pulmonary HTN case

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amyl

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thought this might be a good one for the residents to discuss and hear attendings chime in. no specifics so no hippa violation. old person with severe pulmonary HTN severe TR severe MR. RVSP 70 plus. copd and osa but noncompliant with bipap and with 3L o2 qhs. is totally incontinent with recurrent infections so cards cleared her bc her surgery was "emergent." poor exercise tolerance but stress test was ok, rv/lv function ok, pt has refused cath. booked for 6-7 hours worth of uro-gyn repair. thoughts/plan?
 
amyl said:
thought this might be a good one for the residents to discuss and hear attendings chime in. no specifics so no hippa violation. old person with severe pulmonary HTN severe TR severe MR. RVSP 70 plus. copd and osa but noncompliant with bipap and with 3L o2 qhs. is totally incontinent with recurrent infections so cards cleared her bc her surgery was "emergent." poor exercise tolerance but stress test was ok, rv/lv function ok, pt has refused cath. booked for 6-7 hours worth of uro-gyn repair. thoughts/plan?
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Don't know of any 6-7 hr uro-gyn reconstructions that are "emergent," sounds more like "semi-urgent" at best.

At any rate, pre-induction a-line, pre-induction epidural, pre-induction long conversation. GA w/ETT for controlled ventilation. Minimal narcotic, primarily use epidural if the tube is ever coming out, plus the afterload reduction will only help her regurgitant lesions. TEE available but not in unless struggling. CVL for high likelihood of needing epi or other pressors, though if I could talk someone into doing a PICC beforehand that would kill 2 birds with one stone, because she's going to be in the hospital for awhile needing access. Maybe even 3 birds if the PICC team goes heavy on the sedation...

After that it's just like the cardiologists think it is: avoid hypotension, hypercarbia, yadda yadda.
 
I'm thinking flotrac, epidural, central line, and drips conducive to keeping pulmonary pressures down and flow going in the right direction. No sedation for any pre-induction lines. I put the TEE down immediately after we go to sleep because I am scared of crap like this. I use Ketamine at low doses and the epidural intra-op. Maybe remifentanil. No long acting narcotics whatsoever. And if there's any chance at all that I might have trouble ventilating or intubating, I think seriously about doing the tube awake. I would like to avoid excessive hypercarbia at all costs. Just brainstorming here.
 
Elective surgery. Cancel. Get valves fixed first. If patient wants to kill herself, point to closest tall bridge.

Btw, either the stress test was submaximal, which is not a negative stress test, or the patient does not have poor cardiovascular exercise tolerance, in which case the patient should get surgery after optimization. Also, unless they measured the regurgitant fraction/volume or forward cardiac output, the ventricular function might be overestimated on both sides.

If not a candidate for heart surgery, staged repairs (2-3 hours at a time, with minimal blood loss and conservative fluid management) under epidural and light MAC, after having optimized pulmonary hypertension/OSA/cardiac status for a couple of months. If patient refuses, the incontinence is definitely not that bad for her.

If epidural anesthesia impossible, GA preferably with SV and/or LMA, with available pulmonary vasodilators, pressors, TEE. Postop careful narcotics, toradol, Tylenol etc. , NIPPV. Possible ETT, possible ICU stay.

This is not emergent surgery. The fact that the patient refuses to get optimized for it does not mean that I have to do the surgery just because "this is her baseline". This might be a restaurant, but we only serve food from my menu, and only for properly dressed clients. For example, the patient does not get to refuse diagnostic cath if that will change/improve the management of her severe pulmonary hypertension.
 
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pent sux tube
 
I'm actually thinking rvsp/pasp of 70 is not that bad. We do less extensive /more urgent procedures eg hip orif on patients like this all the time and they do fine. Probably some Preop diuresis if they can handle it, ga/ett, Aline, cvp, go. MR is pretty well tolerated and almost always improves under GA.
 
nimbus said:
I'm actually thinking rvsp/pasp of 70 is not that bad. We do less extensive /more urgent procedures eg hip orif on patients like this all the time and they do fine. Probably some Preop diuresis if they can handle it, ga/ett, Aline, cvp, go. MR is pretty well tolerated and almost always improves under GA.
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What would you think of an RVSP of 45 on a 90 year old? I've seen this a few times on elderly patients.

I assume if you would do an elective case with RVSP of 70 then under 50 isn't a big deal? At what number RVSP would you consider TIVA or SAB where the CO2 is allowed to rise?
 
GETA + A line + Epidural (but don't go crazy with dosing the epidural because you might need that preload if your RV decides to fail).
Conservative fluid management + the usual everyday pressors.
Have a low threshold to keeping her intubated a day or two.
 
