Jet's Case Of The Month

[jetproppilot]

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OK young Jedis. Feast your eyes.

62 y/o WF, h/o ITP , NIDDM, obesity (110 kg), moderate LV dysfunction.

Scheduled for CABG. 😱

My partner pre-ops her in the hospital.

Salient findings are platelet count 60K; EF 30%.

I'm the on-call dude the next day (read: it's MY case)

So I get out my trusty razor cell phone, look up the heart surgeon's number, and hit the green button:

"Hello?"

"Hey Jay, it's Bill."

"Hey Bill, whats up?"

"Look dude, I'm fearless, but the case you've got scheduled for tomorrow is scarin' me!"

"Yeah, I know," Jay the heart surgeon says.

"Only problem is we have no choice. She's got critical-two-vessel-stenoses and is having anginal symptoms in her hospital bed. Cardiologists say they can't stent her. So she's got only one shot, and thats surgery. She is fully aware of the risks and recognizes she may die as a result of the case."

"Uhhhhhhh," I replied.

"OK. But we've gotta have some major resources available for this case."

"Yeah, already got that lined up," Jay replied.

Medical banter continued between us making sure we were on the same mindset as to how the case should proceed.

SO, YOUNG JEDI'S AND ATTENDINGS ALIKE,

tell me how to do this CABG, what your fears are, and how you ameliorate your fears.

Oh, BTW, she was a difficult intubation to boot.

You know it's bad when one of your favorite CRNA's (Becky) mutters, while exposing with her Mac 3:

UHHHHHHHHHH.....Bill...................

"geeeezus $%^&^ing christ", I muttered back. "When it rains, it pours."

Tell me how to do this case.

This was forty eight hours ago.

Pt is now extubated in ICU, minimal chest tube drainage, complaining that she's being forced to get out of bed.

We did SOMETHING right since she's still breathing on this planet.

 

[zippy2u]

Well, the dumb phucks way to do this case is consult the hematologist, let him give you some recs and proceed with the case. Ummm, next case.... Regards ---Zip

 

[A4M]

First of all, if she is having CP with critical stenosis and no one can stent her and all that, I'll talk to my surgeon buddy about placing an IABP before going to OR. At least people should be on the same page about this, the worst case for her is to have her code on induction and then we are done.

I will go ahead with a plt of 60 and ITP, many studies suggest this will not be high risk of intra-op bleeding, although I will have some plt ready in the bloodbank along with the RBCs.

Preop I'll make sure her blood sugar is in check say <150. Some IM morphine, PO ativan on call to OR. The key is not to cause huge sympathetic surge during induction/intubation.

I'll put one big IV and an A-line prior to induction, keep an eye on BP I'll give her 10 morphine and 4 versed. Given her size I'll position her well with shoulder rolls, have some alternative airway ready, eg a light-wand or an intubating LMA. I'll induce with sufentanyl say 2500 mcg, mask ventilate and hit her with vecuronium, then I'll pray that either I or someone else can intubate her. Again making sure she is not hypertensive during all these. Depends on her pre-op BP I may start with some Nitro drip prior to induction.

I'll place a swan, keep her asleep on Desflurane and Sufentanyl. On coming off CPB I'll start her on amio or milrinone drip, I'll take her to ICU intubated, sedate with versed or a little sufent on transport. I'll let her wake up and extubate her in ICU.

I think the key of the case is to avoid hypertension thus increasing myocardial o2 demands. It's also very important not to hit her too hard to get you into the disaster of hypotension/bradycardia situation. Keep her euvolemic. Watch the field for bleeding. Check hct often, transfuse as needed. Intra-op insulin drip. Off-pump inotrop support.

Nobody says it's easy but having some luck and being fearless also help.

 

[Monty Python]

OK young Jedis. Feast your eyes.

62 y/o WF, h/o ITP , NIDDM, obesity (110 kg), moderate LV dysfunction.

Salient findings are platelet count 60K; EF 30%.

critical-two-vessel-stenoses and is having anginal symptoms in her hospital bed. Cardiologists say they can't stent her. .

Precedex gtt started in holding. Wait 10 minutes, place lines.

Continue precedex throughout unless one of the major contraindications or unwanted vital sign changes appear.

Really cuts down on induction drugs, and intraop gas requirements. Makes for railroad vital signs and less up-and-down coming off pump.

