Another Case (#7) by Blade

[BLADEMDA]

Here is lucky case number 7.

81 year old white male for AAA repair. Surgeon is experienced and fast so case will take about 90 minutes.

PMH

8 cm AAA Infrarenal
Coronary Artery disease
PVD
COPD
O2 dependent at night
DM
Stable Angina
S/P CVA 2004 (mild, no residual)


PSH

CABG X 3 1990
REDO CABG X 4 2001
L Carotid Endarterectomy 2004


Note on the chart from Family Physician 500 miles away. "Patient Cleared for Surgery." The H and P from the Family Doc states INOPERABLE CAD with 2 vessel disease. Cardiac Cath done in 2005 and NO angioplasty. CT Surgeon consulted and refused to do THIRD CABG. EF=30% with global hypokinesia.


MEDS

Plavix- off 7 days
ASA- off 7 days
Avandia
Insulin
Toprol XL
Digoxin
Albuterol MDI
Advair
Omeprazole
Imdur


Pt. states no angina at rest. Does get SOB with any activity with only mild chest discomfort (his anginal equivalent). He can walk up one flight of stairs provided you give him 30 minutes to do it.


Labs

EKG; NSR with Q's Inf. leads, Poor R wave progression and non specific St/T
CXR COPD
CBC Hgb=10.1 Plt=187,000
Chem-7; K=4.2 Cr=1.85 BUN=14
ABG on 2 liters: 7.39/49/88
EF=30%
Pt/Ptt=WNL


Surgeon asks you about INCREASED renal protection. What about Corlopam?
Or, do you have something better? Patient requests Epidural for post-op pain do you agree? Do you want any other labs or tests prior to doing the case?
The patient is scheduled to go into the O.R. in 1 hour.

Blade

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[Noyac]

Hey Blade, are you an Oral Board examiner?

Because this was my second case verbatum.

I'll tell you and others how I did it after some residents reply.





I passed by the way. Blade, you even stood up after the examination and shook my hand saying, "Very well done."

I thought you were not supposed to give me any feedback after the exam?

 

[VentdependenT]

AVOID HYPOTENSION/HYPERTENSION/TACHYCARDIA/HYPOXIA.

I just love that.

ANypoops this sounds like a jim dandy.


Any other preop tests...nothing that I can think of. It would be nice to have a look at the echo to see what else is going on, see if his heart can take the clamp for even a minute or two while the pressure gets uncer control.

I'll take some vital signs though.

x-match 4u prbc to room please. I aint letting the HB get lower than 8. Sorry. blood for blood would "probably" be best for this guy.

Anypoops,


Tubage. Fentanyl, versed induction, maybe a squirt of whatever induction agent you like, or a breath down with some sevo then squirt in your fent, versed.

A-line, cordis, swan, throw in an echo to gimme a quick view of the valves, 4 chamber, then transgastric.

Epidural, sure. I'll dose it at the end prior to wake up with a few cc's of lidocaine. Maybe one of those fancy lumbar drains hooked up to a manometer if you're really spicey. Never used one.

Full range of pressors/inotropes/vasodilators available in stick form. Have nitrostick around for aortic x-clam. Prior to x-clamp:
- give some mannitol. How much. I dunno. Some. Ice those kidneys while on clamp.
- drop the pressure to low normal
-have nitroglycerine stick in line
-I would run NICARDIPINE. Which also MIGHT have some intrinsic renal protective stuff. dunno.

Even with INFRARENAL clamping you can get ATN/ARF. If he's really that concerned then he can hook up a bypass to the renal arteries. May be a good idea in this guy who's a disaster waiting to happen.

Prior to unclamp I'd dump in a liter of crystalloid. have some NEO in line.

 

[BLADEMDA]

AVOID HYPOTENSION/HYPERTENSION/TACHYCARDIA/HYPOXIA.

I just love that.

ANypoops this sounds like a jim dandy.


Any other preop tests...nothing that I can think of. It would be nice to have a look at the echo to see what else is going on, see if his heart can take the clamp for even a minute or two while the pressure gets uncer control.

I'll take some vital signs though.

Anypoops,


Tubage. Fentanyl, versed induction, maybe a squirt of whatever induction agent you like, or a breath down with some sevo then squirt in your fent, versed.

A-line, cordis, swan, throw in an echo to gimme a quick view of the valves, 4 chamber, then transgastric.

Epidural, sure. I'll dose it at the end prior to wake up with a few cc's of lidocaine. Maybe one of those fancy lumbar drains hooked up to a manometer if you're really spicey. Never used one.

Full range of pressors/inotropes/vasodilators available in stick form. Have nitrostick around for aortic x-clam. Prior to x-clamp:
- give some mannitol. How much. I dunno. Some. Ice those kidneys while on clamp.
- drop the pressure to low normal
-have nitroglycerine stick in line
-I would run NICARDIPINE. Which also MIGHT have some intrinsic renal protective stuff. dunno.

Even with INFRARENAL clamping you can get ATN/ARF. If he's really that concerned then he can hook up a bypass to the renal arteries. May be a good idea in this guy who's a disaster waiting to happen.

Prior to unclamp I'd dump in a liter of crystalloid. have some NEO in line.

Nice post Venty. What about PFT's? Would you delay the case for those?
Where are you going to place the Epidural? Thoracic or Lumbar? Are you going to discuss any increased risk from Thoracic Epidural to patient because of Heparinazation and/or possible bloody tap?
No Corlopam? What are you going to tell the surgeon about that drug? How much mannitol Venty as NOW you are the Attending on this case?

