severe pulmonary hypertension and severe RV dysfunction

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anbuitachi said:
I think these patients die under Mac more than GA
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No. Only if the MAC is actually a general or ventilation is insufficient. Severe Pulm HTN (>2/3 systemic) +\- failing RV get very minimal anesthetic or deep, no in between. The problem with deep/GA is you have to support and control everything and your increase in invasiveness goes way up, which in and of itself increases morbidity.

This is a next to nothing anesthetic, maybe fentanyl, maybe Ketamine for the dilation, have pressor ready and use your best consultant speak to talk the proceduralist out of any lunacy.
 
anbuitachi said:
I think these patients die under Mac more than GA
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if this patient is tubed they will die with the tube. there is a very strong likelihood they will not survive induction and switching to PPV. even if they did they will never be extubated. defeats the purpose of doing this as a palliative measure
 
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i've taken care of other patients with the same horrible pathology. severe RV dysfunction, severe PH, on 5L oxygen. urgent surgery due to massive pulsating EC aneurysm. all prep work, optimized as much as possible. seen by cards and pulm with no further recommendations. preinduction a-line, etomidate, fentanyl, pressors and inotropes at the ready. no negative intropic effects and minimal vasodilatory effects, but switch to PPV and take away the sympathetic drive and... still the patient died on induction.

I would rather anesthetize a patient with a large active STEMI, than to anesthetize a patient with severe RV dysfunction and severe PH. At least everyone (medicine, surgeon, nurses, family) knows and understands the risks of that STEMI patient.

These ARE the sickest patients you will ever deal with. And part of it may be how deceivingly good they look. They might be sitting there having a conversation with you, not hooked up to any lines or invasive monitors, but u alter their physiology even a little bit and they are dead.
 
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T-burglar said:
GETA Is what I would do if I wanted this guy to die because I didn’t like him. 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.
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exactly.

Avoid tubing this guy at all costs. Use light sedation that you can reverse with naloxone and flumazenil.
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naloxone or flumazenil does not offer any degree of safety to the patient. if they tank they will do so precipitiously and catastrophically.
 
eikenhein said:
exactly.



naloxone or flumazenil does not offer any degree of safety to the patient. if they tank they will do so precipitiously and catastrophically.
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An attempted light reversible anesthetic is better than an attempted light non reversible anesthetic. Presumably you are reversing as soon as you notice that you overdid the respiratory suppression , not trying to reverse after they’ve arrested.
 
Ok. This case just needs to be cancelled. Period. The patient can either get his food pureed or get an IR PEG. i can guarantee you that the GI guy who is pushing to go will throw you under the bus if things go wrong...
 
Robotic Wis-Hipple said:
No. Only if the MAC is actually a general or ventilation is insufficient. Severe Pulm HTN (>2/3 systemic) +\- failing RV get very minimal anesthetic or deep, no in between. The problem with deep/GA is you have to support and control everything and your increase in invasiveness goes way up, which in and of itself increases morbidity.

This is a next to nothing anesthetic, maybe fentanyl, maybe Ketamine for the dilation, have pressor ready and use your best consultant speak to talk the proceduralist out of any lunacy.
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We had a patient arrest on .03 of remi infusion, nothing else. Tte only showed mod phtn with RV dysfunction prior to case
.

I just did a case today, severe RV dysfunction with severe pulmonary artery stenosis. Patient was tachy, RV very dilated, LV was empty with D sign. Induced after arterial line and pressors running . Very stable.

But Yes either Mac or general is high risk. Like someone said above, is this a procedure they can tolerate w very minimal sedation??? If she start valsavaing during the case that could be it
 
dannyboy1 said:
Ok. This case just needs to be cancelled. Period. The patient can either get his food pureed or get an IR PEG. i can guarantee you that the GI guy who is pushing to go will throw you under the bus if things go wrong...
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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.
 
anbuitachi said:
We had a patient arrest on .03 of remi infusion, nothing else. Tte only showed mod phtn with RV dysfunction prior to case.
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Respect the RV. Can you think of why “moderate phtn” may not be accurate in this guy, or, thought about another way, can you think of why a measured pulmonary pressure (RVSP) in the moderate range by TTE (or TEE) may be an “accurate” calculation but not be giving you a true sense of the gravity of the situation?
 
