Difficult AVR

[jetproppilot]

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Did a difficult AVR the other day on a 62 year old dude...who looked 50...with critical aortic stenosis.
It is rare that we are confronted with such an ominous disease process within a patient that appears quite healthy...non obese, in (relatively) good physical shape, no other comorbidities.
Except, for, uhhhh, an extremely f uk ked up aortic valve. Yeah, some LVH but not much else.
When I walked into the heart room that day I expected no drama. After all, whats the absolute most important factor in any successful heart surgery?
The heart surgeon.
If you've gotta rokk star, you, the anesthesiologist, collects your fee metaphorically similar to a kid skipping school. A dude walking into a bank with a Glock, exiting a few minutes later with a thousand benjamins.
In other words, its practically stealing.
If heart surgeon dude is a struggler,well, count on earning your loot.
Thankfully that day I was indeed working with a rokkstar. Quick, efficient, gifted. Predictable.
Note to self: When a rokkstar heart surgeon opens the chest, looks at the aortic root and starts mumbling under his breath, its time for you to LOCK AND LOAD.
Turns out, according to Rokkstar, patient dude shouldda had this operation 10 years ago but refused until now.
Seeing him shake his head as he readied the lines for bypass let me in on the sinister fact that I wasn't gonna steal my physician's fee today. I was gonna earn it.
Prior to induction: Attained patient somnolence with midazolam....6 mg divided. Cuppla big peripheral IVs. A line.
Induction:Glancing at the arterial waveform, I've got a great blood pressure and heart rate for Dude's disease process. 130/80. Heart rate 58. Wanna keep it that way, yes? Rocuronium 5 mg. Sufentanil 100ug. Etomidate around 16mg (couldda used propofol here...just less than normal). Dude goes apneic, succinylcholine 200mg. Ventilated, tubed. Crack the Sevo, give a stikka Vec, ventilator on. Trendelenberg, head to the left, right IJ TLC placed.

Hemodynamically stable. Nurses proceed with foley, prep and drape, blah blah blah.

Rokkstar proceeds.

Now we're back to the part above where I saw him mumbling after seeing and feeling the aorta.

"Its thin. Fragile." (unintelligible mumbling)

Rokkstar dissects and cannulates without incident.

Rokkstar voices somethings unusual about one of the coronary artery's point of origin, and how thats gonna affect myocardial preservation with retrograde pleg....can't make chicken salad outta chicken s h it, so he does his best.

We both know as a result of the patient's anomalous coronary artery anatomy there may be myocardium at risk during the bypass run, and theres not a goddamn thing that can be done about it.

Except be CDAZY fast.

Bypass ensues.

Rokkstar delivers with a new valve forty minutes later.

HERES WHERE IT GETS DICEY.

Last sutures in.

Cross clamp off.

V FIB.

No big deal, right?

Rokkstars just gonna insert the internal paddles, deliver a TAZER ZAP, NSR will ensue, and I'll be under the squat rack at Premier Health And Fitness in a hundred and ten minutes.

WRONG.

No dice.

Still v fib. try again. "BZZZZZZZZT I'M SORRY! WRONG ANSWER!"

Another shock.

Another failure. I'm still seeing a chaotic squiggly line on the monitor where a reflection of systematic myocardial electrical activity should be.

SO NOW ITS NEARING FIVE O CLOCK. MY LEG WORKOUT AT PREMIER FITNESS IS IN JEOPARDY AND I'M GETTING PISSED.

This is a great teaching case.

I don't need to teach you that if this dude remains in V fib he's gonna be sleeping on a dirt pillow soon. And to top it off, I'm gonna miss my leg workout.

Whats going through your mind at this point? What could've happened, controllable or uncontrollable? More importantly, what I just said is rhetoric, right? Because this is where we are now.

Refractory ventricular fibrillation after a very short pump run on a well preserved 60ish dude who looked fifty.

At least he looked that way before the operation.

WHAT NOW????

😱😱

 

[rsgillmd]

Electrolytes, specifically K OK? If you are shocking, I'm presuming you've already warmed to a reasonable temp, but nontheless worth looking at. Air in the chambers? Lido + Esmolol seemed to work well in the past for me when I've ruled out correctable causes. Had better success with defibrillation after that combo.