This case is a real one at my hospital. So, it shows not every Oral Board case is made up junk.

Blade

 

[VentdependenT]

I don't care about PFT's because what are they going to tell me? This guy is ALREADY A DISASTER. If he has restrictive disease nothing I can do. Have the guy loose weight? If he has REVERSIBLE portion of obstructive disease then I can find that out intraop. Give the guy a listen. Hit em with some albuterol. Steroids may be of some benefit 6-8hours after given. I give everyone, even diabetics, 4mg of decadron for PONV. So thats about what...20mg of prednisone. Not bad.

Ahh the epidural. Yes heparinization is of concern to me. I'm not worried about the 5K units intraop, but If this guy ends up going on bypass then I'm friggen hosed. I'd have to pull it right away and even then you have an hour where a hematoma can form...So I guess I'd really just leave the damn thing in. Hopefully tamponade (not the spine I hope, sheesh). Weighing the post op pain, large restriction on breathing by abd wound VS the possibility of going on bypass, I would think a thoracic epidural would seriously help this guy.

I don't want him on the vent early or he may develop a pneumonia and thats it for him. Done deal.

If this were my ORALS I would not place the epidural because as soon as I did they would tell me that we are going on bypass emergently for intraop MI.

We have had people with epidurals in get heparinized on the floor for PE's. But the amount given for bypass far exceeds that given on the floor.

 

[VentdependenT]

Sorry missed parts of the question.

Yes I would explain the risks vs the benifit to the patient about the epidural. A hematoma is a real issue if we go on bypass.

I don't know a DAMN THING about fenaldopam. I didn't even know we had it in this country. Thats what I'd tell the surgeon.

 

[BLADEMDA]

Sorry missed parts of the question.

Yes I would explain the risks vs the benifit to the patient about the epidural. A hematoma is a real issue if we go on bypass.

I don't know a DAMN THING about fenaldopam. I didn't even know we had it in this country. Thats what I'd tell the surgeon.

Venty,

As Chief Resident next month and an attending in 12 months the Vascular Surgeon asks you a few questions.

1. There was an article in my journal Annals Vascular Surgery 2003 Nov;17 (6) 656-662 that stated CORLOPAM increased renal blood flow in pig models.
The article stated "the intraoperative use of a continuous infusion of Corlopam (fenoldopam) during suprarenal aortic cross-clamping results in increased renal blood flow,less postoperative rise in creatinine and better preservation of tubular histology in the pig model."

There was another article in the journal of Cardiovascular Pharmacologic Therapy 2002 jan;6 (1):31-6 that sated FENOLDOPAM infusion is associated with preserving renal function after aortic cross-clamping for aneurysm repair.
This was mostly elderly patients with severe peripheral vascular disease
undergoing AAA repair.

Finally, an article in the European Journal of Anesthesiology 2002 Jan;19 (1):32-39 showed fenoldopam was "renoprotective during and after infrarenal aortic cross-clamping."

So, would you MIND running low dose Corlopam for me during the case and for a few hours afterwards?

2. As the surgeon I like the Epidurals. You have my blessing in putting one in for this patient. But, will it delay the case very much? Anything I should know about Thoracic vs. Lumbar Epidural placement? What if you hit a blood vessel in the thoracic area? Is there a BIG risk with the Epidural and Heparin?
As the surgeon I like 10,000 units of Heparin prior to cross-clamp. Is this a problem?


Venty, my Surgeon is a bright guy and he knows the patient is high risk. He asked me these questions over the years. What are you answers?

Blade

 

[BLADEMDA]

Venty,

I agreed with you about the PFT issue. I didn't see the value of waiting for PFT's in this patient. The ABG on 2 liters wasn't horrible. I ordered no further tests but TEE was available for the case intraopeatively.

Here are the patient's vitals:

weight=77 kg Ht= 5'9" BP= 156/87 Hr=62 RR=18 T=98.6

Venty, if you need help answering the SURGEON'S questions please PM Mil MD, Noyac, etc. and get one of them to answer for you.

Blade

 

[urgewrx]

Vent,
Did you induce before placing invasive monitors (A-line)? I would. Also a PA cath. Tee when asleep.

I'm not very concerned with epidural hematoma. True, it is possible, but assuming the pt has good coagulation, heparin will not be a problem if given 1 hr later. I would probably place it low thoracic/high lumbar.

I would use nicardipine or nitroprusside for the clamp time since they are more arterial dilators than NTG. NTG, levophed and epi drip in the room, in case that tired heart decides to stop cooperating.

Fenoldopam, as far as I know, does not work. In fact, other than mannitol, I don't think anything works. 0.5g/kg is the magic number.

When they are 10 min from closing skin, load the epdermal, give reversal, nausea drugs, and extubate in the room.

 

[VentdependenT]

Blade I see where you're heading with the heparin thing. You're looking for my magic number for heparin dose. I call upon my colleagues for this number. I don't have one. I DO however know that one should wait at least an hour from placement of epidural till heparin injection. So I'm sticking to that.

As far as epidural hematoma risk in a patient with heparin, I'd say it is low, how low I dont know the percentage. I gotta look that up. Just don't pull the thing while the ptt is elevated. If you stop heparin and you pull the epidural, you gotta wait an hour till you start it.

As for the fenoldopam, if the surgeon wants me to run it for him, fine.

