What do you think of this case?

[drrosenrosen]

55M admitted from ED with AMS and BP 225/125. Noncompliant with HTN and DM2 therapy. BNP is 30k, TTE find EF of 45% with severe diastolic dysfxn and moderate MR, inferior infarct with segmental wall motion abnormality. Hep C, cirrhosis, CKD with Cr2.5. Later dx'd with multiple cerebral and cerebellar infarcts, but also a penile infarct. Four days later, he's septic, and urology wants to excise the necrotic tissue. Pt scheduled for TEE to look for clot or vegetations, but cardiology cancels because they decide he needs surgery first. Urologist needs to know if we're going or not because she has to get to clinic. Send him back upstairs for the echo or do the case?

---

Members don't see this ad.

 

[Hoya11]

55M admitted from ED with AMS and BP 225/125. Noncompliant with HTN and DM2 therapy. BNP is 30k, TTE find EF of 45% with severe diastolic dysfxn and moderate MR, inferior infarct with segmental wall motion abnormality. Hep C, cirrhosis, CKD with Cr2.5. Later dx'd with multiple cerebral and cerebellar infarcts, but also a penile infarct. Four days later, he's septic, and urology wants to excise the necrotic tissue. Pt scheduled for TEE to look for clot or vegetations, but cardiology cancels because they decide he needs surgery first. Urologist needs to know if we're going or not because she has to get to clinic. Send him back upstairs for the echo or do the case?

Cardiology already answered your question. Gentle GA with an LMA. If they found vegetations would you cancel the case and let the necrotic tissue worsen?

 

[deleted171991]

Would the echo change your management? And would the echo prioritize surgeries?

 

[nimbus]

He's already had TTE. You have all the info you need to plan anesthetic. TEE will not add anything.

 

[Planktonmd]

It seems to me that your patient is well on his way to needing to be intubated and on pressors for septic/cardiogenic shock. So why don't you do him a favor, intubate him, maybe put in an A line and good IV access and then let the urologist do what needs to be done, then keep him ventilated in the ICU while someone smart properly diagnoses and manages his issues?

 

[deleted171991]

He's already had TTE. You have all the info you need to plan anesthetic. TEE will not add anything.

Actually it will. If the patient has vegetations, he may need open heart surgery, not debridements.

 

[OB1🤙]

Do the TEE during the urology case...

 

[Mman]

Actually it will. If the patient has vegetations, he may need open heart surgery, not debridements.

wouldn't they still want the necrotic tissue removed before doing any sort of cardiac operation?

 

[Mman]

any coagulopathic reason I can't just sit him up and do a saddle block? Minimal hemodynamic effects and minimal/no sedation required.

 

[HollywdAnesth]

The necrotic penis is an obvious and imminent problem. Might try to do this with a light general and a penile block (I don't know how much of the penis is necrotic).

 

[SurferBoyMD]

55M admitted from ED with AMS and BP 225/125. Noncompliant with HTN and DM2 therapy. BNP is 30k, TTE find EF of 45% with severe diastolic dysfxn and moderate MR, inferior infarct with segmental wall motion abnormality. Hep C, cirrhosis, CKD with Cr2.5. Later dx'd with multiple cerebral and cerebellar infarcts, but also a penile infarct. Four days later, he's septic, and urology wants to excise the necrotic tissue. Pt scheduled for TEE to look for clot or vegetations, but cardiology cancels because they decide he needs surgery first. Urologist needs to know if we're going or not because she has to get to clinic. Send him back upstairs for the echo or do the case?

Pt getting septic from the necrotic tissue...source control (debrid) and antibiotics. TEE not needed. Kind of a toughie case in terms of fluid management with two competing treatments: sepsis/septic shock (fluid load) and cardiogenic shock (diuresis).

Penile block. Do the case sitting if he is in CHF. Altered and won't sit still? Ketamine.

 

[deleted171991]

wouldn't they still want the necrotic tissue removed before doing any sort of cardiac operation?

I have been wondering about the same thing. IMO it's more important to get rid of the source of septic emboli, unless it's "limb"-saving. It's a matter of what's more urgent. The penis should be debrided under local.

Whatever they do, they should do fast. If this is acute endocarditis, those valves must be teeming with bacteria.

 

[deleted171991]

Pt getting septic from the necrotic tissue...source control (debrid) and antibiotics. TEE not needed. Kind of a toughie case in terms of fluid management with two competing treatments: sepsis/septic shock (fluid load) and cardiogenic shock (diuresis).

Penile block. Do the case sitting if he is in CHF. Altered and won't sit still? Ketamine.

Patient is getting septic from all the bacteria in his blood. The source is both the necrotic tissues and the vegetations on his heart valves. Until we fix the vegetations, he will keep throwing emboli and probably stay septic.