 

[Idiopathic]

I guess my quick and easy diff includes sever hyperkalemia or hypocalcemia (esp with resistance to defib), severe acidemia (unlikely as primary cause but could be present), air down a coronary, dissection down a coronary, still cold. could there be residual cardioplegia hanging around?

check lytes, give Ca and Mag, lidocaine, try to CV again...go back on pump i guess, check the coronaries

 

[Narcotized]

Electrolytes, specifically K OK? If you are shocking, I'm presuming you've already warmed to a reasonable temp, but nontheless worth looking at. Air in the chambers? Lido + Esmolol seemed to work well in the past for me when I've ruled out correctable causes. Had better success with defibrillation after that combo.

I know beta blockers help to prevent V. Fib in cardiac patients (such as post MI), but is it helpful in acute ventricular fibrillation?

 

[dhb]

I would add air embolism in the coronary arteries in the differential maybe a coronary artery dissection for the abnormal anatomy? Apart from the obvious causes cited the main reason for the V-fib is inadequate myocardial perfusion imho.

 

[badgas]

What is the temp? I had a case last week which was very similar. Asymptomatic 85 year old who looked like he was 50. Critical AS (0.3-0.4 cm2, peak gradient 90 mmhg). We attributed the refractory v.fib to inadequate rewarming since everything else was good. Gave mg 4 g, ca 1 g, amiodarone 300 mg. As soon as his temp hit 36.0 we were good.

 

[Planktonmd]

Jet mentioned an anomalous coronary artery so I think it's possible that the heart suffered ischemic injury during bypass.
At this point I think the next step should be some epinephrine while the cardiac surgeon is massaging the heart then try to shock again.

 

[rsgillmd]

I know beta blockers help to prevent V. Fib in cardiac patients (such as post MI), but is it helpful in acute ventricular fibrillation?

I don't know the science behind it. But I have seen it help. I didn't believe it until I saw it. One of my attendings said the purpose is more to decrease oxygen consumption by the heart, but I don't buy that. I can't imagine decreasing oxygen consumption much when the heart is not getting much flow to begin with.

I reread Jet's post now about the cross clamp being off. If simple measures don't work, it seems easier to just reapply the clamp and go back on full flow while you try to figure out what happened and if there is anything you can do about it.

 

[bullard]

Cool case...I think we all agree on making sure we're warm, checking lytes, amio, lido, calcium.

So then what happened?

 

[sevo85288]

nice case. thanks jet. rule out everything that has been mentioned. give Amioderone 150mg.
you didn't mention TEE or PAC.... Do you use TEE or PACs for these cases? We do...

 

[SleepIsGood]

Check lytes like everyone said. Make sure this is VFIB and not Torsades.

Check out TEE. Maybe that anomalous coronary got knocked out.

Hey Jet, another q. When I reread this,I was wondering, why did you use 200 mg of Succinycholine? You said he's not obese and relatively healthy looking...that' a 'hefty' dose.

 

[bullard]

Check lytes like everyone said. Make sure this is VFIB and not Torsades.

Check out TEE. Maybe that anomalous coronary got knocked out.

Hey Jet, another q. When I reread this,I was wondering, why did you use 200 mg of Succinycholine? You said he's not obese and relatively healthy looking...that' a 'hefty' dose.

I was sorta wondering about this too. Why not just give 80-90 mg of rocuronium and put the tube in? Unless you wanted to do sux because of worries about the airway or something but I didn't see anything about that in the original post.

 

[urge]

Rokkstar voices somethings unusual about one of the coronary artery's point of origin, and how thats gonna affect myocardial preservation with retrograde pleg

Anyone intrigued by that statement?

 

[Planktonmd]

Anyone intrigued by that statement?

Yes!

Jet mentioned an anomalous coronary artery so I think it's possible that the heart suffered ischemic injury during bypass.
At this point I think the next step should be some epinephrine while the cardiac surgeon is massaging the heart then try to shock again.

 

[UTSouthwestern]

Go back on CPB, bypass the oversewn RCA, try again, assuming all other treatable causes are examined quickly.

