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sethco

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For your viewing pleasure this morning, I present a 66 y/o female admitted with Shortness of Breath. Previous medical history of uncontrolled HTN, OSA non-compliant on CPAP, Remote hx of Ovarian Cancer s/p Chemo currently in Remission, and NIDDM. EKG on admission showed AFib with RVR and Echo showed Normal LV Fxn with a Moderate-Large Pericardial Effusion without evidence of Tamponade physiology. Currently BP range is SBP 150-180/80-100 in AFib. Pt weight is 217 kg for a robust BMI of 75. Cardiologist says she weighs too much to fit on the Cath lab table to do a Pericardialcentesis and would have to be transferred to another facility if CT surgery could not do a Pericardial Window. Physical exam showed MP 4 airway with very little discernible neck and landmarks could not be Palpated. Denies any previous surgeries. She is extremely anxious for this surgery

Ok residents/fellows, let's hear Concerns, plans, and most importantly reasoning.

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I’m a smaller hospital PP attending so not gonna do too much mental massage here, but this is my plan:

Obviously try to transfer first, but if we’re stuck doing it they I feel okay taking a crack at it. Pre-induction A-line and CVC, awake fiber optic intubation with 7.5-8.0 ETT then keep spontaneously ventilating. Epi in line, start low dose infusion then give a little versed and slowly turn up the gas. Surgeon at bedside ready to go before any meds/gas, ready for prep splash and cut/saw emergently if needed.

Without knowing HR it’s hard to make a call on the A-fib but I would not make attempts to cardiovert it pre-op. Patient hypertensive/perfusing, and a shock/stun could do more harm than good acutely.
 
Review the images . Confirm no evidence of tamponade. Prop roc tube.
 
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Review the images . Confirm no evidence of tamponade. Prop roc tube.

upload_2018-9-17_10-11-15.jpeg
 
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I’m a smaller hospital PP attending so not gonna do too much mental massage here, but this is my plan:

Obviously try to transfer first, but if we’re stuck doing it they I feel okay taking a crack at it. Pre-induction A-line and CVC, awake fiber optic intubation with 7.5-8.0 ETT then keep spontaneously ventilating. Epi in line, start low dose infusion then give a little versed and slowly turn up the gas. Surgeon at bedside ready to go before any meds/gas, ready for prep splash and cut/saw emergently if needed.

Without knowing HR it’s hard to make a call on the A-fib but I would not make attempts to cardiovert it pre-op. Patient hypertensive/perfusing, and a shock/stun could do more harm than good acutely.

Why awake CVC? Where are you going to place it? Pt is not in tamponade physiology. Does that change your plan? Any concerns about new onset AFib in a location that is not equipped with a Cath lab that can manage this patient if needed?
 
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I’m a smaller hospital PP attending so not gonna do too much mental massage here, but this is my plan:

Obviously try to transfer first, but if we’re stuck doing it they I feel okay taking a crack at it. Pre-induction A-line and CVC, awake fiber optic intubation with 7.5-8.0 ETT then keep spontaneously ventilating. Epi in line, start low dose infusion then give a little versed and slowly turn up the gas. Surgeon at bedside ready to go before any meds/gas, ready for prep splash and cut/saw emergently if needed.

Without knowing HR it’s hard to make a call on the A-fib but I would not make attempts to cardiovert it pre-op. Patient hypertensive/perfusing, and a shock/stun could do more harm than good acutely.
It states the patient is in afib with rvr. I would start amio bolus/infusion to at least get rate control on this patient. Amio can reliably at least get you rate control relatively quickly after it's administered
 
Echocardiographic findings of tamponade don't mean she doesn't have tamponade physiology. It is a clinical diagnosis at the end of the day.

I'd still review the echo images, but outside of your RV diastolic collapse (a very late sign on echo in the first place), all other signs go out the window with a patient in atrial fibrillation anyways. Your RA is going to collapse haphazardly and you're not going to be able to assess respirophasic changes in TV/MV inflow velocities.

I'd look at her CXR and on physical exam look for signs of congestion that could otherwise explain her SOB. Pre-induction arterial line either way. Board answer A) would be an awake window and B) would be for an AFOI in a semi-upright position with titrated fentanyl/versed and ketamine. Obesity does not equal a difficult airway though and she sounds exactly like the kind of person who would not tolerate an AFOI or an awake procedure.

