GI Lab Case

[aredoubleyou]

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59 yo man for endoscopic ultrasound and biopsy of pancreatic mass, did not tolerate with sedation nurse using demerol and midazolam. positioning is lateral, GI fellow says will take 10 min, but will probably last 20-40 minutes realistically.

No medical records or labs. All care up to now at a variety of OSH's.

Past medical hx per pt:
CV: 5 MI's, last one a month ago and was "small." Got a cath that time with 85% blockage of something but they didnt do anything about it. One year ago had MI requiring a few days in the ICU on a ventilator. Says he has CHF, on no diuretics, lots of anti-HTN meds. Uses NTG once evry one to two weeks for sharp left chest pain. Has to take a break walking up stars usually due to DOE. Never hospitalized for CHF exacerbation.

Pulm: COPD, heavy smoker forever, daily cough with brown sputum. No fevers. No oxygen at night. Only on spiriva.

Neuro: Says dx w/ head mass that was not a tumor but has caused him to have seizures, last one 1 month ago. On meds.

Renal: About a year or two ago hospitalized for hyperkalaemia secondary to renal failure. Never happened again. Never on dialysis.

GI: Daily Gerd, worse when supine, breaks through PPI which he uses daily.

Never had surgery

Physical Exam: Appears healthy from the door, mildly thin. S1,2, systolic murmur greatest at apex. Lungs very distant, but basically clear. No peripheral oedema, no ascites...looks healthy otherwise. Mildly enlarged neck strap muscles, but breathing comfortably while talking. Airway: very limited neck extention, possibly limited by pain, MP2.

No labs, no records. ECG is sinus with Q on III, various inverted/ flattened T waves.

Came in from three hours away.

Would you cancel? Do the case? How would you do it?

 

[Planktonmd]

Do some topical anesthesia to the mouth and pharynx then titrate some Propofol.
Why do you want to cancel?

 

[Leverage]

I would be very worried about his recent MI and little to no baseline cardiac/pulm reserve (which we no very little about) for an elective procedure...Dude has ischemic heart dz with recent insult, current abnormal EKG with no old EKG to compare to...Gut is telling me this is not very safe.

Plank, why is this a simple it's a go for you???

 

[jwk]

I would be very worried about his recent MI and little to no baseline cardiac/pulm reserve (which we no very little about) for an elective procedure...Dude has ischemic heart dz with recent insult, current abnormal EKG with no old EKG to compare to...Gut is telling me this is not very safe.

Plank, why is this a simple it's a go for you???

Better question - why not? 😉

Do you think he's ever going to be tuned up better than he is now?

Of course it's not safe, but it's NEVER going to be safe in this guy. He's at high risk from any number of things. How safe do you think it is to do EGD's for chronic alcoholic smokers with bleeding varices, which we see all the time?

Topicalize, judicious dinks of propofol, tell the GI guy to be on his best behavior and not dick around, and get it over with ASAP.

 

[pgg]

an elective procedure

It's elective, yes, but there are shades of elective. The guy's got a mass. There's really nothing to tune up, and an anesthesia delay of his biopsy carries the risk of reducing the success of any future treatment aimed at cure or palliation.

I would have done the case. Frank discussion with patient, risks & benefits, etc etc.

 

[Planktonmd]

Plank, why is this a simple it's a go for you???

Patient most likely has pancreatic cancer but needs a confirmed diagnosis so some meaningful treatment could start.
Even if you think he is not optimized to undergo an endoscopy his first priority now is to address his pancreatic cancer.
Attempting to optimize him medically while ignoring the disease that is most likely going to kill him does not make sense.

 

[2win]

59 yo man for endoscopic ultrasound and biopsy of pancreatic mass, did not tolerate with sedation nurse using demerol and midazolam. positioning is lateral, GI fellow says will take 10 min, but will probably last 20-40 minutes realistically.

No medical records or labs. All care up to now at a variety of OSH's.

Past medical hx per pt:
CV: 5 MI's, last one a month ago and was "small." Got a cath that time with 85% blockage of something but they didnt do anything about it. One year ago had MI requiring a few days in the ICU on a ventilator. Says he has CHF, on no diuretics, lots of anti-HTN meds. Uses NTG once evry one to two weeks for sharp left chest pain. Has to take a break walking up stars usually due to DOE. Never hospitalized for CHF exacerbation.

Pulm: COPD, heavy smoker forever, daily cough with brown sputum. No fevers. No oxygen at night. Only on spiriva.

Neuro: Says dx w/ head mass that was not a tumor but has caused him to have seizures, last one 1 month ago. On meds.

