Case - 79M with CAD, CHF, AS, and ESRD for BKA

[powermd]

---

Members do not see this ad.

79M with CAD c/b MI x 2, s/p DES x 4 (within last 5y), LVEF 15-20%, AS with AVA 0.75 cm2, mean gradient 23, peak 49, ESRD on HD, s/p AICD, PVD with gangrenous L foot. Surgeon wants to do BKA, and to speed things along says he will tie vessels and use bipolar so we don't have to wait for cardiology to turn off AICD. It's 10 pm, and the cardiology fellow is hung up with an MI in the ER, and has a decompensating CCU patient in need of a Swan.
Our patient is hemodynamically stable, and not sick. Doesn't complain of ever having CP/SOB/syncope, but mobility is poor. Foot causes him a lot of pain, difficult to move him around without discomfort. Labs look okay. Good H/H/PLT, K 5.0, coags wnl. ECG sinus rhythm with nstwa. Good airway. Preop vitals 91/50 62 on the chart. On arrival to the room was 124/77 85.

How would you do this case?

After a few comments, I'l post what we actually did.

 

[Noyac]

well, I would probably proceed with a combo FNB/Sciatic block with some fast acting mepivicaine. If not dense enough, I'd put him to sleep for the short case. And get this, I'd use an LMA if he hasn't eaten in the recent past even though he is not considered NPO. The LMA would be something I'd decide on in the moment. Unless there is something in the H&P you didn't tell me about like morbid obesity with Qday GERD on meds, N/V currently, etc.

 

[bullard]

Fem/psiatic is probably best bet, but I think GA is perfectly defensible as long as you 1) beta-block well perioperatively and 2) use neo to avoid hypotension b/c of the severe AS

 

[VolatileAgent]

well, I would probably proceed with a combo FNB/Sciatic block with some fast acting mepivicaine. If not dense enough, I'd put him to sleep for the short case. And get this, I'd use an LMA if he hasn't eaten in the recent past even though he is not considered NPO. The LMA would be something I'd decide on in the moment. Unless there is something in the H&P you didn't tell me about like morbid obesity with Qday GERD on meds, N/V currently, etc.

we use mepivicaine/tetracaine mix with clonidine added in. often use a femoral catheter with a single-shot sciatic block. if really concerned about significant post-op pain, we even do lumbar plexus catheters. however, since ortho generally wants them to get up and move within 24 hours, we try to do minimal regional and often single-shots. with a lumbar plexus catheter, you get a pretty profound and dense sensory and motor block in the affected extremity. this is good if they are going to put them on a ROM exerciser for a day or two.

the nice thing is, if you get them in the pre-op area with a good dense block, you can do the case with sedation only. this minimizes the amount of GA you have to give during the case. i'd have at least one large bore IV too because sometimes these cases can be a little bloody, even with the tourniquet. also important to make sure the patient has been dialyzed before the case and you've got a good grasp on their fluid status, crit, etc.

 

[InGasWeTrust]

Pent, sux, tube.....Next case!

 

[Noyac]

Pent, sux, tube.....Next case!

Yeah, but I get nervous with K above 5. I saw one pt in residency code with a K of 5.1 and given sux. I remember starting a case when they started to resuscitate the pt in the next room. I finished the case (about an hour later) and they were still resuscitating.😱 I know 5.1 is normal but thats just me.

 

[Planktonmd]

Femoral block and lateral popliteal block both single shot, with a mixture of Bupivacaine 0.5 % and lidocaine 2 %, 20 cc each.

 

[urgewrx]

Put A-line. Start Neo drip. Place contineous spinal catheter. Position pt. Titrate LA slowly with tight bp control.



BTW, what is s/p DES x4?

 

[urgewrx]

Pent, sux, tube.....Next case!

Pent wiith that tight AS? That's asking for the pt to code.

 

[Noyac]

Pent wiith that tight AS? That's asking for the pt to code.