As for the mannitol dose, uhh, i dunno, 0.25g/kg I'd guess.

I havent looked any of this stuff up (today) to try and seem smarter. So if I goofed on this stuff lemme have it.

 

[epidural man]

Vent,
Fenoldopam, as far as I know, does not work.

Don't have the references in my head but could find if any one cares, but I think there was pretty good data in preserving renal function in liver transplant cases with fenoldopam.

As far as the epidural, I would not put it in. My concern is having the surgeons bag the artery of adamkowitcz (spelling?) and giving the guy weakness/paralysis post op. If you have an epidural and the guy can't move his legs in the PACU, is it because of an epidural hematoma, or because the surgeon hit something they shouldn't have?

 

[urgewrx]

Don't have the references in my head but ...
.... I think there was pretty good data in preserving renal function in liver transplant cases with fenoldopam.

That shizzle don't work
from: http://www.clinicalevidence.com/ceweb/conditions/knd/2001/2001_I5.jsp

Seven RCTs compared the role of fenoldopam with placebo in preventing acute renal failure. Four small, limited RCTs suggested that fenoldopam may improve renal perfusion and creatinine clearance compared with conventional care. One large RCT, which focused on clinical outcomes in people having invasive cardiovascular procedures, found no evidence that it is more effective than conventional care for preventing acute renal failure. One recent RCT found that low dose fenoldopam did not reduce the need for dialysis or improve survival compared with placebo in people with sepsis. Similarly, another RCT found that fenoldopam did not reduce the incidence of death or dialysis therapy in critically ill people with early acute tubular necrosis. Two RCTs found no difference between fenoldopam and dopamine in incidence of acute renal failure. Fenoldopam may cause hypotension.

 

[Intubate]

Yeah, fenoldopam is nonsense. What a great idea in theory, though.

Place the epidural. If you have to go on bypass, ride it out. You can pull the thing later. (There's a lot of studies of CABG with epidural).

PFTs are a waste of time, money, and effort. They will tell you he is at high risk for pulmonary complications.

 

[pd4emergence]

I think the jury is still out in regards to fenoldopam and renal protection during a brief (depending on the surgeon) ischemic time. Most of the fenoldopam studies done have studied it for renal protection in sepsis and contrast induced nephropathy. It did not really work in those studies. Maybe the physiology is different for cross clamp induced ischemia and it could work. Blade, I did not read that article out of the European Journal but will. Anyway, I don't think there is a clear answer. It may take some deft in telling the surgeon that the fenoldopam studies have not panned out yet, but I would not use it.

 

[urgewrx]

I think the jury is still out in regards to fenoldopam and renal protection

One thing is for sure:

Fenoldopam has great promise but no proof of efficacy in our arena. It is 100 times more expensive than SNP, and 20-50 times that of dopamine. It is 4 times the cost of nicardipine. Therefore, before encouraging routine use, there should be some study suggesting clinical utility.

 

[VentdependenT]

Well, clearly fenoldopam ISNT going go to make much of a difference in this case. Neither is the mannitol.

Droping the metabolic rate of the kidneys with ice should work.

Hooking up shunts to the kidneys should help. But essentially the same "evil humors" (as infrarenal x-clamp) will be released after unclamping and get pumped into those kidneys.

Epidural will help this guy, no doubt about it. Decreased splinting and narcotic induced hypoventilation/cough suppression is a good thing.

Urge, I would totally put an A-LINE in prior to induction. If I have to put a brachial in after sleepy time fine, but I'll take my time and do it now.

Epidural, I like your comment about the PACU. However I'd only be dosing 4 ml of 2% Lido through the catheter (which I would have test dosed up front). Severe weakness due to the local anesthetic isn't on my differential post op. Hematoma would definitely be. As would spinal ischemia from clamping the friggen aorta.

Any of you dudes place a neuraxial cooling system or whatever? Sounds like a major pain in the ass.

 

[Arch Guillotti]

"Any of you dudes place a neuraxial cooling system or whatever? Sounds like a major pain in the ass."

Occasionally we put in lumbar drains, mostly for the very large and/or unusually complex cases. I have read about the cooling but have never known anybody to use it. I have put in probably a couple of lumbar drains and let me tell you what - that needle is a monster, I think it is 14 gauge. We hook up the csf drain to a stopcock on the triple transducer and toggle back and forth between the cvp and csf pressure - if I remember correctly we intermittently drained csf to keep the pressure less than 10. I would be curious to know how often lumbar drains are done in private practice.

 

[urgewrx]

We do lumbar drains for thoracoabdominal aneurysms. Its a BIG needle. We ram it in like there is no tomorrow. Bloody taps are quite common.

A good number of them are done under deep hypothermic circulatory arrest. These patients get full dose heparin and by the end of the procedure are coagulopathic as hell. Many of them need factor 7 after having received, ffp, cryo, and platelets.

In our experience there haven't been any epidural hematomas. They are removed on POD 2 without checking coags since we know the coags will be bad still.

 

[BLADEMDA]

Here is how I answered the surgeon on question number one regarding Corlopam: A recent study in our Journal, Anesthesia and Analgesia October 2006 pages 833-840, showed the drug was not effective.

In fact, the study showed Corlopam was no more effective than Dopamine plus Nitroprusside for preserving renal function. Since, Dopamine has been shown to be worthless there is NO clinical evidence that Corlopam does anything. In addition, that study in your journal where Corlopam helped the Pig kidneys was based on a dose at least TEN times greater than the one we use clinically.

