Recent Case

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Noyac said:
Well, I'm not sure I wouldn't do a spinal.

If the case has been delayed for new onset Afib then let cards handle it. Rate control or conversion, I don't care.

As far as dialysis goes, they can do it but leave the pt euvolemic.
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Well you've got very large balls to do a spinal as these patients tend to run on the low BP side with deceased SVR already. I'm wondering if there is a case report of HRS patient getting a neuraxial technique? Noyac, I enjoy your posts even when we disagree.
 
Noyac said:
Well, I'm not sure I wouldn't do a spinal.

If the case has been delayed for new onset Afib then let cards handle it. Rate control or conversion, I don't care.

As far as dialysis goes, they can do it but leave the pt euvolemic.
Click to expand...

I've been hoping one of you PP guys would bring this up. I'm not sure about any block little lone spinal in this pt despite him having some comorbidities that may benefit from it (mainly his chronic o2 requiring lung disease), aside from the hyperdynamic low svr state I think the coag/plt situation as well as the HRS (does saving vent days matter when he's not likely to leave the hospital either way?) make this a pretty big risk IMO.

Say you give FFP/PCC, and check or don't check the INR afterwards, say you give plts. Are you confident that any of that works? Dudes ESLD, his coag cascade is not reliable, his plts are either sequestered or some degree of dysfunctional with or without recent dialysis.

Basically I can just see a lawyer with/without an expert witness nailing you for performing neuraxial in a liver disease pt with low plts and an INR of 2. Multiple IR guidelines, ASRA etc will be against you (I mean ASRA specifically can't even help you on the plt count as you're not getting it high enough to get out of their massive grey area). Is TEG too new, too expensive, too rare to be a defense here? Even if you can show a perfect TEG pre or post FFP/PCC and Plts, it's certainly not standard of care yet right? Do you make sure you have an INR ~1.5 just for cya? And lastly, if you do get to an INR of 1.5, without TEG how sure are you that means anything?
 
Robotic Wis-Hipple said:
I've been hoping one of you PP guys would bring this up. I'm not sure about any block little lone spinal in this pt despite him having some comorbidities that may benefit from it (mainly his chronic o2 requiring lung disease), aside from the hyperdynamic low svr state I think the coag/plt situation as well as the HRS (does saving vent days matter when he's not likely to leave the hospital either way?) make this a pretty big risk IMO.

Say you give FFP/PCC, and check or don't check the INR afterwards, say you give plts. Are you confident that any of that works? Dudes ESLD, his coag cascade is not reliable, his plts are either sequestered or some degree of dysfunctional with or without recent dialysis.

Basically I can just see a lawyer with/without an expert witness nailing you for performing neuraxial in a liver disease pt with low plts and an INR of 2. Multiple IR guidelines, ASRA etc will be against you (I mean ASRA specifically can't even help you on the plt count as you're not getting it high enough to get out of their massive grey area). Is TEG too new, too expensive, too rare to be a defense here? Even if you can show a perfect TEG pre or post FFP/PCC and Plts, it's certainly not standard of care yet right? Do you make sure you have an INR ~1.5 just for cya? And lastly, if you do get to an INR of 1.5, without TEG how sure are you that means anything?
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Pcc will bring inr to less than 1.5. If you give enough plt, you can get it >75k. We do epidural on pt with plt>75k without cowering to the lawyers all the time. A spinal would be less traumatic. Assuming pt is hemodynamically stable and you're watching the a line with phenylephrine in hand, I think a spinal would be fine once you correct the coags/plt and check a TEG. I agree that a TEG would be useful if not necessary. If you do all this, your chance of a significant epidural hematoma would be very rare. Even if this pt develops and epidural hematoma, your chance of getting sued from it is still small I think. As long as you explain carefully beforehand that this is a small risk, but it may benefit in that it may avoid a prolonged intubation, I think pt and family will understand even if the complication (very rare) develops.

We can't work in fear of getting sued doing what we think is best for the pt. I'm sure there are things you do everyday that if dissected by a greedy lawyer, a random "expert" witness, and a jury of average 'murican, you will be find liable for. I accept that I will likely be sued sometimes in my career as >90% of anesthesiologists will by the time they retire. I see it as a tax for practicing medicine in the US.
 
Chloroform4Life said:
Pcc will bring inr to less than 1.5. If you give enough plt, you can get it >75k. We do epidural on pt with plt>75k without cowering to the lawyers all the time. A spinal would be less traumatic.
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this patient will have a qualitative platelet function defect.
No spinal from me!
 
JobsFan said:
this patient will have a qualitative platelet function defect.
No spinal from me!
Click to expand...
Possibly, but a TEG would let me assess the functional status of his platelets.

