Perioperative Consultation

[militarymd]

This is a case I got involved with a while back.

Old lady...hypertensive, diabetes, diabetic nephropathy (cr 1.8), severe COPD (room air sat about 90%), peripheral vascular disease, and a growing AAA.

Patient went to cath lab 2 days ago and is coming to surgery today....Creatinine on day of surgery is 2.4 mg/dl.

Patient has been seen by every consultation service available....cards, pulm, nephr, endo, and path for unusual antibodies.....everyone gives the thumbs up for the OR for an open repair of the AAA (infra renal).

Everyone saw this lady except me on day of surgery.

What does everyone think about this case? Go or No Go.

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[sevoflurane]

I'm not yet doing pre-ops for anesthesia , so bear with me. There are a couple of issues that come to mind. It depends on the size of the anurysm (rapidly growing vs not, 4cm vs 8 cm), open vs. endovascular, treated vs not treated htn. What is her FEV1, max breathing capacity, etc. Although it is an infrarenal AAA, I'd still like to see her Cr trend down before taking her to the OR, oliguric/anuric? She is old and should be optimized prior to her AAA repair. My feeling w/o looking at the numbers would be to reschedule for a later date. Just for fun... what are her unusual antibodies?

 

[VolatileAgent]

i'd take her.

you have an unstable situation with the AAA. so, you're damned if you do, damned if you don't. she is an asa 4 in my book, but we go. i'd buff her up with fluids in the holding area 2nd to ARF on CRF. she gets (obviously) an art line, and a cvp. intra-op glucose checks. you're running heparin, so your ACT machine is in the room.

point is, you've got enough of a CYA from other disciplines saying she's safe to take, and enough reason not to delay the case, that she goes with the understanding that the benefit-risk ratio is neutral. she's likely to rupture without the surgery, right? then it's ultimately her choice to proceed with the understanding that she may die on the table anyway.

just my $0.02.

 

[VolatileAgent]

unless, of course, you're attempting to suggest that the iv contrast cooked what was remaining of her kidneys during the cath... in which case, you have to really decide if it's worthwhile to take her or delay it. did she get n-acetylcysteine before having the cath?

 

[militarymd]

i'd take her.

you have an unstable situation with the AAA. so, you're damned if you do, damned if you don't. she is an asa 4 in my book, but we go. i'd buff her up with fluids in the holding area 2nd to ARF on CRF. she gets (obviously) an art line, and a cvp. intra-op glucose checks. you're running heparin, so your ACT machine is in the room.

point is, you've got enough of a CYA from other disciplines saying she's safe to take, and enough reason not to delay the case, that she goes with the understanding that the benefit-risk ratio is neutral. she's likely to rupture without the surgery, right? then it's ultimately her choice to proceed with the understanding that she may die on the table anyway.

just my $0.02.

Volatile, my friend, I live in the deep south...."benefit-risk ratio" is a term that many don't understand.

 

[militarymd]

unless, of course, you're attempting to suggest that the iv contrast cooked what was remaining of her kidneys during the cath... in which case, you have to really decide if it's worthwhile to take her or delay it. did she get n-acetylcysteine before having the cath?

yes, and Bicarbonate infusion.

 

[rn29306]

Volatile, my friend, I live in the deep south...."benefit-risk ratio" is a term that many don't understand.

True indeed! I am amazed at the actual understanding (lack thereof) of the public in this area. They probably think you are talking about 'that fancy-azzed stock market thing...."

 

[jetproppilot]

This is a case I got involved with a while back.

Old lady...hypertensive, diabetes, diabetic nephropathy (cr 1.8), severe COPD (room air sat about 90%), peripheral vascular disease, and a growing AAA.

Patient went to cath lab 2 days ago and is coming to surgery today....Creatinine on day of surgery is 2.4 mg/dl.

Patient has been seen by every consultation service available....cards, pulm, nephr, endo, and path for unusual antibodies.....everyone gives the thumbs up for the OR for an open repair of the AAA (infra renal).

Everyone saw this lady except me on day of surgery.

What does everyone think about this case? Go or No Go.

I give her thumbs up too, friend.

Last week while I was on my night week I did a leaking AAA. Mid fifties dude. Had a pretty bad leak since he arrived to us with a pressure of 50 systolic, legs ashen color, still talking but about to bite it....

And he did bite it during the case. Twice. Did CPR both times, gave 31 units PRBCs , many FFPs, cuppla cryos, platelets, etc.

Got him to the ICU peeing with a SBP 90.

He died 48 hours later. For real this time.

So yeah, this lady has risks. But her life is on a timer right now, just like Saw 2.

If she starts leaking flip a coin to guess her morbidity, then subtract about 20% more.

 

[jetproppilot]

This is a case I got involved with a while back.

Old lady...hypertensive, diabetes, diabetic nephropathy (cr 1.8), severe COPD (room air sat about 90%), peripheral vascular disease, and a growing AAA.

