Another great case

[pd4emergence]

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78 year wm sent for preop eval for AAA repair. Pt. with 6 cm infrarenal AAA, recently found due to back pain.

PMhx
HTN
severe COPD with continued tobacco use 3-4 ppd per pt (he actually had a great trick, turning his O2 up to blow out the match he used to light his cigarette per our preop nurse)
severe LV dysfunction
h/o afib
CAD s/p CABG 2004 with AICD placement soon thereafter
Pt recently placed on hospice secondary to his heart failure

Meds
"I can't remember", "some kind of fluid pill", "some kind of blood thinner", "some kind of blood pressure pill", "stopped all my breathing meds years ago because they didn't help"

Physical exam
Vitals nml BP, wt 160, ht 71 inches, P70's
Airway OK
Pulm mod wheezes, no rales, decreased breath sounds, decreased air movement
CV RRR no murmurs
Ext mild edema, pt states much better since he recently starting taking his pills regularly
thin white male asking "doc (breath) can you do (breath) my surgery (breath) tomorrow"

Studies
AICD procedure note (just an AICD, no pacing function)
Pre CABG cath (2004) diffuse CAD, ef 15-20%
Echo post cabg 2004 with no real valve issues but confirming EF 20%
Recent Cards note looking at his AICD, meds as above, and "discussed turning AICD off with patient as he was recently placed under hospice care"
EKG- NSR, no acute st changes

Labs
Pending but assume they are all normal (PT, PTT, CBC, BMP)
CXR pending

General
Pt denies any chest pain currently. He is able to walk outside which is about 40 feet by himself and smoke but has to rest if much more active than that. He was sent by his primary care MD to see a pulmonologist but just didn't feel like going. I did call his surgeon (who is excellent). Surgeon states pt will be amendable to an endovascular repair. Surgeon states to do whatever we need to to get pt ready, case is not urgent.

 

[johankriek]

my recomendation

leave this dude alone

hi risk procedure on a hi risk guy

if he survives he will be in the icu for a very long time

what is so great about this case?

 

[Noyac]

What's the odds that this AAA will rupture?

Are those odds great enough to warrant a major repair in a train wreck?

What's the oods that he will have an MI in the following 6 months post-op?

How about the odds of having a respiratory complication like pneumonia or worse?

Finally, why even consider repairing it? And if we must repair it then why not do it endovascularly? Its infrarenal so put a stent in it if you have to do something. If its too torturous then find someone that can.

 

[Planktonmd]

The answer: Sorry, no go!

 

[milrisome]

Yep, I wouldn't do it. You just can't fix everything. Death is a natural process. That's what hospice is supposed to be about, helping people die with dignity and comfortably. What's dignified or comfortable about spending your last hours in the ICU with a tube protruding from every orifice, not to mention running up all kinds of medical bills for the people left behind?

BTW, don't you love the way pt's take care of themselves?

 

[Laurel123]

No go. This guy is hospice and hospice care does not include major surgery. Tell the patient to enjoy his life, do what he wants, eat what he wants, smoke what he wants.

 

[huktonfonix]

yup. Hospice policy is probably instituted with less than 6 months to live. Pt probably has less than a 10% chance (dont remember the exact numbers) of having that aneurysm rupture per year. Since he's not gonna live a year its a moot point. No surgery as everyone else has said.

 

[jetproppilot]

What's the odds that this AAA will rupture?

Are those odds great enough to warrant a major repair in a train wreck?

What's the oods that he will have an MI in the following 6 months post-op?

How about the odds of having a respiratory complication like pneumonia or worse?

Finally, why even consider repairing it? And if we must repair it then why not do it endovascularly? Its infrarenal so put a STENT in it if you have to do something. If its too torturous then find someone that can.

Theres the right answer, in Noys post above.

 

[Planktonmd]

Theres the right answer, in Noys post above.

Not even that, the guy has terminal heart failure and respiratory failure and does not want medical care ( he chose not to go see a pulmonologist pre-op), He already chose to die in dignity, if his AAA ruptures that would be the fastest way to go and the least painful.
So, we should respect his wishes.
I wouldn't touch him.