How often have you placed epidural in preeclamptics? They also have qualitative platelet defects.
 
BLADEMDA said:
Well you've got very large balls to do a spinal as these patients tend to run on the low BP side with deceased SVR already. I'm wondering if there is a case report of HRS patient getting a neuraxial technique? Noyac, I enjoy your posts even when we disagree.
Click to expand...

I think I'd be more concerned about a spinal in someone hypotensive with high SVR. If they are already "maximally" (I understand it may not be maximally, but to emphasize my point) vasodilated, how much more would the BP drop from a spinal? I don't know.
 
Pharmacodynamics Of Spinal Anesthesia

The pharmacodynamics of spinal injection of local anesthesia are wide-ranging. The next section reviews the cardiovascular, respiratory, and gastrointestinal consequences of spinal anesthesia. This portion of the chapter focuses on the hepatic and renal effects of spinal anesthesia.

Hepatic blood flow correlates to arterial blood flow. There is no autoregulation of hepatic blood flow, thus, as arterial blood flow decreases after spinal anesthesia, so does hepatic blood flow.[123] If the anesthesiologist maintains mean arterial pressure (MAP) after placing a spinal anesthetic, hepatic blood flow will be maintained. Patients with hepatic disease must be carefully monitored and their blood pressure must be controlled during anesthesia to maintain hepatic perfusion. No studies have conclusively shown the superiority of regional or general anesthesia in patients with liver disease.[124-128] In patients with liver disease either regional or general anesthesia can be given, as long as the MAP is kept close to baseline.

Clinical Pearls

bullet.png
If mean blood pressure is maintained after placing a spinal anesthetic, neither hepatic nor renal blood flow will decrease.

bullet.png
Spinal anesthesia does not alter autoregulation of renal blood flow.

Renal blood flow is autoregulated. The kidneys remain perfused when the MAP remains above 50mmHg. Transient decreases in renal blood flow may occur when MAP is less than 50 mm Hg, but even after long decreases in MAP, renal function returns to normal when blood pressure returns to normal. Again, attention to blood pressure is important after placing a spinal anesthetic, and the MAP should be as close to baseline as possible. Spinal anesthesia does not affect autoregulation of renal blood flow. It has been shown in sheep that renal perfusion changed very little after spinal anesthesia.[129-132]

http://www.nysora.com/index.php?news=3424
 
twoliter said:
I think I'd be more concerned about a spinal in someone hypotensive with high SVR. If they are already "maximally" (I understand it may not be maximally, but to emphasize my point) vasodilated, how much more would the BP drop from a spinal? I don't know.
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I agree. I wouldn't expect this guy to drop much below baseline with a spinal, especially using isobaric marcaine. Plus, the drop is gradual and easy to correct with a neo gtt. I bet it would be more stable than a general - coagulation issues aside.
 
BLADEMDA said:
Well you've got very large balls to do a spinal as these patients tend to run on the low BP side with deceased SVR already. I'm wondering if there is a case report of HRS patient getting a neuraxial technique? Noyac, I enjoy your posts even when we disagree.
Click to expand...
I agree and while my balls may be big relatively I am a minimalist in the OR. I believe the less I assault my pt the better they will do.
I would definitely review past and present BP's. A good indicator is their dialysis pressures.
I feel like I can manage spinal hypotension at least as easily as pulmonary issues. I would probably have a unit or two of PRBC in and of course the clotting adjuncts as well. This would give me some preload and then phenylephrine running or even phenylephrine/epi mixture. The key is to not get behind as you know. I would also use isobaric marcaine since it hits softer.
I know I would not have a leg to stand on here if things went wrong but I think it is doable and potentially could be the better choice. It would avoid postop intubation which we can all agree would be a nightmare.
Blade, we do disagree from time to time but I think both of us are open minded and savy enough to see each other's point. Maybe not in this case but usually.
 
If patient and surgeon insist,
+ Come to Jesus talk with pt and family
+ preinduction A line
+ GETA
+ big IV access
+ lots of blood products
+/- TEG/Rotem
+/- TEE if weird stuff happens
+ going to ICU intubated postop given expected disaster factor
 
My plan:

Unit of platelets to be given rolling back to OR.

I PRBCs to be give the night before. Couple more ready in the room.

GETA + a-line. Extubate in OR.

K-Centra....no FFP.

No dialysis if K+ less than 5.5.

My one point I'll mention is that these Home 02 patients always get me riled up and I give them the intubated to ICU story. Yet, they always seem to do well. I think they like that positive pressure.

All I got.

The spinal stuff is weird to me. I'll crawl through the Sahara to keep from having an awake patient. Y'all must be masochists.
 
Ignatius J said:
My plan:

Unit of platelets to be given rolling back to OR.

