Tachycardia Case

[GassYous]

---

Members don't see this ad.

You're on call and the board is starting to clear up. You drop your last patient off in pacu and see that a ortho addon has been posted to the board. You go to see the patient and this is the history you obtain.

65 yo m with pmh remote cva with left hemiplegia, htn, dm2, obesity who fell and presented with a left patellar fracture as well as trace frontal sah.

The first thing you noticed when you went to see the patient is that he is laying comfortably in the hospital bed, chatting with the nurse. The second is a monitor showing a heart rate of 139. What now?

 

[dchz]

Prop succy tube.

 

[ButterButter]

Send him to the floor and tell the team to figure it out. Stable case can wait til the AM. I’m going to sleep zzzzzzzzz

 

[coffeebythelake]

You're on call and the board is starting to clear up. You drop your last patient off in pacu and see that a ortho addon has been posted to the board. You go to see the patient and this is the history you obtain.

65 yo m with pmh remote cva with left hemiplegia, htn, dm2, obesity who fell and presented with a left patellar fracture as well as trace frontal sah.

The first thing you noticed when you went to see the patient is that he is laying comfortably in the hospital bed, chatting with the nurse. The second is a monitor showing a heart rate of 139. What now?

Figure out whether it is sinus or not.
For SAH pt seen by neurosurg and cleared?

 

[narcotics999]

Left hemiplegia with left patella fx? He does not need us.

 

[Katheudontas parateroumen]

Is patella fracture that urgent needs to be done that night? Patient probably isn’t sufficiently NPO probably? In any case...
I’d find out a story how he fell. Mechanical versus something more sinister like syncope. Then sinus vs not sinus, narrow vs wide. Blood pressure stable. The basic things. Could be sinus tachy stress response, hypovolemia, etc. If new onset Afib consult cards. Anything wide complex cancel.

 

[GassYous]

Send him to the floor and tell the team to figure it out. Stable case can wait til the AM. I’m going to sleep zzzzzzzzz

Would you like to provide some guidance for the medicine doctor so your partner doesn't cancel the case again tomorrow?

Figure out whether it is sinus or not.
For SAH pt seen by neurosurg and cleared?

It looks regular but difficult to see p waves on the monitor. You have neurosurgery's blessing.

Left hemiplegia with left patella fx? He does not need us.

He is actually able to ambulate somewhat with a walker but happened to fall.

Is patella fracture that urgent needs to be done that night? Patient probably isn’t sufficiently NPO probably? In any case...
I’d find out a story how he fell. Mechanical versus something more sinister like syncope. Then sinus vs not sinus, narrow vs wide. Blood pressure stable. The basic things. Could be sinus tachy stress response, hypovolemia, etc. If new onset Afib consult cards. Anything wide complex cancel.

The orthopedic surgeon is okay with delaying the case for workup/optimization as the case can go within a week. Patient ate about 6 hours ago. The patient is a poor historian but apparently it was a mechanical fall. He does mention that his legs seem more swollen than before.



Here's the ecg from the ED

 

[teacher2md]

This looks like an atrial tachycardia. The cardiac implications of SAH are well described and involve catecholamine surge— this could be what we’re seeing. This has the potential to get worse with any progression of the bIeed. I would postpone this non-emergent case and give him a beta-blocker now. If his HR doesn’t improve I would involve cardiology and ask NSG about re-scanning his head.

 

[kmurp]

Good advice above. Only a tangent but have any of you done a patella orin with just a femoral block?

 

[coffeebythelake]

Good advice above. Only a tangent but have any of you done a patella orin with just a femoral block?

Can you get a surgical block for this just w fem block?

 

[dchz]

Serious question/poll:

How many of you consider the femoral nerve block a "deep" block? Meaning you can't hold pressure if you hit something that slightly bleeds?

Sciatic?

Supraclav?

Interscalene?

ESP?

Paravertebrals?

