Tamponade

[PpfSuxTube]

Opinions on a case.

60yo M pod 10 cabg with day 1 reopening for massive bleed, presents to ED in and out of fast afib, sob.
Tte shows rv chamber compression in diastole. 3.3cm effusion around rv.
Significant transmitral and transtricispud respirophasic variations.
Last ate 3 hours before. Otherwise had RA, grade 2 dl view for cabg. Normal blood work.

Surgeon wants to do pericardial window. Hes a chill surgeon.

Pt is remarkably stable. Lying flat, no fluids running, no aline. Everyone is chill.

Significant pulsus when i place aline.

How to proceed?

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[PpfSuxTube]

This was 1 of my 3 tamponades yesterday.

 

[Hoya11]

Opinions on a case.

60yo M pod 10 cabg with day 1 reopening for massive bleed, presents to ED in and out of fast afib, sob.
Tte shows rv chamber compression in diastole. 3.3cm effusion around rv.
Significant transmitral and transtricispud respirophasic variations.
Last ate 3 hours before. Otherwise had RA, grade 2 dl view for cabg. Normal blood work.

Surgeon wants to do pericardial window. Hes a chill surgeon.

Pt is remarkably stable. Lying flat, no fluids running, no aline. Everyone is chill.

Significant pulsus when i place aline.

How to proceed?

etomidate, sux, tube

 

[Volatile]

reopening for massive bleed pod 1 w/ 3 tamponades in one day :/ ? If these were all recent post-ops I would have some serious concerns about the skill of my surgeons and probably be looking for a more pleasant place to work.
Otherwise sounds like a typical stable tamponade, a-line in pre-op, patient prepped/draped, suction catheters ready, induce (sevo/ketamine), try to keep him breathing, as soon as he’s asleep, secure the airway. His pathology trumps npo. No one will fault you in a courtroom for trying not to paralyze with an RSI.

 

[Arch Guillotti]

reopening for massive bleed pod 1 w/ 3 tamponades in one day :/ ? If these were all recent post-ops I would have some serious concerns about the skill of my surgeons and probably be looking for a more pleasant place to work.
Otherwise sounds like a typical stable tamponade, a-line in pre-op, patient prepped/draped, suction catheters ready, induce (sevo/ketamine), try to keep him breathing, as soon as he’s asleep, secure the airway. His pathology trumps npo. No one will fault you in a courtroom for trying not to paralyze with an RSI.

No way. Paralyze 100%. The whole reason to prep and drape and have the surgeon in the room is so that he can go to town if the patient crumps on induction.

 

[Volatile]

No way. Paralyze 100%. The whole reason to prep and drape and have the surgeon in the room is so that he can go to town if the patient crumps on induction.

I guess I do my best to tailor my anesthetic to avoid crumps 🤷🏼‍♂️

 

[Arch Guillotti]

I guess I do my best to tailor my anesthetic to avoid crumps 🤷🏼‍♂️

I like to make em sweat.

 

[vector2]

reopening for massive bleed pod 1 w/ 3 tamponades in one day :/ ? If these were all recent post-ops I would have some serious concerns about the skill of my surgeons and probably be looking for a more pleasant place to work.
Otherwise sounds like a typical stable tamponade, a-line in pre-op, patient prepped/draped, suction catheters ready, induce (sevo/ketamine), try to keep him breathing, as soon as he’s asleep, secure the airway. His pathology trumps npo. No one will fault you in a courtroom for trying not to paralyze with an RSI.

What I like to do for tamponade (especially one like this where the pt is chilling supine and isn't imminently arresting) is preinduction aline, IVF bolus, epi and/or norepi push, induce carefully with etomidate/ketamine etc, and then once asleep apply a mask seal with 10-20 cm H2O and do a gentle bag assist. If the hemodynamics are holding with a bit of PPV then I just give some more inotrope/pressor plus sux and put the tube in.