Renal: About a year or two ago hospitalized for hyperkalaemia secondary to renal failure. Never happened again. Never on dialysis.

GI: Daily Gerd, worse when supine, breaks through PPI which he uses daily.

Never had surgery

Physical Exam: Appears healthy from the door, mildly thin. S1,2, systolic murmur greatest at apex. Lungs very distant, but basically clear. No peripheral oedema, no ascites...looks healthy otherwise. Mildly enlarged neck strap muscles, but breathing comfortably while talking. Airway: very limited neck extention, possibly limited by pain, MP2.

No labs, no records. ECG is sinus with Q on III, various inverted/ flattened T waves.

Came in from three hours away.

Would you cancel? Do the case? How would you do it?

" did not tolerate with sedation nurse using demerol and midazolam." - you'll do much better.
The problem is that you cannot improve his medical conditions. Otherwise a delay wouldn't be a problem. The life expectancy unfortunately doesn't sound great...

 

[Jeff05]

high risk patient - high risk of ischemia during procedure. avoid decreased myocardial oxygen supply and increased consumption. so avoid hypoxia, hypotension/hypertension, tachycardia, volume overload.


doesn't sound like his CHF is acute or decompensated, so i would beta block him to the max. make sure he has his nitro paste on. have a stick of phenylephrine and nitro ready. propofol infusion with bits of fentanyl.


this is NOT a fellow procedure. attending must do this one.

 

[cchoukal]

I agree with points already mentioned, but would add that I always like to know what "failed sedation" means. Sometimes they wiggle and the procedure, and other times it's respiratory depression and cardiac arrest (true). The answer may inform my plan.

 

[Arch Guillotti]

I wouldn't sweat this one too much. He is never gonna be "tuned up". Discuss the usual risks/benefits with him.

This scenario is not uncommon - when no real records are available. I have had this situation happen a few times and a couple of these times I have called the cardiologists office directly. I have found this to be the best way to get objective information, cath, EF, etc.

Coming from 3 hours away is a big deal. if you turn him away he may never come back.

 

[Leverage]

I agree that pt is in all likely hood as optimized as he will ever be... To be honest things likely gonna get a whole lot worse for him. I was more thinking on the lines of getting some med records from osh/cardiologist/ect as Arch mentioned. Maybe could help formulate a good plan and getting a feeling of what your about to step into. Jeff05 pretty much summed up the goals during the procedure but being brand new as a CA-1 I was just thinking I should get a better idea about some of his physiology (whats this systolic murmur about, EF, diastolic dysfunction vs systolic, pulmonary artery pressures ect...) Maybe it dosn't end up altering the plan and more just treats my anxiety being so new to the game.

 

[Consigliere]

I agree that pt is in all likely hood as optimized as he will ever be... To be honest things likely gonna get a whole lot worse for him. I was more thinking on the lines of getting some med records from osh/cardiologist/ect as Arch mentioned. Maybe could help formulate a good plan and getting a feeling of what your about to step into. Jeff05 pretty much summed up the goals during the procedure but being brand new as a CA-1 I was just thinking I should get a better idea about some of his physiology (whats this systolic murmur about, EF, diastolic dysfunction vs systolic, pulmonary artery pressures ect...) Maybe it dosn't end up altering the plan and more just treats my anxiety being so new to the game.

You'll feel differently when you are an attending. As mentioned above, pt is as good as he is going to get. It's a low risk procedure in a high risk pt...I do these cases on a daily basis. Propofol titration is all that is necessary.

 

[aredoubleyou]

You'll feel differently when you are an attending. As mentioned above, pt is as good as he is going to get. It's a low risk procedure in a high risk pt...I do these cases on a daily basis. Propofol titration is all that is necessary.

So basically this is what I am learning now - I've taken Plank's message of "unlearning" what you learn in residency to heart in many ways _ although, of course, Im still in residency.

So there would have been a time...uhhhh...like last year as a CA2 that I probably would have wanted an a-line for induction, to r/o hyperkalaemia, RSI for active GERD, concern regarding poor neck extension. He would have received etomidate and sux on induction and felt like crap for the rest of the day...to avoid all the horrible things that Michael Jackson Juice would do: drop svr, depress contractility to some point, precipitate ischaemia, put him in florid heart failure, etc, etc, etc.... And there are plenty of attendings here that would have made that or something simmilar the plan (actulally most would have probably outright cancelled).

