Interesting case, How would you proceed?

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gasp

gasp

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70y/o M who has been having abdominal pain, n/v x 2 days admitted to the hospital for gallstones, surgeon wants to do a Lap Chole. Case was cancelled 2 days ago to await "cardiology clearance" so IR put in a gallbladder drain in the meantime. So pt comes down and you look through chart. Pt has pmhx of HTN, CAD, HLD, GERD. Cardio clearance note says pt had a STEMI in 2011, angio was done at that time showing 100% stenosis of RCA and 70% stenosis of LAD. No stents or PCI was done at the time because 100% stenosis is a contraindication to stent/pci and LAD was distal so they felt it is not a big factor (as per cardio). Echo at the same time showed EF= 40% with inferior and lat wall hypokenesis, no valvulopathy. Since then pt has had "stable cardiac disease" and there have been no cardiac symptoms but mets <4 due to sob so pt is not very active. Today pt has an EKG showing SR, Lat and INF infarcts, and RBBB which is the same as in 2011. No recent angio, no recent echo, no recent stress test as cardio feels that the pt is does not need any further workup. Cardiology has "cleared" pt and wish to proceed with surgery. CXR clear. Trop and Ck neg. BNP 71. How would you proceed?
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So its a 70y with known cad, multiple risk factors, functional tolerance <4mets, presenting for a surgery (lap chole) with intermediate cardiac risk. If you go down the acc/aha algorithm, basically this says to consider further testing if management might change. I think this patient might deserve a SPECT to evaluate for reversible ischemia. If he has significant reversible ischemia, then I would discuss with cardiology again whether he may deserve another cath/stents, or a cabg. If a spect showed all old infarct and no reversible ischemia, then could likely proceed to surgery with close hemodynamics etc.
 
pent sux tube

Just to be clear, when you say "gallstones", do you mean cholecystitis? Not quite the same.
 
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fully realizing he has severe CAD and so anything can happen, im not especially worried about his symptomatology, Any CHF symptoms? Edema, O2 requirement, murmur? Is he on lasix? Does he take nitroglycerin at all/regularly?

I do this case with minimal intervention, probably a second IV, and likely am a little more aggressive about arterial tone. Im assuming that he will get bradycardic if anything and this may cause worsening of his moderate LV function, so would keep a close eye on that.

I assume that even if its stones and not an infection, he must be obstructed or they wouldnt put a drain in
 
Idiopathic said:
I assume that even if its stones and not an infection, he must be obstructed or they wouldnt put a drain in
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I think that's the most important part of what the OP had written.

As the OP is noticing, some cardiologists are less aggressive than others in ordering things like a repeat echo, but even so: if his symptoms are unchanged and he's sick enough to have a drain, going to the OR is reasonable. If things do go south, you have a modicum of protection from the cardiologist giving the pt his blessing.
 
BP under control? Beta-blocker and statin?

If patient is optimized, proceed understanding that he is at increased risk.
 
So he had a 100% RCA occulusion and 70% LAD occlusion in 2011. Is anyone else worried about this guy having 100% occlusion of both vessels? Sure he obviously has some collaterals because he's not dead but that could quickly change once induced even if you are careful. I'm surprised most people so far have been saying to go to the OR at this point. I spoke with others in my group and they all recommended (even the guys who do CT anesthesia) to get at least a recent echo before proceeding. Does anyone think CT surgery should be consulted for poss CABG before surgery?
 
I think if you're worried about the quality of his collaterals, a stress test would provide more information than an echocardiogram.
 
gasp said:
So he had a 100% RCA occulusion and 70% LAD occlusion in 2011. Is anyone else worried about this guy having 100% occlusion of both vessels? Sure he obviously has some collaterals because he's not dead but that could quickly change once induced even if you are careful. I'm surprised most people so far have been saying to go to the OR at this point. I spoke with others in my group and they all recommended (even the guys who do CT anesthesia) to get at least a recent echo before proceeding. Does anyone think CT surgery should be consulted for poss CABG before surgery?
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We would all love to have a recent echo. Ultimately it depends on how sick the patient is. If this case is urgent/emergent then its probably bad idea to do either CABG or PCI, unless you know he can wait 6 weeks after.

My assumption is that if he has a biliary drainage tube, then it is more than simple chloelithiasis/sludge?

