Case from last night

[ssmallz]

I know it's oral board season so I thought I'd post this case for everyone to discuss that was very similar to some of the oral board scenarios I saw when studying. I don't remember all the lab values exactly so I'm only going to list the important ones. I'd hope that some of the more senior attending could wait a bit to chime in so that residents others still studying for the orals have a chance to voice their opinions first.

72 y/o male here for a lap chole

PMH - s/p MIx2, DM, ESLD, cirrhotic liver. Hx of esophageal varies s/p banding, ascities, s/p AICD (pacer/shocker)

PE - External airway anatomy grossly normal, fumanchu mustache, MP3, good c-spine ROM, good TM dist. Pt states he is not very ambulatory, gets SOB < 4 mets, denies chest pain or SOB @ rest. Pts belly looks like he's 9 months pregnant, no LE edema noted. Pt denies hemotemesis since variceal banding

VS - 160/90, HR 70s, Sat 94% on RA

Labs - Chemistry mostly unremarkable, K+ 3.5, H/H 12/36, Plt - 47 but has just been transfused a unit on the floor. INR 1.27. Old stress test from 2007 states EF 25-30% no myocardium at risk, cardiology note confirms this. No echo on file but cards note states that he doesn't have any significant valvular disease. EKG - paced rythem. CXR unremarkable

Lines - 20g in R hand

Are you going to place an A-line? why/why not? If you plan on placing an a-line should you do it pre or post induction? What type of IV access do we need? Should we place a central line?

Do we need to worry about the AICD? Should we call cards to reprogram it?

How will you induce this patient? What are your concerns? How does his ESLD affect your choice of drugs? Nimbex is not stocked in your hospital, what is your choice of muscle relaxant?

Are there any special intraop concerns for this patient outside of the ordinary? How do you plan on manageing them?

Are there any drugs to avoid post op? How will you manage his pain?

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[deleted9493]

I've always enjoyed reading these threads--thank you for posting this scenario, ssmallz:


I would place a post-induction arterial line in this ascitic 72 year old for a laparoscopic procedure, anticipating some drop in preload with insufflation and liver eversion. Furthermore, since I'm reprogramming his pacer to not sense, I'd like a tighter monitor of hemodynamic stability whilst he's not compensating by HR (knowing nothing else of his rhythm). My induction would include the fentanyl for the case, small dose of propofol for amnesia and succynylcholine. I have no problem using vecuronium in this case for maintenance as its clearance remains reasonable until liver failure patients are really in extremis. No reason to obliterate twitches and not reverse at 4 on TOF, nevertheless.

No CVC. I'd feel more likely to cause a problem with the AICD than I would to actually need one. I prefer trending SPV for assessing fluid responsiveness, anyway. Anticipating need for volume replacement in the setting of ascites, I'd have some colloid on hand, a 2nd IV (18g or larger) and an infusion (phenylephrine or NE, don't feel strongly which) ready to kick up his SVR, if/when needed.

Special concerns? Varices. Hepatically-metabolized opioids. Bleeding diathesis.

 

[ssmallz]

I would place a post-induction arterial line in this ascitic 72 year old for a laparoscopic procedure, anticipating some drop in preload with insufflation and liver eversion. Furthermore, since I'm reprogramming his pacer to not sense, I'd like a tighter monitor of hemodynamic stability whilst he's not compensating by HR (knowing nothing else of his rhythm).

Interesting that you would want a post induction a-line after stating that you want tight control over the BP when the induction will be one of the most hemodynamically unstable periods of this case. Also remember that you are alone here so you don't have a resident/crna to push drugs and manage the BP while you do the A-line.

What are you going to reprogram the pacer to? It's 8 at night and there is no medtronic rep in house. Do we have any other alternatives to reprogram the pacer? EKG shows V paced rhythm @ 65

Will you RSI this pt because of aspiration concerns because of ascities and hx of varicies or not? If you RSI, how will you deal with hemodynamic instablitly? If not, how will you deal with increased risk of aspiration?

