severe pulmonary hypertension and severe RV dysfunction

[anbuitachi]

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A friend, had severe gastric pain.
US is crazy: between the 6th vital sign and related non sense you have more death per year from prescription opiods than the Vietnam war.
If you can't stand the procedure, you probably don't need it.

course US is crazy. it's an entitled nation. everyone expects no discomfort for every procedure and zero post op pain.

 

[MirrorTodd]

course US is crazy. it's an entitled nation. everyone expects no discomfort for every procedure and zero post op pain.

Which surgeons love to promise.

 

[2win]

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?

Yea - a lot of them .
1. Define severe pulmonary hypertension . Numbers. How do u see pulmonary hypertension on echo? Why nor cardiac cath? Pressures
Classification of pulmonary hypertension - what type?
Responsive to sildenafil? How do u know?
2. What is that - severe TV dysfunction? Numbers ...
3. Recent PE ? Why he is not anticoagulated? How recent?
4. Large pericaridisal effusion affecting the LC you say .. why not the RV??? Numbers. Echo reading
5. Sympathectomy with sedation This is a new terminology?

At least I have u asked u these questions If u would be in my room for your board exam .
What residency are u in?

 

[chocomorsel]

Just buy em a tennis bracelet and you don’t need anything else 😉

Sick puppy. I saw this coming. Just a matter of time. And no... not that kind of coming either.

Yea - a lot of them .
1. Define severe pulmonary hypertension . Numbers. How do u see pulmonary hypertension on echo? Why nor cardiac cath? Pressures
Classification of pulmonary hypertension - what type?
Responsive to sildenafil? How do u know?
2. What is that - severe TV dysfunction? Numbers ...
3. Recent PE ? Why he is not anticoagulated? How recent?
4. Large pericaridisal effusion affecting the LC you say .. why not the RV??? Numbers. Echo reading
5. Sympathectomy with sedation This is a new terminology?

At least I have u asked u these questions If u would be in my room for your board exam .
What residency are u in?

Welcome back from wherever you’ve been.

 

[coffeebythelake]

Yea - a lot of them .
1. Define severe pulmonary hypertension . Numbers. How do u see pulmonary hypertension on echo? Why nor cardiac cath? Pressures
Classification of pulmonary hypertension - what type?
Responsive to sildenafil? How do u know?
2. What is that - severe TV dysfunction? Numbers ...
3. Recent PE ? Why he is not anticoagulated? How recent?
4. Large pericaridisal effusion affecting the LC you say .. why not the RV??? Numbers. Echo reading
5. Sympathectomy with sedation This is a new terminology?

At least I have u asked u these questions If u would be in my room for your board exam .
What residency are u in?

i'm here to share a case scenario, based on personal experiences, i'm not going to copy and paste the patient's chart and you are not my consult. there is enough information from what I've shared to have a meaningful discussion of morbidity/mortality/management. i made my assessments and decision long before posting on the board here. As I've said earlier in this post, part of the challenge with this patient is how little preparation time there was and how little communication there was between consult services in the management of this palliative patient. Cards and pulm were very hands off, maybe because they don't want anything to do with the family which was pushing for all measures when they should be doing hospice. I found out about the case at 5:00 pm the day before the procedure, which was scheduled for 7:30 am. Explaining the risks to the patient's family (seemingly the first person to do so), and completely changing the plan just hours before procedure isn't fun.

Ok I get it, you are an ABA oral boards examiner. Cool. I've been out of residency for a few years, I am boarded, and I am faculty at a large academic hospital. To question someone's training like this? Because I'm not telling you the patient's exact PH numbers? Seriously? Not cool.

you're right, you don't actually cause a sympathectomy with sedation like you would with neuraxial anesthesia. but functionally, it can take away the sympathetic tone that this patient has that is keeping his heart beating and blood moving. we can argue semantics all you like, but patients with severe heart failure tend to have high sympathetic tone. or are you disagreeing with this as well? and are you also disagreeing that this patient is not high risk?

you need to RELAX and enjoy the discussion.