Robotic Wis-Hipple said:
Respect the RV. Can you think of why “moderate phtn” may not be accurate in this guy, or, thought about another way, can you think of why a measured pulmonary pressure (RVSP) in the moderate range by TTE (or TEE) may be an “accurate” calculation but not be giving you a true sense of the gravity of the situation?
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Bingo.

I’ve heard it called “pulmonary hypotension”

Are the PA pressures better because the pulmonary hypertension is under control, or is the RV failing so bad that it can’t pump a high pressure.
 
T-burglar said:
Bingo.

I’ve heard it called “pulmonary hypotension”

Are the PA pressures better because the pulmonary hypertension is under control, or is the RV failing so bad that it can’t pump a high pressure.
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In this case, the latter. Look at the RV, and you'll get your answer.
 
There are numerous reports of hemodynamic collapse when pericardial effusions are drained in pt's with severe PAH. It's almost always best to leave these alone unless they have clear cut tamponade.

South Med J. 2008 May;101(5):490-4. doi: 10.1097/SMJ.0b013e31816c0169.
Poor outcomes associated with drainage of pericardial effusions in patients with pulmonaryarterial hypertension.
Hemnes AR1, Gaine SP, Wiener CM.
Author information

Abstract
OBJECTIVES:
Pulmonary arterial hypertension (PAH) in its advanced stages is complicated by right heart failure and often pericardial effusion. The optimal treatment of large or hemodynamically significant pericardial effusions in this group has not been defined.

METHODS:
All patients followed at the Johns Hopkins Hospital for PAH during a 1-year period that underwent pericardiocentesis or pericardial window placement were identified. Charts were analyzed for patient characteristics, echocardiographic data, and type/outcome of procedure.

RESULTS:
Six patients were identified; five underwent therapeutic drainage. Pericardiocentesis was performed in four cases; two had surgical pericardial windows. Two patients died after pericardiocentesis and one patient died after surgery. All patients died within 13 hours of the procedure.

CONCLUSION:
We found a high mortality related to pericardial fluid drainage in patients with PAH. The pathophysiologic explanation for these deaths remains unclear, but clinicians should consider conservative management in this situation if possible.
 
Very possibly selection bias. South Medical Journal? 🙂

I am sure you there is a more reliable study among your "numerous reports".

Et voila:
Pericardial effusions are relatively common but rarely of hemodynamic significance in patients with PAH. However, even modest degrees of pericardial fluid are associated with a significant increase in mortality and appear to reflect the presence of associated collagen vascular disease and high right atrial pressure.
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Pericardial effusions in pulmonary arterial hypertension: characteristics, prognosis, and role of drainage. - PubMed - NCBI

My guess is that in extreme RV failure, the pericardial fluid will actually increase RV output and transmit some supplemental LV pressure to the RV. Never thought about it, but I could see it happening, given the specific anatomy of the RV (it will get squeezed between the fluid and the LV).

In which case this patient definitely does not need an endoscopic PEG, or ANYTHING that requires more than local anesthesia.
 
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eikenhein said:
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.
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This is the most important piece of advice here. Have the come to Jesus talk with the patient, family and GI doctor all together. If they want to do then stop trying to get out of the case and just do it. Numb the crap out of everything then give some very light sedation. I have done a couple of these before without difficulty.
 
