severe pHTN for TKA

[vector2]

That's true, but then the OP must have gotten the PASP from a RHC and not from Bernoulli's equation on echocardiography. Otherwise the TR Vmax to calculate an RVSP that high would show a decent degree of TR

Not necessarily. TR vmax and MR vmax have very little to do with the true degree of TR and MR (you'll notice that TR and MR vmax are not part of ASE classification of valvular regurgitation). If anything, when you have severe TR the vmax will decrease as there is now a very small gradient between the two chambers because there is so much communicating flow. For instance, it's not uncommon to have a very high CVP of 35 and a RVSP of 45 with wide open TR. The TR is quite severe but the gradient between the RA and RV is pretty low. As the RV dilates out and function worsens, the TR vmax may go even lower as having poor systolic function will further lower the peak regurgitant velocities.

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[Dexmetaketapropofol]

Yes, you're right, I suppose I'm just making the assumption that the patient's secondary pulmonary hypertension is all being derived from a single TTE. Great discussion, thank you

 

[2Fast2Des]

I did one of these cases in residency, I forget if the systolic PA or mean was 100. We did big IVs, CVL, Art line, TEE. We had to go right to epi, milrinone, and levo (attending preference). The fun part was when the tourniquet went down, seeing all the emboli, watching the RV struggle for a bit, and then some bleeding. Took her to the ICU where she was on nitric for a bit but was extubated POD 1 or 2. Was a fun case I gotta say

 

[Arch Guillotti]

I did one of these cases in residency, I forget if the systolic PA or mean was 100.

My perception is that the case you are describing is a completely different that the one posted by the OP. PA pressure of 100 is incredibly high risk no matter what you are doing.

 

[Dexmetaketapropofol]

I did one of these cases in residency, I forget if the systolic PA or mean was 100. We did big IVs, CVL, Art line, TEE. We had to go right to epi, milrinone, and levo (attending preference). The fun part was when the tourniquet went down, seeing all the emboli, watching the RV struggle for a bit, and then some bleeding. Took her to the ICU where she was on nitric for a bit but was extubated POD 1 or 2. Was a fun case I gotta say

PA Sys of 100 I wouldn't clip that person's toe nail
PA Mean of 100 bring on the funeral procession

I don't miss doing lung or combined heart lung transplants, lol

 

[T-burglar]

I did one of these cases in residency, I forget if the systolic PA or mean was 100. We did big IVs, CVL, Art line, TEE. We had to go right to epi, milrinone, and levo (attending preference). The fun part was when the tourniquet went down, seeing all the emboli, watching the RV struggle for a bit, and then some bleeding. Took her to the ICU where she was on nitric for a bit but was extubated POD 1 or 2. Was a fun case I gotta say

For the patient in the op: whatever you want to do should be fine. I'm more interested in her COPD and whether shes a serious chronic CO2 retainer who will be a bitch to extubate

For the patient who is almost dead from pulmonary hypertension: a line and central line before anything. Then a lateral decubitis spinal with vaso and/or norepi already infusing. Small hits of midaz/fent and ketamine for sedation. Would avoid intubating someone with critical pulmonary hypertension at all costs.

 

[Planktonmd]

He’s so good he does nerve stim ACB’s:

“Sir, tell me when your shin is tingling”

😀

By the way you can very easily do a saphenous nerve block with a nerve simulator or just blind. I know it sounds crazy to most of you but it's really very easy.

 

[deleted697535]

60 y.o. female, morbidly obese (BMI 43), severe pHTN (PASP 65-70 mm Hg), mild-mod RV dysfunction, HTN, COPD on home O2, CHFpEF (LVEF 65%, mild TR, no aortic or mitral valvular abnormalities, grade 2 DD) here for TKA. Etiology of pHTN uncertain, but believed to be from COPD and possibly from OSA as well. Seen by pulmonologist several months ago, on COPD rx and not a candidate for pulmonary vasodilator therapy. Pulmonologist thought sleep study not necessary. Seen by perioperative hospitalist who quoted patient MICA score of 0.7% and hence was not worried. Hopefully the hospitalist didn't convey this number to the patient, because I told patient her risk was substantially higher.

