cardiac workup before bronchs

[pocafx]

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How strict are you all for pre-operative cardiac testing for robotic bronchs.

The scenario is typically a 70 y/o long time smoker, now with lung mass that needs biopsy and diagnosis for further treatment. They are active smokers who can not do >4 METS, likely related to COPD and have +/- O2 use. Typically they have not seen cards and no recent echo, stress test as they are non-compliant with health care, and only here cause they are scared to death of their new lung mass/cancer. Their chest CT always shows mod-severe CAD. Do you proceed with these?

 

[DesiredMemberName?]

How strict are you all for pre-operative cardiac testing for robotic bronchs.

The scenario is typically a 70 y/o long time smoker, now with lung mass that needs biopsy and diagnosis for further treatment. They are active smokers who can not do >4 METS, likely related to COPD and have +/- O2 use. Typically they have not seen cards and no recent echo, stress test as they are non-compliant with health care, and only here cause they are scared to death of their new lung mass/cancer. Their chest CT always shows mod-severe CAD. Do you proceed with these?

Id typically just proceed unless there was some known issue.

These cases need to be done in a timely manner, and a bunch of invasive testing likely won’t change management for the vast majority. Caths have their own risks. Echo likely will be low yield unless maybe they have a murmur.

It shouldn’t be too hard to get them through it safely. Just be gentle with them.

 

[Dantrolene FC]

How strict are you all for pre-operative cardiac testing for robotic bronchs.

The scenario is typically a 70 y/o long time smoker, now with lung mass that needs biopsy and diagnosis for further treatment. They are active smokers who can not do >4 METS, likely related to COPD and have +/- O2 use. Typically they have not seen cards and no recent echo, stress test as they are non-compliant with health care, and only here cause they are scared to death of their new lung mass/cancer. Their chest CT always shows mod-severe CAD. Do you proceed with these?

My understanding of the 2014 guidelines are if they have an RCRI of 0, proceed with surgery regardless of METS status. So basically, no insulin use, no stroke, heart failure, or MI, or cr of 2.0 or greater.

2024 guidelines are a little more involved and you could order a BNP or troponin and proceed if negative. At least, that’s my understanding. I wouldn’t consider a bronch a high risk surgery.

 

[PainInTheAnes]

How strict are you all for pre-operative cardiac testing for robotic bronchs.

The scenario is typically a 70 y/o long time smoker, now with lung mass that needs biopsy and diagnosis for further treatment. They are active smokers who can not do >4 METS, likely related to COPD and have +/- O2 use. Typically they have not seen cards and no recent echo, stress test as they are non-compliant with health care, and only here cause they are scared to death of their new lung mass/cancer. Their chest CT always shows mod-severe CAD. Do you proceed with these?

Your only real intervention is a cath showing an intervenable lesion that’s acted upon.

But will this person want to be on blood thinners for the rest of their life if they have a fungating squamous in their right mainstem?

Figure out what you’re dealing with on the ct scan then decide if the CAD is worth going after. Lung masses take precedence unless there’s active ekg signs imo

 

[dchz]

I would proceed.

If you do find CAD on Left Heart Cath, one would still have to biopsy to find out prognosis for the lung mass before you can make a decision with cabg vs stents. (Typically u wouldn't do a cabg if the life expectancy less than 5 years).

Furthermore, the wait time of scheduling diagnostic card procedures could be detrimental to the patient (sometimes months).

This is a situation where the right thing to do is higher anesthesia risk than cancelling the case and kicking the can down the road. But it's the right thing to do.

 

[pocafx]

Okay. Thanks guys. I agree it’s not high risk surgery, it needs to be done. (Cancer). Just never a great feeling starting these cases but I do generally proceed with them. Just wanted to be sure I wasn’t out of line.

 

[psychbender]

Another thing, the cardiologists may be rightly very hesitant to cath someone and risk the need for DAPT is there is a decent chance that they'll need surgery for their cancer in the very near term. Use kid gloves, get the cancer diagnosis, then see what's actually needed for the patient and their treatment pathway.

 

[aneftp]

The bronchs I get annoyed at not the primary diagnoses.

It’s the repeat bronch when the patient is close to dead with stage 4 mets everywhere.

I have no clue what they are actually trying to diagnose that they can’t treat globally.

So do you delay those bronch for cardiac? Or just cancel them?

 

[Arch Guillotti]

If they can walk in ok then do the case. Only a small chance they will crump.

