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It's been a while since we have had a clinical case

Discussion in 'Anesthesiology' started by Noyac, Aug 10, 2015.

  1. Noyac

    Noyac ASA Member
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    so I will post my case today for discussion.
    60's yo M for spine surgery. Planned procedure is anterior interbody fusion L4-S1, lateral interbody fusion L1-4 and PSF L1-S1.
    PMH: severe dilated cardiomyopathy with EF 25%, CAD with stents in RCA, LAD, and Cx all over 5yrs old.
    AICD Bivent pacer placed for Vtach, recent run of VT and currently in Afib since June. CHF, Capable of <4mets. DM with HgA1c 7.2, OSA, Interstitial Lung Disease with O2 req. PHTN (PAP50mmhg) 1+pitting edema, severe confusion with last GA lasting 2days while in ICU. Anemia (hct 33), HTN,
    Vitals: 188/94, Sats 94% on 2lpm, paced at 80bpm,
    Echo: I don't recall everything but the gist is EF 25%, with moderate AI, TI. No rev ischemia, hypo kinetic everywhere.
    Labs: H/H -11/34 others WNL.
    Plan?
     
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  3. criticalelement

    criticalelement Membership Revoked
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    Why would you even bother doing a procedure (elective) procedure on a patient with this medical history in private practice. ITs a lose/lose. The patient wont do well and wont be happy and you wont be happy because you didnt help him/her Cant you (they) find someone healthier?
     
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  4. NightNight

    NightNight ASA Member
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    What's his underlying spine pathology?
     
  5. Noyac

    Noyac ASA Member
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    Humor us here and tell us if there is a way you can come up with doing this case. The pt is optimized and yes, while refused surgery by 3 spine surgeons, ours has immense respect for the anesthesia care we give here and has reassured this pt that we can improve his life.
     
  6. pulmoblast

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    Do it with ropes, mouth gag and some ether
     
  7. Noyac

    Noyac ASA Member
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    Oops, I forgot to give this part.
    Basically, it is DDD with spinal stenosis and severe radiculolpathy. Failed non surgical interventions.

    I also forgot his meds:
    Losartan
    Amiodarone
    Digoxin
    Metformin
    Plavix
    Lasix
    Coreg
    ASA
     
  8. criticalelement

    criticalelement Membership Revoked
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    If you insist... pre induction art line, induce with mixture of amidate and fentanyl, zoll pads on, de activate aicd 2 ivs, plus minus blood trx, judicious use of fluids but i wouldnt hold them back, post op ventilation and diuresis, ICU stay for sure.
     
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  9. inflamesdjk02

    inflamesdjk02 Senior Member
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    How is an elective spine surgery going to improve his quality of life??? Bad heart, bad lungs, O2 requirement, but fixing his low back is going to magically make everything better?? Give me a break!!!
     
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  10. Noyac

    Noyac ASA Member
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    So you would cancel the case, right?
     
  11. urge

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    pent sux tube, let nature take its course.
     
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  12. Docuronium

    Docuronium ASA Member
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    This whole case strikes me as tempting the fates. Don't know what percentage chance I'd tell the patient that I'd end up having to present the case at M&M, but it'd be high.

    Anything about the case that struck me as off (took his losartan that morning, recent change in functional capacity) and the patient finds their way back to the holding pattern pending optimization
     
  13. pgg

    pgg Laugh at me, will they?
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    No.

    A mentally competent patient, who's medically optimized, who understands the risks, ought to be afforded the autonomy to accept those risks if he and his surgeon think the surgery will help. Not my place to tell such a patient he needs to tough it out and live in pain or stoned on drugs until he drops dead of other causes.

    Has he been off his Plavix for a week? I can't believe the surgeon would be willing to go for this while he's on DAT.

    criticalelement's plan is reasonable. A good outcome is mostly going to be dependent upon a proficient surgeon and an anesthesiologist who pays attention and stays ahead. A-line, tube, keep him where he lives.
     
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  14. Docuronium

    Docuronium ASA Member
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    That being said, it's an excellent case to learn from. My problem is I know as soon as I tell you large bore IV access, pre-induction arterial and central line for the vasoactives he'll almost certainly end up needing and a cardiac style induction, you'll tell me that we'll do the induction, he'll go into V-fib, and the circulator's going to tell me it's against hospital policy to get the defib pads unless I fill out an incident report first.
     
