Per Blocks request

[militarymd]

55 year old lady with no PMHx on no meds coming in for knee arthroscopy. She hurt her knee gardening.

Preop ecg.

Go or no go?

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[Idiopathic]

Stress her.

 

[zippy2u]

Let me have her weight, ht. and her exercise tolerance (i.e., can she walk a mile or mow her yard?). Again, give me lowdown on your surgeon,-- how long does he take, does he shoot LA in knee after case so pts have minimal pain. _Zippy

 

[Willamette]

Man, that EKG comes up small on my screen. I see Left bundle-branch issues, LVH, and crappy R-wave progression. What else?

Also, I think that if you're going to stress her, you need to do it with imaging due to pre-test probabilty and the coin-flip nature of normal stress tests. But what do I know...


Willamette

 

[militarymd]

5'5" 70kg

Power walks with her friends. Detailed ROS is negative although father "died from heart disease in his 60's"

Surgeon is fast...20 minutes tops ....does inject local. His patients typically are on the way home within 90 minutes of leaving the OR.

When shown the ECG, he is concerned, and is OK with whatever anesthesia recommends.

 

[Tenesma]

compare to old EKG

any syncopal events in the past? any possible MI event in the past? any previous cardiac surgery in the past?

if no to all of the above, i would do her, but have an esophageal pacer around or at least some zoll pads just in case...

 

[militarymd]

No old ECG.

Lady says she is healthy as a horse. Only other surgery was a wrist cyst excision a few years back, and she didn't have an ECG performed then.

 

[UTSouthwestern]

Elective case. That's a ****ty ECG for someone who is healthy as a horse. Even the surgeon is hesitant. This one I'd prefer to work up before going through with a surgery especially if there is anything abnormal on her cardiac exam (elevated JVP, apical shift, murmur, rub, gallop, peripheral edema, etc.).

I'd still feel confident about doing the case, but as Tenesma stated, I would have all rescue options available and ready to go, keep her rate controlled with beta blockers, and I'd do it under regional (femoral/triple nerve block).

 

[cchoukal]

I'm no doctor (although I guess starting tomorrow, I will be!) but I see a LBBB and evidence of anteroseptal MI (QS pattern in v1-3), which I'd think would be old because she's not having symptoms; then again, it's discordant with the QS, so this all could be the result of the LBBB... You could wonder if she'd had an old MI (are those big Q's in III?), but I don't think an inferior MI would cause a LBBB. Anyway, in my uninformed opinion, I'd agree with the suggestion to stress and image her. Either a dobutamine echo or one of those fancy nuclear studies...

 

[Willamette]

What is it that you guys SEE in the EKG that has you so fired up?


Willamette

 

[proman]

Can't really see the EKG well but there might be a 1st degree AVB and peaked T waves. What's her potassium?

 

[needadvice]

i have often wondered what added information stress tests give us particularly in this setting. Assume she has coronary artery disease and a bad heart. keep her perfusion up and heart rate down. as you know the benefits of revascularization in this setting are dubious.

 

[mdmccallum]

Can't see to well either but I don't see peaked T waves (looks like sinus to me). If she was gardening and after a thorough interview, she doesn't have any significant s/s of CHF, SOB, DOE, CP,etc. etc. then I'd do her. Preferably with a FNB. I'd also walk down the hall to the Cards dept. and show the ECG to them. While I can read one, they still are better than I am. This way they are familiar with the pt. and I can get her a visit after the surgery.

 

[Idiopathic]

Definite LBB and I would agree with LVH. I dont see any evidence of previous MI, AV block or anything else. If the patient is copacetic, I would stress echo her on a treadmill. If nothing, proceed. ****, she could have three vessel disease, a bad node and a major left bundle. Do we really know how those patients will respond until it happens? Just think of how many nonspecific EKG's with no chest pain have severe ischemic CAD.

Although this EKG is surprising, given her apparent health, lack of comorbidities, et al. Probably wouldnt be an issue. But if this is really a CYA case...

Just my $0.02

 

[militarymd]

Can't really see the EKG well but there might be a 1st degree AVB and peaked T waves. What's her potassium?

don't remember exact number, but normal.

 

[militarymd]

The ECG was read as NSR with LBBB.

