We postpone an AKA case, but why? How would you deal with it?

[DrAmir0078]

Hi SDN Anesthesiologists,
Tonight and Tomorrow I am the team leader of my residents in this teach hospital in Baghdad, and my role is to give support and answer residents consultations regarding their cases in the ORs - OBs and Emergencies beside covid CPAP - and if something difficult, I try consult the on call Attending!

We got a case that we felt to postpone it - but why?
You know, I don't speak myself, but this is the opinion of the Attending.

52 years old patient, presented for above knee amputation + DM, with elevated renal indices, on dialysis, his Hb is 10.8, his Coags PT 18, normal PTT, 1.4 INR
His Na is low, his albumin 2.9
His Echo EF 30, severe : MR, TR, Pulmonary Hypertension, LV dysfunction. Dilated RA, RV and LV with global hypokinesia... Etc

I saw him, he was on wheelchair, can't lay supine, very weak pulse - vitally looks stable (the night tour of the intern)

We postponed the case unless optimization of his labs and for PRBC for his Hb!

We stated very high risk GA, Spinal and suggestion for BKA first for regional anesthesia!

If RA failed - what is next?


He was traveling to India, Iran and North of Iraq to treat his bad hip looking for hip replacement for the last 5 years, last visit to Kurdistan North of Iraq in a private hospital, they refused to give him anesthesia because of his heart!

I am sure tomorrow, the Ortho will consult us!

My question is, do you get such end stage cases? How would you proceed?


Your information is valuable.

Thanks

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[Arch Guillotti]

My question is, do you get such end stage cases? How would you proceed?

All the time. Make sure potassium and dialysis are ok. Put him to sleep. Carefully. No spinal because of INR. Blocks for post op pain if needed.

 

[dhb]

All the amputations i've done in the past 5-6 years have been RA only. I don't mess with vasculopaths (unless you really have to).

 

[dhb]

Put him to sleep.

Once i offered to do the blocks for a collegue who refused and did a GA.
10min later i was paged to the room and he was pumping the patients sternum . We got him back...
N=1=2cents

 

[vector2]

Considering the hyponatremia and the fact that he can't lay flat, he needs dialysis and volume removal before anything.

And even if you want to do RA now....again....he can't lay flat. He's got 4 chamber enlargement and pulm htn. The minute he goes supine he'll act like he's drowning.

Get him on HD. Give him some plasma while he's there for presumptive congestive hepatopathy (I'm guessing you don't have TEG) and ultrafiltrate that extra volume off as well. Then assess his volume status and his symptamotology. If he gets back to his dry weight and he's still having NYHA class IV symptoms, do you have access inotropes and vasopressors? What kind?

I think slow dosed epidural and GA are both viable options but it depends on the anesthesia equipment, monitors, and drugs you have available.

 

[GassYous]

Hospice

 

[Blockit]

The scariest thing about what you describe is the low LVEF combined with pulmonary HTN. VERY dangerous.
Let’s assume you do the most perfect blocks possible. Even with this if the patient becomes hypopneic with sedation and their CO2 rises, acute cor pulmonale and PEA could be in their future.

I agree with dialysis, electrolyte normalization and a subsequent gentle GA.

 

[DrAmir0078]

All the time. Make sure potassium and dialysis are ok. Put him to sleep. Carefully. No spinal because of INR. Blocks for post op pain if needed.

Thanks Dr. Arch for the advice ...
K+ was normal as he got a HD session yesterday, but Na wasn't!

 

[pgg]

his Hb is 10.8

We postponed the case unless optimization of his labs and for PRBC for his Hb!

He probably doesn't need a red cell transfusion. (Unless you're expecting a ton of blood loss from a particular surgeon?)

GA ought to be fine if he has been dialyzed within a day or so.

 

[DrAmir0078]

All the amputations i've done in the past 5-6 years have been RA only. I don't mess with vasculopaths (unless you really have to).

A free ticket to Baghdad - get ready and do your block Dr.
Unfortunately Concorde airplane retired, otherwise in probably 5 hours!

 

[deleted697535]

Hi SDN Anesthesiologists,
Tonight and Tomorrow I am the team leader of my residents in this teach hospital in Baghdad, and my role is to give support and answer residents consultations regarding their cases in the ORs - OBs and Emergencies beside covid CPAP - and if something difficult, I try consult the on call Attending!