Not trying to pick on you hudson and I really appreciate your response, just trying to stimulate discussion

 

[deleted9493]

I did mention my reasons for an arterial line (release of ascites, insufflation, liver eversion). I can perform a rapid sequence in already stated fashion and monitor/treat significant hypotension by way of non-invasive measurements every minute and by physical exam findings. Yes, I could do so for the remainder of the case, as well. BUT, the arterial line gives me a continuous, objective monitor of pressure and in someone with high likelihood of sequelae from malperfusion, I'd opt for one.

Fear of hypotension is a poor reason to not perform an RSI. Inducing anesthesia results in hypotension--whether you do it quickly or slowly. If I see pathology in any patient that could predispose to aspiration, I flip the question on its head and ask, "why should I induce in a standard fashion?" Hypotension I can treat. Aspiration, I cannot.

If I know that it's a Medtronic pacer, I likely know the model. I will do due diligence and call for Medtronic's recommendation, regardless of convenience. I don't want to assume that the device is going to respond the way I want it to if/when I place a magnet on it. I also don't want to assume what its condition will be when the magnet is removed.

 

[dhb]

I know it's oral board season so I thought I'd post this case for everyone to discuss that was very similar to some of the oral board scenarios I saw when studying. I don't remember all the lab values exactly so I'm only going to list the important ones. I'd hope that some of the more senior attending could wait a bit to chime in so that residents others still studying for the orals have a chance to voice their opinions first.

72 y/o male here for a lap chole

PMH - s/p MIx2, DM, ESLD, cirrhotic liver. Hx of esophageal varies s/p banding, ascities, s/p AICD (pacer/shocker)

PE - External airway anatomy grossly normal, fumanchu mustache, MP3, good c-spine ROM, good TM dist. Pt states he is not very ambulatory, gets SOB < 4 mets, denies chest pain or SOB @ rest. Pts belly looks like he's 9 months pregnant, no LE edema noted. Pt denies hemotemesis since variceal banding

VS - 160/90, HR 70s, Sat 94% on RA

Labs - Chemistry mostly unremarkable, K+ 3.5, H/H 12/36, Plt - 47 but has just been transfused a unit on the floor. INR 1.27. Old stress test from 2007 states EF 25-30% no myocardium at risk, cardiology note confirms this. No echo on file but cards note states that he doesn't have any significant valvular disease. EKG - paced rythem. CXR unremarkable

Lines - 20g in R hand

Are you going to place an A-line? why/why not? If you plan on placing an a-line should you do it pre or post induction? What type of IV access do we need? Should we place a central line?

Do we need to worry about the AICD? Should we call cards to reprogram it?

How will you induce this patient? What are your concerns? How does his ESLD affect your choice of drugs? Nimbex is not stocked in your hospital, what is your choice of muscle relaxant?

Are there any special intraop concerns for this patient outside of the ordinary? How do you plan on manageing them?

Are there any drugs to avoid post op? How will you manage his pain?

Pre-induction a-line for sure 25%EF + potential for severe hypotension from vasoplegia d/t ESLD and ascitis. I would strongly consider draining the ascitis (easy under U/S).
No central line but a better peripheral, i wouldn't mind placing it after induction.
Normal induction with head up > 30°. Would try to avoid roc which has a biliary excretion.
I never use a BIS but in these encephalopatic patient it's kind of usefull to keep the gases down the main concern i think is hypotension d/t anti T berg and vasoplegia which i would treat with a low dose of norepi.

Avoid paracetamol post op he'll do fine with a strait morphine PCA.
Keep drugs to a minimim to avoid hepatotoxicity.

 

[MD Dreams]

Both individuals mentioned they may use norepinephrine but both felt central line was not necessary. I would go the more conservative route and put in a cordis. That way I can give fluids/bp fast and don't have to worry about a dinky peripheral line plus I'll have a way of giving norepinephrine, especially if he crumbs and I have to use large doses. I dont like giving norepinephrine through peripheral line.

