severe pulmonary hypertension and severe RV dysfunction

[coffeebythelake]

Patient for EGD with dilation because unable to eat. Essentially palliative procedure. Family didn't want prolonged intubation or hospitalization. Longstanding progressive PH followed by pulmonary and cardiology, on sildafenil. Despite this, echo showing severe pulmonary hypertension, severe RV dysfunction, severely dilated RV and RA, normal LVEF but very small LV, also with large pericardial effusion affecting the LV, and also a recent acute PE. SBP low-normal, just slightly above PA pressures.

I felt risk would be extremely high under both GA or MAC.

Literature is sparse on this. I could only find >50% significant morbidity (and about 10% mortality) with PH (of all different severities +/- RV dysfunction) under anesthesia. Presumably given the high degree of pulmonary hypertension and RV dysfunction in this patient the risk is much greater, but the nature of the procedure is lower risk? In my mind this patient is hanging by a thread, the stimulation of shoving a scope down the throat could shoot her PA through the roof, but the sympathectomy with sedation (even if I used topical lidocaine) could also cause her RV to fail. A retching patient with inadequate sedation would probably be just as bad. Heck, she could have sudden death just sitting there.

1. I quoted family a risk of ~50% severe morbidity or death.

2. Least stimulation, least pain, least amount of sedation is what this patient needs. I suggested IR g-tube with anesthesia support (not PEG tube with GI). Still risky, but likely less risky.

Thoughts?

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[deleted162650]

Liberal topicslization. Like, really thorough. No sedation. Carpenter on standby in the hallway.

 

[Noyac]

Agree with Salty.
I like glyco to dry them up and then viscous lido to topicalize.
I will give something stun them a bit though. Maybe 2-4 cc propofol and give it a chance to work then 10 mg ketamine. Then follow with 2 cc prop as needed. Just maintain a good respiratory effort. You don’t want to stress them out by not sedating them and then having their BP 180/110. Now what?

You can sedate these pts just be gentle and take your time.

 

[coffeebythelake]

Agree with Salty.
I like glyco to dry them up and then viscous lido to topicalize.
I will give something stun them a bit though. Maybe 2-4 cc propofol and give it a chance to work then 10 mg ketamine. Then follow with 2 cc prop as needed. Just maintain a good respiratory effort. You don’t want to stress them out by not sedating them and then having their BP 180/110. Now what?

You can sedate these pts just be gentle and take your time.

I'm in GI lab quite frequently. Yeah i've done this before with severe PH patients with less severe RV dysfunction. They seem to do okay, although several have had profound hypotension even going slow.
Point of concern is the failing RV, which seems to be a looming disaster.
doesnt' take much to go from severely dysfunction RV to nonfunctional RV - even with minimal sedation and good topicalization

 

[deleted171991]

Why not get the pericardial effusion aspirated before the procedure? Palliative or not, I would have refused it otherwise.

 

[coffeebythelake]

Why not get the pericardial effusion aspirated before the procedure? Palliative or not, I would have refused it otherwise.

they've done it before,
per cardiology the effusion reaccumulates almost right away, hence no plans for that
they are surprisingly hands off for this patient

 

[deleted171991]

they've done it before,
per cardiology the effusion reaccumulates almost right away, hence no plans for that
they are surprisingly hands off for this patient

There is this thing called a pericardial catheter. Maybe you should teach cardiology about it.

Put it in, get all the procedures the patient needs to get done under anesthesia, then take it out if they believe in the positive palliating effects of chronic tamponade. I am still not inducing a patient with tamponade, except glyco, topicalize, touch of ketamine, good luck. Fast, full and forward.

 

[coffeebythelake]

the part i find most disturbing from all this is:

I find out about the patient at 5:00 pm the day before the procedure. I talk with the family. Nobody explained the risk of severe morbidity or death to them. The patient has been in the hospital for days-weeks. The plan for procedure was in place for several days. I am literally the first person to tell them bad things can happen during the procedure. It blows my mind.

