Case from monday

[toughlife]

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50 y/o female s/p heart transplant 2/2 rheumatic heart disease now with pheochromocytoma admitted for laparoscopic left adrenalectomy. Other PHMX + for HTN, HPL, DM II.

Patient on doxazosin preop. On DOS, patient tubed, a-line and right IJ placed, esmolol and SNP gtts ready.

Case uneventful except for some HTN during manipulation of tumor. Patient extubated and taken to PACU. One hour later, patient bradies down to 30s, and hypotensive. Transcutaneous pacer placed and isoproterenol gtt started.

Once isoproterenol running, patient HR now in the 100s. Today, patient in SICU still unable to be weaned off isoproterenol.

 

[Planktonmd]

50 y/o female s/p heart transplant 2/2 rheumatic heart disease now with pheochromocytoma admitted for laparoscopic left adrenalectomy. Other PHMX + for HTN, HPL, DM II.

Patient currently on doxazosin. On DOS, patient tubed, a-line and right IJ placed, esmolol and SNP gtts ready.

Case uneventful except for some HTN during manipulation of tumor. Patient extubated and taken to PACU. One hour later, patient bradies down to 30s, and hypotensive. Transcutaneous pacer placed and isoproterenol gtt started.

Once isoproterenol running, patient HR now in the 100s. Today, patient in SICU still unable to be weaned off isoproterenol.

Wow! that is a real zebra.
Her transplanted heart is used to the high concentration of circulating cathecolamines from the pheo, and the cardiac beta receptors are down regulated.
It will take time for those receptors to recover, so she now needs a permanent pace maker.

 

[johankriek]

wow what a case.. whats the chance of getting a heart transplant which is sufficiently rare.. then having a pheochromocytoma which is even more rare.... wow..

 

[johankriek]

Wow! that is a real zebra.
Her transplanted heart is used to the high concentration of circulating cathecolamines from the pheo, and the cardiac beta receptors are down regulated.
It will take time for those receptors to recover, so she now needs a permanent pace maker.

nice explanation.. ill buy it for a buck..

 

[UTSouthwestern]

Wow! that is a real zebra.
Her transplanted heart is used to the high concentration of circulating cathecolamines from the pheo, and the cardiac beta receptors are down regulated.
It will take time for those receptors to recover, so she now needs a permanent pace maker.

Bingo, although I doubt the patient will need a permanent pacemaker. A prolonged weaning process will likely be necessary though.

 

[Noyac]

Just curious, did the isoproterenol not work well enough or did you guys go straight to the internal pacer?

I wonder if epi would have worked?

 

[VentdependenT]

Just curious, did the isoproterenol not work well enough or did you guys go straight to the internal pacer?

I wonder if epi would have worked?

Milrinone and DA?

 

[Noyac]

Milrinone and DA?

yeah, basically anything that gets the HR up.

 

[UTSouthwestern]

Milrinone and DA?

Milrinone would be unnecessary unless the patient specifically requires inotropic support in addition to chronotropic support.

 

[Mman]

Did you give any neostigmine for reversal? There are case reports of asystole in transplanted hearts with neostigmine, though I would think it would be more of an immediate effect rather than a late effect but who knows.

Heard of a case of a patient that got Neostigmine a few years after heart transplant and required isopreterenol for 18 hours postop to maintain HR > 60.

 

[toughlife]

Just curious, did the isoproterenol not work well enough or did you guys go straight to the internal pacer?

I wonder if epi would have worked?

Well, the pacer went on first and then the isoproterenol gtt. The pacer was transcutaneous. I don't think epi was tried. The preop stress test showed pt had EF 50-55% so there were no concerns for inotropic support and once her heart rate went up with isoprot, her BP was WNL.

 

[toughlife]

Did you give any neostigmine for reversal? There are case reports of asystole in transplanted hearts with neostigmine, though I would think it would be more of an immediate effect rather than a late effect but who knows.

Heard of a case of a patient that got Neostigmine a few years after heart transplant and required isopreterenol for 18 hours postop to maintain HR > 60.

Yeah, i gave 3mg. Interesting if that was the case in this patient. I will stop by the SICU tomorrow to check on her.

 

[jetproppilot]

50 y/o female s/p heart transplant 2/2 rheumatic heart disease now with pheochromocytoma admitted for laparoscopic left adrenalectomy. Other PHMX + for HTN, HPL, DM II.

Patient on doxazosin preop. On DOS, patient tubed, a-line and right IJ placed, esmolol and SNP gtts ready.

Case uneventful except for some HTN during manipulation of tumor. Patient extubated and taken to PACU. One hour later, patient bradies down to 30s, and hypotensive. Transcutaneous pacer placed and isoproterenol gtt started.

Once isoproterenol running, patient HR now in the 100s. Today, patient in SICU still unable to be weaned off isoproterenol.

😱

i really don't miss those cases. Actually I did a fellowship in LEFT SIDED knee arthroscopy anesthesia.

 

[toughlife]

😱

i really don't miss those cases. Actually I did a fellowship in LEFT SIDED knee arthroscopy anesthesia.

Well, for right now I feel like a kid in a candy store trying to learn from every weird case I see.

Maybe when I become a vet like all of you, I will want to take it easy. Good learning case for me though. Lucky I ended up with it as a newbie.

 

[DrDre']

I had a lap adrenalectomy for pheo the other day. I was all excited. Read up on it. We lined her up and that was the last of the excitement. There were no unusual derangements. Alpha blockade preop kicks arse.


Oh well, maybe I will get an unstable pheo some day to make up for it!

50 y/o female s/p heart transplant 2/2 rheumatic heart disease now with pheochromocytoma admitted for laparoscopic left adrenalectomy. Other PHMX + for HTN, HPL, DM II.

Patient on doxazosin preop. On DOS, patient tubed, a-line and right IJ placed, esmolol and SNP gtts ready.

Case uneventful except for some HTN during manipulation of tumor. Patient extubated and taken to PACU. One hour later, patient bradies down to 30s, and hypotensive. Transcutaneous pacer placed and isoproterenol gtt started.

Once isoproterenol running, patient HR now in the 100s. Today, patient in SICU still unable to be weaned off isoproterenol.

 

[Noyac]

😱

i really don't miss those cases. Actually I did a fellowship in LEFT SIDED knee arthroscopy anesthesia.

Dude, I did the fellowship for the RIGHT SIDE.

We would make a great team.