my case the other day

[amyl]

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[urge]

zap him

That's a lot of IV access. Are your surgeons that bad?

 

[amyl]

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[sevoflurane]

Slow the rate down or jolt him out of it if he is unstable (are you sure he has ST depression?). ST depression is concerning but may not be there once you break his arrythmia. The patient may have occult CAD but even if he does, he may or may not be a candidate for revascularization. No PMHX? Good exercise tolerance? Doesn't fit. Where exactly does his astrocytoma live? Cervical Sympathetic chain involvement? How was his analgesia when the pins were placed?
First, control the arrythmia. If he has ongoing ST depression, I would start some NTG and wait a couple of minutes. If it goes away, then proceed. If not cancel and work up for acute coronary syndrome as he probably needs a proper workup and anticoagulation = bleed like stink if he has a invading astrocytoma which is extensive. How good and how fast are your surgeons?

 

[urge]

they were planning on hacking up this guys whole cervical region from occiput to first one or two thoracic segments so we did anticipate considerable blood loss.

500cc-700cc maybe? over 3 hrs?

I think a single 18 g can keep up with that.


Did you zap him or no?

 

[IlDestriero]

zap him

That's a lot of IV access. Are your surgeons that bad?

My thoughts exactly. When you get the rate under control, perhaps a proper 12 lead to get a better look at where you are before committing. While your waiting, double stick the neck, float a swan and see if you can get a TEE in the room. Belmont?

 

[hoyden]

My thoughts exactly. When you get the rate under control, perhaps a proper 12 lead to get a better look at where you are before committing. While your waiting, double stick the neck, float a swan and see if you can get a TEE in the room. Belmont?

Guys, she is a RESIDENT! Which means that neurosurgery guys are mostly residents, too. And an attending, which might not be the fastest and driest neurosurgeon under the sun.
Considering this important addition - 2 large bore IVs are a must. Third is welcome - they will tuck the arms and who knows how long this case will last and what lies ahead in terms not only of fluid challenge but also a possibility of more invasive monitoring and vasoactive drugs needed.

Considering the place where the case is being done (teaching hospital) and at this point of time ( with the info given) if it is decided to proceed I would add a central line.

 

[jwk]

Uh, anyone besides me think it's a little crazy to cardiovert someone while they're prone AND their head is spiked and locked in place?

Prior to incision? Treat it, wake em up, come back another day. Something tells me that someone took some shortcuts with the "VIP" and skipped an adequate workup.

 

[sevoflurane]

I think most people here assumed that you would take off the pins and flip the guy supine + central line. I've never zapped anybody prone with pins or placed a central line in that position. VIP should get nml workup, just like everybody else.

 

[Planktonmd]

So, the patient is now prone under GA with pins in his head.
He is in atrial flutter with some ST depression and I am assuming that his blood pressure is still OK.
At this point my goal would be to do anything I can to fix the problem and proceed with the surgery without having to flip the patient to supine.
I would deepen the anesthetic first and give some narcotics, then give a betablocker and see what happens.
I would also give a fluid bolus.
If these simple measures work and he is back in sinus or at least the rate is controlled with improvement of the ST depression I would proceed with the surgery.
On the other hand if I have to flip him over and cardiovert him then the case gets cancelled and he gets a cardiology consult.

 

[dhb]

I wouldn't mind attempting a prone cardioversion

 

[Noyac]

I assume you mean the ventricular rate is 150? What's the atrial rate? It usually is 300. You could try a carotid massage to slow down the AV conduction which will help identify the flutter waves but most of us wouldn't attempt this in a 74 yo gentleman.
Anyhow, my approach would be just like Plank's, try to treat it medically it BP is somewhat stable and proceed if successful. My only addition to Plank's management is that I like Diltiazem in these situations.

My suspicion is that the anesthetic was too light for pinning as others have said.

I would not cardiovert "this" guy while in pins.

 

[gaspasser2004]

This case is a good example of prioritization, which can differ between providers.

