Interesting case

[fathead88]

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Had an interesting learning case present to the OR today. Would be curious to hear other's thoughts.

70 year old F with h/o Graves disease, non ischemic cardiomyopathy with HFrEF (EF 10-15%), paroxysmal Afib currently in NSR that presents for total thyroidectomy with slow ENT surgeon. She is on hospital day 5.

Medical Hx:
Hyperthyroid/Graves disease: on PTU. Had previously failed methimazole due to agranulocytosis. TSH undetectable, fT4 1.6 (normal 0.8-1.4). Endocrinology consulted, does not recommend radioactive iodine and recommends thyroidectomy.
NICM with acute systolic HF: EF 10-15% by TTE. Severe TR, mPAP >55mmHg. Right heart cath with similar values. Prior LHC 6 months ago: 60-70% left main stenosis
pAfib: 6-8 hours of atrial fibrillation per day since admission. s/p cardioversion a few weeks ago with a fib recurrence. She was started on amiodarone 2 days ago. Last episode of afib into the 130-140s this morning.
HTN

Medications:
Amiodarone
Digoxin
Heparin gtt stopped preop
Losartan (last taken day before)
Lasix
Metoprolol
PTU
Spironolactone

Physical exam:
Vitals: HT: 5' 6", Wt: 61 kg, BMI 21. BP 94/62, HR 63, SpO2 95% on RA. Resp 19.
Airway: Mallampati 4, retrognathic, good dentition, normal neck flexion/extension, 2 cm mouth opening. No goiter. No prior anesthetic records available.
CV: RRR, mild pitting edema BLE
Pulm: CTAB
Psych: Moderately anxious

What is your anesthetic plan? Have at it.

 

[Gator7]

Honestly, cancel.

If no other options then I think there’s some case reports of doing awake thyroids.

 

[vector2]

Honestly, cancel.

If no other options then I think there’s some case reports of doing awake thyroids.

Lol what? The graves is probably making her NICM and afib worse and both a surgeon and endocrine think she needs the procedure done.

Pre-op aline. Put the pads on. Make sure her lytes are OK and that her dig level is adequate. Prop, sux, nim tube. Run her on remi and some light gas. Have some inotrope/pressor available. Shock/reload some amio if she goes unstable RVR during the case. Extubate and send her to the unit after.

 

[GravelRider]

Prop/sux/tube +/- a-line. Be ready for a wild cardiac ride.

Honestly, cancel.

If no other options then I think there’s some case reports of doing awake thyroids.

Why are you cancelling? Hoping the fast ENT surgeon will come back from vacation?

 

[Iso4ane]

Lol what? The graves is probably making her NICM and afib worse and both a surgeon and endocrine think she needs the procedure done.

Pre-op aline. Put the pads on. Make sure her lytes are OK and that her dig level is adequate. Prop, sux, nim tube. Run her on remi and some light gas. Have some inotrope/pressor available. Shock/reload some amio if she goes unstable RVR during the case. Extubate and send her to the unit after.

Pretty much agree with all this. The Graves is making everything worse, and she may even get a bit worse right after. Would place a central line too (or at least prep the groin for on), given the need for pressers afterwards will be quite high.

 

[Reveler]

I think he also wants us to do an awake fiber for the M4, retrognathic w/ 2cm mouth opening 🤣

 

[Reveler]

Pretty much agree with all this. The Graves is making everything worse, and she may even get a bit worse right after. Would place a central line too (or at least prep the groin for on), given the need for pressers afterwards will be quite high.

Yea no way this lady gets away without a central line & PAC at my shop

 

[vector2]

Pretty much agree with all this. The Graves is making everything worse, and she may even get a bit worse right after. Would place a central line too (or at least prep the groin for on), given the need for pressers afterwards will be quite high.

Yea no way this lady gets away without a central line & PAC at my shop

Rather than a central line, what I mostly do nowadays (esp in a case like this where the arms are tucked) is place the following in the brachial or basilic vein and then connect it to a multiport manifold that goes to my drips

Combine that with an 18g PIV for my hot line and that's all I need for this case.

 

[Mman]

Rather than a central line, what I mostly do nowadays (esp in a case like this where the arms are tucked) is place the following in the brachial or basilic vein and then connect it to a multiport manifold that goes to my drips

View attachment 355842

Combine that with an 18g PIV for my hot line and that's all I need for this case.

while that sounds lovely, I'm just gonna take the 5 minutes and put a CVP in her. It's still the best way to get meds to her poor heart in a hurry and titrate with the least amount of lag time. That 12 cm catheter is still going to end at her shoulder and meds got a little ways to go to get to the heart.

