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Severe pHTN for bilateral debridement @ Surgicenter : (

ISoNitrous

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Hey everyone,

Interesting case coming up I thought I’d solicit some ideas on.


57 yo F with history of primary pHTN, COPD, OSA non-compliant with CPAP (nocturnal nasal cannula 2L instead), CABG in 2001, DES 4 mo. ago to SVG-RCA. LIMA-LAD patent, otherwise just luminal irregularities and lesions <40%. Scheduled for bilateral venous stasis ulcer debridement at the surgicenter.


No angina. Can “just about” lay flat. But minimal exercise tolerance due to SOB.

Sees pHTN specialist who says she’s optimized on sildenafil TID.

RHC shows PAP 70/44 with systemic BP 108/62.

Echo = Severely dilated/dysfunctional RV. Normal LV, moderate TR but no other valvulopathy.

On Plavix for 4mo. old DES.


The severe pHTN is an exclusion for a case like this to happen at the surgicenter (attached to hospital via covered indoor bridge), but the surgeon told me it is happening there.

On paper, “should be quick,” but with this surgeon, never is.

What’s the plan, Stan?
 
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chocomorsel

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Hey everyone,

Interesting case coming up I thought I’d solicit some ideas on.


57 yo F with history of primary pHTN, COPD, OSA non-compliant with CPAP (nocturnal nasal cannula 2L instead), CABG in 2001, DES 4 mo. ago to SVG-RCA. LIMA-LAD patent, otherwise just luminal irregularities and lesions <40%. Scheduled for bilateral venous stasis ulcer debridement at the surgicenter.


No angina. Can “just about” lay flat. But minimal exercise tolerance due to SOB.

Sees pHTN specialist who says she’s optimized on sildenafil TID.

RHC shows PAP 70/44 with systemic BP 108/62.

Echo = Severely dilated/dysfunctional RV. Normal LV, moderate TR but no other valvulopathy.

On Plavix for 4mo. old DES.


The severe pHTN is an exclusion for a case like this to happen at the surgicenter (attached to hospital via covered indoor bridge), but the surgeon told me it is happening there.

On paper, “should be quick,” but with this surgeon, never is.

What’s the plan, Stan?
Turf them to the hospital. What surgeon plans on doing an outpatient procedure, in a surgicenter, on a patient taking Viagra not for his penile dysfunction?
Your window of error with those two pressures is very narrow.
But I have once told a surgeon that "the patient's PAPs are in the 60s-70's" and he's like "that's good right?"
They are often clueless when it comes to medicine.
And the DES? Just four months out? This doesn't sound like an emergency surgery to me. Does he plan on stopping the Plavix to debride this wound?
Sounds like a cowboy all the way around.
 
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Arch Guillotti

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The PA pressure doesn’t seem that horrible to me:confused:. Maybe I am just used to seeing sick obese patients with sleep apnea who smoke?:excuseme::excuseme::excuseme:. The RV sounds more concerning. And what is the deal with the Viagra? For the case itself, careful induction amd LMA. Bleeding is about more concerning for me.
 
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abolt18

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Hey everyone,

Interesting case coming up I thought I’d solicit some ideas on.


57 yo F with history of primary pHTN, COPD, OSA non-compliant with CPAP (nocturnal nasal cannula 2L instead), CABG in 2001, DES 4 mo. ago to SVG-RCA. LIMA-LAD patent, otherwise just luminal irregularities and lesions <40%. Scheduled for bilateral venous stasis ulcer debridement at the surgicenter.


No angina. Can “just about” lay flat. But minimal exercise tolerance due to SOB.

Sees pHTN specialist who says she’s optimized on sildenafil TID.

RHC shows PAP 70/44 with systemic BP 108/62.

Echo = Severely dilated/dysfunctional RV. Normal LV, moderate TR but no other valvulopathy.

On Plavix for 4mo. old DES.


The severe pHTN is an exclusion for a case like this to happen at the surgicenter (attached to hospital via covered indoor bridge), but the surgeon told me it is happening there.

On paper, “should be quick,” but with this surgeon, never is.

What’s the plan, Stan?
The plan is to tell him that this patient is inappropriate for surgery at an outpatient surgery center and she requires to have her case done at the main hospital.
 
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Hork Bajir

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If this is not an urgent surgery, delay until the cardiologist thinks the patient can stop their plavix. Then do primary blocks. If there is some urgency to the procedure, for example if the ulcers are becoming infected, then admit to the hospital and hold the plavix while starting cangrelor. Stop the cangrelor on call to the OR, then do the same plan (femoral and sciatic blocks with minimal sedation). Resume plavix immediately postop. Either way, make it clear to the surgeon that it is unsafe to do this case in the surgicenter and if he/she insists on proceeding, suggest that they can find a different anesthesiologist who is more willing to take a gamble for the sake of expediency.
 