Intercostals? (LOL)

 

[dchz]

Patient ate about 6 hours ago.

Kind reminder this guy should be RSI regardless of NPO time.

 

[Beeftenderloin]

Can you get a surgical block for this just w fem block?

Although this doesn’t answer your question directly, I did a patella ORIF the other night in a fibro patient who was in “10/10” pain in pre-op. Femoral nerve block right before induction with 0.5% ropi. Did GA with .7 MAC sevo and only 25mcg fentanyl with induction. Vitals didn’t budge on incision and post-op couldn’t feel her leg at all. Once the block wore off the next afternoon she was back to 10/10 pain. I suspect I could have done the case without the sevo/tube.

 

[UnbentLaryngoscope]

In addition to the usual suspects (pain, hypovolemia) and autonomic disturbance related to SAH (good call) I would be interested in some labs. Electrolytes (including Mg and PO4), CK, TSH, pro-BNP, as well as H&H.

Make sure he's on telemetry on the floor, so if there's any arrhythmia/ectopy it is captured for review.

If there is a murmur, get an echo, otherwise no.

If the patient has a new O2 requirement, get a CT angio chest to r/o PE, otherwise no.

 

[GassYous]

This looks like an atrial tachycardia. The cardiac implications of SAH are well described and involve catecholamine surge— this could be what we’re seeing. This has the potential to get worse with any progression of the bIeed. I would postpone this non-emergent case and give him a beta-blocker now. If his HR doesn’t improve I would involve cardiology and ask NSG about re-scanning his head.

Love it.

When I see tachycardia I think about regular vs irregular. Narrow vs wide.

Irregular narrow: af, flutter, mat. Figure out why this happened and control the rate.
Regular: sinus tachy vs svt. You could give some adenosine (I think it's 6, 12, 12) and see if you can slow it down to get a better ecg if you need to differentiate. Or there's the blow into the syringe trick. People talk about vagal maneuvers but I wouldn't go mashing on a carotid in a patient with a previous stroke.
Regular wide: hyperk, v tach, svt with aberrancy. Diagnose and control. Probably give amio or shock.
Irregular wide: hyperk, af wpw, af with aberrancy. Get ready to shock. Maybe try some procainamide. I dunno I'm not a cardiologist.



The medicine doctor attributed the tachycardia to pain. But it was stable and didn't budge at all which made me think svt and reentry. It's pretty close to his maximum heart rate and I thought sinus tachy was less likely. The increased leg swelling made me suspicious for dvt vs tachycardia mediated cardiomyopathy vs some other cause for fluid overload. Didn't hear a murmur but I wanted cardiology to weigh in and for the rate to be controlled. The left axis deviation on this ecg is new. I delayed the case for workup.

k 4 mg 2.5 p 3.3 hgb 12
didn't think of thyroid which is a nice call.

Would you want anything else?



Side note: I have done knee replacements with adductor/ipack with bupi 0.5 10cc/20cc and facemask. I think you need the posterior coverage because there's some pain from edema due to the injury/fluid for scope. You may miss the obturator but a little surgeon local can supplement. Nowadays I would block then place an lma.

 

[Katheudontas parateroumen]

How many of you all would have tried to treat this patient given otherwise stable vitals? Adenosine could possibly first line for narrow complex tachycardia, if it reverts to NSR was probably some SVT. But I’d be hesitant to do such on something essentially elective at this point. Maybe some metoprolol or dilt if I felt inclined. Medicine consult after seeing atrial tachy (tachy with abnormal inverted p wave) is probably the safest bet. Would any POCUS help us out? This is a good case. A lot more than meets the eye.

 

[Urzuz]

Side note: I have done knee replacements with adductor/ipack with bupi 0.5 10cc/20cc and facemask.

wtf?

 

[GassYous]

wtf?

😎

 

[Volatile]

Serious question/poll:

How many of you consider the femoral nerve block a "deep" block? Meaning you can't hold pressure if you hit something that slightly bleeds?