 

[Planktonmd]

So in addition to the cardiomyopathy and heart failure the Thyroid function seems to be not well controlled by PTU and the risk of a thyroid storm here is real and would likely kill her.
I would consider giving old fashion Lugol's solution intra-op which helps with preventing thyroid storm and decreases the bleeding from the Thyroid tissue.
Otherwise this is just another cardiomyopathy patient needing surgery: arterial line helpful, central line only if can't get decent peripheral access otherwise it's a waste of time and effort. Keep fluids to minimum, gentle induction and smooth maintenance, a Remifentanil infusion with low vapor concentration maybe a good idea since these surgeries don't really cause too much post-op pain.

 

[narcusprince]

Anyone concerned about placing a Nims tube in a potentially difficult airway? Why is a frail 61 kg patient a mp 4 likely likely due to decreased mouth opening. Glidescope intubation here with a regular tube if surgeon wants a Nims exchange out the tube with a tube exchanger for Nims tube. Oftentimes the nims tubes can be challenging to use without the appropriate glidescope stylets. Also was their a nasal flexible scope? And tracheal deviation on chest xray this suggests a AFOI.

 

[vector2]

while that sounds lovely, I'm just gonna take the 5 minutes and put a CVP in her. It's still the best way to get meds to her poor heart in a hurry and titrate with the least amount of lag time. That 12 cm catheter is still going to end at her shoulder and meds got a little ways to go to get to the heart.

Venous blood velocities in the axillary and subclavian veins are like 10-20 cm/s, and furthermore it accelerates as it gets closer to the great vessels. Which means the medication onset time pushing through a catheter terminating in the axillary or subclavian vs the SVC is pretty much negligible.

I know this because when I have pts with sick hearts coming for TAVRs (particularly those who don't require an IJ introducer/transvenous pacer because they already have a PPM), I just do the case with a big PIV, basilic or axillary vein midline, and an arterial line.

 

[Beeftenderloin]

Talk with endo about high risk of periop mortality given hyperthyroid state > thyroid storm precipitating malignant arrhythmia and acutely decompensating heart failure. Probable need for inotropes further precipitates risk of malignant arrhythmia. High potential for cardiogenic pulm edema, need for post op ventilation, etc. They don’t think about these things. See if they can reconsider radioactive iodine therapy as this is much less likely to kill the patient than surgery. Or at least do radioiodine therapy to cool off thyroid and get to euthyroid state, which would significantly reduce periop m&m.

If endo isn’t having it and everyone says proceed, it’s not uncommon for this type of patient at my academic mothership to get an IABP perioperatively, just to get them through surgery then take it out after. I would push for that in this patient. Though I recognize thats probably not happening at most shops.

Aside from that, art line, some kind of central access (I like the “mid-line” @vector2 suggested for a case like this), zolls on, initropes in the room. Gentle CV induction, I expect she’s out cold with 50mg lido, 50mcg fentanyl, and 30mg of prop. Just be patient, circulating time will be long. Probably rolling a little levo with induction. Glidescope intubation. Amio bolus for stable RVR, electricity if unstable. Low threshold for dropping a TEE probe. Will try to extubate, but ICU post-op regardless.

If she goes into thyroid storm you’re up **** creek because propranolol sounds like a bad idea for this patient.

 

[vector2]

If endo isn’t having it and everyone says proceed, it’s not uncommon for this type of patient at my academic mothership to get an IABP perioperatively, just to get them through surgery then take it out after. I would push for that in this patient. Though I recognize thats probably not happening at most shops.

Do you just omit anticoagulation when using the IABP for non-cardiac surgery?

 

[deleted875186]

Cardiac anesthesia with TEE available, should be done at a tertiary care with cardiac ICU and advanced heart failure available, awake arterial line and central
Access, norepi before induction, epi drip available for ionotropic support. Maybe paralyze and do case without NIM if hemodynamics don’t allow for deeper plane if anesthesia?

 

[Beeftenderloin]

Do you just omit anticoagulation when using the IABP for non-cardiac surgery?

IABP doesn’t necessarily require anticoagulation, especially with 1:1 augmentation, and for a relatively brief period of time. The data on bleeding risk with heparinization vs thrombosis/ischemia without are mixed at best. For the above reasons we don’t anti-coagulate preoperatively in scenarios like this.