As others have said, this is not emergent and she should have the Cath. My concern is she has some left sided dz, becomes ischemic with surgical stress, left heart can't keep up and it's a death spiral.

Also I would want to clarify what they are going to do. Is this an anterior/posterior repair? Bladder sling? Or are we talking intraabdominal and perineal repairs?

The other factor here is will she tolerate positioning? Is she obese? She may not tolerate lithotomy with trendelenberg and the surgery may not be possible with her in this position.

I would do Aline, epidural with MAC if procedure allows, if not possible then GETA. If GA then TEE would be helpful. Central access is a must for vasoactive meds. Explain to her that she may not get extubated, and I mean ever, and that would mean trach. These patients are very tough to wean sometimes.
 
amyl said:
thought this might be a good one for the residents to discuss and hear attendings chime in. no specifics so no hippa violation. old person with severe pulmonary HTN severe TR severe MR. RVSP 70 plus. copd and osa but noncompliant with bipap and with 3L o2 qhs. is totally incontinent with recurrent infections so cards cleared her bc her surgery was "emergent." poor exercise tolerance but stress test was ok, rv/lv function ok, pt has refused cath. booked for 6-7 hours worth of uro-gyn repair. thoughts/plan?
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I think that this is the most important point here. This is a patient with elevated PA pressures but normal RV function. The thing that makes these patients high risk is not the pulmonary hypertension, its the RV failure that accompanies it. Her RVSP could be 90 but with a normal RV, she's still probably going to do ok. It would seem that her biggest risk is postoperative respiratory failure from her likely severe COPD. Regurgitant lesions, unless they're acute, don't commonly cause intraoperative decompensation, and as a poster said above, the afterload reduction would likely be helpful. I would place an arterial line, but I don't think that this is a patient who needs a central line, nitric, vasopressors, etc. Depending on the severity of the patient's COPD, I would consider doing this with a CSE, but realistically, she's probably going to need a GA for this "7 hour" case.

Also. The "emergent" pelvic reconstruction is bogus.
 
It is absurd to a) call this case emergent because of recurrent UTIs and b) do this elective case before fixing the valves.
Caveat - if she can't ever clear her UTI's I'm not sure how many CT surgeons would put 2 prosthetics in her, and it would be good to know if she's even operable from a cardiac surgical risk standpoint.

Why does she have severe MR? If it's primary - clear indication to fix valve(s) first. If it's secondary, what's causing it? Ischemia? NICCM? Still reasonable to fix the valves first. Why did she refuse the cath?

Also - "normal" ventricular function can be read in pts with severe valvular lesions who don't actually have normal function. Regurgitant fraction is typically >50%, and that pop-off can make the ventricle (LV in MR, and RV in TR) look better than it really is. Left heart failure bad enough to cause PHTN and severe TR? I doubt the RV is truly normal regardless of what the echo report reads.

You can probably get her out of the OR just fine, but that doesn't mean you should do the case.
 
6-7 Hours of a uro-gyn donkey show (which you know will go 8-10) for "emergent" 😕 incontinence in a pt with a dog**** lungs and a dog**** heart?? Ya OK. You need to put your arm around the uro-gynecologists shoulder and say "Here, walk with me, talk with me." Head down the hall and as soon as you're around the corner :wtf::slap::nono:. "We're gonna do a suprapubic cath and all get on with our lives got it. Good. Thanks. See you in the OR"
 
I agree her LV/RV function is probably "normal" due to her regurgitant lesions. If you reported a suboptimal EF you would be asking for serious trouble w/o fixing the valve first. What type of stress test did she get? It's not an emergent case.....
 
1) Need to know what the systemic pressure was at the time of the RVSP 70 to interpret its significance.

2) Pulmonary venous hypertension is a different animal than primary pulmonary arterial hypertension.
 
BLADEMDA said:
What would you think of an RVSP of 45 on a 90 year old? I've seen this a few times on elderly patients.

I assume if you would do an elective case with RVSP of 70 then under 50 isn't a big deal? At what number RVSP would you consider TIVA or SAB where the CO2 is allowed to rise?
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Good question. I tend to think of it more in relation to systemic pressures than as an absolute. >1/2 systemic and I get nervous, <1/3 systemic and I'm much less nervous. In that middle ground, it depends on the tiebreakers: what kind of case, what kind of surgeon, how long, how stimulating, how bad do I want to avoid an ETT, etc. Also a biggie: who is in the room with the pt. Can you trust the resident/CRNA to actually do a MAC or will they end up on 150 of prop as soon as you leave the room?

