Recent case

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bostonblaz

bostonblaz

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Tired of rank stuff so here is something I delt with this morning.
81 y/o for open 8 cm infrarenal AAA repair. Unable to be done endovascular as was attempted twice by two different gurus in two different states. The guy has tons of cash and "doesnt want to drop dead" before he can spend it. Both attemps at endovascular repair were done with him awake because no anesthesiologist wanted to put him to sleep. I forgot to mention he is about as sick as someone can be with a pap of 70, and ef of 20 or so and a sat of 79 on 3 liters nc in the holding area. He also has a host of other comorbidities but he pulmonary hypertension was what was most likely going to make my day a living hell. The vascular surgeon is a great friend of mine and a stud surgeon and had casually mentioned this to me one night over beers a month ago and i thought he was just messing around with me. So now all of us know this wont end well yet i really cant cancel. He has every test and every work up under the sun. He will never get any better and both he and his family want to proced. What would you do? Not so much how would you do it but more what would you say to him and his family and would you do it? I kind of felt like this guy was hating life and wanted to go to "sleep" and not wake up. I also felt like his family wanted it just as bad for the same outcome but their motivation was the $$$$$$ they would collect from his death. I will let you kow what happened but i would like to now what you guys think. Blaz
 
The only elegant way of doing it...

pent sux tube...

The rest is just icing on the cake.
 
pretty terrible case but i could justify a preinduction epidural and arterial line, smooth induction with minimal apneic time, CVL +/- PAC but i think i would avoid it. have a little epi or milrinone in line for trouble and try hard to extubate at the end.
 
I would start by telling him that he will likely not survive this hospitalization, if he survives the surgery. Its the truth. Now, realize you are leaving out alot (renal function, meds, other comorbidities, ? valvular heart disease), but here goes. I would do GA, inhalation induction vs RSI, PA cath, Aline, TEE, and a couple large bores. With an EF of 20% he should have an AICD, if he doesn't then he gets zoll pads. I would also have epi, phenylephrine, dobutamine, nitroG, nitroP, and milrinone ready to go on pumps. I would also want NO available to use, not in the room per se, but available. My main fear would be RV and/or LV failure due to fluid shifts hence the PA and TEE. Keep him "even steven" fluid-wise. Wouldn't even consider a neuraxial for fear of coagulopathy secondary to massive resuscitation. This is where I would start.
 
I would talk him into going home, optimize his BP meds, take them religiously, live a stress free life: sipping lemonade at the beach house, enjoy the sunrise/sunsets, cool ocean breeze. Dying of an ruptured aneurysm at home next week/month/year/years??? while playing with the grandchildren is WAY BETTER than barely surviving a morbid surgery, not being able to be extubated in the ICU, being trached after a few weeks, and eventually dying of pneumonia or sepsis.
 
Tough situation. I would have a sit down with his family, him, and the surgeon present and lay it all out, let him know that because of his poor protoplasm that he has a very goo chance of not making it out of the hospital. I would have the surgeon present because (and maybe not this one) they typically underestimate the pt's true risk. But they have decided to proceed and no matter what you tell them its probably not going to matter. The only question I have is why does his sats suck, is this the usual for him?

Pre induction PAC
I would seriously consider an epidural if the anticoag plan would allow for one
Tee and hope someone was around that was better at looking at it than I am
(I know tee and PAC may be overkill, but one of my goals would be specifically to keep his pa's down)
In addition to the usual I would have milrinone in the line and ready to go
I would probably start the milrinone as soon as we got into the room
Lots of prayer to anyone I could think of


How did it go?
 
Bertelman said:
Why do you assume massive resuscitation? Do you ever use epidurals for AAAs?
Click to expand...

I do and I have, but if the AAA is as nasty as it sounds then it could be an issue. Now, would he benefit from the pain control? Sure....but will it make the difference between him getting extubated or not. Likely not with that level of pulm HTN.
 
W222 said:
I do and I have, but if the AAA is as nasty as it sounds then it could be an issue. Now, would he benefit from the pain control? Sure....but will it make the difference between him getting extubated or not. Likely not with that level of pulm HTN.
Click to expand...

I personally think you should give him the best shot you can at extubation. If you trust the surgeon and he thinks he can get this thing clamped and the bleeding under control I would believe it more with an infrarenal aaa (even at 8cm). If he says its gonna be a blood bath, I would not put it in but I would at least have the discussion.
 
