Cardiac guys: How many CV cases and TEEs are you doing a year?

[92122]

My total dropped a bit last year to a bit over 100 cases that I did without a resident, with probably another 50 that I did with a resident involved to some degree.

Counting TEEs done in the OR got me over 160, with another ~30 coming from the various ICUs.

Is this a bit on the low side compared to what you're experiencing?

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[Wiscoblue]

I'm one of 3 cardiac anesthesiologists at a community hospital. Between the 3 of us we do about 150 hearts and 200 vascular cases (carotids, AAA, fempops). Very few ICU TEEs.

 

[drmwvr]

Can anyone provide evidence that routine cabg patients benefit from tee? In terms of expense? In terms of outcomes? Valves aside, what convincing evidence is there that echo can give practical information routinely that can't already be derived by what is already available? If there are those who would defend it's use for the sake of the unforeseen post bypass catastrophe, why couldn't it be employed at that point in that rare event rather than on every patient at the start of the case? TEE like swan-ganz catheters are tools to be applied as the case and patient requires. At the beginning of my career every single patient was swan'd. Now it might be 20 per cent. Granted, arguments might be made as to the usefulness of PA data vs TEE data, but placing a TEE probe once the drapes are up is easier than floating a swan IME. Forgive me if your institution does not require routine TEE on everyone. Mine does.

 

[ASA6]

at my institution, every single cardiac case gets a tee and a swan.

 

[92122]

Unless there's a contraindication to TEE placement (stricture, etc.), I don't see the reluctance to use it. If nothing else, you might pick up a PFO in need of closure. Also, it's helpful to see your wires poking through the SVC during central line placement.

As for a PAC, we place them in most every candidate, although it's likely more helpful for the ICU management in "healthy" CABG patients who undergo the typically bland perioperative course that didn't *really* need info gleaned from such a device.

 

[BobBarker]

Both are done for billing purposes.

 

[periopdoc]

...placing a TEE probe once the drapes are up is easier than floating a swan IME. Forgive me if your institution does not require routine TEE on everyone. Mine does.

I do not routinely place TEE for straight forward on or off-pump GABG (marginal benefit at best), but placing a TEE once the drapes are up is no trivial job in my institution. They place a "birdcage" over the patients face immediately prior to draping. This gives you ~3 inches of space in front of the face or less. The birdcage is a mayo like table that connects to the bed to give them an extra spot for setting instruments down and for protecting the patient's face. If I have any concerns, I will place TEE in advance. I have inserted a probe a couple of times for intraoperative issues and I was extremely worried about the potential for esophageal tearing in both cases.

Unless there's a contraindication to TEE placement (stricture, etc.), I don't see the reluctance to use it. If nothing else, you might pick up a PFO in need of closure.

What is the data on repairing incidentally discovered PFO at the time of unrelated CABG surgery?

Both are done for billing purposes.

Institution dependent. Sometimes it is for maximum resident benefit. I would much rather have the TEE than the PAC, but the ICU docs want PAC's for all their hearts. Since they aren't placing them, it isn't for billing purposes. I am happy to oblige since I get paid more for placing the useless device than for the TEE, and I don't have to write a damn report like I do for TEE.

- pod

 

[92122]

"What is the data on repairing incidentally discovered PFO at the time of unrelated CABG surgery?"

Can't quote anything off the top of my head, but if it's unrestricted, it's often repaired out of concern out for CVAs by surgeons at my institution.

 

[periopdoc]

Can't quote anything off the top of my head, but if it's unrestricted, it's often repaired out of concern out for CVAs by surgeons at my institution.

Which is a good reason not to perform routine TEE.

- pod

 

[periopdoc]

Should a patent foramen ovale found incidentally during isolated coronary surgery be closed?

here is currently no evidence to suggest that incidental PFO in patients undergoing cardiac surgery is linked with increased morbidity, mortality or decreased long-term survival.

After propensity matched analysis, the authors found closure was associated with a significantly higher risk of postoperative stroke with no advantage in terms of long-term survival.

Obviously, we don't make the decision whether to change the surgery and address the PFO, but if you don't place the probe, you don't have to look for the PFO... If you don't know the PFO is there...