In reality, glidescope and a titrated ketamine induction will probably be just as safe. Have the surgeon in the room in case you need immediate drainage. Don't really care too much about keeping her spontaneous just as long as you don't blast her with tidal volumes and PEEP once she's asleep.


tl;dr ketamine/sux/tube

It states the patient is in afib with rvr. I would start amio bolus/infusion to at least get rate control on this patient. Amio can reliably at least get you rate control relatively quickly after it's administered

I'd be hesitant in doing anything about her rate at this point in time. Very possible that the atrial fibrillation is secondary to her pericardial collection/tamponade physiology. Clearly hemodynamically stable at this point in time despite the fast heart rate and the amiodarone could bring her rate down enough where she spirals, especially with a bolus.
 
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Echocardiographic findings of tamponade don't mean she doesn't have tamponade physiology. It is a clinical diagnosis at the end of the day.

I'd still review the echo images, but outside of your RV diastolic collapse (a very late sign on echo in the first place), all other signs go out the window with a patient in atrial fibrillation anyways. Your RA is going to collapse haphazardly and you're not going to be able to assess respirophasic changes in TV/MV inflow velocities.

I'd look at her CXR and on physical exam look for signs of congestion that could otherwise explain her SOB. Pre-induction arterial line either way. Board answer A) would be an awake window and B) would be for an AFOI in a semi-upright position with titrated fentanyl/versed and ketamine. Obesity does not equal a difficult airway though and she sounds exactly like the kind of person who would not tolerate an AFOI or an awake procedure.

In reality, glidescope and a titrated ketamine induction will probably be just as safe. Have the surgeon in the room in case you need immediate drainage. Don't really care too much about keeping her spontaneous just as long as you don't blast her with tidal volumes and PEEP once she's asleep.


tl;dr ketamine/sux/tube



I'd be hesitant in doing anything about her rate at this point in time. Very possible that the atrial fibrillation is secondary to her pericardial collection/tamponade physiology. Clearly hemodynamically stable at this point in time despite the fast heart rate and the amiodarone could bring her rate down enough where she spirals, especially with a bolus.

Yeah. A good clinical test to do at the bedside is find the radial pulse and then have the patient take a deep breath and hold it - if the pulse goes away or gets very faint then you know you are detailing with the real deal tamponade.
 
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With that awake BP (without an atrial kick) she'll likely tolerate PPV with some vasopressor support until the pericardium is opened. But may be quite hypotensive after induction. So main concern to me is access (prefer at least a reliable 20g to induce bc pressors and some volume are going to go thru).
After establishing a reliable IV, I'd: awake art line, prop, pressor, sux, glidescope, probable CVC (easy and never regretted it).
If I can only get a small IV before sleeping, I'd probably do the same, but inhaled induction + small amount of prop and sux when she obstructs, tube, and definite CVC.
 
For your viewing pleasure this morning, I present a 66 y/o female admitted with Shortness of Breath. Previous medical history of uncontrolled HTN, OSA non-compliant on CPAP, Remote hx of Ovarian Cancer s/p Chemo currently in Remission, and NIDDM. EKG on admission showed AFib with RVR and Echo showed Normal LV Fxn with a Moderate-Large Pericardial Effusion without evidence of Tamponade physiology. Currently BP range is SBP 150-180/80-100 in AFib. Pt weight is 217 kg for a robust BMI of 75. Cardiologist says she weighs too much to fit on the Cath lab table to do a Pericardialcentesis and would have to be transferred to another facility if CT surgery could not do a Pericardial Window. Physical exam showed MP 4 airway with very little discernible neck and landmarks could not be Palpated. Denies any previous surgeries. She is extremely anxious for this surgery

Ok residents/fellows, let's hear Concerns, plans, and most importantly reasoning.

On the orals, access the patient is oxygenating and ventilating, check the vitals, blah blah, blah, yada yada yada.......ok

IV access is very crucial in this patient that we're going to be giving sedation, induction meds, and likely pressors while her effusion is being drained so that would be my first priority. Given the description of the neck, a CVP could take too much time and she probably can't lie flat given her current situation. Hopefully a good IV can be establish antecubital with the U/S.

After that I would get an A-line inserted. I don't think many of us would argue a pre-induction/sedation A-line in this situation.

Now it get's fun.