So what if the echo shows you the exact same thing? Moderately depressed LV function, stable wall motion abnormalities and no valvular issues?
 
Agast said:
I think if you're worried about the quality of his collaterals, a stress test would provide more information than an echocardiogram.
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Good point. So I asked cardio if they could do a stress echo as we were talking. The answer I got was "he's going to have chest pain.. most people have chest pain during a stress test because of the medication.. We already know he has severe CAD"...
 
yeah well the other component is EKG changes, but you could also get a myocardial perfusion scan...i mean if you debating sending him for cabg thats the least you will need. you might get someone to cath him but again it all depends on how sick he is

edit: i guess not very, since this is your case you would probably have told us if he is septic, etc.
 
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G0S2 said:
Agree. How are any further studies going to change your plan? Explain risk to pt and family and go.
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Right. What are we going to do?

Revascularize him and wait? No.

Optimize him? He's not in failure, so there's not much to do in the next day or two.

This doesn't sound like uncomplicated gall stones that can wait a while with no problem. He's admitted and has a perc drain in. Sepsis won't make the case any easier. I agree with the others, after a good talk and documented consent, give him a gentle, stable, good general anesthetic and be done with it.
 
This pt. with known CAD and semi urgent case who had cardiac work up within 2 years and has been otherwise stable does not require further investigation. If he has been at baseline for 2 years with no EkG changes not sure what any further testing will provide. If he is septic the Aline, If not I would even do the case without Aline .
 
wow,really nice case and answers :) :thumbup:
 
gasp said:
. I spoke with others in my group and they all recommended (even the guys who do CT anesthesia) to get at least a recent echo before proceeding. Does anyone think CT surgery should be consulted for poss CABG before surgery?
Click to expand...

This is one of the biggest misconceptions in our field today... ALmost every piece of literature points that pts do no better or much worse after intervention (PCI/CABG) for stable CAD before surgery. The only thing the cath is good for is some extra information we can use and diagnose CAD so the pt can be placed on optimal medical therapy. However if you think a CABG or PCI is gonna decrease his mortality before going for surgery, you're sorely mistaken.

My approach. Insure he's medically optimized. Do my own bedside TTE if available. If not still proceed.

Properly prehydrate. A-line.Some versed, good dose fentanyl, sux RSI. No propofol. Keep em paralyzed and low MAC. And if I really wasnt feeling lazy, maybe even epidural with low concentration infusion to blunt catecholamines on incision. Let them go to town on his gullbladder. Phenylephrine on hand. Wake him up easy with esmolol on hand. .
 
RxBoy said:
This is one of the biggest misconceptions in our field today... ALmost every piece of literature points that pts do no better or much worse after intervention (PCI/CABG) for stable CAD before surgery. The only thing the cath is good for is some extra information we can use and diagnose CAD so the pt can be placed on optimal medical therapy. However if you think a CABG or PCI is gonna decrease his mortality before going for surgery, you're sorely mistaken.

My approach. Insure he's medically optimized. Do my own bedside TTE if available. If not still proceed.

Properly prehydrate. A-line.Some versed, good dose fentanyl, sux RSI. No propofol. Keep em paralyzed and low MAC. And if I really wasnt feeling lazy, maybe even epidural with low concentration infusion to blunt catecholamines on incision. Let them go to town on his gullbladder. Phenylephrine on hand. Wake him up easy with esmolol on hand. .
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For a lap chole?

I guess it depends on how fast or slow the surgeons are. You might have some delayed awakening issues if they knock it out in less than an hr (or in an hr), especially a frail 70 y/o. Then again, if all the old man requires is 250mcg fentanyl or less, then great. If requires more to attain an adequate depth of anesthesia for DL (in addition to narcs during case) then I don't know. Epidural? I'd consider it if open. Otherwise, not really. Even for the blunting of catecholamines. Less is more sometimes.

There is nothing wrong with propofol if titrated appropriately and also giving phenylephrine. I don't know why people shy away from it. Some do so in the heart room and it kinda annoys me. You have an a-line. It's okay to use propofol or etomidate. I'm not a fan of high dose narcotics because by the time they start making that incision they're feeling it anyways and you get a hemodynamic response that leads you to give more narcotics to get the HR and/or BP back down. We don't extubate on the table so it's cool and it works out okay. You have an a-line (presumably pre-induction). Use it to guide your therapy. Could even use etomidate if not propofol. Esmolol would be appropriate if tachy due to light anesthesia or following DL.