Sciatic?

Supraclav?

Interscalene?

ESP?

Paravertebrals?

Intercostals? (LOL)

I wouldn’t think twice about doing a femoral, supraclavicular, interscalene, or ESP block on an anticoagulated pt (obviously all under US). For sciatic blocks it depends where I am doing it and how good my image is under US. I would not do paravertebrals for pt’s on AC, especially when subjectively my ESB’s work just as well. I’ve never done an intercostal so probably not. Everything we do has risk/benefit, we are paid very well to try and decide what is best for a particular pt having a particular procedure. I have done/seen spinals on AC patient’s because the benefit outweighed the risk. Just document well and do what you think is best.

 

[deleted875186]

SVT .... Pain does not cause tachy to 130s in an old patient like that. I’d cancel, send to telemetry floor, full set of labs, have them control the rate, fix volume status, come back tomorrow.

if the surgeon needs to go now for a legit reason, try some beta blocker in preop, have some dilt and amio on hand if needed.

 

[Hoya11]

Can you get a surgical block for this just w fem block?

No. The patella is innervated by both Fem and Sci.

 

[Hoya11]

You're on call and the board is starting to clear up. You drop your last patient off in pacu and see that a ortho addon has been posted to the board. You go to see the patient and this is the history you obtain.

65 yo m with pmh remote cva with left hemiplegia, htn, dm2, obesity who fell and presented with a left patellar fracture as well as trace frontal sah.

The first thing you noticed when you went to see the patient is that he is laying comfortably in the hospital bed, chatting with the nurse. The second is a monitor showing a heart rate of 139. What now?

Would I do the case now? No. Its elective and this high risk guy has uncontrolled tachycardia - whatever the cause.

I am a believer that starting a case with this level of tachycardia can lead to demand ischemia.

If I HAD to do the case how would I manage this tachycardia?

I would give beta blocker (metoprolol) until it comes down to less than 100.

If BP gets soft from metoprolol I would use NEO to drive down the HR further while BP normalizes

He is probably super dry and would give 2L fluid if no reason not to.

I would intubate vs LMA depending on HOW obese and how the airway looks.

 

[Hoya11]

I wouldn’t think twice about doing a femoral, supraclavicular, interscalene, or ESP block on an anticoagulated pt (obviously all under US). For sciatic blocks it depends where I am doing it and how good my image is under US. I would not do paravertebrals for pt’s on AC, especially when subjectively my ESB’s work just as well. I’ve never done an intercostal so probably not. Everything we do has risk/benefit, we are paid very well to try and decide what is best for a particular pt having a particular procedure. I have done/seen spinals on AC patient’s because the benefit outweighed the risk. Just document well and do what you think is best.

Mostly agree.. but can you give an example of when you have done a spinal on an AC patient because the benefit outweighed the risks?

Its very easy to just do GA and not violate guidelines that will raise eyebrows and possibly expose you to liability, regardless if clinically dangerous or not in reality

 

[vector2]

wtf?

The surgeon's 400 cc of infiltrated marcaine didn't count toward his anesthetic

 

[dchz]

I wouldn’t think twice about doing a femoral, supraclavicular, interscalene, or ESP block on an anticoagulated pt (obviously all under US). For sciatic blocks it depends where I am doing it and how good my image is under US. I would not do paravertebrals for pt’s on AC, especially when subjectively my ESB’s work just as well. I’ve never done an intercostal so probably not. Everything we do has risk/benefit, we are paid very well to try and decide what is best for a particular pt having a particular procedure. I have done/seen spinals on AC patient’s because the benefit outweighed the risk. Just document well and do what you think is best.

I second the example of pt therapeutically anticoagulated where a spinal outweighs the risk.