My problem is word description of airways is that you can tell me that someone is BMI 75 and no neck but that doesn't necessarily that it will be the most difficult airway we've ever seen. I'm sure most of us have done bariatric cases and many to most times you can intubate with a glidescope. (On the boards, topicalize, awake FOB, spontaneous breathing once the tube is in). In my world, ketamine and a little prop, muscle relaxant would depend on what she looks like so roc vs sux, and then glidescope and tube and vent settings based on resulting vitals. As said, she's pretty "stable as it is, so you can probably do controlled. The SOB may be more from the A-fib then the effusion so drop a TEE in and look at the LAA and decide whether cardioversion would help once it's established the appendage is clear. All of these decisions are while the surgeon is prepping and doing the window.

Also, if she's that anxious then after that IV and A-line are established, titrate midaz / ketamine to effect prior to airway establishment.
 
So too big for cath lab table but not too big for OR table? Hmm...fine, just awake Aline, awake patient, bring the C-arm or go to Hybrid room to do pericardiocentesis. Patient doesn't have to lie flat.

If that's not feasible then, above responses
 
So too big for cath lab table but not too big for OR table? Hmm...fine, just awake Aline, awake patient, bring the C-arm or go to Hybrid room to do pericardiocentesis. Patient doesn't have to lie flat.

If that's not feasible then, above responses

Amazingly, our OR tables have a weight capacity of 1000 lbs. Every EP lab I have ever worked in had a limit of about 400-450
 
I have very low suspicion of tamponade physiology for a couple reasons. The first is that she's presenting hypertensive. Granted she could be in a very high SVR/ low CO state but the vast majority of true tamponade is normotensive to hypo. Secondly, if she's in afib then even a bad echocardiographer would pick up atrial collapse and comment on it. Thirdly, morbidly obese with OSA and preserved BiV fnx means her right sided pressures and CVP are probably high and this is protective against the compression of an effusion since her venous driving pressure is maintained.

Pads on, Awake a-line, work in some ketamine, see if her BP holds with pressor + a little assisted masking, more ketamine, give the sux.
 
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"If you lose you Y then you die." - Tommy B

The concern here is that pos press vent exaggerates the respiratory variations of pericardial diseases and then the pt crashes on induction. The pressure that is going to take for her BMI of 75 to be mechanically ventilated will augment R sided afterload too much and give your left side no pre load.

The safest thing to do here is awake fiber and gas induction while pt is spon breathing and keep her spon breathing while the tamp physiology is still in play.
Obv i'm getting pre induction a line. In my mind the nuance here is that if we are really inducing and pos press venting the pt, there isn't anything we can do once the pt starts crashing, even if you sugammadex her, you are still hanging her on her life on the fact she will spon breath after induction dose of propofol....
 
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"If you lose you Y then you die." - Tommy B

The concern here is that pos press vent exaggerates the respiratory variations of pericardial diseases and then the pt crashes on induction. The pressure that is going to take for her BMI of 75 to be mechanically ventilated will augment R sided afterload too much and give your left side no pre load.

The safest thing to do here is awake fiber and gas induction while pt is spon breathing and keep her spon breathing while the tamp physiology is still in play.
Obv i'm getting pre induction a line. In my mind the nuance here is that if we are really inducing and pos press venting the pt, there isn't anything we can do once the pt starts crashing, even if you sugammadex her, you are still hanging her on her life on the fact she will spon breath after induction dose of propofol....

I do a few adult gas inductions per year and the biggest problem with this plan is that high dose vapor causes pretty decent muscle relaxation -> pharyngeal relaxation -> obstruction. Last two I did were on a 220lb guy and 140lb lady and both of them required oral airways and a little bag assist to maintain ventilation. What do you think is going to happen to a BMI 75 on sevo 8.0? I like judicious ketamine/versed/glyco here.

Again, based on her presentation I really dont think this lady is gonna crunk from 20cm H20 PPV, but if you do want to limit PPV, keep in mind that postinduction what we really are concerned with is oxygenation. Assuming normal lung parenchyma, put on the norepi drip and you can get away with low TV, reverse tburg, minimal peep, 100% fi02 and just let her be hypercarbic until the effusion is relieved.
 
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I do a few adult gas inductions per year and the biggest problem with this plan is that high dose vapor causes pretty decent muscle relaxation -> pharyngeal relaxation -> obstruction.

Why would pharyngeal obstruction matter if you already have the et tube in?
 
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TBH......what the lady really needs is a ton of local and a pericardiocentesis. I know the cardiologist doesnt want to do or is saying she's too big for the cath lab but if the airway is truly that scary the she needs to be kept awake. Hell, the ketamine with bits of prop is probably enough sedation to do the pericardiocentesis under local.
 
