How do you do your average cardiac case?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
Anyone doing cpap during pump run?

Anyone else using ddavp fairly often?

What do you think about drawing fibrinogen and plt a little bit before coming off pump, in certain cases?

Tee for preserved ef cabg?
 
About ketamine: how many of you have actually had a small dose of ketamine ? At doses that don’t cause deep anesthesia , ketamine SUCKS to experience. It’s a very uncomfortable high unrelated to any “hallucinations”. I don’t give ketamine to anyone that’s not already out from some other hypnotic so that they can skip the acute intoxication and possibly have some of the post effects.

Same reason I don’t give IV lidocaine without heavy sedation first. 60mg of IV lidocaine SUCKS. It is not pleasant .
 
Members don't see this ad :)
anes121508 said:
Anyone doing cpap during pump run?

Anyone else using ddavp fairly often?

What do you think about drawing fibrinogen and plt a little bit before coming off pump, in certain cases?

Tee for preserved ef cabg?
Click to expand...

1) Never. Nope. Surgeons nearly unanimously want the lungs totally deflated during a typical case.

2) Only for ESRD, VWD. So not too often.

3) Not a fan unless there’s been a very long pump run, some preop coagulopathy or DHCA.

4) Almost never. I can get almost all the info I need from direct visualization, especially with the quick surgeons I work with now.
 
Are many people using TEG? We used ROTEM...I liked it, as it allowed me to be a bit more goal directed with a coagulopathic patient post pump. Certainly has its limitations. Surgeons hated it when you said ‘rotem is normal’ when they’re still oozy.
 
T-burglar said:
About ketamine: how many of you have actually had a small dose of ketamine ? At doses that don’t cause deep anesthesia , ketamine SUCKS to experience. It’s a very uncomfortable high unrelated to any “hallucinations”. I don’t give ketamine to anyone that’s not already out from some other hypnotic so that they can skip the acute intoxication and possibly have some of the post effects.

Same reason I don’t give IV lidocaine without heavy sedation first. 60mg of IV lidocaine SUCKS. It is not pleasant .
Click to expand...

It’s heavily patient dependent. I’ve had all of these when I had my appendix out - Ketamine was particularly great afterwards (I tried to get out of the PACU bed and walk around...), and the lidocaine wasn’t bad at all. But I don’t extrapolate these experiences to my clinical practice much, that’s not wise.

Morphine on the other hand was horrendous.
 
  • Like
Reactions: dhb
AdmiralChz said:
1) Never. Nope. Surgeons nearly unanimously want the lungs totally deflated during a typical case.

2) Only for ESRD, VWD. So not too often.

3) Not a fan unless there’s been a very long pump run, some preop coagulopathy or DHCA.

4) Almost never. I can get almost all the info I need from direct visualization, especially with the quick surgeons I work with now.
Click to expand...

1) cpap for cpb - never done it, seen it discussed not sure good data for it, wondering if others know more and have success

2) ddavp- that’s exactly how I’ve used it in the past (if there’s a reason then fine), lately surgeons wanna do it all cases which I’m scratching head wondering if new data came out or something..anyone got anything?

3) fibrinogen and plt near end of pump run - I picked this up from Two different attending some in residency and one in fellowship, I think duke does it hats why , but not sure how accurate and struggling to find data for it, been trying it if long pump run/ckd/vad exchange/dhca ect...anyone know specifics on this topic?

4. tee for preserved ef cabg - I’m new so folks looked at me like I was crazy, but why stick a probe in when lady is frail on steroids and has some questionable gi stuff? Residency program did tee for all and fellowship did selective use, I like the selective use but folks at my new job aren’t kosher with that
 
AdmiralChz said:
It’s heavily patient dependent. I’ve had all of these when I had my appendix out - Ketamine was particularly great afterwards (I tried to get out of the PACU bed and walk around...), and the lidocaine wasn’t bad at all. But I don’t extrapolate these experiences to my clinical practice much, that’s not wise.

Morphine on the other hand was horrendous.
Click to expand...

but how do you know which sedative is causing which effect when you have never had them before and you had them all at once?

And I disagree that you dont extrapolate your personal experiences, personal experiences should be an eye opening experience for you and SHOULd change your practice, i used to poo poo toradol until I had it for a kidney stone when dilaudid wasnt cuting it (at 6mg) it was a miracle.. now i give it to everyone i can..

we are people who have had relatively clean lives and are responsible for forming opinions about giving drugs to people, any personal experience is worth a lot more than some academic study in my book..
 
Lots of voodoo in ct surgery/ anesthesia so cool discussion especially for a relatively new grad...I like hearing practices from other folks to see what I might change
 
Hoya11 said:
but how do you know which sedative is causing which effect when you have never had them before and you had them all at once?