The surgeon appreciated the study and said "forget about that Corlopam for now."

Now, what about question number 2? Do you have any data to show him?
If you get a bloody tap with the epidural needle or the catheter in the thoracic area how long must the surgeon wait before Heparinizing the patient with 10,000 units? Or, can the heparin be given regardless of time?

Blade

 

[BLADEMDA]

We do lumbar drains for thoracoabdominal aneurysms. Its a BIG needle. We ram it in like there is no tomorrow. Bloody taps are quite common.

A good number of them are done under deep hypothermic circulatory arrest. These patients get full dose heparin and by the end of the procedure are coagulopathic as hell. Many of them need factor 7 after having received, ffp, cryo, and platelets.

In our experience there haven't been any epidural hematomas. They are removed on POD 2 without checking coags since we know the coags will be bad still.

Sounds like you need to publish this data as there are no studies backing up your claim. If a hematoma develops do you realize what this means to you?
You are history my friend as even a second year law student would take you to the cleaners in the real world. Most private practice Anesthesiologists don't practice that way for INFRARENAL AAA's and I am pretty sure the Board Examiners would not be happy with your answer.

Now, how do you approach THIS CASE in the community setting? After all, it is an INFRARENAL AAA with an experienced, fast surgeon who will NOT be causing paralysis with his 40 minute clamp time.

Blade

 

[epidural man]

Now, what about question number 2? Do you have any data to show him?
If you get a bloody tap with the epidural needle or the catheter in the thoracic area how long must the surgeon wait before Heparinizing the patient with 10,000 units? Or, can the heparin be given regardless of time?

Blade

ASRA says this
"Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case is warranted."

They mention nothing about time other than 1 hr for everybody.

 

[BLADEMDA]

ASRA says this
"Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case is warranted."

They mention nothing about time other than 1 hr for everybody.

Do you know where the data comes from? I have the study from the old days that these statements originate from (1981).

I am not asking you to cancel the case but where does the data come from that you must wait 1 hour until heparinization occurs after a bloody tap?
NEVER accept any dogmatic statement without reviewing the FACTS behind them.

Blade

 

[BLADEMDA]

Have any of you dealt with this complication or seen the aftermath of its effects on patient's lives?

I have seen this complication 4 times in my career. 3 out of 4 patients were DEVESTATED by this complication. Although rare it can leave permanent neurological damage even after surgical evacuation of the hematoma. Yes, it is time dependent from occurrence to treatment but still the surgical incision is usually large and there can be psychological damage as well. This means there will be a WHEELCHAIR bound patient sitting across from the jury if the patient survives the hospital stay. Those verdicts tend to be in the MILLIONS of dollars if you lose the case. Even the slightest deviation from normal practice and you are guaranteed to lose this case.

If you deviate from the STANDARD OF CARE BLATANTLY then the Medical Board will be reviewing the case as well.

I am not telling you to alter your practice based on fear. But, those who choose arrogance over standard conservative care are seen as cowboys by everyone involved from the patient, to the lawyers and finally the medical board.

Back to the case at hand.

Blade

 

[epidural man]

Do you know where the data comes from? I have the study from the old days that these statements originate from (1981).

I am not asking you to cancel the case but where does the data come from that you must wait 1 hour until heparinization occurs after a bloody tap?
NEVER accept any dogmatic statement without reviewing the FACTS behind them.

Blade

Looked, but couldn't find it - plus I got sidetracked reading past posts on the CRNA/MD issue. I got's to say something because that video really pissed me off - but all the posts were closed. I'll find one that isn't closed where I can speak my mind though...

 

[Planktonmd]

A line, central line and thoracic epidural all done in the holding area (total time 30 minutes).
No Vaso active drugs premixed except the usual Neo.
Go to the OR, induce with Etomidate ( yes Etomidate!) + Fentanyl + Roc then Maintenance with Propofol + Remifentanyl + very little vapor for amnesia only.
If the surgeon is good as Blade said, and not going to cause a blood bath, I will bolus the Epidural in the very beginning with marcaine 0.25% which will allow me to achieve more vaso dilation before clamping and cut down on the Remifentanyl requirement.
I will start fluid replacement early ( before clamping) and watch the urine output and CVP, proper hydration is better than all these things mentioned above to protect the kidneys especially in an infrarenal aneurysm.
just before clamping, increase the vapor and give a bolus of Propofol, after clamping continue fluid mnagement according to CVP and Urine output.
Have a low threshold for tranfusing blood, before unclamping give an amp of Sodium bicarb and ask your surgeon to unclamp one iliac first then the second.
Once stable after unclamping give more marcaine in the epidural and start getting him off Remifentanyl.
The rest is routine.
If the surgeon is really good and can do this in the lateral position with a retroperitoneal approach, then you can get away with doing it under straight epidural anesthetic and this would be a beauty.