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buccsmf1

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but the surgeon told me it is happening there.

i understand we're at pressure to get cases done but youve gotta have a spine at some point. there is no universe in which this case is appropriate to do at a ASC. even if you think youre the best anesthesiologist on the planet if something does go wrong youre toast in court. there are 9 out of 10 of us you could put on the stand that would agree doing this in an ASC is wrong.
 
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jeesapeesa

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Hey everyone,

Interesting case coming up I thought I’d solicit some ideas on.



57 yo F with history of primary pHTN, COPD, OSA non-compliant with CPAP (nocturnal nasal cannula 2L instead), CABG in 2001, DES 4 mo. ago to SVG-RCA. LIMA-LAD patent, otherwise just luminal irregularities and lesions <40%. Scheduled for bilateral venous stasis ulcer debridement at the surgicenter.


No angina. Can “just about” lay flat. But minimal exercise tolerance due to SOB.

Sees pHTN specialist who says she’s optimized on sildenafil TID.

RHC shows PAP 70/44 with systemic BP 108/62.

Echo = Severely dilated/dysfunctional RV. Normal LV, moderate TR but no other valvulopathy.

On Plavix for 4mo. old DES.


The severe pHTN is an exclusion for a case like this to happen at the surgicenter (attached to hospital via covered indoor bridge), but the surgeon told me it is happening there.

On paper, “should be quick,” but with this surgeon, never is.

What’s the plan, Stan?

GA with LMA/ett. Keep well oxygenated and normocarbic....and in a hospital.
 
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Arch Guillotti

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then do the same plan (femoral and sciatic blocks with minimal sedation). Resume plavix immediately postop. Either way, make it clear to the surgeon that it is unsafe to do this case in the surgicenter and if he/she insists on proceeding, suggest that they can find a different anesthesiologist who is more willing to take a gamble for the sake of expediency.

Bilateral blocks on each side. No thanks. It might feel fun to tell the surgeon to piss off and find somebody else. I would just tell him that your group has discussed it and that nobody agrees it is appropriate. End of story.
 
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Beeftenderloin

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The severe pHTN is an exclusion for a case like this to happen at the surgicenter (attached to hospital via covered indoor bridge), but the surgeon told me it is.

As one of my favorite attendings liked to say “I’m not telling you that you can’t do surgery (there), I’m just telling you we won’t be providing anesthesia”
 
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coffeebythelake

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I’m glad I’m not the only one wondering why tf we’re even doing the case here with no mention of infection or other urgencies. All this for venous stasis? Must be a financial emergency for the surgeon.

Agree. I can't see a compelling reason why this case should be done only 4 months after DES, and seems wholly inappropriate for ASC
 
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AdmiralChz

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The severe pHTN is an exclusion for a case like this to happen at the surgicenter (attached to hospital via covered indoor bridge), but the surgeon told me it is happening there.

... this is a very easy no. Just explain how this patient is super high risk from tons of different angles. if they are still persistent just stonewall, again say no, and involve an administrator.
 
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Hoya11

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Keep spontaneous w/ LMA.

Also, when is it ok to use LMA again? I'm in Texas...

when surgicenters opened again, we used them again..

took some a while, some still intubated everyone with glidescope and covered with plastic for about a month

There was never a policy it was always just by individual provider

now we are back to full blown normal, LMAs and DLs - from NYC area
 
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Pinkegg

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While I agree that doing this case at a surgery center seems pretty ridiculous, just to play devil’s advocate, what exactly is different from doing the case in one spot or 200 yards away?
Presumably the surgery center has the same equipment, same drugs, same crash cart, same anesthesiologists, same everything really, as the main OR? If the case goes south, whether it happens in the main OR or SC, the patient will be coded or resuscitated or whatever and then transferred to the unit either way. Especially since it’s an attached surgery center.
 
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Arch Guillotti

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@Arch Guillotti what is your objection to bilateral blocks? Are you worried about LAST or something? If so, I guess one could make a case to do each leg on a separate trip to the OR, but the downside is you’re increasing the time that the patient needs to be off of their anti platelet therapy

2 blocks on each leg is 4 blocks total. Takes a lot of time. LAST is a consideration if you are dosing the blocks for surgical anesthesia. If blocks aren't perfect then your plans goes out the window. Just put in an LMA.
 
