Here's a case for you --

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amyl

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Old guy, esrd, severe ischemic cardiomyopathy ef 5-10% s/p vtach arrest code etc. told he needs a aicd but says no and signs out AMA. Cath two years ago showed 100% occlusion LAD LCX And RCA.... And 60% left main. Now urologist wants to do a stone - cu uretroscopy stent etc. cards says "he is as stable as he is going to get" - thoughts?
 
Look on the bright side. There isn't much myocardium at risk. It's all dead! Some of these ischemic dilated cardiomyopathy patients are hard to kill. Run him on a dopamine or epi drip. Drop a TEE and do a GETA. Have R2 pads and defibrillator in the room v
 
Cases and patients like these are frustrating; on the upside, you have good history and evidence that this patient is high risk.

Aside from pt autonomy issues (pt understands the risks and wants to proceed with high-risk procedure so we can't deny him scope + stent), kidney stones can get infected -> urosepsis -> inc myocardial demand -> pt dies anyway.

Slap on pads preop to shock and possibly pace. Thorough preop discussion with pt and family about this being possibly the last time they see each other awake. Ask pt what he wants done when he codes on the table.
 
5-10% ef with dead myocardium, how are his symptoms and what activity level does he have? Is he a VAD candidate?
 
Is a super low EF like that a contraindication to spinal in anyone's eyes?
 
He's sedentary, vtach arrested sitting on sofa. Sob with minimal exertion. Unable to perform ADLs wo assistance. He refused aicd, I doubt he would go for a vad
 
If the LV is huge, the stroke volume and CO may be better than expected with a 10% ef. I'd still do pre induction Aline and have inotrope in line. Aline will be valuable when doing chest compressions😉
 
Pads on prior to induction, whiff of etomidate + fent, LMA, BIS + whiff of inhalational. Epi within arms reach.
 
Hes stable from a uro standpoint bc they put the case on for next week, so I took this opportunity for him to have a second crack at getting the pm/aicd everyone says he needs.... No signing out AMA this time 🙂 hopefully. First cardiologist cleared him, now it's a different guy on call and he has him booked tomorrow for an aicd/pm placement and probably a repeat cath. I'll let you know how it goes... It'll probably end up being my case next week.
 
amyl said:
He's sedentary, vtach arrested sitting on sofa. Sob with minimal exertion. Unable to perform ADLs wo assistance. He refused aicd, I doubt he would go for a vad
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How many METs does it take to exchange CO2 for O2? Or maybe it was a really exciting show/movie...
 
seriously folks, is it ever an option to just say no? what do you think his 30 days mortality probability is, even without this procedure? I would do my best to have a serious heart to heart with the family and urologist, and dodge this bullet.

but since we're gonna do the case anyway, to preserve this patient's fictive "quality of life"...

if his EF and CAD somehow don't reflect his actual condition / MET tolerance (maybe 3+ MR causing an EF underestimate?)
and he can get out of his hospital bed without angina/syncope
CSE nice and slow + low dose epi, no sedatives. zoll pads.
 
W a bad ef I'm more for slow titration of epidural over spinal. I guess if you wanted CSE w intrathecal narcs only I could get behind that - still think a gentle general is better in this patient.
 
A few people said general with LMA. Just curious if this guy is that close to coding (or at least were concerned) , any reason to pick an ETT over an LMA? I'm just wondering if he truly ends up coding , do I wanna deal with an LMA Vs secured ETT.
 
A-line up front. Spinal catheter would be my regional choice. Inhalation induction, LMA would be my general choice.

I don't think it matters. When we're done with him and gone and postop pain & stress kicks in is when his last myocyte's going to give it up anyway.
 
pgg said:
A-line up front. Spinal catheter would be my regional choice. Inhalation induction, LMA would be my general choice.

