DrOwnage

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Hey guys heres a case.

65 y.o. 77kg, 5'11" BMI 23, with previous medical history of CAD, MI x3 (last in 2017); s/p DES to OM (6/07); periprocedure thalamic CVA x 2 with right-sided weakness; s/p CABG (LIMA-LAD, SVG-RCA/PDA in 4/2010) and DES x4 (OM1 6/2017, LAD 5/2008 and 2017, LCx 5/2015) with ischemic cardiomyopathy, h/o VT and CHB s/p AICD (pacemaker dependent); infected AICD, lead extraction 4/26/2019 and generator change with leadless single chamber pacemaker; chronic stable angina, OSA (on home CPAP) and syncope. From SNG for acute right leg pain after falling out of his wheelchair. Found to have Comminuted fracture of the proximal femur metadiaphysis, with displacement and overriding of the fragments

Plan for open reduction internal fixation, IM nail fixation (R) Hip.

Echocardiogram: Date: 10/23/19
LV ejection fraction (%): 20
Valve Assessment
mild aortic insufficiency
moderate mitral regurgitation
moderate tricuspid regurgitation
Pulmonary Pressure (mmHg): 55, Moderate Pulm Htn
Other: CONCLUSIONS
1. Definity contrast agent was given intravenously to enhance visualization.
2. Mildly increased left ventricular size.
3. Borderline concentric left ventricular hypertrophy.
4. There are no normally-contracting wall segments.
5. The calculated ejection fraction (Simpson's) is 20 %.
6. Upper normal right ventricle in size.
7. Moderately reduced RV systolic function.
8. Severely dilated left atrium in size.
9. Moderately dilated right atrium in size.
10. At least moderate mitral valve regurgitation. If clinically indicated and if management of a patient will alter, a transesophageal echocardiogram (TEE) may be considered.
11. Moderate tricuspid regurgitation.
12. Mild aortic regurgitation.
13. Moderately elevated PA systolic pressure.
14. Elevated right-sided filling pressure.

CT Chest yesterday:
IMPRESSION:
1. Interval development of peripheral lobulated masslike consolidation within the left lower lobe/lingula, small to moderate left pleural effusion and prominent mediastinal lymph nodes. This raises concern for malignancy/lung cancer. Recommend further
evaluation with contrast-enhanced CT and/or, left pleural fluid analysis or lung biopsy depending on clinical scenario.
2. Nodular consolidative opacities in the right lung apex are of indeterminate etiology. Possibility include infection or malignancy
3. Scattered areas of airways impaction, most prominently in the right lower lobe, likely aspiration.
4. Cardiomegaly. Coronary stents. Leadless ICD in the right ventricle

Hgb 10.1
BNP 4.4k
Creatinine 1.22
INR 1.3

This being done at an ortho hospital without intraop TEE. There is a cath lab.

Epidural, a line, central line w/ MAC? General with preinduction a line, central line w/ PAC? What would you guys do? Thanks ahead of time.
 

FFP

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Awake A-line, Zoll pads, large bore IVs, prop-sux-tube, keep his vitals where he lives. +/- chest tube if pleural effusion is significant.
 
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Mikkel

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A lot of that info is unnecessary and won't change management of the intraop anesthetic.

Don't kill the patient.

Gentle LMA after very slow and very little propofol and Nitrous and Desflurane.

Art line if the patient is hemodynamically unstable.

Hopefully your ortho guys are slick and can do a nail quickly, and not send up a fat embolus to finish him off.
 
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caveat87

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consult to IR for pigtail CT placement prior to case. pre-induction art line, etomidate/sux/tube, 2 good IVs. vasopressin/epi as needed. not a fantastic case to be doing at an ortho hospital without access to TEE but so it goes
 

vector2

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consult to IR for pigtail CT placement prior to case. pre-induction art line, etomidate/sux/tube, 2 good IVs. vasopressin/epi as needed. not a fantastic case to be doing at an ortho hospital without access to TEE but so it goes

The "ortho hospital" bit is def the part I'm worried about, not necessarily the lack of TEE. What happens if things go sideways intraop or the pt requires some actual post-op intensive care? I'm also worried that that 4.4k BNP is a regular BNP, not a nt-pro

This case is much more facile if he had a sick heart or sick lungs. The (ischemic CM, multiple valvular abnls, ongoing angina, PPM dependency, CVA) + (pulm HTN, pleural effusions, nodules, RLL infiltrate, OSA) are a recipe for badness.