Not the tightest AS that I have seen, not even recently. And mixed well with Neo, you can do it. I prefer propofol.😱

 

[jetproppilot]

79M with CAD c/b MI x 2, s/p DES x 4 (within last 5y), LVEF 15-20%, AS with AVA 0.75 cm2, mean gradient 23, peak 49, ESRD on HD, s/p AICD, PVD with gangrenous L foot. Surgeon wants to do BKA, and to speed things along says he will tie vessels and use bipolar so we don't have to wait for cardiology to turn off AICD. It's 10 pm, and the cardiology fellow is hung up with an MI in the ER, and has a decompensating CCU patient in need of a Swan.
Our patient is hemodynamically stable, and not sick. Doesn't complain of ever having CP/SOB/syncope, but mobility is poor. Foot causes him a lot of pain, difficult to move him around without discomfort. Labs look okay. Good H/H/PLT, K 5.0, coags wnl. ECG sinus rhythm with nstwa. Good airway. Preop vitals 91/50 62 on the chart. On arrival to the room was 124/77 85.

How would you do this case?

After a few comments, I'l post what we actually did.

Routine GETA with LMA unless LMA strongly contraindicated.

 

[urgewrx]

Not the tightest AS that I have seen, not even recently. And mixed well with Neo, you can do it. I prefer propofol.😱

What's the tightest you have seen?


I'm not saying you cannot do it, but you are adding another hole on the swiss cheese model.


Swiss cheese model: http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html, in case someone is wondering.

 

[UTSouthwestern]

What's the tightest you have seen?


I'm not saying you cannot do it, but you are adding another hole on the swiss cheese model.


Swiss cheese model: http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html, in case someone is wondering.

0.29 cm2 (0.34 by continuity). with a peak grad of 72 mm Hg. Guy was incredibly well compensated lifelong farmer, age 85. Came in with complaints of swelling in his legs, thinking it is because of something he ate and buys an AVR. Went back to farming after he left the hospital and still sends me and the CT surgeon a Christmas pack of veggies and steaks each year.

 

[stanleykristian]

I would do a femoral and lateral popliteal block as one has already stated. MASK or LMA if it gets unpleasant for the patient.

 

[urgewrx]

0.29 cm2 (0.34 by continuity).

Damn!! Was he a midget?

 

[Noyac]

Yeah, thats pretty tight UT. Definitely had a few in that ballpark in my first gig but now the good life has me protected by mostly healthy folks. We do get the occasional 70 -90 yo pt complaining that they can't hike as long as they could a few years back. Echo shows severe AS. Pts are dumbfounded. Still they are fit somewhat.

 

[powermd]

What we did:

Cardiology showed up at the last minute and shut off the AICD. We slapped on some R2 pads and hooked up the defibrillator. Our overnight attending was uncomfortable with peripheral blocks, so that was out. My choice would have been popliteal + femoral and some midazolam. Instead we placed a brachial a-line (no radial territory available, scarred over from previous fiddling), did an epidural, and titrated it up carefully while running phenylephrine to keep BP ~115/50. In the epidural, we gave 100 mcg fentanyl, then 2% lido/bicarb/epi in 3 cc increments every 5 minutes. By 9 cc we had a lower extremity sensory block, and went ahead with surgery. Aside from frequent boluses of phenylephrine and adjustments to the drip, the case was uneventful. The phenylephrine had to be continued for about an hour in the PACU. Blood loss was only about 100 cc.

DES = drug eluting stent.

I wasn't particularly impressed by the AS due to the low gradient until I saw the 15-20% EF. I would think the gradient would be a poor reflection of the severity of the AS in the setting of a low EF. Anyone care to comment?

 

[Noyac]

I find that the popliteal may frequently not cover the surgical area. Therefore, I do sciatic blocks in these cases. If you are amputating just below the knee the popliteal will not work. If you are amputating around the ankle then it will most likely work.

Nice job with the epidural by the way.

 

[Planktonmd]

I find that the popliteal may frequently not cover the surgical area. Therefore, I do sciatic blocks in these cases. If you are amputating just below the knee the popliteal will not work. If you are amputating around the ankle then it will most likely work.

Nice job with the epidural by the way.