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  15. Shimmy8

    Shimmy8 ASA Member
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    CA-2 here.

    I'd pray. Really hard.
     
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  16. Noyac

    Noyac ASA Member
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    WTF? Incident report?
    Your gonna turn off the defibrillator part of the AICD,right? Why would you need an incident to place pads?

    Now give me your induction, maintenance and emergence plan.
     
  17. Noyac

    Noyac ASA Member
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    Amidate, why? What's the down side here?
    What are you gonna have the pacemaker rep program the AICD to?
    Blood products? When and why?
    This is my real question for you, why "judicious" use of fluids? Are you gonna restrict him or tank him up? Hint: dilated cardiomyopathy.
    Post on ventilation? You have been chosen for this case, can't you get him thru this without post-op ventilation?
     
  18. chfo

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    You might be able to get him to survive the operating room with all the right tools. Won't be easy, but can be done. He will be in the ICU for 1-2 weeks. He'll wake up blind in one or both eyes. In hospital 4-6 weeks. And he will feel even ****tier than when he came in.
     
  19. Noyac

    Noyac ASA Member
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    He will be out of ICU tomorrow morning.
    If you do your job.
     
    #18 Noyac, Aug 10, 2015
    Last edited: Aug 10, 2015
  20. chfo

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    For plan: pre-induction a-line. remi gtt + sevo + nimbex gtt + phenylephrine + vaso gtt. Cordis. TEE.
     
  21. chfo

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    Not bad
     
  22. Noyac

    Noyac ASA Member
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    What's with all of the doomsday posts here? This is what separates you from a nurse. This is what makes you the "go to" person for real cases. Any solid anesthesiologist should be able to handle this case.
    This pt is optimized. He wants this surgery. His surgeon says it is appropriate, are you going to second guess this in 10-20min from a simple pre-op interview after all the time and effort put forth by many other people?
     
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  23. Noyac

    Noyac ASA Member
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    Let me push this case along just a bit.
    Surgeon posts this case as ALIF, XLIF and PSF.
    Do we need to do all of this in one operative visit?
     
  24. lakersbaby

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    whats his BMI? if hes morbidly obese + interstitial lung dz and prone position sounds like a nightmare to ventilate. That combined with PHTN puts us in a rough spot. That being said:

    I am with most of the others people's plans here:
    Contact AICD rep - disable defib function. throw on zoll pads preop
    preinduction a-line
    "Cardiac" induction with high dose fentanyl, etomofol, sux
    Assuming SSEP/MEP monitoring, maintenance with 0.5 MAC sevo, propofol gtt, remi gtt. phenylephrine gtt, dopamine gtt hanging. Keep MAPs ~20% of baseline BP for spinal/coronary perfusion
    Frequent ABG checks to monitor blood loss, oxygenation/ventilation
    Vigileo or PPV monitoring for fluid management. Albumin over crystalloid ( post op edema, vent issues etc)
    Finish case, send to ICU extubate the next day (fingers crossed)

    I think if the surgeon is very skilled all 3 procedures (ALIF, XLIF, PSF) can be done. If any trouble during the first portion then can discuss with surgeon to postpone other aspects of case. Have that discussion preop as well. Detailed discussion with patient about risks/benefits of this surgery.
     
  25. Noyac

    Noyac ASA Member
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    AICD issue solved-have deft fxn shut off and pace at 70-80.
    Cardiac induction- fair enough. I didn't do that though. Why didn't I use Etomidate?
    Neurotube monitoring- TIVA with propofol and I used some DES (ET 1.7)
    Albumin over crystalloid- why? When would you give the albumin?
    Frequent ABG's. - good
    I did SIMV with peak pressures set at 2, TV 450-550
    BMI 30.
     
  26. Docuronium

    Docuronium ASA Member
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    I wouldn't say that it separates you from a nurse---I would say that the knowledge that you might (probably) need more info and that there are important things to evaluate and prepare for prior to rolling back to the OR in ten minutes is simply what makes one a good anesthesiologist. As someone wrote on here a while back, the inability to see trouble coming is a poor prognosticator for long term success in anesthesia. A multilevel spinal fusion on someone with an EF of 25%, OSA (and my guess not a great BMI) , a PAP in the 50s, and paced sounds a bit like trouble coming down the pipe. Also so far I've seen a lot of stuff that no one even bothers to think about during these pre-operative appointments and have almost gotten to the point that I simply do not rely on them at all. In fact, I find that a simple clearance from someone else often leads to a train of a lot of other people not examining things more closely. Let's also hope the first time this case is getting evaluated isn't 10 minutes prior to pushing back.