 

[Mman]

Both individuals mentioned they may use norepinephrine but both felt central line was not necessary. I would go the more conservative route and put in a cordis. That way I can give fluids/bp fast and don't have to worry about a dinky peripheral line plus I'll have a way of giving norepinephrine, especially if he crumbs and I have to use large doses. I dont like giving norepinephrine through peripheral line.

Is a cordis really the "conservative route"? Seems a bit aggressive to me. Complication rate from placing a cordis isn't zero.

I'm not saying it's wrong. I'm just saying it's not exactly conservative either.

 

[dhb]

Both individuals mentioned they may use norepinephrine but both felt central line was not necessary.

There's norepi and NOREPI the doses you need in the OR to counter a little vasoplegia are not in the same league as what you use in the ICU for septic patients. I don't usually put a cordis to administer 10mg of ephedrine but that's just me.

 

[ssmallz]

Both individuals mentioned they may use norepinephrine but both felt central line was not necessary. I would go the more conservative route and put in a cordis. That way I can give fluids/bp fast and don't have to worry about a dinky peripheral line plus I'll have a way of giving norepinephrine, especially if he crumbs and I have to use large doses. I dont like giving norepinephrine through peripheral line.

I feel an argument can be made for a TLC because you want to run pressors but I feel a cordis is way overkill. Sure it's nice to give volume but why do you feel the need to give a ton of volume? You have a pt w/a poor heart and kidneys that are ok but not great. You've got a surgery with pretty minimal EBL and even if we open, we're gonna lose a ton of blood. This is the type of case where I feel you would want to limit fluids as much as possible and find alternative means to maintain BP because it would be very easy to fluid overload this guy and get him into CHF and pulm edema.

Would anyone use a CVP to monitor fluid status? How bout a flowtrack (SVV monitor)? Will urine output be useful in this pt?

 

[Mac4]

I have a very low threshold to place a central line on this type of patients (low EF. MIs etc). TLC works fine unless there is a chance for significant bleeding for which I put in QLC. I just feels better that I have secure IV accesses, can give vasopressors, and get labs if A-line goes out when taking care of these sick hearts in the regular ORs.

 

[Idiopathic]

central line absolutely indicated here, especially looking down the road and seeing that this guy has got 3 days minimum of admission following this and likely will have difficulty with access. i also feel comfortable with low dose NE through a good peripheral, but that usually means a 16g above the wrist - barring that, cvl in the neck is the play.

i also worry about fluid shifts here, depending on how bad his ascites is currently - essentially he will get it all drained with lap or open procedure and may get marked hypotension as he fills that space again. tank up with some NS early and colloid after that, he gets admitted to SICU following the case. im not going to trust absolute cvp number, but trends may be helpful, so yes it gets hooked up.

 

[Oggg]

What's QLC stand for? (TLC triple lumen catheter)

 

[MD Dreams]

central line absolutely indicated here, especially looking down the road and seeing that this guy has got 3 days minimum of admission following this and likely will have difficulty with access. i also feel comfortable with low dose NE through a good peripheral, but that usually means a 16g above the wrist - barring that, cvl in the neck is the play.

i also worry about fluid shifts here, depending on how bad his ascites is currently - essentially he will get it all drained with lap or open procedure and may get marked hypotension as he fills that space again. tank up with some NS early and colloid after that, he gets admitted to SICU following the case. im not going to trust absolute cvp number, but trends may be helpful, so yes it gets hooked up.

I like your thinking process. I was thinking along the same lines. Need CVL for the case and what may happen afterwards including large fluid shifts. I can appreciate that a Cordis may be overkill. In my hospital the only other option is the small triple lumens and those are a pain to give fluids through.

 

[Mac4]

What's QLC stand for? (TLC triple lumen catheter)

Quad-lumen catheter. It is basically a TLC plus one big 14G.