 

[UTSouthwestern]

2500 mcg of sufentanil and 10 of morphine??? Tell me you're not serious.

 

[A4M]

Did I say 2500? Oops, I usually draw up 25mcg/kg and limit that to the entire case. 5-10mcg/kg for induction is what I use. Again, I am counting on this one being the usual hypertensive fat lady, that's why I'm doing that much morphine.

 

[VentdependenT]

I havent done hearts yet so I'm fairly useless.

As for the ITP, if the platelet count has been stable at >50,000 and they havent had any major bleeding episodes then I think you are ok. I would however slam in 1 gram of solumedrol night before and morning of to increase platelet count/decrease antibody production. Not sure if leukocyte washed prbc's would be immunologically beneficial or not once transfusion is needed. I guess I'd have to be one of those "dumb phucks" who would buzz a heme fellow in that instance fer some input.

Sounds like a real sphincter clencher though jet.

 

[militarymd]

preop plasmapheresis.


Single donor platelets.

Otherwise, routine case.

 

[UTSouthwestern]

preop plasmapheresis.


Single donor platelets.

Otherwise, routine case.

I'd just go with the SDP. I've seen preop plasmapheresis on a pt with L main critical stenosis cause enough HD shift to kill the patient.

 

[UTSouthwestern]

Did I say 2500? Oops, I usually draw up 25mcg/kg and limit that to the entire case. 5-10mcg/kg for induction is what I use. Again, I am counting on this one being the usual hypertensive fat lady, that's why I'm doing that much morphine.

Still a ton of narcotics. That would be enough for five patients for me.

 

[sevoflurane]

I'd just go with the SDP. I've seen preop plasmapheresis on a pt with L main critical stenosis cause enough HD shift to kill the patient.

SDP??

 

[militarymd]

SDP??

single donor platelet

 

[SilverStreak]

SDP??

Single donor platelets

 

[Sevo]

Easy. Single donor platelets and IV IG +/- plasmapheresis

 

[Noyac]

We did SOMETHING right since she's still breathing on this planet.

Or wrong depending on how you lookat it!

 

[Noyac]

Steroids pre-op (will need to watch blood sugar closely, now).
Usual monitors.
Versed/sufenta (very little needed of both) induction with precedex running in the background and some gas.
OFF-PUMP CABG. Maintains plts fxn better and is less stressful, IMHO.
SDP for post-op. 60K plts in ITP is more effective plts than in someone without ITP.
Otherwise straight forward case besides airway w/c I would manage just like any other bad airway w/c has been discussed here.

thanks Jet

 

[jetproppilot]

Steroids pre-op (will need to watch blood sugar closely, now).
Usual monitors.
Versed/sufenta (very little needed of both) induction with precedex running in the background and some gas.
OFF-PUMP CABG. Maintains plts fxn better and is less stressful, IMHO.
SDP for post-op. 60K plts in ITP is more effective plts than in someone without ITP.
Otherwise straight forward case besides airway w/c I would manage just like any other bad airway w/c has been discussed here.

thanks Jet

Heres how it went.

As far as her difficult airway I was able to get a bougie through the cords on my second attempt so that became a non issue.

Heart surgeon wanted 10U platelets infusing on induction...not sure that would help anything but....

Decided to use the lower dose aprotinin infusion...thought being the last thing we need on this pt is bleeding issues from a non-platelet entity.....additionally one of the aprotinin mechanisms of action reduces platelet glycoprotein loss.....so we used aprotinin despite the Jan 2006 NEJM study. Would like to hear your opinions on this....in other words, would you have used aprotinin? Felt the risk-benefit ratio justified it's use in this case.

She had been heavily loaded with steroids pre-op but her glucose never went higher than mid 200s, which we treated.

Because of her pre-op beta-blockade, coming off pump her heart rate was in the forties, and a junctional rhythm at that...so we paced at 90 for a while with concominant dopamine 3ug/kg/min (heart surgeon's favorite coming-off-pump infusion, not mine). Able to turn off pacer before chest was closed.

10U more platelets after pump run.

Chest tubes surprisingly dry at the conclusion.

Extubated a few hours later in the ICU.

She's still doing fine.

Pretty cool case, although I didnt think it was cool until we arrived in the ICU.