What's his vitals? How much O2 is he on? How's his work of breathing look? Has he been taking his lasix? What's his mentation when you examine him? Is he on AC or antiplatelets?
 
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Noyac

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This is a KISS case.
Don’t put in a CT god’s Sake. It’s small and has been present for a long time.
A line? Sure, why not.
Central line maybe but I wouldn’t. And especially not a MAC.
BNP, well someone tell me. Is this a result of chronic Heart failure? Does he have pitting edema. Either way I’m not terribly concerned because I don’t plan to give him any fluids really.
I’d slip this guy off to sleep as slow and gentle as I can tolerate. Slide in an LMA and tell ortho to use some local. I may do a fascia iliacus block.
But this case is less than an hour at my facility so I’m sure it’s the same at this facility.
 
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GravelRider

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This is a KISS case.
Don’t put in a CT god’s Sake. It’s small and has been present for a long time.
A line? Sure, why not.
Central line maybe but I wouldn’t. And especially not a MAC.
BNP, well someone tell me. Is this a result of chronic Heart failure? Does he have pitting edema. Either way I’m not terribly concerned because I don’t plan to give him any fluids really.
I’d slip this guy off to sleep as slow and gentle as I can tolerate. Slide in an LMA and tell ortho to use some local. I may do a fascia iliacus block.
But this case is less than an hour at my facility so I’m sure it’s the same at this facility.

Honestly, this is exactly what I would do. Gentle induction, slip in an LMA and have the patient breathe a whiff of sevo. I probably wouldn’t bother with the A-line. I would have a frank discussion with patient and family about the risks before getting started. This is a 45 minute case with most of our ortho guys. This patient’s 30 day mortality rate is probably 100%.

To OP: Why do you want TEE for this case?
 
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Noyac

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Plus if you are really expecting something from the TEE that requires intervention then you will probably need a CVL. And the domino’s will continue to fall.
My plan would be to get in and get out.
Let the fleas deal with him postop since they probably are the ones that pushed to get it fixed. And yes, that’s what I tell them. They always call ortho and say, “you need to fix this because he is in pain.” I tell them, “ I’m can get him through just about anything but he is all yours when I’m done. Or you can send him to hospice now. I don’t really care.”
 

vector2

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My orthos would be done before the TEE was.

I'm at the ivory tower where one of the surgeons (who always seems like he's on call when I am) legit takes 2h30m 'minimum' to do a comminuted prox femur, and probably with a much higher EBL than you'd expect.

I wish I could do the KISS stealth ninja plan....
 

Noyac

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Echo underestimates PHTN...sounds like the RV is already flailing...
So can you tell me the difference btw PAP of 60 and 70?
I can’t. But RV failure I can. So I don’t really care how much PHTN is present as long as the RV is working in a case like this.
Don’t get me wrong, I don’t like this case for many reasons. But I’m not gonna walk in at the stroke of midnight and change all the plans that everyone has worked on for the past 4 hrs with the family. I will ask what has been discussed with the family and confirm their understanding though.
Now if this was a rookie new orthopod and he/she wanted to do a hemi then I would have a heart to heart with him/her. Ive had to do this more than once and they get it after we talk, usually.
If they don’t then you just give a little extra propofol and act like you are in the full court press. Then look up at them and say this guy just died but he is back for now he has about 45 min of life left in him. Let’s get him the hell outta here before that.
 
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Noyac

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I'm at the ivory tower where one of the surgeons (who always seems like he's on call when I am) legit takes 2h30m 'minimum' to do a comminuted prox femur, and probably with a much higher EBL than you'd expect.

I wish I could do the KISS stealth ninja plan....
Omg I feel you plan.
I had one in academia that would drape for 45 min. WTF?
See my above post.
 
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dannyboy1

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Definitely agree with the KISS plan. Would try spinal first though. Low dose (like 1.8 cc) 0.5 bupi should get you through the case just fine with minimal hemodynamic changes. I would prefer that to putting the 20% EF under GA if it could be avoided.
 
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drmwvr

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So can you tell me the difference btw PAP of 60 and 70?
I can’t. But RV failure I can. So I don’t really care how much PHTN is present as long as the RV is working in a case like this.