I PRBCs to be give the night before. Couple more ready in the room.

GETA + a-line. Extubate in OR.

K-Centra....no FFP.

No dialysis if K+ less than 5.5.

My one point I'll mention is that these Home 02 patients always get me riled up and I give them the intubated to ICU story. Yet, they always seem to do well. I think they like that positive pressure.

All I got.

The spinal stuff is weird to me. I'll crawl through the Sahara to keep from having an awake patient. Y'all must be masochists.
Click to expand...
Love it.
 
Ignatius J said:
My plan:

Unit of platelets to be given rolling back to OR.

I PRBCs to be give the night before. Couple more ready in the room.

GETA + a-line. Extubate in OR.

K-Centra....no FFP.

No dialysis if K+ less than 5.5.

My one point I'll mention is that these Home 02 patients always get me riled up and I give them the intubated to ICU story. Yet, they always seem to do well. I think they like that positive pressure.

All I got.

The spinal stuff is weird to me. I'll crawl through the Sahara to keep from having an awake patient. Y'all must be masochists.
Click to expand...
Oh and if I do I spinal this pt snoozes with hits of ketamine depending on status.
 
I am absolutely loving this thread.

SDN anesthesia has been a very civil place as of late.... even with the old players in the house.
And all these new emojis...
Carry on. 👽
 
I'm glad I could help in bringing the best out of people. 😎

Our plan for this guy was going to be no dialysis unless K was extremely out of whack, GETA, A-line, slow induction, cisatracurium, 2 16Gs/cordis depending on access, post-induction TEG and PRBCs, FFP and PLTs for volume/PRN. So pretty much mirrors what many have suggested in this thread. We talked about Kcentra, but he had a relatively OK heart that could tolerate the volume from FFP and we figured we'd rely on the TEG to point us in the right direction.

As far as what ended up happening, patient's INR wouldn't correct (obviously) and he remained hypotensive despite the absence of hemodialysis. After a discussion with orthopedics, hepatology and the patient they decided that his risk for surgery was too high and it would make more sense for him to go to hospice.

The reason I wanted to share this case was two-fold. Despite our best efforts, the peri-operative mortality for this patient is extremely high. Based on his MELD score alone, his 7 day mortality was over 70% and his 30 day mortality is close to 100%. (http://www.mayoclinic.org/medical-p...t-operative-mortality-risk-patients-cirrhosis, using an age of 61, INR of 2.2, Bili of 4.5 and Cr of 5.5)

If this guy were having a lap chole done, he's got over a 6% risk of dying, probably much higher.
UTiJXTk.png

http://www.journal-of-hepatology.eu/article/S0168-8278(12)00359-5/pdf

And all this is without taking into account the chronic COPD and Afib.

The other reason was that while it sucks that we weren't able to do anything better for him, there are times when the right call is to not do anything at all, and I wanted to share a situation where it did end up without having to go to the OR.
 
Glad to see that everyone made the right call in this case. Hope is not lost. Some otthopods can be reasoned with.
 
Chloroform4Life said:
Glad to see that everyone made the right call in this case. Hope is not lost. Some otthopods can be reasoned with.
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This was obviously in a teaching hospital and the Orthopod most likely wasn't going to make money doing this procedure, that might explain why no one insisted on fixing the hip.
 
Planktonmd said:
This was obviously in a teaching hospital and the Orthopod most likely wasn't going to make money doing this procedure, that might explain why no one insisted on fixing the hip.
Click to expand...
I am not sure a private ortho pod would have made any money on this case either.
 
One good thing about going away from fee for service and toward value based healthcare is that surgeons will have to think twice about operating on these types of cases. When the surgeon has to take care of complications arising from the surgery and not be paid for it, they will think twice about the risk vs benefit. This is when our input will be invaluable.
 
Chloroform4Life said:
One good thing about going away from fee for service and toward value based healthcare is that surgeons will have to think twice about operating on these types of cases. When the surgeon has to take care of complications arising from the surgery and not be paid for it, they will think twice about the risk vs benefit. This is when our input will be invaluable.
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The Periop Surgical Home will save the day. We will take care of all the complications and not get paid.

Yay!
 
urge said:
The Periop Surgical Home will save the day. We will take care of all the complications and not get paid.

Yay!
Click to expand...

Haha no, we will not be taking care of the surgeon's complications, they will still be doing that. We can help inform them of the patient's overall health status and how they may or may not recover from surgery beforehand so they can make a more informed decision. I know this depends on a surgeon willing to listen, and i think they may start listening when poor outcome start hitting their wallet.

