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So you have a 50 year old cowboy who has bilateral inguinal hernia for the past 5 years not getting better.

Problem is he has ischemic heart disease and EF of 14%.

It has to be done or else he'll end up with strangulated bowel.

What would you do?
 
Straight local.

Stay home or go to the park.
 
Direct Laryngoscopy said:
Do the case under local
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Thats assuming the surgeon wants to do it open. B/l repairs are usually done Laparoscopic but that doesn't mean his mind cant be changed to fit the Plan. I agree with doing it open under MAC/Local. If cannot change surgeon/patients mind, then make sure pt is optimized overall and especially cardiac wise and hopefully there is an echo to make sure he doesnt also have severe valvular problems, explain in depth risks and benefits to pt and family, pre-induction A-line, smooth IV induction with agents you feel comfortable with (I would probably just do fent + etomidate + succ/roc here slowly), Pressors ready, tube, surgery, CCU bed ready, cardiologist to follow him post-op, PACU....Have a drink.
 
30mg 3% 2-chloroprocaine spinal with 15mcg fent. Should not affect hemodynamics much. Maybe slight t-burg to prevent LE venous pooling. Art line might not be a bad idea. Little midaz.
 
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You say he has 'ischemic heart disease' but is there any myocardium at risk? If the patient does get 'ischemic' then how about an angiogram and a bare metal stent placed before going to the OR. I'd do a general anesthetic with ET tube (he might need a laparotomy). I'd do an Aline and CVP. If there is no ischemia but just cardiomyopathy, the patient will do well with a Dopamine drip. I'd do a TAP block for postop pain. Drop a TEE if it makes you feel better. He probably also has some MR from LV dilatation. Or Afib.
 
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Lots of ways to do this. Personally, I don't like the local idea unless the surgeon is gifted at injecting local. Bilateral may end up being a lot of local but that should not matter. If it is a straight forward bil IHR then a simple LMA is probably what I would do. A spinal is also a good option. In my experience, these low EF pts do pretty well with spinals. I'd use hypobaric marcaine for my spinal. Slower onset and therefore less hemodynamic changes. If BP starts to drop, squirt a syringe of neo into the IV bag and let it flow at a rate that maintains adequate BP.

If chance of laparotomy, GETA. but be gentle.

I am usually impressed by how stable these low EF pts are. Maybe because I pay more attention to them, who knows. But they are usually optimized since they see their cardiologists frequently.
 
How quick is the surgeon? Hypobaric bupi spinal, maybe chloroprocaine. Local is an option but bilateral complicates things and guy will likely get antsy and disinhibited with sedation unless its heavy.
 
Noyac said:
CVP for a hernia? Not sure what you are gaining.
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Vasopressor infusion more than anything. The guy has hernias that are causing pain so case likely needs to be done. If surgeon refuses local, now I gotta do an anesthetic that will alter hemodynamica regardless. If his heart gets unhappy during the case i can start drips and they are going through a peripheral and risking infiltration, etc. If he ends up intubated in the ICU on drips so be it. I'm cardiac trained so I have no problem putting someone on drips and taking them to the ICU. If the surgeon is going to operate on a sick cardiac patient she (or he) has got to let me treat them like a sick cardiac patient.

btw I agree with your LMA idea and that's how I'd start unless the case is laparoscopic.
 
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Most important thing is management of expectations with the pt/family.

Aline, etimidate, tube, low Mac volatile, stick of norepinephrine 8mcg/cc ready to maintain svr.
 
In training, we did these kinds of cases - minor surgery on pts with CHF and ESRD - all the time.

Slow induction with 100-200mcg phenylephrine and enough propofol to get the mouth open and insert LMA, and a little bit of gas. And squirt a vial of phenylephrine into a 500cc bag and run it on a micro drip to maintain BP.

It's not scientific, but I base my decision to put art line pre-induction depending on how sick the pt looks while lying on the stretcher. Most of the time they came from home and looked OK.
 
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This a classic "oral boards" "no correct answer" case. I think you can do anything as long as you defend it and have a back up plan. You can always line the patient if crap hits the fan since you'll have the neck near you and arms may not be tucked.
 
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Twiggidy said:
Vasopressor infusion more than anything. The guy has hernias that are causing pain so case likely needs to be done. If surgeon refuses local, now I gotta do an anesthetic that will alter hemodynamica regardless. If his heart gets unhappy during the case i can start drips and they are going through a peripheral and risking infiltration, etc. If he ends up intubated in the ICU on drips so be it. I'm cardiac trained so I have no problem putting someone on drips and taking them to the ICU. If the surgeon is going to operate on a sick cardiac patient she (or he) has got to let me treat them like a sick cardiac patient.

btw I agree with your LMA idea and that's how I'd start unless the case is laparoscopic.
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This argument about having to place a central line just in case we need to give pressors is just not very realistic and highly exaggerated, I know they keep teaching it to residents but it's just a bit silly IMHO.
 