Btw, the treatment for cardiogenic shock is not diuresis. That's the treatment for fluid overload. The treatment for cardiogenic shock is an inotrope. And the treatment for this guy's cardiac problems specifically is a mitral valve replacement +/- CABG.

Right now, he looks to me like an ASA 4.5.

 

[SurferBoyMD]

Patient is getting septic from all the bacteria in his blood. The source is both the necrotic tissues and the vegetations on his heart valves. Until we fix the vegetations, he will keep throwing emboli and probably stay septic.

Btw, the treatment for cardiogenic shock is not diuresis. That's the treatment for fluid overload. The treatment for cardiogenic shock is an inotrope. And the treatment for this guy's cardiac problems specifically is a mitral valve replacement +/- CABG.

Ah, yes. Agreed inotropes and support. I was thinking wrong, and thinking just about a CHF exacerbation.

 

[deleted682700]

55M admitted from ED with AMS and BP 225/125. Noncompliant with HTN and DM2 therapy. BNP is 30k, TTE find EF of 45% with severe diastolic dysfxn and moderate MR, inferior infarct with segmental wall motion abnormality. Hep C, cirrhosis, CKD with Cr2.5. Later dx'd with multiple cerebral and cerebellar infarcts, but also a penile infarct. Four days later, he's septic, and urology wants to excise the necrotic tissue. Pt scheduled for TEE to look for clot or vegetations, but cardiology cancels because they decide he needs surgery first. Urologist needs to know if we're going or not because she has to get to clinic. Send him back upstairs for the echo or do the case?

Cancelled, need the sepsis to be controlled with appropriate antibiotics. Need internal medicine and cardiology to clear the patient and creatinine level to be addressed. High risk of post op renal failure,, chf, death
Ask the urologist to do it under local if he thinks the necrotic tissue is the cause of sepsis.

 

[Mman]

Cancelled, need the sepsis to be controlled with appropriate antibiotics. Need internal medicine and cardiology to clear the patient and creatinine level to be addressed. High risk of post op renal failure,, chf, death
Ask the urologist to do it under local if he thinks the necrotic tissue is the cause of sepsis.

Huh? WTF do you want cardiology to say? They already said he needs surgery before they even do their TEE. Is an IM doc going to add some other words of wisdom?

The patient is "high risk", but they aren't going to get any better.

 

[bcat85]

GA, tube, a-line. I agree with the above--do the TEE in the OR while you're under GA. More than one way to skin a cat here, but I would definitely not cancel the case. You know what his heart looks like (enough to do the case anyway). His heart is really not that terrible structurally. His necrotic penis is not going to get less necrotic with time and it definitely has to be debrided. Whether you find vegetation on the TEE won't change his need for this operation. With this constellation of medical issues, his hospitalization mortality is probably at least 30-50%. He's got a tough course ahead of him either way. Interesting case.

 

[IlDestriero]

The patient will be dead from sepsis without debridement of the necrotic tissue causing the sepsis. It's been 4 days, he's almost certainly already on antibiotics. Actually he'll probably be dead from another MI before long.
I doubt there is any more optimizing to do other than more pressors and careful fluid management.

 

[nimbus]

Actually it will. If the patient has vegetations, he may need open heart surgery, not debridements.

No. We don't place prosthetic valves in septic patients.

 

[deleted171991]

No. We don't place prosthetic valves in septic patients.

Are you sure?

http://my.clevelandclinic.org/services/heart/disorders/valvetreatment/sbesurgery

 

[G0S2]

I would put in pre- A line. Off to sleep. GETA. Central line. My own TEE exam. Have pressors drawn and ready. Big talk with pt and family about death. Keep intubated after to ICU.

 

[nimbus]

Are you sure?

http://my.clevelandclinic.org/services/heart/disorders/valvetreatment/sbesurgery

Yes. We replace valves for endocarditis but not while they are septic and bacteremic. We literally did this case last week. We pull rotten teeth, amputate gangrenous toes before we replace the valve. This case fits in that category.

 

[deleted171991]

Yes. We replace valves for endocarditis but not while they are septic and bacteremic. We literally did this case last week. We pull rotten teeth, amputate gangrenous toes before we replace the valve. This case fits in that category.

What if they are septic or bacteremic from an infected valve?

Nobody does surgery on a bacteremic patient from a secondary source, but when it's the primary...

 

[Orin]

Rubber bands, abx, and sudoku?

 

[WholeLottaGame7]

GA, tube, a-line. I agree with the above--do the TEE in the OR while you're under GA. More than one way to skin a cat here, but I would definitely not cancel the case. You know what his heart looks like (enough to do the case anyway). His heart is really not that terrible structurally. His necrotic penis is not going to get less necrotic with time and it definitely has to be debrided. Whether you find vegetation on the TEE won't change his need for this operation. With this constellation of medical issues, his hospitalization mortality is probably at least 30-50%. He's got a tough course ahead of him either way. Interesting case.

