Interesting case for residents...

[GoldnLead]

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75M for a R anterior total hip arthroplasty. Turns out patient is the father in law of one of our surgeons.

Had a significant R parietal CVA in 1/2013 with L leg weakness. CAD, s/p PTCA 2006. Has had a "negative stress test" 2 months ago. No complaints of angina or dyspnea.

Had a L CEA 2 months ago as well. No issues periop or post op.

You may rightly be asking, "Why the hell are we doing this case?"
Apparently his L leg is weak; R leg is causing pain and thus hampering rehab efforts.

Fair enough. Patient and son in law understand he's at increased risk for periop/postop complications, so let's do this.

Bring him to the OR. No pre medication. For the residents out there, Versed is the most overused drug in anesthesia. Should be reserved for pre-pubescent kids and tearful women. Certainly not needed in geriatric patients. I can't believe how many of my partners slam little old ladies getting their hips pinned with a couple mg's and have em gorked out in the PACU for 2 hours...but I digress.

Awake art line. I notice as soon as I get a flash that the 1cc syringe (I attach a 1cc syringe to a jelco 20g angiocath and use that) fills up immediately.

I transduce. Art BP: 300/90. Transducer is level with heart. Cuff pressure is 275/80 or so. Thousands of Bernanke Bux worth of equipment is open, everyone is ready to operate....

What would you do next???

 

[IveGotTwins]

Bring pressure down with impunity using a combination of IV meds and breathing exercises.

 

[dhb]

Retrograde!













...my bad wrong thread

 

[Arch Guillotti]

Why did you place an art line?

 

[Surfer]

Art line? Why? When the bp cuff read 275 your day was already over.Case canceled and consult medicine. Btw, I rarely rarely cancel anything! But this case? No way you're doing that.

 

[Arch Guillotti]

Art line? Why?

I wouldn't normally place an art line for this case, much less an awake one. I would like to know what the BP was before the pt. was pushed to the OR.

 

[chessknt]

Yea what were the pre op vitals and physical like?

How is the pt's mental status right now?

 

[OB1🤙]

Cancellectomy, agree 1000% about the versed. Also agree with wondering what preop vitals were, and with how an aline made its way into the picture.

 

[VentdependenT]

Depends entirely what he preop office and Holdin bp's are.

 

[KLPM]

For the residents out there, Versed is the most overused drug in anesthesia. Should be reserved for pre-pubescent kids and tearful women. Certainly not needed in geriatric patients. I can't believe how many of my partners slam little old ladies getting their hips pinned with a couple mg's and have em gorked out in the PACU for 2 hours...but I digress.

At my place another common population getting midazolam is tearful young men with young kids going in for simple ortho procedures.

 

[GoldnLead]

I wouldn't normally place an art line for this case, much less an awake one. I would like to know what the BP was before the pt. was pushed to the OR.

I planned to place an awake art line from the get-go given his history of recent CVA and I planned to run his MAPs on the higher side. His pre op BP was 180/80 or so. Not great but not terrible. I didn't even get a cuff pressure in the room til after I placed the art line.

I looked at him and said, "My friend, I've never seen this before; you didn't do cocaine did you?" He laughed and said his BP is always well controlled. Had been in the 130s the day before when he'd seen his nephrologist.

Usually, when people say "I've never seen this before," they're BS-ing you cause they probably screwed up. However, I really had never seen a pressure like that before.

Patient was completely asymptomatic. No HA, no visual changes, no angina, no SOB. No changes on EKG. Again, he'd had a completely negative PThal 2 months ago and his cardiologist had confirmed this.

I started him on nicardipine while I decided whether or not to proceed. Either way, treating him in the OR was the most expeditious course of action. It would've taken over an hour to get him to CCU, give some report to an RN who can't tell her head from her ass and finally get pharmacy to tube the meds up.

Had the drip going in 5 minutes while I skipped down the hall to talk to his cardiologist who happened to be doing a procedure.

He affirmed what the patient said: he was always compliant with meds and well controlled. He agreed with nicardipine.

I looked at his CEA records and his pressures were normal pre and post op.