Arch Guillotti said:
This is the most important piece of advice here. Have the come to Jesus talk with the patient, family and GI doctor all together. If they want to do then stop trying to get out of the case and just do it. Numb the crap out of everything then give some very light sedation. I have done a couple of these before without difficulty.
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If no physician wants to do it why is it being offered? Sometimes we take this “shared decision making” thing too far. Inject some good old fashioned paternalism into the discussion. “Your relative is too sick for this procedure”. Full stop.
 
dannyboy1 said:
If no physician wants to do it why is it being offered? Sometimes we take this “shared decision making” thing too far. Inject some good old fashioned paternalism into the discussion. “Your relative is too sick for this procedure”. Full stop.
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OK change it to a gi bleeder that needs to be urgently done. You need to find a way to do the case safely. This is a total crap case but you need to know how to manage things if your hand is forced for any difficult case.
 
dannyboy1 said:
If no physician wants to do it why is it being offered? Sometimes we take this “shared decision making” thing too far. Inject some good old fashioned paternalism into the discussion. “Your relative is too sick for this procedure”. Full stop.
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The patient is not long for this world, and with the natural course of her disease process and decline it is likely she will die within the next several months anyways. Can you necessarily say that it is better to die from starvation vs taking the risk of doing this procedure? If it was my family member, I would think comfort measures. But if pt's family make an informed decision and want to do it, who am I as the anesthesiologist to tell them no.

Establishing the goals of care (in this case palliative, quality of remaining life) and expectations (it might work, it might not work) gauged along with the risks (good chance patient may die during the procedure, or end up intubated/lined/inotropes/pressors in a way incongruent with the goals of care). I deem this as an elective procedure. It is also not an issue of futility, although alternatives exist which are less risky while providing nutrition + comfort (e.g., TPN, dobhoff feedings, IR g-tube etc). Let family decide if they want to take the risk.
 
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Arch Guillotti said:
OK change it to a gi bleeder that needs to be urgently done. You need to find a way to do the case safely. This is a total crap case but you need to know how to manage things if your hand is forced for any difficult case.
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As brought up multiple times already, there is no way to do any case safely with these patients, but you can choose an anesthetic technique that gives them the best chance. If this is truly urgent and emergent you do it. Maybe they survive. Maybe they don't. Again, expectations and risks need to be set with patient and family.
 
eikenhein said:
The patient is not long for this world, and with the natural course of her disease process and decline it is likely she will die within the next several months anyways. Can you necessarily say that it is better to die from starvation vs taking the risk of doing this procedure? If it was my family member, I would think comfort measures. But if pt's family make an informed decision and want to do it, who am I as the anesthesiologist to tell them no.

Establishing the goals of care (in this case palliative, quality of remaining life) and expectations (it might work, it might not work) gauged along with the risks (good chance patient may die during the procedure, or end up intubated/lined/inotropes/pressors in a way incongruent with the goals of care). I deem this as an elective procedure. It is also not an issue of futility, although alternatives exist which are less risky while providing nutrition + comfort (e.g., TPN, dobhoff feedings, IR g-tube etc). Let family decide if they want to take the risk.
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Because doing chest compressions makes me cranky. Just because they are dying it dosent mean I have to go through the trouble of an inraoperative death, with all of the attendant paperwork m and m’s possibly a lawsuit.
 
dannyboy1 said:
Because doing chest compressions makes me cranky. Just because they are dying it dosent mean I have to go through the trouble of an inraoperative death, with all of the attendant paperwork m and m’s possibly a lawsuit.
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I don't like to code patients either. I don't like intraop deaths either. But concern for this is a selfish reason to deny the patient something that is not futile. Document all discussions, explanations of risk. You don't need an ethics or legal consult for that.

Face it, there are sickass patients out there trying to die all the time. Somebody has to take care of them in surgery, and as a MEDICAL DOCTOR and ANESTHESIOLOGIST who better to do so in their time of need? Sounds to me you just want the easy cases.
 
dannyboy1 said:
Because doing chest compressions makes me cranky. Just because they are dying it dosent mean I have to go through the trouble of an inraoperative death, with all of the attendant paperwork m and m’s possibly a lawsuit.
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Eventually your hand will be forced and you need to know how to handle it.
 
eikenhein said:
I don't like to code patients either. I don't like intraop deaths either. But concern for this is a selfish reason to deny the patient something that is not futile. Document all discussions, explanations of risk. You don't need an ethics or legal consult for that.