Maybe I wasn't clear. My comment was in the context of a flailing RV in the presence of mod to severe PHTN and a spinal. RV doesn't really seem to be working that well. Short a spinal (not a great idea) surviving the OR course with GA is less of an issue than the PACU course with the attendant pain, stress, narcotic (rising CO2). If he even made it to the unit, he'd have a good chance of dying there. Do the case, certainly, just not with SAB
 

Noyac

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Maybe I wasn't clear. My comment was in the context of a flailing RV in the presence of mod to severe PHTN and a spinal. RV doesn't really seem to be working that well. Short a spinal (not a great idea) surviving the OR course with GA is less of an issue than the PACU course with the attendant pain, stress, narcotic (rising CO2). If he even made it to the unit, he'd have a good chance of dying there. Do the case, certainly, just not with SAB
That’s a good question.
I would do an “isobaric” spinal in a real sick pt. Way more stable than a hyperbaric.
But in this guy I would probably avoid it. This is why all the BS studies that say spinal is safer don’t hold water.
I’d probably limp this guy along with some syringe cowboy blips of epi. 10-30mcg at a time.
I wouldn’t worry about narcotics post op since he will be much more comfortable after the repair then he was before. And I would do a fascia iliaca block if that were not the case.
 
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abolt18

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That’s a good question.
I would do an “isobaric” spinal in a real sick pt. Way more stable than a hyperbaric.
But in this guy I would probably avoid it. This is why all the BS studies that say spinal is safer don’t hold water.
I’d probably limp this guy along with some syringe cowboy blips of epi. 10-30mcg at a time.
I wouldn’t worry about narcotics post op since he will be much more comfortable after the repair then he was before. And I would do a fascia iliaca block if that were not the case.
Can you explain why the spinal is a no go for this guy? When I read the initial case it seemed like a great idea to me then no one mentioned it. It could be that I drove for like 9 hours today and my brain has stopped working, but I don't see a problem with a spinal in this guy. I even thought it might be ideal. Add in a low dose norepi or phenylephrine gtt and call it good.
 

woopedazz

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We had an almost identical case the other week. Would like to compare our approach (and intra-op near disaster) to yours.

In our setting:
Patient almost identical in terms of cardiac history + PPM dependent. Ours had fewer cardiac interventions, but the same overall result (stents, CABG, PPM dep, etc). Ours was also ~80 and had some AS.
Patient refused any neuraxial anaesthesia (which is fine, we weren't going to do that regardless).
Had femoral nerve block in ED some 12 hours prior.

What we did:
Clear goals of care + discussion pre-op + requested expedious attending.
Ortho residents state attending has arrived and is getting changed and we can start anaesthesia.
Pads on. Awake A-line. Multiple peripheral IVC, no CVC.
Whiff of midaz. Low-dose fentanyl --> very slow, propofol induction --> TIVA.
2nd Gen LMA --> Pressure demand PPV. We avoided unsupported spont. vent.
FiO2 ~70-80% throughout to try to minimise HPV.
Positioned lateral.
....
Watch as the glorious HD stable induction precedes a stable maintenance phase. Wonderful paced 60bpm. Vent looking great.
Pull out the sudoku.
....
Glance up from sudoku and realise ortho attending is not here yet. Note that the senior ortho resident is assisting/teaching the junior resident.
See the LMA has developed a leak and the patient is not quite sailing as smoothly as previous.
Exchange LMA; leak stops.
....
New LMA starts leaking again 5 minutes later.
Turn to nurse to tell her to prep for a tube while I see what the issue is.
Machine starts beeping; turn around to see something like this staring back at me:

1571974775334.png

Thoughts on what might have happened?
What would you do at this point?
Any obvious issues you see in our plan? What would you have done differently?
 
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nimbus

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His best chance of a decent QOL is to get the fracture fixed. You could consider the ORIF to be palliative. I would do a FICB and preinduction Aline, induce with a tiny dose of propofol and a lot of roc, intubate, maintain on low dose sevo, no narcs. Then reverse with suga and wake him up. Most ICM with 20% EF does fine with GA. He had icd revision 6 months ago and did okay. That is reassuring.
 
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nimbus

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We had an almost identical case the other week. Would like to compare our approach (and intra-op near disaster) to yours.