 

[coffeebythelake]

There is this thing called a pericardial catheter. Maybe you should teach cardiology about it.

Put it in, get all the procedures the patient needs to get done under anesthesia, then take it out if they believe in the positive palliating effects of chronic tamponade. I am still not inducing a patient with tamponade, except glyco, topicalize, touch of ketamine, good luck. Fast, full and forward.

maybe they can do the pericardial drainage while they do the IR g-tube procedure.

how would you gauge the risk for this patient -- of death or major morbidity? was i being too pessimistic?

 

[Mman]

how would you gauge the risk for this patient -- of death or major morbidity? was i being too pessimistic?

Anybody quoting a number is just pulling it out their ass. I gauge their risk for the procedure as high. Maybe I'd call it really high. This patient is at risk of dying just laying in bed. Sedating them for the procedure will stress their body and I don't know how well they will handle it.

 

[OB1🤙]

There's no anesthesia like no anesthesia...

Agree with those above regarding liberal topicalization and then low doses of whatever keep-em-breathing medicine you like to give.

A conversation pre-op regarding thethe extraordin risk of the case is obviously important.

Curious what the pre-op vitals look like.

 

[dchz]

also with large pericardial effusion affecting the LV

Why not get the pericardial effusion aspirated before the procedure? Palliative or not, I would have refused it otherwise.

I'm all for optimizing this pt, but how do we know the pericardial effusion is actually affecting the LV? like tamponade physiology? was there anything telling you this is the case?

if it's not affecting the LV then we've just put this pt more at risk by asking IM docs to poke his heart again.

 

[deleted171991]

maybe they can do the pericardial drainage while they do the IR g-tube procedure.

how would you gauge the risk for this patient -- of death or major morbidity? was i being too pessimistic?

I haven't done enough of these severe PHTN cases, but I think it's always better to over- than underestimate the risks. The pericardial catheter is typically done under local anesthesia (by interventional cardiology), no big deal. That heart is sick enough to need every ounce of help.

 

[deleted171991]

I'm all for optimizing this pt, but how do we know the pericardial effusion is actually affecting the LV? like tamponade physiology? was there anything telling you this is the case?

if it's not affecting the LV then we've just put this pt more at risk by asking IM docs to poke his heart again.

He said small LV, large pericardial effusion affecting the LV. Probably seen on echo.

 

[dchz]

He said small LV, large pericardial effusion affecting the LV. Probably seen on echo.

LV might be small compared to the large RV (and the RV hypertrophy certain affects LV function), but that doesn't rule in or rule out whether the tamponade physiology is in play or you have compensated chronic pericardial effusion... I think i might need a quantitative measures about the tamponade before i subject this pt to more pericardialcentesis.

 

[deleted171991]

LV might be small compared to the large RV (and the RV hypertrophy certain affects LV function), but that doesn't rule in or rule out whether the tamponade physiology is in play or you have compensated chronic pericardial effusion... I think i might need a quantitative measures about the tamponade before i subject this pt to more pericardialcentesis.

To me, low-normal SBP with large effusion is proof enough. I have seen patients go from high pressor dose to zero from effusion evacuation.

 

[dchz]

That heart is sick enough to need every ounce of help.

To me, low SBP is proof enough.

not sure I 100% agree here...

 

[deleted171991]

not sure I 100% agree here...

Let's see what @eikenhein says.

 

[vector2]

I honestly wouldn't be able to come up with an exact m&m number, but I don't think 50% is unreasonable. This is the type of pt who immediately arrests from a number of things. It's not just the sympathectomy from sedation that's a concern, but also maintaining spontaneous ventilation. Tamponade + PH + severe RV dysfunction = 0 cardiac output with PPV.

A couple q's: what's the baseline vitals? How much O2 they on? How bad is the TR and other valve problems? Whats the RHC say? What's the volume status? Do they have organ dysfunction from RV failure? Why are they not on flolan or remodulin? Are they on palliative dobutamine or milrinone? If not, why?

