Quick Resident Preop Case

[OB1🤙]

Your patient is an 89 year old dude with a symptomatic inguinal hernia.

Still active, derives life joy by doddering around in the yard and walking around the neighborhood and the hernia is extremely bothersome while doing this.

You show up in preop to find a pleasant, conversant man. You glance up at the monitor and see complete heart block with a ventricular rate of 35. BP is 170/80. Labs are all normal.

You ask him what gives, and he tells you he's had this for years, he's completely asymptomatic, and he has refused and will continue to refuse a pacemaker.

You try and call his cardiologist but the dude is in Peru. His partner is in clinic, doesn't know the patient at all, and can't come see this guy at the moment.

Your move.

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[dhb]

Pst

 

[Noyac]

Nice!

 

[sethco]

Float a temporary pacing wire. Oh sorry, forgot...Pent, sux, tube

 

[agammaglobulin]

My conclusion is patient has no symptoms from bradycardia at rest or at >4Mets activity. I would try and see the cardiologists note and find any recent Echo/EKG given concern with high pulse pressure, HR and age. Pre-op A-line, pacer pads. Proceed with etomidate induction with pacer pads/esophageal pacer/transcutaneous pacer (whatever is available). Make sure I can capture and pace before start of surgery. I'd have Atropine and dilute Epi drawn up and ready.

 

[Noyac]

My conclusion is patient has no symptoms from bradycardia at rest or at >4Mets activity. I would try and see the cardiologists note and find any recent Echo/EKG given concern with high pulse pressure, HR and age. Pre-op A-line, pacer pads. Proceed with etomidate induction with pacer pads/esophageal pacer/transcutaneous pacer (whatever is available). Make sure I can capture and pace before start of surgery. I'd have Atropine and dilute Epi drawn up and ready.

How are you planning on doing this?

 

[agammaglobulin]

Good point. Heart block is below AVN so would need transvenous pacing and atropine wouldn't work...

 

[GravelRider]

Good point. Heart block is below AVN so would need transvenous pacing and atropine wouldn't work...

How do you know the block is below the AV node? I would actually guess that the heart block is at the level of the AV node or maybe just below based on the fact that this guy has been asymptomatic for so long. Atropine may be useful. An EKG can give you a lot of information here.

 

[deleted171991]

Float a temporary pacing wire. Oh sorry, forgot...Pent, sux, tube

LMA, not tube. It's 2016.

I agree: he needs some pacing wires, if unresponsive to glycopyrrolate in preop holding. The surgeon will probably whine that he cannot do that hernia under local + MAC (a touch of ketafol, or even just propofol).

@agammaglobulin, external pads won't work intraop, just for an emergency. Unless your surgeon can operate on a moving target. Plus you might need to shave the patient (the Zoll pads don't stick well on chest hair).

 

[Hoya11]

Your patient is an 89 year old dude with a symptomatic inguinal hernia.

Still active, derives life joy by doddering around in the yard and walking around the neighborhood and the hernia is extremely bothersome while doing this.

You show up in preop to find a pleasant, conversant man. You glance up at the monitor and see complete heart block with a ventricular rate of 35. BP is 170/80. Labs are all normal.

You ask him what gives, and he tells you he's had this for years, he's completely asymptomatic, and he has refused and will continue to refuse a pacemaker.

You try and call his cardiologist but the dude is in Peru. His partner is in clinic, doesn't know the patient at all, and can't come see this guy at the moment.

Your move.

He gets a pacer before he gets the hernia repair unless the hernia is an emergency. Meaning he gets cancelled and gets an EP referral. Comes back for hernia repair with new pacer. I dont personally feel comfortable placing transvenous pacing wires on my own. If its an emergency Id get ready to externally pace and id consider doing it under spinal or epidural.

 

[Hoya11]

.

 

[Noyac]

Did anyone delve into why he refuses a pacer?

 

[OB1🤙]

He refuses a pacer because he knew a guy who had infected pacer wires who almost died. He reasons that if he doesn't have symptoms he doesn't need a pacer. He's had this for 3 years apparently and has felt fine the whole time.