 

[jetproppilot]

Not even that, the guy has terminal heart failure and respiratory failure and does not want medical care ( he chose not to go see a pulmonologist pre-op), He already chose to die in dignity, if his AAA ruptures that would be the fastest way to go and the least painful.
So, we should respect his wishes.
I wouldn't touch him.

Totally agree.

Many times we dont make that call though.

So if the patient agrees to it, a stent would be much more desirable than a huge AAA operation which would more than likely kill him.

 

[pd4emergence]

The surgeon's plan is to do an endovascular/stent repair. He does a great job with these stent repairs. The patient states he wants to go through with the surgery above all else. He was told the risks in vivid detail and can't be swayed. He basically says he would rather die trying. Apparently, he feels this AAA has been causing him severe back pain and he wants it fixed. I know most everybody has said they would tell him no but this guy really has no where else to go. If we referred it out he would go to the closest academic center where they are no where near as deft at these stent grafts as this surgeon. So the question is would you still not do this guy? If you would what do you want pre op and how would you do the case?

 

[BISof60]

1. Increase his pain medication dose through Hospice to take care of the back pain.


2. If you're putting me in a situation where I have to do this case, I don't think I'd order any further tests. A preop echo/cath would confirm severe CAD and give an uptodate EF but I'm not sure those numbers would make a difference. His lungs are terrible, don't need PFT's to confirm.

Ideally, one would want his CHF "optimized" prior to surgery...not sure how you do that in a guy on hospice for CHF who is noncompliant with meds.

 

[BISof60]

1a. Make sure the AAA is the source of his back pain.

 

[Planktonmd]

The surgeon's plan is to do an endovascular/stent repair. He does a great job with these stent repairs. The patient states he wants to go through with the surgery above all else. He was told the risks in vivid detail and can't be swayed. He basically says he would rather die trying. Apparently, he feels this AAA has been causing him severe back pain and he wants it fixed. I know most everybody has said they would tell him no but this guy really has no where else to go. If we referred it out he would go to the closest academic center where they are no where near as deft at these stent grafts as this surgeon. So the question is would you still not do this guy? If you would what do you want pre op and how would you do the case?

If he wants it done and I find myself in a position that I have to do it, it will go this way:
1- He needs to be DNR (I am sure he already is since he is in hospice).
2- No further preop workup.
3- Go to the OR, Good peripheral IV, no Invasive monitoring, Straight epidural anesthesia.

 

[Noyac]

If he wants it done and I find myself in a position that I have to do it, it will go this way:
1- He needs to be DNR (I am sure he already is since he is in hospice).
2- No further preop workup.
3- Go to the OR, Good peripheral IV, no Invasive monitoring, Straight epidural anesthesia.

I agree.

I'd do it without any further workup and a DNR order. Except I'd probably just do a MAC with very little sedation. I started out doing epidurals for these cases but quickly changed my approach. The procedure isn't painful so mild sedation is plenty enough to keep them comfrotable. If there is a problem, its usually a big one and we need to open. If the problem is a rupture then he ain't gonna tolerate just epidural b/c his BP will plummet (sort of like the reason we don't do spinals in placenta accreta etc.). The epidural sure would be beneficial postop though.

 

[pd4emergence]

I agree with the no workup if he was a DNR. I know he is on hospice and we discussed his hospice status. The only thing he knows about hospice is the fact that a nurse comes out to his house and gives him his meds every day. I asked him about the discussion he had with his cardiologist about turning off his AICD and he said he has no interest in turning it off ("I might die" were his words). He also says that he is doing better actually taking his meds than he has in three years. I sent him for an echo (the one we have is 3 years old), I also sent him for PFT's (originally I thought this was an open procedure and I was looking for concrete data to cancel indefinitely). Anyway, these are still pending. I will probably go the epidural route. If I was doing the case myself I would do a MAC. Unfortunately, not being able to be there every minute and monitor meds given, I am afraid it would end up as a room air general like most of the "MAC's" I do. I know there is the argument that if it ruptures then a sympathectomy from the epidural is not the best thing to have but if it ruptures in this guy he will be dead anyway.