    If now another anesthesiologist has evaluated the patient and said that he's optimized (in this case you) I trust that, and I definitely agree with you, this case can be done. There's going to be a lot of things to make sure he comes out safe on the other side. Getting him out of the ICU tomorrow and with a good outcome shows the type of value a good anesthesiologist adds to care.

    I'm devising my complete plan for another post, thinking same thing as far as my lines from above, induce with etomidate + fentanyl, maintained on dexmedetomidine, iso, remi, TEE + scheduled ABGs intraop, transfusion goal will be based on how the patient responds to anemia but I'm thinking in the 24-27 range. Regarding the possibility of breaking up the surgery, I don't know what the surgeon would be amenable to, but if there was a possibility the surgery could be broken into pieces, it'd be something I'd ask about but wouldn't hold them to until we got to a critical point.
     
  27. PainDrain

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    I am not a spine surgeon but I have seen the "spectacular" work many provide and I am completely honest with patients who ask my opinion of successful outcomes of surgeries such as this. My first question to this patient would be "think of how horrendous the pain is now and then multiply that times a million, still wanna proceed?" Second question would be "do you want a trach and PEG now or should we wait until your two weeks in the ICU riding a vent is up?"

    While I love the mental masturbation of the clinical case does this truly seem like its a good idea or even reasonable? I would love to hear the surgeon's perspective and his idea of a "successful" outcome. Only possible good that could come out of socialized medicine is to put a stop to bullsh!t like this.
     
  28. Hawaiian Bruin

    Hawaiian Bruin Breaking Good
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    The points about the patient not likely to have symptomatic relief from this procedure are irrelevant to the conduct of the case IMO. The patient and surgeon want to proceed, it's our job to get it done safely.

    I would:
    Disable antitachy therapy on ICD and put on pads. Pacer reprogramming depends on underlying rhythm. Maybe I do nothing (leave it VVI in afib), maybe I go asynch, it depends).
    Put in an a-line.
    Do a gentle ketamine + propofol + prn pressor induction. I've said it before and I'll say it again- the concept of a high-narcotic "cardiac induction" is (or should be) a relic of the past. I don't ever use etomidate because it might be poison that kills people. Yeah, it might not be. But it might. So why chance it when suitable alternatives are readily available?
    Put in an Arrow quad lumen central line, indication is likely pressor use intraop.
    Put in a big IV.
    Discuss with the surgeon that if the initial stages of the operation are poorly tolerated, we're staging the procedure.
    I'd put in a TEE to guide fluid administration and discern cause of any instability, but it probably isn't an absolute necessity. I don't trust the noninvasive cardiac output monitors with these sick hearts, and if he's on pressors then Flotrac data is worthless. I use clinical judgement instead. If you go chasing PPV with a bunch of fluid you're gonna hurt the guy.
    Intraop, I'd give judicious balanced crystalloid (Plasmalyte or Normosol) to keep euvolemic. I've been using less and less albumin these days, as the data emerges that it probably isn't 3:1 crystalloid:albumin that results in equivalent intravascular volume (which is what we were all taught), but more like 1.5:1.
    I'd run a low-dose norepi drip to keep the pressures reasonable, to avoid giving a bunch of fluid.
    I'd go multimodal analgesia, with ketamine/tylenol/magnesium/maybe lido/maybe intrathecal opiate by surgeon. Dilaudid as needed at the end.
    Extubate when possible- hopefully on the table. As early as possible in the unit if not.

    To my mind the thing you can't do to this guy is flood him with liters of fluid. That'll hose him good and proper, and buy him days in the ICU. Bonus points if the flooding is done with saline, and you give the guy a hyperchloremic acidosis to go along with the CHF.
     
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  29. JobsFan

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    there is more than one way to leave an ICU.
     
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  30. Planktonmd

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    Gentle induction of GA, A line, good IV access, compensate for blood loss with blood products and some crystaloids without going crazy, return to spontaneous ventilation 30 minutes at least before the end then extubate.
    Keep it simple.
     
