case w pulm HTN

[amyl]

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in need of some clinical stuff here to balance all the match-stuff so i thought i would include some discussion points from our morning report. also, NP missed it to sleep in and i wouldn't want him to have missed anything 😀

60 yo female, chrons, COPDer s/p L pneumonectomy (remotely) for lung ca. admitted for ?PCI d/t syncopal episode. i cannot remember the actual numbers of stenosis the cath showed but all were diffusely affected and less than 75% stenosis so --> medical management. also found to have SBO d/t Right sided colonic obstructing lesion, possibly ca? so now for R hemi-colectomy.
pre-op echo showed systemic R heart pressures, around 110/30ish if i remember properly. no improvement w 40ppm nitric oxide. not on any sidenafil, etc.
4L nasal cannula at home and unable to lie flat at all.
this is what we talked about, so thoughts on:
1. method of induction?
2. swan or no swan?
3. central line R or L IJ?
4. surgeon wants to go laparoscopic -- do you let him?
5. plan to extubate in OR if all goes well?

 

[aredoubleyou]

in need of some clinical stuff here to balance all the match-stuff so i thought i would include some discussion points from our morning report. also, NP missed it to sleep in and i wouldn't want him to have missed anything 😀

60 yo female, chrons, COPDer s/p L pneumonectomy (remotely) for lung ca. admitted for ?PCI d/t syncopal episode. i cannot remember the actual numbers of stenosis the cath showed but all were diffusely affected and less than 75% stenosis so --> medical management. also found to have SBO d/t Right sided colonic obstructing lesion, possibly ca? so now for R hemi-colectomy.
pre-op echo showed systemic R heart pressures, around 110/30ish if i remember properly. no improvement w 40ppm nitric oxide. not on any sidenafil, etc.
4L nasal cannula at home and unable to lie flat at all.
this is what we talked about, so thoughts on:
1. method of induction?
2. swan or no swan?
3. central line R or L IJ?
4. surgeon wants to go laparoscopic -- do you let him?
5. plan to extubate in OR if all goes well?

1. A-line b4 induction. Etomidate, high opiod, roc...tube. Normal pulm htn stuff (avoid hypoxia, hypercarbia, nitrous, yada yada).

2. Swan

3. I don't care, I'd put it in the right.

4. Yes, thats why I've got a swan. Pulm HTN worsens, deflate the belly and unzip her. If you can get away with it, better for the patient.

5. Absolutely, if the patient meets extubation criteria, take the tube out. If you overdid it with opiods, leave it in rather than play around with naloxone.

 

[Planktonmd]

Admit patient day before surgery to ICU.
Place A line and PA catheter and try to lower the PA pressure to a more reasonable number.
You could use Nitroglycerine but with the numbers stated above You might want to use a prostacycline infusion.
The lack of response to Nitric Oxide is not a good sign, it means that the PA pressure is most likely fixed and that your only possible therapeutic option is to try to maintain the cardiac output with Dobutamine and cautious volume replacement.
I would place an epidural and use it cautiously intra-op and post-op as well.
I would recommend open procedure under GA versus laparoscopy because it is highly unlikely that she is going to tolerate the steep trendelenberg and the abdominal inflation.

 

[proman]

this is what we talked about, so thoughts on:
1. method of induction?

Etomidate is probably the gentlest way. I wouldn't give more than 5mcg/kg of fentanyl (not all at once). Paralytic with succinylcholine or rocuronium to intubate rapidly. Pre-induction arterial line and dobutamine started empirically. Post-induction hypotension could be treated with phenylephrine or vasopressin. I would have either norepinephrine or vasopressin infusions available for hypotension. Maintenance would be with low dose volatile anesthetic and opioid/relaxant.

2. swan or no swan?

Swan, my plan would be to start an inodilator like dobutamine empirically. Milrinone is another option though I would be concerned about system vascular resistance falling (can also happen with dobutamine).

3. central line R or L IJ?

Side doesn't matter. I would place it RIJ as it's easier to place a PAC. Side matters most for cardiac transplantation and the frequent biopsies they need. This patient is not a candidate for transplantation.

4. surgeon wants to go laparoscopic -- do you let him?

Laparoscopy is acceptable so long as low insufflation pressures and low flows are utilized. The PAC will allow early detection of dangerous hypercarbia that would prompt venting the abdomen and opening. Trendelenburg is not required for hemicolectomy.

5. plan to extubate in OR if all goes well?

Half of these patients can be extubated in the OR. I would not want to let the patient become hypercarbic or hypoxic during emergence.

Other important points: with fixed PVR, odds of being able to improve it are slim, even with prostacyclin analogs as suggested by Plank. I don't feel an ICU admission is warranted preop. Many PAH patients require lifelong systemic anticoagulation which would impact my decision to place an epidural. The patient may need to be immediately anticoagulated post-op, which would be delayed by an epidural catheter. These cases can definitely be done laparoscopically. I would definitely use low tidal volumes (5-6 cc/kg), and minimal PEEP (5). The PAP of 110/30 is odd (understand you didn't remember the exact). The PAD is likely much higher. I would also quote her a 30 day mortality rate of 7-20% for patients with moderate to severe PAH and undergoing non cardiac surgery. Like Plank said, avoid hypoxia (use 100% oxygen), avoid hypercarbia and hypotension. Volume status is very important too. Hypovolemia reduces cardiac output but hypervolemia impairs gas exchange and precipitate RV failure.