 

[coffeebythelake]

keep the heart beating hard, fast, and full
fortunatley by the description of it your patient is not in extremis.
your CT surgeons old school enough to do a bedside pericardiocentesis prior to induction?

 

[PpfSuxTube]

The surgeons are good. We have very low rate of takebacks usually.

Anyways, i did awake aline, then spont vent fob oral intubation with remi/midaz lido spray. It went fine. 500mls blood in there!

Honestly the guy looked so good, but his echo was really profound rv collapse, huge pulsus swing. If i did rsi and something untoward happened i think i would have questions to answer. The cardiologist really got some high quality shots of tricuapid variations

Plus my colleague had an arrest on induction with a tamponade about 2 months ago which colored my judgment.

10 mins extra work for the peace of mind was worth it in my mind. My old shop did regularly enough fob tubes for a variety of reasons, this new place they almost never do it, so i think i raised some eyebrows. Not all bad mind you. Surgeon didnt care. He was scrubbed but sitting outside



Extubated to regular pacu post op. Patient was very happy with me. Hes had such a tough 10 days. He gave me Thumbs up as i left pacu

Very strange 'extubating' a cardiac case and taking to regular pacu. My colleagues still routinely give 2mg fent each case so i wonder how they would have done it

 

[Hork Bajir]

What I like to do for tamponade (especially one like this where the pt is chilling supine and isn't imminently arresting) is preinduction aline, IVF bolus, epi and/or norepi push, induce carefully with etomidate/ketamine etc, and then once asleep apply a mask seal with 10-20 cm H2O and do a gentle bag assist. If the hemodynamics are holding with a bit of PPV then I just give some more inotrope/pressor plus sux and put the tube in.

I like this approach in general, but what do you do if the patient drops their pressure significantly with positive pressure? Presumably if you’ve pushed etomidate, they’re apneic… Not exactly like you can decide to get them spontaneously breathing and deepen with sevo at that point

 

[Hork Bajir]

The surgeons are good. We have very low rate of takebacks usually.

Anyways, i did awake aline, then spont vent fob oral intubation with remi/midaz lido spray. It went fine. 500mls blood in there!

Honestly the guy looked so good, but his echo was really profound rv collapse, huge pulsus swing. If i did rsi and something untoward happened i think i would have questions to answer. The cardiologist really got some high quality shots of tricuapid variations

Plus my colleague had an arrest on induction with a tamponade about 2 months ago which colored my judgment.

10 mins extra work for the peace of mind was worth it in my mind. My old shop did regularly enough fob tubes for a variety of reasons, this new place they almost never do it, so i think i raised some eyebrows. Not all bad mind you. Surgeon didnt care. He was scrubbed but sitting outside



Extubated to regular pacu post op. Patient was very happy with me. Hes had such a tough 10 days. He gave me Thumbs up as i left pacu

Very strange 'extubating' a cardiac case and taking to regular pacu. My colleagues still routinely give 2mg fent each case so i wonder how they would have done it

Nice, well done. Don’t think I would have necessarily awake intubated this guy, but sounds like it went smoothly and was the right decision for this patient in your hands

 

[vector2]

I like this approach in general, but what do you do if the patient drops their pressure significantly with positive pressure? Presumably if you’ve pushed etomidate, they’re apneic… Not exactly like you can decide to get them spontaneously breathing and deepen with sevo at that point

I find very little apnea or relaxation of airway tone when etomidate is dosed judiciously 2mg at a time. I use it not infrequently for sedation for those RHF/pHTN/very low LVEF getting endo or TEEs. If in a tamponade case it looks like any PPV is gonna cause the pt to **** the bed, then more midaz/ketamine, keep them breathing, mcgrath and tube.