 

[Urzuz]

Rather than a central line, what I mostly do nowadays (esp in a case like this where the arms are tucked) is place the following in the brachial or basilic vein and then connect it to a multiport manifold that goes to my drips

View attachment 355842

Combine that with an 18g PIV for my hot line and that's all I need for this case.

What advantage does this have over a temporary central line in the perioperative period? I assume because you’re essentially just placing a PICC that it has lower rates of infection etc, but shouldn’t you just have a normal PICC placed then (I assume the integrity of the actual PICC line itself is higher than that of the arterial line)?

Just trying to understand why you’re not just placing a regular central line and then have the lady get a regular PICC line later.

 

[deleted875186]

What advantage does this have over a temporary central line in the perioperative period? I assume because you’re essentially just placing a PICC that it has lower rates of infection etc, but shouldn’t you just have a normal PICC placed then (I assume the integrity of the actual PICC line itself is higher than that of the arterial line)?

Just trying to understand why you’re not just placing a regular central line and then have the lady get a regular PICC line later.

I also wonder about this. An awake IJ central line is not painful, perhaps you could argue about complication rate, but I think most can put in an IJ very safely with an ultrasound.

 

[narcusprince]

I also wonder about this. An awake IJ central line is not painful, perhaps you could argue about complication rate, but I think most can put in an IJ very safely with an ultrasound.

That neck is tight. Why stick the neck? One hematoma and your down a very dark pathway in this patient with a large thyroid and potentially challenging airway. I would go femoral. Also the surgeons will be working on the neck. Power PIC isn’t a bad solution.

 

[vector2]

What advantage does this have over a temporary central line in the perioperative period? I assume because you’re essentially just placing a PICC that it has lower rates of infection etc, but shouldn’t you just have a normal PICC placed then (I assume the integrity of the actual PICC line itself is higher than that of the arterial line)?

Just trying to understand why you’re not just placing a regular central line and then have the lady get a regular PICC line later.

I also wonder about this. An awake IJ central line is not painful, perhaps you could argue about complication rate, but I think most can put in an IJ very safely with an ultrasound.

In my hands, the IJ central line complication rate (particularly pneumothorax, carotid puncture or cannulation, local hematoma etc) is close to zero. But it's not zero. And while this patient does have an indication for central venous access, I don't find the indication to be extremely compelling.... since generally I don't think there's even an issue running vasopressors or inotropes through a reliable (placed by me) 18g or 20g PIV during the case. For instance, the last 5 or 10 carotid endarterectomies I've done have been with norepi running through a good PIV.

The 12cm catheter sitting in the axillary or distal subclavian vein is an order of magnitude more reliable than the PIV. I can prep out the whole arm and do the a-line and the "midline" in 10 min in pre-op or in the OR. The pneumothorax rate is zero. The carotid artery puncture rate is zero. The neck hematoma rate is zero. The risk of contributing to future central venous stenosis is zero. The risk of line infection is almost the same as a peripheral IV. And of course, it's more comfortable for the patient.

Not to mention, for this particular surgery it wouldn't need to be prepped into the surgical field:

 

[Southpaw]

No reason to stick the neck when the patient is having thyroid surgery.

 

[deleted875186]

Fair enough, I forgot we were doing a neck surgery, probably wouldn’t do an IJ, but the complication rate from a femoral CVC that’s not going to be in for more than a couple days? I would just place the most reliable access, which is a CVC.

 

[vector2]

Fair enough, I forgot we were doing a neck surgery, probably wouldn’t do an IJ, but the complication rate from a femoral CVC that’s not going to be in for more than a couple days? I would just place the most reliable access, which is a CVC.

Another thing to keep in mind is that this lady just stopped a heparin drip and she also has severe TR, which means her venous pressures are super high and she might have some coagulopathy, both from residual heparin and from congestive hepatopathy.

Her risk of CVC complications from a groin stick is not the same as a random healthy guy off the street.

 

[IlDestriero]

Call endocrine and ask the why TF they think he’s a bad candidate for radioactive iodine.
OMG.
GTFOHWTS!

 

[residency2010]

Rather than a central line, what I mostly do nowadays (esp in a case like this where the arms are tucked) is place the following in the brachial or basilic vein and then connect it to a multiport manifold that goes to my drips

View attachment 355842

Combine that with an 18g PIV for my hot line and that's all I need for this case.

I do a similar one as well. I use the 5fr micro puncture kit the vascular surgeon uses. It comes in a simple pack and the residents love it. Great for drips.