If you don't have an a-line, then I can see the concern potentially. Still, could run a cuff q 1 min and titrate with phenylephrine, but it can run a tad risky with propofol. In that case I'd roll with etomidate.

If I'm wrong, then feel free to school me. I just don't think you need to do a narcotic induction if you have an a-line. Nor do I see a real point to an epidural for a lap chole.

I agree with others though. Better not to delay the case when the pt is septic and requires pressors and may not be easily extubatable.
 
I agree with not using a narcotic Indiction. I usually roll with 4 versed 100 fentanyl 30-50 profofol, etomidate if I'm really worried , DL cycle cuff q2. have neosynephrine and esmolo ,fluids .

wow, you don't extubate on table. we usually extubate on table and if unlikely set up vent in paCu reevaluate in 30 minutes the. get pulm on case let them deal with it and on to the next one
 
RxBoy said:
This is one of the biggest misconceptions in our field today... ALmost every piece of literature points that pts do no better or much worse after intervention (PCI/CABG) for stable CAD before surgery. The only thing the cath is good for is some extra information we can use and diagnose CAD so the pt can be placed on optimal medical therapy. However if you think a CABG or PCI is gonna decrease his mortality before going for surgery, you're sorely mistaken.

My approach. Insure he's medically optimized. Do my own bedside TTE if available. If not still proceed.

Properly prehydrate. A-line.Some versed, good dose fentanyl, sux RSI. No propofol. Keep em paralyzed and low MAC. And if I really wasnt feeling lazy, maybe even epidural with low concentration infusion to blunt catecholamines on incision. Let them go to town on his gullbladder. Phenylephrine on hand. Wake him up easy with esmolol on hand. .
Click to expand...


some of those studies excluded patients with low EF, left main disease, etc, though
 
For me, this case is both basic and necessary. Discuss your concerns with your surgeon, just so he's on the same page, and discuss the risks with the patient/family. Then proceed with your most cardio-protective anesthetic, whatever that is for you. My surgeons are good though, so I'm not doing anything fancy like an epidural or even an a-line for a lap chole.
 
RxBoy said:
My approach. Insure he's medically optimized. Do my own bedside TTE if available. If not still proceed.
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How does your bedside TTE assure optimization? What are you looking for?
 
urge said:
How does your bedside TTE assure optimization? What are you looking for?
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Last echo was 2 years ago and EF was 40%.. Who knows, maybe its 20% now. Severe pulm htn. Maybe new severe AR, MR or TR. THese would be important for me to know. But if I was working at a place I didnt have access, I would still treat the case like a pt with no cardiac reserve.

As for the narcotic induction. 6 cc or so is what I would use. 4 mg versed. Paralyze. No need for propofol. I have had way too many pts crash with even small doses (40 mg) to know when to avoid it. It works very nice without the HD swings. Etomidate is another choice, but personally hate it. You should be able to extubate at the end of a hour with a low MAC. If not, PS in PACU till theyre ready. Nice thing is they will wake up without all the bucking and HD swings (as long as you don't let them get hypercarbic).

If I placed an epidural (probably wouldnt for a lap chole and ef is still 40%) it would only be for intraop and PACU use. Pull it in PACU.
 
Libertas said:
some of those studies excluded patients with low EF, left main disease, etc, though
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Can you show me some literature to support that it decreases mortality? Last I checked, even stable CAD not going for surgery, PCI has only been shown to improve symptomatology (angina) with no decrease in mortality. Haven't looked at the literature in the last 2 years but I would be interested in seeing some new studies.

Also, I highly doubt this pt has reversible ischemia.. Most likely irreversible and a PCI would not improve cardiac function.
 
RxBoy said:
Last echo was 2 years ago and EF was 40%.. Who knows, maybe its 20% now. Severe pulm htn. Maybe new severe AR, MR or TR. THese would be important for me to know. But if I was working at a place I didnt have access, I would still treat the case like a pt with no cardiac reserve.
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Why not get an official echo?
 