 

[BLADEMDA]

A line, central line and thoracic epidural all done in the holding area (total time 30 minutes).
No Vaso active drugs premixed except the usual Neo.
Go to the OR, induce with Etomidate ( yes Etomidate!) + Fentanyl + Roc then Maintenance with Propofol + Remifentanyl + very little vapor for amnesia only.
If the surgeon is good as Blade said, and not going to cause a blood bath, I will bolus the Epidural in the very begining with marcaine 0.25% which will allow me to achieve more vaso dilation before clamping and cut down on the Remifentanyl requirement.
I will start fluid replacement early ( before clamping) and watch the urine output and CVP, proper hydration is better than all these things mentioned above to protect the kidneys especially in an infrarenal aneurysm.
just before clamping, increase the vapor and give a bolus of Propofol, after clamping continue fluid mnagement according to CVP and Urine output.
Have a low threshold for tranfusing blood, before unclamping give an amp of Sodium bicarb and ask you surgeon to unclamp one iliac first then the second.
Once stable after unclamping give mare marcaine in the epidural and start getting him off Remifentanyl.
The rest is routine.
If the surgeon is really good and can do this in the lateral position with a retroperitoneal approach, then you can get away with doing it under straight epidural anesthetic and this would be a beauty.

Well done. Total blood loss for the case was about 400 ml. I would add the BIS monitor on him (you would as well because it is your routine) helps keep the vapor low. Any mannitol prior to cross-clamp? I usually add low dose mannitol (one bottle) prior to the clamp.

Use of TEE in this patient? Any comments on dropping a probe and doing a basic exam? This may be of value during clamping and unclamping the aorta.
I agree about low dose local anesthetics to the Epidural as it MAY increase coronary perfusion and WILL decrease anesthetic requirements.
Still using etomidate TODAY routinely? I used etomidate on this case but doubt I would use it on him today. Instead low dose propofol 60-70 mg plus 50 mg ketamine and narcotic of your choice should do the job nicely (BIS MONITOR in place).

Finally, for the sake of discussion what if you got a bloody catheter after placing your thoracic Epidural? While it didn't happen on this patient that complication has occured to me on other AAA's. What is your plan for this?
Re-do the Epidural? Skip the Epidural and D/C the bloody catheter?
Inform the surgeon? Delay the case?

Blade

 

[pd4emergence]

For a bloody catheter placement, I would pull it out, go to a different level and place another one. I would not cancel or delay, by the time you place the new catheter, get into the OR, induce, prep and drape, and the surgeon gets to the point where he is ready for the heparin, that would be enough time for me to not feel too uncomfortable in giving it.

 

[VentdependenT]

My lack of experience as of yet would lead me to think if I had a bloody tap, I'd try one more time at a different level. If Its too tough then screw it. I dont wanna mess with this guy's back too much.

I don't think I would delay the case if I had a bloody tap which didn't continually ooze while I tried a different level. If the thing kept dribbling then...

Please correct me if you don't agree with me. Like I said...grashoppa.

Remi and propofol eh? nice.

 

[BLADEMDA]

Okay,

Everyone on this board should read this study. It is available online for free and can be downloaded and printed easily.

Stroke 1981;12 879-881

This study is titled "Complications of lumbar puncture follwed by anticoagulation"


Here are the MAJOR FINDINGS:

Major risk factors for anticoagulated patients (these patients were on heparin) include starting anticoagulation within ONE hour of the lumbar puncture, a traumatic lumbar puncture or aspirin treatment at the time of the LP.

Conclusion: this study suggests that if Lumbar puncture is done delaying anticoagulation for at least one hour and avoiding concurrent aspirin therapy
may decrease the risk of developing an extraparenchymal spinal hematoma.

The study also found that aspirin therapy did not increase the incidence of LP
related major complications in patients who were not anticoagulated.

The NUMBERS were DRAMATIC in this study for waiting at least one hour before starting anticoagulation. Check it out. Those people who were heparinized ONE HOUR after the traumatic LP had a HUGE DECREASE in the incidence of major complications compared to the Group who were heparinized in less than one hour.

There 342 patients in the heparinized Group and 342 in the non-heparinized Group. A pretty big study and one that will not likely be repeated any time soon.

A recent study that is also of interest includes the following:

Anethesia and Analgesia Jan;06 (102) 1:45-64

This study looks at the use of Epidural Catheters for CABG patients.

Blade

 

[BLADEMDA]

We have discussed the preoperative area pretty well. It is time to move INTRAOPERATIVELY.

The patient is taken to the O.R. 4 units PRBC are T & C and are ready in the refrigerator if needed. A-line is placed prior to induction after 1 mg midazolam and 20 mg propofol. Iv induction occurs with Etomidate (I would use propofol 50-60 mg and low dose Ketamine 30-50 mg instead today) and rocuronium. Intubation with 8.0 e.t. tube easily completed. Then, 8.5F introducer plus triple lumen central line placed via the R IJ easily. Nurse places Foley while I do central lines.

Due to cost Sufenta infusion started instead of Remi for the case. Patient is loaded with 20 mg Sufenta. Pt. is then turned lateral and Epidural is placed at T6/T7 under general anesthesia. Epidural placed without trauma and no bloood noted during insertion or from catheter. 6 cc 0.25% bupivicaine injected into Epidural Catheter and patient turned supine. Vitals are stable throughout this time but three doses of phenylephrine 100ug required.
BP=116/56 HR=66 Sat=98% BIS 34 Sevoflurane 0.6%

Following the prep Surgeon makes incision only a small increase in BP and HR
but no change in BIS. The epidural is working well. Case proceeds and in about 25 minutes the surgeon is ready for the heparin 10,000 units. Heparin given and in two minutes CLAMP applied to the AORTA SLOWLY. Guess what happens next? One of two things: he tolerates the clamp or Not. Assuming he doesn't tolerate the clamp then what? Venty you are up.