 

[anaesthetic]

Good discussion in here—lots of different ways to skin a cat. Personally, I would have a discussion with the surgeon and patient about expectations and needs for lines and possibly awake fiber if surgeon/scans/patient appearance are worrisome. Whether or not I would place a CVC largely depends on the eyeball test IMO (eg., is the patient short of breath in preop, toxic appearing, deconditioned, etc.), but in a patient with recent A-fib with RVR, severe cardiomyopathy, valvular pathology, and possible thyroid storm perioperatively, my threshold for putting in a CVC is very, very low, especially if I’m anticipating ICU care afterwards.

I am surprised that nobody has mentioned a subclavian line for this patient. Although the risks of a pneumo are there, we place them not infrequently for our liver transplants (ie., coagulopathic patients) and minimally invasive valve repairs/replacements. It takes all of 5-7 minutes to place one, and in my opinion, it’s a reliable and relatively safe line if you’re comfortable with them. If the patient looks like death, I would localize and do it preinduction, but in the last couple of years, I’ve only had to do one “awake” CVC and that was for true tamponade in a patient with EF10% and poor peripheral access.

 

[Agast]

Just for fun -


What would you do if patient is successfully extubated and sitting in PACU when the nurse alerts you to signs of a rapidly worsening postop hematoma?

 

[narcusprince]

Just for fun -


What would you do if patient is successfully extubated and sitting in PACU when the nurse alerts you to signs of a rapidly worsening postop hematoma?

Alert and secure early in the operating room with ENT and neck prepped and surgeon cutting hematoma. If you have time afoi if you have no time glidescope and have suction ready release that suture holding the neck together. Pray you see something resembling an airway.

 

[OptionOffense]

If you have time afoi if you have no time glidescope and have suction ready release that suture holding the neck together. Pray you see something resembling an airway.

what does time have to do with it? Either she needs an awake fiberoptic or not.. correct?

 

[Urzuz]

what does time have to do with it? Either she needs an awake fiberoptic or not.. correct?

Though in ideal circumstances a patient may “need” an AFOI, with a rapidly expanding neck hematoma all you may have time for is opening the sutures, a Glide, and a prayer.

 

[Radetzky]

Just for fun -


What would you do if patient is successfully extubated and sitting in PACU when the nurse alerts you to signs of a rapidly worsening postop hematoma?

Cut the stitches

Otherwise there are a few unanswered questions here. Firstly you haven’t given any indication of her functional status- does she have reasonable ET or is she housebound? A coronary lesion of 60-70% may not be significant when she is sitting around but probably is when her AF starts going at 160 bpm. Why did they not stent her? Did they calculate an FFR? I would talk to the cardiologist to answer these questions. Then I would talk to endocrine to really question whether they have run out non surgical options. Physicians often don’t understand the risks of surgery for a patient like this well enough.

Assuming all of that line of enquiry is fruitless, which it probably will be- awake a line, pressors running through big peripheral then subclavian line once asleep. I would echo her myself preop to get an idea whether the right heart is overloaded and causing septal flattening or not. Remi plus gas to stay asleep

I don’t know what 2cm mouth opening is without seeing- I would spray the nose and have a quick look at the airway with a scope- if looks ok then put off to sleep and glide scope, if not then proceed with AFOI.

 

[nimbus]

Fair enough, I forgot we were doing a neck surgery, probably wouldn’t do an IJ, but the complication rate from a femoral CVC that’s not going to be in for more than a couple days? I would just place the most reliable access, which is a CVC.

I think both are reasonable but a femoral central line is no closer to the heart or more reliable than a midline in the arm. USG subclavian is reasonable too.

 

[Mehd School]

Venous blood velocities in the axillary and subclavian veins are like 10-20 cm/s,

What are the velocities in someone with severe TR and pulm htn? Put a cvl in. Will probably take a whole 90 seconds longer and those long flimsy lines have a way of snaking somewhere they shouldn't.

 

[cincincyreds]

Seems like a lot of people want to do an TLC in the IJ vein. Would that be in the way of this thyroidectomy procedure? Why not do this with two large bore IV's and a pre-induction arterial line with pressors ready to go? I guess with the airway I would like to know if this patient can lay down flat without feeling short of breath. She may need an awake fiberoptic. And obviously make sure all the i's and t's are dotted preop.

 

[maxxor]

Call endocrine and ask the why TF they think he’s a bad candidate for radioactive iodine.
OMG.
GTFOHWTS!