RxBoy said:
Can you show me some literature to support that it decreases mortality? Last I checked, even stable CAD not going for surgery, PCI has only been shown to improve symptomatology (angina) with no decrease in mortality. Haven't looked at the literature in the last 2 years but I would be interested in seeing some new studies.

Also, I highly doubt this pt has reversible ischemia.. Most likely irreversible and a PCI would not improve cardiac function.
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Haha what? irreversible ischemia is the area already infarcted, which obviously, this patient with known decreased EF and wall motion abnormalities, already has. Nothing can really be done about that. Reversible ischemia is area at risk of infarction, which in a patient with bad coronary disease, he probably does have, and this has never really been evaluated for. This would require a nuclear test, cardiac mri, etc. You really think this guy doesn't have progressive blockages? And the point was, the studies regarding symptoms/mortality typically don't include very severe CAD...(very low ef, left main, etc)
 
RxBoy said:
Last echo was 2 years ago and EF was 40%.. Who knows, maybe its 20% now. Severe pulm htn. Maybe new severe AR, MR or TR. THese would be important for me to know. But if I was working at a place I didnt have access, I would still treat the case like a pt with no cardiac reserve.

As for the narcotic induction. 6 cc or so is what I would use. 4 mg versed. Paralyze. No need for propofol. I have had way too many pts crash with even small doses (40 mg) to know when to avoid it. It works very nice without the HD swings. Etomidate is another choice, but personally hate it. You should be able to extubate at the end of a hour with a low MAC. If not, PS in PACU till theyre ready. Nice thing is they will wake up without all the bucking and HD swings (as long as you don't let them get hypercarbic).

If I placed an epidural (probably wouldnt for a lap chole and ef is still 40%) it would only be for intraop and PACU use. Pull it in PACU.
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"6 cc" = i assume 300mcg of fentanyl? for a case that should take about 45 minutes?

and youve had "way too many" patients crash with 40mg of propofol?
 
Idiopathic said:
"6 cc" = i assume 300mcg of fentanyl? for a case that should take about 45 minutes?

and youve had "way too many" patients crash with 40mg of propofol?
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Yup. 300 mcg. Its not as high as you think when you use low dose mac. They wake up groggy, but they wake up. This isnt some fast turn over private practice case. If it was, I would use like 2 cc of fentanyl and all the other goodies. This is a case with a pt who has a bad heart with unknown cardiac function.

At my private gig now, I can blast 99% of my patients with propofol with no worries. Back in residency at my urban hospital, I used to see propofol crashes quite frequently. I used to do transcutaneous aortic valve repairs on 90 yo with critical AS/ESRD/EF in the 20/severe CAD/ect. Propofol kills, even a baby dose on these pts. Even in the ICU, pt needs intubation... a 60 mg push, they crash. The only reason I wouldnt use propofol is because the pts cardiac function is unknown. No recent echo. With a EF of 40s, I would have no issue giving some propofol/phenylephrine.

Your concern is waking them up quick. My concern is their heart. They can wake up in PACU if they have to.
 
you can give propofol safely in these patients. adding lidocaine, maybe a little ketamine, to versed fentanyl and small dose of propofol can be done perfectly safely if you are anticipating the possibilities, and some of us would prefer it more than high dose fentanyl and versed for a short case.
 
Skip2myLou said:
I agree with not using a narcotic Indiction. I usually roll with 4 versed 100 fentanyl 30-50 profofol, etomidate if I'm really worried , DL cycle cuff q2. have neosynephrine and esmolo ,fluids .

wow, you don't extubate on table. we usually extubate on table and if unlikely set up vent in paCu reevaluate in 30 minutes the. get pulm on case let them deal with it and on to the next one
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We dont extubate cardiac cases on the table. They go immediately to CVICU and usually extubated later that evening or next morning if an overnight case. There is a new push to fast-track these cases though, so hopefully the attendings will start getting away from ridiculous high dose narcotic inductions (i.e. 500-750mcg fentanyl and 5-10mg midazolam).
 
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RxBoy said:
Yup. 300 mcg. Its not as high as you think when you use low dose mac. They wake up groggy, but they wake up. This isnt some fast turn over private practice case. If it was, I would use like 2 cc of fentanyl and all the other goodies. This is a case with a pt who has a bad heart with unknown cardiac function.