The popliteal does work if you place it correctly 8 cm above the popliteal fossa crease, before the nerve bifurcates, and you don't have to change the patient's position between the femoral and popliteal.

 

[urgewrx]

... AS due to the low gradient until I saw the 15-20% EF. I would think the gradient would be a poor reflection of the severity of the AS in the setting of a low EF. Anyone care to comment?

You are right. In poor EF gradients are not good. Valve area is better.

 

[deleted59964]

hi all, i'm a med student, just wondering - why the LMA, what's the advantage over putting in an ETT in this patient?
thanks

 

[core0]

What we did:

Cardiology showed up at the last minute and shut off the AICD. We slapped on some R2 pads and hooked up the defibrillator. Our overnight attending was uncomfortable with peripheral blocks, so that was out. My choice would have been popliteal + femoral and some midazolam. Instead we placed a brachial a-line (no radial territory available, scarred over from previous fiddling), did an epidural, and titrated it up carefully while running phenylephrine to keep BP ~115/50. In the epidural, we gave 100 mcg fentanyl, then 2% lido/bicarb/epi in 3 cc increments every 5 minutes. By 9 cc we had a lower extremity sensory block, and went ahead with surgery. Aside from frequent boluses of phenylephrine and adjustments to the drip, the case was uneventful. The phenylephrine had to be continued for about an hour in the PACU. Blood loss was only about 100 cc.

DES = drug eluting stent.

I wasn't particularly impressed by the AS due to the low gradient until I saw the 15-20% EF. I would think the gradient would be a poor reflection of the severity of the AS in the setting of a low EF. Anyone care to comment?

Just out of curiousity why do you have cardiology turn off the AICD. We have the rep do it. Then they interrogate it at the end and turn it back on. Never even call cardiology. We also do not put defib on but we are doing sedation not anesthesia. We do these in the hospital not the AEC so we could have anesthesia and cardiology there pretty quick if we need them.

David Carpenter, PA-C

 

[Planktonmd]

hi all, i'm a med student, just wondering - why the LMA, what's the advantage over putting in an ETT in this patient?
thanks

Less stimulation to airway resulting in less need for deep anesthesia for maintenance, and in this guy the less anesthesia you give the better he will be hemodynamically.

 

[UTSouthwestern]

Yeah, thats pretty tight UT. Definitely had a few in that ballpark in my first gig but now the good life has me protected by mostly healthy folks. We do get the occasional 70 -90 yo pt complaining that they can't hike as long as they could a few years back. Echo shows severe AS. Pts are dumbfounded. Still they are fit somewhat.

I was there when we did the TTE on this guy and everyone was suprised. More suprised that his ascending aorta was only mildly dilated, given that gradient and the eccentricity of the jet.

He has an angel on his shoulder.

 

[BLADEMDA]

The popliteal does work if you place it correctly 8 cm above the popliteal fossa crease, before the nerve bifurcates, and you don't have to change the patient's position between the femoral and popliteal.

Lumbar Plexus plus classic Labat Sciatic Block. Done hundreds with excellent success rate (99%).

Blade

 

[powermd]

Just out of curiousity why do you have cardiology turn off the AICD. We have the rep do it. Then they interrogate it at the end and turn it back on. Never even call cardiology. We also do not put defib on but we are doing sedation not anesthesia. We do these in the hospital not the AEC so we could have anesthesia and cardiology there pretty quick if we need them.

David Carpenter, PA-C

At Columbia the EP fellow reprograms all the AICD/PMs during the day, the cardiology fellow does this at night. How many reps are around your hospital at 10-11pm on a Friday night?

 

[Noyac]

The popliteal does work if you place it correctly 8 cm above the popliteal fossa crease, before the nerve bifurcates, and you don't have to change the patient's position between the femoral and popliteal.

I do my popliteal's at 9cm above the crease. But if the amputation is just below the knee they may feel it. I do a FNB and then drop down to the sciatic from the anterior approach without changing the pts position from the FNB. In my hands this is much better and more dense.