We got a case that we felt to postpone it - but why?
You know, I don't speak myself, but this is the opinion of the Attending.

52 years old patient, presented for above knee amputation + DM, with elevated renal indices, on dialysis, his Hb is 10.8, his Coags PT 18, normal PTT, 1.4 INR
His Na is low, his albumin 2.9
His Echo EF 30, severe : MR, TR, Pulmonary Hypertension, LV dysfunction. Dilated RA, RV and LV with global hypokinesia... Etc

I saw him, he was on wheelchair, can't lay supine, very weak pulse - vitally looks stable (the night tour of the intern)

We postponed the case unless optimization of his labs and for PRBC for his Hb!

We stated very high risk GA, Spinal and suggestion for BKA first for regional anesthesia!

If RA failed - what is next?


He was traveling to India, Iran and North of Iraq to treat his bad hip looking for hip replacement for the last 5 years, last visit to Kurdistan North of Iraq in a private hospital, they refused to give him anesthesia because of his heart!

I am sure tomorrow, the Ortho will consult us!

My question is, do you get such end stage cases? How would you proceed?


Your information is valuable.

Thanks

Well maybe tell us a bit more...
Here someppl call it the 5 P's but procedure, priority, pain, position, postop is important.

Why is he having an aka? What prioity? Does he have infected non healing ulcer or osteomyelitis etc?

Why cant he lie flat? Is it short of breath or pain or both?

What are his sodiun values etc? We need actual numbers and trends over time. Does he pee at all?

Why is he on dialysis and for how long? How is he dialysed and when. It should be day preop approximately but some controversy on that

I would be very very concerned for this patient. Ef 30%with severe mr means he actually has an effective ef in the teens... These guys in North America have legions of heart failure teams following them on all the meds... I doubt he has this....


In your environment i would likely give him a few days hd dialysis to get him euvolemic so he can lie flat with normal lytes then do cse. You could try regional but for an aka the sciatic portion is harder to see as its quite proximal, deep and apparently not as echogenic. Definitely not a block ive done more than 5 times so wouldn't be my go to

Tough case, good luck

 

[DrAmir0078]

Considering the hyponatremia and the fact that he can't lay flat, he needs dialysis and volume removal before anything.

And even if you want to do RA now....again....he can't lay flat. He's got 4 chamber enlargement and pulm htn. The minute he goes supine he'll act like he's drowning.

Get him on HD. Give him some plasma while he's there for presumptive congestive hepatopathy (I'm guessing you don't have TEG) and ultrafiltrate that extra volume off as well. Then assess his volume status and his symptamotology. If he gets back to his dry weight and he's still having NYHA class IV symptoms, do you have access inotropes and vasopressors? What kind?

I think slow dosed epidural and GA are both viable options but it depends on the anesthesia equipment, monitors, and drugs you have available.

Thanks for the advice Dr. Vector2
Yes, some inotropes are available : digoxine, dopamine, dobutamine, adrenaline...
Vassopressors adrenaline, noreadrenaline, ephedrine and phenylephrine (out of the pocket).

Epidural / Gentle GA = I am thinking ....

 

[DrAmir0078]

Hospice

Sadly it is true Dr. GassYours !
His brother was crying and he said I sold my house to afford his medical travel - Sometime, well many times we can't help it !

 

[DrAmir0078]

The scariest thing about what you describe is the low LVEF combined with pulmonary HTN. VERY dangerous.
Let’s assume you do the most perfect blocks possible. Even with this if the patient becomes hypopneic with sedation and their CO2 rises, acute cor pulmonale and PEA could be in their future.

I agree with dialysis, electrolyte normalization and a subsequent gentle GA.

The other day, we gave spinal for moderate PH and EF 42.
But 30 and severe??? With all other abnormalities... It scares me out!
Although the relatives can sign for death complications, however it is very stressful!

 

[DrAmir0078]

He probably doesn't need a red cell transfusion. (Unless you're expecting a ton of blood loss from a particular surgeon?)

GA ought to be fine if he has been dialyzed within a day or so.

Thank you Dr. Pgg
You know, residents will operate not Attending...
We can go opioid based GA like Fentanyl we have (out of our pocket)... But once he is in recovery, the pain would put him in risk of other issues!
Postoperative pain management is really questionable!

 

[pgg]

The other day, we gave spinal for moderate PH and EF 42.
But 30 and severe??? With all other abnormalities... It scares me out!
Although the relatives can sign for death complications, however it is very stressful!