 

[Noyac]

Heres how it went.

As far as her difficult airway I was able to get a bougie through the cords on my second attempt so that became a non issue.

Heart surgeon wanted 10U platelets infusing on induction...not sure that would help anything but....

Decided to use the lower dose aprotinin infusion...thought being the last thing we need on this pt is bleeding issues from a non-platelet entity.....additionally one of the aprotinin mechanisms of action reduces platelet glycoprotein loss.....so we used aprotinin despite the Jan 2006 NEJM study. Would like to hear your opinions on this....in other words, would you have used aprotinin? Felt the risk-benefit ratio justified it's use in this case.

She had been heavily loaded with steroids pre-op but her glucose never went higher than mid 200s, which we treated.

Because of her pre-op beta-blockade, coming off pump her heart rate was in the forties, and a junctional rhythm at that...so we paced at 90 for a while with concominant dopamine 3ug/kg/min (heart surgeon's favorite coming-off-pump infusion, not mine). Able to turn off pacer before chest was closed.

10U more platelets after pump run.

Chest tubes surprisingly dry at the conclusion.

Extubated a few hours later in the ICU.

She's still doing fine.

Pretty cool case, although I didnt think it was cool until we arrived in the ICU.

Why did you think this case was going to be so bad, Jet?
Was it the bleeding issues? I know that an EF of 30% doesn't bother you. Living in N.O., you must see this all the time. I know I did in La.
I agree its a cool case, however and a good one to discuss here. 👍

By the way, I like dopamine coming off pump as well. And the 10 units of plts b/4 pump was a total waste in my opinion.

 

[jetproppilot]

Why did you think this case was going to be so bad, Jet?
Was it the bleeding issues? I know that an EF of 30% doesn't bother you. Living in N.O., you must see this all the time. I know I did in La.
I agree its a cool case, however and a good one to discuss here. 👍

By the way, I like dopamine coming off pump as well. And the 10 units of plts b/4 pump was a total waste in my opinion.

Yeah, that was it Noy. Her other comorbidities didnt bother me.

Guess I worried too much about it since it really went quite well.

 

[mysophobe]

Why do patients have to bleed? When I get into private practice, I'm telling them that I'll do their surgery so long as they don't bleed. If they bleed, I'm charging double.

 

[Noyac]

Yeah, that was it Noy. Her other comorbidities didnt bother me.

Guess I worried too much about it since it really went quite well.

I am not questioning you, Jet. I know better than that! Just wondering if I was missing something else. 🙂

 

[Noyac]

Why do patients have to bleed? When I get into private practice, I'm telling them that I'll do their surgery so long as they don't bleed. If they bleed, I'm charging double.

Then you will need to talk to your surgeons!

 

[mysophobe]

I'm going to be a surgeon, haha.

Blood not where it should be = bad

 

[RUSD8D]

jetro oh wise one: im on cardiac rotation 1st time now: do you find acute acs patients with plavix to have bleeding problems with CABG?

thanks for the input, had this scenario other day, was a mess.

 

[MTGas2B]

Why do patients have to bleed? When I get into private practice, I'm telling them that I'll do their surgery so long as they don't bleed. If they bleed, I'm charging double.

From one of my attendings this past year: "If it wasn't for hemorrhage, anyone could be a surgeon."

 

[jetproppilot]

jetro oh wise one: im on cardiac rotation 1st time now: do you find acute acs patients with plavix to have bleeding problems with CABG?

thanks for the input, had this scenario other day, was a mess.

Absolutely, RUSD. Definitely need platelets for the emergency CABGs that've been on plavix. And they never seem to dry up....and chances for a bring-back are high.

....also a case you wanna make sure you dont hit the carotid with your IJ needle.

 

[Noyac]

jetro oh wise one: im on cardiac rotation 1st time now: do you find acute acs patients with plavix to have bleeding problems with CABG?

thanks for the input, had this scenario other day, was a mess.

They always bleed, alot.

 

[RUSD8D]

THANKS GUYS...............CANT EVEN TALLEY THE PLATELETS AND FFP NEEDED, EVEN GAVE DDAVP.............PLAVIX AND SGY NOT SO GOOD. p.s. SOME OF OUR ATTENDINGS STILL USE APROTININ (TRASYLOL) EVEN WITH RECENT CONTROVERSY......................WAS WONDERING THE PRIVATE PRACTICE FEELING OUT THERE? OBVIOUSLY THE PLATELET PROTECTION IS AN ADVANNTAGE OVER AMICAR............