Patient at her baseline cardiopulmonary status at time of your evaluation.
She was recently started on spiriva which she states has improved her breathing to the point that she doesn't need to use home O2 as frequently. She is compliant with her COPD rx, and took her metoprolol this am, but was instructed not to take her spironolactone and HCTZ. HR is 70. Her BP 210/100, although her base line BP is ~130-140/80's. SpO2 is 95% on RA.

How are you going to do the anesthetic?
What if this is for a hip replacement?

There are many answers given to this that may work fine in real life but would likely lead to failure on an oral board exam. Boy do those guys love Pulm Htn...

Answers that involve Ketamine, Spinal, excess sedation (without the word judicious) open big cans of pain.

Also answers that dont include having preop ABG and physio, mil/dob/adequate preload/vaso/art line/swan/tee/nitric/post op analgesia/hdu/chest physio AVAILABLE wont score well

If you dont demonstrate that you understand drops in SVR or rise in PVR are bad, you will likely fail

But then theres the real world answer. Spinal, prop infusion and back to buying forex. Same as the rest of them

 

[Arch Guillotti]

So what precautions do you take for patients with severe pHTH or RV dysfunction? Sounds like you wouldn't treat this case any different than a healthy person.

Depends on how bad it is. It isn't uncommon for me to see echos with some degree of RV dysfunction and probably everybody else does too. This case requires more vigilance than a healthy person of course but as long as you are careful I would not be overly concerned.

Patient has been seen by a pulmonologist and hospitalist. You have a recent echo.

The RV is not perfect and the PA pressure is high but I bet that this patients echo isn't too different than many others patients that have various anesthetics.

Of course things could go awry but that can happen no matter what.

BMI of 43 is run of the mill as far as I am concerned.

 

[deleted162650]

By the way you can very easily do a saphenous nerve block with a nerve simulator or just blind. I know it sounds crazy to most of you but it's really very easy.

Of course you can. Even young whippersnappers like me were taught blind saphenous blocks. Let’s not pretend that it’s the same as an ACB though.

 

[Noyac]

For the patient in the op: whatever you want to do should be fine. I'm more interested in her COPD and whether shes a serious chronic CO2 retainer who will be a bitch to extubate

For the patient who is almost dead from pulmonary hypertension: a line and central line before anything. Then a lateral decubitis spinal with vaso and/or norepi already infusing. Small hits of midaz/fent and ketamine for sedation. Would avoid intubating someone with critical pulmonary hypertension at all costs.

.’
While this is a noble plan, it isn’t always possible as you well know. Since I practice at altitude my practice is frequently taking care of PHTN pts. Luckily they usually are not severe class. But to date I have not had issues from intubating them. I typically spray the crap out of their trachea with LTA lido and get them breathing on SIMV or PSV as soon as possible depending on the case.

 

[Noyac]

By the way you can very easily do a saphenous nerve block with a nerve simulator or just blind. I know it sounds crazy to most of you but it's really very easy.

That’s how I do them, blind. (No Salty, not literally blind).
I know this may surprise many of you.
They literally work every time too.

 

[Noyac]

Of course you can. Even young whippersnappers like me were taught blind saphenous blocks. Let’s not pretend that it’s the same as an ACB though.

Correct, not the same.
But I struggle to see how a young person like you can learn the blind approach.

 

[MoMoGesiologist]

PA Sys of 100 I wouldn't clip that person's toe nail
PA Mean of 100 bring on the funeral procession

I don't miss doing lung or combined heart lung transplants, lol

They're out there in the real world surviving. They go to sleep in the real world. I'm sure they can get a careful anesthetic and get through it.

 

[DrZzZz]

TAVR I did in training a while back. Wasn't the highest PAP we had during the case, but the highest I caught on camera. GETA, used some Flolan, patient did great, extubated a few hours after the case in ICU after they weaned the Flolan.

 

[Psai]

TAVR I did in training a while back. Wasn't the highest PAP we had during the case, but the highest I caught on camera. GETA, used some Flolan, patient did great, extubated a few hours after the case in ICU after they weaned the Flolan.

:O

 

[anbuitachi]

for those that do spinal catheters for these cases.. how far in do you thread the catheter...? with epidurals, once we thread the catheter, we dont know which direction the catheter is going, up/down etc. if then give iso bupi, wont that matter?