Also, while I would not have placed the Epidural asleep during Residency or in the Oral Exam I do it frequently these days. In fact, My Group has more than 10,000 Epidurals placed under GA with NO MAJOR COMPLICATIONS. I wish that sort of data could be published by the LITTLE GUYS like me. The use of soft tip catheters plus experienced providers makesa big difference in AWAKE vs. ASLEEP. When a CRNA does the Epidural I like the patient awake but sedated especially for thoracic epidurals. However, I understand the apprehension concerning asleep Epidurals and would never criticize anyone taking the usual approach of placing the catheter in an awake patient. In particular, you should NOT attempt to place a Thoracic catheter in a patient under GA without a lot (?a thousand or more) of experience in Epidural placement.

Back to the case. What do you do if the clamp isn't tolerated? Tell me your next move on this guy.

Blade

 

[pd4emergence]

Blade, great post re the bloody epidural stuff. I had always heard to wait an hour in the event of a bloody catheter but had not seen the real data. Thanks for the article.

 

[BLADEMDA]

Blade, great post re the bloody epidural stuff. I had always heard to wait an hour in the event of a bloody catheter but had not seen the real data. Thanks for the article.

You are welcome. I am NOT advocating the routine placement of Thoracic Epidurals under General Anesthesia. But, once you get real "slick" and have a lot of experience with Epidural placement it can be performed safely:

Anesthesia and Analgesia 2003 Jun;96 (6) 1545-6

After you do about thousand epidurals (maybe less depending on your viewpoint) consider placing the LUMBAR epidurals where ONLY narcotics are used under General Anesthesia.

Blade

 

[VentdependenT]

Thanks for the secret files blade. you da man

ANypoops, not tolerating the clamp eh? We getting ST changes? Severe brady? Or worse Tachy? Massive drop in BP? Or just looken poopy when the clamp goeth on.

My first choice would be to decrease afterload = NTG bolus. See how things look. Fast on Fast off. Can't get into too much trouble that way. If it works then kick ass. I'll start a NTG drip or start Nicardipine and thump in slugs of NTG till the stuff kicks in.

Still no good?

I'd ask the surgeon if there is someway to drain off flow from the heart so we can continue with the case. Be it on pump bybass or just a bypass vent (goal being to ultimately drop SVR by having another conduit OR to decrease ventricular load ----->decrease work o' the ventricle).

 

[epidural man]

Okay,

A recent study that is also of interest includes the following:

Anethesia and Analgesia Jan;06 (102) 1:45-64

This study looks at the use of Epidural Catheters for CABG patients.

Blade

I saw this one when you were quizing me about ASRA guidelines earlier. I read the abstract. it looked good - i'll check it out. Also, you guys should publish your data about 10000+ epidurals under general. That would be an interesting read.

 

[BLADEMDA]

Thanks for the secret files blade. you da man

ANypoops, not tolerating the clamp eh? We getting ST changes? Severe brady? Or worse Tachy? Massive drop in BP? Or just looken poopy when the clamp goeth on.

My first choice would be to decrease afterload = NTG bolus. See how things look. Fast on Fast off. Can't get into too much trouble that way. If it works then kick ass. I'll start a NTG drip or start Nicardipine and thump in slugs of NTG till the stuff kicks in.

Still no good?

I'd ask the surgeon if there is someway to drain off flow from the heart so we can continue with the case. Be it on pump bybass or just a bypass vent (goal being to ultimately drop SVR by having another conduit OR to decrease ventricular load ----->decrease work o' the ventricle).

Any other suggestions? Nipride? Increase the Vapor? Is Sevo better than Isoflurance or Vice versa in this patient? I like your "vent" suggestion but why not try something "simpler" first. What about Inotropes to increase contractility? Would you consider this and if so, what agent would you try first?

When the clamp goes on slowly the BP drops to 88/44 and HR=48.

Blade

 

[Intubate]

Still using etomidate TODAY routinely? I used etomidate on this case but doubt I would use it on him today.

Whatcha got against etomidate? Puking, HPA suppression, absolutely beautiful hemodynamics?

I use it, not routinely, but not rarely. Especially in a crusty old person on an ACE or ARB.

 

[BLADEMDA]

Whatcha got against etomidate? Puking, HPA suppression, absolutely beautiful hemodynamics?

I use it, not routinely, but not rarely. Especially in a crusty old person on an ACE or ARB.

20% increase in mortality directly linked to Etomidate (single dose) in one study. I recommend you read the thread "Blade's Cases" for the references.

Blade

 

[VentdependenT]

Any other suggestions? Nipride? Increase the Vapor? Is Sevo better than Isoflurance or Vice versa in this patient? I like your "vent" suggestion but why not try something "simpler" first. What about Inotropes to increase contractility? Would you consider this and if so, what agent would you try first?

When the clamp goes on slowly the BP drops to 88/44 and HR=48.

Blade

Nipride is an drug verging on extinction. I wouldn't reach for it.

Inotropes in a guy with CAD eh? Not such a bright idea. If I had to choose one I'd just go with milrinone AFTER seeing the effect of NTG bolus' on his pressure.

NTG bolus----->response positive?------->NTG drip or Nicardipine drip. Maybe NTG cause of his CAD. Whatever.

 

[BLADEMDA]

Nipride is an drug verging on extinction. I wouldn't reach for it.

Inotropes in a guy with CAD eh? Not such a bright idea. If I had to choose one I'd just go with milrinone AFTER seeing the effect of NTG bolus' on his pressure.