 

[teacher2md]

Sure thing, have had a fournier’s Gangrene pt scheduled for an urgent/emergent washout who was a cardiac and pulmonary cripple. Noted challenging airway in the past due to large goiter, basically coded during an airway attempt in the past requiring cancellation of case. I consulted ENT: they said cutting the neck was not an option. Obviously I wasn’t excited about re-attempting an airway. Final decision was spinal, if I couldn’t get it = case canceled and probably palliative care. I got the spinal, he got nothing else during the case, did fine, actually made it out of the hospital. This decision was made with multiple services involved including risk management.
To quote you “it’s very easy to do just do GA” is very naive. I have had two patients in my career where an ETT is not an option, both due to neck masses. Maybe ECMO? Maybe try and mask them through? Try to sedate a known difficult airway? But a quick spinal sure does seem like a nice option especially when the patient/ hospital is on board.

Did you consider and awake fiberoptic intubation?

I don’t know how the goiter would affect the anatomy for regional airway blocks, but maybe topicalizing well would have worked.

 

[Hoya11]

Sure thing, have had a fournier’s Gangrene pt scheduled for an urgent/emergent washout who was a cardiac and pulmonary cripple. Noted challenging airway in the past due to large goiter, basically coded during an airway attempt in the past requiring cancellation of case. I consulted ENT: they said cutting the neck was not an option. Obviously I wasn’t excited about re-attempting an airway. Final decision was spinal, if I couldn’t get it = case canceled and probably palliative care. I got the spinal, he got nothing else during the case, did fine, actually made it out of the hospital. This decision was made with multiple services involved including risk management.
To quote you “it’s very easy to do just do GA” is very naive. I have had two patients in my career where an ETT is not an option, both due to neck masses. Maybe ECMO? Maybe try and mask them through? Try to sedate a known difficult airway? But a quick spinal sure does seem like a nice option especially when the patient/ hospital is on board.

Just trying to spark a discussion, not trying to get nasty, but you have given examples here of spinal to avoid a difficult airway, when I thought we were discussing how its OK to do a spinal on AC sometimes... where was the anticoagulation factored in? Not trying to argue that sometimes spinal is better than GA. Just looking for rare examples where spinal or neuraxial is preferred to GA despite AC risks..

Spinal on a "cardiac cripple" a little cringe..

I have one...

I had a guy who had multiple craniotomy revisions for brain mets. He was a young guy but had so many revisions his skull was becoming deformed and his wound was not healing..

He is on Plavix and ASA for history of something I can not recall ..

He has a non-healing post - surgical wound, is in the ICU, and has only stopped plavix 2 days ago..

Neurosurgeon pleads with me to put in a lumbar drain to decrease CSF pressure and take pressure off the wound so it would heal..

I did it with an epidural tuohy and catheter in the intrathecal space connected to the drain device

Bleeding was not an issue, it was a clean pass and catheter placement and the drain worked well...

Patient and neurosurgeon understood I was not adhering to the recommended guidelines but wanted to take the chance anyways..

 

[Arch Guillotti]

Good advice above. Only a tangent but have any of you done a patella orin with just a femoral block?

No.

 

[Arch Guillotti]

Sure did, the case that was previously cancelled was an awake fiber optic attempt by a very experienced anesthesiologist also involving ENT. And he had a lot more fiber optic experience than I do. And airway blocks are not an option with some of these neck masses, it’s always topicalization, think neck with a melon sitting on it. My point is, these disaster patients exist, and sometimes you have to make an uncomfortable decision but always include multiple teams including risk management. I still get a knot in my stomach thinking about that case and pray that others never have to deal with something similar..... but great learning opportunity for everyone involved.

How do you get risk management involved on an urgent case? No offense but these cases always seem to come after hours or on the weekends. I don’t thibk risk management has much idea what the real score is on these cases.

