Case from yesterday.....

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ms1inmw

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Interesting times.....

80 year old man with COPD, CHF, CAD, pacemaker, acute on chronic kidney failure etc.

Fun part is pulmonary HTN with systomlic presure in the 80s by recent cath. Aortic stenosis with valve area of .7cm2.

Has a persistent pulmonary effusion with associated pneumothorax. Admitted twice in the last month for hypoxic repsiratory failure. Surgeon want to take him to the OR for thorascopy/talc pleurodesis; she is a big fan of one lung ventilation.

How to proceed??????
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palliative care consult, pleurex catheter

i would not do one lung ventilation in this patient, as its a setup for acute right heart failure at worst, severe hypoxemia at best. i do not think the patient would tolerate it long enough to allow for any procedures. if you could add 5 or 10 of CPAP to the down lung and your HPV were abolished, then perhaps your oxygenation wouldnt be quite that bad, but its not absolutely indicated here, so i would try to avoid it. Maybe short periods of hand ventilation while they work, but thats my take.

norepi and nitro in line, preinduction art line, could do it with peripherals, id probably put a line in, no PAC, echo available. if chf is bad enough, probably swings you towards a PAC from the start.

ideally the valve would be fixed first, but hes probably not a candidate
 
Idiopathic said:
palliative care consult, pleurex catheter

i would not do one lung ventilation in this patient, as its a setup for acute right heart failure at worst, severe hypoxemia at best. i do not think the patient would tolerate it long enough to allow for any procedures. if you could add 5 or 10 of CPAP to the down lung and your HPV were abolished, then perhaps your oxygenation wouldnt be quite that bad, but its not absolutely indicated here, so i would try to avoid it. Maybe short periods of hand ventilation while they work, but thats my take.

norepi and nitro in line, preinduction art line, could do it with peripherals, id probably put a line in, no PAC, echo available. if chf is bad enough, probably swings you towards a PAC from the start.

ideally the valve would be fixed first, but hes probably not a candidate
Click to expand...

I think a good discussion with the family and surgeon is warranted. Let the patient know they will be on a ventilator for a long time after this case is finished. It is important to be upfront so there are no surprises later like "why is my family member on a ventilator?".
 
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The part that concerns me the most is the acute on chronic RF part. That needs to be sorted out... perhaps even getting some short term dialysis.

Risk/Benefit discussion with all team members and family.

Pleurodesis cases are quick. Pleurex catheter would be my first choice... but if they fail (which they do)--> DLT, break up adhesions, talc... in and out.

Theis patient needs to keep his lung up. Air hunger is a terrible thing to live with.... even in the end.
 
Float a swan, run some NTG, get his PA's down, avoid all the stuff we are taught to avoid.

Worse case scenario, you pop up the down lung (after cpap, peep, etc).
 
caligas said:
GA + CHF/AS + NTG might cause some trouble.
Click to expand...

Yes yes yes... we know. PAC (or CVL) trickling NTG to the PA. As idio mentioned... epi/norepi handy. Keep you afterload up and your PA pressures down.

The GA part is everyday cardiac anesthesia.

Tomorrow is a AVR/CABG X4.... in CHF because of his AS. Optimized as best as possible. I won't even tell you the age of the patient. ;)
 
I agree with Sevo. The renal issue needs to be sorted out first.

AVA not too bad. Pulm HTN not too bad. Bet he will tolerate one lung okay given that he is walking around with barely more than one lung right now.

If you are worried about his PASP and the effect of NTG because of AS you could run the case on nitric oxide or flolan or just give him a sildenafil in preop. I bet his PASP doesn't budge until the lung is re-expanded and maybe not even then.

I would float a PAC into the PA feeding the ventilated lung (with TEE or fluoro) then run your pulmonary vasodilator of choice into that PA (or just hook up the nitric oxide). That should reduce the chance of abolishing desired HPV in the non-ventilated lung.

I hate intermittent ventilation of the operative lung as you lose your HPV, but I would let the surgeon know that this is a real possibility.

Patient may or may not require post-op ventilation. I would take a shot at extubation in the OR.

Of course a good discussion of end-of-life goals should be carried out with a patient and his physician (cough, stifle, cough) :laugh:. Ok, Ok this is America. Damn the torpedoes, full speed ahead.