 

[nimbus]

I did a bunch of pulmonary thromboendarterectomies during residency. Probably a dozen where pulmonary pressure were equal to or approaching systemic. They all made it through the OR.

 

[nimbus]

TAVR I did in training a while back. Wasn't the highest PAP we had during the case, but the highest I caught on camera. GETA, used some Flolan, patient did great, extubated a few hours after the case in ICU after they weaned the Flolan.

How was the PAP after TAVR?

 

[DrZzZz]

Flolan cut it to 50-60s intraop, worked great. If I recall, it was in the 70s after they weaned it off in the ICU. So definitely improved from preTAVR.

How was the PAP after TAVR?[/QUOTE

 

[MoMoGesiologist]

I did a bunch of pulmonary thromboendarterectomies during residency. Probably a dozen where pulmonary pressure were equal to or approaching systemic. They all made it through the OR.

The issue is, you know when you're doing a big case or cardiac case such as PTEA, the patient is getting an aline, CVL, PAc, TEE, GA/ETT. It's these small cases like TKA with severe cardiac disease that's really hard to figure out just how aggressive to be with the lines and monitors and type of anesthesia.

For someone with high PA pressures and moderately dysfunctional RV, if you decide neuraxial with some sedation for a TKA, how are you dealing with the tourniquet coming down and all that CO2 and H+ coming to the right heart and pulmonary circulation? Are you bolusing epi and vaso and just praying they don't go into acute RVF? Do you just not have issues because it's academic and patients find a way to survive? Are you better off tubing beforehand so you can just prophylactically blow off CO2? My thought is that these types of patients are at risk of severe hypotension/coding even from induction.

 

[deleted162650]

You see, all this is why I don't bother to look at the patients medical history. Prop, roc, tube, .

 

[deleted162650]

Lotsa tourniquet talk. This is one case where I would really talk to the Orthopod about only putting the tourniquet up for cementing. Like 10-20 mins tops. We have a couple guys that do it this way for all cases.

 

[pgg]

TAVR I did in training a while back. Wasn't the highest PAP we had during the case, but the highest I caught on camera. GETA, used some Flolan, patient did great, extubated a few hours after the case in ICU after they weaned the Flolan.

This is my favorite picture from fellowship. I've cropped out what really makes this picture great though - the reflection of my co-fellow's mildly concerned face in the monitor. IIRC it was a CTEPH patient getting a pulmonary thrombectomy.

 

[MoMoGesiologist]

This is my favorite picture from fellowship. I've cropped out what really makes this picture great though - the reflection of my co-fellow's mildly concerned face in the monitor. IIRC it was a CTEPH patient getting a pulmonary thrombectomy.

...how is that person alive with PA pressures > systemic pressures!?!? How do they even perfuse their RV!?

Also, can I ask how you induced this patient?

 

[deleted697535]

...how is that person alive with PA pressures > systemic pressures!?!? How do they even perfuse their RV!?

Also, can I ask how you induced this patient?

From the looks of it, 5mg/kg ketamine and a boatload of fluid!!

 

[sevoflurane]

This is my favorite picture from fellowship. I've cropped out what really makes this picture great though - the reflection of my co-fellow's mildly concerned face in the monitor. IIRC it was a CTEPH patient getting a pulmonary thrombectomy.

Impressive... most impressive.

Can’t say I’ve seen that much of a delta.

Worst was PA systolics over Systemic systolics with a delta of 35.

 

[sevoflurane]

 

[Psai]

This is my favorite picture from fellowship. I've cropped out what really makes this picture great though - the reflection of my co-fellow's mildly concerned face in the monitor. IIRC it was a CTEPH patient getting a pulmonary thrombectomy.

I didn't even know this was possible

 

[Dexmetaketapropofol]

Jig's up, we know you placed the transducer on the floor 😉

All jokes aside, that's awesome, I would love to see what the TEE looked like

 

[Noyac]

The transducer cables got crossed?

 

[T-burglar]

Put the swan in the aorta?

I also didn’t think that was possible. Adult congenital ?