But he definitely wants the hernia fixed.

So you decide to do an experiment in the holding area. You give 0.4 mg glyco to see if anything happens. His junctional escape rate increases from 35 to 50.

 

[pgg]

Is the patient DNR?

If not, does he understand that if he keels over in the parking lot, he's going to get externally paced if he's not cold and dead by the time help arrives?

If he is, then the discussion needs to veer off into temporarily rescinding his DNR for surgery. Bottom line, if I take him to surgery, I need to have an option, acceptable to the patient, for pacing him if it becomes necessary.

Did anyone delve into why he refuses a pacer?

I'd be curious, and I'd ask him why not, but in the end if "he has refused and will continue to refuse a pacemaker" then you're stuck ... sure it's a class I indication but patient refusal is a class I contraindication.

I'd also ask if he's on any meds that could cause conduction delays or problems, like beta blockers, calcium channel blockers, digoxin. Surely he's not, but I'd ask. If he is, there's a rationale to postpone the case and maybe get off those drugs.

Transcutaneous pacing is not reliable and it's not fun for the patient either. What if you need it during surgery? You going to wake him with it still going, or switch to transvenous against his wishes? No. This is a non-starter.

I might try some glycopyrrolate or atropine to see if his HR responded, but it probably wouldn't. An isoproterenol infusion might work better. Either way, you'd have to be careful. We know his conduction isn't right and he's got coronary disease; poking that bear with a stick to see what happens could precipitate some problems.

You can also count on some vagal stimulation as the surgeon yanks on his spermatic cord.

 

[pgg]

He refuses a pacer because he knew a guy who had infected pacer wires who almost died. He reasons that if he doesn't have symptoms he doesn't need a pacer. He's had this for 3 years apparently and has felt fine the whole time.

But he definitely wants the hernia fixed.

So you decide to do an experiment in the holding area. You give 0.4 mg glyco to see if anything happens. His junctional escape rate increases from 35 to 50.

Successful experiment = off to surgery, right?

 

[GravelRider]

Is the patient DNR?

This is the most important thing to ascertain...maybe even before looking at a 12-lead. I assume code status has been discussed with someone who could easily go asystolic while straining too hard on the can.

I'm not a consult junkie, but I would have a cardiologist (maybe not his) involved before I made any decisions to proceed with the surgery.

I don't know if I would feel comfortable doing this case with a GA or regional technique without at least having access to transvenous pace if needed. Hernias can be done under local, so that would be my preference. If doing just straight local, I would be ok with just having transcutaneous pacer pads in place. I would remind the surgeon to be gentle with the "merchandise."

 

[Robotic Wis-Hipple]

So I'll be the conservative obstructionist role here;

Who books an elective general surgery in an 89yo in complete heart block with no other workup? Sure, he refuses a PPM, great, that's his prerogative. But at the very least I wanna see a history of cath/stress echo and some cards notes, those things have had to be done. We know he's got some CAD but the asymptomatic METS>4 makes everyone completely ok? Are you sure an 89yo with a HR in the 30's can hit 4 Mets? I'm not sure doing experimental stress tests on this dude to prove he can increase his heart rate assures me, in fact it's likely increasing his risk for ischemia.

Look, I'm not afraid of doing this case with all the ducks in a row and after realistic conversation with the guy specifically regarding his desires for pacing strategies and/or cardiac resuscitation, but this is a 100% elective case. Just because we can doesn't mean we should.

 

[link2swim06]

How are you planning on doing this?

Turn the pacer on for a couple of seconds, how else?

 

[dhb]

His heart is beating at 35/min and is going to continue doing so what's the big deal?
On the bright side he can't have a vagal bradycardia.
If you want to be real conservative place a fem intro and have an internal pace ready.

 

[pgg]

On the bright side he can't have a vagal bradycardia.

I wouldn't bet his life on that ...

While true that most vagal efferents go to the SA and AV node, there is some vagal innervation of the ventricular myocardium.