Patient went to cath lab 2 days ago and is coming to surgery today....Creatinine on day of surgery is 2.4 mg/dl.

Patient has been seen by every consultation service available....cards, pulm, nephr, endo, and path for unusual antibodies.....everyone gives the thumbs up for the OR for an open repair of the AAA (infra renal).

Everyone saw this lady except me on day of surgery.

What does everyone think about this case? Go or No Go.

WAIT!!!! MIL, WAIT!!! DONT PUT HER TO SLEEP YET!!!!!

I just got it.

Subtle in your post, yes. But I just got it. Yeah, took me a few minutes, but after all I'm a decrepid 41 years old, you know, with an upper plate and one of those hydraulic pumps in my ball sac. ( )


Take her to specials, have the dude do an endovascular AAA stent.

MUCH less invasive.

And she's the perfect lady to benefit from this (potentially) revolutionary vascular-surgery trend.

 

[militarymd]

WAIT!!!! MIL, WAIT!!! DONT PUT HER TO SLEEP YET!!!!!

I just got it.

Subtle in your post, yes. But I just got it. Yeah, took me a few minutes, but after all I'm a decrepid 41 years old, you know, with an upper plate and one of those hydraulic pumps in my ball sac. ( )


Take her to specials, have the dude do an endovascular AAA stent.

MUCH less invasive.

And she's the perfect lady to benefit from this (potentially) revolutionary vascular-surgery trend.

Something about her anatomy, I was told they had to open her up.

 

[jetproppilot]

Something about her anatomy, I was told they had to open her up.

Oh.

That sucks.

So disregard my second post.

And reread the first one.

 

[MDEntropy]

Is the AA growing over a period of many months or a days?

Will the antibodies interfere with your ability to transfuse, needing specially matched blood? What did path say?

Do you expect her renal function to improve (i.e. return to previous baseline, or do you think she is at a new baseline)? If not, and you can give transfuse without issue - go. T-epidural and TEE (or PA if so inclined) also. Otherwise, wait a few days while renal function returns to baseline.

 

[sevoflurane]

AAA <5.5 cm: 1% annual risk of AAA rupture
AAA 5.5 - 7 cm: 6.6% annual risk of AAA rupture
AAA 7 cm: 19% annual risk of AAA rupture

You devide by 365 for per day risk:

5.5cm = .0027 % of rupture per day
7cm = .0520 % of rupture per day

If she looked as if she was leaking I'd take her to the OR, otherwise I'd give her kidneys a couple of days to recover.

 

[jetproppilot]

AAA <5.5 cm: 1% annual risk of AAA rupture
AAA 5.5 - 7 cm: 6.6% annual risk of AAA rupture
AAA 7 cm: 19% annual risk of AAA rupture

You devide by 365 for per day risk:

5.5cm = .0027 % of rupture per day
7cm = .0520 % of rupture per day

If she looked as if she was leaking I'd take her to the OR, otherwise I'd give her kidneys a couple of days to recover.

With all due respect to your knowledgable post, Sevo,

those numbers mean something only if its not your mom with the AAA.

If it was my mom, I'd take her to the OR.

I'd rather tackle the current deleterious physiologic manifestations (if it was my mom) than risk a leak, that is if her aneurysm teetered on the numbers.

Better (in my opinion) to go to the OR knowing one's scenerio than to be presented, abruptly, with a more-often-than-not mortality-inducing scenerio.

With a deft surgeon, of course.

 

[Noyac]

Personally, I am against doing it unless the AAA is growing rapidly. I find that these people just don't really gain any quality of life when they have comorbidities like this. I'd really push to have it done endovascularly and sure, knock off the remaining kidneys if it should be but at least she can live on dialysis and milk the system for $1,000,000 or more a year. But if they say the anatomy is not favorable then you are stuck. You can't really say go in and try it again now can you. Well you can but they won't. So you more than likely will have to do it or did it.

A-line and I would probably swan this one for post-op management as much as intra-op. Oh, and an epidural would work well. If the surgeon is fast enough, I'd do the whole thing under spinal with some duramorph, aline, 2 large bores.

 

[sevoflurane]

I guess what I was getting at was risk induced by renal failure vs. risk induced by waiting a couple of days (AAA rupture). AAA rupture is certainly a lot worse than renal failure, I'd try to avoid that at all cost. If it was my mother or my patient, I'd do whatever is right.
That being said, I still don't know what's right.. waiting a couple of days or taking her to the OR in renal failure.

 

[sevoflurane]

With all due respect to your knowledgable post, Sevo,

those numbers mean something only if its not your mom with the AAA.

If it was my mom, I'd take her to the OR.

I'd rather tackle the current deleterious physiologic manifestations (if it was my mom) than risk a leak, that is if her aneurysm teetered on the numbers.