 

[dchz]

Let me make myself clear, I wasn't there so i don't know whether or not this pt actually had tamponade physiology.

However, the way it is described in this thread. I would like more specific evidence that the pt requires a procedure before i recommend it.

And no, i don't consider low SBP or the presence of a pericardial effusion to be sufficiently SPECIFIC evidence that this pt is in tamponnade. Correlation =/= causation.

 

[dchz]

I honestly wouldn't be able to come up with an exact m&m number, but I don't think 50% is unreasonable. This is the type of pt who immediately arrests from a number of things. It's not just the sympathectomy from sedation that's a concern, but also maintaining spontaneous ventilation. Tamponade + PH + severe RV dysfunction = 0 cardiac output with PPV.

A couple q's: what's the baseline vitals? How much O2 they on? How bad is the TR and other valve problems? Whats the RHC say? What's the volume status? Do they have organ dysfunction from RV failure? Why are they not on flolan or remodulin? Are they on palliative dobutamine or milrinone? If not, why?

Besides puttin the pt on PPV and finding out that way, is there a good test for tamponade in your opinion?

 

[vector2]

Besides puttin the pt on PPV and finding out that way, is there a good test for tamponade in your opinion?

I assume OP says tamponade because the echo showed some left atrial collapse, LV diastolic collapse, or 20-25% respiratory VTI variation from Doppler flow over one of the valves. Her right sided pressures are so high that I doubt any right side collapse was seen. It's a difficult diagnosis and VTI probably isn't that specific in a pt who already probably has some pulsus alternans from CHF.

Another thing to keep in mind- draining the effusion is not without risk. The high pericardial pressure is probably restricting RA/TV inflow to some degree and keeping the RV somewhere on the starling curve where it still functions. The RV is not gonna like the extra preload that comes from relieving the effusion.

 

[kamilo6]

Hi. Do you mind if I hijack this thread just a little?

What are your thoughts of pulm htn/RV dysfxn and office-based kyphoplasties?
(We just started doing 1 level kypho in the office).

I’m asking specifically about office-based vs ASC vs hospital, and the risks of the polymethyl methacrylate.

Assume we don’t have a vent in the office for backup, but the patient is OK-ish otherwise and PCP/cards say “sure, go ahead”.

 

[Southpaw]

What are your thoughts of pulm htn/RV dysfxn and office-based kyphoplasties?
(We just started doing 1 level kypho in the office).

Bad idea.

patient is OK-ish otherwise and PCP/cards say “sure, go ahead”.

Take that with a grain a salt. It’s easy to give recommendations (however valuable they may potentially be) when you know you won’t be involved in the care.


For the case at hand, I’d have a discussion with cards about the my concerns regarding the effusion. If after that, cards elected not to drain, I’d have a frank discussion with the patient and family (basically what was already done). Then I’d do a ‘less is more’ anesthetic.

 

[coffeebythelake]

Hi. Do you mind if I hijack this thread just a little?

What are your thoughts of pulm htn/RV dysfxn and office-based kyphoplasties?
(We just started doing 1 level kypho in the office).

I’m asking specifically about office-based vs ASC vs hospital, and the risks of the polymethyl methacrylate.

Assume we don’t have a vent in the office for backup, but the patient is OK-ish otherwise and PCP/cards say “sure, go ahead”.

I think it depends on the severity of their PH and RV dysfunction -- the worse the disease process the higher the risk. but I would strongly urge you to do it in the hospital and not a freestanding ASC. Pt should be informed that even with minimal to no sedation they are at risk for morbidity and/or mortality. I don't know the literature on frequency of PMMA embolization or hemodynamic perturbations after kyphoplasties (vs joints where we normally see them). I'm assuming there is no other way to do kyphoplasties except with PMMA?

