Cool Case I did yesterday

[militarymd]

80 ish patient being brought to the OR for ERCP under GA because the GI guy felt he was too sick for sedation in the special procedure suit.

The ICU nurses bring him to the OR, then calls me to say that he's ready for me....and that I should probably hurry because he's kind of sick.

Me and a very experienced CRNA (30 years of experience) walk into the OR to see a sight that made me cringe a little.

Older than dirt patient lying in his ICU bed hooked partly to our monitors and partly to the transport monitor...surrounded by special procedure nurses (ICU nurses long gone)...with spaghetti tangled up everywhere...and 3 ivac pumps beeping because of low batteries.

Vitals...HR 160's....rhythm A.fib. BP 60/40s on 15 mcg/kg/min of dopamine and 180 mcg/min of phenylephrine going into a 20 gauge antecubital IV.

Mental Status: not all there

pertinent exam: an a/w that I know I get tube with a blade....Bob (my 30's + CRNA concurs)

Report from nurses: "He's sick"

I stall by saying "Bob, see if you can get a better IV" while I did a warp speed review of his chart....bottom line ..gallstone pancreatitis (with likely necrosis) and cholangitis with GNR in blood.....

---

Members don't see this ad.

 

[militarymd]

Should I cancel and get a cardiology consult before I do this case?

 

[jetproppilot]

Should I cancel and get a cardiology consult before I do this case?

No.

He's septic and critically ill....will die without removing the problem....sounds like you'll see him again for an operation, if he doesnt die first.

Intubate him with a little etomidate, scopolamine, or whatever....start a central line....seems like whoever was watching him in the ICU would want their inotropes/vasopressors infusing centrally as opposed to peripherally before this point....then address his problems:

1)sepsis: most likely the major contributor to his hypotension. Pour in fluids (liters). Does he need blood? Make sure he's getting pounded with appropriate antibiotics.

2)rapid a-fib...dont think 160 explains the hypotension fully. Is this new onset or does he have a history of it? Need to get heart rate down regardless...hopefully fluids and/or blood will give you some breathing room by bringing up the BP.

The humane answer SHOULD be to send him home so he can die with his family around him, but thats a completely different thread.

 

[Noyac]

The humane answer SHOULD be to send him home so he can die with his family around him, but thats a completely different thread.

Damn Jet, you are starting to sound like someone I know.

 

[entourage]

80 ish patient being brought to the OR for ERCP under GA because the GI guy felt he was too sick for sedation in the special procedure suit.

The ICU nurses bring him to the OR, then calls me to say that he's ready for me....and that I should probably hurry because he's kind of sick.

Me and a very experienced CRNA (30 years of experience) walk into the OR to see a sight that made me cringe a little.

Older than dirt patient lying in his ICU bed hooked partly to our monitors and partly to the transport monitor...surrounded by special procedure nurses (ICU nurses long gone)...with spaghetti tangled up everywhere...and 3 ivac pumps beeping because of low batteries.

Vitals...HR 160's....rhythm A.fib. BP 60/40s on 15 mcg/kg/min of dopamine and 180 mcg/min of phenylephrine going into a 20 gauge antecubital IV.

Mental Status: not all there

pertinent exam: an a/w that I know I get tube with a blade....Bob (my 30's + CRNA concurs)

Report from nurses: "He's sick"

I stall by saying "Bob, see if you can get a better IV" while I did a warp speed review of his chart....bottom line ..gallstone pancreatitis (with likely necrosis) and cholangitis with GNR in blood.....

YEs get a cardiology consult.. absolutely.. or just cardiovert him yourself.. put an aline in him.. once cardioverted sedate him for the ercp.. or do it under general anesthesia.. no big deal

 

[militarymd]

YEs get a cardiology consult.. absolutely.. or just cardiovert him yourself.. put an aline in him.. once cardioverted sedate him for the ercp.. or do it under general anesthesia.. no big deal

Not.

I don't consult cardiology for problems that I know how to handle.

Cardiovert? Not.

The patient is septic............the only thing cardioversion is going to do is leave burn marks on his chest.

I intubated him with a bronchoscope. I gave nothing for the intubation.

Left subclavian cordis after intubation.....Subclavian position chosen because this patient will likely keep this line for a while and subclavian lines are less likely to become infected.