 

[Arch Guillotti]

Just trying to spark a discussion, not trying to get nasty, but you have given examples here of spinal to avoid a difficult airway, when I thought we were discussing how its OK to do a spinal on AC sometimes... where was the anticoagulation factored in? Not trying to argue that sometimes spinal is better than GA. Just looking for rare examples where spinal or neuraxial is preferred to GA despite AC risks..

Spinal on a "cardiac cripple" a little cringe..

I have one...

I had a guy who had multiple craniotomy revisions for brain mets. He was a young guy but had so many revisions his skull was becoming deformed and his wound was not healing..

He is on Plavix and ASA for history of something I can not recall ..

He has a non-healing post - surgical wound, is in the ICU, and has only stopped plavix 2 days ago..

Neurosurgeon pleads with me to put in a lumbar drain to decrease CSF pressure and take pressure off the wound so it would heal..

I did it with an epidural tuohy and catheter in the intrathecal space connected to the drain device

Bleeding was not an issue, it was a clean pass and catheter placement and the drain worked well...

Patient and neurosurgeon understood I was not adhering to the recommended guidelines but wanted to take the chance anyways..

That sounds a bit sketchy but the point os well taken. Advise all parties that you are working outside of established guidelines and there is risk to bear.

 

[Hork Bajir]

Not so long ago I did a thoracic epidural for a rib fractures in a little old lady who had taken her DAPT that morning. She was DNR/DNI, unacceptable level of sedation from even 2.5 of oxycodone, but also unable to cough or breathe well because of pain (O2 sat low 90s on max HFNC). Adamant that she did not want to be intubated. I had a conversation with the patient and her daughter where I made it very clear that epidural analgesia might be her only salvage option, even though doing so clearly violated guidelines and there was a higher than normal (though difficult to quantify) risk of neurologic devastation from the procedure. Before anyone asks, I didn’t think PVB or ESP catheters would be as reliable, and didn’t want to do Q4hr rib blocks for the next few days lol. I wrote all of this out explicitly on the consent form and had both of them sign it.

The epidural went in easily on first attempt, worked like a dream. Came out on day 3 and patient was discharged back to her facility. Could just as easily have gone the other way… Wouldn’t make for this kind of heroic story, but just giving an example of a case where clinical judgments can supersede blind following the guidelines.

 

[Arch Guillotti]

Not so long ago I did a thoracic epidural for a rib fractures in a little old lady who had taken her DAPT that morning. She was DNR/DNI, unacceptable level of sedation from even 2.5 of oxycodone, but also unable to cough or breathe well because of pain (O2 sat low 90s on max HFNC). Adamant that she did not want to be intubated. I had a conversation with the patient and her daughter where I made it very clear that epidural analgesia might be her only salvage option, even though doing so clearly violated guidelines and there was a higher than normal (though difficult to quantify) risk of neurologic devastation from the procedure. Before anyone asks, I didn’t think PVB or ESP catheters would be as reliable, and didn’t want to do Q4hr rib blocks for the next few days lol. I wrote all of this out explicitly on the consent form and had both of them sign it.

The epidural went in easily on first attempt, worked like a dream. Came out on day 3 and patient was discharged back to her facility. Could just as easily have gone the other way… Wouldn’t make for this kind of heroic story, but just giving an example of a case where clinical judgments can supersede blind following the guidelines.

Nice case. Takes time and some guts. A good discussion with the patient and family goes a long way.

 

[coffeebythelake]

No. The patella is innervated by both Fem and Sci.

yeah i know, that was my socratic response to kmurp

 

[kmurp]

No. The patella is innervated by both Fem and Sci.

Interesting. I thought the bone itself was all femoral, but that the incision could extend to the peroneal nerve distribution.

 

[Iso4ane]

Serious question/poll:

How many of you consider the femoral nerve block a "deep" block? Meaning you can't hold pressure if you hit something that slightly bleeds?

Sciatic?

Supraclav?

Interscalene?

ESP?

Paravertebrals?

Intercostals? (LOL)

If you do it wrong, its a deep block.