  31. Noyac

    Noyac ASA Member
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    Good posts.
    We staged this procedure. Back in June we did the ALIF/XLIF part of the case and there was very very little blood loss. The case was done by a partner of mine. He ran the guy on low dose dobutamine with ALINE, CVP, TEE. The pt was extubated and brought to ICU. He had severe delirium/confusion for 2 days and then came around. He was given some ketamine at the start of the case 25mg ( very low dose) and I'm suspicious that that may have contributed to his confusion along with some lower than normal for him BP's. His normal BP is 150-160/90. Otherwise, he did well.

    6weeks later he returned for the PSF which would be the tougher part of the procedure due to blood loss. He was cancelled by another partner for reasons I'm not totally clear on but we can all speculate that it was health reasons. Therefore, this case became assigned to me by surgeon request. Gotta love those. The pt is optimized and wants to proceed.

    Staging this procedure was key. Instead of 8 hrs of surgical time we are doing 4 hrs. Much more manageable.

    My next question: what would you do differently to manage this pt with the history of the previous case?
     
  32. psychbender

    psychbender Cynical Member
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    I'm going to agree with HB regarding induction. I just do not understand the appeal of etomidate in this case, or really just about any case. There is no reason to slam drugs into this patient, so you have the opportunity to titrate in induction agents and pressors as needed. Now that I am no longer the new guy on the heart team, I started trying out tips I learned from this board, and now induce my patients with a combination of ketamine (usually around 0.5-0.75mg/kg), propofol (0.5-1mg/kg), and fentanyl (1-2mcg/kg), and have noticed much more hemodynamic stability than my colleagues who still use etomidate and high doses of fentanyl. Additionally, my total fentanyl for a CABG is down to less than 500mcg now (mean 350-400mcg). I have seen adrenal suppression from etomidate, and do not want to subject this patient to that when there are better alternatives. Additionally, the bolus of ketamine at the onset should increase amplitude and decrease latency of evoked potential monitoring. Another point to consider is that the patient has a dilated cardiomyopathy with reduced LV systolic function. Quite often, this lower EF and LV dilation still translates to a rather normal stroke volume/cardiac output, so long as you don't continue to distend the LV from over-agressive volume loading. He would benefit from some form of goal-directed fluid therapy, whether guided by TEE (if we're remaining supine or lateral, this would be my choice), or pulse-contour analysis (so long as you're not on pressors).

    I also think that this is a bit much to do all at once (unless your surgeons are amazingly fast), so would talke ahead of time about staging this procedure.
     
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  33. psychbender

    psychbender Cynical Member
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    Persistent delerium for two days after 25mg of ketamine at the start of a several hour case? I don't buy the ketamine as the inciting factor. More likely it was the hypotension, surgery itself, and the fact that this elderly gentleman is in the hospital. Given how well he survived the first stage of the procedure, my plan would be to replicate it for the second go-around, but maintain his blood pressure closer to his preop normal (add some norepi or vasopressin alongside that dobutamine). Vasopressin would have the advantage of increasing systemic pressures while leaving his already elevated pulmonary pressure alone. I have never tried to TEE a prone patient, so I may leave that out of the equation this time. Follow ABGs closely, and give blood as needed.
     
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  34. PainDrain

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    I don't buy into this in situations where the procedure may very well end the patient's life because your name will be on the lawsuit no matter what, guaranteed. The malpractice lawyer will ask you why you decided to proceed with a purely elective procedure in a poor candidate and you can't simply fall back on "I'm not a surgeon." That will not hold water.
     
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  35. Noyac

    Noyac ASA Member
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    I'm happy to see people avoiding Etomidate in this case. I avoided it because until recently his DM was poorly controlled and if he had any adrenal suppression from the Etomidate then he would need steroids and then his blood sugars would be difficult to control and it just isn't a good idea. Avoid the whole issue entirely. Plus Etomidate sucks.

    I've never done TEE prone and don't se any reason to start.

    This pt has severely dilated cardiomyopathy. How would he respond to fluids? We're would you try to keep his volume status? What's going to get him in trouble? What's the your preferred drug of choice if some inotrope is needed?
     
  36. Arch Guillotti

    Arch Guillotti Senior Member
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    I would reply that I had an extensive discussion with the patient and family about the risks, benefits and alternatives as documented in the medical record.
     
  37. Planktonmd

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    Only give fluids to compensate for blood loss nothing more. As for what would get him in trouble that would be fluid overload and decreased contractility caused by the anesthetic.
    If an inotrope is needed (hypotension that does not respond to careful use of ephedrine and phenylephrine) then I would have a low threshold to add some Dobutamine.
     