Face it, there are sickass patients out there trying to die all the time. Somebody has to take care of them in surgery, and as a MEDICAL DOCTOR and ANESTHESIOLOGIST who better to do so in their time of need? Sounds to me you just want the easy cases.
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do you really think that after this dilation hes going to be happily enjoying his favorite foods? This is likely another sham procedure. GI doc probably did a terrible job explaining the risks and secretly wants to do the scope. Its not going to help the patient, how many of these silly GI procedures are really meaningful? how many Abd pain --> Gastritis have you done? too many
 
I don’t think it’s my place to decide whether a procedure is indicated. I can give the operator, patient, and family my assessment of risk from the anesthetic and let them all decide if they want to do it. Then I come up with what I think is the safest anesthetic and monitoring.

I did a VT ablation for syncope In this very same patient with scleroderma so bad I could not get a pulse ox reading anywhere lmao.
 
In palliative care, it's not uncommon to feed patients after good oral hygiene even when they're at high risk for aspiration. "Comfort feeding" or "At risk feeding". It's a shame that most physicians have almost no training in palliative care and hospice. Just another option that could be offered to this patient/family. Granted the esophageal stricture might affect this approach.
 
Ronin786 said:
In palliative care, it's not uncommon to feed patients after good oral hygiene even when they're at high risk for aspiration. "Comfort feeding" or "At risk feeding". It's a shame that most physicians have almost no training in palliative care and hospice. Just another option that could be offered to this patient/family. Granted the esophageal stricture might affect this approach.
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Thank you for bring this up. That was my initial question for this thread. Was it necessary to do the procedure?

I had a patient who was cleared for pleasure feeding on thin liquid, literally chocked on apple juice later that morning. No codes. The running joke, at the speech pathologists expense, was at least he died enjoying what he wanted, apple juice. RIP
 
T-burglar said:
I don’t think it’s my place to decide whether a procedure is indicated. I can give the operator, patient, and family my assessment of risk from the anesthetic and let them all decide if they want to do it. Then I come up with what I think is the safest anesthetic and monitoring.

I did a VT ablation for syncope In this very same patient with scleroderma so bad I could not get a pulse ox reading anywhere lmao.
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No pulse ox = no sedation = I don’t need to be there.
 
drmwvr said:
...said the medical student...
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Attending actually. You are going to sedate a patient on whom you can’t even get a pulse ox tracing?? Really?? On an ablation? Patient will sit there for a couple of hours under the drapes, somewhat far away from you and you would run a prop infusion without pulse oximetry? The only thing I would give is a bit of versed and have the patient awake the entire time. And if that is all that they are getting then I don’t need to be there ....
 
dannyboy1 said:
Attending actually. You are going to sedate a patient on whom you can’t even get a pulse ox tracing?? Really?? On an ablation? Patient will sit there for a couple of hours under the drapes, somewhat far away from you and you would run a prop infusion without pulse oximetry? The only thing I would give is a bit of versed and have the patient awake the entire time. And if that is all that they are getting then I don’t need to be there ....
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what do you do for lvad patients with no pulse? pulse ox often dont pick that up either
 
dannyboy1 said:
Attending actually. You are going to sedate a patient on whom you can’t even get a pulse ox tracing?? Really?? On an ablation? Patient will sit there for a couple of hours under the drapes, somewhat far away from you and you would run a prop infusion without pulse oximetry? The only thing I would give is a bit of versed and have the patient awake the entire time. And if that is all that they are getting then I don’t need to be there ....
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Spoken like a medical student...I don't base my involvement in the care of any patient on what monitors are available to me. I can deduce and assume an awful lot without pulse oximetry...you may not remember anesthesia before that technology...I do.