- pod

 

[Dwindlin]

Should a patent foramen ovale found incidentally during isolated coronary surgery be closed?





Obviously, we don't make the decision whether to change the surgery and address the PFO, but if you don't place the probe, you don't have to look for the PFO... If you don't know the PFO is there...

- pod

This sounds an awful lot like the 10th law. . .

 

[sevoflurane]

Should a patent foramen ovale found incidentally during isolated coronary surgery be closed?





Obviously, we don't make the decision whether to change the surgery and address the PFO, but if you don't place the probe, you don't have to look for the PFO... If you don't know the PFO is there...

- pod

If you don't look you don't know.... Not everyone gets an echo.

How easy is it to place a probe once you are prepped and draped and the cage is up?

 

[sevoflurane]

Tee>>>pac

imho.

 

[OB1🤙]

Routine CABGs and uncomplicated AVRs get a FloTrac from me in addition to the CVC. No swan.

We echo everyone, though I understand the arguments against that practice.

And yeah, leave previously undiagnosed asymptomatic PFOs alone.

 

[drmwvr]

Routine CABGs and uncomplicated AVRs get a FloTrac from me in addition to the CVC. No swan.

We echo everyone, though I understand the arguments against that practice.

And yeah, leave previously undiagnosed asymptomatic PFOs alone.

Is a FloTrac useful with an open chest?

 

[OB1🤙]

Is a FloTrac useful with an open chest?

Short answer: yes.

Long answer: The cardiac output is still useful. The SVV, probably not as much. But in the OR, I have my TEE to tell me if the pt needs fluid or not.

The real benefit is in the ICU postop, where they don't have a TEE to help dictate the minute-to-minute management. The Flotrac will give them the CO/CI, which makes them happy. Of course, you don't NEED those numbers, if your patient doesn't have a lactic acidosis there's probably not tissue hypoxia going on, but the ICU RNs find it useful. And since they're vented for a few hours after surgery, the SVV is useful to them postop in determining who may need some fluid.

I don't claim it's a perfect piece of technology, but it has been helpful in weaning our institution off the routine use of the PAC in patients who don't need them.

 

[urge]

Short answer: yes.

Long answer: The cardiac output is still useful. The SVV, probably not as much. But in the OR, I have my TEE to tell me if the pt needs fluid or not.

The real benefit is in the ICU postop, where they don't have a TEE to help dictate the minute-to-minute management. The Flotrac will give them the CO/CI, which makes them happy. Of course, you don't NEED those numbers, if your patient doesn't have a lactic acidosis there's probably not tissue hypoxia going on, but the ICU RNs find it useful. And since they're vented for a few hours after surgery, the SVV is useful to them postop in determining who may need some fluid.

I don't claim it's a perfect piece of technology, but it has been helpful in weaning our institution off the routine use of the PAC in patients who don't need them.

So, your patients get icu care by nurses only?

How much are those things again? $200?

Wouldn't it just be more cost effective to swan them?

 

[OB1🤙]

So, your patients get icu care by nurses only?

How much are those things again? $200?

Wouldn't it just be more cost effective to swan them?

No, it wouldn't, not for us. Because our institution, in its infinite wisdom, only stocks CCO/oximetric swans. Cost of that plus introducer plus (albeit low) morbidity of the swan makes the Flotrac attractive for our situation.

Postop care is generally managed by an intensivist who has two floors to cover. Having a realtime CO provides a margin of safety if the MD is off the floor. It helps the nurses, so it helps the patients.

 

[urge]

No, it wouldn't, not for us. Because our institution, in its infinite wisdom, only stocks CCO/oximetric swans. Cost of that plus introducer plus (albeit low) morbidity of the swan makes the Flotrac attractive for our situation.

Postop care is generally managed by an intensivist who has two floors to cover. Having a realtime CO provides a margin of safety if the MD is off the floor. It helps the nurses, so it helps the patients.

I still think an oximetric swan should be cheaper nominally. They are like $70. The big unknown is how your institution handles them. They could lead to more complications indeed.

 

[nimbus]

Tangentially related. How many here double stick IJ for cvp and pa catheter? Double Alines?