  38. Mman

    Mman Senior Member
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    I agree that a competent patient should be able to make their own decisions even if it is one I disagree with. The question is whether or not the surgeon is giving them accurate information as to the chances of "success" of the operation. I'd do the case and flag it for internal review within the surgeon's department as to the decision making process of that surgeon. Maybe they were right to think they can improve the patient's life, maybe they lied through their teeth so they'd get paid. Not my place to say so on the morning of surgery unless it is drastically out of line.

    I would, though, have a discussion with the patient and family about what might lie ahead for them in terms of being on the vent in the ICU postop and whether or not that'd be OK with them.
     
  39. Noyac

    Noyac ASA Member
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    I like this response. Why would we change the plan, virtually eliminating all the hard work done by the surgeon, his staff and the pt just because we don't agree with the plan?
    If you do this in PP you will find yourself looking for a job every couple years until you decide to work in academics.
     
  40. Colba55o

    Colba55o Junior Member
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    Jack Kevorkian had extensive discussions with patients about risks benefits and alternatives before he euthanized people, didn't he still wind up in jail?
    Do some of you people really do any case as long as the patient wants it, surgeon wants it and they both understand the risks? The thing is when there is a bad outcome it wont be easy to parse out whether it was poor anesthesia or surgical management. This is a cool thread for academic purposes but the cowboys here shouldn't blather on about how its our job to safely do every **** case that is thrown in front of us.
    No one should be faulted for refusing to do this case; if you are 20 yrs into practice have a nice financial cushion and plenty of contacts all over yeah do the case. For those of us who are a few years out of residency, have student loans, families to feed, etc...I'm not willing to have a potential stain on my career this early just to win a who has bigger balls contest.
     
  41. Noyac

    Noyac ASA Member
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    Update: The pt is now intubated after decompensating over night.
     
  42. jwk

    jwk CAA, ASA-PAC Contributor
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    Kevorkian is a poor example since what he did was illegal.

    There are plastic surgery cases being done every day that have ZERO benefit for healthy people, much less those with multiple comorbidities. One could certainly make the case that undergoing a general anesthetic for purely cosmetic reasons has significantly more risk than benefit. Do you tell those patients no as well?
     
  43. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    Did you do the second part of the surgery or he decompensated before that?
     
  44. Noyac

    Noyac ASA Member
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    This is not cowboy anesthesia or a biggest balls competition. It's about knowing what is doable, about what pts want and deserve, and about servicing a surgical arena in a way that is safe and not obstructionistic.
     
  45. IlDestriero

    IlDestriero Ether Man
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    I'm trying to imagine what a few of my partners that cancel kids for pre procedure hiccups would do if they met this patient in pre op. It's causing me great amusement.
     
  46. IlDestriero

    IlDestriero Ether Man
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    I know there are a lot of crappy anesthesiologists out there. I used to work with a few of them.
    Still do...
    What annoys me is when the schedulers shield them from many of the complex cases, which just compounds the problem.
    We've also released a few fellows into the world who, while not bad enough to fail or remediate with additional time, were pretty marginal and wouldn't be getting a LOR from me for any job.
     
  47. pgg

    pgg Laugh at me, will they?
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    Is there an alternative short of firing them? Putting a poor anesthesiologist in a complex case does no one any favors - not the patient, not the surgeon, not your department.
     
  48. pgg

    pgg Laugh at me, will they?
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    Come on, really? You don't see the difference between a felony and a judgment call?


    No, but I'd do this particular case.

    Some day, 150 years from now, when I'm old and broken down and in pain, I hope my doctors will be willing to let me accept the risk of palliative surgery.
     
  49. IlDestriero

    IlDestriero Ether Man
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    That would be my solution. Up your game or find another place to work.
     
  50. Random Anesthesiologist

    Random Anesthesiologist Random Anesthesiologist
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    Did any one say T&C as part of initial management? I've been up for about 48h straight with a needy newborn and may have missed it.
     
  51. pgg

    pgg Laugh at me, will they?
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    Must be nice to have that option. That solution doesn't work if you can't fire people, or if recruiting to the area is so difficult that the replacement is likely to be another retread.

    The rest of us just have to practice the ancient art of "schedule triage" ... :)
     
    Noyac likes this.

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