 

[2Fast2Des]

Nice case. Takes time and some guts. A good discussion with the patient and family goes a long way.

How do you reason with a surgeon that you will need time to discuss options and they can't just go chop chop just because they added the case? I have an easier time to do heroic stuff at academic place I work but in the community hospital the PP surgeons just want to do chop chop and then complain to our chairman if anything delays the case regardless of how cripple the pt is

 

[coffeebythelake]

How do you reason with a surgeon that you will need time to discuss options and they can't just go chop chop just because they added the case? I have an easier time to do heroic stuff at academic place I work but in the community hospital the PP surgeons just want to do chop chop and then complain to our chairman if anything delays the case regardless of how cripple the pt is

Some surgeons are hacks. They probably only think of their patient as a paycheck. These are the same surgeons who have no qualms hiring a CRNA without anesthesiologist supervision to get patients through the meat grinder.

 

[GassYous]

How do you reason with a surgeon that you will need time to discuss options and they can't just go chop chop just because they added the case? I have an easier time to do heroic stuff at academic place I work but in the community hospital the PP surgeons just want to do chop chop and then complain to our chairman if anything delays the case regardless of how cripple the pt is

If I say the patient is not cleared for surgery, they don't go. The surgeons I work with are pretty reasonable and will go with what I say. My partners will back me. Why do you have a chairman in pp? I've never heard of such a thing. Did you mean group president? Regardless, they can do the case if they prefer.

Anyway I canceled the case for medical optimization. Medicine got a lower extremity duplex that was without evidence of dvt and an echo that showed normal function (to evaluate for cardiomyopathy that would induce tachycardia or vice versa).

They started metoprolol po and got the patient to heart rate 80s. Case was done the next day with lma and femoral block. The ecgs at the time were interesting:

Preop ecg (after beta blockage)

Postop ecg:

 

[deleted875186]

If I say the patient is not cleared for surgery, they don't go. The surgeons I work with are pretty reasonable and will go with what I say. My partners will back me. Why do you have a chairman in pp? I've never heard of such a thing. Did you mean group president? Regardless, they can do the case if they prefer.

Anyway I canceled the case for medical optimization. Medicine got a lower extremity duplex that was without evidence of dvt and an echo that showed normal function (to evaluate for cardiomyopathy that would induce tachycardia or vice versa).

They started metoprolol po and got the patient to heart rate 80s. Case was done the next day with lma and femoral block. The ecgs at the time were interesting:

Preop ecg (after beta blockage)
View attachment 319143

Postop ecg:
View attachment 319144

Post op looks like they’re back in some sort of SVT. Preop it’s hard to tell, almost looks like heart block but it’s definitely not a sinus p wave. Not really sure what the rythym was.

 

[MirrorTodd]

Post op looks like they’re back in some sort of SVT. Preop it’s hard to tell, almost looks like heart block but it’s definitely not a sinus p wave. Not really sure what the rythym was.

Preop looks like sinus rhythm to me...possibly with a longer interval mobitz type 2? Admittedly, I don't know how the beta blocker would confound the picture.

 

[GassYous]

Preop is definitely not sinus. You can tell the ectopic focus of the atrial beats from the p wave inversion inferiorly and laterally. Probably near the av node. Although there's the left axis deviation, I don't see any fascicular or bundle branch block. Could also be from old inferior MI since there's q waves in 3 and avf.

You can see the Mobitz 2 by the two dropped beats in the strip with a narrow qrs so it's within the his bundle and not infrahis. Good to know because then you know that sympathetic stimulation can improve conduction through the av node while vagal stimulation would worse conduction. It's the opposite for blocks below the av node.

Causes of mobitz 2: inflammation, infarction, fibrosis, surgery, infiltrative disease (sarcoid which jacks up the septum, amyloid etc), drugs that affect av conduction like beta blockers, calcium channel blockers, dig, amio.