I'm not a conservative person, typically, but I am with pulmonary HTN. Heard too many stories of people getting 0.5 of midaz and 25 of fentanyl for a block for their AVF and then coding.
 
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As everyone keeps saying here, this is obviously not emergent. She has had incontinence for a while. The problem is that all the other physicians (cardiologist, surgeon, pulmonologist) and the patient will always take the same side and they will deem it or say that it is "necessary" or "emergent" due to chronic infections that could potentially be a threat to her life even though it is not right now. How does everyone here handle a case where YOU (as the anesthesiologist) do not have much say other than canceling the case and pissing everyone off (even though your reasons are that you are basically not comfortable with killing or putting this pt in serious danger) ? And yes I get that the pt understands the "risks" and still wants to proceed (and it should be their decision) even after you tell them they are at very high risk and death. However, I've noticed that if I tell them they may die on the table, they still want to proceed because the surgeon told them they will be fine. After I speak with the surgeon and convince them and he/she comes and says the exact same thing to the pt, then they don't want to have surgery anymore. What we say about risks to the pt is taken with a grain of salt while what the surgeon says is the holy grail (and we all know those surgeons who think everything will always be fine). It eventually becomes a moral/ethical issue for us at some point in time so I was curious as to how its handled by most here. BTW, this applies to completely elective cases as well.
 
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PainDrain said:
As others have said, this is not emergent and she should have the Cath. My concern is she has some left sided dz, becomes ischemic with surgical stress, left heart can't keep up and it's a death spiral.

.
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You want a cath despite a normal stress test? Especially for non cardiac surgery?

To those who want to fix her valves, has anyone asked her what she wants? Maybe she doesn't want anything done other than the bladder/utis.
 
urge said:
You want a cath despite a normal stress test? Especially for non cardiac surgery?

To those who want to fix her valves, has anyone asked her what she wants? Maybe she doesn't want anything done other than the bladder/utis.
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As others have pointed out, her stress test wasn't "normal" because she had poor exercise tolerance and you can't call it a negative stress test. Hell, do a chemical stress test with thalium instead of a cath. But don't tell me she has a normal stress test if she couldn't compete reach max capacity.

Would you rather kill her on the table for urinary incontinence? 7 hours of surgery is tough for most people with O2 dependent COPD but throw in her other issues and it is very challenging. Also, as I said above, extubating these patients is tough and she may get herself a nice trach with her reconstructed Lady parts.
 
PainDrain said:
As others have pointed out, her stress test wasn't "normal" because she had poor exercise tolerance and you can't call it a negative stress test. Hell, do a chemical stress test with thalium instead of a cath. But don't tell me she has a normal stress test if she couldn't compete reach max capacity.

Would you rather kill her on the table for urinary incontinence? 7 hours of surgery is tough for most people with O2 dependent COPD but throw in her other issues and it is very challenging. Also, as I said above, extubating these patients is tough and she may get herself a nice trach with her reconstructed Lady parts.
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It is likely a dobutamine stress test. It says "poor exercise tolerance but stress test was ok", not "stress test not completed".

Why do you assume the cardiologist was so stupid to order a treadmill stress test on a patient who cannot exercise?

Can you even imagine a 70 y/o "totally incontinent" woman on a treadmill in the cardiologist's office?
 
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BLADEMDA said:
What would you think of an RVSP of 45 on a 90 year old? I've seen this a few times on elderly patients.

I assume if you would do an elective case with RVSP of 70 then under 50 isn't a big deal? At what number RVSP would you consider TIVA or SAB where the CO2 is allowed to rise?
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Maybe because I'm a dinosaur who still uses pa catheters, I see how dynamic these numbers really are. I've seen pasp drop from 70 to 30s and peak TR jets decline from 4.5 to 3 just by deepening the anesthetic or starting a little ntg.

MR can be just as dynamic. After inducing GA and dropping a tee probe, I sometimes have to perform multiple provocative maneuvers to reproduce the severe MR reported on a Preop echo. Recently we cancelled a mitral repair because the regurgitation was only severe when the systemic pressure was pushed to 180/110. Better just to control the blood pressure.

As an aside, I've also seen patients with 30%lvef become 50%. Our patients and their echo exams are not static. One echo report is not the holy grail.

More than likely the patient presented by amyl has chronic volume overload/lae/rae/dilated mitral annulus....but for me if she is medically optimized and not symptomatic with congestive heart failure and she doesn't want valve repair, I would just proceed.

As for the elderly lady with RVSP of 45, that is a pretty routine case that I see a couple times a month. GA/ett with Aline.