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bigtuna

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I run a PH clinic.
A couple of thoughts:

-this patient is unlikely to have "primary" idiopathic PAH. Sounds like multifactorial PH from untreated OSA, COPD, and probably HFpEF. Monotherapy with sildenafil is not an adequate regimen for idiopathic PAH with RV dysfunction but might be a fairly common off label treatment for multifactorial PH

-my experience is that PAH patients on therapy tolerate general anesthesia pretty well as long as the anesthesiologist is aware of the condition and knows to treat the patient with kid gloves. I have at least 3 IPAH patients that have been labelled as having anaphylaxis to rocuronium that I am sure was coding on induction with PAH that was not diagnosed or treated at the time of the surgery.

-guidelines from PH literature suggest using regional techniques if possible for PAH patients but I don't think that is based on any good data and as noted most of these patients do ok with anesthesia in my experience.

-i try to keep all of my patients with real PH out of ASC's and endoscopy centers. you want to have quick access to inotropes, inhaled vasodilators, even ECMO if one of these patients crashes unexpectedly
 
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Planktonmd

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The PAH here is not horrible and I bet you we treat people like her everyday without even knowing how bad their PAH is.
PAH secondary to COPD is usually better tolerated than primary PAH and does not cause the dramatic picture if acute RH failure everyone is afraid of.
Slow induction, LMA, tell him to inject some local for post op pain.
 
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The PAH here is not horrible and I bet you we treat people like her everyday without even knowing how bad their PAH is.
PAH secondary to COPD is usually better tolerated than primary PAH and does not cause the dramatic picture if acute RH failure everyone is afraid of.
Slow induction, LMA, tell him to inject some local for post op pain.

Sure, I agree many of us anesthetize big OSA-ers with systolic PAPs in the 60-70’s all the time, but not like this. This PAP is approaching 2/3 systemic which is my own personal line in the sand that makes my ears perk up a bit, plus they have a severely dysfunctional RV, not some thick RV ready to do pressure work.

You’ve got a 4mo old DES, bad RV, and severe pulmonary HTN. This is literally the antithesis of an ASC case.

With that said, sure you can get this case done with a simple GA anesthetic with push dose inotropes around but if things go badly just cut the check.
 
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Newtwo

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2 blocks on each leg is 4 blocks total. Takes a lot of time. LAST is a consideration if you are dosing the blocks for surgical anesthesia. If blocks aren't perfect then your plans goes out the window. Just put in an LMA.
Thats at least 3 blocks too many!!
Id just about entertain doing a case with a single block, after that they have to have a GA. Most do fine...

It is always interesting to me when regionalists try to 'save' some dude from a GA, then snow them with fent/midaz whatever...
 
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Beeftenderloin

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It is always interesting to me when regionalists try to 'save' some dude from a GA, then snow them with fent/midaz whatever...

Have an attending like this that is absolutely terrifying to work with. Regional to him means block plus GA with unprotected airway, even with a good surgical block. It’s terrifying.
 
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deleted252565

Agree with everyone here. Definitely not an appropriate patient for ASC setting. If there is a true urgency for the surgery, should have a discussion with cardiologist regarding holding Plavix. In terms of anesthetic plan, I think you may consider epidural with intermittent dosing of 2% lido (less hemodynamic alteration compared to spinal) given proper withholding of antiplatelet/anticoagulant, plus mild sedation, or even awake (since with hx of OSA and presumably obesity can make normocapnea during sedation challenging). If airway/ventilation or patient cooperation seem to be a problem, I would go straight to GETA with careful induction and a preinduction aline with epi on standby. I think with LMA, sometimes you would need to use high inhaled volatile conc to prevent laryngospasm, which can cause significant HD derangement, and depending on body habitus, adequate ventilation using LMA may not be guaranteed.
 
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deleted252565

would you even require them to hold plavix for ulcer debridement? id be fine with proceeding on plavix
I think if it is superficial debridement, plavix probably shouldn’t be held, and this type of case usually can be done in office/at bedside without involvement of anesthesiologist. But since the surgeon asked for anesthesia, it could be a surgical debridement of deeper nonviable tissues bilaterally, and thus came with certain risk of bleeding. I think it would be best to involve surgeon and cardiologist in the discussion of risk vs benefit. And if plavix should be continued, I would not even attempt any kind of regional or neuraxial block.
 
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coffeebythelake

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would you even require them to hold plavix for ulcer debridement? id be fine with proceeding on plavix

Given the recent DES (less than 6 months ago), there would need to be a compelling reason to 1. do the surgery, and 2. stop DAPT.
 
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anbuitachi

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I think if it is superficial debridement, plavix probably shouldn’t be held, and this type of case usually can be done in office/at bedside without involvement of anesthesiologist. But since the surgeon asked for anesthesia, it could be a surgical debridement of deeper nonviable tissues bilaterally, and thus came with certain risk of bleeding. I think it would be best to involve surgeon and cardiologist in the discussion of risk vs benefit. And if plavix should be continued, I would not even attempt any kind of regional or neuraxial block.

we do regional all the time on plavix...
agree if deeper can bleed, but is risk of more bleeding > risk of taking patient off plavix in a sick patient with 4 month old DES stent?
 