At my private gig now, I can blast 99% of my patients with propofol with no worries. Back in residency at my urban hospital, I used to see propofol crashes quite frequently. I used to do transcutaneous aortic valve repairs on 90 yo with critical AS/ESRD/EF in the 20/severe CAD/ect. Propofol kills, even a baby dose on these pts. Even in the ICU, pt needs intubation... a 60 mg push, they crash. The only reason I wouldnt use propofol is because the pts cardiac function is unknown. No recent echo. With a EF of 40s, I would have no issue giving some propofol/phenylephrine.

Your concern is waking them up quick. My concern is their heart. They can wake up in PACU if they have to.
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If you have an a-line, you can titrate accordingly. 20-40 of propofol isn't gonna crash a pt. For intubation stat requests on the floor on a pt with an obvious catecholamine surg and in active CHF, I probably would push 4 versed, 10-20 propofol, 80-160 phenylephrine, and give sux (unless contraindicated, at which point push 50-100mg roc depending on weight), and intubate. DL is quite a vasopressor. I've not had pts crash yet with propofol. The only time I had to deal with severe hypotension was my first or second week as a CA-1 and my lazy ass attending left the induction up to me, and I didn't know any better. So, I told him I'll push 160 propofol, 50 roc, 150 fent in a 75 y/o M pt. Then I intubate. He walks out and I'm left dealing with a SBP in the 60s-70s and I'm ****ting myself as I push 2cc phenylephrine at a time and check BPs q 1-2 mins until the BP stabilizes back to baseline. Learned my lesson in real time nonetheless when it came to lower MAC requirements for the elderly.... :rolleyes:
 
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So the lap chole was supposed to be done last week but we asked cardio to better evaluate the pt because no1 in my group was comfortable providing anesthesia for the poor guy. The surgeon said he's coordinating with another cariologist for a second eval. Pt is still in stable condition, not septic. Last I heard, if cardio #2 doesn't think anything can be optimized, we will go ahead with surgery.. I know he has had severe stable CAD over the last 2 years but I think the main thing is they need to do a cath again so we can atleast make sure there isn't something new requiring pci/stent that has developed since his last cath. I'm talking about reversible areas of ischemia not the 100% RCA and LAD lesions that we know about.. Will let you guys know what happens.
 
gasp said:
So the lap chole was supposed to be done last week but we asked cardio to better evaluate the pt because no1 in my group was comfortable providing anesthesia for the poor guy. The surgeon said he's coordinating with another cariologist for a second eval. Pt is still in stable condition, not septic. Last I heard, if cardio #2 doesn't think anything can be optimized, we will go ahead with surgery.. I know he has had severe stable CAD over the last 2 years but I think the main thing is they need to do a cath again so we can atleast make sure there isn't something new requiring pci/stent that has developed since his last cath. I'm talking about reversible areas of ischemia not the 100% RCA and LAD lesions that we know about.. Will let you guys know what happens.
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he must look pretty bad in person or maybe im just not getting it. i deliver care to guys like this weekly. he has known, stable CAD with decreased systolic function and no exercise tolerance. sure you would like to know some more information, but at some point, you have to do this surgery or commit him to live indefinitely with a t-tube in his bile duct.

his echo at the nadir of his function (peri-STEMI) showed LVEF of 40%. do you think that without ongoing symptoms this has gotten worse? he hasnt had another STEMI, he isnt in renal failure, i assume he doesnt have afib, aortic stenosis or COPD...There are plenty of things to worry about with this case, but I think each can be safely taken care of.

would love to hear how this plays out
 
Nobody in my group would postpone for further work-up. Agree with the above from idiopathic - this is kind of a typical patient where I'm at.
 
With all the debate about the fentanyl induction seems like a good candidate for a Remi induction.
 
I'm curious why people keep saying "stable" cad.....he doesn't do anything, and has no functional capacity, so how would you know? Okay....so he doesn't have crushing unstable angina....and his q -waves on EKG haven't changed....but that's hardly sensitive. We don't have any clue whether his EF and wall motion are stable or he's having progressive lesions.

Not even an echo to check for wall motion/ef? The original scenario says he can't exert physically with dyspnea.
 
