Interesting case for residents...

[dhb]

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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.

Given the history and the fact that the diastolic is 90 i think it is, but i don't disagree with cancelling.

Oggg Versed deficiency.

 

[Bostonredsox]

Good post to read thanks to all who have Imparted wisdom.

IM/CC guy here not gas. Few questions comments.

1, not sure about the overused versed for whiny young dads but I had a vas not too long ago and the preop versed and Mac with propofol was fantastic for me. Keep the drugs coming.

2. I place awake art lines in MICU constantly. From hypertensives on nicardapine, too septics on levophed, too fattys with afib who just have poorly reliable cuff pressures. What's the big deal? They take 5 min. Generally a lot more can go wrong in the OR than in my patients, who I expect to tank given their critically ill states, why doesn't every OR pt have an art line? If anything just for the post induction propofol hypotension you might have to treat with some ephedrine? I think art lines are fabulous and have minimal downside if in trained hands.

3. I agree with other posters. I think you got lucky. This case would have been cancelled at my shop for sure. Hell they cancel total knees because the K is 5.4 with a lab upper limit of normal of 5.3. As with the discussion above, he has no papilledema, no angina, I assume no aki, and no signs of cerebral ischemia thus this is HTN urgency not emergency. Cancellation of this non-emergent case, A medicine consult with work up and boluses of hydralazine Iv should be sufficient though personally I also would have started a Cardene or nipride drip and monitored in SDU until BP was around 220-230 over around 6-10 hours and then titrated off drip to orals plus prn Iv hydralazine to goal of <200. Solely to prevent over correction of the sbp too fast resulting in cerebral hypoperfusion.

Had this been am emergent case, I think what you did was fabulous. Patient did well and you did everything right. But if it wasn't emergent, it could have waited till BP was sorted out as as pgg and others said, next time it might not work out and if it was a elective case, it will be a field day for the lawyer.

Good thread. Thanks guys.

 

[cchoukal]

I want to reiterate a point and ask a question, both related to whether or not this patient's HTN is symptomatic, because I think whether or not it's symptomatic would inform whether or not to do the case.

First, I agree completely with the above-poster who questioned his ability to detect papilledema on the ophthalmoscopic exam. Who even has access to an ophthalmoscope in the OR?

Second, a couple posters have commented that he doesn't have AKI, as if to imply that his HTN is not affecting his kidneys. How do you know? Would you measure the Cr before deciding? How long would it take for the Cr to rise in response to damage induced by a systolic of 300? I'm not claiming to know the answer to this, but I find it specious reasoning to say he doesn't have AKI just by looking at him, and to use that as evidence that his HTN is asymptomatic in support of doing the case.

 

[Bostonredsox]

I assumed his preop bun and cr were baseline and normal and he appears euvolemic Thus my suspicion for aki is low to start with as a precipitating factor. as to whether he has acute aki as a result of the bp, i dont know of any way to test this except perhaps US of the renal arterial system as compared to a baseline when his bp was normal but im fishing. His preop BP was 180-190 on therapy. No mention of ACEI or arb. Does he have underlying renal artery stenosis? Unlikely if all his clinic bps have been normal and he's already been worked up for longstanding htn. Truth is I'm not sure why his BP spiked. But I see patients walk in to clinic all the time with sbp's >250. If they are asymptomatic and there are no OBVIOUS signs of end organ damage, treat them accordingly. Either way I'd probably say cancel the elective case and let me sort it out. Had it been an appendix or even a sick gallbladder, I think what he did was spot on.

 

[Mman]

2. I place awake art lines in MICU constantly. From hypertensives on nicardapine, too septics on levophed, too fattys with afib who just have poorly reliable cuff pressures. What's the big deal? They take 5 min. Generally a lot more can go wrong in the OR than in my patients, who I expect to tank given their critically ill states, why doesn't every OR pt have an art line? If anything just for the post induction propofol hypotension you might have to treat with some ephedrine? I think art lines are fabulous and have minimal downside if in trained hands.

Arterial lines are fabulous, but while they have "minimal" downside, they do have downside. You are placing them constantly in the MICU because those are critically ill patients. If we started putting them in every tom, dick, and harry having an anesthetic, you'd see a lot more ischemic/thrombotic complications from them, not to mention a lot more cost to the patient and system. Arterial lines are great, but you should always have a solid indication to place it. So while you can say "a lot more can go wrong in the OR", it doesn't. Morbidity and mortality in the OR are orders of magnitude less than what you see in majority of ICU settings.

Arterial lines are fantastically useful in certain situations, but in many others they are a big waste of money and only minimally helpful. The NNT with an a-line to prevent a serious complication from BP intra-op on an ASA 1 simple case is probably on the order of 1 per 100K or 1 per 1M.

 

[ColdBrew]

Don't let anyone tell you PP is boring...


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???

On one hand you are extremely conservative placing an Aline for this patient and for this case, yet on the other hand you are extremely cavalier proceeding with the surgery.

Not sure what there is to gain proceeding with the case from every angle.

 

[Jay K]

Cancel.

I give most of my adult patients midazolam; They're never "gorked" in PACU irrespective of age. I find I have more good reasons to do so than to forgo. I DO find that diphenhydramine tends to "gork" patients.

I place most of my A-lines asleep; If I need it pre-induction, I have no qualms about placing them awake either.

Whenever anyone, be it group, hospital, surgeons, etc give me a hard time about postponing/canceling a case, I always tell myself, "I can always get a new job, but it's harder if I've killed someone."

 

[Gern Blansten]

On one hand you are extremely conservative placing an Aline for this patient and for this case, yet on the other hand you are extremely cavalier proceeding with the surgery.

This sums up my thoughts.

 

[KLPM]

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?

White coat hypertension.

 

[loveumms]

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 put almost all my a-lines in awake. Depending on the pt, I will give a little fentanyl (and some versed if they are not ancient). Lido it up and slide the a-line in. I agree, if I'm placing an a-line, I should have it for the most labile portion (INDUCTION). Plus, its usually so much easier pre-induction (even with a very 'controlled' induction, you still see some degree of hypotension).

 

[ph8]

.....Whenever anyone, be it group, hospital, surgeons, etc give me a hard time about postponing/canceling a case, I always tell myself, "I can always get a new job, but it's harder if I've killed someone."

Rising CA-2 here, and I know that graduation and the real-world are closer every day. That's an excellent piece of advice Jay K.

 

[cleansocks]

what level of hypertension is required for you all to cancel a case? raw numbers, percentage above baseline, symptoms? and what evidence do you use to justify your practice?

 

[GoldnLead]

what level of hypertension is required for you all to cancel a case? raw numbers, percentage above baseline, symptoms? and what evidence do you use to justify your practice?

Quick answer: symptoms would lead to cancellation of the case regardless of the degree of HTN.

 

[lilycat]

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.

I agree with the above. I also didn't understand the several objections to art line placement in this case - are people objecting to awake art line placement, art line placement in general, or art line before NIBP measurement? I guess I'm more surprised that it seems like several posters would argue against placing an art line in this patient/case, or is it just the timing that people are arguing against?

As for proceeding with the case, I agree with most of the other posters - cancel, start on nicardipine, call ICU and transfer the patient to be optimized. This is a totally elective case, and the risk of perioperative complications with that kind of a starting pressure just isn't worth it.