BTW...might want to change the avatar...sonny.
 
anbuitachi said:
what do you do for lvad patients with no pulse? pulse ox often dont pick that up either
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Depends on the situation. If it is a MAC like in GI I usually give less. Keep the light on in the room so I can see the patient’s color. Use 100 % non rebreather. You do what you have to do. But to say that you are going to sit in a cath lab for hours on end with the patient far from you and under some drapes and run a propofol infusion without pulse ox seems like living on the edge. (And as I work as an employee for an AMC i see no reason to push the envelope. It’s not like they are going to pay me any more...)
 
dannyboy1 said:
No pulse ox = no sedation = I don’t need to be there.
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dannyboy1 said:
Attending actually. You are going to sedate a patient on whom you can’t even get a pulse ox tracing?? Really?? On an ablation? Patient will sit there for a couple of hours under the drapes, somewhat far away from you and you would run a prop infusion without pulse oximetry? The only thing I would give is a bit of versed and have the patient awake the entire time. And if that is all that they are getting then I don’t need to be there ....
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I placed an arterial line and confirmed solid PO2 on NRB and kept her respiratory rate high by watching the capnogram and giving small hits of Midaz Fent and propofol. She was very nervous in addition to all these other problems

I didn’t run an infusion that would be a bad idea.

You would have canceled this because you couldn’t figure out how to do it?
 
drmwvr said:
Spoken like a medical student...I don't base my involvement in the care of any patient on what monitors are available to me. I can deduce and assume an awful lot without pulse oximetry...you may not remember anesthesia before that technology...I do.

BTW...might want to change the avatar...sonny.
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I don't know what anesthesia was like before standard monitoring technology, nor do I know the level of your abilities of deduction. What I do know is that anesthesia mortality dropped about 20-fold down to an almost unmeasurable number today after the widespread adoption of pulse ox and capnography.
 
vector2 said:
I don't know what anesthesia was like before standard monitoring technology, nor do I know the level of your abilities of deduction. What I do know is that anesthesia mortality dropped about 20-fold down to an almost unmeasurable number today after the widespread adoption of pulse ox and capnography.
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So if you can't get a pulse ox reading on a patient, you guys just cancel the procedure? 🙂
 
Alternative methods exist, and if u cant get a sat then u can always do other things like abg, light sedation, etc. Try different sites, fingers/ear/tongue? Can also try digit block to increase perfusion to extremities, seem to work well for those with raynaulds.
 
Ronin786 said:
In palliative care, it's not uncommon to feed patients after good oral hygiene even when they're at high risk for aspiration. "Comfort feeding" or "At risk feeding". It's a shame that most physicians have almost no training in palliative care and hospice. Just another option that could be offered to this patient/family. Granted the esophageal stricture might affect this approach.
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Good thoughts. Problem is that family does not want to pursue comfort measures. They are in denial. They think she will improve.
 
AdmiralChz said:
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.
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I've had an EGD done with nothing, not even topicalization.
Was it fun? Hell no, but if it's the worse that's going to happen to you in your life you can be pretty happy.
 
dhb said:
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.
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just figured it would be crazily difficult to do a thorough exam on a freaking out, choking patient
you don't need fentanyl, you could do propofol. and what's the problem with topical lidocaine?
 
eikenhein said:
just figured it would be crazily difficult to do a thorough exam on a freaking out, choking patient
you don't need fentanyl, you could do propofol. and what's the problem with topical lidocaine?
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Well i wasn't freaking out but strangely it's almost impossible to stop the retching. You feel the scope's pressure at the back of your throat and you can't stop gagging.
I did it just before doing the sedations for GI so i had to be "clean".
 
dhb said:
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.
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But yet you are thinking of coming here to work.
 
You all should read Jack London's "The Law of Life" its only 5 pages.
 
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