My assessment of this patient is that she has one intermediate clinical predictor with ability to do more than 4 METS activity and undergoing low risk surgery......she went to the OR...got 200 mg of propofol and a size 4 LMA...with a referral to a cardiologist for followup and workup for her asymptomatic LBBB.

 

[jetproppilot]

The ECG was read as NSR with LBBB.

My assessment of this patient is that she has one intermediate clinical predictor with ability to do more than 4 METS activity and undergoing low risk surgery......she went to the OR...got 200 mg of propofol and a size 4 LMA...with a referral to a cardiologist for followup and workup for her asymptomatic LBBB.

Exactly what I would've done. You're a stud. Fire your "road blocking" colleagues, bring in some dudes just like you, and your new group, Military Anesthesia LLC will take over all of Alabama.

 

[AJM]

Out of curiosity, do you guys not use the ACC guidelines for pre-op cardiac risk evaluation? Militarymd was the first person on this thread to mention them. As IM folks, we are consulted all the time for cardiac eval on cases like this, and all we have to do is just refer to the simple flowchart the ACC published.

I would have done exactly what militarymd did -- there is no need for further pre-op cardiac testing in this patient. If anything, militarymd might have been a little on the conservative side, giving the patient one intermediate clinical predictor. I take it that you are saying that she has had a prior MI based on the LBBB (which is what I would say, as well). Some physicians would have interpreted this simply as an abnormal EKG, and therefore given her only a minor clinical predictor. It wouldn't change the overall decision either way as this is a low risk procedure in a patient with good functional status.

 

[VentdependenT]

Out of curiosity, do you guys not use the ACC guidelines for pre-op cardiac risk evaluation? Militarymd was the first person on this thread to mention them. As IM folks, we are consulted all the time for cardiac eval on cases like this, and all we have to do is just refer to the simple flowchart the ACC published.

I would have done exactly what militarymd did -- there is no need for further pre-op cardiac testing in this patient. If anything, militarymd might have been a little on the conservative side, giving the patient one intermediate clinical predictor. I take it that you are saying that she has had a prior MI based on the LBBB (which is what I would say, as well). Some physicians would have interpreted this simply as an abnormal EKG, and therefore given her only a minor clinical predictor. It wouldn't change the overall decision either way as this is a low risk procedure in a patient with good functional status.

Yarr, the flowchart is where to start. With greater than 4 mets and only an abnormal ekg without any symptomatic or other objective evidence of cardiac dysfunction flow chart says go to OR.

Checked it in Faust.

Goodstuff militarymd, keep it comming!

 

[militarymd]

If anything, militarymd might have been a little on the conservative side, giving the patient one intermediate clinical predictor. I take it that you are saying that she has had a prior MI based on the LBBB (which is what I would say, as well). Some physicians would have interpreted this simply as an abnormal EKG, and therefore given her only a minor clinical predictor. It wouldn't change the overall decision either way as this is a low risk procedure in a patient with good functional status.

I presented it as worse case scenario....ie prior MI as cause of her LBBB.....but clearly still a go for the OR if you go by ACC guidelines.

 

[beezar]

So i had one pt in his 60's with, completely inactive, HTN, uncontrolled diabetes, going for a major thoracic spine surgery, anterior approach. Never had stress test And the medicine docs in their preop eval advised to proceed with surgery after pt was placed on beta-blockers.

WTF i said, so called the medicine resident and said that I didn't understand how they came up with their recs (a civil conversation). Next thing I know, their attending pages me and chews me out about how she's had several years of experience with preop eval, has taught preop eval at some big name medical school, and that I didn't know what I was talking about. She then proceeds to quote me soem paper from the Internal Medicine clinics of north america where she based her recs on.

Well, the paper she quoted (which came out after ACC/AHA guidelines) does recommend proceeding with surgery, with some decent evidence. Now what would you do?

 

[militarymd]

Who are you asking?

 

[needadvice]

assuming you didn't have deal with any legal cya issues, how do stress test results change your management really? for a moment, i ask you to forget about the ACC guidelines, which will very likely be revised to look very different in the next year.

we know that there is no good data to support angioplasty/stent/CABG to reduce risk in patients undergoing surgery. so, if a patient has risk factors for CAD or has established CAD, why not treat them as such and forget about risk stratification. assume, they are all high risk. we're supposed to be maintaining adequate perfusion for everyone regardless if they have CAD or not. if they have risk factors for CAD beta block them.

i have begun to think that stress tests are more useful in identifying who may have CAD so that they can be beta blocked rather than stratifying them for any future intervention.