Would love to hear amyl's followup. Maybe she got a repeat echo.
 
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WholeLottaGame7 said:
Good question. I tend to think of it more in relation to systemic pressures than as an absolute. >1/2 systemic and I get nervous, <1/3 systemic and I'm much less nervous. In that middle ground, it depends on the tiebreakers: what kind of case, what kind of surgeon, how long, how stimulating, how bad do I want to avoid an ETT, etc. Also a biggie: who is in the room with the pt. Can you trust the resident/CRNA to actually do a MAC or will they end up on 150 of prop as soon as you leave the room?

I'm not a conservative person, typically, but I am with pulmonary HTN. Heard too many stories of people getting 0.5 of midaz and 25 of fentanyl for a block for their AVF and then coding.
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That's a great way to approach pulm htn.

The ones who drop dead with a little versed/fent are dyspneic at rest although most of them can also be induced safely.
 
The right ventricle is a completely different chamber than the left, as histologic and physiologic properties go. It is crescent-shaped, wrapped around the left, thin-walled (1/6th of the mass of the LV), with a higher volume and lower EF than the LV. Its EF is very dependent on the IV septum bulging into the RV during systole. Its coronary perfusion has to happen both during systole and diastole, not just diastole.

That transeptal gradient of LVESP (SBP) - RVESP (PASP) is normally around 100 at least. So a patient with an PASP of 70 and SBP of 120 at rest can very easily deteriorate with acute (on chronic) pulmonary hypertension (hypoxia, hypercarbia, pain, other sympathetic stimuli), systemic relative hypotension (which will also affect coronary perfusion), fluid overload, worsening MR, worsening TR etc. All the good stuff that can happen during anesthesia and surgery.

Once the septum stops bulging into the RV because of pressure equalization (right-sided overload or left sided failure), the RVEF and CO will drop significantly and the patient will begin circling the drain (RV overload, bulging into the LV, increase in LVEDV, LV overload, decrease in LVEF, decrease in coronary perfusion, more decrease in RVEF and LVEF etc.).

One has to walk a fine line with these patients; they are very fragile, especially if elderly. Not too much fluid, not too little. Just the right blood pressure. No hypoxia/hypercarbia/pain. Now imagine this compounded with severe MR and TR. In these people, it's not the left ventricle I am afraid of. It's the right.

I agree that echo numbers are dynamic. That's why the patient needs a repeat echo after she's been supposedly optimized. If PASP is still 70, she needs to have her PHTN and its response to vasodilators further investigated.

I am not saying the big 8-hour surgery cannot be done. I am only saying there is a good amount of potential for failure, so it shouldn't be done.
 
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urge said:
Can you even imagine a 70 y/o "totally incontinent" woman on a treadmill in the cardiologist's office?
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It wouldn't be the first cardiologist who is full of ****, but it would be the first who has an excuse for it. 🙂
 
WholeLottaGame7 said:
Don't know of any 6-7 hr uro-gyn reconstructions that are "emergent," sounds more like "semi-urgent" at best.

At any rate, pre-induction a-line, pre-induction epidural, pre-induction long conversation. GA w/ETT for controlled ventilation. Minimal narcotic, primarily use epidural if the tube is ever coming out, plus the afterload reduction will only help her regurgitant lesions. TEE available but not in unless struggling. CVL for high likelihood of needing epi or other pressors, though if I could talk someone into doing a PICC beforehand that would kill 2 birds with one stone, because she's going to be in the hospital for awhile needing access. Maybe even 3 birds if the PICC team goes heavy on the sedation...

After that it's just like the cardiologists think it is: avoid hypotension, hypercarbia, yadda yadda.
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this is true but what does after load reduction do to severe PHTN?
 
Noyac said:
this is true but what does after load reduction do to severe PHTN?
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Well as far as I know, the epidural would result in systemic afterload reduction, but not pulmonary afterload reduction, so you run the risk of dropping her left-sided pressures down towards her right-sided pressures, which is not ideal. But, there are too many things wrong with this lady to fix one without f'ing up another. In reality, the benefits of improving her valvular lesions by decreasing her systemic afterload are probably lower than the risk of equalizing her left- and right-sided pressures, so I would keep her pressures as close to wherever she is without anesthesia, because at least she's (sorta) alive there...
 