 

[Planktonmd]

I agree with the no workup if he was a DNR. I know he is on hospice and we discussed his hospice status. The only thing he knows about hospice is the fact that a nurse comes out to his house and gives him his meds every day. I asked him about the discussion he had with his cardiologist about turning off his AICD and he said he has no interest in turning it off ("I might die" were his words). He also says that he is doing better actually taking his meds than he has in three years. I sent him for an echo (the one we have is 3 years old), I also sent him for PFT's (originally I thought this was an open procedure and I was looking for concrete data to cancel indefinitely). Anyway, these are still pending. I will probably go the epidural route. If I was doing the case myself I would do a MAC. Unfortunately, not being able to be there every minute and monitor meds given, I am afraid it would end up as a room air general like most of the "MAC's" I do. I know there is the argument that if it ruptures then a sympathectomy from the epidural is not the best thing to have but if it ruptures in this guy he will be dead anyway.

I don't understand the AICD thing!
He is telling you not to turn it off during the surgery?
There is a point when i tell some patients: "listen, This is what we are going to do because I have medical training and you don't".

 

[Noyac]

AICD's don't necessarily need to be turned off. I'd check with the rep and be sure that I could turn it off with a magnet like most AICD's.

Again, why not do a stent here?

 

[pd4emergence]

At his last Cardiology visit the Cards guy wanted to turn off his AICD forever since he is on hospice. Not just for the case. The guy was absolutely not interested in turning it off forever. He also doesn't understand that hospice means DNR and is not really interested in being a DNR. "Do everything you can Doc". I really think the only reason he is on hospice is that a hospice nurse comes out everyday to give him his meds. A stent which to me is an endovascular repair is what is planned. I found this out after I had seen the patient when the surgeon called me back. Sorry for the confusion.

 

[milrisome]

Ok, so it's going to be a stent. He's on some kind of blood thinner but has normal PT/PTT. So he's either on LMWH or a platelet inhibitor. So you either take him off his anticoagulants or don't do an epidural. Why not just do local with sedation? It has been done successfully in the literature:

J Vasc Surg 2002;23:528-36.

But with 2-5% chance of needing to go to open procedure, gotta be prepared. Large bore IV, OR notified, ready to convert to GA.

 

[Idiopathic]

Yeah, and people can choose to leave hospice at a moments notice. They dont sign away their future rights to comprehensive medical care simply by entering a hospice program.

Also, hard to 'make' someone DNR if they dont want to be. Admittedly, you can elect not to resuscitate or to limit resuscitation, but it doesnt sound like this guy will be anything but 'full code' on his chart.

Im torn here, understanding the practical nature of this patients disease and almost certain outcome limitations, but I would think if you would do this case at all, you should at least prepare for the possibility of intraop complication, which you are really not doing with a peripheral IV and an epidural.

 

[Laurel123]

Ok, so it's going to be a stent. He's on some kind of blood thinner but has normal PT/PTT. So he's either on LMWH or a platelet inhibitor. So you either take him off his anticoagulants or don't do an epidural. Why not just do local with sedation? It has been done successfully in the literature:

J Vasc Surg 2002;23:528-36.

But with 2-5% chance of needing to go to open procedure, gotta be prepared. Large bore IV, OR notified, ready to convert to GA.

Some of the surgeons I work with, when they do these sort of patients, they pretty much tell me that there is 0% chance of opening and that is how they consent the patient. Because if it can't be done endoscopically, they are going to close up and call it a day. Because with a patient like this, if they open, he has no chance. Now, I suppose they will have to open if the patient ruptures, but again, if this guy ruptures, he has no chance.

Anyways, we do a lot of these with spinals/epidurals and sedation. Minimal sedation. We just get their coagulopathies corrected and do the neuraxial block. Once, the surgeon couldn't do the procedure for whatever reason, so he just closed him up and we were done. No open. The patient never got the AAA repaired, and I heard a month later he had an MI and died. Family has happy he got to spend that last month at home instead of in the ICU.

 

[epidural man]

how would you do the case?

LMA, gas (.3-.5mac), remifentanil infusion, BIS

 

[Planktonmd]

LMA, gas (.3-.5mac), remifentanil infusion, BIS

Why do you need BIS???