This isn't a hard situation at all. He's optimized, he understands the risks, he's of sound mind, and we have a surgeon who wants to do it. Document the conversation, RBA explained and do the surgery. Get him up to the ICU and let them worry about extubation.
 
Tell him he can have almost as much fun disposing of his money through his will as he can spending it himself.
 
He’s optimized. Proceed with scheduled case. If this is something he wants done and understands R/B, then document the interaction and proceed. 8cm AAA is only going to get bigger, so fixing it is absolutely appropriate. I would place an epidural without hesitation. Ask the surgeon if he can give you sequential/partial unclamping vs. removal of the cross clamp all at one time in order to reperfuse slowly and avoid wild swings in B.P. and acute metabolic derangements. Once things look good, dose up the epidural and put it on a pump at 6-8 ml/hr. This will help with extubation and atelectasis once he arrives in the ICU.
 
My thoughts: A sat of 79% on oxygen probably predicts 100% mortality rate. Hopefully the surgeon uses a posteriolateral approach to the aorta. But if I were to do this case:

1) Preinduction arterial line & epidural. I place defib pads on all big cases. You'll never regret it.
2) Induce (rare time I would use etomidate), sux to minimize apnea time and hypercarbia
3) Central line and big PIV. PA-catheter for mostly postop management (oximetric CCO)
4) TEE. Need to know both right and left heart function. Many TTE are not accurate.
5) Drips: Based on the TEE, I'd probably have epi, vaso, nitroglycerine ready.
6) I'd minimize crystalloid if possible, transfuse early and keep up
7) For cross clamp, I bolus the epidural with lidocaine 2%. I've used this approach several times and have always been pleased with the stable hemodynamics. And is short-lived so it wears off by the time the clamp comes off
8) If the surgeon is as slick as you describe, this should be a short case.

Some thoughts on what others have said:
These patients don't really get coagulopathic and there's no contraindication for epidurals. Sometimes we will do lumbar drains based on the anatomy (not infrarenal though).
Do not do mask inductions in patients with pulmonary hypertension.
The greatest immediate postoperative risk for this patient is pulmonary. Don't extubate.

Goals: Avoid hypoxia, hypercarbia, hypotension and tachycardia. Keep up with blood loss. Use your epidural. Stay intubated, make sure the heart, lungs and brain are good before trying to extubate. Schedule the trach & PEG.
 
Talk to family just like you would with any other big case. Proceed!

I can't believe some people wouldn't put an epidural in this guy. The question is, do you dose it before or after the case?
 
geogil said:
Why would you not do a mask induction d/t PA HTN?
Click to expand...

Things that raise PVR:

Hypoxia
Hypercarbia
Acidosis
PEEP
Nitrous
Hypothermia

Mask induction could raise CO2. Also, whats the point of farting around with a mask induction when you've gotta put in lines, epidural, TEE, etc.
 
ssmallz said:
Get him up to the ICU and let them worry about extubation.
Click to expand...

Thanks.....douche.

Just kidding. I would proceed with the case as many have said (preinduction a-line and epidural, gentle induction, PAC, big access, dose epidural at end if hemodynamically stable), but I would end it like I am going to extubate, and if he just isn't ready, then proceed to the ICU. If he is otherwise stable and not bleeding and hasn't been massively transfused, there is no reason not to work toward extubation in the OR.

We do have an attending that is notorious for not extubating patients if he thinks "they just didn't look ready". He drags them to the ICU, we reverse them, turn off the sedation and pull the tube within the hour. Hate this weak approach. Sorry for the brief highjack.
 
Last edited:
I did an epidual in his pre op room with out sedation as he didnt really mind and he was more interested in telling me his life story. I didnt do a test dose as i really didnt want to knock any intercostals out with an o2 sat of 79. I put in an aline and put in an u/s guided (usually only use for blocks but since i wasnt sedating the guy i wanted a one pass placement) 8F introducer with a lot of local. To the room and monitors and o2 on. Gave 50 mcg of fent and no midaz and i look up at the monitor and he has a sinus beat ( starting hr of 60's) then long pause, a beat and then nothing. My surgeon buddy was standing next to me and he puts his hands on the chest and starts compressing and i dl and tube him and give some epi. After 2 or so min we get a rthym and he has a few beats and then vtach which his icd detects and fires. I had not put on the magnet as of yet. We stablize him and send him to the unit. Sucked. I had thought he could never handle the cross clamp or the profound acidosis that would follow upon unclamping. I never thought some fentnyl would be the death of him. I will let you kow how it goes but i hope for his sake that it doesnt end with a trach and a peg. Blaz
 
That is hardcore.