Spinals are generally OK in these patients, provided
- coags allow a spinal in the first place
- the patient can lay flat

An isobaric spinal is a really stable anesthetic. Even if all you've got is hyperbaric bupivacaine, it's not all bad. A touch of afterload reduction is good for weak hearts and regurgitant valves, provided you don't let it get out of hand and drop the pressure so much that myocardial perfusion is harmed.

 

[pgg]

Thank you Dr. Pgg
You know, residents will operate not Attending...
We can go opioid based GA like Fentanyl we have (out of our pocket)... But once he is in recovery, the pain would put him in risk of other issues!
Postoperative pain management is really questionable!

Even so I wouldn't preop transfuse RBCs to someone with a Hb of 10.8 ...

A few years back I worked at a hospital in southeast Asia where the standard practice was to transfuse 2 units of RBCs to everyone having lumbar spine surgery. Hb 15 and a single level laminectomy? Two units. (As it turned out, the spine surgeon owned a piece of the for-profit blood bank.) Does anyone at your hospital happen to earn money by transfusing patients?

Careful with the opioid-heavy technique in this guy. His pulmonary hypertension doesn't need any hypoxia or hypercarbia when he gets dropped off in PACU.

 

[DrAmir0078]

Well maybe tell us a bit more...
Here someppl call it the 5 P's but procedure, priority, pain, position, postop is important.

Why is he having an aka? What prioity? Does he have infected non healing ulcer or osteomyelitis etc?

Why cant he lie flat? Is it short of breath or pain or both?

What are his sodiun values etc? We need actual numbers and trends over time. Does he pee at all?

Why is he on dialysis and for how long? How is he dialysed and when. It should be day preop approximately but some controversy on that

I would be very very concerned for this patient. Ef 30%with severe mr means he actually has an effective ef in the teens... These guys in North America have legions of heart failure teams following them on all the meds... I doubt he has this....


In your environment i would likely give him a few days hd dialysis to get him euvolemic so he can lie flat with normal lytes then do cse. You could try regional but for an aka the sciatic portion is harder to see as its quite proximal, deep and apparently not as echogenic. Definitely not a block ive done more than 5 times so wouldn't be my go to

Tough case, good luck

Thank you Dr. Newtwo
I am learning these 5 Ps...

He has infected diabetic foot, actually bilateral - the vascular surgeon said "he rather goes AKA"

His Na was 127

Position wise, he can't lie flat, he got dyspnea - with two to three pillows, beside lying more comfortably on his side like decubitus

Pain, and postoperative pain are very questionable here regarding the care... The best drugs we have Paracetamol IV, Tramadol, and Pethidine or Morphine (may be available, but not always)

So thankful.

 

[DrAmir0078]

Spinals are generally OK in these patients, provided
- coags allow a spinal in the first place
- the patient can lay flat

An isobaric spinal is a really stable anesthetic. Even if all you've got is hyperbaric bupivacaine, it's not all bad. A touch of afterload reduction is good for weak hearts and regurgitant valves, provided you don't let it get out of hand and drop the pressure so much that myocardial perfusion is harmed.

Dr. Pgg
Sounds interesting!
I have plain Bupivacaine 0.5% the one we use for regional anesthesia - it comes in 20 ml
Can I use it as isobaric?
I know since you taught me Glass Spine theory 2 years ago if you remember in a post here...
If I chose L3/L4 - it would be perfect.... Better than hyperbaric Bupivacaine...
You know, we tend to do unilateral spinal for 10 minutes stay still!

 

[DrAmir0078]

Even so I wouldn't preop transfuse RBCs to someone with a Hb of 10.8 ...

A few years back I worked at a hospital in southeast Asia where the standard practice was to transfuse 2 units of RBCs to everyone having lumbar spine surgery. Hb 15 and a single level laminectomy? Two units. (As it turned out, the spine surgeon owned a piece of the for-profit blood bank.) Does anyone at your hospital happen to earn money by transfusing patients?

Careful with the opioid-heavy technique in this guy. His pulmonary hypertension doesn't need any hypoxia or hypercarbia when he gets dropped off in PACU.

Well Dr. Pgg - except Blood, no pro profit of it... Wow

Sounds reasonable to do then Gentle GA... A touch of thing!

