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[Planktonmd]

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70 Y/O,M, heavy smoker, HTN.
History of angina randomly at rest subsides with NTG or spontaneously, although last epissode was 1 month ago.
Does not exercise because of severe back pain and can not walk more than 1 block for same reason.
Going for 2 levels lumbar laminectomy.
Nuclear stress test shows an area of reversible anteroseptal ischemia without symptoms or EKG changes.
They sent him for a cardiac catheter that showed multi-vessel disease but none exceeds 30-40 %.
He was considered low to moderate risk by the cardiologist and "cleared" for surgery.
He forgot to take his Atenolol last night (he takes it at night).
BP= 160/85 , HR = 70 , SPO2 = 95% on RA.
What's the plan??

 

[Lonestar]

since when is recent unstable angina "low-moderate" risk. This dude is moderate-high risk in my book. But anyway, he is going for "moderate risk" surgery. General anesthesia with titrating metoprolol in as needed. Just hope and pray that HR and BP don't fall or rise from baseline too much during induction and emergence. Would use nitroglycerin gtt and boluses as need to control HTN. A-line is probably overkill. would definitely have two good ivs. Fentanyl, lidocaine, etomidate, succ/vec, sevo/iso. gotta love the cardiologists. I am gonna get fried anyway if something were to happen to this guy in the "perioperative" period.

 

[dhb]

Avoid tachycardia, hypertension, hypoxemia

Give B blocker pre-op, a-line (so he already has it for the cath lab 🙂 ) induction with propofol/ketamine for more stability, have blood ready don't let crit go under 30%. Have ntg ready.

 

[Idiopathic]

HR Control with beta blockade
Pain Control with whatever works (PCA)

PIV X 2, A-line, T+S, Neo/Nitro ready

My question is why on earth does this guy have unstable angina with no lesion > 40%? Im guessing his LHC result is what makes him "low-mod" risk, since hes obviously high risk by guidelines standards (unstable angina).

 

[Planktonmd]

So far: Beta blockers, possibly A line and keep hemodynamics stable.
What would you tell the patient about the risk of surgery?
Do you feel that the pre-op workup was appropriate and do you agree with the cardiologist's decision to proceed?
What would you do if there is some ST depression intra-op?
Do you need a PA catheter?
Do you need A TEE?
Let's say you are going to supervise a CRNA doing this case what are your instructions to the CRNA? Any additional concerns?

 

[urge]

Do you feel that the pre-op workup was appropriate and do you agree with the cardiologist's decision to proceed?

He had a cath with no significant lesions amenable to intervention. Medical management it is. Not much more workup to do. Make sure he is well B blocked from his po meds. The metorpolol we give intraop is not proven to do anything. Laminectomy is a mod risk procedure at worst. A line definitely. Central line-probably not, there is not much fluid shift involved. PAC-probably yes, will help you detect ischemia. I'll be more inclined to place it if he had poor EF/CHF. TEE- sure, if you want. It's going to be awkward doing it prone.

 

[VentdependenT]

So far: Beta blockers, possibly A line and keep hemodynamics stable.
What would you tell the patient about the risk of surgery?
Do you feel that the pre-op workup was appropriate and do you agree with the cardiologist's decision to proceed?
What would you do if there is some ST depression intra-op?
Do you need a PA catheter?
Do you need A TEE?
Let's say you are going to supervise a CRNA doing this case what are your instructions to the CRNA? Any additional concerns?

From the history the guy has unstable angina. Big risk factor. His cath aint exactly clean....diffuse disease with several areas approaching >40% stenosis with a perfusion defect on the neuc scan. He may need a CABG soon. Does that mean he should have one before the laminectomy? Probably, but I'm not going to schedule him for one.

1) A-line is a given.
2) Forget PAC/Central Line. A two level lami isn't getting me into this type of territory. Echo is a great idea if you can the damn thing in there. Good luck.
3)Concerning risks of surgery, I am concerned that this person is at moderate to high risk of perioperative MI. Post-op he should be placed in a monitored setting for first 24 hours for this reason alone.
4) ST depression intra op? Hemodynamically stable =Get the HR under control, give nitro, call the cardiologist and have the guy set up for a CABG. Wrap up the case....Now you're screwed because of systemic anticoagulation needs in someone with back surgery. Can they put balloon pumps in prone? Pfff... Unstable? Well now youre totally screwed, again. THis guys gonna be paralyzed from the heparin preop AND for the CABG he's going to get tonight.