Noyac said:
this is true but what does after load reduction do to severe PHTN?
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That would depend. As Bruin pointed out not all PHTN is the same. Are we assuming her PHTN is from her severe MR (pulm venous HTN) or are we assuming her PHTN is primary in nature. What and how you choose to do with these patients is dependent largely on this answer. As a simple thought you can't expect someone with primary PHTN to settle out and have great numbers with systemic after load reduction but venous PHTN due to her MR might very well settle out. Maybe its both so you kind of help. I stand with most people in saying that you have to treat PHTN with great respect, especially if you are even remotely considering doing some monkey humping a door knob urogyn case. Now she may refuse all of her work-up and that is fine but Im not sure why people think that means you have to do the case. Her stupidity does not have to mean you increase your risk for some ridiculous surgery. Can you do the case...sure...I can also drive my car with my feet...doesn't make it a good ****ing idea. If some voodoo happened and she wanted her valves fixed and my cardiac surgeon convinced me he wouldn't fix her valves until she didn't have so many UTI's I still wouldn't do it lol. Catheter of some sort...clear infections...fix valves if patient wanted that...perhaps somewhere down the road consider watching the monkeys hump the door knob if she becomes a better protoplasm. If the words nitric or flolan and potential for trach due to prolonged intubation enter my mind for some elective nonsense I think one must really evaluate what one is doing.
 
OUAnesthesia said:
Now she may refuse all of her work-up and that is fine but Im not sure why people think that means you have to do the case. Her stupidity does not have to mean you increase your risk for some ridiculous surgery. Can you do the case...sure...I can also drive my car with my feet...doesn't make it a good ****ing idea.
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I don't think that is a fair analogy. Driving with your feet is all risk with no clear benefit. Doing the case is risky but you will improve the quality of life of this person if you manage to do it properly.
 
And if not done properly, you will improve the quality of life of her surviving family. 😀
 
urge said:
I don't think that is a fair analogy. Driving with your feet is all risk with no clear benefit. Doing the case is risky but you will improve the quality of life of this person if you manage to do it properly.
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You're probably right on the analogy. My point is that we get this often. Patients refuse work-up or they are not ready and for whatever reason it is on us and we look like the bad guys for telling them no. My point is just because you can do it doesn't mean you should do it. I guess we can argue over the necessity/quality of life stuff later.
 
urge said:
I don't think that is a fair analogy. Driving with your feet is all risk with no clear benefit. Doing the case is risky but you will improve the quality of life of this person if you manage to do it properly.
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Of course there is benefit, my hands don't get tired plus I can have a burger in one hand and a drink in the other. Benefit is always relative 😉.
 
I didn't do an epidural... dropping the BP is a problem for both the regurgitant lesions and the plum htn. yes is was a pharmacologic stress test not an exercise stress test -- i came from the home of the dobutamine stress test and often there they had a saying that if you thought the patient could complete an exercise stress test than you shouldn't order it.... but i digress. pre induction arterial line, central access for possible vasopressors, TEE to watch the volume status and the ventricles intraop. theres nothing like seeing... not to mention it was a good experience for my resident. her systemic pressure were high, we put her to sleep gently and maintained BP a little high. All the equipment and buzz mustve motivated them to get on with it because it actually took shorter than planned. I ran a remi infusion as I wanted to minimize gas. used vasopressin 1unit here and there to keep pressures up and had a drip in the room in case we needed it. she did great and was extubated at the end. i agree "emergent" was bulls--. cardiologist also didn't explain properly to the family who's understanding of things was she "had a little leak in her heart valve that wasn't a big deal or anything to worry about right now." of course my pre-op conversation was long and involved - but they understood in the end and wanted to proceed.
my main comment about this case is I really wish that surgeons and med docs would stop sending these people to cards.... they clear absolutely everybody and anybody.... id rather just deal with it myself -- because now I'm put in the position, often, of basically feeling/saying nicely the cardiologist is wrong. the thinking there is that if they don't need to fixed for their day to day life we shouldn't fix them for surgery. I'm not so sure about this approach... outcomes trials will have to tell the real story.
anyways this one did fine.... you make a good point above.... its RV failure that makes plum HTN a problem... if the ventricles look good you will probably do okay but its still not pent sux tube
 
amyl said:
I didn't do an epidural... dropping the BP is a problem for both the regurgitant lesions and the plum htn. yes is was a pharmacologic stress test not an exercise stress test -- i came from the home of the dobutamine stress test and often there they had a saying that if you thought the patient could complete an exercise stress test than you shouldn't order it.... but i digress. pre induction arterial line, central access for possible vasopressors, TEE to watch the volume status and the ventricles intraop. theres nothing like seeing...


my main comment about this case is I really wish that surgeons and med docs would stop sending these people to cards.... they clear absolutely everybody and anybody.... id rather just deal with it myself -- because now I'm put in the position, often, of basically feeling/saying nicely the cardiologist is wrong. the thinking there is that if they don't need to fixed for their day to day life we shouldn't fix them for surgery. I'm not so sure about this approach... outcomes trials will have to tell the real story.
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Nice.