 

[Noyac]

On call last night and had a pt with an infected knee. BMI >60 Severe PHTN. Echo showed flatten septum, severe RV and RA dilation, Cor Pulmonal.
I channeled th SDN wisdom on this one.
Tourniquet time was brief so this wasn’t much of an issue.
I didn’t place a bunch of lines because the case was only about an hour. But I was ready.
The pt did fine. Gently induced her and topicalized the crap out of her trachea. Oh, of course she ate meatloaf earlier. Then gently slide the ETT in. BP went from 170/90 to 140/80 during induction. Sats maintained 100%.
She required a couple 1u hits of Vasopressin through the case. That’s it.

 

[pgg]

It was real. As I recall they went on bypass moments later.

 

[MoMoGesiologist]

On call last night and had a pt with an infected knee. BMI >60 Severe PHTN. Echo showed flatten septum, severe RV and RA dilation, Cor Pulmonal.
I channeled th SDN wisdom on this one.
Tourniquet time was brief so this wasn’t much of an issue.
I didn’t place a bunch of lines because the case was only about an hour. But I was ready.
The pt did fine. Gently induced her and topicalized the crap out of her trachea. Oh, of course she ate meatloaf earlier. Then gently slide the ETT in. BP went from 170/90 to 140/80 during induction. Sats maintained 100%.
She required a couple 1u hits of Vasopressin through the case. That’s it.

Did you place an aline or central line? What induction drugs and doses did you use? Was it an RSI because of the meatloaf?

 

[coffeebythelake]

Did you place an aline or central line? What induction drugs and doses did you use? Was it an RSI because of the meatloaf?

i'm assuming preinduction art line, decent size IV, no CVC, etomidate vs midaz/fentanyl, suxx
inotropes and pressors on the ready
optimizing vent settings with lowest reasonable airway plateau pressures
noyac's case sounds a lot like my pul HTN pt that coded on induction

 

[Noyac]

Did you place an aline or central line? What induction drugs and doses did you use? Was it an RSI because of the meatloaf?

No invasive monitoring case was just over an hour.
I gave 50 or 100 mcg of fentanyl (can’t remeber off hand) up front.
Then slowly induced with propofol about 50 mg and gave it a minute to work. Then another 30mg as she became somnolent followed by 100mg of suxx (due to meatloaf and her extremely large habitus). Obviously not a true RSI. I was prepared to give some vasopressin with the induction but didn’t need too.
I had to give more propofol Bumps of 20-30 mg as I was increasing the Sevo.
I didn’t need the vasopressin until we dropped the tourniquet.
I wouldn’t blink at anyone putting in an Aline for this but I just felt like it wasn’t a big enough case even though the pt was tenuous.

Also, I think VENT settings make a difference somewhat. I got her breathing spontaneously on SIMV then PSVpro ASAP. And used fentanyl to get her rate down to a comfortable rate 12-14. With the LTA this was pretty easy. I kept the CO2 in the 40’s by adjusting the vent support.

 

[2Fast2Des]

In general, should case duration dictate necessity of lines? Or would it be appropriate to do them regardless of time depending on comorbidities?

 

[Arch Guillotti]

On call last night and had a pt with an infected knee. BMI >60 Severe PHTN. Echo showed flatten septum, severe RV and RA dilation, Cor Pulmonal.
I channeled th SDN wisdom on this one.
Tourniquet time was brief so this wasn’t much of an issue.
I didn’t place a bunch of lines because the case was only about an hour. But I was ready.
The pt did fine. Gently induced her and topicalized the crap out of her trachea. Oh, of course she ate meatloaf earlier. Then gently slide the ETT in. BP went from 170/90 to 140/80 during induction. Sats maintained 100%.
She required a couple 1u hits of Vasopressin through the case. That’s it.

This case is cake anyway,

 

[MoMoGesiologist]

No invasive monitoring case was just over an hour.
I gave 50 or 100 mcg of fentanyl (can’t remeber off hand) up front.
Then slowly induced with propofol about 50 mg and gave it a minute to work. Then another 30mg as she became somnolent followed by 100mg of suxx (due to meatloaf and her extremely large habitus). Obviously not a true RSI. I was prepared to give some vasopressin with the induction but didn’t need too.
I had to give more propofol Bumps of 20-30 mg as I was increasing the Sevo.
I didn’t need the vasopressin until we dropped the tourniquet.
I wouldn’t blink at anyone putting in an Aline for this but I just felt like it wasn’t a big enough case even though the pt was tenuous.