 

[militarymd]

assuming you didn't have deal with any legal cya issues, how do stress test results change your management really? for a moment, i ask you to forget about the ACC guidelines, which will very likely be revised to look very different in the next year.

we know that there is no good data to support angioplasty/stent/CABG to reduce risk in patients undergoing surgery. so, if a patient has risk factors for CAD or has established CAD, why not treat them as such and forget about risk stratification. assume, they are all high risk. we're supposed to be maintaining adequate perfusion for everyone regardless if they have CAD or not. if they have risk factors for CAD beta block them.

i have begun to think that stress tests are more useful in identifying who may have CAD so that they can be beta blocked rather than stratifying them for any future intervention.

What you're describing is a philosophical change in preop evaluation that has developed in the last few years. An approach which I have adopted when Polderman published his data in NEJM in 1999?

The arguement for testing is that this allows you to identify patients who will benefit in the long term from revascularization.....ie >6 months...the benefit is not for the perioperative period.

 

[jetproppilot]

What you're describing is a philosophical change in preop evaluation that has developed in the last few years. An approach which I have adopted when Polderman published his data in NEJM in 1999?

The arguement for testing is that this allows you to identify patients who will benefit in the long term from revascularization.....ie >6 months...the benefit is not for the perioperative period.

This makes sense anecdotally as well- I always found it funny that we could put patients to sleep with tight triple vessel stenoses for their CABGs, but consider cancelling some other case for the same patient. How often does a CABG patient give you arrythmia/ST segment/hemodynamic problems pre-pump? Hardly ever.

 

[UTSouthwestern]

This makes sense anecdotally as well- I always found it funny that we could put patients to sleep with tight triple vessel stenoses for their CABGs, but consider cancelling some other case for the same patient. How often does a CABG patient give you arrythmia/ST segment/hemodynamic problems pre-pump? Hardly ever.

Speak for yourself. I have seen more than a dozen the past six months that came in with L main or equivalent disease that needed IABP placement just to stabilize them enough to transport to the OR. Had two that had to crash onto bypass with EMD which presented while we were just preoxygenating!

 

[jetproppilot]

Speak for yourself. I have seen more than a dozen the past six months that came in with L main or equivalent disease that needed IABP placement just to stabilize them enough to transport to the OR. Had two that had to crash onto bypass with EMD which presented while we were just preoxygenating!

Geez- either I'm very lucky or you are very unlucky. In my previous gig we did over 400 hearts a year and I can count on one hand the times we had to crash on bypass (in 7.5 years).

Guess my anesthesia is better, UT. Are you sure you pre-oxygenated correctly?

Of course you know I'm joking.

 

[UTSouthwestern]

Geez- either I'm very lucky or you are very unlucky. In my previous gig we did over 400 hearts a year and I can count on one hand the times we had to crash on bypass (in 7.5 years).

Guess my anesthesia is better, UT. Are you sure you pre-oxygenated correctly?

Of course you know I'm joking.

Hey, what are you implying?

Our primary cardiac centers are very high risk (St. Paul, Dallas VA) and take a lot of end stage cases. It's great experience, though it can turn your hair white. I am just happy to see this in residency, and I hope not to see it in private practice.

 

[jetproppilot]

Speak for yourself. I have seen more than a dozen the past six months that came in with L main or equivalent disease that needed IABP placement just to stabilize them enough to transport to the OR. Had two that had to crash onto bypass with EMD which presented while we were just preoxygenating!