In our setting:
Patient almost identical in terms of cardiac history + PPM dependent. Ours had fewer cardiac interventions, but the same overall result (stents, CABG, PPM dep, etc). Ours was also ~80 and had some AS.
Patient refused any neuraxial anaesthesia (which is fine, we weren't going to do that regardless).
Had femoral nerve block in ED some 12 hours prior.

What we did:
Clear goals of care + discussion pre-op + requested expedious attending.
Ortho residents state attending has arrived and is getting changed and we can start anaesthesia.
Pads on. Awake A-line. Multiple peripheral IVC, no CVC.
Whiff of midaz. Low-dose fentanyl --> very slow, propofol induction --> TIVA.
2nd Gen LMA --> Pressure demand PPV. We avoided unsupported spont. vent.
FiO2 ~70-80% throughout to try to minimise HPV.
Positioned lateral.
....
Watch as the glorious HD stable induction precedes a stable maintenance phase. Wonderful paced 60bpm. Vent looking great.
Pull out the sudoku.
....
Glance up from sudoku and realise ortho attending is not here yet. Note that the senior ortho resident is assisting/teaching the junior resident.
See the LMA has developed a leak and the patient is not quite sailing as smoothly as previous.
Exchange LMA; leak stops.
....
New LMA starts leaking again 5 minutes later.
Turn to nurse to tell her to prep for a tube while I see what the issue is.
Machine starts beeping; turn around to see something like this staring back at me:

View attachment 284509

Thoughts on what might have happened?
What would you do at this point?
Any obvious issues you see in our plan? What would you have done differently?


How were his vitals before the change? Was he hypercarbic, acidemic, and hyperkalemic? Why I don’t like LMA’s for sick patients and prefer to control ventilation. Regardless, seems like a good time to check a gas and use the R2 pads. Also I don’t give versed to 80 year olds with hip fractures.
 
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woopedazz

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How were his vitals before the change? Was he hypercarbic, acidemic, and hyperkalemic? Why I don’t like LMA’s for sick patients and prefer to control ventilation. Regardless, seems like a good time to check a gas and use the R2 pads.
Pre-change:
ABG taken 10 minutes prior was surprisingly fine. Electrolytes were fine pre-op + ABG.
Vitals were:
SpO2 98%
RR ~8-13 on pressure support.
HR = 60bpm paced.
BP ~110/60 without support.

Immediately pre-change:
SpO2 97%
RR 15-16 pressure support
HR 60bpm paced.
BP 115/60

Also I don’t give versed to 80 year olds with hip fractures.
I don't usually either. I was running support on this case.
 

epidural man

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Can you explain why the spinal is a no go for this guy? When I read the initial case it seemed like a great idea to me then no one mentioned it. It could be that I drove for like 9 hours today and my brain has stopped working, but I don't see a problem with a spinal in this guy. I even thought it might be ideal. Add in a low dose norepi or phenylephrine gtt and call it good.
its a good question.

Physiologic response to spinals can be dramatic - and often unpredictable. I suspect that would be the issue.
 

vector2

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Pre-change:
ABG taken 10 minutes prior was surprisingly fine. Electrolytes were fine pre-op + ABG.
Vitals were:
SpO2 98%
RR ~8-13 on pressure support.
HR = 60bpm paced.
BP ~110/60 without support.

Immediately pre-change:
SpO2 97%
RR 15-16 pressure support
HR 60bpm paced.
BP 115/60


I don't usually either. I was running support on this case.

My guess is you put a magnet on it and the the joker who programmed his asynchronous rate set the backup to something silly like 120. I've seen that a couple times before.

Alternatively, his PPM/icd is doing antitachycardia pacing because it detected some incoming badness.

If it's not those things and you're telling me acid base status, lytes, oxygenation, ventilation and hemodynamics are OK, then he might be having worsening ischemia.
 

Mikkel

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Does the surgeon planning supine on distraction table with crotch post? You don't need a lot of anesthesia to get this guy through
We had an almost identical case the other week. Would like to compare our approach (and intra-op near disaster) to yours.

In our setting:
Patient almost identical in terms of cardiac history + PPM dependent. Ours had fewer cardiac interventions, but the same overall result (stents, CABG, PPM dep, etc). Ours was also ~80 and had some AS.
Patient refused any neuraxial anaesthesia (which is fine, we weren't going to do that regardless).
Had femoral nerve block in ED some 12 hours prior.