Regarding PSH, I dont like it either. I didnt go into anesthesia to do clinic. But there are too many driving forces pushing it forward for it to be ignored. The healthcare system is pushing toward it with bundled payment and value based payments. Even our own organization has been pushing it hard. For a young anesthesiologist, i see it as part of my future and there is not much i can do about it. So might as well embrace it and turn it into something i can tolerate.
 
Chloroform4Life said:
Haha no, we will not be taking care of the surgeon's complications, they will still be doing that. We can help inform them of the patient's overall health status and how they may or may not recover from surgery beforehand so they can make a more informed decision. I know this depends on a surgeon willing to listen, and i think they may start listening when poor outcome start hitting their wallet.

Regarding PSH, I dont like it either. I didnt go into anesthesia to do clinic. But there are too many driving forces pushing it forward for it to be ignored. The healthcare system is pushing toward it with bundled payment and value based payments. Even our own organization has been pushing it hard. For a young anesthesiologist, i see it as part of my future and there is not much i can do about it. So might as well embrace it and turn it into something i can tolerate.
Click to expand...
No, the healthcare system is not pushing for it! It is the ASA that has become the property of the big AMCs who invented this mutant idea and trying to shove it up the health care system behind!
 
Chloroform4Life said:
Haha no, we will not be taking care of the surgeon's complications, they will still be doing that. We can help inform them of the patient's overall health status and how they may or may not recover from surgery beforehand so they can make a more informed decision. I know this depends on a surgeon willing to listen, and i think they may start listening when poor outcome start hitting their wallet.

Regarding PSH, I dont like it either. I didnt go into anesthesia to do clinic. But there are too many driving forces pushing it forward for it to be ignored. The healthcare system is pushing toward it with bundled payment and value based payments. Even our own organization has been pushing it hard. For a young anesthesiologist, i see it as part of my future and there is not much i can do about it. So might as well embrace it and turn it into something i can tolerate.
Click to expand...

I think your first comment about the surgeon not wanting to do high risk cases for fear of having to take care of the complications without pay was very naive. That is not how billing is done. They don't keep billing their patients for their complications or daily rounds. That's why surgical notes are very short, because they are not billing for them. Medicine notes on the other hand are very long because for every section they bill more, and they bill for every one.

Good outcome or bad outcome it is all the same money wise for the surgeon. And the reality is they have PAs to do the rounding and note writing.

So, your initial premise was wrong.

As is your understanding of the PSH. You will round for free, because the surgeons don't want to do it anymore (or don't want to keep paying a PA to do it) and the ASA is ready to lap it up, for free.
 
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Chloroform4Life said:
. I know this depends on a surgeon willing to listen, and i think they may start listening when poor outcome start hitting their wallet.
Click to expand...

Since you are clueless about the direction medicine is taking, I'll toss you a bone.

"Big Data" (Google it if you have no clue what that is) is what will deter surgeon from doing cases with expected poor outcomes.
 
urge said:
Since you are clueless about the direction medicine is taking, I'll toss you a bone.

"Big Data" (Google it if you have no clue what that is) is what will deter surgeon from doing cases with expected poor outcomes.
Click to expand...

Not sure why you feel the need to make it so personal with your insults, but whatever.😎

I am trying to look into the future, not dwell on the present or the past.

The future as i see it involves a lot more bundled payment, as medicare is starting to roll that out this year with their joint replacement program. Unless healthcare is overhauled again, i think more of this is coming.

http://www.hhs.gov/about/news/2015/...ent-initiative-hip-and-knee-replacements.html

With bundled payment, surgeon fee, hospital fee, anesthesia fee, etc all becomes intertwined and complications will negatively affect all parties. See JAMA article:

http://jama.jamanetwork.com/mobile/article.aspx?articleid=1679400

All parties will then be incentivised to procceed with cases that make sense. I.e. elective cases with lower chances of complication (better patient selection, work up, and follow up).

Yes, we may be rounding on patients post op, but it wont be "for free". I mean yeah, we are not paid directly for the rounding, but we are part of the bundle payment, which we will have to negotiate for, and that rounding may get us a bigger piece of the pie during negotiation, and thats how we're paid for our rounding.

Again, im just spit balling. I may be wrong (hopefully am). But no need to get ugly with your comments.😉
 
Planktonmd said:
No, the healthcare system is not pushing for it! It is the ASA that has become the property of the big AMCs who invented this mutant idea and trying to shove it up the health care system behind!
Click to expand...

Bundled payments have been in the works for some time, and for us, that means collaborating with the hospital for quality measures. That's the way it is headed and there is nothing we can do about it. Reimbursement will be affected, but it is absolutely a chance to demonstrate the value of the specialty.
 
Are you guys getting any push back from Pharmacy or Hematology for using KCentra in patients not taking VKA, as was suggested for this patient?
 
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