After about 45 minutes of observing him in the OR, his BPs came down to the 150s. I elected to proceed. If he'd had a catastrophic bleed, he would have manifested neurologic sx, of which he had none.

Case went uneventfully. Drip was at about 1.5mg/hr throughout the case. Kept his MAPs in the 80s with about .75MAC sevo and some fentanyl. Patient woke up well with no complaints. I planned to observe him in CCU post op.

Medicine saw him in PACU and asked if they could pull art line and start hydralazine. I said sure, knock yourself out. I wanted a more titratable med, that's why I did nicardipine.

Was discharged 2 days later.

I wouldn't fault anyone for canceling, but I felt that this was a result of impaired BP autoregulation from the CEA he had done a few months back. There have been a few case reports on PubMed, but if anyone else has insight into this, I'd appreciate some info!

 

[GoldnLead]

Depends entirely what he preop office and Holdin bp's are.

On the right track my friend. BTW, been following your posts since about 2005. Keep it pimpin.

 

[pgg]

Glad it worked out, but no way would I have done that case.

I think nicardipine on a guy who shows up 300/90 is fine, but his destination should be the ICU not the OR.

And you observed him in the OR for 45 minutes before electing to proceed? That's odd.

Whatever you write off his hypertensive emergency to (reaching ... reaching ... aha impaired autoregulation) he's still at markedly elevated risk for perioperative badness, and you have no defense if anything goes wrong.

When the autopsy comes back showing a pheo 😀 you may as well hang it up.


Agree about the midazolam though. 🙂

 

[Dwindlin]

Glad it worked out, but no way would I have done that case.

I think nicardipine on a guy who shows up 300/90 is fine, but his destination should be the ICU not the OR.

And you observed him in the OR for 45 minutes before electing to proceed? That's odd.

Whatever you write off his hypertensive emergency to (reaching ... reaching ... aha impaired autoregulation) he's still at markedly elevated risk for perioperative badness, and you have no defense if anything goes wrong.

When the autopsy comes back showing a pheo 😀 you may as well hang it up.


Agree about the midazolam though. 🙂

While I cannot comment on whether to proceed with a case because of severe hypertension, I don't think this is a hypertensive emergency. Unless I misread the gentleman was completely asymptomatic. I believe current trends are moving towards not being as aggressive with acute treatments with asymptomatic hypertension (regardless of actual numbers). This is not to say that walking around with blood pressure that high are good, but that it is probably okay to use oral medications and not need to be in the ICU.

 

[risnwb]

While I cannot comment on whether to proceed with a case because of severe hypertension, I don't think this is a hypertensive emergency. Unless I misread the gentleman was completely asymptomatic. I believe current trends are moving towards not being as aggressive with acute treatments with asymptomatic hypertension (regardless of actual numbers). This is not to say that walking around with blood pressure that high are good, but that it is probably okay to use oral medications and not need to be in the ICU.

I'd probably advise against treating an SBP of 300 with oral antihypertensives😉

 

[risnwb]

.

 

[Dwindlin]

I'd probably advise against treating an SBP of 300 with oral antihypertensives😉

Unless they are symptomatic that is what is done here. Granted I don't know that I've seen 300, but I have seen plenty of 250's - 260's, and thus far they have done fine with slowly bring their pressures down with nothing but orals in a tele bed.

Our ED's here have embraced ACEP's position statement that asymptomatic hypertension does not need to be treated in the ED, so often times they will do nothing except call the primary and ask what they want done. If they have no primary they will come in to get their BP down (slowly) and get established.

I dunno, maybe we're crazy but it seems to work well and saves the patient a probably unnecessary ICU admission.

 

[chessknt]

While I cannot comment on whether to proceed with a case because of severe hypertension, I don't think this is a hypertensive emergency. Unless I misread the gentleman was completely asymptomatic. I believe current trends are moving towards not being as aggressive with acute treatments with asymptomatic hypertension (regardless of actual numbers). This is not to say that walking around with blood pressure that high are good, but that it is probably okay to use oral medications and not need to be in the ICU.

Aside from retinal hemorrhage a lot of the symptoms of malignant HTN are going to be invisible initially. It needs to be treated aggressively to protect end-organ function. This has been well studied in the ICU setting and I see no reason why it would be different in a non-critically ill pt.