- pod
 
periopdoc said:
I agree with Sevo. The renal issue needs to be sorted out first.

AVA not too bad. Pulm HTN not too bad. Bet he will tolerate one lung okay given that he is walking around with barely more than one lung right now.

If you are worried about his PASP and the effect of NTG because of AS you could run the case on nitric oxide or flolan or just give him a sildenafil in preop. I bet his PASP doesn't budge until the lung is re-expanded and maybe not even then.

I would float a PAC into the PA feeding the ventilated lung (with TEE or fluoro) then run your pulmonary vasodilator of choice into that PA (or just hook up the nitric oxide). That should reduce the chance of abolishing desired HPV in the non-ventilated lung.

I hate intermittent ventilation of the operative lung as you lose your HPV, but I would let the surgeon know that this is a real possibility.

Patient may or may not require post-op ventilation. I would take a shot at extubation in the OR.

Of course a good discussion of end-of-life goals should be carried out with a patient and his physician (cough, stifle, cough) :laugh:. Ok, Ok this is America. Damn the torpedoes, full speed ahead.

- pod
Click to expand...

im not sure i want any purely pulmonary vasodilators here, especially if the PHTN is 2/2 LV failure, as youll potentially just worsen your edema.
 
periopdoc said:
AVA not too bad. Pulm HTN not too bad. Bet he will tolerate one lung okay given that he is walking around with barely more than one lung right now.
- pod
Click to expand...

This. These patients get significantly better pulmonary numbers without the pleural effusions. The pulmonary hypertension will probably improve too.

Idiopathic said:
im not sure i want any purely pulmonary vasodilators here, especially if the PHTN is 2/2 LV failure, as youll potentially just worsen your edema.
Click to expand...

Pulmonary hypertension and one lung ventilation is a difficult combination because the pulmonary vasodilators abolish hypoxic pulmonary vasoconstriction. Can't have it both ways. The only thing I would consider in this case is selective administration of inhaled nitric oxide or Iloprost to the ventilated lung. I don't think I'd do a PA catheter for a case like this because of what Pod states above. Also, we don't know LVEF.
 
I would suggest doing it under light mac & local. PIV and that's it. Those are short cases.

With an inexperienced surgeon asking for ga, I would do aline, good iv, bronchial blocker, and echo. Can easily turn into an m&m.
 
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urge said:
I would suggest doing it under light mac & local. PIV and that's it. Those are short cases.

With an inexperienced surgeon asking for ga, I would do aline, good iv, bronchial blocker, and echo. Can easily turn into an m&m.
Click to expand...

VATS under local? educate me...
 
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urge said:
I would suggest doing it under light mac & local. PIV and that's it. Those are short cases.

With an inexperienced surgeon asking for ga, I would do aline, good iv, bronchial blocker, and echo. Can easily turn into an m&m.
Click to expand...

You can do pleurodesis via a chest tube but if he has loculations it won't work. Is this what you meant?
 
sevoflurane said:
Never done one under local alone. Sounds sketchy... but my N=0
Click to expand...

Putting the camera in is basically like a chest tube, but the white powder is a hell of a drug.
I had to smack the patient with 3-400mg of propofol , ketamine and fentanyl and he was still squirming...
 
Interesting thread, just curious on what y'all criteria are on putting in PAC's since everyone seems to have a different opinion
 
Idiopathic said:
VATS under local? educate me...
Click to expand...

Works well of those 35kg 100 yo pts. 1 of versed or your favorite drug. Local by surgeon. In goes the camera, look around & drain some fluid. Followed by the talc.
 
periopdoc said:
I would float a PAC into the PA feeding the ventilated lung (with TEE or fluoro) then run your pulmonary vasodilator of choice into that PA (or just hook up the nitric oxide).
Click to expand...

You're better off feeding the PAC into the nondependent lung and carefully inflating it if pt doesn't tolerate one lung very well. This will shunt most of the blood to the dependent side. Seen it done once.

But as others have said, I do not think this pt will do very well especially post op. These patients are very difficult to extubate even in the icu.
 
RxBoy said:
You're better off feeding the PAC into the nondependent lung and carefully inflating it if pt doesn't tolerate one lung very well. This will shunt most of the blood to the dependent side. Seen it done once.