Do they think it won't work fast enough or something? I'm a NucRad and I'd treat this patient if the I-123 thyroid uptake was sufficient.

Although I'd have wished they'd consulted me before giving amiodarone...

 

[Mehd School]

Seems like a lot of people want to do an TLC in the IJ vein. Would that be in the way of this thyroidectomy procedure? Why not do this with two large bore IV's and a pre-induction arterial line with pressors ready to go? I guess with the airway I would like to know if this patient can lay down flat without feeling short of breath. She may need an awake fiberoptic. And obviously make sure all the i's and t's are dotted preop.

I would do subclavian or femoral. I have no issues running dilute pressors through reliable PIV so long as I have access to the arms. In this case you almost certainly won't. I've had very reliable IV's become unreliable when arms are tucked, surgeons are leaning on the arms etc.

 

[nimbus]

I would do subclavian or femoral. I have no issues running dilute pressors through reliable PIV so long as I have access to the arms. In this case you almost certainly won't. I've had very reliable IV's become unreliable when arms are tucked, surgeons are leaning on the arms etc.

Is a femoral CVL any closer to the heart than a midline in the brachial vein?

 

[Mehd School]

Is a femoral CVL any closer to the heart than a midline in the brachial vein?

Not my concern. It is a definitive line. If putting long flimsy arterial lines in the upper arm was as reliable it would be more common place. Is this guy hep-locking it afterwards? How long is it staying in? When SHTF how much can he really infuse through there? None of these are my concern. I would only do femoral if I struggled with subclavian or there was a reason not to place a subclavian line. I appreciate new approaches and innovative techniques but I don't this is the patient I would mess around with.

 

[nimbus]

Not my concern. It is a definitive line. If putting long flimsy arterial lines in the upper arm was as reliable it would be more common place. Is this guy hep-locking it afterwards? How long is it staying in? When SHTF how much can he really infuse through there? None of these are my concern. I would only do femoral if I struggled with subclavian or there was a reason not to place a subclavian line. I appreciate new approaches and innovative techniques but I don't this is the patient I would mess around with.

I’ve used the brachial midline many times. It is not a great volume line but the case is a thyroidectomy and it is a great line for infusing inotropes and vasopressors. I’ve never had one fail. I would argue that it is also a “definitive line”, whatever that means. In my experience it is as reliable as a central line. Plug one of these into it, connect your drips and you’re good to go. If they weren’t working on the neck, I’d do an 8fr 2lumen IJ because that is a good volume line and it’s 5 units😉

 

[woopedazz]

I wouldn't do a subclavian in a 60kg lady with a potential retrosternal goitre. But I'm **** at subclav lines and never do them anyway! What's the CT show? It's there a goitre? Is the airway ****? These questions are interesting, but distracting us from the actual issue here. The issue is the decision to proceed to surgery in this patient...

Surgery is relatively contraindicated in this poorly optimised, high risk patient. Radioiodine therapy is not. I'd personally get the endocrinologist, surgeon, crit care doc in a room and ask WTF are they thinking here?

Spoilers for when OP updates; the airway is gonna be a woody, oedematous disaster that gets worse with every AFOI attempt while the patient panics and flicks into AF. At some point they oversedate, lose the airway and switch to an oral CMAC with a smaller tube. 😌

EDIT: endocrine being involved as a consulting team is the issue? They should be the admitting team? Of course surgery is gonna be the suggested destination therapy for this patient who might have a cancer, but surely it isn't the appropriate management for this current presentation? Seems bizarre. Any endocrine people around on this forum?

 

[Hoya11]

In my hands, the IJ central line complication rate (particularly pneumothorax, carotid puncture or cannulation, local hematoma etc) is close to zero. But it's not zero. And while this patient does have an indication for central venous access, I don't find the indication to be extremely compelling.... since generally I don't think there's even an issue running vasopressors or inotropes through a reliable (placed by me) 18g or 20g PIV during the case. For instance, the last 5 or 10 carotid endarterectomies I've done have been with norepi running through a good PIV.

The 12cm catheter sitting in the axillary or distal subclavian vein is an order of magnitude more reliable than the PIV. I can prep out the whole arm and do the a-line and the "midline" in 10 min in pre-op or in the OR. The pneumothorax rate is zero. The carotid artery puncture rate is zero. The neck hematoma rate is zero. The risk of contributing to future central venous stenosis is zero. The risk of line infection is almost the same as a peripheral IV. And of course, it's more comfortable for the patient.