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pgg

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we do regional all the time on plavix...
agree if deeper can bleed, but is risk of more bleeding > risk of taking patient off plavix in a sick patient with 4 month old DES stent?
Plavix or no Plavix, surgery itself is pro inflammatory. We don't dodge the reocclusion risk by keeping the DAPT going when we take them to the OR for a procedure, so I wouldn't be particularly swayed by the surgeon's kind offer to compromise and leave the Plavix on.

Anyway, it may be that these ulcers really do need to be debrided sooner rather than later, hard to know from the short description how much nonviable tissue there is, and the infection/sepsis risk if the surgeon just leaves it for another (sorta arbitrary) 2 months to get to 6 months post stent. I wouldn't refuse to do the case at a hospital, but I would at an ASC.
 
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Hey everyone,

Interesting case coming up I thought I’d solicit some ideas on.


57 yo F with history of primary pHTN, COPD, OSA non-compliant with CPAP (nocturnal nasal cannula 2L instead), CABG in 2001, DES 4 mo. ago to SVG-RCA. LIMA-LAD patent, otherwise just luminal irregularities and lesions <40%. Scheduled for bilateral venous stasis ulcer debridement at the surgicenter.


No angina. Can “just about” lay flat. But minimal exercise tolerance due to SOB.

Sees pHTN specialist who says she’s optimized on sildenafil TID.

RHC shows PAP 70/44 with systemic BP 108/62.

Echo = Severely dilated/dysfunctional RV. Normal LV, moderate TR but no other valvulopathy.

On Plavix for 4mo. old DES.


The severe pHTN is an exclusion for a case like this to happen at the surgicenter (attached to hospital via covered indoor bridge), but the surgeon told me it is happening there.

On paper, “should be quick,” but with this surgeon, never is.

What’s the plan, Stan?
The dude can’t even lie flat? Are people really doing cases like this at an ASC. Jesus. “Should be quick” I’d reply, “should be done in the hospital.”
We’d never do a case remotely this ill at our ASCs, though they’re not attached.
No way.
When it all goes to hell and you have to transfer to the big house do you report the transfer the the DOH, have a formal review, etc?
 
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I trained at one hospital that called one location with 4 procedure rooms, separate pre/post area an ASC, but it wasn’t really an ASC and they did sick as stool patients there all the time. If they got admitted, whatever. It sucked. Smaller, less resources in an emergency, less experienced staff, hassle when you need to admit a patient. Just a big headache.
 
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anbuitachi

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Plavix or no Plavix, surgery itself is pro inflammatory. We don't dodge the reocclusion risk by keeping the DAPT going when we take them to the OR for a procedure, so I wouldn't be particularly swayed by the surgeon's kind offer to compromise and leave the Plavix on.

Anyway, it may be that these ulcers really do need to be debrided sooner rather than later, hard to know from the short description how much nonviable tissue there is, and the infection/sepsis risk if the surgeon just leaves it for another (sorta arbitrary) 2 months to get to 6 months post stent. I wouldn't refuse to do the case at a hospital, but I would at an ASC.

agree. i imagine there is prob some urgency to this case. unlikely to leave ulcers that need to be debrided sitting there for months.

back when i was in residency a while ago, i believe the data was for urgent cases, can stop at 3 months for DES. For elective cases its 6 months. And if the patient had a DES stent bc of a STEMI, then its 12 months.
I think recently they changed the guidelines to 6 months instead of 12, though the cardiology guidelines (not for surgery) still appear to be 12 if i remember correctly
 
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bcat85

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Sure, I agree many of us anesthetize big OSA-ers with systolic PAPs in the 60-70’s all the time, but not like this. This PAP is approaching 2/3 systemic which is my own personal line in the sand that makes my ears perk up a bit, plus they have a severely dysfunctional RV, not some thick RV ready to do pressure work.

You’ve got a 4mo old DES, bad RV, and severe pulmonary HTN. This is literally the antithesis of an ASC case.

With that said, sure you can get this case done with a simple GA anesthetic with push dose inotropes around but if things go badly just cut the check.

Agree completely. Do whatever anesthetic you want (I probably wouldn’t do this under regional..) but keep the blood pressure up. Airway and induction technique probably doesn’t matter as long as you support the RV. I wouldn’t put much stock in the PA pressures alone, as declining PAPs may actually be the result of progressive RV failure.

100% not an ASC case.
 
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Arch Guillotti

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These PH pts come all the time to endoscopy and get propofol sedation. Seem to do ok too. Still always scary to do these cases and make me hate life the whole time they are in the GI suite...
Same here.
 
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