I don't think it matters. When we're done with him and gone and postop pain & stress kicks in is when his last myocyte's going to give it up anyway.
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Exactly, but I was told in another thread on this site that this isn't the time when trouble raises its ugly head but rather it is during the intr-op period. I'm still waiting for some proof of that.
 
IlDestriero said:
Tachycardia from stimulation of ETT, stress, MI, arrhythmia, death.
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spike7585 said:
A few people said general with LMA. Just curious if this guy is that close to coding (or at least were concerned) , any reason to pick an ETT over an LMA? I'm just wondering if he truly ends up coding , do I wanna deal with an LMA Vs secured ETT.
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Ther is no reason other than what Ildetriero stated. But it is very easy to avoid all of that and place an ETT. Just spray the crap out of their cords and trachea before placing the tube. IT will be as gentle as an LMA for him.
 
pgg said:
I don't think it matters. When we're done with him and gone and postop pain & stress kicks in is when his last myocyte's going to give it up anyway.
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He is going to meet his maker sooner than later. The periop period is just as good as any other time, if not better.
 
spike7585 said:
A few people said general with LMA. Just curious if this guy is that close to coding (or at least were concerned) , any reason to pick an ETT over an LMA? I'm just wondering if he truly ends up coding , do I wanna deal with an LMA Vs secured ETT.
Click to expand...

A well-seated LMA is fine in a code, IMO. Hell, masking him is. I believe ACLS even did away with securing the airway ASAP in a code. It is now "to be considered". Not that it isn't important, but Tube versus LMA versus BMV doesn't matter in my opinion as long as you're moving air.
 
Ignatius J said:
A well-seated LMA is fine in a code, IMO. Hell, masking him is. I believe ACLS even did away with securing the airway ASAP in a code. It is now "to be considered". Not that it isn't important, but Tube versus LMA versus BMV doesn't matter in my opinion as long as you're moving air.
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The best part of securing an airway during a code is that it frees the best airway manager (you) to run the code.

The sooner the responding anesthesiologist gets a tube in the trachea, the sooner he can take over running the code, too. Outside the ER and ICU, that's probably for the best, even if air was being moved by mask. 🙂
 
Noyac said:
Exactly, but I was told in another thread on this site that this isn't the time when trouble raises its ugly head but rather it is during the intr-op period. I'm still waiting for some proof of that.
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Right, I think the assertion was that periop MIs were always occurring the first day, but just not noticed until day 2 or 3? And now we're getting better at noticing and the at-risk period is recognized to be closer to surgery?

I think they're still mainly occurring postop. Absent major surgical blood loss or other big events during surgery, I doubt the peak occurrence of these MIs is in the OR while we're watching them and keeping their vitals in a tight box with q3min or better vitals. Much more plausible to believe the risk is after they leave the OR ... but whether the peak risk is 12h or 36h later, who knows.
 
pgg said:
The best part of securing an airway during a code is that it frees the best airway manager (you) to run the code.

The sooner the responding anesthesiologist gets a tube in the trachea, the sooner he can take over running the code, too. Outside the ER and ICU, that's probably for the best, even if air was being moved by mask. 🙂
Click to expand...

Whatever definition we use for "securing the airway", an LMA should be adequate.
 
Noyac said:
ACLS and intraop codes can be very different.

Put a tube in your codes.
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Not a one size fits all. I've seen people seemingly mucking with the airway forever in a blueberry of a patient, holding up chest compressions and the whole code when they could have slipped in an LMA and done the damn thing. Time is of the essence. Sure, if you can put the tube in great. But not at the expense of the patient receiving oxygen to his brain. Let's face it- codes can have non-ideal circumstances- positioning, location, body habitus and efficiency is of the essence.
 
Surprised no one said saddle block. Aline preop. 10 mg hyperbaric bupivicaine and keep him sitting for a full 5 minutes. Monitor pressure throughout with aline... BP start drifting, treat with baby doses of epi (5-10 mcg). Have him sniff some versed too... you wont even need to inject it with a guy this old and sick
 
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