 

[powermd]

To be "on hospice" one either has to consent to comfort care only (no life saving or life prolonging interventions), or be so incompetent that someone else consents to it for them. It sounds like your guy is competent, and hasn't consented even to DNR, let alone hospice.

If the guy wants this stent graft, has a surgeon willing to do the procedure, and an insurer willing to pay for it, it's going to happen. Even if it's entirely futile with greater risk than benefit. This is a GREAT example of how screwed up the incentives are in our health care system.

Here's how I would do this case:

Have a long discussion with the patient and his family about his goals of care. See if we can't get him to try a week of optimizing his pain management, since that seems to be what's important to him.

If he's dead set on surgery, have a candid discussion about the risks and consequences, including prolonged post-op ICU stay, ICU complications, and likelihood of dying with tubes jammed up every orifice, surrounded by bleeping monitors, instead of dying comfortably at home, surrounded by loving family members, clergy, pets, etc.

Optimize what's optimizable.

Find out what meds he's actually receiving. Figure out how his AICD works. If there is any possibility of opening, it needs to be turned off, and pacing/defib pads placed on the chest and back. If it doesn't get switched off, have a magnet ready anyway.

Meke sure he's effectively beta-blocked, and not zipping in and out of RAF. Optimize control of his heart failure with diuretics and vasodialators, if needed - in consultation with his cardiologist. Get him to stop smoking for 48 hrs, using nicotine patches if needed. On the day of surgery, give a bronchodialator. Check a blood gas to see if he's a CO2 retainer. One good PIV, standard monitors, nasal canula O2, a little midaz, and we should be good to go. If he needs better pain control, I would have the surgeons give more local. If he's uncomfortable on the table, I might start a ketofol infusion. I would try to avoid opiates to maintain normocarbia if he's a CO2 retainer. If not, a little fentanyl or remi would be fine.

If the surgeon decides to open, I would do RSI with etomidate and sux, and an ETT. I wouldn't try to maintain SV with an LMA since the patient is likely going to die on the table, and will need reliable controlled ventilation once they open. I would call for 10 units of red cells, 4 ffp, and 6 platelents. I would place a RIJ DLC, and hook up the rapid infuser. The case would probably be over at that point, with 10's of thousands of dollars wasted, plus someone's last six months of life.

I agree with the no workup if he was a DNR. I know he is on hospice and we discussed his hospice status. The only thing he knows about hospice is the fact that a nurse comes out to his house and gives him his meds every day. I asked him about the discussion he had with his cardiologist about turning off his AICD and he said he has no interest in turning it off ("I might die" were his words). He also says that he is doing better actually taking his meds than he has in three years. I sent him for an echo (the one we have is 3 years old), I also sent him for PFT's (originally I thought this was an open procedure and I was looking for concrete data to cancel indefinitely). Anyway, these are still pending. I will probably go the epidural route. If I was doing the case myself I would do a MAC. Unfortunately, not being able to be there every minute and monitor meds given, I am afraid it would end up as a room air general like most of the "MAC's" I do. I know there is the argument that if it ruptures then a sympathectomy from the epidural is not the best thing to have but if it ruptures in this guy he will be dead anyway.

 

[epidural man]

Why do you need BIS???

cuz i'm not a very good anesthesiologist and need it to keep my volitile as low as possible (around .3 Mac).

In addition, I don't buy this idea that MAC requirements go down as we age, instead, I think that as we age, we have an increase in baseline MAC . For example, an 85 year can barely remember were he left his keys the day before - this is because he lives at an already existing .3-.4 MAC. 🙂

I would keep his BIS at 60-70 and primarily titrate remi. I know that some might say "well 70 is a recall number!"

No way! This guy can't remember that he is probably on HCTZ and has been told these four simple letters probably hundreds of times yet he can't recall them - no way is he going to remember this case with a little bit of volitile. Plus, I would most likely induce with 6-15 mg of versed.

 

[BLADEMDA]

my recomendation

leave this dude alone

hi risk procedure on a hi risk guy

if he survives he will be in the icu for a very long time

what is so great about this case?

