prop sux tube

[Psai]

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60 yo female PMH htn, hld, diabetes not on insulin, ESRD on HD, right breast cancer status post lumpectomy and sentinel lymph node biopsy and also treated with chemotherapy and radiation 1 year ago. MP4, thick neck, good mouth opening, edentulous. NPO since midnight. She states that she has been a very difficult stick in the past. Plan is for atrial fibrillation ablation. What's your plan?

 

[Hoya11]

60 yo female PMH htn, hld, diabetes not on insulin, ESRD on HD, right breast cancer status post lumpectomy and sentinel lymph node biopsy and also treated with chemotherapy and radiation 1 year ago. MP4, thick neck, good mouth opening, edentulous. NPO since midnight. She states that she has been a very difficult stick in the past. Plan is for atrial fibrillation ablation. What's your plan?

Get IV access, if not peripheral than an US guided 18g IJ 2 inch catheter from the kit awake, then go to sleep with etom and roc and intubate with GS 4. Then put in a temp probe in the esophagus. Then sit on the stool for 5 hrs...

id be curious to hear others plans, at my place our "surgeons" are horrendously slow and oblivious of anesthesia/complications

 

[urge]

Stick an iv in the fistula. Pent sux tube.

 

[Morzh]

US-guided IV if necessary. Either basilic vein in non-fistula arm, EJ, or awake IJ if truly no options.

Then 120mg propofol, chase with preemptive phenylephrine 100mcg, turn gas on, roc, and tube.

 

[Planktonmd]

Get IV ... put her to sleep!

 

[Psai]

Anyone curious as to why they need an ablation? Any other workup you want?

You can't thread the catheter into the ej and when you ultrasound the ij, you see clots on both sides. Plan?

 

[Planktonmd]

Anyone curious as to why they need an ablation? Any other workup you want?

You can't thread the catheter into the ej and when you ultrasound the ij, you see clots on both sides. Plan?

Femoral?

 

[dannyboy1]

Anyone curious as to why they need an ablation? Any other workup you want?

You can't thread the catheter into the ej and when you ultrasound the ij, you see clots on both sides. Plan?

They don’t tell me how to do anesthesia, I don’t tell them how/when to ablate the heart.
As for the IV access, it’s pretty simple, she needs an IV. If you can’t go IJ maybe the cardiologist can stick the groin awake then you can piggyback on his line or just stick in a femoral TLC and the cardiologist can double stick that vein for his procedure. maybe subclavian is an option, maybe there is something on the foot. bottom line , no iv=no anesthesia. If nothing can be obtained send her to IR for a PICC and do the case a different day....

 

[sethco]

Ummm, isn't the EP going to get Femoral access anyway? Just get them to get access, hook up to the side port and go to sleep. Are they currently in AFib? Do you need to do a TEE prior to procedure?

 

[Psai]

They don’t tell me how to do anesthesia, I don’t tell them how/when to ablate the heart.
As for the IV access, it’s pretty simple, she needs an IV. If you can’t go IJ maybe the cardiologist can stick the groin awake then you can piggyback on his line or just stick in a femoral TLC and the cardiologist can double stick that vein for his procedure. maybe subclavian is an option, maybe there is something on the foot. bottom line , no iv=no anesthesia. If nothing can be obtained send her to IR for a PICC and do the case a different day....

Do you care about the etiology of the a fib? Would you want to see an echo? Anything that would change your management? What if they're in fib now vs sinus rhythm?

 

[MoMoGesiologist]

A bunch of old people get AF. Not sure I would delay for a work up. I'm not going to ask for a TSH preop. Also cardiology is pretty good about working patients up before their procedures. Given pt comorbidities, I would assume some cardiac dysfunction and just titrate meds to effect. I'll look for an echo in the chart (cards probably did it already). If she tells me she has DOE and low functional capacity, I'll assume it's the AF that needs to be treated. However, it could also be CHF, valvular heart disease, even ischemic heart disease. If cards didn't feel the need to work these up... unless if your cards guys just go straight to ablation instead of working up patients or talking to them, I'm gonna assume it's fine to just go ahead.

@Psai youve asked twice now if we want further work up so now I feel like I'm missing something!?

 

[T-burglar]

this person must have had an echo to evaluate her a fib. If not then she needs one before general anesthesia or sedation even though the likelihood that you will do anything different is pretty low. It's always possible, but not that common, that a fib is secondary to a very anesthesia sensitive lesion.

 

[AdmiralChz]

Do you care about the etiology of the a fib?

Been asked twice, and the answer is still no.

If they are doing an ablation, it means they have tried other noninvasive approaches and ruled out reversible causes.

If I’m super worried about her status when I look at her in preop I can do brief transthoracic exam to get me what I need (major valvulopathy, ventricular dysfunction) using one of their many probes in the cath lab.

 

[DM27]

Regarding the echo I agree she should have on in the context of the AF ablation, but I would not require one prior to starting my care unless she was describing a significant functional limitation or worsening DOE/SOB/CP symptomatology with no recent echo.

Access wise I have a low threshold for putting in a 7Fr if access is an issue and if IJs were clotted I would just proceed femorally. I am assuming if she had a port it has since been removed.

 

[anbuitachi]

sounds like a pretty average patient getting a pretty average case. gets IV access. then prop sux tube. ultrasound the arms if you need to. thick neck so probably no good EJ visible. for fat people depending on where their fat is localized, i find blind saphenous to be pretty easy. give some local, and stick the 18 in . its usually untouched. i find it extremely rare that you cant get a saphenous on someone without leg issues

if her mets is garbage then i would want to see an echo. usually cardiology is good with having that stuff

 

[Psai]

Function is fine, 4 mets. Currently in sinus so lack of atrial kick is not an issue. No plan for tee.