 

[coffeebythelake]

Let's see what @eikenhein says.

i don't think the patient is tamponading. the small LV is likely a consequence of the overloaded RV. no mention that previous pericardiocentesis improved her hemodynamically, again part of the reason why they didn't pursue this further

 

[coffeebythelake]

A couple q's: what's the baseline vitals? How much O2 they on? How bad is the TR and other valve problems? Whats the RHC say? What's the volume status? Do they have organ dysfunction from RV failure? Why are they not on flolan or remodulin? Are they on palliative dobutamine or milrinone? If not, why?

4L O2 at rest, basically looks ok sitting there, can't take more than a few steps without severe SOB. does have severe valve issues, if i remember correctly sev TR. not grossly fluid overloaded, being diuresed with lasix 40 qd felt to be "euvolemic". don't know why she was never started on other advanced therapies.

 

[Robotic Wis-Hipple]

I assume OP says tamponade because the echo showed some left atrial collapse, LV diastolic collapse, or 20-25% respiratory VTI variation from Doppler flow over one of the valves. Her right sided pressures are so high that I doubt any right side collapse was seen. It's a difficult diagnosis and VTI probably isn't that specific in a pt who already probably has some pulsus alternans from CHF.

Another thing to keep in mind- draining the effusion is not without risk. The high pericardial pressure is probably restricting RA/TV inflow to some degree and keeping the RV somewhere on the starling curve where it still functions. The RV is not gonna like the extra preload that comes from relieving the effusion.

Wait, did OP say tamponade? Did I miss this, because I don’t see it. If Tamponade, effusion needs drained, and while in IR receiving local just put in the G tube. But I agree with your statements regarding unlikely chamber collapse if her R sided pressures are as high as implied. Overall agree with topicalization and very little Anesthesia x fast efficient minimally stimulating endoscopy. The desire for a few more burgers shouldn’t trump the very high possibility that her palliative procedure is more of a hastening one.

Quick questions; How much O2 is the Pt on? Can they lie down at all, or what happens to her pressures when she changes her level of recumbency?

 

[Robotic Wis-Hipple]

Hi. Do you mind if I hijack this thread just a little?

What are your thoughts of pulm htn/RV dysfxn and office-based kyphoplasties?
(We just started doing 1 level kypho in the office).

I’m asking specifically about office-based vs ASC vs hospital, and the risks of the polymethyl methacrylate.

Assume we don’t have a vent in the office for backup, but the patient is OK-ish otherwise and PCP/cards say “sure, go ahead”.

No. Think about the physiological parameters that change with that cement, and then the implications in pulmonary hypertension and a suboptimal RV. It’s just not something to risk for the perk of doing it in an office.

 

[drmwvr]

i don't think the patient is tamponading. the small LV is likely a consequence of the overloaded RV.

 

[coffeebythelake]

Liberal topicslization. Like, really thorough. No sedation. Carpenter on standby in the hallway.

Have u ever tried to do an EGD with dilation with only topicalization? No sedation at all?? I think it is impossible. i topicalize the crap out of the high risk patients, yet they always grunt and gag and resist the endoscopy. As i said before stimulation = increased PA pressures = very bad for these patients. Your topicalization is not coating thr whole esophagus. They alwayd end up getting a little versed or fentanyl or propofol or ketamkne. The procedure is stimulating not just pushing the endoscope down but also with the dilation.

 

[Noyac]

There is this thing called a pericardial catheter. Maybe you should teach cardiology about it.

Put it in, get all the procedures the patient needs to get done under anesthesia, then take it out if they believe in the positive palliating effects of chronic tamponade. I am still not inducing a patient with tamponade, except glyco, topicalize, touch of ketamine, good luck. Fast, full and forward.

He doesn’t have tamponade. He has an effusion.