In my opinion, this patient is unstable. He needs to be flipped back to supine so that life saving procedures can be more easily performed (cardioversion, possibly ACLS with chest compressions if condition worsens). I don't think it is a good idea to manage this patient's probelms in the prone position while pinned.

In my opinion, surgery needs to wait for another day. Incision has not yet been made and this is not an emergency. The a-flutter needs to be worked up by a cardiologist, preferably an electrophysiologist. Perhaps this patient has a conduction problem that can be cured with a RF ablation - this would make his subsequent neck whack much safer.

I understand that the patient and his family have set aside this day to have surgery. I understand that the surgeon has set aside block time to do this case. I understand that fee for service anesthesiologists won't "eat" if they don't do this case today. I understand that some would call canceling this case "obstructionist" behavior by an anesthesiologist. The bottom line is that the first rule of medicine is "do no harm" and this patient has significantly greater potential for harm by cowboying it up and doing this case today than taking a step back and seeing what is going on with his ticker and going to the OR at a later date.

 

[urge]

I would flip him and cardiovert. I would not let him with flutter all day while they do a lami. Assuming he goes back to SR and everything looks good, flip him again and proceed. If flutter is persistent or EKG still funny: call cardiology.

 

[Arch Guillotti]

I wouldn't mind attempting a prone cardioversion

prone cardioversion in pins?

no thanks for me

 

[aredoubleyou]

If he has never had a-fib/flutter before than: take off pins, put him on a bed, metoprolol followed by a zap (probably going to be needed). Wake him up, admit him to the hospital, cards consult, put him on the schedule for tomorrow.

If he has a history than do what plank and noyac said.

 

[amyl]

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[IlDestriero]

What exactly did they do that took 13 hrs and 3L blood loss?
😱

 

[aredoubleyou]

his BP dropped and didn't respond to anything but a whiff of epi.
staff called cards and they said go ahead but control the rate (no **** sherlock).
esmolol drip and a ton of IV push metoprolol eventually converted him and then all was right in the world. BP perfected w return of atrial kick, heart rate normalized. concerning that you guys said 700cc EBL though... i guess the surgeons were bad 'cause we ended up loosing 2L (and that was probably conservative).... and it took 13h.
he was breathing spontaneously at the end of the case... i wanted to pull the tube and see how it went but staff didn't even wanna try, oh well. cards recommened amiodarone if beta blockade didn't work. thoughts?

reconfirms to me that the cards guys have no clue about introperative management of patients outside of reading aha guidelines and spitting it back out at you. Your attending should have known better, its obvious to me he knew it was going to be a blood bath (extra ivs, a-line), that is no setting for high dose chemical cardioversion with bblockers on a purely elective case. Also, I realize that the guy was prone and in pins, but the treatment for unstable a-flutter shouldnt be epi, its pads...especially when they are already anesthetized. Maybe thats why I'm not a chairman 🙂

 

[aredoubleyou]

What exactly did they do that took 13 hrs and 3L blood loss?
😱

No question they said 10 times during the case....'no one would be toughing this guy out in the community', followed by a couple...'i'd like to see a private guy do this (complex) surgery.'

 

[urge]

Cool case. Sounds like a good one for the oral boards. I wonder what the powers that be would believe to be the right answer.

Irregardless, I'm amazed at how lazy people are. If this guy were supine I bet most of the people would have cardioverted. However, he is prone and flipping is a pain, so that's a good reason to deviate from common practice? 👎


13 hrs... that was no regular lami. Anyway, 2 L EBL in 13 hrs is not exactly a gusher. Don't get me wrong. I'm a believer in 2 IVs. 3 IVs... not so much.

 

[IlDestriero]

We do BIG whack neuromuscular scoliosis cases in less than half the time, with half the blood loss. They usually get a central line though, to monitor CVP. Those kids ain't right, and sometimes you need the CVP to guide management decisions.
They must have done more than a lami.
BTW, our surgeons don't say anything about their private/community colleagues, but one regularly says his big challenging cases are "the worst I've ever seen/done"

 

[dhb]

Irregardless, I'm amazed at how lazy people are. If this guy were supine I bet most of the people would have cardioverted. However, he is prone and flipping is a pain, so that's a good reason to deviate from common practice? 👎

What complication will occur if you cardiovert prone vs supine?

