Pre-op Consult

[Noyac]

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83 yo male for a L CEA.

History of PVD, Hypotension down to 70 systolic on occasion, wheelchair bound due to dizzyness secondary to ototoxicity from gentamycin, 2+ pitting edema (suspected from dependent wheelchair position at all times), DDD pacer dependent. Mildly obese with absolutely no exercise tolerance due to dissyness😕.

Surgical history: CABG '89, R CEA '05,

Labs pending
Echo: EF 72%, mild LVH, some diastolic dysfunction. Oh and a endovascular stent in the RV which migrated there during attempted placement in the illiac vein one year ago. 😱

 

[Licoricestick]

Crap.... that's my initial thought!
This is seriously out of my present comfort zone, but a few thoughts...

Meds? Specifically anything that explains his hypotension? It's a big call to write the dizzyness off to gent ototoxicity with a BP like that.

A phone call to those who put the stent it - was it known that the stent migrated to his RV a year ago or is this new information? If known - what is it still doing there?

Quick search brings up:
http://www.springerlink.com/content/j737750230326043/
http://www.springerlink.com/content/5842637517tg0107/
http://www.cardiothoracicsurgery.org/content/3/1/12
http://www.springerlink.com/content/412247727871j717/
Suggesting percutaneous removal would the be first choice and should be expected to have a good chance of success.

Send him back to the guys that put it in...and they can take it out.

 

[Noyac]

Hypotension: Full workup at the Mayo Clinic came to the ototoxicity cause for dizziness and not the hypotension. The low BP's are random and the dizziness is constant.

Stent: Phone call was made. Stent migration was recognized at the time of placement and pt was referred to larger center for retrieval which was unsuccessful. Pt has been asymptomatic during this time.


Abstract of case with pulmonary artery stent migration:
http://ndt.oxfordjournals.org/cgi/content/full/17/3/511

 

[urge]

pent, sux, tube.

 

[maceo]

just make sure the patient realizes that that stent in the rv can migrate anywhere and anything can happen from it including death. i would spell it out to him in those terms and his family. Other than getting a stress test I think you are good to go. its a high risk case and most likely will have complications especially if you cant extubate. careful induction with an a line, titration of agents intra op. keep him on the lighter side and hope for the best at the end of the case. try to extubate him for the neuro exam. If he gets hypertensive throughout the case i would hit him with some lasix which he is undoubtedly on. And of course get someone to turn his pacer to demand mode. with cautery so close to the op site it may cause an issue

 

[Noyac]

just make sure the patient realizes that that stent in the rv can migrate anywhere and anything can happen from it including death. i would spell it out to him in those terms and his family. Other than getting a stress test I think you are good to go. its a high risk case and most likely will have complications especially if you cant extubate. careful induction with an a line, titration of agents intra op. keep him on the lighter side and hope for the best at the end of the case. try to extubate him for the neuro exam. If he gets hypertensive throughout the case i would hit him with some lasix which he is undoubtedly on. And of course get someone to turn his pacer to demand mode. with cautery so close to the op site it may cause an issue

The pacer is on DDD mode.

Would you use TEE? Why or why not?

Does the orientation of the stent matter? For example vertical or horizontal?

 

[Bertelman]

The pacer is on DDD mode.

Would you use TEE? Why or why not?

Does the orientation of the stent matter? For example vertical or horizontal?

I would fear a horizontal lie, as release might lead to outflow obstruction or valve compromise. Vertical lie is still a problem, but the current would hopefully just carry it downstream until it lodged in a PA branch, a la your link.

 

[Planktonmd]

Are you thinking that the episodes of low BP are caused by the stent obstructing the pulmonary artery or the tricuspid randomly?
You would think that after one year the stent is probably stuck to the ventricular wall and not mobile anymore.
If it is confirmed that the stent is still moving inside the ventricle and randomly causing obstruction to blood flow then I think this should be addressed before addressing any other problems because the patient will most likely die from it rather than dying from his carotid stenosis.

 

[Noyac]

Are you thinking that the episodes of low BP are caused by the stent obstructing the pulmonary artery or the tricuspid randomly?
You would think that after one year the stent is probably stuck to the ventricular wall and not mobile anymore.
If it is confirmed that the stent is still moving inside the ventricle and randomly causing obstruction to blood flow then I think this should be addressed before addressing any other problems because the patient will most likely die from it rather than dying from his carotid stenosis.