She had an echo a week ago with 20% ef, huge left atrium, severe mitral regurg, moderate aortic stenosis. Do you want invasive monitoring?

Patient says she was told not to use the right arm for anything. Would you use it for an iv, a line, blood pressure cuff?

If you use the femoral access, what about iv access for transport and postop?

 

[DM27]

I would avoid using the right arm for access/a-line/NIBP. I would get more info as to the specifics of a R limb precaution (assuming lymph node dissection) and tell her that in the event I could not obtain whatever access I required on the left arm (assuming I am doing an a-line, which I would), then I would need to use the right side. My reasoning, which I would also tell her, is that there is no real evidence that I am aware of for the majority of limb precautions aside from them "seeming like a good idea" and if her scenario is due to the breast cancer history, the theoretical concerns mostly relate to infusions and the venous system and not arterial access for invasive BP monitoring.

 

[pgg]

She had an echo a week ago with 20% ef, huge left atrium, severe mitral regurg, moderate aortic stenosis.

LOL

Why not include that in the initial history? 🙂

What other information do we have but not have?

Yes I'd put in an arterial line. I'd get my own IV access, not piggyback on the cardiologist's. I'd avoid the forbidden arm, mainly to avoid the discussion with her nurses about why it's OK. The way our cardiologists do these, I'd have some anxiety over the way they pace and slam in adenosine 12 or 18 mg at a time. I would ask them to minimize that, not do it at all, give some recovery time in between provocations, etc.

 

[AdmiralChz]

I monitor ABP for all these cases regardless of function (it’s an intracardiac procedure!), if the cardiologist wants to get femoral arterial access for the case then so be it and I can link in. Otherwise, radial.

 

[Southpaw]

Anyone curious as to why they need an ablation? Any other workup you want?

Function is fine, 4 mets. Currently in sinus so lack of atrial kick is not an issue. No plan for tee.

She had an echo a week ago with 20% ef, huge left atrium, severe mitral regurg, moderate aortic stenosis. Do you want invasive monitoring?

Patient says she was told not to use the right arm for anything. Would you use it for an iv, a line, blood pressure cuff?

If you use the femoral access, what about iv access for transport and postop?

That’s not a normal afib ablation and the conversation needs to be had that the cause of her fib is in fact the severe MR/mod AS, where that’s from, and what’s the plan to fix it.

Honestly I don’t see the big deal regarding access. Get some. Move on.

 

[Psai]

I would avoid using the right arm for access/a-line/NIBP. I would get more info as to the specifics of a R limb precaution (assuming lymph node dissection) and tell her that in the event I could not obtain whatever access I required on the left arm (assuming I am doing an a-line, which I would), then I would need to use the right side. My reasoning, which I would also tell her, is that there is no real evidence that I am aware of for the majority of limb precautions aside from them "seeming like a good idea" and if her scenario is due to the breast cancer history, the theoretical concerns mostly relate to infusions and the venous system and not arterial access for invasive BP monitoring.

Yeah we used that arm for iv for induction and an a line but was wondering what other people do. I figured that if it's not a modified radical mastectomy with axillary dissection there should be no issue.

 

[DM27]

Yeah we used that arm for iv for induction and an a line but was wondering what other people do. I figured that if it's not a modified radical mastectomy with axillary dissection there should be no issue.

In general I am aware of no study that indicates a proven risk for vascular access or NIBP placement. Same for PICC lines. I just know of the theories of why it is "best avoided". I had a discussion with a vascular surgeon about placing an IV and a-line on the same side as an AV fistula and they essentially told me it should be avoided, but if you have to use that side it's not going to likely cause any harm. They also said (this may be more of a no-brainer) that if it's a fistula that is no longer used there is no need to even avoid the arm. This was from someone who I felt has good judgement.

 

[T-burglar]

Is this a combined mitraclip tavr a fib ablation ?

Lmao @ not including that he patient has burnt out cardiomyopathy secondary to multivalve disease

 

[sethco]

I don't know of any EP doc that would do an Ablation on this patient. Did you just make this up or did this really happen?

 

[Psai]

I don't know of any EP doc that would do an Ablation on this patient. Did you just make this up or did this really happen?

Based on a real case with a few changes. The mr may have been moderate, I did the case a while ago.

 

[anbuitachi]

Function is fine, 4 mets. Currently in sinus so lack of atrial kick is not an issue. No plan for tee.

She had an echo a week ago with 20% ef, huge left atrium, severe mitral regurg, moderate aortic stenosis. Do you want invasive monitoring?

Patient says she was told not to use the right arm for anything. Would you use it for an iv, a line, blood pressure cuff?

If you use the femoral access, what about iv access for transport and postop?

I would use the R arm. Get IV, Arterial line, put her to sleep. and then get groin port from proceduralist. She had a sentinel node biopsy.. whats the worst that can happen if you use the right arm? i dont think it would explode

 

[Noyac]

Just curious, does she have a pericardial effusion possibly due to breast cancer?

Also, was she on an anticoagulant prior to this procedure? If not, why?

 

[Psai]

Just curious, does she have a pericardial effusion possibly due to breast cancer?

Not noted on echo

 

[Noyac]

Not noted on echo

Does that mean not presently as well?

 

[Psai]

Does that mean not presently as well?

Didn't hear a rub and the echo was not that far from the procedure. I think the cancer was found and treated about five years ago

 

[vector2]

Frank discussion with patient about using right arm for arterial and venous access. If she refuses then have EP get groin access and slave off of them. Then prop, neo, sux, tube. I'm not too terribly concerned about afib vs NSR assuming her AS is on the low-mod vs mod-severe side. Her LA pressures are so high that there likely wouldn't be a huge difference in diastolic filling unless she's RVR with rates over 120.

As an aside, what's the RV fnx and PA pressures on echo?