 

[Hoya11]

Hi SDN Anesthesiologists,
Tonight and Tomorrow I am the team leader of my residents in this teach hospital in Baghdad, and my role is to give support and answer residents consultations regarding their cases in the ORs - OBs and Emergencies beside covid CPAP - and if something difficult, I try consult the on call Attending!

We got a case that we felt to postpone it - but why?
You know, I don't speak myself, but this is the opinion of the Attending.

52 years old patient, presented for above knee amputation + DM, with elevated renal indices, on dialysis, his Hb is 10.8, his Coags PT 18, normal PTT, 1.4 INR
His Na is low, his albumin 2.9
His Echo EF 30, severe : MR, TR, Pulmonary Hypertension, LV dysfunction. Dilated RA, RV and LV with global hypokinesia... Etc

I saw him, he was on wheelchair, can't lay supine, very weak pulse - vitally looks stable (the night tour of the intern)

We postponed the case unless optimization of his labs and for PRBC for his Hb!

We stated very high risk GA, Spinal and suggestion for BKA first for regional anesthesia!

If RA failed - what is next?


He was traveling to India, Iran and North of Iraq to treat his bad hip looking for hip replacement for the last 5 years, last visit to Kurdistan North of Iraq in a private hospital, they refused to give him anesthesia because of his heart!

I am sure tomorrow, the Ortho will consult us!

My question is, do you get such end stage cases? How would you proceed?


Your information is valuable.

Thanks

he had HD yesterday, often thats as good as it gets.
and ill take that hct for someone with esrd

i would have proceeded.

a line
neo drip
2 IVs
GA with an LMA

my main concern is blood loss and severe hypotension, so i dont want a spinal adding to that possible situation.

blocks if necessary after

 

[Arch Guillotti]

No way I am doing regional only for an AKA!

 

[DrAmir0078]

he had HD yesterday, often thats as good as it gets.
and ill take that hct for someone with esrd

i would have proceeded.

a line
neo drip
2 IVs
GA with an LMA

my main concern is blood loss and severe hypotension, so i dont want a spinal adding to that possible situation.

blocks if necessary after

Thanks Dr. Hoya11

LMA - neat option for less irritation

Neo drip - I Google it and did you mean phenylephrine?

a-line unfortunately doesn't exist only in Cardiac centers


My respect.

 

[FiO2@21]

Note I'm just a resident. Great case, great learning exercise for me. Apologize for inability to be succinct.

You have 2 broad concerns:
- Hemodynamic instability
- Respiratory insufficiency

Get him a couple more dialysis sessions, maybe even daily. HD to stave off uremia interspersed with pUF to get volume off. With all his travel I don't have a grasp for how adherent he was to dialysis.

If I had an arterial line I would carefully go to sleep. But you don't have that.... Honestly my first thought is perhaps this patient should go to one of these cardiac centers. I don't know how feasible that is.

If he can't go elsewhere and you don't have any way to perform continuous BP monitoring, I actually would favor an isobaric spinal. That would be 0.5% bupi. I would consider adding 10-25 mcg fentanyl to add some density to the block. Depending on how slow your surgeons are, you could add 100-200 mcg epinephrine. I personally have not seen significant hypotension with isobaric spinals.

But the concern for hemodynamic collapse is still there given the inability to slowly titrate (unless you placed an intrathecal catheter). I would do the spinal with an epinephrine/adrenaline infusion hooked up ready to start. I think epinephrine makes more sense for this patient compared to phenylephrine. Make sure the IVs are fresh and working. Low threshold for central line by experienced physician. Cycle cuff every 1 min to start and slowly space out to 2.5 min. Ideally you would do this case with no sedation, spinal, BIPAP and have no problems.

Let's say your spinal fails or you can't get it to start with. I would do popliteal and adductor blocks and then go to sleep.

I would start the epinephrine at a low rate and slowly induce with cuff cycling every minute. Would probably use etomidate, 5 mg at a time. I would intubate, not LMA. You need the ability to control his ventilation if needed. Succinylcholine is okay in ESRD patients provided potassium is low enough. I would give him a chance though and keep him on 5/5 BIPAP/pressure support. Again if you are not confident about IV access, place a central line if you are able to.

Then you'd have to make the decision about his ability to extubate.

 

[abolt18]

Thank you Dr. Newtwo
I am learning these 5 Ps...