Very good questions. I believe the stent is fixed to the ventricle since it has been there for a year and since the attempts to remove it were unsuccessul. They were able to reach it but they could not get it to "let go".

The hypotension was reported long b/4 the stent fiasco.

 

[Planktonmd]

Very good questions. I believe the stent is fixed to the ventricle since it has been there for a year and since the attempts to remove it were unsuccessul. They were able to reach it but they could not get it to "let go".

The hypotension was reported long b/4 the stent fiasco.

OK,
Since no one seems to want to participate I will keep going here:
The dizziness that the patient describes could be caused by vertebro-basilar insufficiency in the presence of carotid stenosis which limits the ability of the carotid circulation to compensate for the vertebro-basilar circulation.
The hypotensive episodes might very well be secondary to the vagal response caused by the vertigo.
At this point I don't think there is anything to optimize about this patient and I think the carotid surgery might actually improve his quality of life.
I would proceed without any further workup.
I don't think a TEE would help change any thing I do.
What do you guys think?

 

[jetproppilot]

OK,
Since no one seems to want to participate I will keep going here:
The dizziness that the patient describes could be caused by vertebro-basilar insufficiency in the presence of carotid stenosis which limits the ability of the carotid circulation to compensate for the vertebro-basilar circulation.
The hypotensive episodes might very well be secondary to the vagal response caused by the vertigo.
At this point I don't think there is anything to optimize about this patient and I think the carotid surgery might actually improve his quality of life.
I would proceed without any further workup.
I don't think a TEE would help change any thing I do.
What do you guys think?

I think you're spot on.

 

[jetproppilot]

83 yo male for a L CEA.

History of PVD, Hypotension down to 70 systolic on occasion, wheelchair bound due to dizzyness secondary to ototoxicity from gentamycin, 2+ pitting edema (suspected from dependent wheelchair position at all times), DDD pacer dependent. Mildly obese with absolutely no exercise tolerance due to dissyness😕.

Surgical history: CABG '89, R CEA '05,

Labs pending
Echo: EF 72%, mild LVH, some diastolic dysfunction. Oh and a endovascular stent in the RV which migrated there during attempted placement in the illiac vein one year ago. 😱

Mikey,

whaddya doin' cases like this for up in SKI PARADISE???

knee scopes and ACLs with the occasional hernia/GB/appendix, puh-lease.

 

[Noyac]

Mikey,

whaddya doin' cases like this for up in SKI PARADISE???

knee scopes and ACLs with the occasional hernia/GB/appendix, puh-lease.

Really. I thought I was protected from these types of cases just by leaving Louisiana.
Can I send him to you, Jet?😉

 

[Noyac]

So it seems like most people want to proceed.
I have a topic then that the residents may be more interested in discussing here. This guy has gained about 75lbs in the last 2 years due to his wheelchair being under his arse at all times. He is SOB with any exertion and even with long sentences while lying on the stretcher.

Since he has had a CEA on the right side 3 yrs ago are there any issues I need to be aware of? He most likely has some degree of OSA and COPD.

 

[jetproppilot]

Really. I thought I was protected from these types of cases just by leaving Louisiana.
Can I send him to you, Jet?😉

Mind as well.

Tomorrow I'm doing a CABG on a dude who went to a neurosurgeon for myelopathic symptoms secondary to cervical disc radiculopathy....

Preop clinic, abnormal EKG, cardiology consult, cathed, triple vessel CAD needing CABG before neck surgery!!!

Dudes showing up in a C collar......I'm gonna take a look with the appropriate amount of sux....will resort to FOB if needed.

Trying to say yeah Mikey send the sick dude here since I'm used to the ASA 4s!!!

Someday I'll be placing LMA#4s in ortho cases all day, deferring anyone above an ASA 2 to DA BIG HOUSE....😀

 

[cubs3canes]

So it seems like most people want to proceed.
I have a topic then that the residents may be more interested in discussing here. This guy has gained about 75lbs in the last 2 years due to his wheelchair being under his arse at all times. He is SOB with any exertion and even with long sentences while lying on the stretcher.