 

[Noyac]

Have u ever tried to do an EGD with dilation with only topicalization? No sedation at all?? I think it is impossible. i topicalize the crap out of the high risk patients, yet they always grunt and gag and resist the endoscopy. As i said before stimulation = increased PA pressures = very bad for these patients. Your topicalization is not coating thr whole esophagus. They alwayd end up getting a little versed or fentanyl or propofol or ketamkne. The procedure is stimulating not just pushing the endoscope down but also with the dilation.

That’s not entirely true. I know people that do this in their office with no sedation. The pts are frequent flyers though.

 

[deleted171991]

He doesn’t have tamponade. He has an effusion.

Let's just disagree on this. He has a "large" effusion. I have seen patients with no tamponade who got much better in similar situations. A pericardial catheter is an echo-guided low-risk bedside procedure.

 

[coffeebythelake]

That’s not entirely true. I know people that do this in their office with no sedation. The pts are frequent flyers though.

And there are people who can swallow swords...

 

[T-burglar]

I would review the images to see how where they are on the tamponade spectrum for myself. If you can’t review the images and you don’t know and trust the cardiologist and it’s been a while since they’ve been scanned then you’re in a bit of a pickle in my opinion.

The effusion is a larger concern than the pulmonary hypertension for this case in particular because light careful sedation should be fine (GETA is another story) for the right heart failure but light sedation can and does precipitate “low pressure” tamponade if the patient is right on the edge. You don’t know what his pericardial pressure is, and tamponade occurs the second you drop the right atrial pressure below the pericardial pressure. This can still happen even in terrible RV failure , it’s not “protective”. Even in the worst RV failure the CVP doesn’t get higher than 25 or so. 25 or so is also the limit of venous return compensation for pericardial hypertension in a normal heart.


If you cause cardiac arrest that will be the end of this patient. They will never resuscitate even if you were ready to do a damn sternotomy.

Ultimately it’s tough to judge what’s needed without imaging and invasive monitoring.

I think since this is just an EGD, if the patient is not tachycardic or “ill appearing” and can lie flat without feeling “doom” then I would do it with light sedation and a norepinephrine infusion after confirming that the norepinephrine was in fact increasing the pressure.

 

[Ezekiel2517]

A few months back I had basically this same case with the same type of patient. I gave 2 cc's of prop. That's it. I worked my ass off for the next hour just to keep her from coding. Wound up tubing her and sending her to the unit. Patients with really bad pulm HTN are the sickest of them all.

 

[OB1🤙]

In Japan, they do most EGDs with no sedation.

 

[coffeebythelake]

In Japan, they do most EGDs with no sedation.

Yeah, but in this case no sedation in a retching or freaking out patient is bad to his hemodynamics and cardiac function.

This isn't a conveersation about whether u can do EGD with no sedation. It is about whether it can be done safely for a patient with a failing RV and severe PH

 

[OB1🤙]

*Nothing* can be done safely for a patient with a failing RV and severe PH.

I'm not advocating for literally zero sedation here, but it can be done.

 

[deleted162650]

Yeah, but in this case no sedation in a retching or freaking out patient is bad to his hemodynamics and cardiac function.

This isn't a conveersation about whether u can do EGD with no sedation. It is about whether it can be done safely for a patient with a failing RV and severe PH

What’s more dangerous here, hypoventilation from sedation, or stimulation?? There’s no great way to do this case.

 

[vector2]

What’s more dangerous here, hypoventilation from sedation, or stimulation?? There’s no great way to do this case.

Hypoventilation is almost certainly worse. With sympathetic stim, as long as you can keep systemic mean above PA mean and have some inotropy ready if needed then survival is possible. With hypoventilation, loss of negative pressure inspiration to maintain R sided preload + hypercarbia/hypoxemia raising the PAPs will be rapidly fatal.

 

[AdmiralChz]

I did a super sick EGD case as a resident with topicalization only - I’ll never forget the horrible gagging and tortured look of the patient. It was awful. I swore I’d never do it again. People often on here talk of doing it, and y’all can do what works for you but personally that’s a non-starter.