Libertas said:
I'm curious why people keep saying "stable" cad.....he doesn't do anything, and has no functional capacity, so how would you know? Okay....so he doesn't have crushing unstable angina....and his q -waves on EKG haven't changed....but that's hardly sensitive. We don't have any clue whether his EF and wall motion are stable or he's having progressive lesions.

Not even an echo to check for wall motion/ef? The original scenario says he can't exert physically with dyspnea.
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With an echo, you can safely do the case knowing poor function.

Without an echo, you can safely do the case assuming poor function.

Are we doing an inpatient with a perc drain any favors by having him sit around in a hospital full of resistant bacteria and nurses with insulin syringes for a couple extra days, waiting for a second cardiac consult?
 
Libertas said:
I'm curious why people keep saying "stable" cad.....he doesn't do anything, and has no functional capacity, so how would you know? Okay....so he doesn't have crushing unstable angina....and his q -waves on EKG haven't changed....but that's hardly sensitive. We don't have any clue whether his EF and wall motion are stable or he's having progressive lesions.

Not even an echo to check for wall motion/ef? The original scenario says he can't exert physically with dyspnea.
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stable because he has managed to live and do his normal ADLs without worsening of symptoms. also, not just that he doesnt have crushing unstable angina...he doesnt have any angina.

what are these progressive lesions that you hope to see with an echo? i guarantee you his CAD will have progressed, and for an elective case, i can absolutely justify a stress echo, but a simple TTE tells me nothing of value.
 
pgg said:
Are we doing an inpatient with a perc drain any favors by having him sit around in a hospital full of resistant bacteria and nurses with insulin syringes for a couple extra days, waiting for a second cardiac consult?
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No
 
pgg said:
With an echo, you can safely do the case knowing poor function.

Without an echo, you can safely do the case assuming poor function.
Click to expand...

:thumbup::thumbup::thumbup::

Agreed. Echo would be nice but Im not gonna cancel the case without one.



As for PCI, again not doing the pt any favors by opening his coronaries so they can clot off intraoperatively. I don't know why some are so fixated on PCI. Read the studies on prophylactic PCIs for stable CAD. (Im fully aware of the exclusion criteria).
 
yeah if you do PCI then you commit to not doing this case for 6 weeks. no question. so, if thats what he otherwise needs, then by all means do it, but it doesnt seem like thats for certain.
 
I know it hasn't been that long since Gasp's last post, but I'm just bumping this thread because I'm very curious if the case ended up going and how you went about running the anesthetic.
 
Idiopathic said:
he must look pretty bad in person or maybe im just not getting it. i deliver care to guys like this weekly. he has known, stable CAD with decreased systolic function and no exercise tolerance. sure you would like to know some more information, but at some point, you have to do this surgery or commit him to live indefinitely with a t-tube in his bile duct.
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I don't get it either. This gomer is a dime a dozen.
 
RxBoy said:
Properly prehydrate. A-line.Some versed, good dose fentanyl, sux RSI. No propofol. Keep em paralyzed and low MAC. And if I really wasnt feeling lazy, maybe even epidural with low concentration infusion to blunt catecholamines on incision. Let them go to town on his gullbladder. Phenylephrine on hand. Wake him up easy with esmolol on hand. .
Click to expand...

I would get laughed out of the hospital if I put an epidural in for this case. probably an aline also.
 
RxBoy said:
At my private gig now, I can blast 99% of my patients with propofol with no worries. Back in residency at my urban hospital, I used to see propofol crashes quite frequently. I used to do transcutaneous aortic valve repairs on 90 yo with critical AS/ESRD/EF in the 20/severe CAD/ect. Propofol kills, even a baby dose on these pts. Even in the ICU, pt needs intubation... a 60 mg push, they crash. The only reason I wouldnt use propofol is because the pts cardiac function is unknown. No recent echo. With a EF of 40s, I would have no issue giving some propofol/phenylephrine.

Your concern is waking them up quick. My concern is their heart. They can wake up in PACU if they have to.
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No offense but if you saw propofol crashes quite frequently maybe an induction wasn't done properly. Baby propofol dose does not "kill" if used properly in any way shape or form.

Patients with severe cardiopulmonary problems can be induced safely (most of the time) as long as proper attention is paid to the induction and it isn't rushed. Art line is nice pre-induction but isn't always necessary or feasible. Very rarely do I put in an art line preinduction (I don't do hearts though).
 
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