What we did:
Clear goals of care + discussion pre-op + requested expedious attending.
Ortho residents state attending has arrived and is getting changed and we can start anaesthesia.
Pads on. Awake A-line. Multiple peripheral IVC, no CVC.
Whiff of midaz. Low-dose fentanyl --> very slow, propofol induction --> TIVA.
2nd Gen LMA --> Pressure demand PPV. We avoided unsupported spont. vent.
FiO2 ~70-80% throughout to try to minimise HPV.
Positioned lateral.
....
Watch as the glorious HD stable induction precedes a stable maintenance phase. Wonderful paced 60bpm. Vent looking great.
Pull out the sudoku.
....
Glance up from sudoku and realise ortho attending is not here yet. Note that the senior ortho resident is assisting/teaching the junior resident.
See the LMA has developed a leak and the patient is not quite sailing as smoothly as previous.
Exchange LMA; leak stops.
....
New LMA starts leaking again 5 minutes later.
Turn to nurse to tell her to prep for a tube while I see what the issue is.
Machine starts beeping; turn around to see something like this staring back at me:

View attachment 284509

Thoughts on what might have happened?
What would you do at this point?
Any obvious issues you see in our plan? What would you have done differently?

I wouldn't have given versed and fentanyl.

All he needed was a little gas to scramble his neurons.

The less anesthesia the easier it is for the body to tolerate.

Remember, he wasn't dead before you started.
 

woopedazz

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My guess is you put a magnet on it and the the joker who programmed his asynchronous rate set the backup to something silly like 120. I've seen that a couple times.
This is pretty close. Nice! No magnet though.
It ended up being what we think was a paced VT.
At the time we went deer in headlights and quickly surveyed the scene before the truth came apparent. Took us a solid 30-60s to work it out, but in the meantime he was:
Running at 130bpm wide complex, nothing else really visible (including any pacing spikes.)
RR = high, virtually no seal
Art. Line = tracing with cardiac output maintained.
Surgeons... the surgeons had the guys leg in an impossible position and were putting enormous force on it.

So basically his pacemaker was picking up signals from his enormous sympathetic drive from severe pain that we'd clearly underestimated. Ppm max rate was 130. So it took off from 60 --> 130 in a single beat and just carried on.

Telling the surgeons to chill, slugging him with another 200 fent and we were golden. 2 hours into the case at this point...

Trops at their baseline (elevated baseline) post-op.

Still **** myself though
 

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So basically his pacemaker was picking up signals from his enormous sympathetic drive from severe pain that we'd clearly underestimated. Ppm max rate was 130. So it took off from 60 --> 130 in a single beat and just carried on.

Sounds like a rate response feature of the pacemaker wasn't turned off.
 
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jwk

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The "ortho hospital" bit is def the part I'm worried about, not necessarily the lack of TEE. What happens if things go sideways intraop or the pt requires some actual post-op intensive care? I'm also worried that that 4.4k BNP is a regular BNP, not a nt-pro

This case is much more facile if he had a sick heart or sick lungs. The (ischemic CM, multiple valvular abnls, ongoing angina, PPM dependency, CVA) + (pulm HTN, pleural effusions, nodules, RLL infiltrate, OSA) are a recipe for badness.

What's his vitals? How much O2 is he on? How's his work of breathing look? Has he been taking his lasix? What's his mentation when you examine him? Is he on AC or antiplatelets?
The "ortho hospital" has a cath lab but no TEE? That makes zero sense.
 

drmwvr

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its a good question.
Physiologic response to spinals can be dramatic - and often unpredictable. I suspect that would be the issue.

My concern with a spinal is with the first patient's RV. It's failing against a dilated LV and elevated PA pressure. Do anything to suddenly (raise venous capacitance) unload it, downstream RCA perfusion will fall and he's done. An isobaric technique is more of a gradual onset, but every bit as profound as a hyperbaric one and lasts longer. GA can be turned off.
 
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Noyac

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My concern with a spinal is with the first patient's RV. It's failing against a dilated LV and elevated PA pressure. Do anything to suddenly (raise venous capacitance) unload it, downstream RCA perfusion will fall and he's done. An isobaric technique is more of a gradual onset, but every bit as profound as a hyperbaric one and lasts longer. GA can be turned off.
Exactly. I don’t think I said a spinal couldn’t be done but the issue is that the spinal is permanent and a GA can be turned off. But isobaric seems to be a bit more controllable. Allowing for small doses of neo or epi. That’s all.
 