 

[urge]

I'll just sit on the sidelines and wait for jet to update.

I imagine it will have to do with the anomalous coronary but I need to picture it.

😕

 

[Idiopathic]

yeah i think we can predict that the patient was warm and the lytes were normal. we seem to all agree that the coronary is involved

im assuming no mention was made of high retrograde pressures indicating malposition of the cannula, etc

 

[ProRealDoc]

Did a difficult AVR the other day on a 62 year old dude...who looked 50...with critical aortic stenosis.
It is rare that we are confronted with such an ominous disease process within a patient that appears quite healthy...non obese, in (relatively) good physical shape, no other comorbidities.
Except, for, uhhhh, an extremely f uk ked up aortic valve. Yeah, some LVH but not much else.
When I walked into the heart room that day I expected no drama. After all, whats the absolute most important factor in any successful heart surgery?
The heart surgeon.
If you've gotta rokk star, you, the anesthesiologist, collects your fee metaphorically similar to a kid skipping school. A dude walking into a bank with a Glock, exiting a few minutes later with a thousand benjamins.
In other words, its practically stealing.
If heart surgeon dude is a struggler,well, count on earning your loot.
Thankfully that day I was indeed working with a rokkstar. Quick, efficient, gifted. Predictable.
Note to self: When a rokkstar heart surgeon opens the chest, looks at the aortic root and starts mumbling under his breath, its time for you to LOCK AND LOAD.
Turns out, according to Rokkstar, patient dude shouldda had this operation 10 years ago but refused until now.
Seeing him shake his head as he readied the lines for bypass let me in on the sinister fact that I wasn't gonna steal my physician's fee today. I was gonna earn it.
Prior to induction: Attained patient somnolence with midazolam....6 mg divided. Cuppla big peripheral IVs. A line.
Induction:Glancing at the arterial waveform, I've got a great blood pressure and heart rate for Dude's disease process. 130/80. Heart rate 58. Wanna keep it that way, yes? Rocuronium 5 mg. Sufentanil 100ug. Etomidate around 16mg (couldda used propofol here...just less than normal). Dude goes apneic, succinylcholine 200mg. Ventilated, tubed. Crack the Sevo, give a stikka Vec, ventilator on. Trendelenberg, head to the left, right IJ TLC placed.

Hemodynamically stable. Nurses proceed with foley, prep and drape, blah blah blah.

Rokkstar proceeds.

Now we're back to the part above where I saw him mumbling after seeing and feeling the aorta.

"Its thin. Fragile." (unintelligible mumbling)

Rokkstar dissects and cannulates without incident.

Rokkstar voices somethings unusual about one of the coronary artery's point of origin, and how thats gonna affect myocardial preservation with retrograde pleg....can't make chicken salad outta chicken s h it, so he does his best.

We both know as a result of the patient's anomalous coronary artery anatomy there may be myocardium at risk during the bypass run, and theres not a goddamn thing that can be done about it.

Except be CDAZY fast.

Bypass ensues.

Rokkstar delivers with a new valve forty minutes later.

HERES WHERE IT GETS DICEY.

Last sutures in.

Cross clamp off.

V FIB.

No big deal, right?

Rokkstars just gonna insert the internal paddles, deliver a TAZER ZAP, NSR will ensue, and I'll be under the squat rack at Premier Health And Fitness in a hundred and ten minutes.

WRONG.

No dice.

Still v fib. try again. "BZZZZZZZZT I'M SORRY! WRONG ANSWER!"

Another shock.

Another failure. I'm still seeing a chaotic squiggly line on the monitor where a reflection of systematic myocardial electrical activity should be.

SO NOW ITS NEARING FIVE O CLOCK. MY LEG WORKOUT AT PREMIER FITNESS IS IN JEOPARDY AND I'M GETTING PISSED.

This is a great teaching case.

I don't need to teach you that if this dude remains in V fib he's gonna be sleeping on a dirt pillow soon. And to top it off, I'm gonna miss my leg workout.

Whats going through your mind at this point? What could've happened, controllable or uncontrollable? More importantly, what I just said is rhetoric, right? Because this is where we are now.