 

[Dwindlin]

Aside from retinal hemorrhage a lot of the symptoms of malignant HTN are going to be invisible initially. It needs to be treated aggressively to protect end-organ function. This has been well studied in the ICU setting and I see no reason why it would be different in a non-critically ill pt.

Below I linked emedicine article on hypertensive emergencies, below that are several citations of sources that support the non-urgent lowering of asymptomatic hypertension (the cardiology text goes as far to say that it can be addressed on a completely outpatient basis). I apologize that I cannot link them as they are accessed through my programs library, but if you have access to the resources you should be able to pull them up.

http://emedicine.medscape.com/article/241640-overview

Slesinger TL, Perry CM, Zhou Q. Chapter 14. Hypertensive Crises. In: Farcy DA, Chiu WC, Flaxman A, Marshall JP, eds. Critical Care Emergency Medicine. New York: McGraw-Hill; 2012. http://www.accessemergencymedicine.com/content.aspx?aID=55811452. Accessed June 10, 2013.

Atkins G, Rahman M, Wright, Jr JT. Chapter 70. Diagnosis and Treatment of Hypertension. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst's The Heart. 13th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=7824590. Accessed June 10, 2013.

Kotchen TA. Chapter 247. Hypertensive Vascular Disease. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012. http://www.accessmedicine.com/content.aspx?aID=9104833. Accessed June 10, 2013.

Stone C, Humphries RL. Chapter 34. Cardiac Emergencies. In: Stone C, Humphries RL, eds. CURRENT Diagnosis & Treatment Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. http://www.accessemergencymedicine.com/content.aspx?aID=55753550. Accessed June 10, 2013.

Cline DM, Machado AJ. Chapter 61. Systemic and Pulmonary Hypertension. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011. http://www.accessemergencymedicine.com/content.aspx?aID=6359436. Accessed June 10, 2013.

Sutters M. Chapter 11. Systemic Hypertension. In: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment 2013. New York: McGraw-Hill; 2013. http://www.accessmedicine.com/content.aspx?aID=3177080. Accessed June 10, 2013.

 

[Idiopathic]

At my place another common population getting midazolam is tearful young men with young kids going in for simple ortho procedures.

this seems to me to be precisely who the drug is for.

 

[GoldnLead]

Glad it worked out, but no way would I have done that case.

I think nicardipine on a guy who shows up 300/90 is fine, but his destination should be the ICU not the OR.

And you observed him in the OR for 45 minutes before electing to proceed? That's odd.

Whatever you write off his hypertensive emergency to (reaching ... reaching ... aha impaired autoregulation) he's still at markedly elevated risk for perioperative badness, and you have no defense if anything goes wrong.

When the autopsy comes back showing a pheo 😀 you may as well hang it up.


Agree about the midazolam though. 🙂

I had him on nicardipine for 45 minutes while deciding whether or not to proceed. Again, I was his quickest method of treatment.

I entertained a pheo, but why would it show up the minute he's in the OR versus any point before? Remember, he had a CEA only 2 months prior. ALL of his BPs in clinic were normal.

 

[KLPM]

Aside from retinal hemorrhage a lot of the symptoms of malignant HTN are going to be invisible initially. It needs to be treated aggressively to protect end-organ function. This has been well studied in the ICU setting and I see no reason why it would be different in a non-critically ill pt.

Correct me if I am wrong but I think we are mixing definition a bit.

Under the broad heading of hypertensive crises we have hypertensive "urgency" and hypertensive "emergency". Hypertensive urgencies do not display evidence of progressive end-organ dysfunction and evidence seems to suggest a gradual lowering of BP over hours rather than acutely is more beneficial. Malignant hypertension is specifically hypertensive emergency in the presence of retinopathy (exudates, haemorrhage, papilledema).

Take everything I say with a grain of salt. I am just a student.

edit: I think hypertensive retinopathy are frequently asymptomatic or minimally symptomatic. Unless of course they had something like a frank detachment they might just notice some visual field obscuration.