 

[chessknt]

Glad to see these responses--my local anesthesia team has only once demanded a cardiac workup (which we got done urgently in pre-op) because the guy said he had chest pain (from his mass of course). If they need a stent this procedure becomes much harder (it not impossible) to do on DAPT and risk of metastasis drastically increases last a certain size threshold where a delay of weeks can upstage, let alone months.

 

[PpfSuxTube]

My understanding of the 2014 guidelines are if they have an RCRI of 0, proceed with surgery regardless of METS status. So basically, no insulin use, no stroke, heart failure, or MI, or cr of 2.0 or greater.

2024 guidelines are a little more involved and you could order a BNP or troponin and proceed if negative. At least, that’s my understanding. I wouldn’t consider a bronch a high risk surgery.

Pls say you didn't quote rcri on here... the most bastardised scoring system ever created...

Cruder than my uncle and less educated.
What does it even mean? Imagine a scoring system that has insulin use as a binary score in today's world of dm mgt. It's like what cavemen used when they were drawing feces art of their favorite buffalo

 

[PpfSuxTube]

What is a robotic bronch?

 

[Dantrolene FC]

Pls say you didn't quote rcri on here... the most bastardised scoring system ever created...

Cruder than my uncle and less educated.
What does it even mean? Imagine a scoring system that has insulin use as a binary score in today's world of dm mgt. It's like what cavemen used when they were drawing feces art of their favorite

Pls say you didn't quote rcri on here... the most bastardised scoring system ever created...

Cruder than my uncle and less educated.
What does it even mean? Imagine a scoring system that has insulin use as a binary score in today's world of dm mgt. It's like what cavemen used when they were drawing feces art of their favorite buffalo

Nobody has time to do a DASI score.

 

[pgg]

What is a robotic bronch?

It's a bronch machine that the pulmonologist can steer by wire instead of by handling the scope. Usually involves a couple runs of fluoro with a C-arm.

Nothing special from our side. Intubate with the biggest tube you can safely get away with, paralyze. You can TIVA them if you want but volatile is easy - much less gas leaking around the scope than when they're driving it scope by hand.

 

[DrOwnage]

I came from a place where we used to do a **** ton of robotic bronchs. I used to igel and paralyze. Now I will say there’s something about the robotic bronch that I think makes it riskier than a normal bronch. They do a TON more passes, they’re long as balls, and they always want high ass PEEP. I myself have seen 2 large air emboli. One that most likely airlocked the coronaries and caused the patient to Brady and code. Another with massive air emboli to the brain. Also saw a STEMI during one of these. So yeah they’re risky and the patients are usually physiologically turds. But as others have mentioned, delaying it isn’t going to do much.

 

[kb1900]

I came from a place where we used to do a **** ton of robotic bronchs. I used to igel and paralyze. Now I will say there’s something about the robotic bronch that I think makes it riskier than a normal bronch. They do a TON more passes, they’re long as balls, and they always want high ass PEEP. I myself have seen 2 large air emboli. One that most likely airlocked the coronaries and caused the patient to Brady and code. Another with massive air emboli to the brain. Also saw a STEMI during one of these. So yeah they’re risky and the patients are usually physiologically turds. But as others have mentioned, delaying it isn’t going to do much.

How did they get an air embolus?

 

[nimbus]

I came from a place where we used to do a **** ton of robotic bronchs. I used to igel and paralyze. Now I will say there’s something about the robotic bronch that I think makes it riskier than a normal bronch. They do a TON more passes, they’re long as balls, and they always want high ass PEEP. I myself have seen 2 large air emboli. One that most likely airlocked the coronaries and caused the patient to Brady and code. Another with massive air emboli to the brain. Also saw a STEMI during one of these. So yeah they’re risky and the patients are usually physiologically turds. But as others have mentioned, delaying it isn’t going to do much.

How much PEEP is considered “high ass”?

 

[psychbender]

How much PEEP is considered “high ass”?

Not that high, just 10, maybe 12. The part that hurts my intensivist soul is using tidal volumes of ~10/kg. It's all to minimize atelectasis, as the navigation system is mapped to the recent CT, and atelectasis can move the target, such the wire is off course, and the pulmonologists is driving blind.

 

[DrOwnage]

How did they get an air embolus?

It’s an associated complication. Air is either entrained into a pulmonary artery or pulmonary vein. High ass as in 10-12 baseline even in skinny ass patients. That high peep is the reason for air entrainment and air embolus.

