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Challenging case

Hork Bajir

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Had an interesting case recently, wondering how others would have tackled it:

72 yo M with poorly controlled HTN, IDDM, morbidly obese (190kg), pAF, CAD s/p remote CABG complicated by ischemic CM (LVEF 25% w/ RWMAs), post-capillary pulmonary HTN (mPAP ~50, R heart dilated and mildly reduced fxn), and AS s/p TAVR now w/ severe prosthetic valve stenosis. ESRD on HD, however he is now progressively volume overloaded because he has been getting hypotensive during attempts at ultrafiltration over the past week (despite trials of midodrine pre-HD), thus limiting how much volume could be pulled off. Had a RHC several days ago, wedge pressure 32mmHg, CI 2.2 by Fick. Currently admitted for expedited workup of possible valve-in-valve TAVR, however before proceeding with any cardiac intervention, his non-healing and chronically infected lower extremity ulcers need to be dealt with... Hence why he is now coming to the OR for a left BKA.

When I go to see him the evening before, vascular surgeon has him on a heparin drip for his critical limb ischemia. He's borderline encephalopathic after having gotten some morphine for leg pain, alert and oriented x 2. Can lay flat, but doesn't love doing it. O2 sat is 94% on 4L NC with bibasilar crackles.

Clearly, this man is dying sooner or later... However, I prefer not to have him die in the OR during the BKA. Patient and his family are determined that they want to proceed with all interventions. How will you do this case?
 
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dchz

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Prop sux tube

with phenylephrine.

I usually never get to say this first!!!

I wouldn't worry about his BMI, it'll be fixed after the operation (unless they do bilateral)

Most likely time of this pt having an event is post op. Have you talked to your ICU colleagues??

His gonna be fine. You only have one option of general so do it well. Pre induction Aline with a big volume line.
 
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AdmiralChz

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Impressive that heart can sustain 190 kg. Probably says something about overall risk.

Exactly as above. No neuraxial given ESRD (with inadequate HD!) and heparin gtt - good luck getting platelets that work. An epidural hematoma would be fatal to this patient.

I can’t believe the cardiac group is actually considering V-in-V. That’d be a no go here with this story.
 
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marr65

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In a guy who weighs 190kg and is 94% on 4L? Yea okay good luck

If you are talking about the block it’s not difficult if you tape the belly out of the inguinal crease and go right at the popliteal crease. I have done more than a few 400lbs fem/pop without much difficulties. I wouldn’t do an adductor canal block though, go straight for the femoral.
 
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vector2

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Impressive that heart can sustain 190 kg. Probably says something about overall risk.

Exactly as above. No neuraxial given ESRD (with inadequate HD!) and heparin gtt - good luck getting platelets that work. An epidural hematoma would be fatal to this patient.

I can’t believe the cardiac group is actually considering V-in-V. That’d be a no go here with this story.

I wish we had a group like yours! One of our last TAVRs was moderate to severe MR, moderate to severe TR, PAP in 70s, COPD 2l o2 so likely group III PH component as well, morbidly obese. Overall, just a perfect candidate for a $30k valve that would allow her to return to aggressive couch sitting life.




But for the OPs pt, are they doing a guillotine or true BKA and formalization? For the more extensive surgery, send to ICU first, preop HD or CVVHD with IV pressors to get some volume off (esp some of that interstitial lung water). Pre-OP aline. General. Keep the perfusion pressure up with pressor, extubate to mild CPAP, go to ICU. Should do OK since he's s/p CABG and revascularized plus RV function is not horrific. Consider a whiff of dobutamine if you think hypoperfusion is an issue.
 
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nimbus

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If you are talking about the block it’s not difficult if you tape the belly out of the inguinal crease and go right at the popliteal crease. I have done more than a few 400lbs fem/pop without much difficulties. I wouldn’t do an adductor canal block though, go straight for the femoral.

Agree. Femoral is usually much more superficial than AC in big patients.

I would intubate him though and make his and my life easier.
 
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Newtwo

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Im on the fence. You could make a decent case for regional vs neuraxial vs ga

I dont really like regional but id consider giving it a lash if i wasnt too busy otherwise. id imagine finding the sciatic wouldnt be so easy on this dude.