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TBH......what the lady really needs is a ton of local and a pericardiocentesis. I know the cardiologist doesnt want to do or is saying she's too big for the cath lab but if the airway is truly that scary the she needs to be kept awake. Hell, the ketamine with bits of prop is probably enough sedation to do the pericardiocentesis under local.

Ketamine with a bit of prop is probably enough to put in the tube.
 
Echocardiographic findings of tamponade don't mean she doesn't have tamponade physiology. It is a clinical diagnosis at the end of the day.

I'd still review the echo images, but outside of your RV diastolic collapse (a very late sign on echo in the first place), all other signs go out the window with a patient in atrial fibrillation anyways. Your RA is going to collapse haphazardly and you're not going to be able to assess respirophasic changes in TV/MV inflow velocities.

.

I know we are all fond of this phrase but actually tamponade is an echo diagnosis. If the RV isn’t collapsing due to pericardial hypertension then pericardial hypertension literally is not present and there is no tamponade, period. It’s not a clinical diagnosis.

This patient will tolerate a HD stable induction and incubation. The airway is the bigger issue.
 
I know we are all fond of this phrase but actually tamponade is an echo diagnosis. If the RV isn’t collapsing due to pericardial hypertension then pericardial hypertension literally is not present and there is no tamponade, period. It’s not a clinical diagnosis.

This patient will tolerate a HD stable induction and incubation. The airway is the bigger issue.

Uptodate says that tamponade can only be confirmed with hemodynamic and clinical response to pericardial fluid drainage. I think echo is unnecessary for diagnostic purposes.
 
Uptodate says that tamponade can only be confirmed with hemodynamic and clinical response to pericardial fluid drainage. I think echo is unnecessary for diagnostic purposes.

The article says it 'can best be confirmed' by draining in the bullet points at the end. Earlier in the article (in the echocardiography section) it says 'Although cardiac tamponade is a clinical diagnosis...' echo plays a major role and is highly recommended by ACC, AHA, ESC and ASE.

That being said, I think ultimately it is a clinical diagnosis and no one should be stopping to get an echo when the pt history and presentation are obvious and the course is rapidly deteriorating. The lady the OP is talking about does not fit this picture.
 
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TBH......what the lady really needs is a ton of local and a pericardiocentesis. I know the cardiologist doesnt want to do or is saying she's too big for the cath lab but if the airway is truly that scary the she needs to be kept awake. Hell, the ketamine with bits of prop is probably enough sedation to do the pericardiocentesis under local.
Finally! :)
 
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I know we are all fond of this phrase but actually tamponade is an echo diagnosis. If the RV isn’t collapsing due to pericardial hypertension then pericardial hypertension literally is not present and there is no tamponade, period. It’s not a clinical diagnosis.

This patient will tolerate a HD stable induction and incubation. The airway is the bigger issue.
I disagree. It's hemodynamic instability that responds to pericardial fluid drainage. The spectrum of tamponade ranges from hypotension due to restricted filled to RV collapse and arrest. Theres no way of predicting when the tipping point will be.
 
I disagree. It's hemodynamic instability that responds to pericardial fluid drainage. The spectrum of tamponade ranges from hypotension due to restricted filled to RV collapse and arrest. Theres no way of predicting when the tipping point will be.

Yes, true tamponade is pericardial hypertension severe enough to cause instability due to restricted filling, and arrest is usually imminent in these cases. The "spectrum" ranging from hypotension to arrest is extremely narrow. Hypotension is a late sign indicating pre-arrest. This patient does not have tamponade.

And it is VERY predictable where the tipping point will be whether the effusion is slowly accumulating or rapidly accumulating. As soon as they become hypotensive and tachycardic, and have echocardiographic signs of tamponade, they could arrest any second. Thats the tipping point. I've done a ****load of windows and doors and the only ones that arrest on induction are those that are already unstable, and they all have actual echo signs of pericardial hypertension. Simply having a large effusion with no signs of tamponade is very reassuring.

There is a phenomenon called "low pressure tamponade". Pericardial pressure that is not causing a problem in a patient that is normovolemic, can turn into pericardial hypertension if the patient loses enough volume so that filling pressures become very low (and the pressures become imbalanced). So large effusions with early signs of high pericardial pressure are concerning when the surgery could potentially cause major blood loss, or in the dialysis unit for example.
 
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Why awake CVC? Where are you going to place it? Pt is not in tamponade physiology. Does that change your plan? Any concerns about new onset AFib in a location that is not equipped with a Cath lab that can manage this patient if needed?

