Upcoming case tomorrow...

[vector2]

56yo F scheduled for a left partial robotic assisted nephrectomy. 5.3 x 3.9cm lesion which was thought originally to be a cyst, but is now enhancing with contrast and growing since last imaging. She has a history of:

-CAD s/p DES to L cfx in 2007. Rethrombosed 9/2015 and was angioplastied and restented. She has been on DAPT since this time. Also has likely total ostial occlusion of RCA with collaterals as no RCA was visualized.
-currently 2-3 mets, has not had stress test since stenting
-PAD s/p L SFA stent
-hx TIA
-COPD with 40 pack year hx. still smoking 1ppd. on meds. no home O2
-HTN on coreg, hydralazine, and norvasc. 179/70 at pre-op visit
-CKD III
-GERD
-Obese
-Anxiety/depression on celexa (crying at pre-op visit about anesthesia/surgery fears)

2d echo, 9/2015 right before hitting the cath lab
CONCLUSIONS
1 - Normal left ventricular systolic function (EF 60-65%).
2 - Concentric hypertrophy.
3 - Moderate left atrial enlargement.
4 - Left ventricular diastolic dysfunction. Pseudonormalization filling with increase filling pressures.

RV function appears normal. No TR, no PASP in echo report

EKG now
Sinus bradycardia
LVH with repolarization abnormality
Cannot rule out Septal infarct ,age undetermined
Abnormal ECG
When compared with ECG of 22-FEB-2016 14:16,
Minimal criteria for Septal infarct are now Present
T wave inversion now evident in Inferior leads
T wave inversion more evident in Anterior leads

CBC and CMP are wnl except for decreased GFR.


Urologist has had frank discussion about risks of surgery. Pt does not want to wait until September to get the tumor out. Joint discussion with cardiologist leads to plan to hold DAPT for only 3 days instead of 7-10.

This is probably a routine case for the old timers, but would like to hear from students/residents about concerns or challenges. How do you proceed?

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[vector2]

and before anyone else says it

prop/sux/tube

 

[Hoya11]

What other options do you have? Intubate and put in 2 IVs and an aline and do the case. Discuss possible post op ventilation. Might need a neo drip. Lots of descriptive detail there, but this is like an everyday case...right?

 

[Planktonmd]

Yes... there isn't much to do other than proceed with GA. She might need a few days intubated in the ICU post-op.

 

[Chloroform4Life]

Stopping dapt is likely fine after 6 months per AHA's recently updated guideline.

If no change in symptoms from 9 months ago, procceed.

If change in sx, consider discuss with cardiologist if stress test can lead to reintervention....it likely won't, especially if the tumor is suspected to be cancer.

 

[GravelRider]

Avoid hypotension and hypoxia.

 

[Chloroform4Life]

Keep patient stable

 

[Robotic Wis-Hipple]

In the timeline you have you aren't fixing anything with her heart pre-surgery so it's all mental masturbation for nothing. Epidural would likely benefit her both from intraop MVO2 and postop MV requirement/splinting standpoints but that too is off the table. Soooo, cardiologist recommendation style, acceptable risk for GA, avoid hypoxia and tachycardia

 

[Robotic Wis-Hipple]

And just a plug for residents in general, it benefits you to go to a place where there is at least 1 if not a handful of these on the OR schedule Every. Single. Day.

 

[Ignatius J]

Curiously, why a partial nephrectomy? That is a good-sized mass.

 

[Robotic Wis-Hipple]

I'd guess trying to save some nephrons in the already ckd3 patient.

 

[Ignatius J]

I'd guess trying to save some nephrons in the already ckd3 patient.

Unless he is lightning quick with a clamp on, I wouldn't count on that happening. But he knows more than me.

 

[lobelsteve]

Turf to crna. If patient passes, make a stink about it. If patient does well, move to private forum.