Cordis....for volume and for possible PAC.

3 liters of LR...patient stabilized a little....dopamin weaned to 5 mcg/kg/min

ERCP performed....pus came out of the duct.

 

[militarymd]

afib to nsr the next morning w/o any other therapy.

 

[entourage]

Not.

I don't consult cardiology for problems that I know how to handle.

.

This particular patient sounds like he was septic cholangitis and thats why he was requiring the levophed and who knows why he was on dopamine.. not my first choice for a septic patient..

The picture is not entirely clear and any patient with hypotension with atrial fib I think merits a cardiologist consultation. I certainly would get input from the cardiologist. Nobody will fault you and its the right thing to do. medicolegally..

The lawyer:Why didnt you consult cardiology? for a cardiac problem?

YOU: becuase i didnt think it was a cardiac problem

The lawyer: you didnt think a fib was a cardiac problem

YOu: I knew how to handle it!!

the lawyer: better than a cardiologist??

I rest my case your honor.

 

[militarymd]

The lawyer: you didnt think a fib was a cardiac problem

YOu: I knew how to handle it!!

the lawyer: better than a cardiologist??

YOU: YES, your honor...and I rest my case

I rest my case your honor.

Per first post...patient has gram negative sepsis with the biliary tree and pancreas as the source.

Pretty clear to me why the patient is hypotensive. Delaying definitive therapy to get a consult for an annoying cardiac rhythm is malpractice....something many junior and poorly trained anestheiologists do.

The patient should have been on norepinephrine, but the primary chose dopamine (SCCM guidelines says its OK), and I didn't have time to change it.

 

[cloud9]

This particular patient sounds like he was septic cholangitis and thats why he was requiring the levophed and who knows why he was on dopamine.. not my first choice for a septic patient..

The picture is not entirely clear and any patient with hypotension with atrial fib I think merits a cardiologist consultation. I certainly would get input from the cardiologist. Nobody will fault you and its the right thing to do. medicolegally..

The lawyer:Why didnt you consult cardiology? for a cardiac problem?

YOU: becuase i didnt think it was a cardiac problem

The lawyer: you didnt think a fib was a cardiac problem

YOu: I knew how to handle it!!

the lawyer: better than a cardiologist??

I rest my case your honor.

As a physician, haven't you been trained how to handle A-fib? Or tachycardic HR's? Or consider potential causes of tachycardia? If the HR can't be explained or remedied, then "Consult" (IMBO).

You're a physician. Treat the problem.

 

[entourage]

I can handle basically all in the OR with out consultation. But we as consultants should respect other peoples specialties. Im not going to start treating someone with afib without consulting cardiology. OF course I can treat it.. but can i do it better thatn a cardiologist? I would hope someone would call me wreckless it if i said I could.. and medicolegally i think its best to obtain appropriate consultation.. afib with hypotension should have a consultation with cardiology.. even if you treated it.. you should consult them post op.

I am not a big fan of the gastroenterologists who say they can provide sedation for endoscopies.. Of course they can do it, but I think they should obtain our consultation for this.

 

[drrosenrosen]

I can handle basically all in the OR with out consultation. But we as consultants should respect other peoples specialties. Im not going to start treating someone with afib without consulting cardiology. OF course I can treat it.. but can i do it better thatn a cardiologist? I would hope someone would call me wreckless it if i said I could.. and medicolegally i think its best to obtain appropriate consultation.. afib with hypotension should have a consultation with cardiology.. even if you treated it.. you should consult them post op.

I am not a big fan of the gastroenterologists who say they can provide sedation for endoscopies.. Of course they can do it, but I think they should obtain our consultation for this.

Cardiologists are excellent at treating cardiac arrhythmias - obviously, it's their job. No one disputes this. But our job is to provide total care of anesthetized and critically ill patients. This includes all manner of cardiac and hemodynamic issues. This patient has a surgical condition that requires emergent surgical management. Your job is to keep him stable using all your knowledge and skill while the patient receives definitive therapy. I agree w/ Mil - waiting for a consultation while the pt gets more septic is malpractice. I know that there's a lot of medicine in anesthesia, but threads like this and mindsets like this make me feel that some surgical training should be mandatory for the CBY. Having had surgical training myself, I've already, in my CA-1 year, noticed that I frequently have more insight into the nature of surgical illness than many of my medically trained colleagues. This isn't a guy on the floor or the MICU who has been sitting on your service for months, and every day you call a new consult to address this or that issue. This is a patient who can very likely die in the next 48 hours if the nidus of his sepsis is not dealt with. Sac up and be a doctor.