And I disagree that you dont extrapolate your personal experiences, personal experiences should be an eye opening experience for you and SHOULd change your practice, i used to poo poo toradol until I had it for a kidney stone when dilaudid wasnt cuting it (at 6mg) it was a miracle.. now i give it to everyone i can..

we are people who have had relatively clean lives and are responsible for forming opinions about giving drugs to people, any personal experience is worth a lot more than some academic study in my book..
Click to expand...

I’ve had a few procedures. Lidocaine causes a pleasant perioral tingling otherwise isn’t bad at all for me. I’ve never had a patient complain about it, personally, and I use it nearly every case. But I’m new in my career.
 
I'm of the opinion that all cardiac cases with sternotomy / thoracotomy should get a TEE. This paper (Impact of intraoperative transesophageal echocardiography in cardiac and thoracic aortic surgery: Experience in 1011 cases - ScienceDirect) demonstrated a 6% incidence of TEE leading to either a minor or major change in the surgical plan across a variety of cardiac surgeries, i.e. picking up undiagnosed moderate AI and cardioplegia, undiagnosed MR, ASD, LAA clot, bad ascending atheromatous disease, etc. Even in pure CABG, it was still helpful at a high enough rate for picking up new intraop WM, post pump aortic dissection and unexplained low cardiac output syndrome.

Just last month my non cardiac partner had a routine normal EF cabg. Pt **** the bed about 10 min after the protamine. Turned into a whole thing, unsure if it was graft failure or protamine reaction. Back on pump, balloon pump, nitric, the whole nine yards. No echo probe or machine in the room when the event occurred. Has to go searching for one (since we share with cath lab) which delays any diagnosis. It's a rare event, but the risk of TEE probe insertion is so low that I'd rather always have one in case this kind of situation occurs.
 
vector2 said:
I'm of the opinion that all cardiac cases with sternotomy / thoracotomy should get a TEE. This paper (Impact of intraoperative transesophageal echocardiography in cardiac and thoracic aortic surgery: Experience in 1011 cases - ScienceDirect) demonstrated a 6% incidence of TEE leading to either a minor or major change in the surgical plan across a variety of cardiac surgeries, i.e. picking up undiagnosed moderate AI and cardioplegia, undiagnosed MR, ASD, LAA clot, bad ascending atheromatous disease, etc. Even in pure CABG, it was still helpful at a high enough rate for picking up new intraop WM, post pump aortic dissection and unexplained low cardiac output syndrome.

Just last month my non cardiac partner had a routine normal EF cabg. Pt **** the bed about 10 min after the protamine. Turned into a whole thing, unsure if it was graft failure or protamine reaction. Back on pump, balloon pump, nitric, the whole nine yards. No echo probe or machine in the room when the event occurred. Has to go searching for one (since we share with cath lab) which delays any diagnosis. It's a rare event, but the risk of TEE probe insertion is so low that I'd rather always have one in case this kind of situation occurs.
Click to expand...

Hard to argue with that
 
vector2 said:
I'm of the opinion that all cardiac cases with sternotomy / thoracotomy should get a TEE. This paper (Impact of intraoperative transesophageal echocardiography in cardiac and thoracic aortic surgery: Experience in 1011 cases - ScienceDirect) demonstrated a 6% incidence of TEE leading to either a minor or major change in the surgical plan across a variety of cardiac surgeries, i.e. picking up undiagnosed moderate AI and cardioplegia, undiagnosed MR, ASD, LAA clot, bad ascending atheromatous disease, etc. Even in pure CABG, it was still helpful at a high enough rate for picking up new intraop WM, post pump aortic dissection and unexplained low cardiac output syndrome.

Just last month my non cardiac partner had a routine normal EF cabg. Pt **** the bed about 10 min after the protamine. Turned into a whole thing, unsure if it was graft failure or protamine reaction. Back on pump, balloon pump, nitric, the whole nine yards. No echo probe or machine in the room when the event occurred. Has to go searching for one (since we share with cath lab) which delays any diagnosis. It's a rare event, but the risk of TEE probe insertion is so low that I'd rather always have one in case this kind of situation occurs.
Click to expand...

Devils advocate ....

Undiagnosed moderate AI and catdioplegia:
- tte should theoretically pick it up and often the field and ekg can tell if you are distending and not getting an arrest , also moderate ai doesn’t mean antegrade wont work

Laa clot:
- I guess tee is a whole lot better , but if they had major risk factors they probably be on Coumadin for prevention, what’s the chance they have low risk and still have clot?

