1. Dismiss Notice
  2. Download free Tapatalk for iPhone or Tapatalk for Android for your phone and follow the SDN forums with push notifications.
    Dismiss Notice
  3. Hey Texans—join us for a DFW meetup! Click here to learn more.
    Dismiss Notice

Sick Sinus Syndrome

Discussion in 'Anesthesiology' started by acidbase1, May 3, 2018.

  1. acidbase1

    7+ Year Member

    Joined:
    Jul 28, 2011
    Messages:
    573
    Likes Received:
    271
    Status:
    Medical Student
    I have to take a guy to the OR with acute in chronic cholecystitis. (Now gangrenous) Perc chole drain was placed in January and is now no longer draining. Patient had been septic on and off for months, now it has to come out. He has SSS, refuses PPM. Has intermittent junctional bradycardia. He’s on the lower end of normal pressure wise, but not hypotensive. I’m going to place art line and have pacing capabilities periop along with sympathomimetics. Any other advice?
     
  2. Note: SDN Members do not see this ad.

  3. dchz

    dchz Avoiding the Dunning-Kruger
    Gold Donor Classifieds Approved 5+ Year Member

    Joined:
    Sep 25, 2012
    Messages:
    497
    Likes Received:
    450
    Status:
    Resident [Any Field]
    transcutaneous pads and transvenous leads
     
    sethco, eikenhein and acidbase1 like this.
  4. anbuitachi

    anbuitachi ASA Member
    7+ Year Member

    Joined:
    Oct 26, 2008
    Messages:
    3,736
    Likes Received:
    1,105
    Status:
    Resident [Any Field]
    He is OK with temporary PM?
     
  5. acidbase1

    7+ Year Member

    Joined:
    Jul 28, 2011
    Messages:
    573
    Likes Received:
    271
    Status:
    Medical Student
    Yes
     
  6. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,569
    Likes Received:
    2,140
    Status:
    Attending Physician
    This is a good topic. I would proceed just as you have described. I would use short acting meds for treatment of Brady or tachycardia. External pacing pads of course. May even place a central line/cordis so I could quickly insert pacing leads if needed. That depends on how symptomatic the pt is.
     
    acidbase1 likes this.
  7. Arch Guillotti

    Arch Guillotti Senior Member
    Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Aug 8, 2001
    Messages:
    7,452
    Likes Received:
    1,130
    Status:
    Attending Physician
    No way in the world I would place transvenous pacing leads in this guy. I wouldn't even know where to find them.
     
  8. acidbase1

    7+ Year Member

    Joined:
    Jul 28, 2011
    Messages:
    573
    Likes Received:
    271
    Status:
    Medical Student
    So this is how it went down. Small dose narcotic, ketamine, whiff of prop, lidocaine—> Bradys down to low 30. Atropine... nothing. Ephedrine... nothing. Glyco... nothing. As I’m diluting out epi and messing with pacer (pads placed preinduction) he jumps back up to 80s. Stable as a rock the rest of the way.

    Oh and I forgot to add, dude had severe AS. Poor candidate for AVR, refused TAVR.
     
  9. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,569
    Likes Received:
    2,140
    Status:
    Attending Physician
    I’m with you on this. I have never done it. I was mostly thinking cards could come in and do it but I’d have the access ready to go.
     
  10. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,569
    Likes Received:
    2,140
    Status:
    Attending Physician
    Ha ha. Well you forgot a lot. That’s f’ed up. How was his BP with a HR of 30. I’m assuming it was ok. Probably had a thick ass ventricle able to create respectable pressure.
     
    acidbase1 likes this.
  11. acidbase1

    7+ Year Member

    Joined:
    Jul 28, 2011
    Messages:
    573
    Likes Received:
    271
    Status:
    Medical Student
    It was boarderline, around MAPs of 50-60s. Preinduction was 90-100s.
     
  12. caligas

    caligas ASA Member
    5+ Year Member

    Joined:
    Aug 17, 2012
    Messages:
    1,226
    Likes Received:
    997
    Wait, did you just “yada yada yada” severe AS?

    well played.
     
  13. anbuitachi

    anbuitachi ASA Member
    7+ Year Member

    Joined:
    Oct 26, 2008
    Messages:
    3,736
    Likes Received:
    1,105
    Status:
    Resident [Any Field]
    Why atropine and then glyco?
     
    Ronin786 and sethco like this.
  14. Arch Guillotti

    Arch Guillotti Senior Member
    Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Aug 8, 2001
    Messages:
    7,452
    Likes Received:
    1,130
    Status:
    Attending Physician
    Why would you put pads on if you are placing transvenous leads?
     