 

[entourage]

Cardiologists are excellent at treating cardiac arrhythmias - obviously, it's their job. No one disputes this. But our job is to provide total care of anesthetized and critically ill patients. This includes all manner of cardiac and hemodynamic issues. This patient has a surgical condition that requires emergent surgical management. Your job is to keep him stable using all your knowledge and skill while the patient receives definitive therapy. I agree w/ Mil - waiting for a consultation while the pt gets more septic is malpractice. I know that there's a lot of medicine in anesthesia, but threads like this and mindsets like this make me feel that some surgical training should be mandatory for the CBY. Having had surgical training myself, I've already, in my CA-1 year, noticed that I frequently have more insight into the nature of surgical illness than many of my medically trained colleagues. This isn't a guy on the floor or the MICU who has been sitting on your service for months, and every day you call a new consult to address this or that issue. This is a patient who can very likely die in the next 48 hours if the nidus of his sepsis is not dealt with. Sac up and be a doctor.

If the case were not urgent or emergent would you consult the cardiologist for rapid a fib?

 

[drrosenrosen]

If the case were not urgent or emergent would you consult the cardiologist for rapid a fib?

Moot question. It is an urgent case. There's no time to futz around with consultations. But if I had a 65 year old pt, here for his TKR, who had undiagnosed rapid afib in the preop, I'd probably say the pt is not optimized for surgery and needs a cardiac workup. Rate-controlled afib, previously undiagnosed: go ahead with the case. I can take care of whatever happens in the or.

 

[entourage]

Moot question. It is an urgent case. There's no time to futz around with consultations. But if I had a 65 year old pt, here for his TKR, who had undiagnosed rapid afib in the preop, I'd probably say the pt is not optimized for surgery and needs a cardiac workup. Rate-controlled afib, previously undiagnosed: go ahead with the case. I can take care of whatever happens in the or.

the point im trying to make is.. Use your consultants.. dont be a cowboy..

 

[cloud9]

the point im trying to make is.. Use your consultants.. dont be a cowboy..

For a CCM doc, treating a-fib in a septic patient probably doesn't qualify as a rare occurrence, so being "cowboy" about it really doesn't apply.

Oh, and doing what the cardiologist would do means that you treat the a-fib equally well as a cardiologist does, not better.

 

[militarymd]

I can handle basically all in the OR with out consultation. But we as consultants should respect other peoples specialties. Im not going to start treating someone with afib without consulting cardiology. OF course I can treat it.. but can i do it better thatn a cardiologist? I would hope someone would call me wreckless it if i said I could.. and medicolegally i think its best to obtain appropriate consultation.. afib with hypotension should have a consultation with cardiology.. even if you treated it.. you should consult them post op.

I am not a big fan of the gastroenterologists who say they can provide sedation for endoscopies.. Of course they can do it, but I think they should obtain our consultation for this.

There are several aspects to the management of Afib.....The ACC has extensive guidelines on it.

I will summarize the gist of what pertains mostly to us.

There is acute management and chronic managment of afib.

Cardiologists do both...while anesthesiologists mostly handle the acute aspects.

Management consists of:
1) rhythm and rate management
2) figuring out WHY the patient's conduction system decides to become disorganized.

Which you do first depends on how unstable the patient is.

In my patient, it was fairly clear to me why the patient had afib
1) old guy with high likelihood of structural heart disease ----- can't fix that
2) Sepsis/SIRS from GI source ----- GI gonna fix it with ERCP and ABx
3) hypoxia from extrapulmonary ARDS ----- Gas guy (me) gonna fix it with tube
4) high dose of dopamine for hypotension ---- gi and gas guy gonna fix it with our combined therapies + fluids

This is a patient that I take care of more than my cardiologists do, so I have no problems saying that I know how to take care of this patient's afib better than a cardiologist.

If this had been a total knee who walks in for preop and was found on exam to have an irregularly irregular heartbeat, then the cardiologist needs to fix it...because I don't know how very well.