Atheromatous disease:
- most are coming with CT scan, and if scan does show or if it isn’t done they can use epiOrtic US which has data behind its use for cannulation

Asd
- I mean I guess any asymtpmatic congenital thing could be there, I’d assume tte is somewhat decent for picking up, when would you even fix it...pfo often missed but I believe in just a cabg unless septal aneurysm data doesn’t support going after it


New rwma
- ekg? see it sooner on tee vs ekg I guess, I’ve seen surgeons use some flow and Doppler interrogation when they worried about their targets or graft

Post pump dissection:
I’ve caught it before But I don’t see why epi aortic couldn’t do the same if cannulation was straightforward and you were worried about it

Low cardiac output syndrome unexplained or protamine reaction or something else
- agree it’s tough without a pa cath or tee to really know...

I’ve seen someone die from tee probe before that’s why I bring up the food for thought

If Risk of complication from tee probe > chances tee making meaningful difference then it’s worth a thought....not sure we have all the answers yet though
 
Members don't see this ad :)
In the heart room.....errrbody gets a TEE (lol....but serious, at my gig we place them for all heart cases)
 
Hoya11 said:
we are people who have had relatively clean lives and are responsible for forming opinions about giving drugs to people, any personal experience is worth a lot more than some academic study in my book..
Click to expand...

tenor.gif
 
vector2 said:
I'm of the opinion that all cardiac cases with sternotomy / thoracotomy should get a TEE. This paper (Impact of intraoperative transesophageal echocardiography in cardiac and thoracic aortic surgery: Experience in 1011 cases - ScienceDirect) demonstrated a 6% incidence of TEE leading to either a minor or major change in the surgical plan across a variety of cardiac surgeries, i.e. picking up undiagnosed moderate AI and cardioplegia, undiagnosed MR, ASD, LAA clot, bad ascending atheromatous disease, etc. Even in pure CABG, it was still helpful at a high enough rate for picking up new intraop WM, post pump aortic dissection and unexplained low cardiac output syndrome.

Just last month my non cardiac partner had a routine normal EF cabg. Pt **** the bed about 10 min after the protamine. Turned into a whole thing, unsure if it was graft failure or protamine reaction. Back on pump, balloon pump, nitric, the whole nine yards. No echo probe or machine in the room when the event occurred. Has to go searching for one (since we share with cath lab) which delays any diagnosis. It's a rare event, but the risk of TEE probe insertion is so low that I'd rather always have one in case this kind of situation occurs.
Click to expand...

This right here............makes me think of that whole, "Should I do a cardiac fellowship?" thread
 
On a serious note, I've been wrestling with the notion of "poly-pharmacy" in my relatively young attending-hood. I used to do the whole old school attending thing of midaz 10 mg / fentanyl 500 mcg for the starts of all my cases but I've learned to become more delicate in my inductions and more of a "less is more" type person with just about every case I do.

I'm very anti-midazolam / ketamine when a patient is getting a general anesthetic. The propofol or gas takes care of everything if they're deep enough and (knock on wood) I've never had a patient recall intubation because I didn't use versed. I also think a lot of these elderly patients wake up a lot better with clearer head which is good for examining neuro status. I only like ketamine if I have to stick a TEE in or do a sort of awake intubation and even then I don't like that potential for laryngospasm that tends to happen with ketamine, which is also why I've stopped using it on L&D during C/S.

I'm not sure if this is the reason Lidocaine came up, but mix my propofol with 2% lidocaine because I don't want to hear about it stinging, even though sometimes it still does (usually with a poorly place PIV from Preop)

1000 mcg of fentanyl for a cardiac case MAX, unless the patient is Shaq.

I have no problem drawing a 10cc syringe propofol and using it to induce my elective cardiac cases.....they make Neo for a reason
 
AdmiralChz said:
It’s heavily patient dependent. I’ve had all of these when I had my appendix out - Ketamine was particularly great afterwards (I tried to get out of the PACU bed and walk around...), and the lidocaine wasn’t bad at all. But I don’t extrapolate these experiences to my clinical practice much, that’s not wise.

Morphine on the other hand was horrendous.
Click to expand...

I know patient experiences vary, but after having certain drugs myself I never want that to happen to my patients. Never had anyone complain about injection pain with enough sedation before pushing the propofol so I can skip the lidocaine , and I never have any need to give ketamine to anyone who is mostly awake, it CAN be a superfluous drug if you want it to be in your practice.

I do give 25mg of ketamine once people are out for LMA cases because I think it keeps them from moving without having to paralyze or give excessive opioid and gas.
 
I too think everyone who is going to get cannulated for bypass should have TEE. I also think anyone that gets cannulas should have a cerebral oximeter, but I’ll bever get support for that. How many massive strokes are attritbuted to aortic plaque or air but were really poor SVC drainage. How many of you monitor SVC pressure routinely? On all bicaval cannulations?

Personally I think the worst thing that can happen in heart surgery is not suboptimal repair or revasc but a big stroke.
 