 

[fakin' the funk]

i'm here to share a case scenario, based on personal experiences, i'm not going to copy and paste the patient's chart. there is enough information from what I've shared to have a meaningful discussion of morbidity/mortality/management.

Really surprised you dignified 2win's blathering with this response. But good on you for doing it, I guess.

 

[fakin' the funk]

The GI guy didn't want to do the case, but family pushed for it. They thought it would be low risk. Once I set them straight family decided not to take the risk.

Just gonna raise my hand here and call out your GI guy for being a turd.

GI guy doesn't wanna do the case and doesn't appropriately scare the patient/family about the risk? Then dumps it on your lap? Super BS.

 

[Robotic Wis-Hipple]

Yea - a lot of them .
1. Define severe pulmonary hypertension . Numbers. How do u see pulmonary hypertension on echo? Why nor cardiac cath? Pressures
Classification of pulmonary hypertension - what type?
Responsive to sildenafil? How do u know?
2. What is that - severe TV dysfunction? Numbers ...
3. Recent PE ? Why he is not anticoagulated? How recent?
4. Large pericaridisal effusion affecting the LC you say .. why not the RV??? Numbers. Echo reading
5. Sympathectomy with sedation This is a new terminology?

At least I have u asked u these questions If u would be in my room for your board exam .
What residency are u in?

Ok, I’ll bite;

mPAP >40, most sources would say >55 makes it “severe”, though some hemodynamic sources drive the range to >60. If using RVSP >60 is sometimes called “severe” (ASE). In the echo world there’s data just saying to use the TR jet Vmax. So, tbh, what is severe? Show me a defined guideline. This is further confused as some definitions are used in the pediatric/congenital population while others are using echo vs RHC which have variable correlation based upon comorbidities. Regardless, an RVSP of 60 doesn’t scare me necessarily and would I treat RVSP of 59 differently than 61? No.

If a patient is essentially comfort care/palliative they likely aren’t going to have a RHC (though in this particular example she had “progressive longstanding PH”...PAH?, so I’m sure she has RHCs and likely vasoreactivity testing of which we can infer her response based on +\- CCB), but if we don’t have these records do we ignore the likely PHTN because it wasn’t documented by the gold standard invasive test? Likewise, how does knowing the WHO class of her PHTN change your management other than recognizing most pulm hypertensives are not PAH but instead secondary to left heart or lung disease? All of this is for an EGD btw, I’m not a cardiologist trying to fix her over the course of a few years. My goal is to not perturb her current state of on-edge compensation. In the end, know the ways you get in trouble, but her RV is what I’m most interested in, not whether her PAP is 40, 60, 80, or systemic.

I also don’t think most of those questions, especially the echo ones, are oral board fodder/appropriate.

 

[T-burglar]

Yea - a lot of them .
1. Define severe pulmonary hypertension . Numbers. How do u see pulmonary hypertension on echo? Why nor cardiac cath? Pressures
Classification of pulmonary hypertension - what type?
Responsive to sildenafil? How do u know?
2. What is that - severe TV dysfunction? Numbers ...
3. Recent PE ? Why he is not anticoagulated? How recent?
4. Large pericaridisal effusion affecting the LC you say .. why not the RV??? Numbers. Echo reading
5. Sympathectomy with sedation This is a new terminology?

At least I have u asked u these questions If u would be in my room for your board exam .
What residency are u in?

Who gives a **** if he’s anticoagulated for this EGD. This reads like you quickly opened an oral board vignette about cases you never touch in person and just copy pasted .

 

[BobLoblaw78]

Thanks for all the responses. I have enjoyed reading and learning on a very difficult case. I didn't see it mentioned but physical exam could tell you a little. How were the radial pulses, pulsus paradoxus or JVD's? Echo's can poorly estimate the pulmonary hypertension. I would keep in mind what the patient's body was telling you. I am a little (understatement) worried about that RV being at the end of its reserve. IR was a pretty good option if available. If not, maybe it should be. If you decide to proceed: topicalize (not cetacaine) after glycopyrrolate, NRB with scope port, start out with minimal propofol vs precedex, keep patient warm, take your time.