And BTW, a cardiologist was called to see the patient for after the ERCP, but he converted to NSR before the cardiologist got to see him.

 

[militarymd]

I just read my original post.....I meant to say an airway that I know that I can't tube with a blade.

 

[foxtrot]

The patient should have been on norepinephrine, but the primary chose dopamine (SCCM guidelines says its OK), and I didn't have time to change it.[/QUOTE]

Can you go over why Levophed is better than Neo is pt's with septic shock? I know that Levo is indicated for septic shock and not Neo but I just wasn't sure why?

 

[militarymd]

Can you go over why Levophed is better than Neo is pt's with septic shock? I know that Levo is indicated for septic shock and not Neo but I just wasn't sure why?

Take a look at the SCCM guidelines for hemodynamic support....they have the references.

But overall, norepinephrine and dopamine both do a better job of maintaining splanchnic perfusion as measured by gastric tonometry in septic hypotensive patients.

Phenylephrine and epinephrine both seem to do worse......that's where the recommendations come from.

 

[s204367]

Just a couple of things.
1) totally agree, no cards consult....the guy is banging on death's door knob as it is, needs treatment now. should have had the consult earlier, but.... If he were not septic and hypotensive, put him to sleep, vert him, then consult cards or echo yourself for thrombus and anti coag

2.) Levo plus vasopressin for septic shock in all my pts....

3.) I tube almost ALL of my ERCPs...most are old and sick as ****. You put a scope right down past pyloris and LES which allows for aspiration....if an airway goes to ****, pt is on his stomach. ERCPs are faster with a tube, no fighting, a LOT easier....tube em and run propofol if you want. upper endoscopy i usually just sedate, but it is such less of a headache to tube all ERCPs and does not delay the case at all if u keep em spon breathing.....

Overall a **** case here, but seems to be all too common......

 

[Noyac]

Just a couple of things.
1) totally agree, no cards consult....the guy is banging on death's door knob as it is, needs treatment now. should have had the consult earlier, but.... If he were not septic and hypotensive, put him to sleep, vert him, then consult cards or echo yourself for thrombus and anti coag

2.) Levo plus vasopressin for septic shock in all my pts....

3.) I tube almost ALL of my ERCPs...most are old and sick as ****. You put a scope right down past pyloris and LES which allows for aspiration....if an airway goes to ****, pt is on his stomach. ERCPs are faster with a tube, no fighting, a LOT easier....tube em and run propofol if you want. upper endoscopy i usually just sedate, but it is such less of a headache to tube all ERCPs and does not delay the case at all if u keep em spon breathing.....

Overall a **** case here, but seems to be all too common......

My partners tube most of the ERCP's as well but I tube about 1 in 10. I feel the aspiration risk is small since the scope has suction and the GI guy sucks out everything in the stomach in order to see what he is doing. I have not seen a large amount of gi contents in the stomach to this date. I give versed till sedated then run propofol at about 50 mcg/kg/min and keep hitting them with ketamine. To my dismay however, I am mostly requested for the difficult ones by the GI guys b/c they like my technique. Now if I get one of the GI guys that is slow and over poor at endoscopy then I tube the pt for my convienence. But I disagree with the statement that they should all be tubed and that they are a high risk for aspiration.

PS: vasopressin in sepsis

 

[militarymd]

PS: vasopressin in sepsis

Vasopressin DOES work well in reversing hypotension, but I'm not 100% sure that it is good for the patient in the end......has the jury come in on this yet?

 

[dhb]

>s204, woudn't you rather have the echo before the version in order to anti-coagulate appropriatly?

ps what antibiotic did you end up giving?

 

[militarymd]

imipenem and levofloxacin....the patient was on them prior to coming to the or

 

[toughlife]

80 ish patient being brought to the OR for ERCP under GA because the GI guy felt he was too sick for sedation in the special procedure suit.

The ICU nurses bring him to the OR, then calls me to say that he's ready for me....and that I should probably hurry because he's kind of sick.

Me and a very experienced CRNA (30 years of experience) walk into the OR to see a sight that made me cringe a little.

Older than dirt patient lying in his ICU bed hooked partly to our monitors and partly to the transport monitor...surrounded by special procedure nurses (ICU nurses long gone)...with spaghetti tangled up everywhere...and 3 ivac pumps beeping because of low batteries.