So it was the right patient with the right attending to do what it seems that all the private attendings on this forum would do and give a little propofol and get the case done - quickly and easily...couldnt of gone smoother, and probably got the guy out to the parking lot an hour later to have a smoke

 

[Intrathecal]

I think as a resident, one loses sight of the big picture. The patient has a pancreatic mass, and an intracranial mass. He needs this biopsy not today, but 2 weeks ago, to make a diagnosis and plan management. You will not achieve anything from delaying the case, or trying to get old records, except doing this patient a dis-service by making him drive 3 hours for nothing, and letting his CANCER spread while you dilly dally looking for old records or telling him to go see a cardiac surgeon.

I agree with all the attendings on this post. Titrate in 1-2mg midaz, 25-50mcg fent, bump some driprivan, let the GI dude do his thing. The patient will be fine, if you know what you're doing. Make sure you treat any hemodynamic shifts, with esmolol if HR goes up, neo if pressure drops from the propofol. Don't fluid overload him... that's another thing that residents need to learn, fluids are not benign! I have seen academic attendings literally drown healthy OB patients in LR (pulmonary edema) on D&C cases done under MAC. Judicious admin of fluids is the key, I would say under 500cc.

Now, for mental exercise and since I'm studying for oral boards, how would u manage this patient when he comes in for his whipple or if the neuro guy decides he wants to take out his intra-cranial mass?

 

[Planktonmd]

Same patient comes for whipple:
If not coagulopathic place thoracic epidural pre-op.
Get good peripheral IV access and an A line pre-op.
After induction insert central line and do a good GA.
Very easy.

I think as a resident, one loses sight of the big picture. The patient has a pancreatic mass, and an intracranial mass. He needs this biopsy not today, but 2 weeks ago, to make a diagnosis and plan management. You will not achieve anything from delaying the case, or trying to get old records, except doing this patient a dis-service by making him drive 3 hours for nothing, and letting his CANCER spread while you dilly dally looking for old records or telling him to go see a cardiac surgeon.

I agree with all the attendings on this post. Titrate in 1-2mg midaz, 25-50mcg fent, bump some driprivan, let the GI dude do his thing. The patient will be fine, if you know what you're doing. Make sure you treat any hemodynamic shifts, with esmolol if HR goes up, neo if pressure drops from the propofol. Don't fluid overload him... that's another thing that residents need to learn, fluids are not benign! I have seen academic attendings literally drown healthy OB patients in LR (pulmonary edema) on D&C cases done under MAC. Judicious admin of fluids is the key, I would say under 500cc.

Now, for mental exercise and since I'm studying for oral boards, how would u manage this patient when he comes in for his whipple or if the neuro guy decides he wants to take out his intra-cranial mass?

 

[Intrathecal]

How about a PA catheter if patient comes for Whipple? I myself am not a big fan of them since I've personally seen patients go into Vtach at the end of cardiac cases with seasoned attendings putting them in. However I think it would give you some valuable info, at the very least following trends in physiologic parameters. There will be big fluid shifts during a Whipple. Therefore I think the benefits outweigh the risks, especially with this guy with CAD, CHF, COPD, likely pHTN, and whatever else.

Yeah yeah, I think TEE would be better, but alot of hospitals don't offer intraop TEEs.

Ok, now same patient, and he comes in for crani for resection of intracranial mass. What would you do?

 

[Arch Guillotti]

I almost never place a CVP for a whipple, let alone float a swan.

TEE could be helpful for a whipple if he has problems, but I wouldn't place one initially.

 

[Arch Guillotti]

I think as a resident, one loses sight of the big picture. The patient has a pancreatic mass, and an intracranial mass. He needs this biopsy not today, but 2 weeks ago, to make a diagnosis and plan management. You will not achieve anything from delaying the case, or trying to get old records, except doing this patient a dis-service by making him drive 3 hours for nothing, and letting his CANCER spread while you dilly dally looking for old records or telling him to go see a cardiac surgeon.

I agree with not dilly dallying BUT there is absolutely no harm in calling the cardiologists office and either getting the objective info or actually speaking with the cardiologist himself. You never know, you may get them on the line (I have a couple of times). Hearts guy may know the patient right off the bat and tell you that he is as tuned up as he is gonna ever get. It may not change your management any, but if you are truly concrened about a patient then it is foolish not to at least make a cursory attempt and getting more information.

Change the batting order of the cases if you have to. In a GI lab since the procedures are usually relatively quick there is almost always another patient who can get checked in. My experience is that the GI guys are pretty reasonable about things when a sick patient shows up without any info. This is a dump on us so while I would not cancel the case, I wouldn't feel the need to rush blindly forward.

I would not place an aline.

Ther's no real need to give much of any IV fluid for this case.