Im leaning 95% to doing a spinal if they let me switch the heparin off for 6 hours which they surely would. I mean come on they're gonna chop this dudes leg off anyway. Epidural hematoma is a concern sure, but 6 hours and normal coag is all ASRA ask for so why worry more?
 

Newtwo

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Spinal isn't a bad idea but the guy is 400+ lbs!
True but he can still up & hopefully position well which makes things a lot easier.


Quote---
Any concerns about spinal w/ severe AS, and a R heart that’s going to be volume sensitive?

---
Not really. 10mg hyperbaric/fent, keep him sitting for a couple mins. Saddle block. Wont rise above lumbar levels. Obvi id assume everyone would do aline and phenyl drip in line but thats about it

We do some of our AoV replacements for critical AoStenosis under total spinal.

Spinal is not contraindicated for these patients, hypotension is
 
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Lidolover

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Agree with fem/pop blocks preop or spinal with neo gtt even before starting the spinal. Post op icu and lidocaine gtt (works perfect for amputations guys). I would consider at least a bedside echo because I have had patient with exact same characteristics (ESRD on suboptimal HD) and Anticoagulation developing sudden hemopericardium vs uremic pericardial effusion (we never figured that out) and tamponade. Just sayin’
 

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Had you said BKA in the first sentence i could have skipped the rest and just yelled "Block!".
Anything amputation i'll do a block and not look at the rest of the chart.

Amazing the kind of abuse the body can take for 7 decades! They never make it to the 8th though in my experience.
 
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ButterButter

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This guy's a sh***y candidate for all anesthetic types. But he's got a real solid chance of coding on induction so it's not unreasonable to go fem/pop or spinal and prepare him for the likely discomfort of being a little more awake than most. And when he gets cranky and says "can't ya just knock me out??" Tell him he can either be comfortable and dead or temporarily uncomfortable and (hopefully) alive.
 
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Arch Guillotti

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Most of his discomfort is gonna be lying flat on an OR table with 400 lbs of flab trying to fight its way through his diaphragm
That and blocks that provide surgical anesthesia are 2 big wildcards.
 
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abolt18

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I'd say gentle GA with preinduction art line and with post induction fem/pop blocks mainly for the opioid sparing component post-op and ?reduced phantom pain?

Minimize fluids. Extubation sitting close to straight up and wide awake. Not much else worth doing in my mind. Keep it clean and straightforward.
 
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vector2

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This guy's a sh***y candidate for all anesthetic types. But he's got a real solid chance of coding on induction so it's not unreasonable to go fem/pop or spinal and prepare him for the likely discomfort of being a little more awake than most. And when he gets cranky and says "can't ya just knock me out??" Tell him he can either be comfortable and dead or temporarily uncomfortable and (hopefully) alive.

Can you even imagine the biventricular afterload this beluga's heart sees when he's asleep and tries and inhale against a partially or totally obstructed airway? The fact that this guy can go to sleep with his body habitus/likely OSA and degree of prosthetic AS and still wakeup the next morning tells me his heart can likely tolerate more than what you'd think at first glance.
 
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Lidolover

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Can you even imagine the biventricular afterload this beluga's heart sees when he's asleep and tries and inhale against a partially or totally obstructed airway? The fact that this guy can go to sleep with his body habitus/likely OSA and degree of prosthetic AS and still wakeup the next morning tells me his heart can likely tolerate more than what you'd think at first glance.

of course, an attending of mine used to tell me “it is really hard to kill a patient”...
 
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vector2

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of course, an attending of mine used to tell me “it is really hard to kill a patient”...

In all honesty, this kind of pt is not necessarily "dime a dozen," but he is certainly a "not uncommon" pt for TAVR, ICD placements, atrial or ventricular ablations, these kind of vascular or other wound management surgeries, etc, and you can get them through surgery the vast majority of the time with a very low morbidity/mortality given the comorbidities.

The number one thing that kills these pts? Doing deep sedation/unprotected airway general -> hypoventilation / hypoxia -> acute pulm HTN -> decreased CO and MAP -> RV/LV ischemia -> arrest.