After I posted my reply, one of those times we had to crash on bypass came to mind. Most amazing case I've ever seen. Mid 40s male, sheriff in a neighboring town, heavy smoker, comes to our ER with an acute MI, rushed to cath lab, codes during intervention, worked on for over 30 minutes to no avail, cardiologists decide to call the heart surgeon.
Dude comes through the OR doors, RN straddling him doin CPR, somebody is bagging him (already tubed). He was blue like a smurf doll, no exaggeration.Got him on the table, surgeon has him on the pump likkity split, somehow we got the A line, etc etc.
Surgeon does his grafts, time to come off pump. Paced rhythm, unable to get his BP above 40-50 systolic, despite using all the epi in the OR, pushing more epi than I ever have, tried every other pharmacologic agent applicable. BP still 50, heart looks like crap. Balloon pump helps a little but not much. I told the surgeon if the dude lived I was gonna start going to church. We limp off bypass. 90 minutes later I'm in the doctors lounge, T. Mack the heart surgeon comes in and says "Dude, what mass are you gonna go to?"
I said "Whaddya mean?"
"Patient's pressure is now in the seventies, he's peeing, and asking for a notepad so he can write something."
Patient left the hospital 3 weeks later and is still alive. And oh, I started going to church again. Definitely divine intervention on that case.

 

[UTSouthwestern]

Just an example of why anesthesiologists need to get better reimbursement for doing these types of cases. Had a similar case to yours, except my guy's heart was basically one giant scar. Had to go back on pump and put a VAD in. Month later, he got a transplant and walked out of the hospital a month after that. Imagine the cost of being in a hospital for two months, having two major cardiac surgeries and 3 smaller surgeries, and spending the bulk of that time in the ICU. Could pay the annual budget of a small city.

 

[Tenesma]

TI - Bundle-branch block as a risk factor in noncardiac surgery.
AU - Dorman T; Breslow MJ; Pronovost PJ; Rock P; Rosenfeld BA
SO - Arch Intern Med 2000 Apr 24;160(8):1149-52.

BACKGROUND: Despite extensive data examining perioperative risk in patients with coronary artery disease, little attention has been devoted to the implications of conduction system abnormalities. OBJECTIVE: To define the clinical significance of bundle-branch block (BBB) as a perioperative risk factor. METHODS: Retrospective, cohort-controlled study of all noncardiac, nonophthalmologic, adult patients with BBB seen in our preoperative evaluation center. Medical charts were reviewed for data regarding cardiovascular disease, surgical procedure, type of anesthesia, intravascular monitoring, and perioperative complications. RESULTS: Bundle-branch block was present in 455 patients. Right BBB (RBBB) was more common than left BBB (LBBB) (73.8% vs 26.2%). Three patients with LBBB and 1 patient with RBBB died; 1 patient had a supraventricular tachyarrhythmia. Three of the 4 deaths were sepsis related. There were 2 (0.4%) deaths in the control group. There was no difference in mortality between BBB and control groups (P = .32). Subgroup analysis suggested an increased risk for death in patients with LBBB vs controls (P = .06; odds ratio, 6.0; 95% confidence interval, 1.2-100.0) and vs RBBB (P = .06; odds ratio, 8.7; 95% confidence interval, 1.2-100.0). CONCLUSIONS: The presence of BBB is not associated with a high incidence of postoperative cardiac complications. Perioperative mortality is not increased in patients with RBBB and not directly attributable to cardiac complications in patients with LBBB. These data suggest that the presence of BBB does not significantly increase the likelihood of cardiac complications following surgery, but that patients with LBBB may not tolerate the stress of perioperative noncardiac complications.

 

[Tenesma]

takling about VADs.... i hate them with a vengeance.... those damn beasts allow heart surgeons to never declare anybody in the OR....

There is nothing worse than a guy who dies on the cath table being brought down to the OR... blue like a smurf... getting a 5 vessel CABG... unable to come off pump... go back on pump and place an LVAD... still can't come off pump... go back on pump and place and RVAD.... comes off pump with Levo at 1000mcg/min, Epi at 200mcg/min, Neo at 1500 mcg/min (yeah two different neo bags) etc.... just so that the family can wave goodbye in the SICU after 16 hours of slave work in the OR and 170 units of blood.... what a waste of resources....

 

[UTSouthwestern]

takling about VADs.... i hate them with a vengeance.... those damn beasts allow heart surgeons to never declare anybody in the OR....

