST) (<3 times the upper limit of normal [ULN]) following statin therapy do not appear to lead to significant liver toxicity over time (C).
* Other medications that lower low-density lipoprotein (LDL), and might be substituted for statins, may not improve morbidity and mortality (C).
Strength of recommendation (SOR)
 
Thank you Blade for all the literature :)
So, The patient is in holding area at the hospital with the above mentioned problems:
Low EF and Transaminase in the 200-300 range.
Creatinine = 1.6, BUN= 50, K= 5.4
The AICD is a Medtronic, you contacted the rep and he told you that the magnet function is not disabled on the device which means you can apply a magnet that will disable the defibrillation function temporarily.
BP is 90/50, HR is 70 paced, SPO2 is 95% on RA.
Patient is in no acute distress.
OK for GA??
What's the plan?
 
Planktonmd said:
Thank you Blade for all the literature :)
So, The patient is in holding area at the hospital with the above mentioned problems:
Low EF and Transaminase in the 200-300 range.
Creatinine = 1.6, BUN= 50, K= 5.4
The AICD is a Medtronic, you contacted the rep and he told you that the magnet function is not disabled on the device which means you can apply a magnet that will disable the defibrillation function temporarily.
BP is 90/50, HR is 70 paced, SPO2 is 95% on RA.
Patient is in no acute distress.
OK for GA??
What's the plan?
Click to expand...

Is there any other way to do this case?

Are all her other issues being treated? Liver? Kidney?

The EF and AICD are not any concern to me but I wouldn't want my sinuses roto-rootered with my PT at 1.5.
 
Noyac said:
Is there any other way to do this case?.
Click to expand...
No

Noyac said:
Are all her other issues being treated? Liver? Kidney?
Click to expand...
How do you treat them?
Assuming that the liver and kidney dysfunction are secondary to heart failure is there something we can do to make them better?
Remember the cardiologist said she is "cleared for surgery".

Noyac said:
The EF and AICD are not any concern to me but I wouldn't want my sinuses roto-rootered with my PT at 1.5.
Click to expand...
Agree.
 
Planktonmd said:
How do you treat them?
Assuming that the liver and kidney dysfunction are secondary to heart failure is there something we can do to make them better?
Remember the cardiologist said she is "cleared for surgery".
Click to expand...

Personally, I get on the phone and call the cardiologist. I get the real scoop not the "cleared for surgery" scoop. I ask real questions like, why the liver failure/impairment? Why the kidney insufficiency? Can they be improved? How long have these issues been present? Stable issues? Let me see the last few lab results and I'll decide if they are stable or not.

That's my approach.

Oh, and I'd ask the cardiologist if s/he thinks this surgery is necessary from their standpoint.
 
Who is the idiot surgeon who even thought about scheduling this case at an ASC? I would cancel the case in a heartbeat and reconsider whether or not I should even be working with a surgeon with such poor judgement, and I would let him know that...I would do the case at an actual hospital, +/- A-line...and I would probably want the patient monitored overnight with a medicine consult...
 
ncdoc1974 said:
Who is the idiot surgeon who even thought about scheduling this case at an ASC? I would cancel the case in a heartbeat and reconsider whether or not I should even be working with a surgeon with such poor judgement, and I would let him know that...I would do the case at an actual hospital, +/- A-line...and I would probably want the patient monitored overnight with a medicine consult...
Click to expand...

I did not agree to doing the case at the ASC and I called the cardiologist and addressed my concerns about what appears to be significant liver congestion possibly secondary to right ventricular failure.
The plan was to postpone the surgery and adjust medications to improve cardiac function, then re evaluate in a few months.
 
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