Since he has had a CEA on the right side 3 yrs ago are there any issues I need to be aware of? He most likely has some degree of OSA and COPD.

Awake CEA with regional anesthetic. Safe. You can monitor cerebral perfusion with verbalization.

 

[SleepIsGood]

Noy-

here's my take.. I agree with whoever said do GETA. Of course titrates inhalation agents and narcotics appropriately.

I think you need some sort of invasive monitoring. Definitely an A line. Then the question becomes TEE vs PAC. This gentlemen is hypotensive and obviously is a cardiac patient, although by his echo it doesnt seem that bad. But given these low BPs and also the often 'wide' swings in BP you will see in CEA surgery I think it would be prudent to somehow assess preload and afterload and atleast indirectly get an idea of filling pressures.

Given this 'foreign' body in the ventricle, I'm hesitant to put a PAC. I would put a TEE. Atleast this will give me some idea of the hemodynamics of this ill pt. But also, I can 'track' this foreign body (stent) and atleast can have an eye on it during the surgery to mk certain no migration has occurred and it isnt causing an obx for example.

 

[Arch Guillotti]

Awake CEA with regional anesthetic. Safe. You can monitor cerebral perfusion with verbalization.

Ugh, that is one of my most unfavorite things to do. I would do a general.

 

[Arch Guillotti]

Dudes showing up in a C collar......I'm gonna take a look with the appropriate amount of sux....will resort to FOB if needed.
[/B]😀

Interesting approach.

The "ivory tower" types that predominate in training would have a filed day with this approach. For them, AFOI is required for myelopathic symptoms. This is a prudent approach that you can never be faulted for. It can also be a cluster if the blocks aren't completely adequate. I would argue that going to sleep is OK as well too, so long as you are careful about it. I assume this guy is going to have an awake aline because of his CAD, so it is sort of a moot point - but if I were going to put a myelopathic pt. to sleep I would most likely put an aline in ahead of time. I probably wouldn't do a DL. I would use a lightwand or a fiber or something to minimize neck extension.

Perhaps this is overkill and I am sure my practice patterns will evolve as time goes on. It takes some time to shake some of the nonsense that we are taught in residency.

 

[proman]

At this point, best workup for this guy would be a stress (dobutamine) echo. You have no idea of what his coronaries are going to do. The risk of cardiac M&M is mostly related to the operation (and to hemodynamics of anesthetics). No matter how you're going to anesthetize him, he'll have the same operation. I don't know what the implications of a pacer are on a stress echo. Can you just crank the rate up instead of giving a drug? Also, is there any way he could have an endovascular carotid stent instead?

 

[Robert Loblaw]

first post in awhile, a few years, actually--anyway...

cea is intermediate risk surgery with respect to MACE--the stress echo would potentially show RWMA...then what, schedule him for cabg/carotid/excision of foreign device from ventricle procedure (maybe, actually)?

he doesn't need "assessment of pre/after load" either as another poster suggested. there is limited blood loss and crystalloid requirement is minimal. the echo doesn't comment on RV function but i would presume that some component of the peripheral edema is related to RV dysfunction--either primarily through OSA or secondarily through left-sided dysfunction (he does have diastolic failure and is dyspneic). i would clinically assess the volume status on the day of surgery and decide whether he were compensated (i.e. not in active failure, in which case i'd probably cancel) and then keep him at or near this volume status.

major morbidity from CEA is neurologic, without checking the literature, i think the MACE rate is probably less than 3%. the wide swings in blood pressure are usually momentary and can be treated with drugs. this is the kind of case that everyone gets excited about but really only requires a simple plan but executed with extreme vigilance, i.e. you can always put a tee in later...besides, why should our anesthetic increase the likelyhood of the stent migrating out of the RV? a tee probe would only provide me the horror of watching it migrate in real life--if it moved into the PA, i'm sure you would have a non-subtle clue as to its occurence. i'd be more worried about an abdominal surgery in this guy, even a laparoscopic one, especially with respect to pulmonary mechanics.