"Overall cardiopulmonary adverse events were identified in 22 patients (34.38%) of the etomidate group and 33 patients (51.56%) of the propofol group, without significant difference (P = .074). However, the incidence of oxygen desaturation (4/64 [6.25%] vs 20/64 [31.25%]; P =.001) and respiratory depression (5/64 [7.81%] vs 21/64 [32.81%]; P =.001) was significantly lower in the etomidate group than in the propofol group"

Etomidate versus propofol sedation for complex upper endoscopic procedures: a prospective double-blinded randomized controlled trial - PubMed

Etomidate administration resulted in fewer respiratory depression events and had a better sedative efficacy than propofol; however, it was more frequently associated with myoclonus and increased blood pressure during endoscopic procedures. (Clinical trial registration number: KCT0001701.).

pubmed.ncbi.nlm.nih.gov

"Compared with other anesthetics, such as propofol and barbiturates, etomidate has a smaller impact on the respiratory system. After induction of anesthesia with etomidate at a dose of 0.3 mg/kg, a short period of hyperventilation occurs. Several studies in patients reported a brief period of apnea [110, 111], with a mean duration of 20 s [17]. These apnea periods result in a change in PaCO2 of ± 15% and have no significant effect on PaO2 [105]. The occurrence of apnea following anesthetic induction doses of etomidate also seem to depend on the type of premedication applied prior to etomidate administration."

Etomidate and its Analogs: A Review of Pharmacokinetics and Pharmacodynamics - Clinical Pharmacokinetics

Etomidate is a hypnotic agent that is used for the induction of anesthesia. It produces its effect by acting as a positive allosteric modulator on the γ-aminobutyric acid type A receptor and thus enhancing the effect of the inhibitory neurotransmitter γ-aminobutyric acid. Etomidate stands out...

link.springer.com

 

[Hork Bajir]

I find very little apnea or relaxation of airway tone when etomidate is dosed judiciously 2mg at a time. I use it not infrequently for sedation for those RHF/pHTN/very low LVEF getting endo or TEEs. If in a tamponade case it looks like any PPV is gonna cause the pt to **** the bed, then more midaz/ketamine, keep them breathing, mcgrath and tube.


"Overall cardiopulmonary adverse events were identified in 22 patients (34.38%) of the etomidate group and 33 patients (51.56%) of the propofol group, without significant difference (P = .074). However, the incidence of oxygen desaturation (4/64 [6.25%] vs 20/64 [31.25%]; P =.001) and respiratory depression (5/64 [7.81%] vs 21/64 [32.81%]; P =.001) was significantly lower in the etomidate group than in the propofol group"

Etomidate versus propofol sedation for complex upper endoscopic procedures: a prospective double-blinded randomized controlled trial - PubMed

Etomidate administration resulted in fewer respiratory depression events and had a better sedative efficacy than propofol; however, it was more frequently associated with myoclonus and increased blood pressure during endoscopic procedures. (Clinical trial registration number: KCT0001701.).

pubmed.ncbi.nlm.nih.gov

"Compared with other anesthetics, such as propofol and barbiturates, etomidate has a smaller impact on the respiratory system. After induction of anesthesia with etomidate at a dose of 0.3 mg/kg, a short period of hyperventilation occurs. Several studies in patients reported a brief period of apnea [110, 111], with a mean duration of 20 s [17]. These apnea periods result in a change in PaCO2 of ± 15% and have no significant effect on PaO2 [105]. The occurrence of apnea following anesthetic induction doses of etomidate also seem to depend on the type of premedication applied prior to etomidate administration."

Etomidate and its Analogs: A Review of Pharmacokinetics and Pharmacodynamics - Clinical Pharmacokinetics

Etomidate is a hypnotic agent that is used for the induction of anesthesia. It produces its effect by acting as a positive allosteric modulator on the γ-aminobutyric acid type A receptor and thus enhancing the effect of the inhibitory neurotransmitter γ-aminobutyric acid. Etomidate stands out...

link.springer.com

Interesting, I have always found etomidate to be more “on or off” with regard to level of sedation/Depth of anesthesia, similar to methohexital where it’s kind of all or nothing… but in fairness, I am usually not titrating in smaller doses of etomidate in the same way that many of us frequently do with propofol. Will have to experiment with this technique