Refractory ventricular fibrillation after a very short pump run on a well preserved 60ish dude who looked fifty.

At least he looked that way before the operation.

WHAT NOW????

😱😱

back on pump, drop in TEE to see what's cooking.

 

[Coastie]

we've got jet and utsw on this thread? What is this, 2006?

 

[bigdan]

we've got jet and utsw on this thread? What is this, 2006?

Danny like.

 

[racerx]

we've got jet and utsw on this thread? What is this, 2006?

A good thing!!! 👍

Although jet and I had an "ancient-history" disagreement, I find he has some great cases and insight and look forward to him and UTSW doin' some teachin' of us newbies.

Welcome back and please stay a while!

 

[jetproppilot]

WOW. My faith in residency education has been somewhat restored.

We all think the same things when a clinical scenario goes awry.

Which also reenforces the value of SDN Anesthesia as an educational tool for my resident colleagues, my attending colleagues, and myself.

And, since the above is true, next time I'm in a bind I'm gonna put out an S.O.S. from my Droid in real time.

Maybe I didnt make myself clear about part of the case since a cuppla posters suggested going back on bypass. Thats absolutely a great option if you've come off bypass. We weren't off bypass when s hit hit the fan. The aortic cross clamp had been removed. Ventricular fibrillation ensued. We were still on full bypass.

Yeah, that should comfort you a little, but not alot. Gives you some time to sort out whats going on and figure out a game plan, but

remember the esoteric biochemistry from undergrad and med school? Of course you do. Probably better than I.

V fib is an energy consuming process. It eats ATP faster than Kirstie Alley eats tacos at an all-you-can-eat mexican buffet. Which is bad for the myocardium. And for Kirstie.

The longer a myocardium experiences V fib, the more ATP is consumed.

Myocardium deplete of ATP stores is essentially dead... at some pivotal point there will be a point of no return. The goal is to convert to another rhythm as quickly as possible.

So yeah, if you are off bypass and a lethal arrhythmia ensues, assuming you're still cannulated, like the posters suggested, go back on bypass. I wanna emphasize tho that if you are still on bypass and v fib ensues, you should still feel the tick tock...tick tock...dude will still die (on bypass) if you can't convert v fib.

We did most of what all of you suggested. The only abnormal electrolyte was K+....6.0...a little high but not enough to explain the situation. We of course treated it. Calcium had already been given. Mg had already been given.

When it comes to sinister ventricular arrhythmias, I'm a lidocaine fan. Immediately after v fib ensued the pump tech astutely threw in lidocaine 100mg and we started a drip at 2mg/min. After a couple minutes and a few in-vain shocks, I suggested we bring serum lidocaine levels to maximum therapeutic range (or close anyway) so another 100mg was given and drip was increased to 4 mg/min.

There was a slight base deficit (-3) which was corrected.

Realize while you are reading this that this whole scenario took place over probably 12-15 minutes. Seems longer as you read a narrative, I know. Bad situations are rarely chronologically lengthy.

Rokkstarr continues his electrical onslaught.

Tommy the CRNA is calling out the internal shocks:

"Charging at fifty. Ready! Charge delivered."

Thankfully on the last of this triad of shocks the patient's rhythm changed.

Dr Tubb and I, literally frozen in position, stared hopefully at the monitor.

Time stood still as we willed a rhythm to appear. We were awarded with a slow supraventricular rhythm at about 58, albeit with a wide QRS complex.

I believe in keeping situations light, independent of stress level, which explains the following interaction between Dr Tubb and I, word for word btw:

Jet: "Looks good, Dr Tubb!"

Dr Tubb (kinda annoyed): "With that QRS complex?"

Jet: "Dude, we were just in v fib for a long time and now we've got THAT. So it looks good, yes?"

Sometimes...no...most times....conveying an engaged, yet relaxed persona makes everything easier.

We sat on bypass for ten minutes, simultaneously starting an epinephrine infusion.

Slowly, bypass was subsequently weaned. Successfully.

Dude made it to the ICU hemodynamically stable on a 10ug/min epi drip, which isnt an outlandish dose of epi. I'll give you an update on his status when I return to work next week.