Im not telling anyone what they SHOULD do, only what I would do, and again, I can defend it.

I can trend CVP for his failing heart
I can run vasoactive infusioms if needed
It takes 5-10 min to do and gives me options

PA, yeah thats silly but. no M&M in the country will fault someone for dropping an IJ real quick.

I mean we joke about this everyday at work. Everything attending in residency will tell you the way they do it is the ONLY way. Then you go out on practice and realize there's a thousand ways to skin the cat. Just make sure after skinning that first, the patient is alive; second, the surgeon is happy; third, you get paid.
 
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Id first look at the echo to see Id this guy has a huge dilated ventricle. If so, that 15% EF likely translates to a pretty decent cardiac output and he is more likely to be relatively stable on induction. Either way though id go with pre induction a-line, a small dose of propofol (50 mg or so), then turn on the gas and breathe him down slowly and slip in an lma. I don't have a preference for lap vs. Open because as far as I understand it these aren't intra-peritoneal (at least where I work) and I haven't seen significant hemodynamic changes on insufflation.
 
And it's also true that how you do this case depends on where you work and who's doing the cutting.
 
First question would be if he is active and what his exercise tolerance is. If I have 4 mets, I give him the choice of what to do but have no reservations with GA. We always think doom and gloom with severely depressed EFs, but some of them have hearts the size of Secretariat's and will do just fine. Did a lap nephrectomy on a EF of 10% the other day and he was my most stabile patient of the day. He walked three miles per day. As with a lot of things, have to tease out the information.
 
teeva said:
In training, we did these kinds of cases - minor surgery on pts with CHF and ESRD - all the time.

Slow induction with 100-200mcg phenylephrine and enough propofol to get the mouth open and insert LMA, and a little bit of gas. And squirt a vial of phenylephrine into a 500cc bag and run it on a micro drip to maintain BP.

It's not scientific, but I base my decision to put art line pre-induction depending on how sick the pt looks while lying on the stretcher. Most of the time they came from home and looked OK.
Click to expand...
That's exactly how I would do it.
 
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Twiggidy, I can appreciate that you are cardiac trained and that It makes you feel comfortable doing something more cardiac oriented here. But I feel like you are doing it for your security more than for pt needs.

Like you stated, it only takes a few minutes to place a central line and this is a Bil hernia so things won't go south fast if you are gentle with the pt. Therefore, I feel like you would have time to place one if you needed it and otherwise not add additional procedures with their inherent risks and complications until needed. Also, I would not expect CVP to change much in this case since it's a hernia. It's not like this guy will even need a liter of IVF for the case.

But if it's your case then it's your call.

Ps: I'm not calling you crazy, I'm just giving my take on the case.
 
OK, so why CVP?
1. It's known not to correlate with fluid responsiveness.
2. It shows caval/right atrial pressure. Nothing more. What does an intraop increase in CVP mean? Increased venous return? Increased venous tone? Hypervolemia? TR? RV failure? Pulmonary hypertension? PE? Pneumothorax? Increased airway pressures? (Worsening of) MR/MS? LV failure? (Worsening of) AR/AS? Etc. What will you do with that number, except for raising the transducer to keep the pressure "normal" for some stupid surgeon?
3. But you can decrease the chances for kidney injury in septic patients, by keeping the CVP under 8. Apparently those two are the only things that correlate. 😛
 
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Very true Noyac and FFP. Cardiac is my bread and butter so when I see sick patients I tend to approach them that way. Personally, I hate digging under drapes and hunching over and putting in "less sterile" central lines, when I can do it at the beginning, sterile, and if need start my infusions if his heart can't handle the case. So I tend to look at it as: 1) the patient could need it and 2) yes, it makes me feel better.

No the CVP won't tell me anything about his heart function, per se. My thoughts are, why wait for trouble to build up my arsenal and instead have my arsenal ready when trouble arrives.

Alot of factors in this case, which is why I think it's funny when threads are like "EF 15%..would you do the case? K+ 5.2...would you do the case", so much more goes into the thought process. Even where I work I think we CVP people who don't need them (due to surgeon request), which is probably why I'm so quick to put one in if I think the situation may need it. But that's private practice for you. Keep the business happy.
 
I wouldn't place a CVP unless it was going to be a case where I expected significant fluid shifts and I wanted to follow his CVP to try aid in decision making along with the Aline. This is a zero fluid shift case which should be under an hour. The need for drips post op in the ICU is also zero.
Any temporary drips or neo squirts can go through his 18g PIV.
I don't place a CL on every case that may need infusions, only the ones that I'm pretty sure will and/or will need them post op as well, or big complex fluid shift cases.
 
Agree with the minimalists on this thread. No central line.

Low EFs scare people, but if the *cardiac output* is normal, if *oxygen delivery* is adequate, they should do fine. Just be gentle.
 
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