Did you get a peak TR jet under anesthesia? I bet it was lower than reported.

The patients around here get cardiology consults to pre-empt last minute anesthesia delays. Probably there too.
 
amyl said:
I didn't do an epidural... dropping the BP is a problem for both the regurgitant lesions and the plum htn. yes is was a pharmacologic stress test not an exercise stress test -- i came from the home of the dobutamine stress test and often there they had a saying that if you thought the patient could complete an exercise stress test than you shouldn't order it.... but i digress. pre induction arterial line, central access for possible vasopressors, TEE to watch the volume status and the ventricles intraop. theres nothing like seeing... not to mention it was a good experience for my resident. her systemic pressure were high, we put her to sleep gently and maintained BP a little high. All the equipment and buzz mustve motivated them to get on with it because it actually took shorter than planned. I ran a remi infusion as I wanted to minimize gas. used vasopressin 1unit here and there to keep pressures up and had a drip in the room in case we needed it. she did great and was extubated at the end. i agree "emergent" was bulls--. cardiologist also didn't explain properly to the family who's understanding of things was she "had a little leak in her heart valve that wasn't a big deal or anything to worry about right now." of course my pre-op conversation was long and involved - but they understood in the end and wanted to proceed.
my main comment about this case is I really wish that surgeons and med docs would stop sending these people to cards.... they clear absolutely everybody and anybody.... id rather just deal with it myself -- because now I'm put in the position, often, of basically feeling/saying nicely the cardiologist is wrong. the thinking there is that if they don't need to fixed for their day to day life we shouldn't fix them for surgery. I'm not so sure about this approach... outcomes trials will have to tell the real story.
anyways this one did fine.... you make a good point above.... its RV failure that makes plum HTN a problem... if the ventricles look good you will probably do okay but its still not pent sux tube
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That sounds pretty pent sux tubbish to me.
 
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I really wish that surgeons and med docs would stop sending these people to cards.... they clear absolutely everybody and anybody.... id rather just deal with it myself -- because now I'm put in the position, often, of basically feeling/saying nicely the cardiologist is wrong. the thinking there is that if they don't need to fixed for their day to day life we shouldn't fix them for surgery. I'm not so sure about this approach... outcomes trials will have to tell the real story.
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I don't agree with your thinking. I don't think patients should have procedures done for the sole purpose of lowering your anesthetic risk. Either they need it for their daily life or don't.

I think they should be seen by their cardiologist for the sole purpose of optimizing their medication therapy.

You don't have to say the cardiologists is wrong. Portray it as high risk, but you are prepared to do a good job and hopefully get rewarded with a good outcome.
 
amyl said:
I didn't do an epidural... dropping the BP is a problem for both the regurgitant lesions and the plum htn. yes is was a pharmacologic stress test not an exercise stress test -- i came from the home of the dobutamine stress test and often there they had a saying that if you thought the patient could complete an exercise stress test than you shouldn't order it.... but i digress. pre induction arterial line, central access for possible vasopressors, TEE to watch the volume status and the ventricles intraop. theres nothing like seeing... not to mention it was a good experience for my resident. her systemic pressure were high, we put her to sleep gently and maintained BP a little high. All the equipment and buzz mustve motivated them to get on with it because it actually took shorter than planned. I ran a remi infusion as I wanted to minimize gas. used vasopressin 1unit here and there to keep pressures up and had a drip in the room in case we needed it. she did great and was extubated at the end. i agree "emergent" was bulls--. cardiologist also didn't explain properly to the family who's understanding of things was she "had a little leak in her heart valve that wasn't a big deal or anything to worry about right now." of course my pre-op conversation was long and involved - but they understood in the end and wanted to proceed.
my main comment about this case is I really wish that surgeons and med docs would stop sending these people to cards.... they clear absolutely everybody and anybody.... id rather just deal with it myself -- because now I'm put in the position, often, of basically feeling/saying nicely the cardiologist is wrong. the thinking there is that if they don't need to fixed for their day to day life we shouldn't fix them for surgery. I'm not so sure about this approach... outcomes trials will have to tell the real story.
anyways this one did fine.... you make a good point above.... its RV failure that makes plum HTN a problem... if the ventricles look good you will probably do okay but its still not pent sux tube
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If you thought that "dropping the BP is a problem for both the regurgitant lesions and the plum htn" and that's why you avoided epidural analgesia, then maybe Remifentanil was not a good idea either!
 