Also, I think VENT settings make a difference somewhat. I got her breathing spontaneously on SIMV then PSVpro ASAP. And used fentanyl to get her rate down to a comfortable rate 12-14. With the LTA this was pretty easy. I kept the CO2 in the 40’s by adjusting the vent support.

Maybe a dumb question, but given her BMI 60, severe pHTN, and e/o RV dysfunction, were you worried that going from spontaneous negative pressure ventilation to PPV on the vent with high airway pressures (likely 30s given her BMI) would cause her RV and whole hemodynamics to collapse?

 

[MoMoGesiologist]

This case is cake anyway,

I can't tell if you're serious. My residency made me really worried about inducing severe forms of AS, pHTN, and RV dysfunction. However, the people on this forum make it sound so easy. I hope to get to that point one day!

 

[2Fast2Des]

I can't tell if you're serious. My residency made me really worried about inducing severe forms of AS, pHTN, and RV dysfunction. However, the people on this forum make it sound so easy. I hope to get to that point one day!

Prop sux tube errbody! What more do you need?😎

 

[coffeebythelake]

I can't tell if you're serious. My residency made me really worried about inducing severe forms of AS, pHTN, and RV dysfunction. However, the people on this forum make it sound so easy. I hope to get to that point one day!

He seems to be a prop suxx tube kind of guy

 

[drmwvr]

This is my favorite picture from fellowship. I've cropped out what really makes this picture great though - the reflection of my co-fellow's mildly concerned face in the monitor. IIRC it was a CTEPH patient getting a pulmonary thrombectomy.

/QUOTE]


One hell of an RV right there...

 

[Noyac]

In general, should case duration dictate necessity of lines? Or would it be appropriate to do them regardless of time depending on comorbidities?

Since this was a knee (leaving me all the access in the world available) and I was confident that I could induce in such a manner that she wouldn’t crump and I could place them as needed.

 

[Noyac]

Maybe a dumb question, but given her BMI 60, severe pHTN, and e/o RV dysfunction, were you worried that going from spontaneous negative pressure ventilation to PPV on the vent with high airway pressures (likely 30s given her BMI) would cause her RV and whole hemodynamics to collapse?

There are no dumb questions 😉

That is why I went to PSV ventilation and one reason why I used suxx. I thought I made that point earlier.

 

[Noyac]

I can't tell if you're serious. My residency made me really worried about inducing severe forms of AS, pHTN, and RV dysfunction. However, the people on this forum make it sound so easy. I hope to get to that point one day!

The hardest part of this case was trying to explain to the orthopod her cardio/pulmonary disease and concerns.

 

[anbuitachi]

On call last night and had a pt with an infected knee. BMI >60 Severe PHTN. Echo showed flatten septum, severe RV and RA dilation, Cor Pulmonal.
I channeled th SDN wisdom on this one.
Tourniquet time was brief so this wasn’t much of an issue.
I didn’t place a bunch of lines because the case was only about an hour. But I was ready.
The pt did fine. Gently induced her and topicalized the crap out of her trachea. Oh, of course she ate meatloaf earlier. Then gently slide the ETT in. BP went from 170/90 to 140/80 during induction. Sats maintained 100%.
She required a couple 1u hits of Vasopressin through the case. That’s it.

Would you consider doing epidural and just titrate? I know it's infected knee but I don't know if it's systemic but putting in epidural and having risk of infection ( just for the case) seems less risky than inducing the patient. Let's you avoid ppv as well and maintain airway reflex.

 

[coffeebythelake]

Would you consider doing epidural and just titrate? I know it's infected knee but I don't know if it's systemic but putting in epidural and having risk of infection ( just for the case) seems less risky than inducing the patient. Let's you avoid ppv as well and maintain airway reflex.

If choice to do neuraxial, would the patient be able to lay flat? And if so what would respiratory parameters look like? No sedation?

This pt is sick and fat and no good option for anesthetic exists

 

[Noyac]

Would you consider doing epidural and just titrate? I know it's infected knee but I don't know if it's systemic but putting in epidural and having risk of infection ( just for the case) seems less risky than inducing the patient. Let's you avoid ppv as well and maintain airway reflex.

She was also on Coumadin. I just looked back at my post because I was sure I gave the details of her having a DVT and being on Coumadin. But I didn’t I guess.