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OTCAwesome

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My concern with a spinal is with the first patient's RV. It's failing against a dilated LV and elevated PA pressure. Do anything to suddenly (raise venous capacitance) unload it, downstream RCA perfusion will fall and he's done. An isobaric technique is more of a gradual onset, but every bit as profound as a hyperbaric one and lasts longer. GA can be turned off.

I concur, like you're saying, at least with general anesthesia I always have the backup of versed and paralytic for pts who are actively trying to die.
 

SaltyDog

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If you really want to do this under neuraxial, just thread an IT catheter and dose it up gradually with isobaric a couple mg at a time.
 
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vector2

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The "ortho hospital" has a cath lab but no TEE? That makes zero sense.

I assume he meant they don't have access to a cardiologist or anesthesiologist who can do an intraop one, but presumably any cath lab would have the equipment.
 

woopedazz

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Wopedazz, would you do anything different after all this?

Quite a lot. But a few simple things:
  • Volatile, not TIVA.
  • Attending in the room or don't start the case.
  • Lower threshold to magnet anything funky.
  • I'm also considering advocating for a functional block pre-induction if there are grave concerns re: HD stability intra-op. If I had placed a FIB pre-op while we waited for the attending the whole case would be smoother.
 
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Arch Guillotti

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I'm also considering advocating for a functional block pre-induction if there are grave concerns re: HD stability intra-op. If I had placed a FIB pre-op while we waited for the attending the whole case would be smoother.

Sometimes a little stimulation helps things!
 
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FFP

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I wouldn't place a block if I plan a general. That's the recipe for chasing hypotension the whole case. A block is not like a volatile anesthetic; one can't take it back if the patient is too "deep". And an EF 20% heart won't like phenylephrine and will have limited reserve.
 

epidural man

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Just curious as the Titan of TIVA - why would you all want gas? Is it for the benefits of preconditioning that the fluranes provide?
 

vector2

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Just curious as the Titan of TIVA - why would you all want gas? Is it for the benefits of preconditioning that the fluranes provide?

The hemodynamic and amnestic effects of 0.7 mac volatile are infinitely more predictable IMO than a tiva titration
 
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FFP

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The hemodynamic and amnestic effects of 0.7 mac volatile are infinitely more predictable IMO than a tiva titration
Plus balanced anesthesia doesn't mean gas-ONLY. One should use the best tools that get the job done safely, regardless of "religion".
 

SaltyDog

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Just curious as the Titan of TIVA - why would you all want gas? Is it for the benefits of preconditioning that the fluranes provide?

I though you wanted to stop saying stupid things?
 
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dchz

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I wouldn't place a block if I plan a general. That's the recipe for chasing hypotension the whole case. A block is not like a volatile anesthetic; one can't take it back if the patient is too "deep". And an EF 20% heart won't like phenylephrine and will have limited reserve.

Essentially you're saying you'd rather use the patients endogenous epi rather than pushing phenylephrine?
 

FFP

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Essentially you're saying you'd rather use the patients endogenous epi rather than pushing phenylephrine?
I'd rather not suppress it. Phenylephrine and increased afterload can depress the heart and CO in somebody with really low EF.
 
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needledox

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I'm at the ivory tower where one of the surgeons (who always seems like he's on call when I am) legit takes 2h30m 'minimum' to do a comminuted prox femur, and probably with a much higher EBL than you'd expect.

I wish I could do the KISS stealth ninja plan....

And let the med student close at 2 am
 
D

deleted500612

BNP, well someone tell me. Is this a result of chronic Heart failure? Does he have pitting edema. Either way I’m not terribly concerned because I don’t plan to give him any fluids really.

BNP 4.4k? Yikes.

Not entirely clear from the hx if this low EF is a new finding or if he is known to have chronic HFrEF. Assuming it's chronic and he's not having a severe acute decompensation (we don't have physical exam findings, but CT scan from yesterday doesn't suggest pulmonary vascular congestion or any significant pulmonary edema) I'd say the most likely scenario is that he's on Entresto GDMT for HFrEF and that BNP is "falsely" elevated
 
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