He has infected diabetic foot, actually bilateral - the vascular surgeon said "he rather goes AKA"

His Na was 127

Position wise, he can't lie flat, he got dyspnea - with two to three pillows, beside lying more comfortably on his side like decubitus

Pain, and postoperative pain are very questionable here regarding the care... The best drugs we have Paracetamol IV, Tramadol, and Pethidine or Morphine (may be available, but not always)

So thankful.

Sounds like some hypervolemia. Dialysis a few times to get a few liters of fluid off him, and watch for that sodium to come back to >130.

 

[woopedazz]

Why is this diabetic foot getting an AKA as the first intervention? That seems a little extreme...

 

[Blockit]

Why is this diabetic foot getting an AKA as the first intervention? That seems a little extreme...

Because they are going to get there anyway and they don’t have a greedy surgeon profiting every time he does a little bit more chopping.
😂🤣😂

 

[DrAmir0078]

Note I'm just a resident. Great case, great learning exercise for me. Apologize for inability to be succinct.

You have 2 broad concerns:
- Hemodynamic instability
- Respiratory insufficiency

Get him a couple more dialysis sessions, maybe even daily. HD to stave off uremia interspersed with pUF to get volume off. With all his travel I don't have a grasp for how adherent he was to dialysis.

If I had an arterial line I would carefully go to sleep. But you don't have that.... Honestly my first thought is perhaps this patient should go to one of these cardiac centers. I don't know how feasible that is.

If he can't go elsewhere and you don't have any way to perform continuous BP monitoring, I actually would favor an isobaric spinal. That would be 0.5% bupi. I would consider adding 10-25 mcg fentanyl to add some density to the block. Depending on how slow your surgeons are, you could add 100-200 mcg epinephrine. I personally have not seen significant hypotension with isobaric spinals.

But the concern for hemodynamic collapse is still there given the inability to slowly titrate (unless you placed an intrathecal catheter). I would do the spinal with an epinephrine/adrenaline infusion hooked up ready to start. I think epinephrine makes more sense for this patient compared to phenylephrine. Make sure the IVs are fresh and working. Low threshold for central line by experienced physician. Cycle cuff every 1 min to start and slowly space out to 2.5 min. Ideally you would do this case with no sedation, spinal, BIPAP and have no problems.

Let's say your spinal fails or you can't get it to start with. I would do popliteal and adductor blocks and then go to sleep.

I would start the epinephrine at a low rate and slowly induce with cuff cycling every minute. Would probably use etomidate, 5 mg at a time. I would intubate, not LMA. You need the ability to control his ventilation if needed. Succinylcholine is okay in ESRD patients provided potassium is low enough. I would give him a chance though and keep him on 5/5 BIPAP/pressure support. Again if you are not confident about IV access, place a central line if you are able to.

Then you'd have to make the decision about his ability to extubate.

Thanks mate resident... Your explanation is like for final written board question essay.
I am so thankful...

 

[DrAmir0078]

Sounds like some hypervolemia. Dialysis a few times to get a few liters of fluid off him, and watch for that sodium to come back to >130.

It is indeed, he needs work up to be done!
Thanks

 

[DrAmir0078]

Because they are going to get there anyway and they don’t have a greedy surgeon profiting every time he does a little bit more chopping.

Exactly, although the extent of df was distally with ulceration, discharge, and the vascular surgeon suggested aka.

 

[dabears505]

Isn't this every aka patient? Are those dilated heart chambers acute or chronic? I'm not sure more needs to be done. Prop, sux, tube.

 

[DrAmir0078]

Isn't this every aka patient? Are those dilated heart chambers acute or chronic? I'm not sure more needs to be done. Prop, sux, tube.

Propofol, Sux and Tube !
How about cardiac depression of prop?
It is chronic!

 

[FiO2@21]

Isn't this every aka patient? Are those dilated heart chambers acute or chronic? I'm not sure more needs to be done. Prop, sux, tube.

30% EF with severe MR? That’s more like 15% forward flow. You’d do prop sux tube without an art line in that patient?

 

[BlueRug]

Maybe I’m biased but this seems pretty straightforward. Certainly healthier than 80% of the patients I see. Art line, epi gtt and ett.

 

[FiO2@21]

Maybe I’m biased but this seems pretty straightforward. Certainly healthier than 80% of the patients I see. Art line, epi gtt and ett.

They don’t have access to arterial lines apparently

 

[BlueRug]

They don’t have access to arterial lines apparently

Oh I missed that part. Still should be doable. Just be patient with induction and q3 min NIBP

 

[DrAmir0078]

Oh I missed that part. Still should be doable. Just be patient with induction and q3 min NIBP

Wow... Pretty straightforward and healthier than 80 % of what you have seen... Seriously amazing!