Alotta good things came outta this thread. I wanna take this opportunity to say that every time...EVERY..SINGLE...TIME you are close to weaning from bypass, a checklist should emerge in your head:

1)Have I resumed ventilation?
2)Is the patient normothermic?If not, wait.
3)Is there an acceptable intrinsic or paced rhythm that will survive once bypass is terminated?
4)Do I have a blood pressure of at least 90 systolic and a heart rate around 80-90?
5)Are electrolytes OK? Did I give Mg when rewarming? Is the K+ from the cardioplegia gone? Calcium OK?
6)Am I ensuring amnesia after the pump tech turns off his vaporizer?(I like giving midazolam when rewarming...in addition to Mg and more non depolarizer)

This is my checklist. Very similar to landing an aircraft, where you ensure landing gear down, lights on, props forward, flaps at appropriate position, seatbelts, radio call....

I'm sure you're asking: "JET, WTF? WHY REFRACTORY V FIB?"

Dudes, I don't know. I have an opinion. Thats all.

I can assure you we didnt miss anything. Electrolyte imbalance wasnt the answer. We checked. Yeah, the K was 6.0 but IMHO that doesnt cause refractory v fib. Mg was given. Ca was given. There existed no overwhelming acidosis.

I'm convinced that because of the patient's anomalous coronary anatomy...the anatomy that alarmed Dr Rokkstarr....that despite best efforts at myocardial preservation for the bypass run....because of said patient's anatomy, myocardial preservation for the pump run was incomplete, leading to a partial "shocked" myocardium, deplete of ATP....which lead to a lethal ventricular arrythmia we almost couldn't reverse.

I think raising the lidocaine level raised the patient's fibrillation threshold enough to allow successful defibrillation.

I think staying on bypass for a (short) while after accomplishing a survivable rhythm enabled the "shocked" portion of myocardium to recover enough to endure bypass separation.

Cuppla you dudes astutely asked why I gave 200mg sux. Good question! Turns out my normal "regular dose" for the last cuppla months has lead to bucking...don't know if we've got a bad lot at my institution or what...I've compensated for that...on patients I'm not airway-worried...by giving the whole stick. And why not give 90mg roc? Certainly an option. In my experience, if youre looking for speed, sux is like no other. I like sux. I use it unless theres a contraindication.

I'm sure I've left some stuff out. Looking forward to interacting with you on this thread.

Thats how it went down.👍

 

[jetproppilot]

A good thing!!! 👍

Although jet and I had an "ancient-history" disagreement, I find he has some great cases and insight and look forward to him and UTSW doin' some teachin' of us newbies.

Welcome back and please stay a while!

Thanks, Dude.

Looking forward to interacting with you and my other colleagues as well.

 

[canjosh]

V fib is an energy consuming process. It eats ATP faster than Kirstie Alley eats tacos at an all-you-can-eat mexican buffet. Which is bad for the myocardium. And for Kirstie.

I will remember this little teaching pearl...forever! 👍

 

[jetproppilot]

Go back on CPB, bypass the oversewn RCA, try again, assuming all other treatable causes are examined quickly.

Wonderful to hear from you.

 

[sevo85288]

thanks jet. Your check list is good. I would add HGB to that; want to ensure O2 delivery is adequate to already ischemic myocardium that is being asked to deliver output. TEE is not as helpful in vfib, but can aid in excluding certain things. massive air, thrombus, anatomic anomalies, etc... I am a big believer in following Lido, and Mg with Amiodarone 150 mg. ASAP in these cases. Also, what joules do you like to start shocking with. We rarely use more than 10 joules of direct current to myocardium.

 

[jetproppilot]

thanks jet. Your check list is good. I would add HGB to that; want to ensure O2 delivery is adequate to already ischemic myocardium that is being asked to deliver output. TEE is not as helpful in vfib, but can aid in excluding certain things. massive air, thrombus, anatomic anomalies, etc... I am a big believer in following Lido, and Mg with Amiodarone 150 mg. ASAP in these cases. Also, what joules do you like to start shocking with. We rarely use more than 10 joules of direct current to myocardium.

Thank YOU, Sevo.

HEMOGLOBIN!!!

TOLDJA I'D FORGET TO MENTION SOME IMPORTANT STUFF!!