Planktonmd said:
If you thought that "dropping the BP is a problem for both the regurgitant lesions and the plum htn" and that's why you avoided epidural analgesia, then maybe Remifentanil was not a good idea either!
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Seriously? 🙂

We don't really have an equivalent substance, as duration of action goes, for epidurals.

Interesting case report about a similar case: http://ispub.com/IJA/15/2/11600
 
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FFP said:
Seriously? 🙂

We don't really have an equivalent substance, as duration of action goes, for epidurals.

Interesting case report about a similar case: http://ispub.com/IJA/15/2/11600
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I didn't say it was wrong to use Remi! actually I think it's a good idea!
But saying that "dropping the BP is a problem for both the regurgitant lesions and the plum htn" then choosing to use a medication that causes hypotension and bradycardia (theoretically both bad for mitral and tricuspid regurgitation) makes little sense to me!
Also Remi is not going to help this patient with Post-op pain, they will have to give her long acting opiates and I wonder how well that is going to be tolerated by this patient!
 
If everyone is on board with the surgery, including patient, patient's family, cards, internist, surgeon, then you should be on board too.

Just reiterate the high risk nature of the anesthesia, and that you will do everything necessary to get the patient through the surgery.

Then proceed with surgery. Aline, central line, swan. Gentle induction. Depending on ease of airway, no relaxant, and use topical + transtrach, ETT via glidescope. Keep patient on PSV, average PEEP to minimize atelectasis but not overPEEP to minimize risk of overdistension of alveoli. Half-MAC sevo plus 50% nitrous.

Normal use of IV narcotic. Depending on nature of procedure, surgeons can probably put enough local to make a difference. (It sounds like it wasn't as extensive of a procedure as everyone initially though.)

Phenylephrine gtt to maintain pressure near pre-op.

If patient movement is an issue, or surgeons need relaxation, or patient hypoventilates and the resulting hypercarbia actually shows a elevation in PAP, then immediately NMB and switch to controlled ventilation. Patients do not go into sudden RV failure just with a little hypercarbia for a few minutes. If you're talking a long time of hyercarbia, worsening pHTN, ischemia, then you're screwed. Just be aggressive when the trend is in that direction and you'll be fine.

Don't need TEE.

Replace blood 1:1.

If patient is stable on PSV, then the case is easy. Extubate at end.
 
i get that urge, i agree with you... I was just frustrated because the cardiologist framed it to the patient like it was no big deal. they frustrate me because they act so cavalier about the risk of surgery.... the family seriously thought she was healthy and was unconcerned.... Remi is more hemodynamically stable than cranking the gas. bradycardia, if it happens, is fixable.... but she started high normal so i thought i had room. vasopressin is pressor of choice for me here.... neo will drop the HR considerably. lots of ways to do anesthesia....
 
chfo said:
If everyone is on board with the surgery, including patient, patient's family, cards, internist, surgeon, then you should be on board too.
Click to expand...

I would agree that if everyone is truly on board, and appreciates the risk, that my threshold for being the lone showstopping person is somewhat higher.

But I don't agree that we should automatically go along with what all those people want. Of the six people in your hypothetical room - patient, family member, cardiologist, internist, surgeon, and you - only one of them is an anesthesiologist and fully understands that piece of the risk.


chfo said:
Half-MAC sevo plus 50% nitrous.
[...]
Phenylephrine gtt to maintain pressure near pre-op.
Click to expand...
For patients with severe pulmonary hypertension, I wouldn't use nitrous, and vasopressin may be better than phenylephrine.
 
Interesting that a lot of you guys are pretty comfortable with going against Class I guidelines. From the 2014 ACC/AHA perioperative guideline executive summary:
"Class I: For adults who meet standard indications for valvular intervention (replacement and repair) on the basis of symptoms and severity of stenosis or regurgitation, valvular intervention before elective non-cardiac surgery is effective in reducing perioperative risk. (Level of Evidence: C)"
Yea yea, level C. But still, if we disregarded all Class I Level C recommendations we'd have some interesting practice habits.

