TEE and Cardioversion

[jeesapeesa]

hey guys and gals, had a 52 yo male, BMI 45 with afib with RVR, pmhx of DM2, HTN, OSA, EF 38% of previous TTE scheduled for TEE and cardioversion. cardiologist wanted this done bedside in the ICU. told him to bring down pt to OR or endo suite for the procedure. this is one of the facilities that i have not done previous cardiofversions or TEE in. deep down if **** hits the fan I know i would be the last stop and i did not feel comfortable doing this bedside (nurses are not the best/helpful/knowledgeable). note that there are no anesthesia techs, residents, or OR nurse is with me.

i guess my question is...was my request out of the norm? received some flak from the cardiologist but i told my side of it. nonetheless, he had no choice and we did it in the OR with no issues but i felt more comfortable having all i needed.

 

[dipriMAN]

hey guys and gals, had a 52 yo male, BMI 45 with afib with RVR, pmhx of DM2, HTN, OSA, EF 38% of previous TTE scheduled for TEE and cardioversion. cardiologist wanted this done bedside in the ICU. told him to bring down pt to OR or endo suite for the procedure. this is one of the facilities that i have not done previous cardiofversions or TEE in. deep down if **** hits the fan I know i would be the last stop and i did not feel comfortable doing this bedside (nurses are not the best/helpful/knowledgeable). note that there are no anesthesia techs, residents, or OR nurse is with me.

i guess my question is...was my request out of the norm? received some flak from the cardiologist but i told my side of it. nonetheless, he had no choice and we did it in the OR with no issues but i felt more comfortable having all i needed.

Why was he in the ICU? If really very sick I think it’s ok to do it in the OR. Then again, what would you do in the OR that you couldn’t at the bedside, just have them bring in a vent or have an ambu bag and airway equipment ready.

 

[jeesapeesa]

Why was he in the ICU? If really very sick I think it’s ok to do it in the OR. Then again, what would you do in the OR that you couldn’t at the bedside, just have them bring in a vent or have an ambu bag and airway equipment ready.

he was on cardizem and amio drips. yes, i did think about bringing my stuff up there and having a vent ready, but having experienced an airway disaster in this particular ICU where we were called once, i had second thoughts. lets just say that everything up there moves like molasses.

 

[deleted171991]

TEE in the OR? Seriously? Of course this should be done bedside, in the ICU.

Viscous lidocaine gargle or spray, ketamine + propofol. Easy. You just need to set expectations with the patient (i.e. he will not be "asleep" just comfortable).

No offense, but if you can't manage giving propofol in a BMI 45 person in LLD, you have a problem. The EF is not an issue, and I assume the HR was under control. Worst case scenario, you would have had to, gasp, push some phenylephrine.

 

[dragonark]

I like bringing things to the bedside because I'm lazy. But if you feel more comfortable doing it in the OR and you get that feeling, then you did the right thing. You're the one responsible, not the cardiologist or anyone else. The cardiologist is sure as hell going to blame you if ANYTHING went wrong, not be helpful in an airway disaster, and probably not be helpful in a code situation. So why make compromises for someone who will throw you under the bus in a second? For tradition? Because it's easier for them? No thanks.

 

[deleted171991]

I like bringing things to the bedside because I'm lazy. But if you feel more comfortable doing it in the OR and you get that feeling, then you did the right thing. You're the one responsible, not the cardiologist or anyone else. The cardiologist is sure as hell going to blame you if ANYTHING went wrong, not be helpful in an airway disaster, and probably not be helpful in a code situation. So why make compromises for someone who will throw you under the bus in a second? For tradition? Because it's easier for them? No thanks.

Because it's ridiculous. Asking to do a TEE in the OR is like doing a benign EGD in the OR, just because the patient is obese and is an ASA 4. You will be laughed out in any serious PP; just tell them the story at the interview.