 

[deleted59964]

Less stimulation to airway resulting in less need for deep anesthesia for maintenance, and in this guy the less anesthesia you give the better he will be hemodynamically.

thanks plankton😎

 

[Planktonmd]

I do my popliteal's at 9cm above the crease. But if the amputation is just below the knee they may feel it. I do a FNB and then drop down to the sciatic from the anterior approach without changing the pts position from the FNB. In my hands this is much better and more dense.

That's a nice way to do it if you are good at doing anterior approach sciatic blocks.

 

[core0]

At Columbia the EP fellow reprograms all the AICD/PMs during the day, the cardiology fellow does this at night. How many reps are around your hospital at 10-11pm on a Friday night?

As many as we want. You pick up the phone and the rep shows up. Every once and a while during the day you might have to wait if all the reps were doing something. We very occasionally have to delay a case if all the reps are working. If the cardiologist had to show up to turn off an AICD in private practice I would guess that there would be a dramatic decline in the use of that particular AICD.

David Carpenter, PA-C

 

[Noyac]

That's a nice way to do it if you are good at doing anterior approach sciatic blocks.

I'm getting better and better every time I do one.😀

Really, they are easy and worth trying.

 

[Noyac]

That's a nice way to do it if you are good at doing anterior approach sciatic blocks.

I'm getting better and better every time I do one.😀

Really, they are easy and worth trying. I use the FNB and the anterior sciatic block for all my ACL repairs now.

 

[Unconscious]

Did a similar case not too long ago, (guillatine amp.) tough AS was not as bad (I believe Area at 0.8-0.9) did it with unilateral spinal using hyperbaric 0.5% bupiv (1.6 mL) pt did beautifully.
My Attending have done tons of those. Otherwise I would have done Sciatic/FNB.
Good case 👍

 

[urgewrx]

hyperbaric 0.5% bupiv (1.6 mL)

I didn't know that was on the market. Did you mix it up yourself? How?

I only know of .75 hyperbaric bupi, or .5 plain bupi. If you add glucose to the .5 bupi then it is not .5 anymore.

 

[Unconscious]

I didn't know that was on the market. Did you mix it up yourself? How?

I only now of .75 hyperbaric bupi, or .5 plain bupi. If you add glucose to the .5 bupi then it is not .5 anymore.

Sorry, my bad!, I miss quoted myself, I ment to write 0.75%😳

 

[maximuum]

Thought I would post a quick reply since I had a very similar case last night. I am an intern currently on vascular surgery, and I learned last night never to take the vascular pathology lightly. We had a 75 yo M s/p MI x 3, 5 vessel CABG with an EF of 15% who underwent a left BKA under general about 5 days ago. The stump necrosed, and last night he went for a revision to an above the knee amputation. On the floors the last couple days, he had some issues with renal insufficiency (Cr increased to 2.0 from a baseline of 1.1) and a bicarb of 17 on a basic. He was also hyponatremic secondary to his CHF w/ a Na of 129. The surgeon who did his case decided late in the day he wanted to take him back that day (while he was being evaluated for renal insufficiency by nephrology). No regional technique. On induction with etomidate, ended up going into asystole and dying.

 

[Planktonmd]

Thought I would post a quick reply since I had a very similar case last night. I am an intern currently on vascular surgery, and I learned last night never to take the vascular pathology lightly. We had a 75 yo M s/p MI x 3, 5 vessel CABG with an EF of 15% who underwent a left BKA under general about 5 days ago. The stump necrosed, and last night he went for a revision to an above the knee amputation. On the floors the last couple days, he had some issues with renal insufficiency (Cr increased to 2.0 from a baseline of 1.1) and a bicarb of 17 on a basic. He was also hyponatremic secondary to his CHF w/ a Na of 129. The surgeon who did his case decided late in the day he wanted to take him back that day (while he was being evaluated for renal insufficiency by nephrology). No regional technique. On induction with etomidate, ended up going into asystole and dying.

Was that Etomidate + Sux?