How did you manage the BP after all those beta blockers?

 

[hoyden]

his BP dropped and didn't respond to anything but a whiff of epi.
staff called cards and they said go ahead but control the rate (no **** sherlock).
esmolol drip and a ton of IV push metoprolol eventually converted him and then all was right in the world. BP perfected w return of atrial kick, heart rate normalized. concerning that you guys said 700cc EBL though... i guess the surgeons were bad 'cause we ended up loosing 2L (and that was probably conservative).... and it took 13h.
he was breathing spontaneously at the end of the case... i wanted to pull the tube and see how it went but staff didn't even wanna try, oh well. cards recommened amiodarone if beta blockade didn't work. thoughts?

WOW, you are pretty darn courageous )))

 

[aredoubleyou]

What complication will occur if you cardiovert prone vs supine?

How did you manage the BP after all those beta blockers?

broken neck, brother. Seen a guy jump not insignificantly with barely a twitch on hand held nerve stimulator

 

[Planktonmd]

Your attending called a cardiologist to ask how to manage the patient intraoperatively?

his BP dropped and didn't respond to anything but a whiff of epi.
staff called cards and they said go ahead but control the rate (no **** sherlock).
esmolol drip and a ton of IV push metoprolol eventually converted him and then all was right in the world. BP perfected w return of atrial kick, heart rate normalized. concerning that you guys said 700cc EBL though... i guess the surgeons were bad 'cause we ended up loosing 2L (and that was probably conservative).... and it took 13h.
he was breathing spontaneously at the end of the case... i wanted to pull the tube and see how it went but staff didn't even wanna try, oh well. cards recommened amiodarone if beta blockade didn't work. thoughts?

 

[ProRealDoc]

I assume you mean the ventricular rate is 150? What's the atrial rate? It usually is 300. You could try a carotid massage to slow down the AV conduction which will help identify the flutter waves but most of us wouldn't attempt this in a 74 yo gentleman.
Anyhow, my approach would be just like Plank's, try to treat it medically it BP is somewhat stable and proceed if successful. My only addition to Plank's management is that I like Diltiazem in these situations.

My suspicion is that the anesthetic was too light for pinning as others have said.

I would not cardiovert "this" guy while in pins.

Agree. Been there. I like to give a hit of propofol (50mg) right before pinning.

 

[Arch Guillotti]

Your attending called a cardiologist to ask how to manage the patient intraoperatively?

I am confused about this as well😕

Also - epi for someone that is hemodynamically unstable with a very rapid ventricular rate - can you explain your rationale?

 

[Arch Guillotti]

Agree. Been there. I like to give a hit of propofol (50mg) right before pinning.

I like narcotic - remi, sufenta or alfenta all seem to work very well. I like narcs because I think they provide superior analgesia for the profound stimulus associated with head pinning.

 

[urge]

I like narcotic - remi, sufenta or alfenta all seem to work very well. I like narcs because I think they provide superior analgesia for the profound stimulus associated with head pinning.

Anyone worked with a surgeon that puts local? Pts don't flinch. I don't know why people don't do it more often.

 

[proman]

We should be doing more scalp blocks for cranis.

 

[sevoflurane]

We should be doing more scalp blocks for cranis.

I don't do these anymore, but they definately worked. I also like alfenta.

 

[ProRealDoc]

Anyone worked with a surgeon that puts local? Pts don't flinch. I don't know why people don't do it more often.

I've seen the surgeons put local at the pinning sites after removing the pins. In awake cranis they obviously use local prior to pinning.

 

[IDBasco]

Can one of you folks explain to this to-be 3rd year what pinning is? I can tell its got something to do with attaching something to the skull for immobilization, but other than that I haven't seen it done I looked in my Miller and came up with nothing.