Vitals...HR 160's....rhythm A.fib. BP 60/40s on 15 mcg/kg/min of dopamine and 180 mcg/min of phenylephrine going into a 20 gauge antecubital IV.

Mental Status: not all there

pertinent exam: an a/w that I know I get tube with a blade....Bob (my 30's + CRNA concurs)

Report from nurses: "He's sick"

I stall by saying "Bob, see if you can get a better IV" while I did a warp speed review of his chart....bottom line ..gallstone pancreatitis (with likely necrosis) and cholangitis with GNR in blood.....

consult cards for what? Do the case and consult after case is over. Doing otherwise would be considered *****-esque in my book.

 

[toughlife]

YEs get a cardiology consult.. absolutely.. or just cardiovert him yourself.. put an aline in him.. once cardioverted sedate him for the ercp.. or do it under general anesthesia.. no big deal

You cardiovert that guy and you stand a good chance of throwing him into a more unstable arrythmia up to and including vfib.

 

[toughlife]

duplicate

 

[Tenesma]

entourage is either a srna/crna or a brand spanking new resident...

"consult cardiology for this case"... if entourage had said that in the OR i would have handed him an alcohol wipe and instructed him to start cleaning the induction room so as not to interfere with my anesthetic management

 

[toughlife]

entourage is either a srna/crna or a brand spanking new resident...

"consult cardiology for this case"... if entourage had said that in the OR i would have handed him an alcohol wipe and instructed him to start cleaning the induction room so as not to interfere with my anesthetic management

If entourage would have said that in front of my attendings, he/she would've gotten a bitch-slap and thrown out of the OR and asked never to return again.

 

[Annette]

YEs get a cardiology consult.. absolutely.. or just cardiovert him yourself.. put an aline in him.. once cardioverted sedate him for the ercp.. or do it under general anesthesia.. no big deal

Cardiology consult????? Even a medicine person wouldn't get a cards opinion first! A hospice opinion would be more likely. Even if a patient has a history of Afib, the question is always why the RVR. This patient is septic, needs fluids and antibiotics yesterday. And, in older patients, afib is treated with rate control and anticoagulation, not conversion to nsr.

 

[militarymd]

follow up..


The guy is extubated and organ failure has reversed.

He's eating a regular diet and grateful to be alive!!!!

 

[jetproppilot]

follow up..


The guy is extubated and organ failure has reversed.

He's eating a regular diet and grateful to be alive!!!!

Wow.

In addition to thanking the doctors that saved his life, he better start going to church since thats a frikkin' miracle!

Nice case.

 

[dhb]

sometimes those old dudes are doing fine until s h i t happens and is subsequently mismanaged but can recuperate spectacularly once proper treatment of the underlying condition is given

Mil's the man... no cards needed here...

 

[FliteSurgn]

I agree with the anesthetic management issues, but I question the ERCP with a patient in extremis. I'd have opted for a bedside cholecystostomy tube to relieve the pressurized pus in the biliary system. This would've stabilized the patient and not necessitated any anesthetics other than local. Then definitive (elective) management could've been done without as much "pucker" factor. Just my 2 cents from the other side of the ether screen.

 

[militarymd]

I agree with the anesthetic management issues, but I question the ERCP with a patient in extremis. I'd have opted for a bedside cholecystostomy tube to relieve the pressurized pus in the biliary system. This would've stabilized the patient and not necessitated any anesthetics other than local. Then definitive (elective) management could've been done without as much "pucker" factor. Just my 2 cents from the other side of the ether screen.

would a bedside cholecystostomy tube have treated the pancreatitis also?

I was going to punt the patient for a perc drainage if the patient didn't have possible necrotizing pancreatitis.....that would have been after I intubated him and stabilizied.

and the other question is...is a bedside cholecystostomy tube less invasive than an ERCP? Either ways, the patient needed to be intubated and "anesthetized".

 

[FliteSurgn]

A cholecystostomy tube would've treated (relieved) his source of sepsis which was ascending cholangitis. In early cholangitis, I'm all for the GI docs relieving the biliary obstruction and converting the definitive management of his gallstones into an elective event. OTOH, in decompensated shock from ascending cholangitis, I think the last thing that a patient needs is someone screwing around with positioning, fluoroscopy, guidewires, sphincterotomes, and stone baskets.