 

[Planktonmd]

Excellent answer.
If I were an oral examiner this would be the answer I want to hear.

first post in awhile, a few years, actually--anyway...

cea is intermediate risk surgery with respect to MACE--the stress echo would potentially show RWMA...then what, schedule him for cabg/carotid/excision of foreign device from ventricle procedure (maybe, actually)?

he doesn't need "assessment of pre/after load" either as another poster suggested. there is limited blood loss and crystalloid requirement is minimal. the echo doesn't comment on RV function but i would presume that some component of the peripheral edema is related to RV dysfunction--either primarily through OSA or secondarily through left-sided dysfunction (he does have diastolic failure and is dyspneic). i would clinically assess the volume status on the day of surgery and decide whether he were compensated (i.e. not in active failure, in which case i'd probably cancel) and then keep him at or near this volume status.

major morbidity from CEA is neurologic, without checking the literature, i think the MACE rate is probably less than 3%. the wide swings in blood pressure are usually momentary and can be treated with drugs. this is the kind of case that everyone gets excited about but really only requires a simple plan but executed with extreme vigilance, i.e. you can always put a tee in later...besides, why should our anesthetic increase the likelyhood of the stent migrating out of the RV? a tee probe would only provide me the horror of watching it migrate in real life--if it moved into the PA, i'm sure you would have a non-subtle clue as to its occurence. i'd be more worried about an abdominal surgery in this guy, even a laparoscopic one, especially with respect to pulmonary mechanics.

 

[huktonfonix]

At this point, best workup for this guy would be a stress (dobutamine) echo. You have no idea of what his coronaries are going to do. The risk of cardiac M&M is mostly related to the operation (and to hemodynamics of anesthetics). No matter how you're going to anesthetize him, he'll have the same operation. I don't know what the implications of a pacer are on a stress echo. Can you just crank the rate up instead of giving a drug? Also, is there any way he could have an endovascular carotid stent instead?

1. If he shows ischemia are you going to send him for cath/CABG?
2. in regards to the pacer and ischemic testing, you can always just do a perfusion study.

 

[Noyac]

first post in awhile, a few years, actually--anyway...

cea is intermediate risk surgery with respect to MACE--the stress echo would potentially show RWMA...then what, schedule him for cabg/carotid/excision of foreign device from ventricle procedure (maybe, actually)?

he doesn't need "assessment of pre/after load" either as another poster suggested. there is limited blood loss and crystalloid requirement is minimal. the echo doesn't comment on RV function but i would presume that some component of the peripheral edema is related to RV dysfunction--either primarily through OSA or secondarily through left-sided dysfunction (he does have diastolic failure and is dyspneic). i would clinically assess the volume status on the day of surgery and decide whether he were compensated (i.e. not in active failure, in which case i'd probably cancel) and then keep him at or near this volume status.

major morbidity from CEA is neurologic, without checking the literature, i think the MACE rate is probably less than 3%. the wide swings in blood pressure are usually momentary and can be treated with drugs. this is the kind of case that everyone gets excited about but really only requires a simple plan but executed with extreme vigilance, i.e. you can always put a tee in later...besides, why should our anesthetic increase the likelyhood of the stent migrating out of the RV? a tee probe would only provide me the horror of watching it migrate in real life--if it moved into the PA, i'm sure you would have a non-subtle clue as to its occurence. i'd be more worried about an abdominal surgery in this guy, even a laparoscopic one, especially with respect to pulmonary mechanics.

I agree with Plank, excellent answer.

 

[Noyac]

Noy-

here's my take.. I agree with whoever said do GETA. Of course titrates inhalation agents and narcotics appropriately.

I think you need some sort of invasive monitoring. Definitely an A line. Then the question becomes TEE vs PAC. This gentlemen is hypotensive and obviously is a cardiac patient, although by his echo it doesnt seem that bad. But given these low BPs and also the often 'wide' swings in BP you will see in CEA surgery I think it would be prudent to somehow assess preload and afterload and atleast indirectly get an idea of filling pressures.

Given this 'foreign' body in the ventricle, I'm hesitant to put a PAC. I would put a TEE. Atleast this will give me some idea of the hemodynamics of this ill pt. But also, I can 'track' this foreign body (stent) and atleast can have an eye on it during the surgery to mk certain no migration has occurred and it isnt causing an obx for example.

What would you do if it did migrate?

 

[urge]

Excellent answer.
If I were an oral examiner this would be the answer I want to hear.

pent, sux, tube doesn't cut it?

 

[Noyac]

pent, sux, tube doesn't cut it?