This also makes me wonder what I would do when running the code on this patient! 🙂

 

[AdmiralChz]

Just gonna raise my hand here and call out your GI guy for being a turd.

GI guy doesn't wanna do the case and doesn't appropriately scare the patient/family about the risk? Then dumps it on your lap? Super BS.

Agree. We joke about this often, but I often tell trainees to beware of proceduraists who aren’t trained surgeons - they simply have a different mentality about risks and complications. They also often can’t deal with their own complications so they aren’t as familiar with management of them.

This case is a good example of GI, but for cardiology it’s the high risk lead extractions they get more and more cavalier with (do we really need a CVL?) until one goes poorly and patient can hemorrhage in a minute. If cards dissects the femoral artery - they throw up their hands and leave while CT surg deals with it.

OB is in the same boat - c-sections are routine and good until they aren’t and you have a rapidly deteriorating patient. Or they bag part of the bowel or iliac artery requiring another surgeon to come in and help.

I think y’all get the idea. It falls on us to look out in the best interest of the patient, and @eikenhein did a great job of advocating for a more reasonable approach. I have no problem taking that role, personally, as it’s what I signed up for.

 

[deleted162650]

This also makes me wonder what I would do when running the code on this patient! 🙂

Call it.

 

[Psai]

Agree. We joke about this often, but I often tell trainees to beware of proceduraists who aren’t trained surgeons - they simply have a different mentality about risks and complications. They also often can’t deal with their own complications so they aren’t as familiar with management of them.

This case is a good example of GI, but for cardiology it’s the high risk lead extractions they get more and more cavalier with (do we really need a CVL?) until one goes poorly and patient can hemorrhage in a minute. If cards dissects the femoral artery - they throw up their hands and leave while CT surg deals with it.

OB is in the same boat - c-sections are routine and good until they aren’t and you have a rapidly deteriorating patient. Or they bag part of the bowel or iliac artery requiring another surgeon to come in and help.

I think y’all get the idea. It falls on us to look out in the best interest of the patient, and @eikenhein did a great job of advocating for a more reasonable approach. I have no problem taking that role, personally, as it’s what I signed up for.

Oh my god this is so true. They're packing in more and more cases but don't stick around when things go downhill. I wish only surgeons would do these procedures, I trust them way more. It's especially bad when people try to do things they shouldn't, like cardiologists going into the leg.

 

[BobLoblaw78]

Call it.

Lol. I was thinking correct oxygen, CO2, warm them, PAC with vasodilators, mech vent with low pressure and iNO, and ECMO....then call it anyway because where else would you rather do this than in an endoscopy suite.

 

[chocomorsel]

i'm here to share a case scenario, based on personal experiences, i'm not going to copy and paste the patient's chart and you are not my consult. there is enough information from what I've shared to have a meaningful discussion of morbidity/mortality/management. i made my assessments and decision long before posting on the board here. As I've said earlier in this post, part of the challenge with this patient is how little preparation time there was and how little communication there was between consult services in the management of this palliative patient. Cards and pulm were very hands off, maybe because they don't want anything to do with the family which was pushing for all measures when they should be doing hospice. I found out about the case at 5:00 pm the day before the procedure, which was scheduled for 7:30 am. Explaining the risks to the patient's family (seemingly the first person to do so), and completely changing the plan just hours before procedure isn't fun.

Ok I get it, you are an ABA oral boards examiner. Cool. I've been out of residency for a few years, I am boarded, and I am faculty at a large academic hospital. To question someone's training like this? Because I'm not telling you the patient's exact PH numbers? Seriously? Not cool.

you're right, you don't actually cause a sympathectomy with sedation like you would with neuraxial anesthesia. but functionally, it can take away the sympathetic tone that this patient has that is keeping his heart beating and blood moving. we can argue semantics all you like, but patients with severe heart failure tend to have high sympathetic tone. or are you disagreeing with this as well? and are you also disagreeing that this patient is not high risk?

you need to RELAX and enjoy the discussion.