 

[drmwvr]

Tangentially related. How many here double stick IJ for cvp and pa catheter? Double Alines?

In the cardio thoracic OR, an academic exercise for the gratification of the operator(s). Can't speak for transplant centers nowadays tho...In private practice, a waste of money and time with increased morbidity.

 

[deleted171991]

Tangentially related. How many here double stick IJ for cvp and pa catheter? Double Alines?

Where I trained as a resident, neither.

 

[OB1🤙]

I still think an oximetric swan should be cheaper nominally. They are like $70. The big unknown is how your institution handles them. They could lead to more complications indeed.

It turns out that for reasons too political and involved for our purposes here, all we have is not only the oximetric swan, but the super deluxe one that claims to provide RVEDV and SV as well. So its cost is up there. I'm not quite sure what you're insinuating by your statement about the way our institution handles them, but I'll give you the benefit of the doubt for now that you weren't trying to be an ass.

And again, I see the Swan as being a procedure that is not indicated for these cases, which is to say that the (small) risk outweighs the (small) benefit. You can debate the cost effectiveness of the Flotrac, but it's an add-on monitor to a procedure already being done, and it confers no additional procedural risk to the patient. A Swan is flat-out not indicated for a routine CABG with a normal heart.

Our ultimate goal is to wean our unit off the Flotrac as well, but since they're only just getting used to not having a Swan in every heart, it has been useful for us.

But hey, you do what works for you.

 

[urge]

It turns out that for reasons too political and involved for our purposes here, all we have is not only the oximetric swan, but the super deluxe one that claims to provide RVEDV and SV as well. So its cost is up there. I'm not quite sure what you're insinuating by your statement about the way our institution handles them, but I'll give you the benefit of the doubt for now that you weren't trying to be an ass.

And again, I see the Swan as being a procedure that is not indicated for these cases, which is to say that the (small) risk outweighs the (small) benefit. You can debate the cost effectiveness of the Flotrac, but it's an add-on monitor to a procedure already being done, and it confers no additional procedural risk to the patient. A Swan is flat-out not indicated for a routine CABG with a normal heart.

Our ultimate goal is to wean our unit off the Flotrac as well, but since they're only just getting used to not having a Swan in every heart, it has been useful for us.

But hey, you do what works for you.

My point was whether people are constantly inflating the balloon and moving the swan to get lvedp, or they just look at pa pressures and cardiac output.

What's the name of that fancy swan? Who makes it?

I'm not aware of a swan that can do rvedv. Perhaps new in the market?

 

[urge]

Found it. No idea how much it costs but I imagine it would be up there with the Flotrac.

 

[sevoflurane]

It turns out that for reasons too political and involved for our purposes here, all we have is not only the oximetric swan, but the super deluxe one that claims to provide RVEDV and SV as well.

Very cool.
I'm interested in how they arrive at end diastolic volume. High fidelity catheter?

Just for fun, you ever check it with a modified simpson's of the RV? How does that compare? Certainly, it sounds a lot less laborious if it's a continual reading.
Nice.

 

[OB1🤙]

It turns out this thing costs us $290 a pop.

Sevo- I actually think the RVEDV part is completely worthless, especially since we have the echo in anyway. There's never a question as to RV pythias when you can see it on the screen, vs calculated from thermodilution.

 

[sevoflurane]

Thanks for the feedback HB. Never tried out one of those PAC's.
The idea of volume vs pressure sounds nice as I believe it to be a better surrogate to flow. As you know, pressure doesn't always mean flow.
I wonder if it would be useful in say... AAA/major vascular/or big surge/onc cases that don't get an echo either due to unavailability or unfamiliarity with a TEE machine.
We use Flotrack for those cases.

I've also used this in the past. It was fun to use and useful in certain cases with poor protoplasm. (Fun to watch with suprarenal clamps going on and off).

 

[urge]

The thought that a medicare heart pays around 800 bucks for the anesthesia vs the cost of the equipment makes me nauseous.

 

[nimbus]

The thought that a medicare heart pays around 800 bucks for the anesthesia vs the cost of the equipment makes me nauseous.

Then you really don't want to think about robotic mitral repairs.