If it kept up, it could progress to complete heart block. Can be an indication for pacemaker. Unlikely here.



Cardiology said that the patient usually lives around a heart rate of 110-120 and to decrease the beta blocker dose to improve the mobitz 2 block. So the metoprolol was decreased then stopped. The postop ecg is back to his atrial tachycardia but in the 120s. The patient did okay postop and was discharged a few days later.

 

[deleted59964]

Not so long ago I did a thoracic epidural for a rib fractures in a little old lady who had taken her DAPT that morning. She was DNR/DNI, unacceptable level of sedation from even 2.5 of oxycodone, but also unable to cough or breathe well because of pain (O2 sat low 90s on max HFNC). Adamant that she did not want to be intubated. I had a conversation with the patient and her daughter where I made it very clear that epidural analgesia might be her only salvage option, even though doing so clearly violated guidelines and there was a higher than normal (though difficult to quantify) risk of neurologic devastation from the procedure. Before anyone asks, I didn’t think PVB or ESP catheters would be as reliable, and didn’t want to do Q4hr rib blocks for the next few days lol. I wrote all of this out explicitly on the consent form and had both of them sign it.

The epidural went in easily on first attempt, worked like a dream. Came out on day 3 and patient was discharged back to her facility. Could just as easily have gone the other way… Wouldn’t make for this kind of heroic story, but just giving an example of a case where clinical judgments can supersede blind following the guidelines.

I'd still do the ESBs for this.
sure not as reliable - but a whole lot more defendable

 

[MoMoGesiologist]

Couldn’t you have just given some metop in preop and done the case then? Obviously this is safe only in retrospect, but we get tachy pts all the time and I’m never sure whether to just give some BB or delay for cards, who inevitably just starts metop and pt is back the next day...

 

[GassYous]

Couldn’t you have just given some metop in preop and done the case then? Obviously this is safe only in retrospect, but we get tachy pts all the time and I’m never sure whether to just give some BB or delay for cards, who inevitably just starts metop and pt is back the next day...

What is the advantage of that? The patient is significantly tachycardic and stating he has increased leg swelling. ECG has a left axis and inferior q waves of uncertain significance. When the patient sues you after suffering from decompensated heart failure, perioperative MI or coding on induction what will you say to the jury? That you couldn't afford a quarter on metoprolol and a few hours to optimize the patient? The patient deserves a probe on the chest in holding at the very least.

For a nonemergent case and an unoptimized patient, I don't see the utility of rushing to the OR. The surgeons also don't want bad outcomes for their patient and don't mind waiting to do the case if necessary.

 

[deleted682700]

Sorry patellar fracture is not an emergency. If the ortho insists, let them. Write a Progress note stating it is an emergency. Cardiac clearance and I will just let another anesthesiologist to concur with what I did.

 

[UnbentLaryngoscope]

The first EKG in the thread is not normal, but it's not AFib, AFlutter, or AVNRT. It's not an MI. Most importantly, the patient is not symptomatic with any of this. I'm not super worried about the patient... but I would not just beta-block the patient in preop and go. The etiology of the tachycardia is unclear, and it needs to be investigated before proceeding with a non-emergent case.

If my surgical colleague was really chomping at the bit to do the case tonight I am capable of investigating this tachycardia myself. I would be agreeable to doing the case in an hour or two once I had the labs I requested back (Electrolytes, CK, TSH, pro-BNP, H&H), assuming they were all normal. If labs are normal (feeling comfortable that it's not CHF as evidenced by a normal pro-BNP), I would probably bolus the patient a liter of fluid before going back rather than giving beta-blockade anyway.

If this tachycardia is not bothering the patient symptomatically or physiologically, I'm not especially interested in taking it away from them with AV nodal blocking drugs. As it turns out, our friends from cardiology in this case gave beta blockade and put the patient in Mobitz II second degree heart block. Now the patient has an iatrogenic problem.