 

[dhb]

He affirmed what the patient said: he was always compliant with meds and well controlled

The 180/80 reading in pre-op and the 90systolic in the OR + the history makes me think this isn't as bad as some would think.
I guess i would have done as the OP. If with a reasonable treatment you can get the BP to acceptable levels i would proceed if the pressure would have stayed high despite adequate tratment i would cancel of course.

 

[pgg]

The 180/80 reading in pre-op and the 90systolic in the OR + the history makes me think this isn't as bad as some would think.
I guess i would have done as the OP. If with a reasonable treatment you can get the BP to acceptable levels i would proceed if the pressure would have stayed high despite adequate tratment i would cancel of course.

Starting a vasoactive drip on someone pushes the envelope of casual/reasonable treatments ... it's not like he got 10 mg of labetalol + a 10 minute rest after running into the surgicenter 10 minutes late, and then his BP went from 190/120 to 150/90. This guy had a systolic BP of 300!

You can make ANY systolic pressure look reassuring over 45 minutes of infusing vasodilators. That doesn't mean the problem is fixed or that risk is back to baseline.

Anything goes wrong perioperatively, anything, and you're done. It's totally indefensible. A 75 year old with coronary and cerebrovascular disease comes in for a not-a-cataract surgery for which non-trivial blood loss is a possibility, pops a 300/90 BP on an a-line, confirmed 275/80 NIBP.

I think you guys are absolutely nuts to even consider taking this guy to the OR.

He should be admitted and his hypertension investigated. An a-line + vasoactive drip = ICU or at least a step-down / telemetry bed some places.

 

[nap$ter]

sounds like a holding area cuff pressure wasn't acquired or reviewed? if our QA reviewers looked at this case they would say:

a - an arterial line should never be placed until after a cuff pressure is obtained, and

b - any pt (much less one c sig CV/Neuro hx) presenting for an elective case c a sbp of 300 should be cancelled

you got lucky

 

[cincincyreds]

Starting a vasoactive drip on someone pushes the envelope of casual/reasonable treatments ... it's not like he got 10 mg of labetalol + a 10 minute rest after running into the surgicenter 10 minutes late, and then his BP went from 190/120 to 150/90. This guy had a systolic BP of 300!

You can make ANY systolic pressure look reassuring over 45 minutes of infusing vasodilators. That doesn't mean the problem is fixed or that risk is back to baseline.

Anything goes wrong perioperatively, anything, and you're done. It's totally indefensible. A 75 year old with coronary and cerebrovascular disease comes in for a not-a-cataract surgery for which non-trivial blood loss is a possibility, pops a 300/90 BP on an a-line, confirmed 275/80 NIBP.

I think you guys are absolutely nuts to even consider taking this guy to the OR.

He should be admitted and his hypertension investigated. An a-line + vasoactive drip = ICU or at least a step-down / telemetry bed some places.

I agree with the above. Unless this was an emergency like an appendix or ruptured AAA,..., I wouldn't do this case.

I dare you to give this answer on your oral boards, and I'm curious to see if the oral board examiner would laugh at you for this response.

I don't want to sound mean, but you need to have an optimized patient for the operating room. A systolic BP of 300 mmHg is not optimized. You can play Russian roulette only so many times before the bullet shows up.

 

[jwk]

Did you take another cuff pressure after placing the A-line? Bad transducers, "over-ring", hyperdynamic traces - all can give you false highs. Do a simple return-to-flow with the BP cuff on the same side as the A-line and see where your waveform returns. That should give you an indication of whether or not you might have a transducer problem. If you get a return-to-flow at 180 and your transducer is telling you 300, get another transducer.

 

[chessknt]

Below I linked emedicine article on hypertensive emergencies, below that are several citations of sources that support the non-urgent lowering of asymptomatic hypertension (the cardiology text goes as far to say that it can be addressed on a completely outpatient basis). I apologize that I cannot link them as they are accessed through my programs library, but if you have access to the resources you should be able to pull them up.

http://emedicine.medscape.com/article/241640-overview

Slesinger TL, Perry CM, Zhou Q. Chapter 14. Hypertensive Crises. In: Farcy DA, Chiu WC, Flaxman A, Marshall JP, eds. Critical Care Emergency Medicine. New York: McGraw-Hill; 2012. http://www.accessemergencymedicine.com/content.aspx?aID=55811452. Accessed June 10, 2013.