Sounds like he would have down great with extubation😛😉😀.

bostonblaz said:
I did an epidual in his pre op room with out sedation as he didnt really mind and he was more interested in telling me his life story. I didnt do a test dose as i really didnt want to knock any intercostals out with an o2 sat of 79. I put in an aline and put in an u/s guided (usually only use for blocks but since i wasnt sedating the guy i wanted a one pass placement) 8F introducer with a lot of local. To the room and monitors and o2 on. Gave 50 mcg of fent and no midaz and i look up at the monitor and he has a sinus beat ( starting hr of 60's) then long pause, a beat and then nothing. My surgeon buddy was standing next to me and he puts his hands on the chest and starts compressing and i dl and tube him and give some epi. After 2 or so min we get a rthym and he has a few beats and then vtach which his icd detects and fires. I had not put on the magnet as of yet. We stablize him and send him to the unit. Sucked. I had thought he could never handle the cross clamp or the profound acidosis that would follow upon unclamping. I never thought some fentnyl would be the death of him. I will let you kow how it goes but i hope for his sake that it doesnt end with a trach and a peg. Blaz
Click to expand...
 
😱 Didn't expect THAT to happen.

bostonblaz said:
I did an epidual in his pre op room with out sedation as he didnt really mind and he was more interested in telling me his life story. I didnt do a test dose as i really didnt want to knock any intercostals out with an o2 sat of 79. I put in an aline and put in an u/s guided (usually only use for blocks but since i wasnt sedating the guy i wanted a one pass placement) 8F introducer with a lot of local. To the room and monitors and o2 on. Gave 50 mcg of fent and no midaz and i look up at the monitor and he has a sinus beat ( starting hr of 60's) then long pause, a beat and then nothing. My surgeon buddy was standing next to me and he puts his hands on the chest and starts compressing and i dl and tube him and give some epi. After 2 or so min we get a rthym and he has a few beats and then vtach which his icd detects and fires. I had not put on the magnet as of yet. We stablize him and send him to the unit. Sucked. I had thought he could never handle the cross clamp or the profound acidosis that would follow upon unclamping. I never thought some fentnyl would be the death of him. I will let you kow how it goes but i hope for his sake that it doesnt end with a trach and a peg. Blaz
Click to expand...
 
bostonblaz said:
Gave 50 mcg of fent and no midaz and i look up at the monitor and he has a sinus beat ( starting hr of 60's) then long pause, a beat and then nothing
Click to expand...

So much for narcotics being cardiac stable.... 🙄

Honestly though, this is a very unusual code if it is indeed 2/2 50mcgs of fent.

Even if the PA pressures superceeded systemic pressures, you should still see an EKG tracing as the heart attempts to overcome PA pressures... at least initially (hard to tell not knowing what his a-line b.p. was before and after the 50mcgs.)

This actually seems as if the culprit is an overiding parasynpathetic/vagal tone which progressed to asystole... but then again maybe it was pulmonary-systemic pressure reversal or just raw funkyness.

What were you guys thinking as far as a cause?

Crazyness.

Thanks for sharing Blaz. 👍
 
If the patient really wanted this case done, I would just find one of the partners in my group along with a priest to do the case. This isn't a license for murder in my eyes.
 
sevoflurane said:
This actually seems as if the culprit is an overiding parasynpathetic/vagal tone which progressed to asystole... but then again maybe it was pulmonary-systemic pressure reversal or just raw funkyness.
Click to expand...

This reminded me of a patient with ESRD, EF 40%, DM2, vascular path, pHTN with PASP ~40-50s, who ended up coding on the OR table during his BKA. TEE showed hypovolemia and he actually survived after very aggressive fluid resuscitation. However, before he coded, he started brady down to 30s and then went into VT first. Then we shocked him back to PEA and then eventually got pulse back after a couple runs of chest compression and epi/norepi.

The only thing we could figure out / correct for him was his hypovolemia (from hemorrhage 2/2 uremic platelets) and that would explain his PEA but I never really figure out why he became bradycardia first or why bradycardia lead to VT....