I'm not saying you guys are wrong for just agreeing to do the case because everyone else is on board. I don't have the years and judgement some of you do. But that lack of experience means I'm pretty conservative when it comes to going against guidelines. Am I hearing that many of you aren't all that impressed by this particular guideline? It's easy to say a case is going to go just fine. Just recently a pt who was being worked up for AVR needed an emergent femur fracture repair. Did just fine, but that doesn't mean it should have been done if it were elective. We are in an era where (for example, in TAVR trials) "inoperable" patients have an estimated 15% mortality risk. So more than 8 out of 10 times you operate on "inoperable" patients they're expected to live. I think that is where a lot of the cavalier attitude from surgeons and cardiologists comes from. Maybe her risk of death is 2 or 3% (just guessing) but what is the general risk for that procedure? 0.1%? Less? I'm not comfortable in principle increasing her risk by 20-30x (while still being 97-98% sure it's going to go fine) but I do admit it's not as clear cut as that.
 
itwasalladream said:
Interesting that a lot of you guys are pretty comfortable with going against Class I guidelines. From the 2014 ACC/AHA perioperative guideline executive summary:
"Class I: For adults who meet standard indications for valvular intervention (replacement and repair) on the basis of symptoms and severity of stenosis or regurgitation, valvular intervention before elective non-cardiac surgery is effective in reducing perioperative risk. (Level of Evidence: C)"
Yea yea, level C. But still, if we disregarded all Class I Level C recommendations we'd have some interesting practice habits.

I'm not saying you guys are wrong for just agreeing to do the case because everyone else is on board. I don't have the years and judgement some of you do. But that lack of experience means I'm pretty conservative when it comes to going against guidelines. Am I hearing that many of you aren't all that impressed by this particular guideline? It's easy to say a case is going to go just fine. Just recently a pt who was being worked up for AVR needed an emergent femur fracture repair. Did just fine, but that doesn't mean it should have been done if it were elective. We are in an era where (for example, in TAVR trials) "inoperable" patients have an estimated 15% mortality risk. So more than 8 out of 10 times you operate on "inoperable" patients they're expected to live. I think that is where a lot of the cavalier attitude from surgeons and cardiologists comes from. Maybe her risk of death is 2 or 3% (just guessing) but what is the general risk for that procedure? 0.1%? Less? I'm not comfortable in principle increasing her risk by 20-30x (while still being 97-98% sure it's going to go fine) but I do admit it's not as clear cut as that.
Click to expand...

You need to consider that valve replacement or repair has significant risk, often higher than proceeding with noncardiac surgery in these patients.

So you may reduce the perioperative risk of the bladder surgery but in order to do that, you just put the patient through a procedure that has 2-4% operative mortality.
 
pgg said:
For patients with severe pulmonary hypertension, I wouldn't use nitrous, and vasopressin may be better than phenylephrine.
Click to expand...

Have you ever used nitrous in a patient with severe pulmonary hypertension with swan in place? You might be surprised to hear that it has zero effect on PAP or systemic pressure. Dogma discourages use of nitrous.


Is phenylephrine a bad choice to counteract the vasodilation effect of sevo in patients with chronic severe pulmonary hypertension?
 
There are studies going both ways on nitrous in PHTN. I rarely use nitrous anyway, for anything, and don't see that it adds much here. So I wouldn't use it.

Vasopressin will accomplish the same thing phenylephrine will WRT systemic vasodilation from the gas, but may have benefits WRT the pulmonary circulation.

I'm sure you could use both nitrous and phenylephrine and do just fine, but no-nitrous and vasopressin appear to be superior choices to me.

Severe pulmonary hypertension can be trouble, so I just prefer to stack the deck in my favor.
 
I am always reluctant to put too much clinical significance on secondary pulmonary hypertension in patients with severe chronic lung disease.
These patients tend to tolerate anesthesia much better than patients with primary pulmonary hypertension and this patient is probably an example of that type of PHTN.
She has severe lung disease that caused the PHTN and right ventricle dilatation with secondary TR.
The main problem in these patients is the lung disease and that's where the anesthesia issues will be.
 
Planktonmd said:
I am always reluctant to put too much clinical significance on secondary pulmonary hypertension in patients with severe chronic lung disease.
These patients tend to tolerate anesthesia much better than patients with primary pulmonary hypertension and this patient is probably an example of that type of PHTN.
She has severe lung disease that caused the PHTN and right ventricle dilatation with secondary TR.
The main problem in these patients is the lung disease and that's where the anesthesia issues will be.
Click to expand...
Yes and no. I am not a pulmonologist but, once the PAP gets into really high numbers, I would expect that pulmonary artery to exhibit significant irreversible changes in the muscular layer. It's like with long-standing poorly- treated severe systemic hypertension, except that we don't really have the same level of medications for it.

The RV can take a lot of strain so I get scared not just from high pulmonary numbers, but especially when I see RV failure or low stress tolerance at baseline, after optimizing the optimizable. And to me, severe TR at baseline is trouble, unless I have a cath report that shows good forward cardiac output under stress. This is also where a good internist/cardiologist who knows the patient well is gold, while an average one is just producing global warming.

It's not like, if we are wrong with our anesthetic plan, we can just go on bypass.
 
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