Atkins G, Rahman M, Wright, Jr JT. Chapter 70. Diagnosis and Treatment of Hypertension. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst's The Heart. 13th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=7824590. Accessed June 10, 2013.

Kotchen TA. Chapter 247. Hypertensive Vascular Disease. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012. http://www.accessmedicine.com/content.aspx?aID=9104833. Accessed June 10, 2013.

Stone C, Humphries RL. Chapter 34. Cardiac Emergencies. In: Stone C, Humphries RL, eds. CURRENT Diagnosis & Treatment Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. http://www.accessemergencymedicine.com/content.aspx?aID=55753550. Accessed June 10, 2013.

Cline DM, Machado AJ. Chapter 61. Systemic and Pulmonary Hypertension. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011. http://www.accessemergencymedicine.com/content.aspx?aID=6359436. Accessed June 10, 2013.

Sutters M. Chapter 11. Systemic Hypertension. In: Papadakis MA, McPhee SJ, Rabow MW, eds. CURRENT Medical Diagnosis & Treatment 2013. New York: McGraw-Hill; 2013. http://www.accessmedicine.com/content.aspx?aID=3177080. Accessed June 10, 2013.

I see your point--in some cases a nonaggressive lowering is indeed appropriate (http://www.aafp.org/afp/2010/0215/p470.html lays this out well). My point is that this pt does not normally exist at this level and, as far as we can tell, it just started in the OR (his preop BP was lower). My retinal hemorrhage detection skills are pretty subpar and you would need to recheck his kidneys to be able to confidently say there is no evidence of end-organ damage. I feel that the low risk of harming him by aggressively lowering his blood pressure (to SBP 180, then backing off) is outweighed by the risk of trying to correctly classify it. Not to mention his medical history also puts him at higher risk for end organ damage.

 

[Surfer]

Awake a-line for an elective case? You're already headed down a dark road. Now you have a systolic of 300? Iv vasoactive meds for 45 minutes before surgery? With a past medical history you described?

You could have potentially committed mal practice and put your livelihood on the line...for what ???

Cancel this case, do the patient and your future career a favor. As others have said, you played Russian roulette and got lucky, but if anything went wrong you would have been 100% totally indefensible.

Sometimes less is more...

 

[sevoflurane]

Don't be so harsh dude... He doesn't have to share his case with us. 🙄

 

[pgg]

Don't be so harsh dude... He doesn't have to share his case with us. 🙄

I think these are some of the best cases to discuss. Not trying to be harsh when I say I think it's nuts to take this guy to the OR, just emphatic. 🙂


Almost all of the interesting cases presented here are handled very skillfully and while there's a lot to learn from them, mistakes and M&M are also great things to learn from. I like the ones where things go wrong and decisions can be MMQB'd.

For example I wasn't real proud of the decision to take this 76 year old to the OR for a THA but I wouldn't have had the chance to learn something from the thread if I'd never posted about the old guy with an active cardiac condition that I missed in preop ...

Anyway, thanks for posting the case, GoldnLead.

 

[TrustMe]

Thanks for sharing. I probably would not have done the case but that is beside the point now. These are the kinds of cases and situations that I have struggled with as a first year attending and they are good to see and discuss with others. As a resident you don't have as many of these delimas because you do fewer cases (in room provider doing one case at a time, versus ACT model where you may evaluate and anesthetize 10-15 patients/day or more. I have personally only cancelled one case that the surgeon didn't agree with (several others have been cancelled/postponed after discussion with the surgeon and he agreed that we should not proceed) in my first year as an attending and I struggled with that one (I'll share if anyone wants to hear it), but I have done several cases that I wished I had postponed when we were several hours into the case. I feel like this area is the hardest part of the transition to being an attending.

 

[dhb]

Starting a vasoactive drip on someone pushes the envelope of casual/reasonable treatments ... it's not like he got 10 mg of labetalol + a 10 minute rest after running into the surgicenter 10 minutes late, and then his BP went from 190/120 to 150/90. This guy had a systolic BP of 300.

Ok so lets say you send him back to pre-op wait 45min retake his bp which will probably be 180/90 again what do you do cancel?