So, wondering why even in India, Iran and private hospitals in Iraq with better facilities they did not risk giving him GA nor Regional / neuraxial ... At least out of Iraq, they love to profit from the patient, at least he could get his hip fixed !

There is problem in understanding the physiology at least!

I wish in a dream that one day I can visit one of the busiest hospital in the US, and grant one month observership to see such critically ill patients you guys manage easily, this will add up experience.

Impressive!

 

[FiO2@21]

Oh I missed that part. Still should be doable. Just be patient with induction and q3 min NIBP

I’d be with you if it was *just* the garden variety AKA/BKA with 35% EF, ESRD, COPD, bad diabetes.

But it’s 35% EF with severe MR… sure the anesthesia makes MR better, but still the actual EF practically is at least low 20s if not teens.

If I had a gun to my head or couldn’t get the spinal or an epidural I’d induce slowly with epi in line and would probably be able to muddle through.

 

[BlueRug]

I’d be with you if it was *just* the garden variety AKA/BKA with 35% EF, ESRD, COPD, bad diabetes.

But it’s 35% EF with severe MR… sure the anesthesia makes MR better, but still the actual EF practically is at least low 20s if not teens.

If I had a gun to my head or couldn’t get the spinal or an epidural I’d induce slowly with epi in line and would probably be able to muddle through.

With his dilated LV his stroke volume may be near normal.

 

[DrAmir0078]

I’d be with you if it was *just* the garden variety AKA/BKA with 35% EF, ESRD, COPD, bad diabetes.

But it’s 35% EF with severe MR… sure the anesthesia makes MR better, but still the actual EF practically is at least low 20s if not teens.

If I had a gun to my head or couldn’t get the spinal or an epidural I’d induce slowly with epi in line and would probably be able to muddle through.

I am so curious about epinephrine drip !

1 mg in 500 NS = 2mcg / ml, so what is your rate?

Why choosing epinephrine? and when you can choose it?

Why not others inotropes?

Your all plan of management will be discussed with my close colleagues tomorrow - very rich information !

 

[DrAmir0078]

With his dilated LV his stroke volume may be near normal.

Is it an assumption?
SV = EDV - ESV

Or there is a link with the MR?

Then how about his afterload, CO?

How do you guys calculate these things based on EF % only?

I didn't mention other parameters, although they do exist, however I didn't recall!

 

[FiO2@21]

Is it an assumption?
SV = EDV - ESV

Or there is a link with the MR?

Then how about his afterload, CO?

How do you guys calculate these things based on EF % only?

I didn't mention other parameters, although they do exist, however I didn't recall!

The issue with MR is that a significant chunk of your stroke volume is being diverted in the wrong direction.

So when people say “oh EF is normal” and neglect to mention the severe MR, they’re not realizing that most of that stroke volume isn’t ejecting into the aorta but going back up to the left atrium with subsequent pulm edema, right heart failure, etc.

If you wanted to quantify the actual stroke volume on a TTE, you’d have to look at the LVOT velocity time integral and calculate the stroke volume and cardiac output.

 

[BlueRug]

Is it an assumption?
SV = EDV - ESV

Or there is a link with the MR?

Then how about his afterload, CO?

How do you guys calculate these things based on EF % only?

I didn't mention other parameters, although they do exist, however I didn't recall!

I was being a facetious but think of things that would kill the patient and avoid them.

No one has died of MR that is (supposedly) on room air. The MR is pretty much irrelevant for MAP goals (you mention afterload). Reduction of afterload for the pursuit of reduction of MR and the subsequent reduction of coronary perfusion has, however.

When in doubt, keep the patient where they live normally. Avoid hypotension, hypercarbia, etc.

Echo is so prevalent now that we are aware of so much more than in the past. I’m sure we have all done cases with 99% left main or 10% LVEF that just never had an echo.

 

[DrAmir0078]

The issue with MR is that a significant chunk of your stroke volume is being diverted in the wrong direction.

So when people say “oh EF is normal” and neglect to mention the severe MR, they’re not realizing that most of that stroke volume isn’t ejecting into the aorta but going back up to the left atrium with subsequent pulm edema, right heart failure, etc.