 

[SexPanther]

:

Also - epi for someone that is hemodynamically unstable with a very rapid ventricular rate - can you explain your rationale?

Agreed, to me aflutter w/RVR and hemodynamically unstable/signs of inadequate perfsuion (ST depression etc) = cardioversion.

 

[PL32]

This patient's BP is unstable and he needs electrical cardioversion, no doubt about it. If not unstable then IV treatment makes sense. What nobody has mentioned is that in patients with WPW accessory pathway it is well documented that they can have quite significant ST changes to the point it looks like they're having an STEMI, but it's just a conduction "artifact", not real ischemia. I'm not convinced this patient has underlying CAD that the high myocardial 02 demand has unveiled, I think it's possible this is WPW. In either case cardiology needs to be in the room not on the phone, and a stat EKG should be done as well (for diagnostic and legal reasons). This should all be done supine, obviously. Cardioversion should be done supine as well. It's not a big deal to flip him, this is an emergency scenario and cardioverting prone falls out out what I think most would call "standard" (in a courtroom) should something go wrong. I agree with Plankton that once he's supine and all this is carried out, the odds of me cancelling the case for a day or two (if EP ablation is eventually deemed necessary it may be prudent for that to precede the operation--although I recognize the urgency of the tumor removal).

The other thing I question is the NOT extubating just because it's been a long case with some fluid shifts. What's the point of waiting several hours in the ICU under more positive pressure ventilation? Is this going to help that much or are people just somewhat afraid to extubate? I think barring the suspicion that cardiopulmonary status will worsen in the coming hours (example being a fresh trauma with GSW to abdomen and peritonitis, or somewhat with obvious large pulmonary contusions on admission) if the patient meets EXTUBATION CRITERIA at the end of the case, he can be Safely extubated. He's been spontaneously breathing for at least a half hour towards end of case, there's no evidence of pulmonary edema, massive atelectasis or whatever....so if he meets objective standard criteria why not extubate?
I understand this patient's post surgical airway may be a concern for some, especially as 9pm (13 hr case) rolls around. So in this case I can see the argument, but on an ortho type case equally long with equal blood loss why are people always hesitant to extubate based on a long intraop time?

 

[Bertelman]

Can one of you folks explain to this to-be 3rd year what pinning is? I can tell its got something to do with attaching something to the skull for immobilization, but other than that I haven't seen it done I looked in my Miller and came up with nothing.

These little treats are suspending your head and neck above the ground. They're screwed in until they've engaged your calvaria. Leave a nice third eye on your forehead for a couple days.

 

[amyl]

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[IDBasco]

These little treats are suspending your head and neck above the ground. They're screwed in until they've engaged your calvaria. Leave a nice third eye on your forehead for a couple days.

Well that sounds pleasant.

 

[ProRealDoc]

A lot happened quickly. first, tachy and then SVT w rates to 150s and ST depression and initially stable BP. betablockers. then not stable BP that didn't respond to neo/ephedrine but did to 10mcg of epi. BP stablized but HR remained in 120s and ST depression resolved. yes, staff called cardiology but i think this was to comment (CYA) on ability to proceed with the case. they were picking at this damn thing from his occiput and all the way down to the upper thoracic so i think thats what took a long time.
question for you guys tho: i was running sevo at about 0.6 mac with a remi infusion at 0.1mcg/kg/min when all this happened. after all this he made me stop the remi -- ideas why? also when he first got a little tachy i went up on the remi and staff freaked... any idea why?[/QUOTE


Likely because of the brady/hypotension that can be seen with remi and given your patient's hemodynamics he/she probably felt remi was going to make pt more hypotensive (I know, staff sometimes can be drama kings/queens). Ventricular arrythmias are also listed as one of the severe adverse side effects of remi but I have yet to see one.

