EL Mitral Stenosis

[VentdependenT]

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65 year vato with MET greater than 4, GERD, Asthma (never intubated), Mitral Stenosis with a valve area around 1.2 cm2, and in A FIB with rate control (buh bye atrial kick). No signs or symptoms of CHF.

The surgery; x lap fer SBO.

As a CA-1 I was concerned but everything went ok.

To you experts or novices, would you care to elicit the worries and management of this patient during the operation. I can tell you that an A-Line was placed, zero inhalational agent on board. Rocked it from there. In fact I had a similar patient the following morning.

Getten me feet wet.

 

[militarymd]

65 year vato with MET greater than 4, GERD, Asthma (never intubated), Mitral Stenosis with a valve area around 1.2 cm2, and in A FIB with rate control (buh bye atrial kick). No signs or symptoms of CHF.

The surgery; x lap fer SBO.

As a CA-1 I was concerned but everything went ok.

To you experts or novices, would you care to elicit the worries and management of this patient during the operation. I can tell you that an A-Line was placed, zero inhalational agent on board. Rocked it from there. In fact I had a similar patient the following morning.

Getten me feet wet.

You said it all there. Nothing to worry about.

In general, Cardiac output and O2 requirements decrease during anesthesia, so the risks of acute pulmonary edema (per Gorling equation) is relative lylow....and if it does occur...who cares...patient is intubated...take him over to ICU for the intensivist to deal with it.

 

[VentdependenT]

Ran it by attending and here's how it went.

Modified RSI. Etomidate .2mg/kg. Fentanyl 250mcg, Versed 2,2,1. Lidocaine for the uniform pvc trigeminy. ETube.

Agent you ask? Its called fentanyl and versed. No nitrous for fear o' the increased pulm htn. No potent inh agent for fear o' decreased afterload, preload and reflex tachy. Slugged in around 5mcg/kg of fentanyl up front. Kept twitches at 2/4 with sustained tetany by end o case without reversal needed to be given. Titrated in versed by totally ambiguous feelings per me. Ended up getten around 15 mg total for the case (case lasted 1.5 hrs). Had to use a wee bit o' narcan at the end (20mcg). Kept maps within 20% o' the original. Pt woke up happy and without cardiovascular embarrasement.

MMD, of course, made things simple as above. That wise son of a #*&^$.

 

[militarymd]

wait until you get out of academics and get a bunch of asa 4s under your belt.


The above case will be done like this:

propofol
sux
tube
O2/air/des/fent
vec

neostigmine and glycopyyrolate to finish it off.

 

[2ndyear]

This sounds like a good case for a remifentanyl infusion. Turn it on, crank it up and then titrate some longer acting narcotics towards the end. Could you argue that a BIS monitor would be helpful in titrating the anesthetic in this case?

 

[Noyac]

wait until you get out of academics and get a bunch of asa 4s under your belt.


The above case will be done like this:

propofol
sux
tube
O2/air/des/fent
vec

neostigmine and glycopyyrolate to finish it off.

Exactly!

There is nothing special about this case, you will be doing them quite often. Don't get cute with the anesthetic. Personally, I would not have done it the way you guys did but that may be why I am in Private Practice. So you mentioned pulm HTN but the only thing I really worry about is tachycardia with MS. OK, not the only thing but the one thing that will get you in trouble. Now you are using versed and fentanyl for GA which in an elderly pt will prove difficult to titrate. You guys had to use narcan to wake the pt up and that could have caused some tachycardia due to pain. Then you would have had to treat that and possibly the pulm edema related to the tachycardia. All this dancing around could have been avoided with the technique Mil mentioned.

 

[The_Sensei]

wait until you get out of academics and get a bunch of asa 4s under your belt.


The above case will be done like this:

propofol
sux
tube
O2/air/des/fent
vec

neostigmine and glycopyyrolate to finish it off.

So true!

 

[IN2B8R]

wait until you get out of academics and get a bunch of asa 4s under your belt.


The above case will be done like this:

propofol
sux
tube
O2/air/des/fent
vec

neostigmine and glycopyyrolate to finish it off.

Don't know about the propofol as a good induction agent in this particular case. Can you make a good argument for it? I am indeed aware that you can get away with using it, but, in my personal opinion, there are better agents....

 

[The_Sensei]

Don't know about the propofol as a good induction agent in this particular case. Can you make a good argument for it? I am indeed aware that you can get away with using it, but, in my personal opinion, there are better agents....

Just give a little less than a full induction dose......if the BP drops, hit 'em with some Neo.