These are great learning cases.

 

[amyl]

as an intern i saw two pts w PA rupture -- i was wondering if the swan was really necessary. appears to be fixed pulm HTN. not sure how swan was going to change management. there would be other signs of low CO or R heart failure, not necessitating swan? a little on the fence about the swan...

 

[Planktonmd]

Laparoscopy is acceptable ..... Trendelenburg is not required for hemicolectomy.

Are you sure about that?
In my experience they do and it is a very steep trendelenburg.

Why is a laparoscopic procedure better here?
A laparoscopic procedure is longer, requires inflating the abdomen with CO2 and in my experience requires steep trendelenburg, so why is it better in this patient with severe Pulm htn???

 

[Planktonmd]

as an intern i saw two pts w PA rupture -- i was wondering if the swan was really necessary. appears to be fixed pulm HTN. not sure how swan was going to change management. there would be other signs of low CO or R heart failure, not necessitating swan? a little on the fence about the swan...

You saw two PA rupture from PA catheter placement in one year?
Wow!

 

[amyl]

yup. happened when icu nurses wedged 'em. actually i saw two in the same month. the attending that was on at the time was a freak about wedging the catheters all the time and gave the nurses crap about not wedging them and just using the PAD.... he was a cardiologist not an anesthesiologist btw.

 

[amyl]

lap is better from a post operative pain standpoint -- uncontrolled pain postop would likely hinder this pts already compromised respiratory efforts.... course an epidural or TAP block would help with this...
in this particular case the surgeons did the best they could w/o t-burg and other bed acrobatics

 

[proman]

Are you sure about that?
In my experience they do and it is a very steep trendelenburg.

Why is a laparoscopic procedure better here?
A laparoscopic procedure is longer, requires inflating the abdomen with CO2 and in my experience requires steep trendelenburg, so why is it better in this patient with severe Pulm htn???

Yes, the surgeon used a lap liver retractor to keep everything out of the way. After that case, my appreciation of his skill increased significantly. I think the benefits post op of lap technique is worth starting that way, with a low threshold of opening.

 

[proman]

yup. happened when icu nurses wedged 'em. actually i saw two in the same month. the attending that was on at the time was a freak about wedging the catheters all the time and gave the nurses crap about not wedging them and just using the PAD.... he was a cardiologist not an anesthesiologist btw.

The highest risk of PA rupture in PAH that I've seen is about 0.05%, completely acceptable. Like you saw, it usually happens on wedging. You don't need left heart numbers, so main or r/l PA readings are fine. The bigger risk in PAH is arrhythmia with PACs. I would still place one.

Just one thing, fixed PAH refers to lack of vasodilation to a challenge (like iNO, NTG). Fixed PAH doesn't get better with vasodilators but can definitely get worse.

 

[ssmallz]

Is the pt optimized? Thats really the key here b/c they do so poorly post op. I'd talk to her pulmonolgist and make sure this is the best she can be

A-line and Central line preop, site doesn't matter IMO. I'd attempt a swan but just be aware of the significant risk of arrythmia which can be caused when floating. I wouldn't bother to wedge it b/c the pHTN and dysfunction will cause your numbers to be off anyways.

Type of induction doesn't really matter too much IMO, just be gentle and avoid ketamine and nitrous. I'd go w/etomidate, fentanyl, and versed, w/sevo for maintance. I don't see any reason to RSI this lady, and I'd actually avoid it if possible b/c if she is light or reacts it could worsen here hemodynamics. Maintanance w/sevo, if you're having problems switch to a propofol drip which has been shown to have slightly better PAO2s and CO2s than the gases

Lap vs Open - I think its fine to try as long as they are willing to convert to open at the first sign of things going wrong

Def try to extubate this pt, the longer she has that tube in the worse its gonna be

 

[amyl]

RSI for SBO.

 

[sevoflurane]

Would you drop a TEE with her recent cardiac events?

 

[sevoflurane]

if so... would you still need a swan?

 

[deleted126335]

if so... would you still need a swan?

Anybody here ever personally tried to float a PA catheter on a post pneumonectomy patient? I have---unsuccessfully. She became unstable from the ectopy so I abandoned the procedure. Did the case with a CVP. Did fine. Not inclined to try again after my series of one.

 

[sevoflurane]

Exactly. I have experienced significant arrythmias floating a swan in post-pneumonectomy patients. Most of them have significant underlying arrythmians anyways. I would float a swan on some, on others I proabably wouldn't.

This patient surely has TR. You can figure out PA pressures with TEE:

PAPs = 4 × VTR Squared + CVP.

You can also see how the right heart behaves when you inflate the belly as well as global systolic function/RWMA in the setting of recent syncope/MI.