Thoughts?
 
bostonblaz said:
I did an epidual in his pre op room with out sedation as he didnt really mind and he was more interested in telling me his life story. I didnt do a test dose as i really didnt want to knock any intercostals out with an o2 sat of 79. I put in an aline and put in an u/s guided (usually only use for blocks but since i wasnt sedating the guy i wanted a one pass placement) 8F introducer with a lot of local. To the room and monitors and o2 on. Gave 50 mcg of fent and no midaz and i look up at the monitor and he has a sinus beat ( starting hr of 60's) then long pause, a beat and then nothing. My surgeon buddy was standing next to me and he puts his hands on the chest and starts compressing and i dl and tube him and give some epi. After 2 or so min we get a rthym and he has a few beats and then vtach which his icd detects and fires. I had not put on the magnet as of yet. We stablize him and send him to the unit. Sucked. I had thought he could never handle the cross clamp or the profound acidosis that would follow upon unclamping. I never thought some fentnyl would be the death of him. I will let you kow how it goes but i hope for his sake that it doesnt end with a trach and a peg. Blaz
Click to expand...

You know it will. Best case scenario, at least his care will be paid for in full and maybe the hospital will get a generous donation from the family for their efforts.

Also, I still don't fully understand Bezold-Jarisch, but it definitely sounds like something vagal.
 
bostonblaz said:
he has a sinus beat ( starting hr of 60's) then long pause, a beat and then nothing... then vtach which his icd detects and fires.
Click to expand...

His icd didn't pace him?? When was the last time it was interrogated? Doesn't seen right.
 
Hypotension is sensed by the carotid sinus(baroreceptor) which send out sympathetic signals to increase heart rate and contractility. The left ventricle, even though preload is reduced, senses this increased sympathetic outflow as increased pressures within itself, which triggers bradycardia

That's my understanding of the Bezold-Jarisch reflex
 
Idiopathic said:
bezold-jarisch
Click to expand...

👍

Good discussion and review.

http://www.ncbi.nlm.nih.gov/pubmed/11573596

Reflex cardiovascular depression with vasodilation and bradycardia has been variously termed vasovagal syncope, the Bezold-Jarisch reflex and neurocardiogenic syncope. The circulatory response changes from the normal maintenance of arterial pressure, to parasympathetic activation and sympathetic inhibition, causing hypotension. This change is triggered by reduced cardiac venous return as well as through affective mechanisms such as pain or fear. It is probably mediated in part via afferent nerves from the heart, but also by various non-cardiac baroreceptors which may become paradoxically active. This response may occur during regional anaesthesia, haemorrhage or supine inferior vena cava compression in pregnancy; these factors are additive when combined. In these circumstances hypotension may be more severe than that caused by bradycardia alone, because of unappreciated vasodilation. Treatment includes the restoration of venous return and correction of absolute blood volume deficits. Ephedrine is the most logical choice of single drug to correct the changes because of its combined action on the heart and peripheral blood vessels. Epinephrine must be used early in established cardiac arrest, especially after high regional anaesthesia.
 
Interesting scenario, bostonblaz. Please keep us posted if the guy makes any sort of recovery.

Also interesting is the Sherlockian case of the pacemaker that didn't pace.
 
even though this patients heart would likely never be "empty", he would not be able to augment his high catecholamine state and any significant drop in preload would not be tolerated well. i think the principle of bezold reflex in this patient is more aplicable than the actual "empty heart" problem seen in younger patients following spinal, etc.

curious about the pacer also. would follow up on that.
 
Did you have an ABG prior to this fiasco? I'll bet he was acidotic on arrival to the OR.

Sats 79%.

Metabolical acidosis very likely.

ICD's will lose ability to capture in metabolically compromised environments.

Did you check his metabolic status prior to induction?
 
I just wanted to say that this was an awesome thread. Sometimes it is easy to get lost in the residency ranking process and forget the coolness of the field we will be entering.
 
bostonblaz said:
I did an epidual in his pre op room with out sedation as he didnt really mind and he was more interested in telling me his life story. I didnt do a test dose as i really didnt want to knock any intercostals out with an o2 sat of 79. I put in an aline and put in an u/s guided (usually only use for blocks but since i wasnt sedating the guy i wanted a one pass placement) 8F introducer with a lot of local. To the room and monitors and o2 on. Gave 50 mcg of fent and no midaz and i look up at the monitor and he has a sinus beat ( starting hr of 60's) then long pause, a beat and then nothing. My surgeon buddy was standing next to me and he puts his hands on the chest and starts compressing and i dl and tube him and give some epi. After 2 or so min we get a rthym and he has a few beats and then vtach which his icd detects and fires. I had not put on the magnet as of yet. We stablize him and send him to the unit. Sucked. I had thought he could never handle the cross clamp or the profound acidosis that would follow upon unclamping. I never thought some fentnyl would be the death of him. I will let you kow how it goes but i hope for his sake that it doesnt end with a trach and a peg. Blaz
Click to expand...