T-burglar said:
I too think everyone who is going to get cannulated for bypass should have TEE. I also think anyone that gets cannulas should have a cerebral oximeter, but I’ll bever get support for that. How many massive strokes are attritbuted to aortic plaque or air but were really poor SVC drainage. How many of you monitor SVC pressure routinely? On all bicaval cannulations?

Personally I think the worst thing that can happen in heart surgery is not suboptimal repair or revasc but a big stroke.
Click to expand...

Very true. Something you can’t detect until well out of the OR
 
T-burglar said:
I too think everyone who is going to get cannulated for bypass should have TEE. I also think anyone that gets cannulas should have a cerebral oximeter, but I’ll bever get support for that. How many massive strokes are attritbuted to aortic plaque or air but were really poor SVC drainage. How many of you monitor SVC pressure routinely? On all bicaval cannulations?

Personally I think the worst thing that can happen in heart surgery is not suboptimal repair or revasc but a big stroke.
Click to expand...
We used cerebral oximeter routinely in residency. Except nobody did anything about a drop so it was a moot point.
 
I’m not a cardiac guy, but at my shop the default plan for elective cardiac cases involves IT duramorph and extubating on the table.
 
We used to do sufentanil bolus for induction followed by an intraop infusion but with the opioid shortage we’ve been doing most of our cardiac cases without IV opioids. Preop oral Tylenol, Neurontin and methadone. No OG suction before TEE. Ketamine GTT intraop. Precedex GTT after. It’s actually worked better than we expected without much change in pain after (anecdotally) and likely faster extubation times.

I do miss using sufentanil for induction (so smooth) but luckily there is still a little bit available for transplants or emergency/unstable cases.
 
anes121508 said:
Devils advocate ....

Undiagnosed moderate AI and catdioplegia:
- tte should theoretically pick it up and often the field and ekg can tell if you are distending and not getting an arrest , also moderate ai doesn’t mean antegrade wont work

Laa clot:
- I guess tee is a whole lot better , but if they had major risk factors they probably be on Coumadin for prevention, what’s the chance they have low risk and still have clot?

Atheromatous disease:
- most are coming with CT scan, and if scan does show or if it isn’t done they can use epiOrtic US which has data behind its use for cannulation

Asd
- I mean I guess any asymtpmatic congenital thing could be there, I’d assume tte is somewhat decent for picking up, when would you even fix it...pfo often missed but I believe in just a cabg unless septal aneurysm data doesn’t support going after it


New rwma
- ekg? see it sooner on tee vs ekg I guess, I’ve seen surgeons use some flow and Doppler interrogation when they worried about their targets or graft

Post pump dissection:
I’ve caught it before But I don’t see why epi aortic couldn’t do the same if cannulation was straightforward and you were worried about it

Low cardiac output syndrome unexplained or protamine reaction or something else
- agree it’s tough without a pa cath or tee to really know...

I’ve seen someone die from tee probe before that’s why I bring up the food for thought

If Risk of complication from tee probe > chances tee making meaningful difference then it’s worth a thought....not sure we have all the answers yet though
Click to expand...

A whole lotta "ifs" in this post.

TTE should pick up a lot of things, but I live in an area where my average male cardiac pt is 5'8" and >230lb (female 5'3" and also >230lb lol), so the mileage varies quite a bit on what a TTE will actually pick up. Some of my patients don't even have a TTE available when they come to surgery (chest pain-> +trop -> cath with normal LV gram and LVEDP -> proceed to CABG), but I do review the images from the most recent TTE if a pt has one before I TEE them, and you'd be shocked at how much pathology can be missed or miscalled, especially when talking about posterior structures, degrees of valve disease and MAC, or things that require fine resolution.

Agreed, moderate AI doesn't automatically rule out antegrade. But if it was you on the table, wouldn't you rather the surgeon had some idea beforehand about the operative (not preoperative) degree of AI (and maybe a backup plan) rather than rolling the dice and seeing the heart blow up?

LAA clot without risk factors is rare. So are TEE complications. Very few CABGs where I'm at have gotten a CT scan unless they had a history or the aorta looked crazy calcified on cath. Regardless, CT won't pick up big, soft atheroma that well (which is really the kind you should be worrying about since surgeons can palpate calcium). Also, between residency, fellowship, current gig, and locums gig I've worked at 4 different hospitals that did cardiac in the last 5 years and I've seen only one surgeon do epiaortic one time. It's cumbersome and just not a thing at the places I've been.

Picking up RWMA with EKG? LOL. The surgeon may do flowmetry on the graft but that doesn't mean the graft is gonna remain great as the chest is closed and the thing kinks off. There's a reason a lot of fellowships instruct trainees not to take the probe out until the skin is almost closed.

Significant ASD (qp:qs > 2) should be fixed. TTE can miss these if the RA/RV isn't crazy blown up and they're not looking closely.