 

[Planktonmd]

A lot happened quickly. first, tachy and then SVT w rates to 150s and ST depression and initially stable BP. betablockers. then not stable BP that didn't respond to neo/ephedrine but did to 10mcg of epi. BP stablized but HR remained in 120s and ST depression resolved. yes, staff called cardiology but i think this was to comment (CYA) on ability to proceed with the case. they were picking at this damn thing from his occiput and all the way down to the upper thoracic so i think thats what took a long time.
question for you guys tho: i was running sevo at about 0.6 mac with a remi infusion at 0.1mcg/kg/min when all this happened. after all this he made me stop the remi -- ideas why? also when he first got a little tachy i went up on the remi and staff freaked... any idea why?

Remi causes hypotension but it usually does that through bradycardia which could have been a good thing here, so I am not sure why your attending was freaking out either, maybe he was freaking out for the same reason he needed a cardiologist to tell him how to proceed with this anesthetic?

 

[ProRealDoc]

I wouldn't mind attempting a prone cardioversion

Interesting you mention that. I found this case report from the BJA about a successful prone cardioversion. http://bja.oxfordjournals.org/cgi/reprint/89/5/799

 

[JackADeli]

74 yo male, doctor, VIP, healthy, no cardiac hx, claims decent exercise tolerance... no signif pmhx ...now is coming for total cervical laminectomy in the prone position -- ...prep and drape. no incision yet. all of the sudden pt goes into flutter w HR 150s and has ST depression diffusely ...proceed, cancel, call cards? ...surgeons want to proceed.

...The patient may have occult CAD ...No PMHX? Good exercise tolerance? Doesn't fit...

...Prior to incision? Treat it, wake em up, come back another day...

This case is a good example of prioritization, which can differ between providers.

In my opinion, this patient is unstable. He needs to be flipped back to supine so that life saving procedures can be more easily performed...

In my opinion, surgery needs to wait for another day...

...I understand that some would call canceling this case "obstructionist" behavior by an anesthesiologist. The bottom line is that the first rule of medicine is "do no harm" and this patient has significantly greater potential for harm by cowboying it up and doing this case today than taking a step back and seeing what is going on with his ticker and going to the OR at a later date.

his BP dropped ....we ended up loosing 2L (and that was probably conservative).... and it took 13h...

I can't speak to what anesthesia's management choices and/or teachings are or what neurosurgeries' choices are....

But, as a surgeon, based on the scenario provided, I would have canceled the case. It is a 74yo, male, "claims" decent exercise tolerance, etc... This is an elective case anticipated to be on the longer side in duration in a suboptimal position for emergent interventions. What you have going for you at this initial point is he is not cut open yet. He is having arrythmias and ST depressions. Unless this guy had a cardiac cath recently demonstrating he has no vascular disease, I would be concerned at his ~demand ischemia with a HR of 150 before we even cut skin. Presumably a stress test might have shown this ischemic potential. Cancel, admit, further work-up to assure he can tolerate the procedure. It seems like VIPs get the wrong care too often. IMHO, if such a VIP, you would think of doing everything possible to make it as safe as possible as opposed to cowboying it.

 

[ProRealDoc]

I can't speak to what anesthesia's management choices and/or teachings are or what neurosurgeries' choices are....

But, as a surgeon, based on the scenario provided, I would have canceled the case. It is a 74yo, male, "claims" decent exercise tolerance, etc... This is an elective case anticipated to be on the longer side in duration in a suboptimal position for emergent interventions. What you have going for you at this initial point is he is not cut open yet. He is having arrythmias and ST depressions. Unless this guy had a cardiac cath recently demonstrating he has no vascular disease, I would be concerned at his ~demand ischemia with a HR of 150 before we even cut skin. Presumably a stress test might have shown this ischemic potential. Cancel, admit, further work-up to assure he can tolerate the procedure.

I don't know where you work but where I work surgeons are expected to produce and generate enough billing units to justify their job. If you go around cancelling cases, your APR (annual performance review) will not be satisfactory and you will be shown the door at the end of your one-year contract.