If you want to be real conservative place a fem intro and have an internal pace ready.

In a patient who's steadfastly refused pacing? He might agree. It could be PRT of the consent and SNR discussion. I've never placed transvenous pacing wires. Not comfortable winging it.

 

[Planktonmd]

He obviously has a junctioal pacemaker that took over many years ago and proved to be very stable and reliable since there is no history of syncope and good exercise tolerance.
He is refusing the pacemaker and wants his hernia repaired, and from the OP it sounds like he is fully competent.
I would explain my concerns to him, document our discussion, and proceed with the surgery.
I would probably do an ilioinguinal/iliohypogastric nerve block combined with a cautious GA using LMA and some vapor.
It wouldn't hurt to have a percutaneous pacer placed on him but most likely not going to need it.
Simple case!

 

[Planktonmd]

Turn the pacer on for a couple of seconds, how else?

You're going to do that while he is awake sitting in the holding area?

 

[pgg]

He obviously has a junctioal pacemaker that took over many years ago and proved to be very stable and reliable since there is no history of syncope and good exercise tolerance.
He is refusing the pacemaker and wants his hernia repaired, and from the OP it sounds like he is fully competent.
I would explain my concerns to him, document our discussion, and proceed with the surgery.
I would probably do an ilioinguinal/iliohypogastric nerve block combined with a cautious GA using LMA and some vapor.
It wouldn't hurt to have a percutaneous pacer placed on him but most likely not going to need it.
Simple case!

Probably. HB's original post just mentioned a "ventricular rate of 35" so I assumed they were wide complex escape beats.

In his followup he mentioned he was junctional ... and responsive to atropine. That alters the risk profile somewhat.

 

[GravelRider]

Probably. HB's original post just mentioned a "ventricular rate of 35" so I assumed they were wide complex escape beats.

In his followup he mentioned he was junctional ... and responsive to atropine. That alters the risk profile somewhat.

Does he have wide complex QRS? That would make me more nervous. I would guess that this guy has a narrow QRS junctional rhythm with a block at the AV node and a ventricular pacemaker in the bundle of His before the bifurcation. Patients with a narrow QRS tend to be more stable and respond to atropine.

 

[Noyac]

You're going to do that while he is awake sitting in the holding area?

Why not? It's better than giving glyco and waiting!

 

[Robotic Wis-Hipple]

This case just epitomizes the issue with fee for service surgery and preop evaluation by a surgeon. I mean I'm sure cards has evaluated his coronaries, found his occluded RCA with collaterals and otherwise nonobstructive CAD 3yrs ago and gave this guy their blessing after he refused PPM. And I'm 85% sure this guy gets thru his minor, non-high risk surgery just fine. But the surgeon didn't care to acquire those cards records prior to booking him? He really didn't think we'd have some questions? Or is he himself oblivious to the guy's heart rate? I'm not sure if that's out of naïveté or disrespect but it bugs me.

If this guy Brady or vfib arrests due to ischemia and you trying to hit him with epi to get thru a simple elective case are you really comfortable arguing that an 89yo man in heart block who walks around his property and picks weeds without chest pain/sob/syncope equals fit for surgery without objective data that is likely done but not proven to be so? I mean he obviously had an asymptomatic infarction at some point......

 

[sethco]

For everyone that is advocating putting on pacer pads and doing transcutaneous pacing, have you ever done this on a real patient?

There is a difference between a board answer and a real life answer. If you would go down this path in your boards, I can almost guarantee that the board examiner will put you in a situation where you can't get capture. What then?

 

[sethco]

I wouldn't bet his life on that ...

While true that most vagal efferents go to the SA and AV node, there is some vagal innervation of the ventricular myocardium.



In a patient who's steadfastly refused pacing? He might agree. It could be PRT of the consent and SNR discussion. I've never placed transvenous pacing wires. Not comfortable winging it.

