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Noyac

Noyac

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I had a good case today. 85 yo female with a perforated duodenum s/p ERCP 2 days ago. Very dehydrated (base def -6.0) with a history of HTN, CHF, and of course CAD. I have them bring her to the PACU b/4 surgery as I am finishing my last case and when I get to her she looks like total ****. She is holding her chest and states that she feels like something heavy is on her chest. BP 80-120/ 40-60, P 108, sats 92% on 3LPM. 20g in the left AC.

What next?
 
Noyac said:
I had a good case today. 85 yo female with a perforated duodenum s/p ERCP 2 days ago. Very dehydrated (base def -6.0) with a history of HTN, CHF, and of course CAD. I have them bring her to the PACU b/4 surgery as I am finishing my last case and when I get to her she looks like total ****. She is holding her chest and states that she feels like something heavy is on her chest. BP 80-120/ 40-60, P 108, sats 92% on 3LPM. 20g in the left AC.

What next?
Click to expand...

i dont have my degree yet.

EKG and Cardiac enzymes x3? help me because this is something i would like to know
 
You're damned if you do and damned if you don't.


I would evaluate the patient for acute myocardial ischemia...the ongoing issue that will kill the patient first.

Perforated duodenum won't kill the patient right away.
 
Ok Ill give it a shot

Is this an MI?, reffered pain from perf?, bad reflux? who cares she needs that perf fixed, warn her and family that she may die on table. Preop EKG
RIJ introducer in PACU run in a liter befor induction. A-line pre induction.

RSI w/ etomidate

My thought is give her as much volume as she needs, with CHF as a secondary concern. Depending on her response to said volume i would consider TEE. No doubt if this goes any way like Im thinking, she is going to need a pressor or 2.,\

BTW F*k a PA catheter........
 
milmd.....

I was thinking of not proceeding. But assume it is an MI, how long can you let a perf just sit there? Is her perf going to worsen before she gets cardiology clearance if in fact she does have a MI?
 
InGasWeTrust said:
milmd.....

I was thinking of not proceeding. But assume it is an MI, how long can you let a perf just sit there? Is her perf going to worsen before she gets cardiology clearance if in fact she does have a MI?
Click to expand...

Perforated duodenal ulcers can sit for days....If there is active ischemia, you don't need a cardiology clearance, you need to start therapy to STOP/TERMINATE the ischemia....once that is done, you can take them to the OR.
 
militarymd said:
Perforated duodenal ulcers can sit for days....If there is active ischemia, you don't need a cardiology clearance, you need to start therapy to STOP/TERMINATE the ischemia....once that is done, you can take them to the OR.
Click to expand...

Why can't you treat it in the OR? Just to be the devil's advocate.
 
shouldn't u give her sublingual nitro first and see if the chest pain goes away? then do an ekg looking for any ST abonormalities. draw cardiac enzymes. if the chest pain goes away and you r/o MI, procede with surgery?
 
Im with Noyac....

I think you are damned if you do and damned if you dont.....she can die from an MI, I think a perf can kill her faster if not fixed.


Noyac, mind spillin the beans on the case and outcome?
 
InGasWeTrust said:
Im with Noyac....

Noyac, mind spillin the beans on the case and outcome?
Click to expand...


Sure.
I got an ECG and had it read by the cardiologist immediately. I started giving metoprolol as I interviewed the pt to get her HR down and then NTG. Cards said "good luck". To the OR with an a-line and 2 PIV's.
Induction:
Neo 100mcg
Metoprolol 5mg (in pre-op)
NTG 10 mcg (started NGT drip in pre-op til chest pain resolved, took about 2 cc/hr for 5 min).
Etomidate 10mg
Sux 100mg
Fent 100mcg

One of the most stable inductions I have had in some time ( I did a bad heart for a knee scope the case before and fought more with his BP then I did with this case).

In the room at 1052am induction at 1054am
Cordis in and running at 1058am
Cut at 1106am.
extubated and to PACU without any sequelae.
 
Let me play devil's advocate a smidgen...

You would have to careful not to place too much credence in relief of symptomotology by SL nitro in this case. On the chest pain differential is also esophogeal spasm, which she has every reason to potentially have as well AND SL nitro will relieve pain from esophogeal spasm. Of course, a goose in spasm is not likely to cause EKG changes not + enzymes. But, it takes a while even for our most senstive enzyme assays to turn positive. Furthermore, approx 25% of active ischemia patients will have a normal EKG.

Now - with a perf'd duodenum...a fresh perf in a younger, healthy pt - maybe sit a spell & be OK, but with that pt population, it would be very rare to be having to cope with her co-morbidities. Being as she old, frail & has been sitting on her perf, I think she needs bright lights & cold steel ASAP...assuming you can get the active ischemia to lax up.