 

[GoldnLead]

Awake a-line for an elective case? You're already headed down a dark road. Now you have a systolic of 300? Iv vasoactive meds for 45 minutes before surgery? With a past medical history you described?

You committed mal practice and put your livelihood on the line...for what ???

Cancel this case, do the patient and your future career a favor. As others have said, you played Russian roulette and got lucky, but if anything went wrong you would have been 100% totally indefensible.

I'm guessing you're probably at the end of your CA-3 year and think you know it all, so let me provide you with a bit of clarity regarding your first two sentences.

If you're going to PP (working for any group that is worth working for), you play by the rules, because you provide a service to the hospital and surgeons. At our institution, that means awake art lines. Surgeons are not going to wait around--even for 5 minutes-- after you intubate while you try to get an art line. It may not be right, it may not be fair, doesn't matter. You don't like it? You work somewhere else; more power to you.

You better realize that quick if you haven't done so already. It's not academics where you can dick around (sometimes necessarily) for an hour.

Now, I'm not sure exactly WTF you mean by your idiotic statement that I'm heading down a dark road by placing an awake art line for an elective case. Generally you want art lines for patients with cardiac/pulm or neuro issues and as you should know by now, induction is one of the most labile periods of physiologic stress.

You want to cancel the case, absolutely, make an argument, but don't go around making stupid comments like you just did.

 

[GoldnLead]

Thanks for sharing. I probably would not have done the case but that is beside the point now. These are the kinds of cases and situations that I have struggled with as a first year attending and they are good to see and discuss with others. As a resident you don't have as many of these delimas because you do fewer cases (in room provider doing one case at a time, versus ACT model where you may evaluate and anesthetize 10-15 patients/day or more. I have personally only cancelled one case that the surgeon didn't agree with (several others have been cancelled/postponed after discussion with the surgeon and he agreed that we should not proceed) in my first year as an attending and I struggled with that one (I'll share if anyone wants to hear it), but I have done several cases that I wished I had postponed when we were several hours into the case. I feel like this area is the hardest part of the transition to being an attending.

Thanks! This is why I wanted to discuss with you guys. I've been reading the forums for years and have gleaned a lot of useful info and now want to give back.

 

[Surfer]

I'm guessing you're probably at the end of your CA-3 year and think you know it all, so let me provide you with a bit of clarity regarding your first two sentences.

If you're going to PP (working for any group that is worth working for), you play by the rules, because you provide a service to the hospital and surgeons. At our institution, that means awake art lines. Surgeons are not going to wait around--even for 5 minutes-- after you intubate while you try to get an art line. It may not be right, it may not be fair, doesn't matter. You don't like it? You work somewhere else; more power to you.

You better realize that quick if you haven't done so already. It's not academics where you can dick around (sometimes necessarily) for an hour.

Now, I'm not sure exactly WTF you mean by your idiotic statement that I'm heading down a dark road by placing an awake art line for an elective case. Generally you want art lines for patients with cardiac/pulm or neuro issues and as you should know by now, induction is one of the most labile periods of physiologic stress.

You want to cancel the case, absolutely, make an argument, but don't go around making stupid comments like you just did.

i'm a board certified anesthesiologist who's been practicing in private practice for years. i just never bothered to change my "resident" status because quite frankly i don't care.

you committed mal practice, defined as a deviation from the standard of care. the standard of care for an elective joint does not involve 45 minutes of nicardipine and systiolics above 300. you're lucky nothing bad happened because as many of your peers have pointed out, your actions would have been INDEFENSIBLE.

I appreciate the case, but there's not much to discuss here. residents shouldn't get the idea that "if you can get the bp normalized in the OR, you can proceed with an elective case."

i don't see why you were willing to risk it all to make some surgeon happy? would she/he been happy if you killed their mother-in-law by doing a case that should have been canceled? do you still think somehow the case was reasonable to proceed? sorry if i sound harsh, but i speak the truth.

 

[Surfer]

At our institution, that means awake art lines. Surgeons are not going to wait around--even for 5 minutes-- after you intubate while you try to get an art line. It may not be right, it may not be fair, doesn't matter. You don't like it? You work somewhere else; more power to you.

your practice routinely does awake a-lines just to make surgeons happy? wow. your group needs to grow a pair. where i work, surgeons look at us as experts and rarely, if ever, question our judgment.

