Case for Monday

[proman]

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Tomorrow morning I'm doing a pulmonary lobectomy. Interested in how people would approach this case:

60 year old female, 2 months ago had an inferior AMI, s/p bare metal stent. EF peri-MI was 30%, repeat EF one month ago was 50%. Lung mass diagnosed during workup of MI. Other PMH only significant for hypertension, hyperlipidemia. Meds include Toprol, ASA and Plavix. Plavix was stopped 1 week ago.

 

[2win]

Tomorrow morning I'm doing a pulmonary lobectomy. Interested in how people would approach this case:

60 year old female, 2 months ago had an inferior AMI, s/p bare metal stent. EF peri-MI was 30%, repeat EF one month ago was 50%. Lung mass diagnosed during workup of MI. Other PMH only significant for hypertension, hyperlipidemia. Meds include Toprol, ASA and Plavix. Plavix was stopped 1 week ago.

In order to elaborate I think that there is one question that has to be answered - where is the mass? main bronchus involvement?
Otherwise you know the drill...

 

[proman]

In order to elaborate I think that there is one question that has to be answered - where is the mass? main bronchus involvement?
Otherwise you know the drill...

Right upper lobe. Wedge resection not an option. What's your drill?

 

[seinfeld]

If you trust the surgeon then 2 large bore IV's, Aline, Left side double lumen tube, epidural. If doesnt look like easy IV access then introducer.

 

[2win]

Right upper lobe. Wedge resection not an option. What's your drill?

Decrease anxiety preop, a line, good peripheral access, check the meds am, thoracic epidural, smooth induction, DLT...
I mean that I don't see anything special to do in this case compared with any lobectomies except the stent/plavix forever dillema, starting the post op plavix and so on...
BTW the decision about the neuoro axial technique has to be done with the cardiologist consult. If they want to start the plavix ASAP after the surgery - my good sense (not the available data) is telling me to ask the surgeon to do an intercostal block. To be repeated if necessary (pain not controlled by narcotics or major side effects from them) q 12h. And I'll forget about the epidural.

 

[SleepIsGood]

Decrease anxiety preop, a line, good peripheral access, check the meds am, thoracic epidural, smooth induction, DLT...
I mean that I don't see anything special to do in this case compared with any lobectomies except the stent/plavix forever dillema, starting the post op plavix and so on...
BTW the decision about the neuoro axial technique has to be done with the cardiologist consult. If they want to start the plavix ASAP after the surgery - my good sense (not the available data) is telling me to ask the surgeon to do an intercostal block. To be repeated if necessary (pain not controlled by narcotics or major side effects from them) q 12h. And I'll forget about the epidural.

Why not do the epidural since the plavix is stopped. You can use the epidural in order to decrease your MAC requirements etc intraop. Dose the epidural wth some good fent/morphine,etc for post op pain. If they really want to restart plavix, you can always pull it out after you gave a nice dose of morphine,etc. Intercostal nerve block is just not good enough.

 

[2win]

Why not do the epidural since the plavix is stopped. You can use the epidural in order to decrease your MAC requirements etc intraop. Dose the epidural wth some good fent/morphine,etc for post op pain. If they really want to restart plavix, you can always pull it out after you gave a nice dose of morphine,etc. Intercostal nerve block is just not good enough.

Why to decrease the MAC requirements?
And here we go - cardioprotective effects of volatile anesthetics...
Most of the time I prefer to don't have a hypotensive patient (gas+epidural) - and to titrate vasopressors. It's much easier to treat hypertension....
Regarding the epidural and plavix - I cannot substantiate with specific data my approach...
Agree that intercostal blocks are not so good as a well placed epidural but this is a way to reduce the pain. You can use a pleural catheter if you like...

 

[proman]

I think it's a good question. With an epidural you blunt the sympathetic response that could be detrimental from a myocardial oxygen consumption perspective. But, there's nothing we do can blunt the pro-coagulant effects of surgery. So maybe restarting the Plavix ASAP is a better approach.

This surgeon is good. We normally do 2 IVs and an a-line, DLT, thoracic epidural for our standard thoracotomy. He also places a pleural catheter in everyone. Our issue isn't epidurals not working, but the units running thoracic patients so dry their pressure tanks with the epidural.

 

[ultm8frisbee]

Why is he still on Plavix? Current AHA guidlines recommend 4 weeks of dual anitplatelet therapy, then ASA indefinetly. The data supports him not needing plavix anymore, I'd put an epidural in him. We also run into the same problems with hypotension post-op. I try to get the surgeons to give at least a touch of albumin and running very dilute .0625 bupi with higher conc. of narcotic, so as to reduce some of the hypotensive effects.

 

[SleepIsGood]

I cant think of the exact study....I think it came out last year. It compared pleural caths w/ epidurals. I believe it also looked at paravertebral blocks as well.

Basically, it showed that pleural caths dont really work tha well (chest tube sucks out the local anesthetic).

Now that I think about it, it was for prostate CA or breast CA surgery. They showed since epidural use decreases the immunosuppresive effects of anesthesia, there is apparently a decrease in cancer recurrence as well.

 

[aredoubleyou]

Guy had an ef of 30% during the MI chances are it was either a good sized MI or they got the echo as the MI was developing...more likely the former. I'd err on the side of blocking the catecholamine surge best I could with an epidural and hope that his remaining vessells are patent enough to tolerate 3 days of hypotension as hes run bone dry...Im sure the cardiologist has no clue that his DBP will be nearly nonexistant. Chances of acutley thrombosing a 2 month old bare metal stent is certainly not zero, but I think you still have a greater chance of morbidity on such a fresh heart with tachycardia and hypertension.

 

[cchoukal]

Why is he still on Plavix? Current AHA guidlines recommend 4 weeks of dual anitplatelet therapy, then ASA indefinetly.

I don't think this is true anymore. The current thinking is that the longer you're on dual agents, the better, regardless of whether your stent is bare metal or drug-eluting. As I recall, a couple studies were published in Anesthesiology in the last year looking at time of recurrent MIs, stent closures, etc. after stopping anti-platelet agents, and both stent types had a cutoff where the risks went down, but the step-off wasn't huge, and the upshot was "the longer the better."

 

[proman]

So far so good. Placed a T7-ish epidural with 2mg of midaz. Gently titrated induction, a line, 2 IVs. Was initially worried that I had placed a sham-dural since there was no sympathectomy or sensory level after the test dose, then finished off the 5cc after. No reaction to incision. Surgeon decided to try VATS first, got the RUL out after an hour. Nodes took about 30 more min. Ran her on 3/4 MAC, controlled hemodynamics with esmolol or phenylephrine. 150 mcg of fentanyl total. Took to the ICU (would have downgraded had a monitored bed been available). About 20 min before the end I gave 4 cc of bupi 0.125%, ordered a PCEA of bupi 0.125% with fentanyl 2mcg/ml 3/1/10/6 (mostly for anticipated BP issues). Pain service was called later and changed to 4/2/10/6. Saw her post-op, zero pain.