But as others have said, I do not think this pt will do very well especially post op. These patients are very difficult to extubate even in the icu.
Click to expand...

if i have to internally occlude a distal PA to allow my patient to tolerate OLV then they can go to DLV
 
RxBoy said:
You're better off feeding the PAC into the nondependent lung and carefully inflating it if pt doesn't tolerate one lung very well. This will shunt most of the blood to the dependent side. Seen it done once.

But as others have said, I do not think this pt will do very well especially post op. These patients are very difficult to extubate even in the icu.
Click to expand...

I thought we were concerned about pulm htn. That will make it worse.

What you describe should work to improve saturation during OLV. You are playing with fire and risking a PA rupture. The surgeon can clamp the PA if he wishes to continue operating in a pt that is not tolerating the procedure. Honestly OLV is a luxury in my mind. I wouldn't risk the patient to give the best view possible so the surgeon can fool around for another 2hrs with the scope.
 
"I would float a PAC into the PA feeding the ventilated lung (with TEE or fluoro) then run your pulmonary vasodilator of choice into that PA (or just hook up the nitric oxide). That should reduce the chance of abolishing desired HPV in the non-ventilated lung."

Running the dilator through the yellow port of the PAC would work. Obviously, the next closest port (blue) is about 26 cm distal to that, so systemic infusion would be achieved if it or the white port were used.

Doing this would render the PAC readings faulty but you could at least watch for trends and respond appropriately.

"You're better off feeding the PAC into the nondependent lung and carefully inflating it if pt doesn't tolerate one lung very well. This will shunt most of the blood to the dependent side. Seen it done once."

I agree with the person who alluded to it being too risky from a PA rupture standpoint.

The surgeon wants OLV; he/she can clamp the bloody PA if shunting gets out of hand.

While we often think that merely writing things down in the chart as "...per surgeon request," it won't do a lot to help you in court if things go south. We're doctors, not nurses, and claiming that another doctor asked us (e.g. wedge the PAC for large part of the case) to do something is very different than when it's a nurse (of any type--CRNA included) making the same statement.
 
Work in a hospital that does no cardiac; so the likes of nitric oxide, TEE, and flolan are not around. I really felt that general anesthesia would be deadly; patient looked even worse in person than on paper.

Expressed concern with surgeon; casually hinted at a MAC. He had never done one; nor had I. But both of us were willing to give it a try.

Brought patient to OR. Positioned; touch of fentanyl and versed; local by surgeon; camera; talc. Case over.

Patient still going about trying to die; but at least we got in and out of OR.
 
Nice. :thumbup:

Never done one like that before. Any adhesions/loculations to take down? Painful?

Thx for sharing.
 
ms1inmw said:
Work in a hospital that does no cardiac; so the likes of nitric oxide, TEE, and flolan are not around. I really felt that general anesthesia would be deadly; patient looked even worse in person than on paper.

Expressed concern with surgeon; casually hinted at a MAC. He had never done one; nor had I. But both of us were willing to give it a try.

Brought patient to OR. Positioned; touch of fentanyl and versed; local by surgeon; camera; talc. Case over.

Patient still going about trying to die; but at least we got in and out of OR.
Click to expand...

Was doing it under MAC/local your plan all along? What if the surgeon said no, would you have canceled the case? I truly never thought this is even an option. This is why I keep coming back to SDN.
 
Nice Case.

There's no anesthesia like no anesthesia :)

Since the plan was MAC/local from the get go, what do you guys think of either a paravertebral or thoracic epidural (say they needed to do a fair amuont of loculation break-up)? Granted epidural would need to be slowly/cautiosly dosed given the AS.
 
PVB is a good idea. I would have started with that if I was going local/regional route. Nay on the epidural.
 
ms1inmw said:
Work in a hospital that does no cardiac; so the likes of nitric oxide, TEE, and flolan are not around. I really felt that general anesthesia would be deadly; patient looked even worse in person than on paper.

Expressed concern with surgeon; casually hinted at a MAC. He had never done one; nor had I. But both of us were willing to give it a try.

Brought patient to OR. Positioned; touch of fentanyl and versed; local by surgeon; camera; talc. Case over.

Patient still going about trying to die; but at least we got in and out of OR.
Click to expand...

F-in sweet; Gonna tuck this one away - thanks for the update, and thanks to urge for the cme.
 
No, I'm in San Diego. I took that quote from John Drummond. He's full of little jewels like that.
 
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