  15. dchz

    dchz Avoiding the Dunning-Kruger
    Gold Donor Classifieds Approved 5+ Year Member

    Joined:
    Sep 25, 2012
    Messages:
    497
    Likes Received:
    450
    Status:
    Resident [Any Field]
    I would start with trancutaneous pads on. this would be plan A if pt goes into complete block actuely. This is my bridge if the patient recovers spontaneously in the OR, but it's not a long term solution. I also don't think you'd want the patient awake for this as it's pretty high voltage to capture sometimes.

    A lot of things would make me think about transvenous pacing. It's better for long term because it is more targeted to the ventricle. I would also want this if the tranvenous has trouble capturing. This would be the bridge to pace maker and patient can be completely unsedated with this in. Furthermore, the fact that the patient is septic and you're introducing bacteria in the myocardium when you screw on the pacer should also be on the back of your mind. But it's no excuse to let the patient die.
     
    nimbus likes this.
  16. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,569
    Likes Received:
    2,140
    Status:
    Attending Physician
    It’s not you, it’s me.
     
  17. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,569
    Likes Received:
    2,140
    Status:
    Attending Physician
    And what was the atropine dose given? Why does this matter?
     
  18. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,569
    Likes Received:
    2,140
    Status:
    Attending Physician
    Personally, I would go for transvenous pacing leads since the surgery is in the general vicinity of the pads. Plus it’s better capture.
     
    dchz likes this.
  19. nlax30

    nlax30 Fellow
    Physician 10+ Year Member

    Joined:
    Oct 4, 2006
    Messages:
    3,924
    Likes Received:
    600
    Status:
    Fellow [Any Field]
    I would. Placing a TVP is easy but they can dislodge, lose capture, etc... plus as you’re placing it could theoretically cause ventricular ectopy->VT.
     
    #18 nlax30, May 5, 2018
    Last edited: May 5, 2018
  20. anbuitachi

    anbuitachi ASA Member
    7+ Year Member

    Joined:
    Oct 26, 2008
    Messages:
    3,736
    Likes Received:
    1,105
    Status:
    Resident [Any Field]
    well if you go to VT, then you dont have to worry about the brady anymore. problem solved
     
    BobLoblaw78, dchz and nlax30 like this.
  21. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,569
    Likes Received:
    2,140
    Status:
    Attending Physician
    Exactly. You need to remember what was the reason for pacing in the first place.
     
    acidbase1 likes this.
  22. acidbase1

    7+ Year Member

    Joined:
    Jul 28, 2011
    Messages:
    573
    Likes Received:
    271
    Status:
    Medical Student
    The better question is why not
     
  23. dannyboy1

    10+ Year Member

    Joined:
    Aug 11, 2008
    Messages:
    436
    Likes Received:
    301
    Status:
    Medical Student
    This changes everything. Would have cards place transvenous pacer prior to OR. no way I want to be pushing epi on a guy with severe AS if I could avoid it. If patient refuses then refuse the surgery.
     
  24. Wiscoblue

    Wiscoblue ASA Member
    5+ Year Member

    Joined:
    Feb 10, 2013
    Messages:
    543
    Likes Received:
    374
    Status:
    Attending Physician
    Pacing swan?
     
  25. T-burglar

    Joined:
    May 13, 2017
    Messages:
    152
    Likes Received:
    172
    Status:
    Attending Physician
    What’s this guys fubctional status? Is he walking around and never gets lightheaded or has palpitations or syncopizes?

    His clinical symptoms inform how worried you should be here. If he has no history suggesting severely symptomatic bradycardia or AS then you can probably stand down in terms of major disaster planning.

    Assuming he actually has concerning symptoms then I think it’s malpractice to not have a placed and TESTED hot wire prior to a laparoscopy. Either consult a cardiologist , consult your CT anesthesia group, or hand it off to CT aneshesia
     
    sethco likes this.
  26. SnapperRocks

    SnapperRocks ASA Member
    2+ Year Member

    Joined:
    Jun 9, 2015
    Messages:
    81
    Likes Received:
    64
    Status:
    Resident [Any Field]

    Where exactly did you learn to place these? Certainly doesn’t seem like standard training at my program. Maybe in retrospect I’d pretreat with Gyco or atropine, for sure transcutaneous pads. No way would i be placing transvenous leads for the first time emergently by myself. For an elective procedure, that doesn’t seem like all that reasonable of a backup plan.
     
  27. anbuitachi

    anbuitachi ASA Member
    7+ Year Member

    Joined:
    Oct 26, 2008
    Messages:
    3,736
    Likes Received:
    1,105
    Status:
    Resident [Any Field]
    why would it be malpractice? the guy has SSS with known intermittent junctional brady. The guy is still alive so clearly it hasn't killed him yet.

    Mostly TAVRs since their risk of CHB is so high, but in those rooms we can check with xray afterwards to confirm positioning...
     