Johan's right. If this was my Father I would follow the AAA and NOT operate.
How long do you think he has anyway? 6-18 months? If the AAA does not expand much then NO Surgery.

Now, if he decides to go ahead with the surgery someone needs to talk frankly with the patient and his family. Expected mortality/morbidity along with prolonged artificial ventilation plus possible trach. DO you know how many times I have seen this scenario? I put his odds at about 50/50 that he leaves the hospital in a week or less. Flip a coin.

Now on to the anesthetic courteous of our Medicare system. If opening is possible, I would do a GA and prepare for the worst (which is not a quick death in his case). Stop his Plavix for a week, get baseline PFT's and ABG, recent echo report (not really relevant at 10% EF as TEE intraop better) and document that discussion stated above.

If NO chance of opening I would do a spinal.

For post-op pain (open procedure) I would consider thoracic epidural but due to our screwed up legal system I doubt that any of my partners would do it. They would go PCA but would consider a single shot of spinal duramorph with whitacre needle.

Blade

 

[sdn1977]

No go. This guy is hospice and hospice care does not include major surgery. Tell the patient to enjoy his life, do what he wants, eat what he wants, smoke what he wants.

I'm no physician, but if you're in hospice, you've turned over your insurance to the hospice provider.

They won't pay for anything other than comfort care (which includes continuing the maintenance medications) as well a providing for pain management, but no intravenous replacement. No chemo, no tumor reduction surgery, no feeding tube placement, etc.. But - if major surgery is planned to "fix" something - hospice will drop him because he doesn't meet their criteria & they may have already maxed out his insurance for the month.

I'd check coverage first - altho you could do it for nothing I guess if you felt strongly enough about it.

 

[Planktonmd]

cuz i'm not a very good anesthesiologist and need it to keep my volitile as low as possible (around .3 Mac).

In addition, I don't buy this idea that MAC requirements go down as we age, instead, I think that as we age, we have an increase in baseline MAC . For example, an 85 year can barely remember were he left his keys the day before - this is because he lives at an already existing .3-.4 MAC. 🙂

I would keep his BIS at 60-70 and primarily titrate remi. I know that some might say "well 70 is a recall number!"

No way! This guy can't remember that he is probably on HCTZ and has been told these four simple letters probably hundreds of times yet he can't recall them - no way is he going to remember this case with a little bit of volitile. Plus, I would most likely induce with 6-15 mg of versed.

May I ask why you need to keep your "Volatile as low as possible" as long as the hemodynamics are stable?
and if the hemodynamics are not stable who cares what the BIS number is?
And since you are inducing with 6 - 15 mg Midazolam you are obviously not concerned about rapid emergence.
And how do you know that 0.3 MAC of vapor is enough to avoid awareness? is it based on the promises provided by ASPECT or there is some real DATA on that?
The point I am trying to make is: You don't need a BIS monitor to titrate your anesthetic, it only gives you a false sense of security.

 

[epidural man]

May I ask why you need to keep your "Volatile as low as possible" as long as the hemodynamics are stable?
and if the hemodynamics are not stable who cares what the BIS number is?
And since you are inducing with 6 - 15 mg Midazolam you are obviously not concerned about rapid emergence.
And how do you know that 0.3 MAC of vapor is enough to avoid awareness? is it based on the promises provided by ASPECT or there is some real DATA on that?
The point I am trying to make is: You don't need a BIS monitor to titrate your anesthetic, it only gives you a false sense of security.

excellent points!

 

[pd4emergence]

Case finally got done. Repeat echo was unchanged. PFT's were not as bad as expected FEV1 of 2L (according to my partner). Case done with two peripherals and an aline. Induced with ketamine and propofol. GA with LMA. Stent placed with no problems according to my partner (I was post call). I saw the guy on POD 1. He actually asked me for a cigarette and asked me why the food was so "shi**y". It was very gratifying.

 

[LightsOut50]

Can you ask him how he blows out the match with his O2?

 

[pd4emergence]

Per one of our preop nurses, he would light a cigarette, pull his nasal canula out of his nose, and turn up his O2 and use the nasal canula to blow out his match. It scared our nurse so bad that she said she didn't even get to smoke more than a quarter of her cigarette.