Did you already start Cardiac fellowship? You should definitely get experience placing them during fellowship. It is not very difficult under Fluoro guidance

 

[Robotic Wis-Hipple]

Did you already start Cardiac fellowship? You should definitely get experience placing them during fellowship. It is not very difficult under Fluoro guidance

How did you do this? At my shop I can't imagine cards/CTS letting anesthesia get in on these. Politics....

 

[B-Bone]

How did you do this? At my shop I can't imagine cards/CTS letting anesthesia get in on these. Politics....

I assume he's talking about temporary TV pacers (pacing swans, etc). We definitely did this during residency and I've had to do it a handful of times in practice (not CV fellowship trained).

 

[OB1🤙]

He obviously has a junctioal pacemaker that took over many years ago and proved to be very stable and reliable since there is no history of syncope and good exercise tolerance.
He is refusing the pacemaker and wants his hernia repaired, and from the OP it sounds like he is fully competent.
I would explain my concerns to him, document our discussion, and proceed with the surgery.
I would probably do an ilioinguinal/iliohypogastric nerve block combined with a cautious GA using LMA and some vapor.
It wouldn't hurt to have a percutaneous pacer placed on him but most likely not going to need it.
Simple case!

Yeah, this was pretty much what happened.

Pgg- by ventricular rate I meant his actual rate produced by his junctional pacemaker- he had P waves going at a totally different rate. But his QRS was narrow. Oh and the dude was definitely not DNR. He just didn't want a complication-prone solution to a problem that didn't exist as he saw it.

I figured the fact that I could goose his junctional rate was a good sign. Missing in the discussion of pacer pads thus far has been body habitus. This dude was very slim. Had he been a fluffy fellow, I might have floated a wire prior to going to sleep, knowing ultimately both would be probably overkill.

I did not learn how to float TVP in residency or fellowship, though I saw many. Not until out in PP doing Corevalves did I start doing them myself.

As it was I put pads on him and induced him with propofol and popped in an LMA. His junctional rate came up to 75 after propofol and stayed in the 70s-80s for the whole case. I did a TAP at the end. No narcs. I did have TVP stuff around and they were doing a joint next door so I could have commandeered their c-arm if need be.

In pacu he drifted back down to his baseline rate.

I thought the tough decision in this case was the cardiology consult part. If his guy had been available, I would have asked him to weigh in, only because he knows the pt. Ultimately I figured anyone else would just say "wtf do you want me to say, I don't know this guy, get him a pacemaker." His original cardiologist had been fine with him living at home in the condition he presented in. If this is as optimized as he's willing to get, and I can fix the problems that might come up, I felt OK proceeding.

 

[pgg]

Did you already start Cardiac fellowship? You should definitely get experience placing them during fellowship. It is not very difficult under Fluoro guidance

I'm 5 months in. Haven't placed any. Not sure any of my co-fellows have either. Might get the opportunity during some EP days, or during a CTICU month. For cases in the OR, anything transvenous is going to get placed by the proceduralist, I think.

I'll have to start trolling for an opportunity ...

 

[Noyac]

I assume he's talking about temporary TV pacers (pacing swans, etc). We definitely did this during residency and I've had to do it a handful of times in practice (not CV fellowship trained).

Wow I've never done that.

 

[Noyac]

I'm 5 months in. Haven't placed any. Not sure any of my co-fellows have either. Might get the opportunity during some EP days, or during a CTICU month. For cases in the OR, anything transvenous is going to get placed by the proceduralist, I think.

I'll have to start trolling for an opportunity ...

There just doesn't seem to be the need for this in cardiac cases unless they are not cracking the chest. Otherwise, leads are placed in the field, right?

 

[Noyac]

He obviously has a junctioal pacemaker that took over many years ago and proved to be very stable and reliable since there is no history of syncope and good exercise tolerance.
He is refusing the pacemaker and wants his hernia repaired, and from the OP it sounds like he is fully competent.
I would explain my concerns to him, document our discussion, and proceed with the surgery.
I would probably do an ilioinguinal/iliohypogastric nerve block combined with a cautious GA using LMA and some vapor.
It wouldn't hurt to have a percutaneous pacer placed on him but most likely not going to need it.
Simple case!