 

[dhb]

Did you have a TEE probe for the case?
Any ST changes associated with the widened QRS?
I still like the bubbles in the coronary theory especially considering the timing of events...

 

[coldweatherblue]

Thanks for taking the time to post these cases. As an MS2, I don't have many answers, but reading the explanations and putting together all that pathophys/pharm in a practical scenario is really useful for me at this stage. 👍

 

[IN2B8R]

Take this hint from a cardiac guy: learn TEE. You can easily visualize your cardioplegia in real time via TEE--a lost art, but obviously could have been helpful to you. I do TEE on all valve cases and trashed EF's. I also have a rock star in the OR too, but even a 20-30 min pump run can ruin a previously healthy myocardium.

WOW. My faith in residency education has been somewhat restored.

We all think the same things when a clinical scenario goes awry.

Which also reenforces the value of SDN Anesthesia as an educational tool for my resident colleagues, my attending colleagues, and myself.

And, since the above is true, next time I'm in a bind I'm gonna put out an S.O.S. from my Droid in real time.

Maybe I didnt make myself clear about part of the case since a cuppla posters suggested going back on bypass. Thats absolutely a great option if you've come off bypass. We weren't off bypass when s hit hit the fan. The aortic cross clamp had been removed. Ventricular fibrillation ensued. We were still on full bypass.

Yeah, that should comfort you a little, but not alot. Gives you some time to sort out whats going on and figure out a game plan, but

remember the esoteric biochemistry from undergrad and med school? Of course you do. Probably better than I.

V fib is an energy consuming process. It eats ATP faster than Kirstie Alley eats tacos at an all-you-can-eat mexican buffet. Which is bad for the myocardium. And for Kirstie.

The longer a myocardium experiences V fib, the more ATP is consumed.

Myocardium deplete of ATP stores is essentially dead... at some pivotal point there will be a point of no return. The goal is to convert to another rhythm as quickly as possible.

So yeah, if you are off bypass and a lethal arrhythmia ensues, assuming you're still cannulated, like the posters suggested, go back on bypass. I wanna emphasize tho that if you are still on bypass and v fib ensues, you should still feel the tick tock...tick tock...dude will still die (on bypass) if you can't convert v fib.

We did most of what all of you suggested. The only abnormal electrolyte was K+....6.0...a little high but not enough to explain the situation. We of course treated it. Calcium had already been given. Mg had already been given.

When it comes to sinister ventricular arrhythmias, I'm a lidocaine fan. Immediately after v fib ensued the pump tech astutely threw in lidocaine 100mg and we started a drip at 2mg/min. After a couple minutes and a few in-vain shocks, I suggested we bring serum lidocaine levels to maximum therapeutic range (or close anyway) so another 100mg was given and drip was increased to 4 mg/min.

There was a slight base deficit (-3) which was corrected.

Realize while you are reading this that this whole scenario took place over probably 12-15 minutes. Seems longer as you read a narrative, I know. Bad situations are rarely chronologically lengthy.

Rokkstarr continues his electrical onslaught.

Tommy the CRNA is calling out the internal shocks:

"Charging at fifty. Ready! Charge delivered."

Thankfully on the last of this triad of shocks the patient's rhythm changed.

Dr Tubb and I, literally frozen in position, stared hopefully at the monitor.

Time stood still as we willed a rhythm to appear. We were awarded with a slow supraventricular rhythm at about 58, albeit with a wide QRS complex.

I believe in keeping situations light, independent of stress level, which explains the following interaction between Dr Tubb and I, word for word btw:

Jet: "Looks good, Dr Tubb!"

Dr Tubb (kinda annoyed): "With that QRS complex?"

Jet: "Dude, we were just in v fib for a long time and now we've got THAT. So it looks good, yes?"

Sometimes...no...most times....conveying an engaged, yet relaxed persona makes everything easier.

We sat on bypass for ten minutes, simultaneously starting an epinephrine infusion.

Slowly, bypass was subsequently weaned. Successfully.

Dude made it to the ICU hemodynamically stable on a 10ug/min epi drip, which isnt an outlandish dose of epi. I'll give you an update on his status when I return to work next week.