Using epiaortic to check dissection? Again, good luck getting the surgeon to do that. Half the time with CABGs coming off I barely get about 10 seconds to eyeball the heart before the surgeon is yelling "protamine???"
 
vector2 said:
A whole lotta "ifs" in this post.

TTE should pick up a lot of things, but I live in an area where my average male cardiac pt is 5'8" and >230lb (female 5'3" and also >230lb lol), so the mileage varies quite a bit on what a TTE will actually pick up. Some of my patients don't even have a TTE available when they come to surgery (chest pain-> +trop -> cath with normal LV gram and LVEDP -> proceed to CABG), but I do review the images from the most recent TTE if a pt has one before I TEE them, and you'd be shocked at how much pathology can be missed or miscalled, especially when talking about posterior structures, degrees of valve disease and MAC, or things that require fine resolution.

Agreed, moderate AI doesn't automatically rule out antegrade. But if it was you on the table, wouldn't you rather the surgeon had some idea beforehand about the operative (not preoperative) degree of AI (and maybe a backup plan) rather than rolling the dice and seeing the heart blow up?

LAA clot without risk factors is rare. So are TEE complications. Very few CABGs where I'm at have gotten a CT scan unless they had a history or the aorta looked crazy calcified on cath. Regardless, CT won't pick up big, soft atheroma that well (which is really the kind you should be worrying about since surgeons can palpate calcium). Also, between residency, fellowship, current gig, and locums gig I've worked at 4 different hospitals that did cardiac in the last 5 years and I've seen only one surgeon do epiaortic one time. It's cumbersome and just not a thing at the places I've been.

Picking up RWMA with EKG? LOL. The surgeon may do flowmetry on the graft but that doesn't mean the graft is gonna remain great as the chest is closed and the thing kinks off. There's a reason a lot of fellowships instruct trainees not to take the probe out until the skin is almost closed.

Significant ASD (qp:qs > 2) should be fixed. TTE can miss these if the RA/RV isn't crazy blown up and they're not looking closely.

Using epiaortic to check dissection? Again, good luck getting the surgeon to do that. Half the time with CABGs coming off I barely get about 10 seconds to eyeball the heart before the surgeon is yelling "protamine???"
Click to expand...

All excellent points. TEE is mandatory for pump cases. Unfortunately I work with some old ass surgeons in my current job who only want echos on valves.

Why won’t the heart arrest?? Well let me put the probe in and maybe I can tell you. Oh look the coronary sinus is massively dilated.

Why does my venous drainage suck?? No I don’t care if the cannula is jammed into a hepatic vein just add vacuum and volume to the pump.

The patient is unstable and I can’t get this venous cannula in, what gives? Man I wish I knew that there was an obstructive eustachian remnant before it was time to cannulate emeregently .

Etc
 
Ronin786 said:
We used cerebral oximeter routinely in residency. Except nobody did anything about a drop so it was a moot point.
Click to expand...

same here, so we stopped around my ca-3 year

fellowship came where we did circ arrest more often...found it somewhat helpful then once in a while

not sure there is any evidence that says routine use for basic cabg decreases stroke
 
GoSoxGo said:
We used to do sufentanil bolus for induction followed by an intraop infusion but with the opioid shortage we’ve been doing most of our cardiac cases without IV opioids. Preop oral Tylenol, Neurontin and methadone. No OG suction before TEE. Ketamine GTT intraop. Precedex GTT after. It’s actually worked better than we expected without much change in pain after (anecdotally) and likely faster extubation times.

I do miss using sufentanil for induction (so smooth) but luckily there is still a little bit available for transplants or emergency/unstable cases.
Click to expand...

interesting

if i remember correctly, sufenta for induction makes more sense from a kinetics standpoint as opposed to fent, i'll often use it
 
i preface this post with i'm only playing devils advocate because i've seen two schools of thought during residency and fellowship and currently figuring out what i really think and how i'll practice...also it's just fun to argue sometimes for the sake of a good debate

i'll start by saying that the ASE guidelines say something along the lines of "tee indications....SOME cabg and ALL open heart"




"A whole lotta "ifs" in this post"
- yes, every thing is a "what if"....that's why we are all generally in favor of the tee probe being placed..."what if x y z was missed or happens", isn't your whole argument based on WHAT IF?


"TTE should pick up a lot of things, but I live in an area where my average male cardiac pt is 5'8" and >230lb (female 5'3" and also >230lb lol), so the mileage varies quite a bit on what a TTE will actually pick up. Some of my patients don't even have a TTE available when they come to surgery (chest pain-> +trop -> cath with normal LV gram and LVEDP -> proceed to CABG), but I do review the images from the most recent TTE if a pt has one before I TEE them, and you'd be shocked at how much pathology can be missed or miscalled, especially when talking about posterior structures, degrees of valve disease and MAC, or things that require fine resolution."