Guess you’ve never interacted with 2Win.
Don’t take it personally. Just how he rolls. In your face. He can come off a little rough around the edges.

 

[anbuitachi]

Thanks for all the responses. I have enjoyed reading and learning on a very difficult case. I didn't see it mentioned but physical exam could tell you a little. How were the radial pulses, pulsus paradoxus or JVD's? Echo's can poorly estimate the pulmonary hypertension. I would keep in mind what the patient's body was telling you. I am a little (understatement) worried about that RV being at the end of its reserve. IR was a pretty good option if available. If not, maybe it should be. If you decide to proceed: topicalize (not cetacaine) after glycopyrrolate, NRB with scope port, start out with minimal propofol vs precedex, keep patient warm, take your time.

This also makes me wonder what I would do when running the code on this patient! 🙂

People still do physical exams??

 

[2win]

i'm here to share a case scenario, based on personal experiences, i'm not going to copy and paste the patient's chart and you are not my consult. there is enough information from what I've shared to have a meaningful discussion of morbidity/mortality/management. i made my assessments and decision long before posting on the board here. As I've said earlier in this post, part of the challenge with this patient is how little preparation time there was and how little communication there was between consult services in the management of this palliative patient. Cards and pulm were very hands off, maybe because they don't want anything to do with the family which was pushing for all measures when they should be doing hospice. I found out about the case at 5:00 pm the day before the procedure, which was scheduled for 7:30 am. Explaining the risks to the patient's family (seemingly the first person to do so), and completely changing the plan just hours before procedure isn't fun.

Ok I get it, you are an ABA oral boards examiner. Cool. I've been out of residency for a few years, I am boarded, and I am faculty at a large academic hospital. To question someone's training like this? Because I'm not telling you the patient's exact PH numbers? Seriously? Not cool.

you're right, you don't actually cause a sympathectomy with sedation like you would with neuraxial anesthesia. but functionally, it can take away the sympathetic tone that this patient has that is keeping his heart beating and blood moving. we can argue semantics all you like, but patients with severe heart failure tend to have high sympathetic tone. or are you disagreeing with this as well? and are you also disagreeing that this patient is not high risk?

you need to RELAX and enjoy the discussion.

Sorry man - got it. Sucks to be in your role - all of us were or will be there.
I agree with you - I tried to be an dingus ...
TO go to the point - I would suggest only topical anesthesia with very mild sedation, full monitoring and ready for everything.
I did it before and works.
Cheers - good case

 

[vector2]

Thanks for all the responses. I have enjoyed reading and learning on a very difficult case. I didn't see it mentioned but physical exam could tell you a little. How were the radial pulses, pulsus paradoxus or JVD's? Echo's can poorly estimate the pulmonary hypertension. I would keep in mind what the patient's body was telling you. I am a little (understatement) worried about that RV being at the end of its reserve. IR was a pretty good option if available. If not, maybe it should be. If you decide to proceed: topicalize (not cetacaine) after glycopyrrolate, NRB with scope port, start out with minimal propofol vs precedex, keep patient warm, take your time.

This also makes me wonder what I would do when running the code on this patient! 🙂

Echo may poorly estimate PASP if your TR jet / CW doppler envelope is poor, but keep in mind that right sided structures are anterior and are imaged well with transthoracic assuming the pt isn't the size of a humpback whale. As you pointed out, the exact PAP isn't nearly as important as the overall context of RV function and whether this pt has systemic signs of RV failure. Physical exam, liver function, kidney function, LE edema, imaging of the RV lateral and anterior walls, TAPSE, chamber size, and PA acceleration time can give you a pretty compelling picture- even if you weren't able to get a PASP from the TR jet.