I concur. You must have had some good senior residents teaching you in your program...

GA, ETT, a-line (probably pre-induction), some pressors available for when he crumps, TEE while you're there. You know the debridement is going to be more extensive than whatever urology tells you. So I don't know that you've bought him a whole lot by doing it under spinal or local, other than an RT putting in his ETT and a surgical intern his a-line at midnight when he crashes later in the ICU after the local/spinal wears off and he gets IV narcs for the pain.

 

[nimbus]

What if they are septic or bacteremic from an infected valve?

Nobody does surgery on a bacteremic patient from a secondary source, but when it's the primary...

It needs to be determined on a case by case basis. At every place I have ever worked or trained, we never took septic patients to the OR for valve replacement. We treat with antibiotics and supportive measures and IF they survive and are no longer floridly septic, then they come for valve replacement. Maybe at CCF they do.

Anyway, the point I was trying to make was that the TTE gave you enough information to conduct the anesthetic for the debridement so you don't need to delay the case to get a Preop TEE. I agree with the others about intraop TEE. That's a great idea.

 

[risnwb]

Nobody is gonna replace that valve with a rotten penis. That's a recipe for disaster. Snip the tip and do the TEE intra op or in ICU after.

 

[Ignatius J]

One of those where he is so sick it is easy. Infection with necrotic tissue has to go.

Induce and hope for the best. Not much else to say. Invasive lines at your prerogative. They won't save or kill the patient. I would do a poor man's a-line (cuff STAT during induction) and put it in after induction with what should be a quite palpable pulse.

Sounds like you're at 0.4 MAC already so you have that going for you. A couple Cc's of etomidate may be all you need. A little sux and get 'er tubed and done.

 

[sleepallday]

any coagulopathic reason I can't just sit him up and do a saddle block? Minimal hemodynamic effects and minimal/no sedation required.

I would probably avoid sticking a needle in a septic guy's back.

 

[sleepallday]

Cancelled, need the sepsis to be controlled with appropriate antibiotics. Need internal medicine and cardiology to clear the patient and creatinine level to be addressed. High risk of post op renal failure,, chf, death
Ask the urologist to do it under local if he thinks the necrotic tissue is the cause of sepsis.

You're joking here, right?

 

[sleepallday]

In addition to what others have said, I may also consider a central line. Its seems likely that his pressure will tank after induction and will need an inotropic and/or pressor support.

 

[Mman]

I would probably avoid sticking a needle in a septic guy's back.

I'd avoid putting an epidural in, but a single shot spinal with a 25 g needle is much lower risk of an infectious complication.

 

[epidural man]

I really like the spinal idea.

 

[drrosenrosen]

So here's what ended up happening:

Urologist has to get to clinic, but her partner agrees to do it later that day. Since it's on hold anyway, we get the TEE. No vegetations, but some plaque in the ascending aorta, which has probably been showering emboli to his brain. Case ends up getting done by the call team, proceeds with art line and tube, no CVL. case proceeds uneventfully, and as of now it looks like the penis was the source of the sepsis, as he's clearing up from that point of view.

When it was still on my plate, I thought of doing it with spinal, too, but was worried about bacteremia and seeding the spinal canal. Also, since his CVA, he's very uncooperative and can't hold still for procedure under spinal/sedation. So decided to go with GA, which is how they ended up doing the case.

 

[nimbus]

So here's what ended up happening:

Urologist has to get to clinic, but her partner agrees to do it later that day. Since it's on hold anyway, we get the TEE. No vegetations, but some plaque in the ascending aorta, which has probably been showering emboli to his brain. Case ends up getting done by the call team, proceeds with art line and tube, no CVL. case proceeds uneventfully, and as of now it looks like the penis was the source of the sepsis, as he's clearing up from that point of view.

When it was still on my plate, I thought of doing it with spinal, too, but was worried about bacteremia and seeding the spinal canal. Also, since his CVA, he's very uncooperative and can't hold still for procedure under spinal/sedation. So decided to go with GA, which is how they ended up doing the case.

Another victory for man's greatest anesthetic! Pent sux tube......I love it!

 

[amyl]

Badness likely. Inform family of risks/expectations. No spinal for several reasons. I agree - fix him for the icu... Tube Aline cvp. Necrosis isn't debatable. Gotta do the case.... That's why you make the big $

 

[deleted682700]

Septic patients can die during induction. And they may not be revivable. Has happened to me as a resident in patient with s/p cardiac transplant. Depending on the extent of necrosis, I think penile block and local anesthesia is enough. Start with the least and if it doesn't work then keep escalating.