- - ase guidelines 2013 - " Inappropriate Routine use of TEE... when a diagnostic TTE is reasonably anticipated to resolve all diagnostic and management concerns".....now sure totally how to interpret this, but I think it has relevance to your statement

- agree with most of this, i routinely pull up the tte just to check the quality of the images to see if i should put any weight behind the read, if something is questionable on the tte or completely not imaged well then tee is a definite... and no i'm not shocked any more at the amount of pathology is miscalled or missed...even the most basic stuff...the real question here though is how often does it make a meaningful impact?

- you mentioned patient for cabg with normal lv gram and normal LVEDP with out tte, how often do you find significant valvular disease that warrants intervention at time of cabg despite the normal LV gram? you also mentioned mac, how would that change anything for cabg?

- rarely have i had a patient without a preop tte come for cabg so i can't speak from tons of experience, but the lack of tte for elective cabg by the ct surgeon or cardiologist says to me one of two things: 1. they really don't care because nothing is going to change their operation in the setting of a normal lv gram ....OR ....2. they trust your tee more than their terrible tte and will make a decision on additional intervention after induction, in which case you are likely going to be asked to place a probe

"Agreed, moderate AI doesn't automatically rule out antegrade. But if it was you on the table, wouldn't you rather the surgeon had some idea beforehand about the operative (not preoperative) degree of AI (and maybe a backup plan) rather than rolling the dice and seeing the heart blow up?"

- yep absolutely, for some reason i work with a surgeon who will routinely roll the dice and ask me if the lv if blowing up, answer is usually yes, then yes, then yes again a little later....of course, without the tee probe there in the first place, we wouldn't know.

- I propose this question/scenario though: elective cabg and has preop tte with good windows and you like the shots after reviewing them, pt has absolutely zero AI...do you feel that the benefit of placing a tee probe for the chance of detect signifiant AI and subsequent significant LV distension at the time of cardioplegia admin outweighs the risk of complication in a pt with a relative contraindication to TEE placement?


"LAA clot without risk factors is rare. So are TEE complications."
- agree which is exactly why I bring up this topic. although, i believe dysphagia after tee is common. either way, catastrophic tee complications are rare. when a patient has risk factors for that rare tee complication, i believe we should discuss placing a probe for simple elective preserved ef cabg with a quality preop tte.


Very few CABGs where I'm at have gotten a CT scan unless they had a history or the aorta looked crazy calcified on cath. Regardless, CT won't pick up big, soft atheroma that well (which is really the kind you should be worrying about since surgeons can palpate calcium). Also, between residency, fellowship, current gig, and locums gig I've worked at 4 different hospitals that did cardiac in the last 5 years and I've seen only one surgeon do epiaortic one time. It's cumbersome and just not a thing at the places I've been."

- agree, US is better for identification of atheroma than CT. agree, i believe it's also been shown that surgeons can't really palpate calcium. completely disagree however about epiaortic. we did it routinely and it takes minimal effort skill or time. additionally, just google epiaortic US and stroke prevention, tons of data and support for it

Picking up RWMA with EKG? LOL. The surgeon may do flowmetry on the graft but that doesn't mean the graft is gonna remain great as the chest is closed and the thing kinks off. There's a reason a lot of fellowships instruct trainees not to take the probe out until the skin is almost closed.
- I don't every take out the probe untill after the chest is closed. When supervising i routinely instruct the CRNA to call me back to the room prior to chest closure to take another look in case of an event
- however, "The sensitivity of TEE to detect graft failure was 20%, specificity 25%, positive predictive and negative values were 62.5% and 4.8%, respectively."....not fool proof
- i've seen the graft kink on chest closure, we didn't have a probe in, the BP tanked quickly, EKG changed, and it was obvious what the problem was

Significant ASD (qp:qs > 2) should be fixed. TTE can miss these if the RA/RV isn't crazy blown up and they're not looking closely.
- incidence for asd is 1/1500, so 0.06%. incidence with a shunt that warrants fixing and is missed on TTE or LV gram is how low? incidence of complications from TEE is 1.2-1.5%, for all people. Not just those with risk factors.

Using epiaortic to check dissection? Again, good luck getting the surgeon to do that. Half the time with CABGs coming off I barely get about 10 seconds to eyeball the heart before the surgeon is yelling "protamine???
- lol, very true....you forgot to mention the question that comes 30 seconds later ...."so is it in yet?"
 
urge said:
Not aware of any data to support its use on ANY case.
Click to expand...

...based on numerous studies that have speculated on the purported reduction in perioperative morbidity associated with the use of TEE in cardiac surgical patients undergoing MV procedures [15, 20].