 

[Unconscious]

Thought I would post a quick reply since I had a very similar case last night. I am an intern currently on vascular surgery, and I learned last night never to take the vascular pathology lightly. We had a 75 yo M s/p MI x 3, 5 vessel CABG with an EF of 15% who underwent a left BKA under general about 5 days ago. The stump necrosed, and last night he went for a revision to an above the knee amputation. On the floors the last couple days, he had some issues with renal insufficiency (Cr increased to 2.0 from a baseline of 1.1) and a bicarb of 17 on a basic. He was also hyponatremic secondary to his CHF w/ a Na of 129. The surgeon who did his case decided late in the day he wanted to take him back that day (while he was being evaluated for renal insufficiency by nephrology). No regional technique. On induction with etomidate, ended up going into asystole and dying.

what was the K?, did they use sux?

 

[joshmir]

Noy-

in your post re the BKA, you said you'd use an LMA if the pt was not


"Qday GERD on meds"

can I ask you to detail what you were implying?

ie, do you ask specifically if the GERD wakes them from sleep? do you ask them if they taste bile whenever they lie down? what specific question do you ask to assess the nature of the GERD? what answer changes your management?

how about lack of GERD symtoms but hx of hiatal hernai or gastric banding/bypass?


if someone was having those problems, and NOT on meds, one may believe they can reduce the risk of aspiration pneumonia with pepcid/bicitra/reglan.

are you implying that fact that they are on medication AND still having problems is significantly worse (compared to someone describing the above symptoms and not receiving concurrent GERD tx), and that pepcid/bicitra/reglan would not have much hope of decreasing the theoretical risk of aspiration pneumonia?

thx!

 

[Noyac]

Noy-

in your post re the BKA, you said you'd use an LMA if the pt was not


"Qday GERD on meds"

can I ask you to detail what you were implying?

ie, do you ask specifically if the GERD wakes them from sleep? do you ask them if they taste bile whenever they lie down? what specific question do you ask to assess the nature of the GERD? what answer changes your management?

how about lack of GERD symtoms but hx of hiatal hernai or gastric banding/bypass?


if someone was having those problems, and NOT on meds, one may believe they can reduce the risk of aspiration pneumonia with pepcid/bicitra/reglan.

are you implying that fact that they are on medication AND still having problems is significantly worse (compared to someone describing the above symptoms and not receiving concurrent GERD tx), and that pepcid/bicitra/reglan would not have much hope of decreasing the theoretical risk of aspiration pneumonia?

thx!

Yes, someone who is being treated for GERD (ie: pepcid, nexium, etc) who still has symptoms is a higher risk than someone treated and having no symptoms. Aside from this case, if I have a pt who is NPO coming for same day surgery who takes nexium and has no symptoms but does have symptoms off the nexium I consider them not to have GERD any longer if they are taking their meds.

I ask about heartburn, meds for heartburn (even TUMs, rolaides), heartburn with only certain foods (I don't consider occasional heartburn with red chili as a problem). I ask if they can recline after a big meal, however I don't really know if this means much. But I have had pts say they don't get heartburn as long as they don't lie down after dinner.

If they are truely NPO and don't get daily GERD sx's then I don't get too excited.

The reglan, bicitra, pepcid combo may be beneficial but I am not a big user of these meds. I don't even give bicitra to my c/s pts unless they are activily having heartburn. I just love it when the nurse runs in the room just b/4 getting started on the c/s and says "wait, she didn't get her bicitra".😱

If they have had HH repair and have no sx's then they don't have GERD in my book. I guess I would consider gastric banding (not a fix for GERD) in the same category, no sx's = no GERD. But HH repairs frequently fix the GERD problem.

Another side note in all of this. I don't mask the pts very long b/4 placing the LMA especially if they are difficult to mask (rarely). I don't want any air in the stomach. It can increase the risk of reflux and PONV. I usually induce and give them about a minute or so (sometimes less) without breathing for them, letting the propofol sink in and then placing the LMA.

How's that?

 

[VentdependenT]

Fem Sci with 0.5% ropivicaine 40ML in the butt. 50/50 Lidocaine 2% and Ropivicaine 0.5% with 20 ML on the inguinal side.