  28. dhb

    dhb Member
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Jul 12, 2006
    Messages:
    3,547
    Likes Received:
    760
    Status:
    Attending Physician
    If you can float a swan you can do a transvenous pacing.
     
    sethco, dchz and nlax30 like this.
  29. Ronin786

    Ronin786 ASA Member
    7+ Year Member

    Joined:
    Mar 27, 2011
    Messages:
    1,198
    Likes Received:
    563
    Status:
    Fellow [Any Field]
    A general anesthesiologist should be able to handle any case that a CT anesthesiologist can. If your training is worth its salt that is. Advanced TEE is a different ballgame (and even that is debatable) but there's nothing here that a good anesthesiologist can't handle.
     
    dchz likes this.
  30. nlax30

    nlax30 Fellow
    Physician 10+ Year Member

    Joined:
    Oct 4, 2006
    Messages:
    3,924
    Likes Received:
    600
    Status:
    Fellow [Any Field]
    I probably should’ve prefaced my comment, I’m a cardiologist and an EP fellow....

    That said, a TVP is a straightforward procedure. It’s not currently part of standard anesthesia training programs? I would’ve thought it would be.
     
  31. DrZzZz

    DrZzZz ASA Member
    2+ Year Member

    Joined:
    Feb 6, 2014
    Messages:
    119
    Likes Received:
    60
    Status:
    Resident [Any Field]
    Unfortunately no. Not a lot of opportunity for them. As an above poster mentioned, the most common indication when we're involved is CHB post TAVR. I got to place two for that reason as a resident, but the cardiac anesthesiologist I was with for the case said he was jealous. He had been out of residency & fellowship for like 7 years or so and had never placed one. And I think I'm the only resident at my program who got to place any.
     
  32. anbuitachi

    anbuitachi ASA Member
    7+ Year Member

    Joined:
    Oct 26, 2008
    Messages:
    3,736
    Likes Received:
    1,105
    Status:
    Resident [Any Field]
    Where would the anesthesia residents get these numbers for TVP? Do IM residents place a lot of TVPs??

    As a resident i've only done TVP in the fluoro room. I've never done it without fluoro confirmation before

    For most general anesthesiologist, TVP is a rescue procedure, so many people go thru residency without seeing a single case that require a TVP (except cardiac rotation), it's kind of like going thru residency without doing single cricothyrotomy
    The toughest part i think isn't even placing the TVP, it's finding where they keep it..

    i somewhat disagree with this statement. there are many procedures that a general anesthesiologist are not familar with or have only done a couple of during residency. while the general anesthesiologist may be able to get the patient thru the case, the outcomes may favor the CT trained anesthesiologist. There's a reason it's a 1 yr long fellowship. Sure a general anesthesiologist can almost be good at it if you load your electives with cardiac months... but not everyone do that.
     
    #31 anbuitachi, May 6, 2018
    Last edited: May 6, 2018
    chocomorsel and dchz like this.
  33. nlax30

    nlax30 Fellow
    Physician 10+ Year Member

    Joined:
    Oct 4, 2006
    Messages:
    3,924
    Likes Received:
    600
    Status:
    Fellow [Any Field]
    Good to know. To be honest we don’t do that many either. Doing general cards fellowship I only did a handful. Not that it’s a very technically challenging procedure that requires hundreds of attempts though....

    I wonder how many ED residents and CC fellows are doing?
     
  34. SnapperRocks

    SnapperRocks ASA Member
    2+ Year Member

    Joined:
    Jun 9, 2015
    Messages:
    81
    Likes Received:
    64
    Status:
    Resident [Any Field]

    Why the lidocaine?

    Profound bradycardia with lidocaine during anesthesia induction in a silent sick sinus syndrome patient. - PubMed - NCBI
     
    eikenhein and anbuitachi like this.
  35. Airlife91

    10+ Year Member

    Joined:
    Apr 26, 2008
    Messages:
    101
    Likes Received:
    13
    Status:
    Fellow [Any Field]
    I don't think this has been mentioned here...probably because it is not very common...at all. But you could try transESOphageal pacing. I've never personally done it, but have read about it and seen presentations at it. In fact, I saw a case report on it at the SCA annual meeting a couple weeks ago. Of course, it would require the proper equipment which is probably hard to find. Other issues is you can only reliably atrial pace. Placement is easy, and you could place it right after induction, verify capture, and only use it if necessary.