Better (in my opinion) to go to the OR knowing one's scenerio than to be presented, abruptly, with a more-often-than-not mortality-inducing scenerio.

With a deft surgeon, of course.

I guess what I was getting at was risk induced by renal failure vs. risk induced by waiting a couple of days (AAA rupture). AAA rupture is certainly a lot worse than renal failure, I'd try to avoid that at all cost. If it was my mother or my patient, I'd do whatever is right.
That being said, I still don't know what's right.. waiting a couple of days or taking her to the OR in renal failure

 

[supahfresh]

how big is the aneurysm? and was it rapidly growing?

how bad was her CAD? was she revascularized (not that it changes my management at this point)? just curious.

 

[jetproppilot]

I guess what I was getting at was risk induced by renal failure vs. risk induced by waiting a couple of days (AAA rupture). AAA rupture is certainly a lot worse than renal failure, I'd try to avoid that at all cost. If it was my mother or my patient, I'd do whatever is right.
That being said, I still don't know what's right.. waiting a couple of days or taking her to the OR in renal failure

Assuming deft (ninety-minute) surgeon,

I'll protect her kidneys as well as I pharmacolgically can, and take her to the OR. Propofol/sux/tube/blower.

Then its all up to the surgeon. And if he's good, she'll do good, most likely.

 

[supahfresh]

Assuming deft (ninety-minute) surgeon,

I'll protect her kidneys as well as I pharmacolgically can, and take her to the OR. Propofol/sux/tube/blower.

Then its all up to the surgeon. And if he's good, she'll do good, most likely.

wait, even if he's a hack, isn't she more likely to die from an MI?

 

[jetproppilot]

wait, even if he's a hack, isn't she more likely to die from an MI?

An MI?

Nope.

 

[Idiopathic]

did she get n-acetylcysteine before having the cath?

Yes, to make the physician feel better. I hope that she got bicarb though.

I personally dont think the kidneys are an issue in why you should or should not do this surgery. Other comorbidities may be enough to not do it, but she must either be leaking or growing too fast. Preop rupture or no-op rupture are obviously the worst case scenarios for the patient (maybe not for the docs though?), so these should be avoided.

 

[militarymd]

The AAA has grown over the course of the week....no impending rupture.

Because of her unusual antibodies....20 "special" units of blood has been typed and crossmatched just for her.

Every consultant service + vasc surgeron has talked to her giving her the green light....while sprinkling some dirt on her (to get her used to being 6 feet under)...before bringing her to the OR.

I met her after all the t's have been crossed and I's have been dotted....as she had been cancelled by several other anesthesiologists in the prior days because of cardiac/pulm/ blood bank issues....hence multiple consultation services....and return trip to the cath lab 2 days prior.

I expressed concern with her contrast induced nephropathy ( already got NAC and bicarb) because that is one thing that is not at baseline...but Nephrologist says don't worry.

Against by better judgement, I took her to the OR.

Urine output stopped with the clamp and never restarted.

Dialysis started POD#2.

She died from MODS 2 weeks later.

 

[Noyac]

The AAA has grown over the course of the week....no impending rupture.

Because of her unusual antibodies....20 "special" units of blood has been typed and crossmatched just for her.

Every consultant service + vasc surgeron has talked to her giving her the green light....while sprinkling some dirt on her (to get her used to being 6 feet under)...before bringing her to the OR.

I met her after all the t's have been crossed and I's have been dotted....as she had been cancelled by several other anesthesiologists in the prior days because of cardiac/pulm/ blood bank issues....hence multiple consultation services....and return trip to the cath lab 2 days prior.

I expressed concern with her contrast induced nephropathy ( already got NAC and bicarb) because that is one thing that is not at baseline...but Nephrologist says don't worry.

Against by better judgement, I took her to the OR.

Urine output stopped with the clamp and never restarted.

Dialysis started POD#2.

She died from MODS 2 weeks later.

Sorry to hear that she died but I can't say I'm surprised. These pts don't do well as I stated earlier. With the AAA expanding as fast as this one was, I can't say that you had any options, MIl. Just curious, what lines did you place for the case and for the ICU afterwards. I am not a fan of Swan's as I have said b/4 but this would have been a case for one in my opinion. Mostly for post-op.

 

[militarymd]

She could have waited a few days before going to the OR........Might have made the difference between post op renal failure or not.


Renal failure has an incredibly high attributable mortality.

I put a triple lumen and a 9.5 fr cordis in the right IJ...double stick so they are next to each other....

Large bore IV and a-line....PAC floated per surgeon request, but was not used in the OR....

She followed a perioperative course that I predicted......Waiting for her creatine to stabilize prior to going to the OR may have prevented her anuric renal failure....

We might have had to take her emergently if her AAA starts to bleed, but that outcome would have been no different than gonig with an elevated creatine.......timing of death was just different.