That's the standard attending answer. It's fine but.

 

[SleepIsGood]

What would you do if it did migrate?

Depends on what it did when it migrated...

I agree there may be nothing 'drastic' you would do unless a pulmonary artery or other vessel were somehow compromised.

regardless with a TEE you could 'confirm' your dx. If you dont have one in and say for example you have some sort of hemodynamic issues going on and you suspect migration of the FB...now you have to call for a TEE probe and a TEE machine....i dont know about you guys but it's not something we can gt into our rooms in 5 sec.

I think if you visaulize the FB right away you can hve the CT/CV surgeon across the drape do something if he and YOU deemed it necessary.

 

[Noyac]

Depends on what it did when it migrated...

I agree there may be nothing 'drastic' you would do unless a pulmonary artery or other vessel were somehow compromised.

regardless with a TEE you could 'confirm' your dx. If you dont have one in and say for example you have some sort of hemodynamic issues going on and you suspect migration of the FB...now you have to call for a TEE probe and a TEE machine....i dont know about you guys but it's not something we can gt into our rooms in 5 sec.

I think if you visaulize the FB right away you can hve the CT/CV surgeon across the drape do something if he and YOU deemed it necessary.

I agree that you can watch the FB and if hemodynamics start to dwindle you can see the effect of the FB.

I was thinking more along the lines of watching the RV and seeing if a full or empty RV had any effect on the position of the stent with regards to filling or out flow obstruction. I really doubt that after a year the stent would move any but if the pt gets behind on fluid the stent may be in position to cause an obstruction.

BTW I really hope nobody would have put a Swan in this pt. That's a "see you next year" answer on the boards.

 

[aredoubleyou]

BTW I really hope nobody would have put a Swan in this pt. That's a "see you next year" answer on the boards.

Wouldnt even dare to put any sort of central line in - dont want to be blamed for the wire dislodging the stent....my luck I would accomplish what the specialists could not - somehow tear that thing off and have it shoot right for the PA.

 

[SleepIsGood]

Wouldnt even dare to put any sort of central line in - dont want to be blamed for the wire dislodging the stent....my luck I would accomplish what the specialists could not - somehow tear that thing off and have it shoot right for the PA.

agree with this too.

You can't put a PAC, let alone a CVP. That's why I chose TEE. I think you need something to track 'volume' status and hemodynamics. TEE seems the most 'least invasive'.

 

[Noyac]

Does nobody want to tackle what happens to the respiratory drive or dependency after bilateral CEA's?

 

[proman]

1. If he shows ischemia are you going to send him for cath/CABG?

Well, yes. Granted combined CAB/CEA is higher risk than either alone, why should he not get revascularized?

 

[Noyac]

Well, yes. Granted combined CAB/CEA is higher risk than either alone, why should he not get revascularized?

I would rather do the CEA b/4 the CABG.

In the words of one of the very talented CV surgeons that I did the last CABG/CEA of my career with, " Well, that's the last time I try to do anything that stupid again."

I'll do them separate, thank you. Carotid first.

 

[aredoubleyou]

agree with this too.

You can't put a PAC, let alone a CVP. That's why I chose TEE. I think you need something to track 'volume' status and hemodynamics. TEE seems the most 'least invasive'.

Personally not to woried about his volume status, dont expect to much blood loss and not a very deep dissection. If the stent rips off hes dead. Hes a ticking timebomb. The less you do to him the better. That being said... it would be cool to look at with the TEE.

 

[aredoubleyou]

Does nobody want to tackle what happens to the respiratory drive or dependency after bilateral CEA's?

Last CEA was 2005....shouldn't be a problem*. Otherwise supplemental O2 and easy on the narcs.






*famous last words 🙂

 

[Noyac]

Last CEA was 2005....shouldn't be a problem*. Otherwise supplemental O2 and easy on the narcs.
)

Fair enough. I guess it's not a topic many want to discuss. Probably b/c it's well understood by everyone.

 

[Nasty Gas]

I'm glad to hear you guy are actually doing sick patients out in pp. Another ivory-tower myth dispelled! Only a few more dozen to go...

 

[Planktonmd]

I'm glad to hear you guy are actually doing sick patients out in pp. Another ivory-tower myth dispelled! Only a few more dozen to go...