If he had an infected pancreatic necrosis, ERCP was contraindicated. In that case, he needed a laparotomy with debridement of the dead, infected pancreas and an open cholecystectomy vs. cholecystostomy tube. In fact, ERCP may turn a sterile pancreatic necrosis into an infected one. And an ERCP does nothing to relieve sepsis from infected pancreatic necrosis.

You stated yourself what a cluster***k you saw when you entered the OR. Tangled lines, mismatched monitors, pumps with dead batteries, etc. Doing a bedside procedure in the supine position while in the ICU seems much more attractive to me than taking a patient on 2 pressors while in uncontrolled septic shock to the OR for an ERCP. I just questioned the initial decision for an ERCP in this particular setting and I realize that wasn't your call. From my standpoint, you managed the patient superbly once the situation presented itself to you in the OR. I was just adding commentary on what I would consider optimal management of the underlying condition based on the patient circumstances as presented.

 

[militarymd]

would a bedside cholecystostomy tube have treated the pancreatitis also?

I was going to punt the patient for a perc drainage if the patient didn't have possible necrotizing pancreatitis.....that would have been after I intubated him and stabilizied.

and the other question is...is a bedside cholecystostomy tube less invasive than an ERCP? Either ways, the patient needed to be intubated and "anesthetized".

I should have been more clear on that. The guy HAD pancreatitis...presumably gallstone related, but contrast wasn't used for his abdominal CT because his creatinine was 3+.

So, it was unclear whether he had dead pancreas or not....GI guy thought he might have...but we did know it was inflamed.

For my education...why would a ERCP in this setting change non-infected tissue into infected tissue? Is it the contrast being injected forcing bacteria into the pancreas?

Because common bile duct is blocked already...and the pus was there already from the biliary tree.

 

[militarymd]

If he had an infected pancreatic necrosis, ERCP was contraindicated. In that case, he needed a laparotomy with debridement of the dead, infected pancreas and an open cholecystectomy vs. cholecystostomy tube. In fact, ERCP may turn a sterile pancreatic necrosis into an infected one. And an ERCP does nothing to relieve sepsis from infected pancreatic necrosis.

.

I just reread your post....why is it contraindicated?

 

[FliteSurgn]

For my education...why would a ERCP in this setting change non-infected tissue into infected tissue? Is it the contrast being injected forcing bacteria into the pancreas?

Yes, with pancreatic necrosis, you have a big collection of saponified material that is like a petri dish. All it needs is something to seed it with bacteria. Instrumentation of the bile duct via the GI tract can certainly convert the sterile necrosis into an infected one.

In general, if someone has pancreatic necrosis and they are septic you assume the sepsis is from the necrosis and they need to have debridement of their pancreas. Saponification creates a thick soupy material that won't evacuate through most surgical drains and certainly won't come out through the normal biliary system. So, unless you can drain the soupy crap out of there, the infection will continue to drive the sepsis. To give you an idea how thick the stuff is, I learned to use 36fr chest tubes as drains after debriding an infected pancreatic necrosis. Those usually won't clog.

These types of cases are never straight-forward or easy to deal with. Fortunately, they don't come along that often.

 

[militarymd]

Yes, with pancreatic necrosis, you have a big collection of saponified material that is like a petri dish. All it needs is something to seed it with bacteria. Instrumentation of the bile duct via the GI tract can certainly convert the sterile necrosis into an infected one.

In general, if someone has pancreatic necrosis and they are septic you assume the sepsis is from the necrosis and they need to have debridement of their pancreas. Saponification creates a thick soupy material that won't evacuate through most surgical drains and certainly won't come out through the normal biliary system. So, unless you can drain the soupy crap out of there, the infection will continue to drive the sepsis. To give you an idea how thick the stuff is, I learned to use 36fr chest tubes as drains after debriding an infected pancreatic necrosis. Those usually won't clog.

These types of cases are never straight-forward or easy to deal with. Fortunately, they don't come along that often.

what about this setting where there is another source of KNOWN infection...and presence or absence of necrosis is unclear?

Thank the lucky stars they don't come that often....Fortunately for me, I only remember one case , a fat lady who went to the OR multiple times before expiring....

 

[militarymd]

Flightsurgeon,


thanks btw for posting here and giving a surgical pov on the care of this patient