Find a way, even if it’s low-dose precedex or something. Or if this guy is one shove away from the afterlife, convince the proceduralist to not be responsible for that and cancel.

 

[anbuitachi]

the part i find most disturbing from all this is:

I find out about the patient at 5:00 pm the day before the procedure. I talk with the family. Nobody explained the risk of severe morbidity or death to them. The patient has been in the hospital for days-weeks. The plan for procedure was in place for several days. I am literally the first person to tell them bad things can happen during the procedure. It blows my mind.

I think it's because they dont know about the risks of anesthesia since they aren't really trained in anesthesia. I had a similar experience just yesterday with the medicine doctor calling a procedure low/intermediate risk, when shes actually very high risk

Patient for EGD with dilation because unable to eat. Essentially palliative procedure. Family didn't want prolonged intubation or hospitalization. Longstanding progressive PH followed by pulmonary and cardiology, on sildafenil. Despite this, echo showing severe pulmonary hypertension, severe RV dysfunction, severely dilated RV and RA, normal LVEF but very small LV, also with large pericardial effusion affecting the LV, and also a recent acute PE. SBP low-normal, just slightly above PA pressures.

I felt risk would be extremely high under both GA or MAC.

Literature is sparse on this. I could only find >50% significant morbidity (and about 10% mortality) with PH (of all different severities +/- RV dysfunction) under anesthesia. Presumably given the high degree of pulmonary hypertension and RV dysfunction in this patient the risk is much greater, but the nature of the procedure is lower risk? In my mind this patient is hanging by a thread, the stimulation of shoving a scope down the throat could shoot her PA through the roof, but the sympathectomy with sedation (even if I used topical lidocaine) could also cause her RV to fail. A retching patient with inadequate sedation would probably be just as bad. Heck, she could have sudden death just sitting there.

1. I quoted family a risk of ~50% severe morbidity or death.

2. Least stimulation, least pain, least amount of sedation is what this patient needs. I suggested IR g-tube with anesthesia support (not PEG tube with GI). Still risky, but likely less risky.

Thoughts?

General anesthesia. A line, central line, PA catheter, pressors/epi running, would not do it in endo suite

 

[T-burglar]

You would completely line and tube this guy for an EGD?....

 

[fakin' the funk]

General anesthesia. A line, central line, PA catheter, pressors/epi running, would not do it in endo suite

 

[fakin' the funk]

Liberal topicslization. Like, really thorough. No sedation. Carpenter on standby in the hallway.

Lots of preop coaching and consent. Lots of coaching of your GI doc, who needs to be fast and good and will listen if you say abort. Topical - lots. Will prob need something during the dilation part but that might be 25mcg fentanyl. Vasopressin my pressor of choice. Would not drain the effusion just for this procedure unless echo evidence of tamponade. If/when he codes, wouldn't try too hard.

 

[anbuitachi]

You would completely line and tube this guy for an EGD?....

that's what the GI docs always say. it's always JUST an egd!

 

[T-burglar]

GETA Is what I would do if I wanted this guy to die because I didn’t like him. Avoid tubing this guy at all costs. Use light sedation that you can reverse with naloxone and flumazenil.

I also wouldn’t do a right heart cath for any reason , or for any surgery . If he arrests you will know why without swan numbers, and you aren’t getting him back either. Passing the swan can cause VT or several nonperfusing beats/rhythms/pauses, or worsen the TR.

 

[anbuitachi]

GETA Is what I would do if I wanted this guy to die because I didn’t like him. Avoid tubing this guy at all costs. Use light sedation that you can reverse with naloxone and flumazenil.

I also wouldn’t do a right heart cath for any reason , or for any surgery . If he arrests you will know why without swan numbers, and you aren’t getting him back either. Passing the swan can cause VT or several nonperfusing beats/rhythms/pauses, or worsen the TR.

I think these patients die under Mac more than GA