 

[GoldnLead]

i don't see why you were willing to risk it all to make some surgeon happy? would she/he been happy if you killed their mother-in-law by doing a case that should have been canceled? do you still think somehow the case was reasonable to proceed? sorry if i sound harsh, but i speak the truth.

Absolutely not. Nothing was done to make the surgeon happy. Step one was to normalize BP. It wasn't 300 for 45 minutes (I should have specified), I observed for a total of about 45 minutes in the OR while his systolics normalized because it was the MOST EXPEDITIOUS way of treating him instead of handing him off to PACU, having him get lost on an elevator and then trying to get ahold of a PP intensivist who may or may not be in house.

During that time I was having a face to face consultation with his long-term cardiologist, not going out and sipping a latte.

So instead of saying CANCEL!! as a knee jerk (which is fine, but about 5 other people have said it), why don't you proffer some ideas as to what caused this so we can learn a bit more from this?

 

[GoldnLead]

your practice routinely does awake a-lines just to make surgeons happy? wow. your group needs to grow a pair. where i work, surgeons look at us as experts and rarely, if ever, question our judgment.

We have a good relationship with our surgeons who trust us as well. However, they'd rather get home or to their clinics ASAP rather than sitting around extolling your IQ.

 

[Idiopathic]

whats wrong with an awake art line, for whatever reason? i think it was indicated in this case, in order to effectively recognize and treat hemodynamic perturbation during induction in an 84 year old patient who recently had a CVA, but I would do it to save time as well. I dont think its necessarily about making the surgeon happy either.

 

[pgg]

Ok so lets say you send him back to pre-op wait 45min retake his bp which will probably be 180/90 again what do you do cancel?

I wouldn't send him back to the waiting room and recheck 45 minutes later. I'd call the hospitalist on duty, draw a line through the case on the whiteboard and put a CX next to it, then see if the next case could get started early.

I see no reason to suspect a SBP of 275-300, confirmed via a-line and NIBP, is going to just get better if we all just sit and wait 45 minutes and start over. It's real, it's extraordinarily high, and it can't be written off as white coat syndrome or a jog into the hospital because he overslept.

Bottom line, this is a totally elective procedure in an old vasculopath with silly-high uncontrolled HTN. I'd cancel it without a second thought, and not play hopeful games with rechecking later.


Really, if you're EVER going to cancel a case because a patient shows up asymptomatically hypertensive, this is it.

 

[jwk]

your practice routinely does awake a-lines just to make surgeons happy? wow. your group needs to grow a pair. where i work, surgeons look at us as experts and rarely, if ever, question our judgment.

We routinely place awake art lines in our pre-op area because it's expedient, efficient, and less expensive than wasting valuable OR time in a fast-paced private practice. Maybe you're in academics where you don't have to worry about such things, but the rules are quite different in the real world than academia. Time is indeed money.

 

[Surfer]

i have no problem with awake a-lines when indicated. but i believe those indications are rare (at least in my practice). our a-lines go in while the nurse is prepping the belly. no lost time, unless it's a difficult stick, in which case you probably wouldn't have been successful in the preop area anyways... time is money, agreed, but in private practice patient satisfaction is a big deal. speaking of, did you know as part of obamacare patients can report you for not "communicating" effectively? this will be registered in a database that is searchable.

 

[B-Bone]

i have no problem with awake a-lines when indicated. but i believe those indications are rare (at least in my practice). our a-lines go in while the nurse is prepping the belly. no lost time, unless it's a difficult stick, in which case you probably wouldn't have been successful in the preop area anyways... time is money, agreed, but in private practice patient satisfaction is a big deal. speaking of, did you know as part of obamacare patients can report you for not "communicating" effectively? this will be registered in a database that is searchable.

I disagree. I think that if you've talked yourself into an a-line for the patient's medical condition, it should be done awake because (as mentioned above) induction is one of the most volatile times for the BP. For me this would include pretty much all hearts and most major vascular cases, just based on the medical problems that brought them to the OR.