Mishra M, Chauhan R, Sharma KK, et al. Real-time intraoperative transesophageal echocardiography—how useful? Experience of 5,016 cases. J Cardiothorac Vasc Anesth 1998; 12:625–32

20. Savage RM, Cosgrove DM. Systematic transesophageal echocardiographic examination in mitral valve repair: the evolution of a discipline into the twenty-first century. Anesth Analg 1999;88:1197–9.


dont hold me accountable for defending these if they are junk
 
"Specific reasons why intraoperative TEE was not performed in the remaining 10,274 cardiac surgical patients were not available from the database. However, historically in our institution, intraoperative TEE has not been performed in patients undergoing only CABG who also had a preoperative ejection fraction of 40% or greater."

obviously i heard this side of the story in training
 
anes121508 said:
...based on numerous studies that have speculated on the purported reduction in perioperative morbidity associated with the use of TEE in cardiac surgical patients undergoing MV procedures [15, 20].

Mishra M, Chauhan R, Sharma KK, et al. Real-time intraoperative transesophageal echocardiography—how useful? Experience of 5,016 cases. J Cardiothorac Vasc Anesth 1998; 12:625–32

20. Savage RM, Cosgrove DM. Systematic transesophageal echocardiographic examination in mitral valve repair: the evolution of a discipline into the twenty-first century. Anesth Analg 1999;88:1197–9.


dont hold me accountable for defending these if they are junk
Click to expand...
I was talking about cerebral oximetry.
 
My point is that thousands of hearts have been done without tee during the tee era by people who who write papers supporting the use of TEE and it's impact on surgical decision making. People who are regarded as leadership in CT anesthesia and CT surgery and writing the guidelines. Wether or not you agree, it's worth pointing out and discussing.
 
urge said:
I was talking about cerebral oximetry.
Click to expand...

oh....yeah i was taught it doesn't help....specifically remember a guy from residency with a million publications to his name on the topic of cerebral oximetry and helped develop the technology telling me he didnt even use it in the OR. He does hearts now in a major academic center and doesn't actually believe in it or use it


of course every single heart at my new job has cerebral oximetry placed.
we also place preinduction brachial lines, 9Fr IJ catheters and CCO PA catheters in every single patient.
 
DesiredMemberName? said:
Although competent ICU clinicians don't need the numbers to diagnose/treat, when you are relying on NPs/PAs to babysit the patient while you sleep, the numbers are useful.
Click to expand...

The question really remains, how are you best going to guide resuscitation in post CT surgery pts? My views on the everyone gets a swan controversy tempered a bit after ICU fellowship. Gold standard for me is TEE > swan (svo2/cco) > lidco > lactate > UOP/bp/other indirect indicators.

In the immediate post-op period, the pt is still having significant lung compliance, vascular compliance and fluid shifts secondary to changing temperature and diffuse SIRS/capillary leak. Indwelling TEE is just not practical for everyone. I found it more and more invaluable to quickly be able to assess a baseline stroke volume index, give a 500 cc LR challenge, and then see if the SVI, CI, svo2 significantly augments.

Does every cardiac pt need a swan? No. Can I show that mortality is improved by swan goal directed therapy? Probably not. Me personally, I just feel better targeting my resuscitation to essentially the best measure we have of the patient's cardiac output and oxygen delivery.
 
i Go back and forth about the usefulness of PA catheters. Putting them in everyone has taught me that the echo is far from the final word in valve disease severity and I find that the information helps me be more sure about grading disease severity because it really helps you correlate and interpret echo findings
 
DesiredMemberName? said:
Although competent ICU clinicians don't need the numbers to diagnose/treat, when you are relying on NPs/PAs to babysit the patient while you sleep, the numbers are useful.
Click to expand...

This is exactly why our surgeons want it. From home they can be told the numbers and help manage and it makes their lives easier
 
Another how do you do your average case...

I’ve slowly been changing things during my first year out based on stuff I see my partners do that I like...

One is US aline with micropuncture for all

My first pass success is 100% since switching and it doesn’t add more than 30 seconds since the probe and everything is already in there

I realize I’ll get harassed for this, but I’ll take it

I’ll also just use the use glidescope fromcthe get go with folks who have a sick heart and bad lungs with potential for airway or mask ventilation to be iffy....I figure why not make life simple since these guys won’t tolerate much anyways. Just sick of watching someone struggle then inevitably pt goes downhill quick and you are trying to retrace steps


This is a good thread. Especially for guys like me still changing the way they do things based on reasonable stuff that others do
 
T-burglar said:
i Go back and forth about the usefulness of PA catheters. Putting them in everyone has taught me that the echo is far from the final word in valve disease severity and I find that the information helps me be more sure about grading disease severity because it really helps you correlate and interpret echo findings
Click to expand...