 

[gaspasser2004]

I don't know where you work but where I work surgeons are expected to produce and generate enough billing units to justify their job. If you go around cancelling cases, your APR (annual performance review) will not be satisfactory and you will be shown the door at the end of your one-year contract.

A perioperative death in an elective case where the surgeon decided to proceed despite a cardiac event prior to incision doesn't look good on the APR either...

 

[doctor712]

Remi causes hypotension but it usually does that through bradycardia which could have been a good thing here, so I am not sure why your attending was freaking out either, maybe he was freaking out for the same reason he needed a cardiologist to tell him how to proceed with this anesthetic?

LOL.

 

[ProRealDoc]

A perioperative death in an elective case where the surgeon decided to proceed despite a cardiac event prior to incision doesn't look good on the APR either...

It's a catch 22 for the surgeon. Either way he is screwed. 😀

Best thing to do for the surgeon is to allow the anesthesiologist to take care of the patient and let him decide whether he/she feels it would be safe to proceed.

I've had surgeons tell me that they are really just OR technicians. Everyone else from cards, medicine and anesthesia tells them whether they are allowed to operate on the patient. I agree with that assessment.

 

[aredoubleyou]

A lot happened quickly. first, tachy and then SVT w rates to 150s and ST depression and initially stable BP. betablockers. then not stable BP that didn't respond to neo/ephedrine but did to 10mcg of epi. BP stablized but HR remained in 120s and ST depression resolved. yes, staff called cardiology but i think this was to comment (CYA) on ability to proceed with the case. they were picking at this damn thing from his occiput and all the way down to the upper thoracic so i think thats what took a long time.
question for you guys tho: i was running sevo at about 0.6 mac with a remi infusion at 0.1mcg/kg/min when all this happened. after all this he made me stop the remi -- ideas why? also when he first got a little tachy i went up on the remi and staff freaked... any idea why?

I'm not trying to be critical, but in essence what happened is that you guys gave a standard reflexive treatment for a very specific cause of hypotension. The underlying problem is a-flutter with RVR. Increasing sympathetic tone with ephedrine is moving things in the wrong direction, as for the epi, I would say the same although it may be more debatable. A chairman of anesthesia should not need a cardiologist to decide whether or not to proceed.

 

[ProRealDoc]

I'm not trying to be critical, but in essence what happened is that you guys gave a standard reflexive treatment for a very specific cause of hypotension. The underlying problem is a-flutter with RVR. Increasing sympathetic tone with ephedrine is moving things in the wrong direction, as for the epi, I would say the same although it may be more debatable. A chairman of anesthesia should not need a cardiologist to decide whether or not to proceed.

I think she meant to say it was the neurosurgery chairman not anesthesia. Am I correct?

 

[JackADeli]

I don't know where you work but where I work surgeons are expected to produce and generate enough billing units to justify their job. If you go around cancelling cases, your APR (annual performance review) will not be satisfactory and you will be shown the door at the end of your one-year contract.

A perioperative death in an elective case where the surgeon decided to proceed despite a cardiac event prior to incision doesn't look good on the APR either...

13hr cases in general eat into any APR and RVU volume. That is why in surgery, they will commonly speak to a few trachs and a PEG being worth more then a whipple.

We don't cowboy our way forward into a 13hr elective case in the face of a cardiac event. That would look far worse on an APR. Also, trying to explain that to a jury (or pear review or license board) would look bad. Loosing such a potential case would not only look bad on the current hospital APR but would make it that much more difficult to obtain a future/alternate hospital position. Also, keep in mind that neurosurgeons generally do NOT manage their patients critical care issues beyond ICP. My experience with neurosurgery has been for them to ask general surgeons/trauma surgeons/critical care/anesthesia and/or cardiology if a patient was safe for proceeding. So, I would generally not rely on the neurosurgeon to determine safety in general in order to procede forward.

Finally, neurosurgery is so highly in demand, I don't see any neurosurgeon needing to cowboy through such a scenario for fear of an APR. They can only hurt themselves.