These kind of BKAs take 1.5hr+ at my shop with residents. This pt is encephalopathic. I guarantee you will not be able to position him for a spinal, and getting surgical anesthesia for a high BKA with only blocks in a pt this size is not a walk in the park. And say you do get surgical anesthesia with neuraxial or regional, this guy is gonna tolerate flat positioning without snowing him to suppress the air hunger? Nah.

Bottom line: put the tube in.
 
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nimbus

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of course, an attending of mine used to tell me “it is really hard to kill a patient”...

Yeah. How bad can his AS really be if he’s 400lbs and has a CI 2.2?

In real life I would block, Aline, ga/ett. Paralyze, low dose Sevo, phenylephrine infusion prn. As @abolt18 mentioned above, I’d have no problem doing postinduction blocks in this patient getting a bka.
 
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nimbus

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True but he can still up & hopefully position well which makes things a lot easier.


Quote---
Any concerns about spinal w/ severe AS, and a R heart that’s going to be volume sensitive?

---
Not really. 10mg hyperbaric/fent, keep him sitting for a couple mins. Saddle block. Wont rise above lumbar levels. Obvi id assume everyone would do aline and phenyl drip in line but thats about it

We do some of our AoV replacements for critical AoStenosis under total spinal.

Spinal is not contraindicated for these patients, hypotension is
Look it up. It's a not uncommon technique in cardiac


There’s an even older video from New York Hospital in the 1970s of a guy getting mitral valve repair under some type of regional. This one is under tepi in India.



 
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ButterButter

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Can you even imagine the biventricular afterload this beluga's heart sees when he's asleep and tries and inhale against a partially or totally obstructed airway? The fact that this guy can go to sleep with his body habitus/likely OSA and degree of prosthetic AS and still wakeup the next morning tells me his heart can likely tolerate more than what you'd think at first glance.

lol, this guy's one foot out the door. Sure he's waking up now, but at his age and with those co-morbidities, not for long. Not sure using his current state of health to conclude his cardiac function is adequate is the correct inference in this situation.
 

AdmiralChz

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There’s an even older video from New York Hospital in the 1970s of a guy getting mitral valve repair under some type of regional. This one is under tepi in India.




When I was a CA-1 I went to the SCA conference (not recommended, I had no clue what was being discussed) and there was a whole session from Indian and Asian continent anesthesiologists about cardiac surgery done under epidural. I was completely blown away, and afterwards everyone had the same reaction - “but..... why???”
 
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dchz

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Any concerns about spinal w/ severe AS, and a R heart that’s going to be volume sensitive?

No more concern than general. if you do spinal you're still allowed to use your anesthesia drugs like a general case. how volume sensitive can his right heart be? he's ESRD on HD. He is literally volume challenged every 2-3 days before his HD. I think he will be ok as long as the anesthesiologist knows in this guy more volume doesn't necessarily mean more blood pressure so he doesn't get an iatragenic RV failure.


Tell him he can either be comfortable and dead or temporarily uncomfortable and (hopefully) alive.

The more I do anes the more I don't believe in this. I would actually argue this 300+ pounder being awake is more dangerous. If I find myself telling my patients the only way they'd be comfortable is that they are dead, then I am doing something wrong.

After seeing the patient, I texted the surgeon to express my concerns. He offered to stop the heparin drip pre-op if I wanted to do regional/neuraxial. Does that change any of your plans?

It doesn't change my mind because heparin isn't the only thing contributing to coagulopathy in this patient. Remember Heyde syndrome and uremic platelet dysfunction. I wouldn't mind adding on regional so they don't keep giving this guy morphine, because hematoma in leg is far less dangerous than hematoma in spine.

72
450lb
EF 25%
OSA (?)
AKF/ESRD
DM
ASA 4E

Will he ever get out of the hospital?
Any odds maker out there?

I'd say >80%, higher if they fix his valve this hospital stay.

When I was a CA-1 I went to the SCA conference (not recommended, I had no clue what was being discussed) and there was a whole session from Indian and Asian continent anesthesiologists about cardiac surgery done under epidural. I was completely blown away, and afterwards everyone had the same reaction - “but..... why???”

One of my dreams is to do a heart surgery under T epidural.... after i read it in Kaplan as a Ca-2.