 

[ssmallz]

RSI for SBO.

lol...ooops, missed the SBO part. Agree w/the RSI part

 

[proman]

Even with TEE I would still attempt to place a PAC. It would be nice to have the most sensitive monitor for ischemia, and TEE would probably allow for rapid detection of RV failure. It's somewhat tedious to do cardiac output and PA pressures in real-time. I'd rather have a CCO or regular PAC (plus it would be helpful in the ICU) with continually displayed PA pressures.

 

[22go]

Agreed with preop lines, would bail on PAC if arrthymias become a problem. use TEE if you have the skills...many times I will see someone billed as severe pulmonary HTN preop and once the lines are in and the numbers are cooking they aren't nearly as bad a they are labeled...but then again some times they are really that bad.. would stay with vasopressin over phenylephrine/norepinephrine as a 1st line agent for SVR....both neo and norepi seem to make PVR worse if the numbers are really that bad....

 

[nap$ter]

agree with pre-induction a-line, epidural (pretty unlikely she'll tolerate insufflation, but it's worth a try).

induction etomidate/remi/roc. run on remi gtt, epidural, low flurane level.

yes on swan attempt, have tee available. all pulm htn yeas/nays.

begin milrinone/vasopressin and optimize (fluid challenge) preload c albumin PRIOR to insufflation to optimize chance of success.

1 of midaz c aline or nothing if she's chill, and remi/epidural only throughout case - extubate asap.

not much different from what others have said...

 

[Hockeyguy]

A-line then standard induction. Avoid hypoxia, hypercarbia (at insuflation crank up your MV) and acidosis. Plus epidural for post op pain to avoid the above effects from post op narcotics. In my opinion you know why she has pulm htn you will likely not make it better with any interventions you just don't want it to get worse. If she crumps you'll know why drop a TEE to confirm right heart failure and start your epinephrine gtt to support right heart. Overnight in ICU. In my opinion these patients seem to do well in our hands. They run in to trouble post-op when the surgical intern floods them with crystalloid.

Just my 2 cents.

 

[Robert Loblaw]

in need of some clinical stuff here to balance all the match-stuff so i thought i would include some discussion points from our morning report. also, NP missed it to sleep in and i wouldn't want him to have missed anything 😀

60 yo female, chrons, COPDer s/p L pneumonectomy (remotely) for lung ca. admitted for ?PCI d/t syncopal episode. i cannot remember the actual numbers of stenosis the cath showed but all were diffusely affected and less than 75% stenosis so --> medical management. also found to have SBO d/t Right sided colonic obstructing lesion, possibly ca? so now for R hemi-colectomy.
pre-op echo showed systemic R heart pressures, around 110/30ish if i remember properly. no improvement w 40ppm nitric oxide. not on any sidenafil, etc.
4L nasal cannula at home and unable to lie flat at all.
this is what we talked about, so thoughts on:
1. method of induction?
2. swan or no swan?
3. central line R or L IJ?
4. surgeon wants to go laparoscopic -- do you let him?
5. plan to extubate in OR if all goes well?

agree with the preinduction aline and PAC. induction with 1-2mcg/kg fentanyl q 2 minutes (to 5-8mcg/kg total dose) and assess response, ndmb, crack of sevo, seamless transition to assisted ventilation, 50-80mg propofol for laryngoscopy. probably have flolan on the circuit and milrinone available for the case. epidural for analgesia but maintain adequate preload and MAP. i'd probably plan to leave intubated and extubate in icu asap unless rock solid.

we don't know two things that i'd really like to know before deciding how worried i am about this patients right heart--left heart function and RV morphology. obviously there could be some component of lv failure contributing to high PAPs but clearly there is a large primary component. a dilated lv also can worsen efficiency of contraction (septal position, biv synchrony, etc) so LV function should be optimized.

if the lv is normal or seminormal and the rv is hypertrophied and not dilated i'm suddenly less concerned about acute RVF. any signs of decompensated RVfailure (transaminitis, edema, etc?) an rv that can generate PASP of 100 has remodeled and adapted, and at this point, maintaining rv preload is of primary importance (to maintain lv preload). to this point, i'd be a lot more worried if he had a severely dilated RV with PASP of 30...

i wouldn't do intraop echo unless condition deteriorated.

 

[seinfeld]

Aline pre indcution, Tell surgeon open or nothing (it will be quicker, and doesnt require CO2 insufflation) Propofol, phenylephrine, Roc Tube. Like our internal med friends say, Keep her systemic pressure normal and avoid hypoixia and hypercarbia.

A pa cath is going to give you little information, The PAD is unlikely gonna tell you little about left sided filling pressure or fluid balance or the CVP for that matter. Use the aline and check SPV (systolic pressure variation). Also it may make you overtreat, its hard to stare at PA pressure greater than 60 no less 100 and do nothing about it. If you start an inotrope what is your goal? Make a functioning R heart fxn better? When do you stop it? Remember inotropes increase myocardial oxygen demand. If the hemodynmics get out of control place a TEE.