Take a cart with you to the ICU. Set up everything you like ahead of time, as if you were in the OR. What's the big deal? There should be NO airway disaster in a BMI 45 during TEE. If there is, you suck as an anesthesiologist. First of all, that probe is stenting your airway open... And, second, as I said, it should be sedation not GA.

If one is concerned about the airway supine, one can do the TEE in left lateral decubitus (that's what I would do in a BMI 45), let the patient wake up, then turn him supine and knock him out again for 30 seconds of cardioversion.

 

[sevoflurane]

hey guys and gals, had a 52 yo male, BMI 45 with afib with RVR, pmhx of DM2, HTN, OSA, EF 38% of previous TTE scheduled for TEE and cardioversion. cardiologist wanted this done bedside in the ICU. told him to bring down pt to OR or endo suite for the procedure. this is one of the facilities that i have not done previous cardiofversions or TEE in. deep down if **** hits the fan I know i would be the last stop and i did not feel comfortable doing this bedside (nurses are not the best/helpful/knowledgeable). note that there are no anesthesia techs, residents, or OR nurse is with me.

i guess my question is...was my request out of the norm? received some flak from the cardiologist but i told my side of it. nonetheless, he had no choice and we did it in the OR with no issues but i felt more comfortable having all i needed.

Thanks for posting. Yeah, any decent ICU should have everything you need to do a TEE. TEE/cardioversions are typically done supine/sitting at 45 degrees.

As far as the floors (non-ICU), some are less desirable locations for a multitude of reasons. We have a dedicated TEE room that we bring all of our TEEs for the day to (inpatient and outpatient). We also do bedside TTE/TEE for ICU patients. The hassle of bringing down a patient with a multitude of pumps running just isn’t worth it.

Doing a TEE in a room that doesn’t have the necessary equipment or doing them in a “closet procedure room” isn’t ideal either.

 

[vector2]

hey guys and gals, had a 52 yo male, BMI 45 with afib with RVR, pmhx of DM2, HTN, OSA, EF 38% of previous TTE scheduled for TEE and cardioversion. cardiologist wanted this done bedside in the ICU. told him to bring down pt to OR or endo suite for the procedure. this is one of the facilities that i have not done previous cardiofversions or TEE in. deep down if **** hits the fan I know i would be the last stop and i did not feel comfortable doing this bedside (nurses are not the best/helpful/knowledgeable). note that there are no anesthesia techs, residents, or OR nurse is with me.

i guess my question is...was my request out of the norm? received some flak from the cardiologist but i told my side of it. nonetheless, he had no choice and we did it in the OR with no issues but i felt more comfortable having all i needed.

Sorry man, taking this guy to the OR is absurd. Bring a stick of propofol, pressor of choice, and sux to the room. Have the airway cart and a video laryngoscope nearby for backup. Preox with a NRB mask, stick a nasal trumpet in once the prop starts hitting him if you're worried about obstruction. Shock. In and out in 10 min.

 

[drmwvr]

....stick a nasal trumpet in once the prop starts hitting him if you're worried about obstruction. Shock.

Just make sure he's not anticoagulated before you do that...you'll be sorry.

 

[dragonark]

Because it's ridiculous. Asking to do a TEE in the OR is like doing a benign EGD in the OR, just because the patient is obese and is an ASA 4. You will be laughed out in any serious PP; just tell them the story at the interview.

Take a cart with you to the ICU. Set up everything you like ahead of time, as if you were in the OR. What's the big deal? There should be NO airway disaster in a BMI 45 during TEE. If there is, you suck as an anesthesiologist. First of all, that probe is stenting your airway open... And, second, as I said, it should be sedation not GA.

If one is concerned about the airway supine, one can do the TEE in left lateral decubitus (that's what I would do in a BMI 45), let the patient wake up, then turn him supine and knock him out again for 30 seconds of cardioversion.

I like the criticism. You're not there, this person is there, knows the ICU sucks, and looks at the patient. Normally yes, easy peasy TEE and CV. But when you look at the patient and think...nah, and you look around you and say...nah, you have the right to do what you think is safest for the patient. You want an even better story to tell a PP group? Tell them how you f'ed up a simple TEE CV because you got cocky.