NTG bolus----->response positive?------->NTG drip or Nicardipine drip. Maybe NTG cause of his CAD. Whatever.

Just continuing the discussion and asking you the type of questions a CA-1 might want answered. Anytime you want the case concluded let me know.

Although Nipride may be heading for the casket it is cheap, readily available and effective for the very short term. Yes, it has negative effects on the Kidney and the heart but it has been used safely for decades

What about the vapor? Sevo vs. Iso in this case? Preference for a particular agent? (HR=48 Contractility decreased with increased afterload).

Blade

 

[VentdependenT]

Vapor eh? Iso is the SVR dropper. Sevo comes off faster and I'm more comfortable with it (I've used it a few times).

Both are negative inotropes/cardiac depressants. BAD.

Either, theoretically is capable of preconditiong. GOOD.

So what should I do then? Ah....Ill run EITHER ONE at a half mac to cut down on the cardiac depression. Probably stick to sevo. I'll cover my butt with narcotic infusion: Remi or sufenta. Or maybe just give fenty bolus'. Keep him at 2 twitchy with tne nimbex (low mac = pt move with stimulation).

NOW I gotta get back to my liver. Looking at 3 pooled platelets, 2 pooled cryo, 50prbc, 50ffp, countless cell saver (we have 2, friggen 2, cell savers going full time), nova 7 (KA-CHING$$$), Neo maxed, Levo maxed, Epi started, Vasopressin maxed, need I say more.....oh wait, ITS STILL BLEEDING! Methylene blue? Pfff why bother its gotta get sucked out within SECONDS.


MUHAHAHAHAHAHAHAH

 

[VentdependenT]

Well, that sucked.

Time to try and catch some zzzzz before my pain pager blows up again.

 

[BLADEMDA]

Well, that sucked.

Time to try and catch some zzzzz before my pain pager blows up again.

Venty,

You are right about the vapor. Sevo has less effect on the SVR but may potentially cause bradycardia especially when combined with propofol or narcotics. Clinically, at 0.5 MAC either vapor should be fine. I used Sevo throughout the case.

It turns out that NTG WAS sufficient to deal with the clamp problem. I asked the surgeon to unclamp fo a minute. I boulsed a little NTG and started the drip. I also gave Ephedrine 5mg to increase the BP and HR prior to the clamp (did not do much except HR went up 5 beats). Then, the surgeon applied the clamp gradually and slowly allowing the heart to adjust to the afterload.
It took about three minutes to apply the clamp but it was worth the extra time. The patient tolerated the clamp with NTG running about 2 ug/kg/min.

This was a case where the EF=30% or so I thought. I suspected the actual EF may have been lower after the case and in hindsight, should have placed a TEE and/or S-G catheter to assist with management. After applying the clamp the surgeon went about putting in the graft while I gave fluids to the patient.

From here on out the case was uneventful. Total clamp time=39 minutes with EBL=400. Unclamp slowly with 1/2 amp HCO3 and a little CaCl added to the mixture. NTG was titrated off easily and the BP/HR was stable. Urine output good for the case.

I turned off the Sufenta drip just prior to closing. The patient was extubated in the room and transported to PACU with facemask. Epidural was still working well but it was time to start the infusion and top it off. For the sake of discussion, what would you use/run on him for post-op pain relief?

Blade

 

[VentdependenT]

Bupivicaine 0.1% at 4cc/hour continuous infusion. Add 2cc bolus Q30min PCEA.

 

[Planktonmd]

Blade,

I wasn't able to follow this discussion the past couple of days but here is my 2 cents for those who care
1- TEE is good to have but not necessary to do this case.
2- your Thoracic epidural under GA is problematic for many reasons:
- First, you have to position the patient lateral then back to supine (too much work).
- Second, you are also shortening the time between the epidural placement and heparinization by doing it in the OR.
- Third, you are among a minority of anesthesiologists who would even consider doing thoracic epidurals under GA.
On the other hand you are experienced and obviously very confident, still, I wouldn't do it.
3- If I get a bloody catheter I would just take it out and redo the epidural. I wouldn't delay the case or do anything different except checking for neurological deficit post op and maybe using Fentanyl only for post op epidural infusion with frequent neuro checks.
4- Post- Op epidural infusion: If you use your epidural intra operatively and achieve good preemptive analgesia, post op Fentanyl alone can be enough and it will not cause hypotension, so I use Fentanyl 10 mcg/cc at 4 cc/ hr with a PCEA mode. on rare occasions I add Bupivacaine 0.625 % and reduce Fentanyl to 2.5 Mcg/cc.
5- You said that you think Sevo could cause "Bradycardia" could you explain this to me?

 

[BLADEMDA]

Blade,

I wasn't able to follow this discussion the past couple of days but here is my 2 cents for those who care
1- TEE is good to have but not necessary to do this case.
2- your Thoracic epidural under GA is problematic for many reasons:
- First, you have to position the patient lateral then back to supine (too much work).
- Second, you are also shortening the time between the epidural placement and heparinization by doing it in the OR.
- Third, you are among a minority of anesthesiologists who would even consider doing thoracic epidurals under GA.
On the other hand you are experienced and obviously very confident, still, I wouldn't do it.
3- If I get a bloody catheter I would just take it out and redo the epidural. I wouldn't delay the case or do anything different except checking for neurological deficit post op and maybe using Fentanyl only for post op epidural infusion with frequent neuro checks.
4- Post- Op epidural infusion: If you use your epidural intra operatively and achieve good preemptive analgesia, post op Fentanyl alone can be enough and it will not cause hypotension, so I use Fentanyl 10 mcg/cc at 4 cc/ hr with a PCEA mode. on rare occasions I add Bupivacaine 0.625 % and reduce Fentanyl to 2.5 Mcg/cc.
5- You said that you think Sevo could cause "Bradycardia" could you explain this to me?