 

[SilverStreak]

Steroids pre-op (will need to watch blood sugar closely, now).
Usual monitors.
Versed/sufenta (very little needed of both) induction with precedex running in the background and some gas.
OFF-PUMP CABG. Maintains plts fxn better and is less stressful, IMHO.
SDP for post-op. 60K plts in ITP is more effective plts than in someone without ITP.
Otherwise straight forward case besides airway w/c I would manage just like any other bad airway w/c has been discussed here.

thanks Jet

Are you doing a lot of the off pumps yet? We're doing only a few. Had one the other night who was a minimally invasive valve repair. Anesthesia (CRNA) said in his oppinion these were of little benefit yet when compared to doing the open chest way b/c of the additional anesthesia time required. He also said pts could be extubated in the OR and come over awake and recover quickly if they had a sternal approach instead of thoracotomy approach that was off pump. Am I missing something? I clarified twice what he was telling me, but it makes no sense. I would think a minimally invasive approach off pump would be better for the patient. His main concern seemed to be the extra time the patient spends under anesthesia b/c the surgeons are not yet as proficient as they are with the traditional approach. It just seems to me if you can avoid the inflammation process that goes along with pump use, and not have the chest cracked open the patient will ambulate and have a quicker and easier recovery with less potential complications.

 

[militarymd]

Are you doing a lot of the off pumps yet? We're doing only a few. Had one the other night who was a minimally invasive valve repair. Anesthesia (CRNA) said in his oppinion these were of little benefit yet when compared to doing the open chest way b/c of the additional anesthesia time required. He also said pts could be extubated in the OR and come over awake and recover quickly if they had a sternal approach instead of thoracotomy approach that was off pump. Am I missing something? I clarified twice what he was telling me, but it makes no sense. I would think a minimally invasive approach off pump would be better for the patient. His main concern seemed to be the extra time the patient spends under anesthesia b/c the surgeons are not yet as proficient as they are with the traditional approach. It just seems to me if you can avoid the inflammation process that goes along with pump use, and not have the chest cracked open the patient will ambulate and have a quicker and easier recovery with less potential complications.

There have been quite a fair number of studies comparing different endpoints between on-pump vs off-pump revascularization surgeries.....

graft patency , neuropsychiatric dsyfunction, post-op mi, etc.

To date, the jury is still out on which is superior.

 

[Noyac]

There have been quite a fair number of studies comparing different endpoints between on-pump vs off-pump revascularization surgeries.....

graft patency , neuropsychiatric dsyfunction, post-op mi, etc.

To date, the jury is still out on which is superior.

Mil is right. The jury is still out. But I have some opinions that I can't back up with any good studies but they are my opinion none the less.
First of all, I don't do OPCABG or any other hearts at this time since I switched jobs. I was brought on in my new job b/c of my heart experience when I would do as many as 5-15 hearts a week depending on the schedule. We did over 90% off-pump. the surgeons were good at it and they went fast,very fast. I would finish the 3rd heart of the day by around 3pm sometimes. We did everyone off pump unless it was a valve. I find them much easier technically and the pts usually recover faster (but not always better). Many believe that OPCBAG's will come back for bleeding more often due to poor grafts. I found the opposite (maybe b/c no pump run?). Yes they can be extubated sooner and occasionally on the table. But our pump cases were extubated within 6hrs anyway.
So are they better and if I were to have a CABG would I do it on or off pump. I think the neuro complications are less off pump but not as much as one might think. Maybe this is from anesthesia, microemboli from the aortic clamp, or some other entity. I think the stress is less off pump but I am not sure the grafts are as good. I think we will find out in the near future as to how patent these off pump grafts realy are. My cards buddies are telling me that they are starting to see some graft failures now that are less than 10 years out from surgery. Not Good.
I don't know which way I would go if it were me. But you can rest assured, I'd have the best damn surgeon I could find and the best damn anethesiologist (sorry but no crna for me on this one) I could find, period, without exception.

 

[mysophobe]

From one of my attendings this past year: "If it wasn't for hemorrhage, anyone could be a surgeon."

That's a good one. I like that.