Case: OPCAB s/p plavix load

[deleted171991]

---

Members don't see this ad.

I sort of think you’re only getting the TEE expertise you need by doing a ACTA fellowship , unfortunately . Even cardiologists miss things like severe hypovolemia in my experience if they don’t do much time in the post bypass period.

Disagree. I trained in a place where one could do 2 months of echo. We probably did 100+ TEEs each, in the OR, that we also read and wrote reports on. One of us went on to become board-certified in TEE (after the ICU fellowship). Plus we reviewed a ton of TEEs/TTEs and focused TTE was a regular part of our point-of-care ultrasound exam in the ICU.

For ICU purposes, one doesn't even need much of the advanced echo knowledge. One just needs to know the postop complications, and be able to rule them out/quantify them and answer one's clinical questions. I may be wrong (I am not covering cardiac patients, thank Gods).

I (and many others) would be happy if cardiac anesthesiologists would follow their cardiac surgical patients in the ICU, for the first 24 hours or so, until all surgical complications are excluded, instead of intensivists (or surgeons). I would rather leave my job than work in the CTICU, that's how much I can't stand most cardiac surgeons.

 

[T-burglar]

Disagree. I trained in a place where one could do 2 months of echo. We probably did 100+ TEEs each, in the OR, that we also read and wrote reports on. One of us went on to become board-certified in TEE (after the ICU fellowship). Plus we reviewed a ton of TEEs/TTEs and focused TTE was a regular part of our point-of-care ultrasound exam in the ICU.

For ICU purposes, one doesn't even need much of the advanced echo knowledge. One just needs to know the postop complications, and be able to rule them out/quantify them and answer one's clinical questions. I may be wrong (I am not covering cardiac patients, thank Gods).

I (and many others) would be happy if cardiac anesthesiologists would follow their cardiac surgical patients in the ICU, for the first 24 hours or so, until all surgical complications are excluded, instead of intensivists (or surgeons). I would rather leave my job than work in the CTICU, that's how much I can't stand most cardiac surgeons.

Exceptions exist. I think the average ICU fellowship doesn’t even come close to the needed experience.

I would also love the latitude to dictate 100% the care of my fresh post ops. Less than half of my partners would like to do that though. I’m in a private practice. Right now it’s the midlevels managing things based on PAC numbers and ordering TEE from cardiology when they think it’s needed . That’s just how it is in a community practice, things are still going as if this was the golden age of heart surgery and TEE was brand new.

If we just had a probe that sat in the ICU that I could drop in any of my post ops whenever I wanted I would be very happy and injuries could be prevented.

 

[Psai]

Exceptions exist. I think the average ICU fellowship doesn’t even come close to the needed experience.

I would also love the latitude to dictate 100% the care of my fresh post ops. Less than half of my partners would like to do that though. I’m in a private practice. Right now it’s the midlevels managing things based on PAC numbers and ordering TEE from cardiology when they think it’s needed . That’s just how it is in a community practice, things are still going as if this was the golden age of heart surgery and TEE was brand new.

If we just had a probe that sat in the ICU that I could drop in any of my post ops whenever I wanted I would be very happy and injuries could be prevented.

The midlevels sometimes still use urine output to titrate inotropes. I could take care of those patients way better as a ca1 but I'm here to be in the OR.

 

[anbuitachi]

Major teaching point is that serious cardiac surgery should not be done in a place with an ICU run by amateurs/midlevels at night (which probably would eliminate 25-50% of the community hospices, I mean hospitals).

There should be a TEE/TTE-trained surgical intensivist in-house, to properly diagnose and manage the patient, and with the appropriate resources, not just "telemedicine" based on numbers (because this is 1988), by the cardiac surgeon. Cardiac (and not only) surgeons should stop practicing intensive care; they suck at it.

why surgical intensivist

 

[deleted171991]

why surgical intensivist

Because the medical ones don't properly know and look for the surgical complications.

 

[anbuitachi]

Because the medical ones don't properly know and look for the surgical complications.

Wait are you including anes intensivist as part of surgical or medical. at least at my institution most of the CTICU intensivists are anesthesiology ccm.

 

[deleted171991]

Anesthesiologists are typically trained as surgical intensivists.

 

[dchz]

I am still curious, if the pt needs CPB during the case. What is the appropriate amount of heparin (or perhaps other anticoags?) to give?

 

[anbuitachi]

I am still curious, if the pt needs CPB during the case. What is the appropriate amount of heparin (or perhaps other anticoags?) to give?

I think similar to without platelet inhibitors. it's still based on the ACT cut off.

 

[Ronin786]

I think similar to without platelet inhibitors. it's still based on the ACT cut off.

And you can always reverse the effect of heparin. Though I'd probably err on the side of a lower dose w/TEG directed supplementation given the anti-platelet effects of protamine on top of the plavix load.

 

[drmwvr]

And you can always reverse the effect of heparin. Though I'd probably err on the side of a lower dose w/TEG directed supplementation given the anti-platelet effects of protamine on top of the plavix load.

Heparin level assays (where available) can predict a heparin dose for a given patient and are useful in any patient let alone someone like this which is pretty common. These whole blood heparin activity assays guide heparin dosing and protamine reversal.

At the end of the day, though, after protamine, the patient will get a six pack or two of platelets.

 

[drmwvr]

[QUOTE="FFP, post: 20055585, member: 1
(I am not covering cardiac patients, thank Gods).

I (and many others) would be happy if cardiac anesthesiologists would follow their cardiac surgical patients in the ICU, for the first 24 hours or so, until all surgical complications are excluded, instead of intensivists (or surgeons). I would rather leave my job than work in the CTICU, that's how much I can't stand most cardiac surgeons.[/QUOTE]

Ha! Still not sure what you think of me, but your naivete is charming...do you really think that following post cardiac surgical patients by a CT anesthesiologist would hold sway with a cardiac surgeon? Please...

 

[Psai]

Ha! Still not sure what you think of me, but your naivete is charming...do you really think that following post cardiac surgical patients by a CT anesthesiologist would hold sway with a cardiac surgeon? Please...

Cardiac anesthesiologists aren't interested in it either.