 

[deleted171991]

I like the criticism. You're not there, this person is there, knows the ICU sucks, and looks at the patient. Normally yes, easy peasy TEE and CV. But when you look at the patient and think...nah, and you look around you and say...nah, you have the right to do what you think is safest for the patient. You want an even better story to tell a PP group? Tell them how you f'ed up a simple TEE CV because you got cocky.

If the OP knows so much, why was he unsure about his decision?

I hate providing anesthesia in non-OR locations as much as the next person, but nothing I read on this thread has been impressive.

The OP was not complaining about the room, but the nurses etc. That's the concerning part. To me, what matters the most in an emergency is to have my own setup ready and SPACE to move around fast. What I need the most from the ICU nurses is not to stand in my way.

This is a MAC case; as with a difficult intubation, one doesn't get in trouble unless one takes the patient too deep. As long as the patient is breathing spontaneously, worst case scenario it's TEE out LMA in. Plus there are places that do TEEs with some conscious sedation; it's like swallowing a big steak.

It's all about setting the right patient and cardiologist expectations. For example, I never promise a BMI 45 that he will be asleep, just that I will keep him as comfortable as possible within safety limits.

 

[vector2]

I like the criticism. You're not there, this person is there, knows the ICU sucks, and looks at the patient. Normally yes, easy peasy TEE and CV. But when you look at the patient and think...nah, and you look around you and say...nah, you have the right to do what you think is safest for the patient. You want an even better story to tell a PP group? Tell them how you f'ed up a simple TEE CV because you got cocky.

dude, the OP says he told cards to bring them to the OR or the endo suite. i could probably do a cardioversion just as safely in the damned parking garage as compared to the average cramped, peripherally located, poorly stocked endo room

 

[anbuitachi]

hey guys and gals, had a 52 yo male, BMI 45 with afib with RVR, pmhx of DM2, HTN, OSA, EF 38% of previous TTE scheduled for TEE and cardioversion. cardiologist wanted this done bedside in the ICU. told him to bring down pt to OR or endo suite for the procedure. this is one of the facilities that i have not done previous cardiofversions or TEE in. deep down if **** hits the fan I know i would be the last stop and i did not feel comfortable doing this bedside (nurses are not the best/helpful/knowledgeable). note that there are no anesthesia techs, residents, or OR nurse is with me.

i guess my question is...was my request out of the norm? received some flak from the cardiologist but i told my side of it. nonetheless, he had no choice and we did it in the OR with no issues but i felt more comfortable having all i needed.

i think its out of the norm but if you aren't familiar with the institution then why not. do what you feel is most comfortable and then as you learn about hte place you can change your ways. like if i'm starting out in a new institiution and i dont know where anything is, or how good any of the surgeons are, i might just put a 2nd IV in that prostatectomy case

 

[coffeebythelake]

Agree by the description this should be easily performed in the ICU. Topicalize the crap out of the airway. Judicious versed, fentanyl, propofol.

 

[BeatriZZ]

To the OP,pay no mind to the cowboys on here who talk a lot of smack.
In my practice TEEs are always done in our endo suite, never in the ICU.
Of course, every practice is different so rather than posing the question here where you'll get useless criticism, see what your partners do. If you are the only one who requests the OR for these cases you will have a problem.

 

[Dr.whom]

We do our TEE and cardioversion in PACU for our convenience, no need for the OR. Never had to intubate one before. Just be gentle with your propofol/brevital and worse airway scenario: you ambu bag them for a couple minutes

 

[psychbender]

I've never brought and ICU patient out of the ICU to perform a TEE. As has been mentioned already, give viscous lidocaine, and just enough slowly titrated propofol to make his eyelids droopy. The most stimulating portion is getting the probe past the posterior pharynx. A TEE to rule out clot should take less than five minutes. If he's starting to come around when the probe comes out, give him another tiny bit of prop to get him to shut his eyes, then deliver the electricity. You really shouldn't need anything long-acting like fentanyl and versed for this procedure.