My approach as well.

 

[dannyboy1]

Am I the only one who thinks it's crazy to take a purely elective case to the OR when the patient is in complete heart block, without a note from his cardiologist OKing it. Seems like a great way to get raked over the coals in M & M

 

[sigrhoillusion]

Am I the only one who thinks it's crazy to take a purely elective case to the OR when the patient is in complete heart block, without a note from his cardiologist OKing it. Seems like a great way to get raked over the coals in M & M

Yea, I'd definitely want to see a cardiology note. This guy might say he refused a pacemaker, but I'd like to have the note on file from the cardiologist about that discussion. Cause worst thing that could happen is that this guy croaks and his wife/POA brings a cardiology note stating that this guy needs a pacemaker.

That bieng said, assuming the guy is competent and the cardiologist agrees, then I'd proceed as others have mentioned. Oh and of course make my own documentation of the risks and benefits.

 

[urge]

Tell the surgeon to do it under local.

 

[urge]

Float a temporary pacing wire. Oh sorry, forgot...Pent, sux, tube

I'm more concerned about discharging him than the anesthetic. I would not place a pacemaker under any circumstance.

The problem is that he does not meet criteria for discharge before doing the case.

I would only do the case at the big house, telemetry post op for a few days and discharge home by cardiology.

 

[OB1🤙]

The only cardiologist who can speak intelligently about whatever discussions have taken place is in the Peruvian Andes, probably halfway through his hike to Machu Picchu.

We like to strut around and say "cardiologists don't clear patients for surgery, I do." But then cases like this come up and we get nervous. Shoot, I was nervous.

But aside from a pacemaker, no cardiologist out there can offer you additional intervention. They don't have meds that we don't have. Any cardiologist seeing this guy for the first time would just say something along the lines of "I'm not getting my hands dirty with this, postpone it until his dude comes back from his soul searching hike."

The patient wants this done. He understands the concerns and is fine with the risk.

In private practice, this isn't a case I cancel. Nothing will make this guy better than he is right now, and I have the tools to treat the problem that could arise.

Good discussion. Thanks everyone. Happy Thanksgiving.

 

[urge]

The only cardiologist who can speak intelligently about whatever discussions have taken place is in the Peruvian Andes, probably halfway through his hike to Machu Picchu.

We like to strut around and say "cardiologists don't clear patients for surgery, I do." But then cases like this come up and we get nervous. Shoot, I was nervous.

But aside from a pacemaker, no cardiologist out there can offer you additional intervention. They don't have meds that we don't have. Any cardiologist seeing this guy for the first time would just say something along the lines of "I'm not getting my hands dirty with this, postpone it until his dude comes back from his soul searching hike."

The patient wants this done. He understands the concerns and is fine with the risk.

In private practice, this isn't a case I cancel. Nothing will make this guy better than he is right now, and I have the tools to treat the problem that could arise.

Good discussion. Thanks everyone. Happy Thanksgiving.

I'm not sure what you want the Peruvian cardiologist to tell you. "Yes, he meets criteria to need a pacemaker implated but he is obstinate and refuses. Good luck with the anesthetic and hopefully he does not go asystolic at home since you will be on the hook for that one. Happy Thanksgiving".

 

[urge]

His original cardiologist had been fine with him living at home in the condition he presented in. If this is as optimized as he's willing to get, and I can fix the problems that might come up, I felt OK proceeding.

I doubt the cardiologist has been "fine with it". I bet every note says "patient advised about needing a pacemaker but refuses" in an attempt to limit his liability.

 

[dannyboy1]

I'm not sure what you want the Peruvian cardiologist to tell you. "Yes, he meets criteria to need a pacemaker implated but he is obstinate and refuses. Good luck with the anesthetic and hopefully he does not go asystolic at home since you will be on the hook for that one. Happy Thanksgiving".