If you wanted to quantify the actual stroke volume on a TTE, you’d have to look at the LVOT velocity time integral and calculate the stroke volume and cardiac output.

Do you actually as a resident looks at TEE?

Are you obligated to all to learn how to use it?

Yet, we have lectures, we have Echo at special ICUs in some teaching center, but again for ICU genius Attendings use it and sometimes teach residents!
Wow, it is sucks here!

 

[DrAmir0078]

I was being a facetious but think of things that would kill the patient and avoid them.

No one has died of MR that is (supposedly) on room air. The MR is pretty much irrelevant for MAP goals (you mention afterload). Reduction of afterload for the pursuit of reduction of MR and the subsequent reduction of coronary perfusion has, however.

When in doubt, keep the patient where they live normally. Avoid hypotension, hypercarbia, etc.

Echo is so prevalent now that we are aware of so much more than in the past. I’m sure we have all done cases with 99% left main or 10% LVEF that just never had an echo.

Can only say "impressive"
EF 10% and was good to go?

I liked the idea of keeping him as he is... Maintaining his current vitals during the induction and maintenance to extubation precautions.... Think of keep him alive with his parameters!

There is a phrase called "on the knife edge their catecholalamines" - they always mention it in the textbooks... Don't play hard, gentle!

 

[FiO2@21]

I am so curious about epinephrine drip !

1 mg in 500 NS = 2mcg / ml, so what is your rate?

Why choosing epinephrine? and when you can choose it?

Why not others inotropes?

Your all plan of management will be discussed with my close colleagues tomorrow - very rich information !

I personally divide inotropes into 2 categories:
- inodilators
- inopressors

Inodilators include dobutamine, milrinone.

Inopressors include epinephrine, dopamine.

Your goal is to maintain a goal MAP, maintain inotropy, reduce backwards flow.

Phenylephrine is a pure pressor that could result in some reflex bradycardia, which would allow more time for the stroke volume to go in the wrong direction. Amongst the pressors, norepinephrine (noradrenaline) would be better since you get a mild increase in HR.

Epinephrine would maintain/increase inotropy, maintain MAP, maintain HR.

Epi also takes itself back very quickly which is always attractive in anesthesia.

How are you infusing? With microdrip sets that you estimate visually? Or an infusion pump?

I would start low, 3-5 mcg/min. If I was infusing epi with a drip set I would dilute it to a liter personally to make it easier to titrate.

Also if the patient can’t lie supine, I doubt he’s truly tolerating room air.

 

[FiO2@21]

Do you actually as a resident looks at TEE?

Are you obligated to all to learn how to use it?

Yet, we have lectures, we have Echo at special ICUs in some teaching center, but again for ICU genius Attendings use it and sometimes teach residents!
Wow, it is sucks here!

No I would say you would have to be motivated in order to pick up some echo basics. Most anesthesia residents here probably can’t interpret anything besides the most basic portions of echo, even with the TEE exposure we have in our cardiac rotations.

That being said, even though I’m motivated and interested in echo, I’m extremely aware of my own limitations.

 

[DrAmir0078]

No I would say you would have to be motivated in order to pick up some echo basics. Most anesthesia residents here probably can’t interpret anything besides the most basic portions of echo, even with the TEE exposure we have in our cardiac rotations.

That being said, even though I’m motivated and interested in echo, I’m extremely aware of my own limitations.

Very interesting discussion. I am so thankful. This thread will be with a hot tea after lunch tomorrow...

Epinephrine use - jaw dropping!

 

[Radetzky]

Doing daily dialysis to remove fluid is probably not going to fix this guys issues lying supine.

Many patients with chronic MR have increased lymphatic flow and more compliant LAs, which allows them to oxygenate normally when they’re compensated. That does not mean they can’t die quickly from their MR.

How much do his ulcers affect his quality of life? Would he prefer to deal with ulcers for the (likely) last few years of his life or take the chance of death now to avoid it?

 

[Hork Bajir]

When I was a resident, I worked with an anesthesiologist who had trained and practiced in rural India. He showed me how to transduce an arterial line using a sphygmomanometer (no electricity necessary, just watching the needle jump mechanically on the dial). I wish I could recall the details of how he set it up… All I remember is that there was an air-fluid interface in the tubing that moved towards the patient, you had to keep an eye on it and reset periodically lest you give the patient an air embolus

anyone here ever seen or done anything like that? If we could figure it out, might prove useful for Dr Amir