😕
If any one is under the impression that private practice is the place to do simple bread and butter cases, get a fat pay check, and turf the difficult cases to the geniuses at the university hospital then allow me to clarify this misconception:
In private practice not only you do complex cases but you also do them on your own with no backup at all.
The average age of my patients last week was like 85, many of them were above 95 and they all had every disease known to man kind.
They came to us for a variety of procedures from thoracic surgery to ruptured abdominal aortic aneurysms and acute abdominal disasters.
They all got the best anesthetic care they can get anywhere.
If you want easy cases then stay in academia where you are allowed to make a big deal of every minutia and you have residents who will do the dirty work for you and who you can blame if you screw up.

 

[dhb]

Does nobody want to tackle what happens to the respiratory drive or dependency after bilateral CEA's?

I'd like to know, never heard anything about this

 

[adr3000]

here is a link

http://www.springerlink.com/content/q6gw027658036405/fulltext.pdf

 

[aredoubleyou]

😕
If any one is under the impression that private practice is the place to do simple bread and butter cases, get a fat pay check, and turf the difficult cases to the geniuses at the university hospital then allow me to clarify this misconception:
In private practice not only you do complex cases but you also do them on your own with no backup at all.
The average age of my patients last week was like 85, many of them were above 95 and they all had every disease known to man kind.
They came to us for a variety of procedures from thoracic surgery to ruptured abdominal aortic aneurysms and acute abdominal disasters.
They all got the best anesthetic care they can get anywhere.
If you want easy cases then stay in academia where you are allowed to make a big deal of every minutia and you have residents who will do the dirty work for you and who you can blame if you screw up.

👍

 

[dhb]

here is a link

http://www.springerlink.com/content/q6gw027658036405/fulltext.pdf

Thanks for the link. The description of the case report looks more like opiate induced respiratory depression though.

 

[dhb]

Does nobody want to tackle what happens to the respiratory drive or dependency after bilateral CEA's?

Do you have anything substantial? A literature search yielded nothing...

 

[Planktonmd]

Do you have anything substantial? A literature search yielded nothing...

What Noyac is trying to say is that by doing a bilateral CEA you basically eliminate the function of the carotid chemo receptors and in a COPD patient this might mean decreased response to hypoxia since hypercarbia is not an effective stimulus in these patients.
I think that these effects are transitory and could only be relevant in the first few hours.

 

[adr3000]

The link posted describes a case in which both carotid bodies were damaged, due to this patients were very suceptible to resp. depression related to post op narcotics, this is exactly what Noyac would be talking about, I presume.

 

[Noyac]

Yep, I'm basically talking about the pt's impaired response to hypoxia with Bil CEA. Now add this to COPD and someone with an already impaired CO2 response and "theoretically" you have a bad combination.

Has anyone seen this?

 

[Noyac]

I'm glad to hear you guy are actually doing sick patients out in pp. Another ivory-tower myth dispelled! Only a few more dozen to go...

Actually, the misconception that the "Ivory Towers" has about us not doing difficult cases is quite understandable.

You see when we get these types of cases they are handled in the most professional manner, therefore they seem to be routine. We don't mentally masturbate on every case that is not straight forward. We do the workup, get the tests necessary and no more. Then we do the case. You guys in the ivory towers don't hear about them b/c they are not what makes us feel important. Sure we could write some cases up and it would probably help our society but honestly we are either too busy to write them up or we just are not interested b/c we do them without all the hoopla. Hell, some of my partners don't even know about this case.

 

[dhb]

What Noyac is trying to say is that by doing a bilateral CEA you basically eliminate the function of the carotid chemo receptors and in a COPD patient this might mean decreased response to hypoxia since hypercarbia is not an effective stimulus in these patients.

Ok but i don't see any description of this in the literature. I have never done a bilateral CEA myself.

 

[Noyac]

Ok we discussed one of the things I wanted to address in CEA's in general. But there is another issue here. Everyone just assumed that the dizziness due to ototoxicity was real and the fact that he has a DDD pacer in place didn't alert anyone to the other possibility. TO recap, he has episodes of hypotension with dizziness whenever he stands leaving him wheelchair bound. Family does report syncope or near syncope with standing. Anyone have any ideas? Remember, he has had a CEA back in 2005 and these symptoms occurred after that surgery.