 

[pgg]

hey guys and gals, had a 52 yo male, BMI 45 with afib with RVR, pmhx of DM2, HTN, OSA, EF 38% of previous TTE scheduled for TEE and cardioversion. cardiologist wanted this done bedside in the ICU. told him to bring down pt to OR or endo suite for the procedure. this is one of the facilities that i have not done previous cardiofversions or TEE in. deep down if **** hits the fan I know i would be the last stop and i did not feel comfortable doing this bedside (nurses are not the best/helpful/knowledgeable). note that there are no anesthesia techs, residents, or OR nurse is with me.

i guess my question is...was my request out of the norm? received some flak from the cardiologist but i told my side of it. nonetheless, he had no choice and we did it in the OR with no issues but i felt more comfortable having all i needed.

I know where you're coming from. Out-of-OR cases where the equipment, space, and staff aren't optimal should give you pause. You just have to be diligent and extra paranoid about your setup, make a conservative plan, trust no one, and depend on no one.

The main thing about your reasoning that I would suggest needs to change is the bit about the nurses in the ICU being less capable. This implies your plan depended on them in some way. Their ability or inability is really irrelevant because you should never make a plan, anywhere, that relies on a nurse, tech, or other non-anesthesiologist for help.

Other people are there for convenience and efficiency, not safety.

From my perspective, the problem here isn't that you insisted on doing the case in the OR. Rather, the root issue is that whatever plan you executed in the OR somehow depended on other staff there to assist or be part of your plan B.


As I write this, I'm sitting in interventional radiology. Not my favorite place: it's remote, cramped, my stuff is in the "wrong" position and orientation, the patient's head is usually not in easy arm's reach of the machine during the procedure, it's a totally dead cell phone region, postprocedure transport requires an elevator, etc. Some of our sickest vasculopaths get procedures here.

My machine, which was set up and checked by a tech this morning, had an empty backup O2 cylinder.

The safety blanket of other people is an illusion. You are alone, no matter where you are.

 

[Man o War]

hey guys and gals, had a 52 yo male, BMI 45 with afib with RVR, pmhx of DM2, HTN, OSA, EF 38% of previous TTE scheduled for TEE and cardioversion. cardiologist wanted this done bedside in the ICU. told him to bring down pt to OR or endo suite for the procedure. this is one of the facilities that i have not done previous cardiofversions or TEE in. deep down if **** hits the fan I know i would be the last stop and i did not feel comfortable doing this bedside (nurses are not the best/helpful/knowledgeable). note that there are no anesthesia techs, residents, or OR nurse is with me.

i guess my question is...was my request out of the norm? received some flak from the cardiologist but i told my side of it. nonetheless, he had no choice and we did it in the OR with no issues but i felt more comfortable having all i needed.

hey guys and gals, had a 52 yo male, BMI 45 with afib with RVR, pmhx of DM2, HTN, OSA, EF 38% of previous TTE scheduled for TEE and cardioversion. cardiologist wanted this done bedside in the ICU. told him to bring down pt to OR or endo suite for the procedure. this is one of the facilities that i have not done previous cardiofversions or TEE in. deep down if **** hits the fan I know i would be the last stop and i did not feel comfortable doing this bedside (nurses are not the best/helpful/knowledgeable). note that there are no anesthesia techs, residents, or OR nurse is with me.

 

[Man o War]

My advice to new docs who come to our practice is always, always do what YOU are comfortable with. Ultimately, anything that goes wrong on your end is on you. I don’t know your ICU setup or situation, so I’m not going to judge your decision.
As the years advance, I sometimes just get a strange feeling about some cases. Listen to your gut.
@pgg gave you some great advice. Rely on nobody but yourself to keep your patient safe. The ability of the nurses shouldn’t matter. Assume they all suck and forge ahead with your plan.

 

[Psai]

If it's so easy to do bedside in the icu, why don't they just do it by themselves?