Pre-induction CVC is because of extreme BMI, likelihood of difficult/poor PIV access, and plan to have light epi going pre-induction. Also may need aggressive volume administration to keep pre-load up if induction is not well tolerated. I would leave the AF/RVR alone because she is generating plenty of BP. She may need the tachycardia/“RVR” for CO. Any attempt to throw her out of what are “acceptable” hemodynamics at this point (mentating patient) may do more harm than good. The idea of what constitutes tamponade in this type of setting is not always clear, and the situation is potentially evolving. It’s best to assume it IS tamponade.

It states the patient is in afib with rvr. I would start amio bolus/infusion to at least get rate control on this patient. Amio can reliably at least get you rate control relatively quickly after it's administered

Amio has significant beta blockade when bolused. I’d feel like a clown if I bolused a beta blocker in a previously stable-ish patient with effusion +/- tamponade and they coded. Lawyers would love it.
 
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Well it's been many days. I guess I don't have the confidence nor the experience to know the tipping point of tamponade.

What actually happened @sethco
 
I’ve seen pericardiocentesis done with c arm.

I might have missed it but What’s to say this isn’t more of a chronic effusion related to cancer rather than some acute process? Stable bp and echo has no tamponade. Moderate to large isn’t that impressive either. Suspicious for compensated chronic. Sure there is the afib and the dyspnea. Maybe af is causing the dyspnea and has another underling cause. Maybe something is causing both the af and dyspnea. Super morbid obesity with no compliant cpap screams pa htn to me. I’m sure she is fairly immobile and at risk of PE which may cause dyspnea and af. Handful of things that could be driving her dyspnea or af that probably need to be considered. I noticed you left out sats, rv function, and any other imaging. Are we even doing the right procedure? Seems fishy.
 
Well it's been many days. I guess I don't have the confidence nor the experience to know the tipping point of tamponade.

What actually happened @sethco

I completely forgot about this, but there have been some great answers and debate. There are multiple ways to do this and an obvious board answer is not always the way things happen in private practice. However, there was enough going on here with the patient that steered me towards conservative management. First, I took a look at the TTE and the images, not shockingly for her size, really sucked. There was some question of possible RV diastolic collapse. I usually lean towards caution in these cases of there is any question. While she was indeed hypertensive, I did not believe she would stay that way under GA. My concern, since her RV filing is already missing the Atrial contribution from her AFIB, is that she definitely wouldn't tolerate PPV without inotropic/vasopressor support. I could of done an Awake Intubation and secured the airway whole maintaining spontaneous ventilation, which could certainly be an adequate board answer, but seems like overkill for a 15 min procedure. So, I told the surgeon we would do it under local/sedation. My choice was a little Midazolam, Fentanyl, and Ketamine. If she needed it, I was going to give a little Nitrous, but she didn't. Surgeon gave local. Pt did just fine. Like I said, just a Window. Haha
 
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I completely forgot about this, but there have been some great answers and debate. There are multiple ways to do this and an obvious board answer is not always the way things happen in private practice. However, there was enough going on here with the patient that steered me towards conservative management. First, I took a look at the TTE and the images, not shockingly for her size, really sucked. There was some question of possible RV diastolic collapse. I usually lean towards caution in these cases of there is any question. While she was indeed hypertensive, I did not believe she would stay that way under GA. My concern, since her RV filing is already missing the Atrial contribution from her AFIB, is that she definitely wouldn't tolerate PPV without inotropic/vasopressor support. I could of done an Awake Intubation and secured the airway whole maintaining spontaneous ventilation, which could certainly be an adequate board answer, but seems like overkill for a 15 min procedure. So, I told the surgeon we would do it under local/sedation. My choice was a little Midazolam, Fentanyl, and Ketamine. If she needed it, I was going to give a little Nitrous, but she didn't. Surgeon gave local. Pt did just fine. Like I said, just a Window. Haha

You are lucky to have a skilled surgeon. Not all of them can do the case under local at all, let alone a BMI OF 75.
 
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You are lucky to have a skilled surgeon. Not all of them can do the case under local at all, let alone a BMI OF 75.

Despite their reputation, with very few exception, the vast majority of CT surgeons that I have worked with have been very reasonable and skilled. Maybe I have built up enough cases with them that they trust when we have to deviate from usual care based off clinical situations. There needs to be trust and understanding between the team. This is especially the case in Cardiac surgery
 
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