If there's no murmur, no need for echo. If there's no new O2 requirement, no need to scan the chest. If there's no chest pain (or anginal equivalent symptoms) and the patient could do 4 MET's before they were injured I don't need a stress test or trops or cardiology consult.

 

[deleted697535]

Sure did, the case that was previously cancelled was an awake fiber optic attempt by a very experienced anesthesiologist also involving ENT. And he had a lot more fiber optic experience than I do. And airway blocks are not an option with some of these neck masses, it’s always topicalization, think neck with a melon sitting on it. My point is, these disaster patients exist, and sometimes you have to make an uncomfortable decision but always include multiple teams including risk management. I still get a knot in my stomach thinking about that case and pray that others never have to deal with something similar..... but great learning opportunity for everyone involved.

Case series of gaiters from aus. Afoi failed. Banged em off to sleep next time, worked great for all of the initial affiliate failures.

Goitres seems to be a particular type of neck mass that doesn't obey mediating mass rules ie you can get a tube past it

 

[pgg]

How do you reason with a surgeon that you will need time to discuss options and they can't just go chop chop just because they added the case? I have an easier time to do heroic stuff at academic place I work but in the community hospital the PP surgeons just want to do chop chop and then complain to our chairman if anything delays the case regardless of how cripple the pt is

If that's a problem, it lies with your chairman, not the surgeon.

 

[2Fast2Des]

If I say the patient is not cleared for surgery, they don't go. The surgeons I work with are pretty reasonable and will go with what I say. My partners will back me. Why do you have a chairman in pp? I've never heard of such a thing. Did you mean group president? Regardless, they can do the case if they prefer.

If that's a problem, it lies with your chairman, not the surgeon.

The group through it's time has catered to surgeons whims because unhappy surgeon equals no more contract\renewal and they don't want to make the leadership of the hospital unhappy. The unwillingness to turn down units and also to not piss off surgeons lead to the current way things are done, we just do anything that comes through the door. I remember one of my colleagues cancelled a case where the pt was completely unoptimized chf and copd but the surgeon threw a hissy fit so another anesthesiologist ended doing the case. Pt ended up in ICU after I think because unable to extubate... But hey got the case done lol

We have a couple of hospitals that we work out of, each campus has a chairman for the anesthesia department for the hospital who is the point person for leadership. But we do have a group president and ceo for the overall group management standpoint as well

 

[Urzuz]

The group through it's time has catered to surgeons whims because unhappy surgeon equals no more contract\renewal and they don't want to make the leadership of the hospital unhappy. The unwillingness to turn down units and also to not piss off surgeons lead to the current way things are done, we just do anything that comes through the door. I remember one of my colleagues cancelled a case where the pt was completely unoptimized chf and copd but the surgeon threw a hissy fit so another anesthesiologist ended doing the case. Pt ended up in ICU after I think because unable to extubate... But hey got the case done lol

We have a couple of hospitals that we work out of, each campus has a chairman for the anesthesia department for the hospital who is the point person for leadership. But we do have a group president and ceo for the overall group management standpoint as well

That sucks, sorry you have to practice in an environment like that. It sounds like your group needs to elect an anesthesiologist with a spine to a chair position, who has the ability and desire to sit these surgeons down and actually talk to them as colleagues and not as a subservient invertebrate that does their bidding.

Maybe it is a culture thing, but I have been lucky enough to join a practice where most if not all surgeons are reasonable when it comes to cancelling/postponing cases for optimization and risk mitigation. Some will bitch and moan about it, sure, but ultimately they'll leave the decision to us.

Out of curiosity, are you part of a supervision practice or MD-only? I feel like one of the huge advantages of being in an MD-only practice is that you actually spend an inordinate amount of time with the surgeons you work with, so you get to know them quite well and develop a rapport with them both professionally and socially. That way, when you actually do have to delay/cancel cases, you aren't just some faceless, nameless person who is preventing them from hitting the links by 2pm.