    As someone above noted, if you can float a swan, you can float a TV pacer. I did a handful in residency (three emergently in the ICU for unstable CHB after cardiac surgery in patients with either no or failed epicardial leads). Did a couple during TAVRs.
    upload_2018-5-7_14-6-52.png
     
    eikenhein likes this.
  36. GaseousClay

    2+ Year Member

    Joined:
    Oct 23, 2013
    Messages:
    235
    Likes Received:
    125
    Status:
    Resident [Any Field]
    dose should be greater than 0.5mg or possible paradoxical bradycardic effect likely centrally mediated
     
    eikenhein likes this.
  37. acidbase1

    7+ Year Member

    Joined:
    Jul 28, 2011
    Messages:
    573
    Likes Received:
    271
    Status:
    Medical Student
    eikenhein likes this.
  38. anbuitachi

    anbuitachi ASA Member
    7+ Year Member

    Joined:
    Oct 26, 2008
    Messages:
    3,736
    Likes Received:
    1,105
    Status:
    Resident [Any Field]
    How much narc did they use???
     
  39. acidbase1

    7+ Year Member

    Joined:
    Jul 28, 2011
    Messages:
    573
    Likes Received:
    271
    Status:
    Medical Student
    50mcg fentanyl

    Point being, it was neither the lidocaine or fentanyl. He had three episodes of Brady throughout the case and had many such events days leading up to surgery
     
  40. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,569
    Likes Received:
    2,140
    Status:
    Attending Physician
    Bingo
     
  41. acidbase1

    7+ Year Member

    Joined:
    Jul 28, 2011
    Messages:
    573
    Likes Received:
    271
    Status:
    Medical Student
    Good, I gave 0.5
     
    drmwvr and eikenhein like this.
  42. Ronin786

    Ronin786 ASA Member
    7+ Year Member

    Joined:
    Mar 27, 2011
    Messages:
    1,198
    Likes Received:
    563
    Status:
    Fellow [Any Field]
    I've never tried this, but apparently you can use the same epicardial leads and just stitch them onto the chest well. Serves like transcutaneous pads in a pinch or if you're having trouble with the pads.
     
    acidbase1 likes this.
  43. turkeyjerky

    Physician 10+ Year Member

    Joined:
    Sep 27, 2008
    Messages:
    1,709
    Likes Received:
    98
    Status:
    Resident [Any Field]
    EM here. I think I placed two or three during my residency--which was above average. I've placed a few during my 3 years of attending hood, which I gather from talking to colleagues is atypical.
     
  44. eikenhein

    eikenhein Supreme Commander Anesthesiologist
    Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Apr 9, 2006
    Messages:
    1,475
    Likes Received:
    351
    Status:
    Attending Physician
    I wonder if this will hurt a lot more since the electric current is not distributed over a wider surface area
     
    chocomorsel likes this.
  45. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,569
    Likes Received:
    2,140
    Status:
    Attending Physician
    That’s what gets the heart rate up.
     
    Ronin786 and SaltyDog like this.
  46. fakin' the funk

    fakin' the funk ASA Member
    10+ Year Member

    Joined:
    Aug 23, 2004
    Messages:
    2,613
    Likes Received:
    483
    Status:
    Attending Physician
    You... Didn't have epi ready to go??
     
  47. fakin' the funk

    fakin' the funk ASA Member
    10+ Year Member

    Joined:
    Aug 23, 2004
    Messages:
    2,613
    Likes Received:
    483
    Status:
    Attending Physician
    I agree with others that transvenous pacing is your best bet here. This guy has a jacked up rhythm and needs a pacemaker *at baseline* let alone while septic and having a not-straightforward upper abdominal procedure.

    I DISagree that placing a TVPM is anywhere close to the scope of a general anesthesiologist. My anecdotal experience is that I have done zero in 9 years of training and practice.

    So, you park this dude in your ICU and get cards to do it urgently, or have them do it in the cath lab or whatever your local arrangement is. If your hospital can't do that, time to transfer.
     
    Foodie, chocomorsel and nlax30 like this.
  48. pgg

    pgg Laugh at me, will they?
    Moderator Physician Faculty 10+ Year Member

    Joined:
    Dec 14, 2005
    Messages:
    11,525
    Likes Received:
    6,522
    Status:
    Attending Physician
    I've never placed a transvenous pacer. About 9 years of practice plus a CT fellowship at a somewhat reputable place.
     
    chocomorsel and acidbase1 like this.
  49. dhb

    dhb Member
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Jul 12, 2006
    Messages:
    3,547
    Likes Received:
    760
    Status:
    Attending Physician
    But does that mean you couldn't do it?
    I haven't either but i wouldn't have a problem with it.
     
    Ronin786 likes this.
  50. fakin' the funk

    fakin' the funk ASA Member
    10+ Year Member

    Joined:
    Aug 23, 2004
    Messages:
    2,613
    Likes Received:
    483
    Status:
    Attending Physician
    We all could probably do a diagnostic angio or place a tunneled HD cath or an open chest tube, doesn't mean it's in our scope of practice.
     
  51. dhb

    dhb Member
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Jul 12, 2006
    Messages:
    3,547
    Likes Received:
    760
    Status:
    Attending Physician
    Dude you are soft as baby $hit
     
    acidbase1 likes this.

Share This Page