 

[PpfSuxTube]

To the guys that mention judicious bolus of x, then vl/dl when asleep...
Ive done this very little except in an already basically dead person

So ive no knowledge/skill with this in a fully awake person, who was already super pissed he was coming for his 3rd heart surgery in 10 days

This guy also had a full stomach so i preferred the fob to avoid the intensity of dl/vl

My co fellow tried your judicious boluses then vl technique one time in a younger guy with severe rt heart failure but still fully awake. He vomited when the glide blade went in which again has colored my judgment away from it...

I find the fob is tolerated crazy well, how i learned it . Next time ill try your way maybe.
Thanks

 

[vector2]

To the guys that mention judicious bolus of x, then vl/dl when asleep...
Ive done this very little except in an already basically dead person

So ive no knowledge/skill with this in a fully awake person, who was already super pissed he was coming for his 3rd heart surgery in 10 days

This guy also had a full stomach so i preferred the fob to avoid the intensity of dl/vl

My co fellow tried your judicious boluses then vl technique one time in a younger guy with severe rt heart failure but still fully awake. He vomited when the glide blade went in which again has colored my judgment away from it...

I find the fob is tolerated crazy well, how i learned it . Next time ill try your way maybe.
Thanks

Again, I prefer just giving sux whenever it seems reasonable, and I think it's reasonable more times with tamponade than people think because typically they're not using enough inotrope/pressor prophylactically with induction and before pushing paralytic.

But I also want to point out that you keep writing "fully awake." I never said fully awake when talking about judicious boluses. I said "induce carefully with etomidate/ketamine etc, and then once asleep..." and then to give more midaz/ketamine if you have to go down the route of not using paralytic if the pt doesn't tolerate any PPV with the mask. Yes, there is a non-zero chance of gagging and vomiting with this technique but it's not the same as the "fully awake" pts you're talking about.

 

[Arch Guillotti]

Again, I prefer just giving sux whenever it seems reasonable, and I think it's reasonable more times with tamponade than people think because typically they're not using enough inotrope/pressor prophylactically with induction and before pushing paralytic.

Agree.

 

[Arch Guillotti]

Plus my colleague had an arrest on induction with a tamponade about 2 months ago which colored my judgment.

Do you know the circumstances under which the arrest occurred and what the outcome was?

 

[PpfSuxTube]

Do you know the circumstances under which the arrest occurred and what the outcome was?

Not fully, must explore.
Surgeon opened quickly and they got rosc.
Im junior and new so didnt want any hassle like that

 

[ryanjmy]

they're not using enough inotrope/pressor prophylactically with induction and before pushing paralytic.

This is 100% the right answer. Assuming the pt isn't already on a ton of pressors, add about 30mcg of Norepi to your normal sick heart induction and you will be fine.

 

[drmwvr]

This is 100% the right answer. Assuming the pt isn't already on a ton of pressors, add about 30mcg of Norepi to your normal sick heart induction and you will be fine.

Amen...pre-induction inopressor is the most overlooked anti-arrest adjunct in CT anesthesia...and they're all just hanging there set up....

 

[DrN2O]

Anyways, i did awake aline, then spont vent fob oral intubation with remi/midaz lido spray. It went fine. 500mls blood in there!

I always wonder the utility/safety of awake intubation with an anesthetized/gagless airway for a full stomach. I hear this answer all the time, but isn't awake intubation for difficult airway? You can suck down a tube, but not the vomit? What's people's real life experience?

 

[PpfSuxTube]

I always wonder the utility/safety of awake intubation with an anesthetized/gagless airway for a full stomach. I hear this answer all the time, but isn't awake intubation for difficult airway? You can suck down a tube, but not the vomit? What's people's real life experience?

Yeah not sure. I did it because of the echo & pulsus not really the stomach

That being said in my limited experience ive not seen many aspirate from 2 of midaz, 40 remi