 

[ToKingdomCome]

If they are symptomatic but I would be worried about moderate to severe pulm HTN and maybe RV failure as a result. So an echo could be potentially helpful, a cath less so

 

[CopaceticOne]

If they are symptomatic but I would be worried about moderate to severe pulm HTN and maybe RV failure as a result. So an echo could be potentially helpful, a cath less so

This.

Stress echos are good if you can get them because you can see function and anatomy. For a cancer bronch, I talk with patients about risks and what we can do to be prepared. Might not cancel for a positive test, but it might help tip the scale for things like pre-induction artline, where the case is going to be physically done, who is assigned to the case, limits placed on the pulm doc for saying “we’re done”.

Knowledge is power.

 

[ToKingdomCome]

This.

Stress echos are good if you can get them because you can see function and anatomy. For a cancer bronch, I talk with patients about risks and what we can do to be prepared. Might not cancel for a positive test, but it might help tip the scale for things like pre-induction artline, where the case is going to be physically done, who is assigned to the case, limits placed on the pulm doc for saying “we’re done”.

Knowledge is power.

Yesirrr!

 

[GassYous]

I came from a place where we used to do a **** ton of robotic bronchs. I used to igel and paralyze. Now I will say there’s something about the robotic bronch that I think makes it riskier than a normal bronch. They do a TON more passes, they’re long as balls, and they always want high ass PEEP. I myself have seen 2 large air emboli. One that most likely airlocked the coronaries and caused the patient to Brady and code. Another with massive air emboli to the brain. Also saw a STEMI during one of these. So yeah they’re risky and the patients are usually physiologically turds. But as others have mentioned, delaying it isn’t going to do much.

wtf I've never seen this what are your pulmonologists doing??

 

[Beeftenderloin]

Not that high, just 10, maybe 12. The part that hurts my intensivist soul is using tidal volumes of ~10/kg. It's all to minimize atelectasis, as the navigation system is mapped to the recent CT, and atelectasis can move the target, such the wire is off course, and the pulmonologists is driving blind.

Interesting about the Vt. The pulmonologist I do most robot bronchs with asks for 10 of PEEP and Vt on the the low side, usually 300-400cc.

 

[Beeftenderloin]

https://www.nejm.org/doi/full/10.1056/NEJMoa041905

I’m surprised no one has referenced the CARP trial yet. Or maybe someone did and I missed it.

5859 patients in need of major vascular surgery (AAA repair or leg revascularization), with diagnosed clinically significant CAD, were randomized to coronary revascularizarion prior to surgery (59% CABG, 41% stent) or no revascularizarion prior to surgery. There was no difference in rates of MI within 30 days of surgery and no difference in mortality out to 2.7 years.

I don’t apply this ethos to everyone across the board. But anyone with urgency associated with their surgery: things that need to happen on the coming weeks to months, I think it’s helpful to keep this paper in mind.

 

[Beeftenderloin]

This.

Stress echos are good if you can get them because you can see function and anatomy. For a cancer bronch, I talk with patients about risks and what we can do to be prepared. Might not cancel for a positive test, but it might help tip the scale for things like pre-induction artline, where the case is going to be physically done, who is assigned to the case, limits placed on the pulm doc for saying “we’re done”.

Knowledge is power.

Something I didn’t actually learn until I did a rotation reading TTE with cards was that for stress echos, literally all they are looking for is RWMAs. The techs aren’t doing a full exam, just getting LV views to look at wall motion with stress. The cardiologist isn’t looking at valves, or the RV, or anything else.

 

[CopaceticOne]

Something I didn’t actually learn until I did a rotation reading TTE with cards was that for stress echos, literally all they are looking for is RWMAs. The techs aren’t doing a full exam, just getting LV views to look at wall motion with stress. The cardiologist isn’t looking at valves, or the RV, or anything else.

Correct, but the big bads are generally obvious and the the techs take a few more images. Also, before the stress part they’ll call the cardiologist to look at the images to make sure it is ok to proceed given the possibility of badness (severe valvular disease, RV flailing, etc). That is why it is a good option.

 

[pgg]

Interesting about the Vt. The pulmonologist I do most robot bronchs with asks for 10 of PEEP and Vt on the the low side, usually 300-400cc.

What they ask for and what I give them are often quite different. Somehow the case still gets done. 🙂

 

[pocafx]

What they ask for and what I give them are often quite different. Somehow the case still gets done. 🙂

Problem is they are standing next to the vent to do the bronch and can see the numbers. No fake roc for them

 

[CopaceticOne]

Problem is they are standing next to the vent to do the bronch and can see the numbers. No fake roc for them

Gotta rotate the bed, then they can’t easily look at the numbers.