Not to mention, for this particular surgery it wouldn't need to be prepped into the surgical field:

View attachment 355849

That all makes sense, but where I work the RNs and the docs in the unit will freak out and put in a IJ after the case anyhow. "OMG can you believe they are giving all these pressors through a midline"? "Can you believe they dropped off this patient without a central line"?

 

[vector2]

What are the velocities in someone with severe TR and pulm htn? Put a cvl in. Will probably take a whole 90 seconds longer and those long flimsy lines have a way of snaking somewhere they shouldn't.

In actuality, you're gonna have 2-3m/s of flow going backward no matter whether the line is terminating in the SVC.

Not my concern. It is a definitive line. If putting long flimsy arterial lines in the upper arm was as reliable it would be more common place. Is this guy hep-locking it afterwards? How long is it staying in? When SHTF how much can he really infuse through there? None of these are my concern. I would only do femoral if I struggled with subclavian or there was a reason not to place a subclavian line. I appreciate new approaches and innovative techniques but I don't this is the patient I would mess around with.

One, your characterization of these lines as "flimsy" isn't accurate. These 20cm arrow kits (plus argons or micropuncture kits) were designed to be intermediate to long-term indwelling femoral or brachial arterial lines. People getting arterial lines are in critical condition so these lines wouldn't be so popular if they were failing or kinking all the time. Anecdotally I've never had one of these lines fail when placed venous in 4+ years of anesthesia and critical care practice.

Two, your statement about "it would be more commonplace" is simply a fallacy. Medicine moves at a snail's place. Obviously beneficial or less morbid techniques take years to become mainstream (look at the decades long pushback against ultrasound for CVC or VL). Historically, ultrasound guided IVs weren't even a thing. My partners back in the day put IJ CVCs into fatties coming in for damn colonoscopies if they couldn't get access. My point is, don't conflate your unfamiliarity or relative inexperience with a technique with the idea that the technique is necessarily flawed or unreliable.

 

[vector2]

That all makes sense, but where I work the RNs and the docs in the unit will freak out and put in a IJ after the case anyhow. "OMG can you believe they are giving all these pressors through a midline"? "Can you believe they dropped off this patient without a central line"?

I don't change what I'm doing in the OR simply because I know the ICU might mucl it up after. Not to mention one our ICUs has gone full-on loco with pulling lines and foleys out of pts, even when they're critically ill.

 

[anaesthetic]

I don't change what I'm doing in the OR simply because I know the ICU might mucl it up after. Not to mention one our ICUs has gone full-on loco with pulling lines and foleys out of pts, even when they're critically ill.

Glad it’s not just our ICUs doing dumb s***. I like midlines, but we don’t have many of them readily available in our ORs. I get called to do US-guided IVs pretty often, so they would be a nice bridge to avoid a CVC in a patient with difficult access. I use the long IVs quite often, but some still don’t reach the deeper veins.

 

[abolt18]

Rather than a central line, what I mostly do nowadays (esp in a case like this where the arms are tucked) is place the following in the brachial or basilic vein and then connect it to a multiport manifold that goes to my drips

View attachment 355842

Combine that with an 18g PIV for my hot line and that's all I need for this case.

Have done similar several times, but with the arrow 20g single lumen pediatric IJ kit. Works phenomenally.

 

[chessknt]

I don't change what I'm doing in the OR simply because I know the ICU might mucl it up after. Not to mention one our ICUs has gone full-on loco with pulling lines and foleys out of pts, even when they're critically ill.

Cant have a CLABSI without a CL or a CAUTI without a C. CMS wins, patients lose.

 

[IMGASMD]

Cant have a CLABSI without a CL or a CAUTI without a C. CMS wins, patients lose.

No culture = no source

 

[DrOwnage]

Honestly as a PP anesthesiologist, I probably would refuse to do this case and send it to a tertiary care center. You’re talking about a lady with severe PHTN, severe cardiomyopathy, CAD, most likely difficult access, high chance of intraoperative a fib w/ RVR/malignant arrythmia. Now in a perfect world I would want proof of a prior echo to see how her function has evolved. There’s a good chance this might not even revert her to a decent EF. It might stop the a fib (for who knows how long). This patient is an ASA 4.5 and I would do everything to try and get endocrine to do it non invasively. What are the risks of radioactive iodine/candidacy in this patient that outweigh her surgical risk?

 

[cchoukal]

Honestly, as an academic anesthesiologist at a tertiary care center, I probably would refuse to do this case and send it to the quarternary care center...

 

[Mehd School]

The quinary centers are on diversion.