As to why; same reason that people argue to do this BKA under Spinal I guess.... because they CAN! :p
 
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Arch Guillotti

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If someone does not feel comfy with blocks, can always consult regional or acute pain service.
GA and tube have high likelihood of prolonged intubation in this particular pt.
Dude most of us are the pain service.
 
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vector2

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lol, this guy's one foot out the door. Sure he's waking up now, but at his age and with those co-morbidities, not for long. Not sure using his current state of health to conclude his cardiac function is adequate is the correct inference in this situation.

His cardiac function is more than adequate for this current hospital stay, and the only reason he appears to be decompensated is cause he hasn’t been getting his dialysis. Yea, epidemiologically this guy is probably dead within two years, but I’m about 90-95% confident I could get this guy through an amputation with geta and a tavr uneventfully, especially if I have a bit of time to get some volume off and improve the pulmonary congestion beforehand
 
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pgg

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When I was a CA-1 I went to the SCA conference (not recommended, I had no clue what was being discussed) and there was a whole session from Indian and Asian continent anesthesiologists about cardiac surgery done under epidural. I was completely blown away, and afterwards everyone had the same reaction - “but..... why???”
Cost ... it's actually pretty amazing to me what kind of surgeries the developing world gets done with a (sometimes reused) needle and 40 cents worth of bupivacaine.
 
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chocomorsel

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Cost ... it's actually pretty amazing to me what kind of surgeries the developing world gets done with a (sometimes reused) needle and 40 cents worth of bupivacaine.
I can't believe this isn't common sense. Resources are limited outside of this country. It's not an ever-ending supply of dollar trees hanging out in everyone's yard.
The amount of money we waste in healthcare in this country is disgusting. Hopefully Covid does something to change the landscape. Cases like these are a prime example.
 
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fakin' the funk

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Had an interesting case recently, wondering how others would have tackled it:

72 yo M with poorly controlled HTN, IDDM, morbidly obese (190kg), pAF, CAD s/p remote CABG complicated by ischemic CM (LVEF 25% w/ RWMAs), post-capillary pulmonary HTN (mPAP ~50, R heart dilated and mildly reduced fxn), and AS s/p TAVR now w/ severe prosthetic valve stenosis. ESRD on HD, however he is now progressively volume overloaded because he has been getting hypotensive during attempts at ultrafiltration over the past week (despite trials of midodrine pre-HD), thus limiting how much volume could be pulled off. Had a RHC several days ago, wedge pressure 32mmHg, CI 2.2 by Fick. Currently admitted for expedited workup of possible valve-in-valve TAVR, however before proceeding with any cardiac intervention, his non-healing and chronically infected lower extremity ulcers need to be dealt with... Hence why he is now coming to the OR for a left BKA.

When I go to see him the evening before, vascular surgeon has him on a heparin drip for his critical limb ischemia. He's borderline encephalopathic after having gotten some morphine for leg pain, alert and oriented x 2. Can lay flat, but doesn't love doing it. O2 sat is 94% on 4L NC with bibasilar crackles.

Clearly, this man is dying sooner or later... However, I prefer not to have him die in the OR during the BKA. Patient and his family are determined that they want to proceed with all interventions. How will you do this case?

This patient has chronic heart, lung, and kidney failure. Bet this person has zero function. Severe obesity that limits correction of all of the above. This is called: dying. Stop it.
 
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pgg

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I can't believe this isn't common sense. Resources are limited outside of this country. It's not an ever-ending supply of dollar trees hanging out in everyone's yard.
The amount of money we waste in healthcare in this country is disgusting. Hopefully Covid does something to change the landscape. Cases like these are a prime example.
Well to be fair, a lot of those two-dollar anesthetics sucked. The algorithm for dealing with a partial or failed blockis usually just that the patient sucked it up, or gets some ketamine if available. Then the yelling is blamed on the ketamine not the pain.

A spinal for an ex-lap works but has some drawbacks.

But they get stuff done.
 
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anbuitachi

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Can you even imagine the biventricular afterload this beluga's heart sees when he's asleep and tries and inhale against a partially or totally obstructed airway? The fact that this guy can go to sleep with his body habitus/likely OSA and degree of prosthetic AS and still wakeup the next morning tells me his heart can likely tolerate more than what you'd think at first glance.

he probably sleeps with 18 pillows. helps with the obstruction
 
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