Peace out

 

[militarymd]

Don't know about the propofol as a good induction agent in this particular case. Can you make a good argument for it? I am indeed aware that you can get away with using it, but, in my personal opinion, there are better agents....

Why is propofol not a good induction agent for this patient?

What would be better?

 

[jetproppilot]

Don't know about the propofol as a good induction agent in this particular case. Can you make a good argument for it? I am indeed aware that you can get away with using it, but, in my personal opinion, there are better agents....

Great interaction of two philosophies on this thread, and looking back on my residency, I learned all the theoretical reasons why you "can't" use certain agents in certain situations, or how certain agents are "better" than others in certain situations. Yes, cases exist where one must select very carefully, but academic medicine goes overboard in this regard.

The propofol debate for example...there is no literature showing increased morbidity/mortality in a case like this. There IS literature showing it is a very versatile induction agent if the clinician adjusts the dose accordingly.

Private practice dudes are not cowboys in comparison to academic attendings. We've just figured out how to do cases more efficiently while keeping the same safety profile.

Next time your attending tells you you NEED an A-line, or a SWAN, or you NEED to use etomidate, etc, be the devil's advocate, and ask yourself, why? Then try and find substantiation for the decision. I think what you'll find is that alot of time is being wasted.

You need an a-line for a carotid. CABG. Valve case. You dont for a fem-pop.

There are very, very few operative cases where you need a SWAN, CABGs included.

There are very few cases where you need to use one particular induction agent over the other, as long as you tailor the dose of what you're using accordingly.

 

[militarymd]

Can you make a good argument for it? I am indeed aware that you can get away with using it, but, in my personal opinion, there are better agents....

Can you make a good argument against using propoful?

 

[VentdependenT]

Exactly!

There is nothing special about this case, you will be doing them quite often. Don't get cute with the anesthetic. Personally, I would not have done it the way you guys did but that may be why I am in Private Practice. So you mentioned pulm HTN but the only thing I really worry about is tachycardia with MS. OK, not the only thing but the one thing that will get you in trouble. Now you are using versed and fentanyl for GA which in an elderly pt will prove difficult to titrate. You guys had to use narcan to wake the pt up and that could have caused some tachycardia due to pain. Then you would have had to treat that and possibly the pulm edema related to the tachycardia. All this dancing around could have been avoided with the technique Mil mentioned.

Word.

You guys always get me thinking.

I didn't feel this was a special case but valvular heart disease and anesthetic management is a worthwhile topic.

 

[militarymd]

I'm going to bump a good thread up.

 

[jetproppilot]

Word.

You guys always get me thinking.

I didn't feel this was a special case but valvular heart disease and anesthetic management is a worthwhile topic.

Venty,

An anesthesia resident, even one with an IQ of 160 like you, will emerge from residency thinking like the attendings that taught you your trade.

Asking yourself "why?" frequently will make you a better anesthesiologist.

 

[Noyac]

1<a href='http://www.smileycentral.com/?partner=ZSzeb008_ZNxmk502YYUS' target='_blank'><img src='http://smileys.smileycentral.com/cat/36/36_17_4.gif' border=0></a>

 

[Laryngospasm]

Agree that often academic medicine goes overboard, I do think however that if we only did procedures on those who needed them how would we learn to do them 😛

 

[jetproppilot]

Agree that often academic medicine goes overboard, I do think however that if we only did procedures on those who needed them how would we learn to do them 😛

TOTALLY agree, but at least they could say "Dude, this is a soft call"... as opposed to "THIS IS ABSOLUTELY HOW THIS CASE SHOULD BE DONE. IN THE NAME OF THE FATHER, THE SON, AND (place your favorite academic MD here)."

 

[IN2B8R]

Can you make a good argument against using propoful?

Tachycardia that results from a lowered SVR comes to mind.

 

[Laryngospasm]

Tachycardia that results from a lowered SVR comes to mind.

Ive seen tachycardia with etomidate just as often on induction, often avoiding the hypotension, but often with hypertension, just a thought.

 

[militarymd]

Ive seen tachycardia with etomidate just as often on induction, often avoiding the hypotension, but often with hypertension, just a thought.

You beat to it.

I actually see tachycardia more often with etomidate.

 

[IN2B8R]

Ive seen tachycardia with etomidate just as often on induction, often avoiding the hypotension, but often with hypertension, just a thought.

To be honest with you, I generally induce with fentanyl and a trivial amount of Etomidate. But that is what have adapted to my practice. Generally speaking, as noted by others who have already alluded to this, this particular patient is fairly functional and can easily handle carefully administered propofol. My commentary was only meant to illicit other practisioners experiences.

Best regards.