Do you think if you would have spent a little more time in the preop area, ya know, talking, discussing, joking and laughing....that you could have got him to help pay off some of your student loans?

Cuz that's what I would have been thinking this whole time..."the guy has lots of money and is about to die, I wonder if I can talk him into paying off some student loans for me?"
 
Any update on our friend?
 
So here is the update. I didnt check a gas going into the or because i didnt want yet another reason why i shouldnt do the case. Medtronic came to look at his icd afterwards and said pace attempts were made during the event with out capture. I didnt have the monitor on pace detect as his primary reason for the icd is low ef and he has no conduction issue. Cards and medtronic both believed that it was a pH dependent phenomon. I did his gas for peg and trach today. He will spend one more night then head out to rehab. Really sad. He wrote on a piece of paper today he feels like s**t and he knows he will be dead soon. Then he wrote it was worth a try and you should have let me die. Sucks. I have another good one from today and i will put it up soon. Blaz
 
Rough case... sorry to hear the short term outcome. Thanks for posting, though - it's really nice reading clinical threads!
 
bostonblaz said:
So here is the update. I didnt check a gas going into the or because i didnt want yet another reason why i shouldnt do the case. Medtronic came to look at his icd afterwards and said pace attempts were made during the event with out capture. I didnt have the monitor on pace detect as his primary reason for the icd is low ef and he has no conduction issue. Cards and medtronic both believed that it was a pH dependent phenomon. I did his gas for peg and trach today. He will spend one more night then head out to rehab. Really sad. He wrote on a piece of paper today he feels like s**t and he knows he will be dead soon. Then he wrote it was worth a try and you should have let me die. Sucks. I have another good one from today and i will put it up soon. Blaz
Click to expand...

As soon as he gets your bill, he will become so pissed and hypertensive that it will be the end of it.
 
bostonblaz said:
So here is the update. I didnt check a gas going into the or because i didnt want yet another reason why i shouldnt do the case. Medtronic came to look at his icd afterwards and said pace attempts were made during the event with out capture. I didnt have the monitor on pace detect as his primary reason for the icd is low ef and he has no conduction issue. Cards and medtronic both believed that it was a pH dependent phenomon. I did his gas for peg and trach today. He will spend one more night then head out to rehab. Really sad. He wrote on a piece of paper today he feels like s**t and he knows he will be dead soon. Then he wrote it was worth a try and you should have let me die. Sucks. I have another good one from today and i will put it up soon. Blaz
Click to expand...

That's what I was thinking. Did y'all (you/pt/surgeon) have a discussion on DNR status before surgery? Like, "we'll give this a shot, but if it doesn't work we're not going to leave you on a vent in the ICU." You said in your first post "I kind of felt like this guy was hating life and wanted to go to "sleep" and not wake up," so it sounds like your spidey-sense was already tingling.

I know hindsight is 20/20, but I also think we as a group (physicians, but also anesthesiologists in general) don't cover end-of-life issues very well. I know we have a limited amount of time with patients, and the surgeon or their PCP has a longer-term relationship, but we also know the risks of surgery/anesthesia the best.
 
2win said:
👍👍👍
Click to expand...

bostonblaz said:
I did an epidual in his pre op room with out sedation as he didnt really mind and he was more interested in telling me his life story. I didnt do a test dose as i really didnt want to knock any intercostals out with an o2 sat of 79. I put in an aline and put in an u/s guided (usually only use for blocks but since i wasnt sedating the guy i wanted a one pass placement) 8F introducer with a lot of local. To the room and monitors and o2 on. Gave 50 mcg of fent and no midaz and i look up at the monitor and he has a sinus beat ( starting hr of 60's) then long pause, a beat and then nothing. My surgeon buddy was standing next to me and he puts his hands on the chest and starts compressing and i dl and tube him and give some epi. After 2 or so min we get a rthym and he has a few beats and then vtach which his icd detects and fires. I had not put on the magnet as of yet. We stablize him and send him to the unit. Sucked. I had thought he could never handle the cross clamp or the profound acidosis that would follow upon unclamping. I never thought some fentnyl would be the death of him. I will let you kow how it goes but i hope for his sake that it doesnt end with a trach and a peg. Blaz
Click to expand...

That's what happens when you deviate from protocol.
 
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