For cases where I'm putting in an a-line because of what the surgeon is going to do to the patient (pushing on heart, potential massive EBL, etc) I will usually place a-line asleep because I'm not particularly worried about the patient's response to induction (patient specific, of course). This includes cases like thoracotomies, craniotomies, big gyn whacks, etc.

Most of the times I put in an art line are for the patient, rather than the procedure. Thus, most of my a-lines go in awake.

 

[cincincyreds]

i'm a board certified anesthesiologist who's been practicing in private practice for years. i just never bothered to change my "resident" status because quite frankly i don't care.

you committed mal practice, defined as a deviation from the standard of care. the standard of care for an elective joint does not involve 45 minutes of nicardipine and systiolics above 300. you're lucky nothing bad happened because as many of your peers have pointed out, your actions would have been INDEFENSIBLE.

I appreciate the case, but there's not much to discuss here. residents shouldn't get the idea that "if you can get the bp normalized in the OR, you can proceed with an elective case."

i don't see why you were willing to risk it all to make some surgeon happy? would she/he been happy if you killed their mother-in-law by doing a case that should have been canceled? do you still think somehow the case was reasonable to proceed? sorry if i sound harsh, but i speak the truth.

Surfer, I agree with you. The only reason this is not malpractice is the patient didn't have an adverse outcome.

I'm also "board certified", whatever that means as we have cRNAs that think they are better than us. But I agree, I wouldn't proceed to make the surgeon happy. I really only care about the health and well being of the patient. If the surgeon has a stroke because I want an internest to evaluate a systolic BP of 300 in a non-emergent case, so be it. And I have had plenty of disagreements with surgeons because I do what is best for the patient.

This is not a case of the patient is nervous preop and just needs a little versed and cardene. You don't want this patient waking up with a hemorrhagic stroke. The lawyer will find many board certified anesthesiologists lined up who will not agree with the management of this case.

 

[Mman]

For this case as described I would not likely have placed an awake arterial line, but would've seen what the cuff pressure was in the OR and if normal would've placed during induction while the CRNA was mas ventilating the patient. Once or twice a year I'll see a BP so out of whack I'll change course to place awake a-line in the room prior to induction to see if it correlates with the cuff.

I've never seen a pre induction pressure of 300. If I did, I'd start a drip and cancel the case. Too many unknowns for me for an elective case and not worth the risk IMHO. Besides, if it's that high before we start it might be all over the place during the case. And if I was going to do the case? Probably a spinal. I'd rather talk to the patient during the case to make sure they weren't having neurologic changes.


just my 2 cents

I routinely push the envelope in PP, but SBP of 300 is too much for me. Anything above 220 starts to give me serious pause.

 

[W222]

I am a recent grad compared to most but would I be a complete p@ssy to cancel this case? I just don't seethe point of rushing to do this. I would opt for micu admission and do it in two days. Ps. I once saw a bp by a-line of 325/150 during a pheo case. We were slamming him with nitro and he was on 4 drips at that point. He was a vet so needless today he was eating pancakes in the ICU the next morning.

 

[GoldnLead]

I am a recent grad compared to most but would I be a complete p@ssy to cancel this case? I just don't seethe point of rushing to do this. I would opt for micu admission and do it in two days. Ps. I once saw a bp by a-line of 325/150 during a pheo case. We were slamming him with nitro and he was on 4 drips at that point. He was a vet so needless today he was eating pancakes in the ICU the next morning.

Not at all. That's why we're discussing this.

No evidence that this guy had a pheo. I'm still curious as to what some possibilities can be as to what caused this.

Acute head bleed? No evidence of any cerebrovascular malformations on recent scans.
Stone cold neuro exam. GCS 15.
Aortic dissection? No chest/back pain. Both arms read similar bps with the cuff.
Drug abuse? No.
Beta blocker or anti hypertensive med withdrawal? No. Took metoprolol morning of. Per wife and cardiologist, has always been compliant.
Thyroid storm? Not tachycardic. Normothermic. No diaphoresis. Otherwise feeling fine.

Any other ideas?

 

[MTGas2B]

At least diastolic is under 100. You've got that going for your, which is nice.

 

[Oggg]

Versed deficiency.