The note is to limit your liability. Ideally it should say something like " evaluated patient for upcoming hernia repair and he is as good as he is going to get without pacemaker which patient continues to refuse. R/B discussed in detail". Agree with local (or possibly slowly titrated epidural), with pacing pads on. Post op telemetry is a great idea. Let cardiology discharge him.

 

[Robotic Wis-Hipple]

I don't even care that he is in stable heart block. I even believe he's asymptomatic and decently active. I don't care about the lack of PPM per say. I definitely don't care for a note from cardiology "for clearance" or to have them document that it's truly stable. I want the records to document they know WHY he's in heart block and that they ruled out significant coronary disease and/or arrythmias. I mean if this guy comes in with new LBBB, stable or not don't people question why? Wouldn't your oral board examiner expect you to go down your ACC/AHA algorithm for an elective case?

Yes, I do have all the drugs I'd need to treat his Brady or arrhythmia or arrest just like any other scenario, I can get him paced.....maybe. But I just don't see how you argue that you did right by the pt or family if this guy arrests because you didn't verify he doesn't have flow limiting lesions prior to a GA for an elective hernia. And I'll go back to the opinion that this delay would be on the surgeon for booking a gomer in heart block without making sure cardiac records were available.

 

[dhb]

Slam dunk case anything else is ivory tower masturbation.
Sorry

 

[floridaboy18]

I agree with those above that if the guy is as competent as he sounds and understands the risks would proceed with surgical ilioinguinal/iliohypogastric block and be done with it. He gets a sniff of sedation and undertakes the risks.

Cases like this prove to me how useful regional is... another example from this past week...I did selective terminal nerve blocks (ulnar, radial, median) distal to elbow for patient undergoing bilateral hand work (amputations, etc). Guys pressure was 70s systolic. He got 25 mcg of fetnanyl and that was it for the entire case. Too sick to get much else and general probably would have killed him.

For those curious why we didn't do bilateral brachial plexus blocks... first because he was a tiny patient and would have been approaching toxic doses. Second reason was simply because we could.

Regional is awesome when it can be used.

Sent from my SM-N910V using Tapatalk

 

[floridaboy18]

P.s. the guys pulse ox worked a lot better following the blocks... I've heard of people doing digital blocks to make pulse ox's work but was cool to see in this guy.

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[sigrhoillusion]

I agree with those above that if the guy is as competent as he sounds and understands the risks would proceed with surgical ilioinguinal/iliohypogastric block and be done with it. He gets a sniff of sedation and undertakes the risks.

Cases like this prove to me how useful regional is... another example from this past week...I did selective terminal nerve blocks (ulnar, radial, median) distal to elbow for patient undergoing bilateral hand work (amputations, etc). Guys pressure was 70s systolic. He got 25 mcg of fetnanyl and that was it for the entire case. Too sick to get much else and general probably would have killed him.

For those curious why we didn't do bilateral brachial plexus blocks... first because he was a tiny patient and would have been approaching toxic doses. Second reason was simply because we could.

Regional is awesome when it can be used.

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I'm assuming the fentanyl was prior to the blocks for the initial "pinch and burn" . otherwise I'd think a touch of versed might have been more beneficial to take the edge off. Assuming the blocks worked, not sure why the patient would need narcotics afterwards.

 

[floridaboy18]

I'm assuming the fentanyl was prior to the blocks for the initial "pinch and burn" . otherwise I'd think a touch of versed might have been more beneficial to take the edge off. Assuming the blocks worked, not sure why the patient would need narcotics afterwards.

Was for the blocks. Didn't get anything after that.

Also didn't give midazolam given that his blood pressure measurement was hit or miss, he was ESRD and would hang around forver, and his mental status was our best measurement of his pulse ox which didn't work well given his poor perfusion.

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[urge]

To all of you who would do the case and send him home:

6 mo later you get served a lawsuit because the guy went home and died in his sleep the same night of the surgery. They claim that you negligently did the case, plus you also negligently discharged him home. They also claim that anesthesia has many chronotropic effects that you did not disclose to him and if you had done so he would have never consented to the anesthetic.

What is your defense?