I will admit I wish I was better and did this more routinely. The more Sr guys in my group are just way quicker and better at using information from the swan.

Can you give specific examples for stenosis and regurgitation that you routinely use and feel might trump or carry more weight than tee.
 
anes121508 said:
Another how do you do your average case...

I’ve slowly been changing things during my first year out based on stuff I see my partners do that I like...

One is US aline with micropuncture for all

My first pass success is 100% since switching and it doesn’t add more than 30 seconds since the probe and everything is already in there

I realize I’ll get harassed for this, but I’ll take it

I’ll also just use the use glidescope fromcthe get go with folks who have a sick heart and bad lungs with potential for airway or mask ventilation to be iffy....I figure why not make life simple since these guys won’t tolerate much anyways. Just sick of watching someone struggle then inevitably pt goes downhill quick and you are trying to retrace steps


This is a good thread. Especially for guys like me still changing the way they do things based on reasonable stuff that others do
Click to expand...

I’m of the opinion that you do what works for you - if you always have access to the micro kit and an US then have at it. We didn’t have those kits reliably in fellowship, although I used them for tough lines in residency.

I never was really good at a-lines for a long time (only really users the arrow kit) - in fellowship I started using a standard angiocath with frequent through-and-through with a separate wire and it has revolutionized my practice. Couple it with ultrasound and I don’t miss many anymore - and if I do, I usually switch locations either contralateral radial or brachial.

Point is - be flexible. We sometimes get called to help around the hospital with a-lines and I never know what kit will be up there so often if I have time I’ll go grab my own supplies.
 
anes121508 said:
I will admit I wish I was better and did this more routinely. The more Sr guys in my group are just way quicker and better at using information from the swan.

Can you give specific examples for stenosis and regurgitation that you routinely use and feel might trump or carry more weight than tee.
Click to expand...
There really isn’t. The swans are usually for post op
 
anes121508 said:
I will admit I wish I was better and did this more routinely. The more Sr guys in my group are just way quicker and better at using information from the swan.

Can you give specific examples for stenosis and regurgitation that you routinely use and feel might trump or carry more weight than tee.
Click to expand...

You’re essentially doing a diagnostic right heart cath every case if you treat it that way so you can use the information and correlate it with your echo findings. It’s pretty useful for the tricuspid because hepatic vein flows are really variable compared to pulmonary vein flows and affected by many things. Catheter based RAP and V waves are helpful for differentiating significant TR and RV diastolic disease.

It’s similar for the left sided valves and PA pressures. I’ve had a few cases where the patients symptoms were surely from severe diastolic disease and not their valve.

It’s also interesting to note that you can have blowing flow reversal in the pulmonary veins and normal PA pressures. There’s a deeper understanding of real physiology to be gained from cathing people routinely
 
T-burglar said:
You’re essentially doing a diagnostic right heart cath every case if you treat it that way so you can use the information and correlate it with your echo findings. It’s pretty useful for the tricuspid because hepatic vein flows are really variable compared to pulmonary vein flows and affected by many things. Catheter based RAP and V waves are helpful for differentiating significant TR and RV diastolic disease.

It’s similar for the left sided valves and PA pressures. I’ve had a few cases where the patients symptoms were surely from severe diastolic disease and not their valve.

It’s also interesting to note that you can have blowing flow reversal in the pulmonary veins and normal PA pressures. There’s a deeper understanding of real physiology to be gained from cathing people routinely
Click to expand...

Can you expound a little bit on the variability of hepatic vein flows? My understanding was full systolic wave reversal was a pretty sensitive and specific indicator of severe TR
 
vector2 said:
Can you expound a little bit on the variability of hepatic vein flows? My understanding was full systolic wave reversal was a pretty sensitive and specific indicator of severe TR
Click to expand...

compliance and Rhythm on the right can give the reversal...I think but I’ll dbl check the guidelines that recently made this point
 
anes121508 said:
Sensitive not specific I believe...compliance and Rhythm on the right can give the reversal...I think but I’ll dbl check the guidelines that recently made this point
Click to expand...

I’d imagine it’s just like pulmonary vein flow reversal, pretty specific for severe regurg while systolic blunting can be caused by any number of things.
 
You must log in or register to reply here.

Similar threads

DrOwnage
Would you: Take a pay cut so you don’t work for AMC/pay cut to do your own cases solo?
2
Replies
60
Views
4K
sloh
S
P
cardiac workup before bronchs
Replies
29
Views
1K
CopaceticOne
CopaceticOne
castafari
Cardiac call rates
Replies
28
Views
2K
caligas
C
B
Doing your own billing?
Replies
1
Views
717
BLADEMDA
BLADEMDA
Drwine
Narcotic administration in cardiac surgery cases
2 3 4
Replies
162
Views
10K
castafari
castafari
Top