Alotta good things came outta this thread. I wanna take this opportunity to say that every time...EVERY..SINGLE...TIME you are close to weaning from bypass, a checklist should emerge in your head:

1)Have I resumed ventilation?
2)Is the patient normothermic?If not, wait.
3)Is there an acceptable intrinsic or paced rhythm that will survive once bypass is terminated?
4)Do I have a blood pressure of at least 90 systolic and a heart rate around 80-90?
5)Are electrolytes OK? Did I give Mg when rewarming? Is the K+ from the cardioplegia gone? Calcium OK?
6)Am I ensuring amnesia after the pump tech turns off his vaporizer?(I like giving midazolam when rewarming...in addition to Mg and more non depolarizer)

This is my checklist. Very similar to landing an aircraft, where you ensure landing gear down, lights on, props forward, flaps at appropriate position, seatbelts, radio call....

I'm sure you're asking: "JET, WTF? WHY REFRACTORY V FIB?"

Dudes, I don't know. I have an opinion. Thats all.

I can assure you we didnt miss anything. Electrolyte imbalance wasnt the answer. We checked. Yeah, the K was 6.0 but IMHO that doesnt cause refractory v fib. Mg was given. Ca was given. There existed no overwhelming acidosis.

I'm convinced that because of the patient's anomalous coronary anatomy...the anatomy that alarmed Dr Rokkstarr....that despite best efforts at myocardial preservation for the bypass run....because of said patient's anatomy, myocardial preservation for the pump run was incomplete, leading to a partial "shocked" myocardium, deplete of ATP....which lead to a lethal ventricular arrythmia we almost couldn't reverse.

I think raising the lidocaine level raised the patient's fibrillation threshold enough to allow successful defibrillation.

I think staying on bypass for a (short) while after accomplishing a survivable rhythm enabled the "shocked" portion of myocardium to recover enough to endure bypass separation.

Cuppla you dudes astutely asked why I gave 200mg sux. Good question! Turns out my normal "regular dose" for the last cuppla months has lead to bucking...don't know if we've got a bad lot at my institution or what...I've compensated for that...on patients I'm not airway-worried...by giving the whole stick. And why not give 90mg roc? Certainly an option. In my experience, if youre looking for speed, sux is like no other. I like sux. I use it unless theres a contraindication.

I'm sure I've left some stuff out. Looking forward to interacting with you on this thread.

Thats how it went down.👍

 

[urge]

You can easily visualize your cardioplegia in real time via TEE--a lost art, but obviously could have been helpful to you.

Say that again?

 

[IN2B8R]

Say that again?

You can visualize the cardioplegia solution going down the coronary arteries via TEE. Sounds like you have not done that before?

 

[urge]

You can visualize the cardioplegia solution going down the coronary arteries via TEE.

Say that again?

 

[Idiopathic]

ive been told that it can be done but havent seen it myself

 

[IN2B8R]

Say that again?

I'll b*tch slap you if you type that again.

 

[urge]

Say that aga....


naahhh!

Nevermind.

jk. Never seen it. Don't know how it would help. You might see flow in the ostia, maybe the LM, maybe the bifurcation, but that doesn't warranty the myocardium will get perfused. That's why we still cath people, do nuclear studies...., right?

 

[IN2B8R]

You are right on, bro'👍. But seeing the stuff go down the coronary arteries is still helpful: there was a mention in the original post that there was an anamolous coronary vessel--that's something that I would have investigated further with the help of TEE... Furthermore, I assumed that the patient in the original presentation had no CAD and came in only for the AVR.... But you are right, though, just because you see flow into the coronary arteries, there is no guarantee that it is getting beyond all blockages and protecting the myocardium.... I tend to rely on a cold, decompressed, still and dead heart (flat lined) as the best indicator of good myocardium preservation. That said, it never hurts to look and see that the preservant is shot down the right "tube," though.

Say that aga....


naahhh!

Nevermind.

jk. Never seen it. Don't know how it would help. You might see flow in the ostia, maybe the LM, maybe the bifurcation, but that doesn't warranty the myocardium will get perfused. That's why we still cath people, do nuclear studies...., right?