There is nothing worse than a guy who dies on the cath table being brought down to the OR... blue like a smurf... getting a 5 vessel CABG... unable to come off pump... go back on pump and place an LVAD... still can't come off pump... go back on pump and place and RVAD.... comes off pump with Levo at 1000mcg/min, Epi at 200mcg/min, Neo at 1500 mcg/min (yeah two different neo bags) etc.... just so that the family can wave goodbye in the SICU after 16 hours of slave work in the OR and 170 units of blood.... what a waste of resources....

It is a pretty big waste of resources. My case of survival was definitely the exception, not the rule. While giving the family an opportunity to say goodbye is one factor, the factor that drives our surgeons to do that is to prevent raising the intraoperative mortality rate.

 

[militarymd]

Speak for yourself. I have seen more than a dozen the past six months that came in with L main or equivalent disease that needed IABP placement just to stabilize them enough to transport to the OR. Had two that had to crash onto bypass with EMD which presented while we were just preoxygenating!

UT,

You've presented a different clinical situation than what we were discussing. What you describe is unstable coronary syndromes...either with thrombus formation or disease progression to the point where it is not compatible with further life.

The situation that jet and others were talking about was patients with moderate to severe but stable disease.

Patient's with stable disease rarely develop ischemia with GA....unless you cause hypotension.

 

[militarymd]

takling about VADs.... i hate them with a vengeance.... those damn beasts allow heart surgeons to never declare anybody in the OR....

There is nothing worse than a guy who dies on the cath table being brought down to the OR... blue like a smurf... getting a 5 vessel CABG... unable to come off pump... go back on pump and place an LVAD... still can't come off pump... go back on pump and place and RVAD.... comes off pump with Levo at 1000mcg/min, Epi at 200mcg/min, Neo at 1500 mcg/min (yeah two different neo bags) etc.... just so that the family can wave goodbye in the SICU after 16 hours of slave work in the OR and 170 units of blood.... what a waste of resources....

don't miss doing those.

 

[UTSouthwestern]

UT,

You've presented a different clinical situation than what we were discussing. What you describe is unstable coronary syndromes...either with thrombus formation or disease progression to the point where it is not compatible with further life.

The situation that jet and others were talking about was patients with moderate to severe but stable disease.

Patient's with stable disease rarely develop ischemia with GA....unless you cause hypotension.

We, Jet and I, were discussing patients with severe CAD going to surgery and having signs/symptoms of ischemic changes at some point during the anesthetic (pre-pump or otherwise).

Half of the patients I was talking about were severe diabetics with no subjective symptoms reported.

I really like this color function.

 

[jetproppilot]

We, Jet and I, were discussing patients with severe CADgoing to surgery and having signs/symptoms of ischemic changes at some point during the anesthetic (pre-pump or otherwise).

Half of the patients I was talking about were severe diabetics with no subjective symptoms reported.

I really like this color function.

UH OH! UT has a new toy.... virtual crayons!!!!

 

[VentdependenT]

I've never heard of a VAD before. Now I know. Subconsciously I always wanted a little plastic heart in my abdomen hooked up to a sweet fanny pack. Perhaps its better than dying....but I'd rather not find out the hard way.

 

[UTSouthwestern]

I've never heard of a VAD before. Now I know. Subconsciously I always wanted a little plastic heart in my abdomen hooked up to a sweet fanny pack. Perhaps its better than dying....but I'd rather not find out the hard way.

Now let's be honest: It's a bionic heart. It's better than your original ticker. I've already convinced one CA-1 to give up his own useless heart in exchange for one of these new fangled fancy hearts.

I'll just put your name down on the heart DONOR's list Vent.

 

[VentdependenT]

Sign me up. This thing's overdue for an MI or lethal arrythmia thanks to the rapid infusion of Red Bull or Thermoblastamagigger GNC drink I put down every morning.

 

[Alpha_Male]

Sign me up. This thing's overdue for an MI or lethal arrythmia thanks to the rapid infusion of Red Bull or Thermoblastamagigger GNC drink I put down every morning.

Better stock up.........you'll need em' for Dr. Rothenberg.....

 

[VentdependenT]

Better stock up.........you'll need em' for Dr. Rothenberg.....

Thats why I invested in the new Red Bull enema. Its fantastic!

 

[jetproppilot]

55 year old lady with no PMHx on no meds coming in for knee arthroscopy. She hurt her knee gardening.

Preop ecg.

Go or no go?

.