Plankton, thank you for your respones. I will attempt to answer your points one by one.

1. TEE would have been helpful when the clamp was applied and the BP dropped. Although not required for the case it would have provided input into wall motion, contractility and fluid management.

2. I explained in detail the Thoracic Epidural and the fact that MOST do this awake. However, I provided a study where nearly 5,000 Epidurals were placed in patients under GA. My Group has placed more than 10,000 under GA.
In Pediatrics, thousands of Epidurals have been placed under GA. Perhaps, with experience (1,000 or more) and the use of soft tip catheters having every patient "awake" is unnecessary. That said, I respect your opinion for awake epidural placement. When supervising a CRNA placing an Epidural Catheter the patient is sedated and not under GA.

3. I do not have a block room and my holding area is not well-equiped for Epidural placement. Thus, I must place the majority of them in the O.R.
The surgeons are aware of this limitation and accept there may be a 30 minute delay (rarely with the use of soft tip catheters and experienced MD's)
for bloody stick or catheter.

4. If you are going to use NARCOTICS only why bother with a thoracic approach? I have personally placed well over 1,000 lumbar epidurals and an infusion of Duramorph works very well; in fact, just as well as Fentanyl at the thoracic level. Try it and see for yourself. In addition, the patient can definitely be asleep for lumbar epidural placement when only narcotics are used.

5. Bloody Catheter- Yes, I will try ONCE more and depending on the patient (does he need local anesthetic plus narcotic at the thoracic level for better post-op pulmonary function) I will try thoracic again or move to Lumbar where safety is increased.

6. Sevoflurane- I should have been more specific about the bradycardia comment. In my experience I have seen bradycardia more likely when SEVO is combined with propofol or Sufenta/Remi. Usually, SEVO by itself does not cause bradycardia but a slight increase in the HR. There have been several (at least 5-7) case reports of severe bradycardia in children with Sevoflurane. Here are a few references:

CANJANAESTH 2004 Oct;51 (8) 806-809
Br. J Anaesth 1998 Mar; 80 (3) 410
Br. J Anaesth 2002 Apr; 88 (4) 614

Here is one study where Sevoflurane seemed to have a bradycardic effect on the elderly undergoing hip surgery (22% had bradycardia with SEVO).

Eur J Anaesthesiology 2003 Aug;20 (8) 640-6

I suspect that the elderly may be similar to the pediatric population; or perhaps the use of B-Blockers is the cause for the increased bradycardia when combined with Sevo. Whatever the reason I have seen it much more with Sevo than any other vapor (halothane excluded).

Again, thank you for your comments.

Blade

 

[VentdependenT]

Why do you say that a narcotic only epidural infusion is safer asleep? You worried about a high spinal? If so, then a poop load of narcotic by itself in the spine will cause the same sx I would imagine. Sure you can give naloxone but its still an adverse outcome.

Or am i way friggen off base?

 

[Planktonmd]

4. If you are going to use NARCOTICS only why bother with a thoracic approach? I have personally placed well over 1,000 lumbar epidurals and an infusion of Duramorph works very well; in fact, just as well as Fentanyl at the thoracic level. Try it and see for yourself. In addition, the patient can definitely be asleep for lumbar epidural placement when only narcotics are used.
Blade

The reason it's better to have a thoracic epidural, is for intra-op management with local anesthetics since I almost always bolus the epidural in the OR, and having a thoracic epidural will also allow you to wake up the patient with no pain with just a few CC's of local and less sympathetic block than when you are using a lumbar approach, then you switch to narcotic post op.
I agree with you that for narcotic use, lumbar and thoracic epidurals are the same, infact there was a study done on that and showed no difference (don't have the reference).

 

[Planktonmd]

Why do you say that a narcotic only epidural infusion is safer asleep? You worried about a high spinal? If so, then a poop load of narcotic by itself in the spine will cause the same sx I would imagine. Sure you can give naloxone but its still an adverse outcome.

Or am i way friggen off base?

I think he was saying that if you are using Narcotics only you can use a lumbar epidural and then you have less chance of hitting the cord.

 

[BLADEMDA]

I think he was saying that if you are using Narcotics only you can use a lumbar epidural and then you have less chance of hitting the cord.

Yes, that was my point. The SAFEST way to place any Epidural is on an awake patient particularly if you have placed less than a few hundred of them.

I agree that the use of a thoracic epidural is a nice adjunct to your anesthetic technique. However, we did a series of 23 AAA's (open) using Lumbar Epidurals plus Duramorph. These patients did well and had good intraop and postop pain relief. In my opinion, the thoracic epidural with local plus narcotics was SLIGHTLY better postoperatively because the amount on narcotic was reduced allowing the patients to be more alert in the ICU.

No big deal here. But, why not try different techniques for yourself and see what you think? A patient without significant lung disease is a good candidate for the lumbar epidural plus Duramorph technique.

Blade

 

[VentdependenT]

Can you place a high lumbar epidural (L2-3) and just thread it deeper (hoping that it travels into mid thoracic region)? Or is that not to smart because one cannot be sure which direction the catheter will thread?