1 of versed in the O.R.

Bring the fentanyl & ketamine along for the ride if need be.

If not comfortable with above then an epidural is acceptable as is an LMA. Just keep in mind to to keep afterload and HR as stable as preop status = Reasonable fluid bolus up front with neosynephrine on hand and SLOW titration of induction agent which can be supported with mask inhalation.

For the epidural I'd titrate in 7ml bumps of 2% lido with bicarb every 5-10 minutes until desired sensory level.


I think the A-Line can and should be argued for the LMA because of induction. Perhaps for the epidural, but I wouldn't let a LACK of one preclude me from doing the case.

 

[VentdependenT]

Pent, sux, tube.....Next case!

LMAO.

 

[VentdependenT]

Femoral block and lateral popliteal block both single shot, with a mixture of Bupivacaine 0.5 % and lidocaine 2 %, 20 cc each.

Plank, you give em 40ml on each side or what? My attendings vary on volume with some giving 30-40ml in the sci and anywhere from 10-40ml for the femoral.

Personally, in my limited experience, I find that the volume really covers your tail.

I do like the mix of ropi and lido for onset and toxicity profiles.

 

[Planktonmd]

Plank, you give em 40ml on each side or what? My attendings vary on volume with some giving 30-40ml in the sci and anywhere from 10-40ml for the femoral.

Personally, in my limited experience, I find that the volume really covers your tail.

I do like the mix of ropi and lido for onset and toxicity profiles.

20 cc each.

 

[jetproppilot]

Yes, someone who is being treated for GERD (ie: pepcid, nexium, etc) who still has symptoms is a higher risk than someone treated and having no symptoms. Aside from this case, if I have a pt who is NPO coming for same day surgery who takes nexium and has no symptoms but does have symptoms off the nexium I consider them not to have GERD any longer if they are taking their meds.

I ask about heartburn, meds for heartburn (even TUMs, rolaides), heartburn with only certain foods (I don't consider occasional heartburn with red chili as a problem). I ask if they can recline after a big meal, however I don't really know if this means much. But I have had pts say they don't get heartburn as long as they don't lie down after dinner.

If they are truely NPO and don't get daily GERD sx's then I don't get too excited.

The reglan, bicitra, pepcid combo may be beneficial but I am not a big user of these meds. I don't even give bicitra to my c/s pts unless they are activily having heartburn. I just love it when the nurse runs in the room just b/4 getting started on the c/s and says "wait, she didn't get her bicitra".😱

If they have had HH repair and have no sx's then they don't have GERD in my book. I guess I would consider gastric banding (not a fix for GERD) in the same category, no sx's = no GERD. But HH repairs frequently fix the GERD problem.

Another side note in all of this. I don't mask the pts very long b/4 placing the LMA especially if they are difficult to mask (rarely). I don't want any air in the stomach. It can increase the risk of reflux and PONV. I usually induce and give them about a minute or so (sometimes less) without breathing for them, letting the propofol sink in and then placing the LMA.

How's that?

Very nice. 👍

Totally agree with you Noy.

 

[fval28]

I think you did the patient a great service by doing a regional technique as opposed to straight general- the incidence of phantom limb pain is lower in patients who have a peripheral or neuraxial blockade of sympathetics- I cna't remember the exact references (and I'm too lazy yo look them up right now) but I believe most of the current thinking regarding phantom limb pain follows the general plan you put forth- nice work.

 

[maximuum]

Sorry for the delay on the reply. K was 4.1, cisatracurium was used for NMB. Required multiple doses of phenylephrine, and was finally started on an epinephrine gtt. TEE intraop showed hypokinetic inferior wall and EF of 10% at best.

 

[Jeff05]

as long as you maintain adequate afterload and beta-blockade it doesn't matter if you do regional vs. general (study of around 400 vasculopaths for lower ext. vascular procedures in mid 90s).

i would lean towards a tube (vs LMA) - ESRD and IDDM (he had that right?) and the fact that if this guy aspirates, he's done.

the technique you described with neo and epidural was slick.