Can you do the case, sure you can. Should you I dunno. Thats the question eh?

 

[dhb]

I'm on the fences about this "unstable" angina, i would classify it as a stable unstable angina 😀 : ok it comes at rest but it doesn't last or deteriorate so... if you can suppress surgical stress he should be as good as usual.

I would tell the patient he's at a higher risk for this surgery and wouls explain the possible adverse events but if he can't function because of the pain there isn't a formal reason not to go through.

PA cath is overkill tee would be good to detect early events before ekg modification.

To CRNA: ensure adequate level of analgesia (remi would actually be good for this case) and titrate level of anesthesia to hemodynamic parameters a BIS could be usefull too. Call if blip on the radar.

 

[Lonestar]

So far: Beta blockers, possibly A line and keep hemodynamics stable.
What would you tell the patient about the risk of surgery?
Do you feel that the pre-op workup was appropriate and do you agree with the cardiologist's decision to proceed?
What would you do if there is some ST depression intra-op?
Do you need a PA catheter?
Do you need A TEE?
Let's say you are going to supervise a CRNA doing this case what are your instructions to the CRNA? Any additional concerns?

I would tell the pt that surgery will exercerbate his CAD and his chances of having an MI are increased due to his clinical history. I would also say that i will take precautions to minimize this risk. I feel the pre-op workup is adequate and the pt should have surgery as long as he is medically optimized. If pt has ST depression intra-op, i would start nitro gtt, control HR with metoprolol, maintain BP with inotropes if necessary, ask the hammer boyz to stop hammering, get cardiology consultation for follow-up in PACU, start an A-line if one hasn't been started, send off enzymes, and talk to the pt/family about what happened.

I think a PA catheter is probably overkill for this case. TEE would be nice. If i was supervising a CRNA, i would tell him/her to keep the HR down with metoprolol, maintain adequate analgesia, and keep the diastolic value of BP from dropping.

 

[Idiopathic]

This guy is not going to have ischemia intraoperatively, unless his BP tanks. He will more likely have ischemia 12-24 hours after surgery, however, when he is on the floor. He probably has unstable 50% plaques.

I would think that continuing beta blockade and postop pain control are the most important things to consider, IMHO.

 

[Dr Serenity]

Given this clinical history and perioperative risks, do y'all think it would be best for this patient to go to the ICU after surgery rather than PACU --> to floor? It seems as if this patient's going to need some close monitoring right after surgery.

Thoughts?

 

[VentdependenT]

Given this clinical history and perioperative risks, do y'all think it would be best for this patient to go to the ICU after surgery rather than PACU --> to floor? It seems as if this patient's going to need some close monitoring right after surgery.

Thoughts?

Since we're going to end up doing the case knowing all this in advance I think it would be wise to send him to either a step down unit or a cardiac monitored floor for 24hours post op. This will not prevent an MI but maybe it'll cover your ass until the infarct happens 2 weeks later at rehab during OT or during a heafty valsva inducing bowel movement.

 

[Dr Serenity]

This will not prevent an MI but maybe it'll cover your ass until the infarct happens 2 weeks later at rehab during OT or during a heafty valsva inducing bowel movement.

Unless the guy's a true GOMER...then he'll wind up being admitted to some medicine service a week post-op for chest pain and shortness of breath, where he'll become some poor intern's worst nightmare. The MI will never happen because GOMERS DON'T DIE...

 

[Planktonmd]

Unless the guy's a true GOMER...then he'll wind up being admitted to some medicine service a week post-op for chest pain and shortness of breath, where he'll become some poor intern's worst nightmare. The MI will never happen because GOMERS DON'T DIE...

Did you just read The house of god?

 

[Dr Serenity]

Did you just read The house of god?

A few months back...😀 Fortunately I began it during a holiday AFTER finishing my internal medicine clerkship.

I'm in the middle of my Medicine sub-I and thus my cynicism quotient is very high at the moment. 😛