I totally agree with lining her out prior to induction (9Fr IJ & an a-line). And, before starting beta-blockers, dump a liter of LR in her.

Regarding cooling out the ischemia & stabilizing hemodynamics - I agree w/ NTG & neo gtts, but I would have used esmolol for my beta-blocker gtt - much more rapid response to titration. If her BP took a dump after the metoprolol, you are in for much longer lasting hypotensive ride whereas you could just turn off the esmolol & your out of the woods in a couple of minutes...hopefully.

I disagree w/ the eVOMIdate induction. Hell, she's acting like a heart w/ known & active disease; so treat her like a heart. Plus, it's not like she gonna be d/c'd home from same day. I would do a benzo/opiate induction just like I would for a CABG or valve. Take her down nice & easy with midazolam & fentanyl. Frail old lady shouldn't take more than 5~7mg midaz & 10~15ml fentanyl. Plus, she'll be cozy & comfy on the blower all the way to the ICU where she can chill overnight. You know damned good & well from your description she's gonna spend some time in the ICU on a vent. Were she younger &/or with fewer co-morbids - she might be extubated post-op, but in her case, I seriously doubt it.
 
Neo 100mcg
Metoprolol 5mg (in pre-op)
NTG 10 mcg (started NGT drip in pre-op til chest pain resolved, took about 2 cc/hr for 5 min).
Etomidate 10mg
Sux 100mg
Fent 100mcg

Just a curiosity question here: B-blocker, NTG would help out the heart, but why did you use the Neo--to help your preload in the setting of ischemia and hypotension? To my understanding, Neo will also increase your afterload and cause the heart to get even more ischemic, no? If she was perforated and tachycardic secondary to intravascular volume depletion and needed volume resuscitation, then why not gently do just that to improve her hemodynamics? Offcourse I do not have the full story here, but a sick perforation is always interesting and your post is very much appreciated. Thanks.
 
IN2B8R said:
Neo 100mcg
Metoprolol 5mg (in pre-op)
NTG 10 mcg (started NGT drip in pre-op til chest pain resolved, took about 2 cc/hr for 5 min).
Etomidate 10mg
Sux 100mg
Fent 100mcg

Just a curiosity question here: B-blocker, NTG would help out the heart, but why did you use the Neo--to help your preload in the setting of ischemia and hypotension? To my understanding, Neo will also increase your afterload and cause the heart to get even more ischemic, no? If she was perforated and tachycardic secondary to intravascular volume depletion and needed volume resuscitation, then why not gently do just that to improve her hemodynamics? Offcourse I do not have the full story here, but a sick perforation is always interesting and your post is very much appreciated. Thanks.
Click to expand...

I used the Neo to slow the heart, maintain Bp during induction, and increase coronary perfusion. With the NTG the coronaries are dilated and the Neo will increase afterload therefore increasing coronary perfusion via backpressure. The betablockers increase perfusion time as you know. I did this quite often during my off-pump CABG's. I would run NTG and Neo to keep the rate down and the coronary perfusion up. YOu are right about the increased afterload leading to more ischemia but it is a balancing act that allows you to get away with it. Even when you use etomidate the pressure will drop when inducing a hypovolemic pt. especially if they are having a MI which she may have been headed towards. You are also right about volume loading which I did inthe PACU. I gave her 1L of NS b/4 induction and once the cordis was in I gave her another 1.5L over 45-60 mins.
I did another cse like this right out of residency on a guy that perf'd his duodenum and continued to drink heavily for 2 days afterwards. He finally came ntothe ER when he started to have CP. We brought him to the OR after preloading him I gently induced him but without the Neo, NTG, betablockers. I coded right there and I couldn't get any response from him hemodynamically with atropine or epi big doses. I said make your incision and get some of the ascites off. When the surgeon cut the abd while I am during the full court press, the ascites shot across the room and hit the wall on the other side (no lie). I finally got some response from him and we completed the case. He died 5 days later in the ICU. There is alot more to this story but thats the gist of it. I learned a sh*tload on that one.
 
Noyac said:
Sure.
I got an ECG and had it read by the cardiologist immediately. I started giving metoprolol as I interviewed the pt to get her HR down and then NTG. Cards said "good luck". To the OR with an a-line and 2 PIV's.
Induction:
Neo 100mcg
Metoprolol 5mg (in pre-op)
NTG 10 mcg (started NGT drip in pre-op til chest pain resolved, took about 2 cc/hr for 5 min).
Etomidate 10mg
Sux 100mg
Fent 100mcg

One of the most stable inductions I have had in some time ( I did a bad heart for a knee scope the case before and fought more with his BP then I did with this case).

In the room at 1052am induction at 1054am
Cordis in and running at 1058am
Cut at 1106am.
extubated and to PACU without any sequelae.
Click to expand...

Nice, nice case, Noy.

Youre a stud.
 
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