Why would hospitalist think this is a good idea.. sickle cell pt

[coffeebythelake]

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20 something year old HbSS, being hospitalized with acute sickle cell vaso-occlusive crisis,
Hgb sitting around 7. No exchange transfusion or blood transfusion. On hydroxyurea.
Poor pain control for several days. Still 10/10 pain, hypertensive, tachycardic, on NC.
Recent URI, has bacteremia being treated on IV antibiotics. Their plan was for several weeks of IV abx.
But hospitalist also want to do a TEE to rule out endocarditis.

- antibiotic plan would not change regardless of outcome of TEE
- patient is in active sickle cell crisis
- cardiologist thought it was nuts

I don't think that anesthetizing a patient in an active crisis is the best thing to do.
I spoke with the hospitalist and basically said... "if you feel this is urgent or emergent, and would change your management for this patient, we will proceed recognizing the increased risks. otherwise let's not." Case cancelled.
At my hospital we don't encounter sickle cell patients often. I've taken care of 5 in the last 7 years.

But really?

 

[chocomorsel]

While I may have never done this, I honestly don't see the downside from your end. A little Propofol, a nice slug of narcotics may help her pain out some.
What are you concerned about?
The cardiac docs do this all the time without us. Some Versed and Fentanyl. Why do they need an anesthesiologist in this case anyway? Are her VSS completely through the roof?
Management may change just in case she has a severe vegetable on one of her valves. And requires surgery. But she doesn't sound septic from supposed possible endocarditis.

 

[dannyboy1]

Lol. At my hospital having both a heart and an esophagus are indication enough. Sometimes I ask the cardiologists why we are doing the TEE and he shrugs and says some service requested it. Patients sick a fu(k also. We end up canceling quite a few.....

 

[coffeebythelake]

While I may have never done this, I honestly don't see the downside from your end. A little Propofol, a nice slug of narcotics may help her pain out some.
What are you concerned about?
The cardiac docs do this all the time without us. Some Versed and Fentanyl. Why do they need an anesthesiologist in this case anyway? Are her VSS completely through the roof?
Management may change just in case she has a severe vegetable on one of her valves. And requires surgery. But she doesn't sound septic from supposed possible endocarditis.

hypoxemia and stasis for one thing. in a patient dealing with an acute vaso-occlusive episode.
where the outcome of the TEE make no difference in management.
no murmur, no suggestion of any vegetation, very low suspicion for anything, just want to "rule it out."
as evident by how quickly they decided to cancel the case when i brought up concerns.

 

[chocomorsel]

hypoxemia and stasis for one thing. in a patient dealing with an acute vaso-occlusive episode.
where the outcome of the TEE make no difference in management.
no murmur, no suggestion of any vegetation, very low suspicion for anything, just want to "rule it out."
as evident by how quickly they decided to cancel the case when i brought up concerns.

If no suspicion for sepsis, which it doesn't sound like it, then, they don't need an unnecessary procedure. Completely in agreement.
But as far as giving them sedation, honestly, I wouldn't even think the procedure would last long enough to cause any significant problems as long as one is vigilant.

 

[MoMoGesiologist]

I really hate the “just to rule it out” work ups, which this sounds like. However, if this person had other S/S endocarditis aside from the bacteremia, a TEE confirmed diagnosis may influence duration therapy abx, surgical management, future abx prophy. I’m curious if the hospitalist had ID weigh in; our ID docs seemed to have a low threshold to ask for endocarditis rule out TEEs.

 

[Robotic Wis-Hipple]

Agree. Unless wide open AI/TR/MR it’s not a surgical fix, and if you had that the Pt would have a murmur and/or signs/sxs of heart failure. So even if you find a little veg it’s not changing management as you’re not taking an intact valve to the OR especially while in crisis.

Abx based on micro, let the Pt get past the sickle crisis, if bacteremia persists then TEE and decide if it’s surgical vs extended course abx.

 

[ProRealDoc]

TTE and move on.

 

[IlDestriero]

TTE and move on.

The vast majority of pediatric echos are (poor) TTEs and somehow they manage to get the information they need. Every image, etc. doesn’t need to be museum quality and publication ready.

 

[nimbus]

I bet anesthesia and anesthetic concerns were not even on the hospitalist’s radar when he ordered the TEE. To him he was just ordering a diagnostic exam, no different than a CT or TTE. It’s just a click on EMR.

 

[coffeebythelake]

Lol. At my hospital having both a heart and an esophagus are indication enough. Sometimes I ask the cardiologists why we are doing the TEE and he shrugs and says some service requested it. Patients sick a fu(k also. We end up canceling quite a few.....

Something thing at my institution. The cardiologist is there to do the TEE, they often find out about the pt right before doing procedure.

 

[Mman]

acute chest syndrome?

 

[coffeebythelake]

acute chest syndrome?

I dont think so.

 

[WholeLottaGame7]

20 something year old HbSS, being hospitalized with acute sickle cell vaso-occlusive crisis,
Hgb sitting around 7. No exchange transfusion or blood transfusion. On hydroxyurea.
Poor pain control for several days. Still 10/10 pain, hypertensive, tachycardic, on NC.
Recent URI, has bacteremia being treated on IV antibiotics. Their plan was for several weeks of IV abx.
But hospitalist also want to do a TEE to rule out endocarditis.

- antibiotic plan would not change regardless of outcome of TEE
- patient is in active sickle cell crisis
- cardiologist thought it was nuts

I don't think that anesthetizing a patient in an active crisis is the best thing to do.
I spoke with the hospitalist and basically said... "if you feel this is urgent or emergent, and would change your management for this patient, we will proceed recognizing the increased risks. otherwise let's not." Case cancelled.
At my hospital we don't encounter sickle cell patients often. I've taken care of 5 in the last 7 years.

But really?

I dunno, sounds like everything worked about as well as expected. Someone came up with a dumb plan, someone else was going to go along with it because they were going to get paid for it, you told everybody to pump the breaks, and they listened.

I spent about an hour and a half last week talking with 3 surgeons, the PICU, and a peds cardiologist to prevent doing what was likely a dangerous and unnecessary procedure that nobody REALLY wanted and several people actively didn't want but were either too busy or unwilling to make the decision.

Not sure if it's an academic-specific thing or not, but sometimes ideas get floated, plans get put in place, and then everybody's just along for the ride. It's hard to stop the inertia at that point, and Lord knows I've failed in that regard before, but that time I think it was the right thing to do.

Sometimes, as in this case, people are just looking for someone else to be the bad guy and take responsibility. As I get older, I'm increasingly happy to play that role, even though it's not always satisfying.

 

[Hoya11]

20 something year old HbSS, being hospitalized with acute sickle cell vaso-occlusive crisis,
Hgb sitting around 7. No exchange transfusion or blood transfusion. On hydroxyurea.
Poor pain control for several days. Still 10/10 pain, hypertensive, tachycardic, on NC.
Recent URI, has bacteremia being treated on IV antibiotics. Their plan was for several weeks of IV abx.
But hospitalist also want to do a TEE to rule out endocarditis.

- antibiotic plan would not change regardless of outcome of TEE
- patient is in active sickle cell crisis
- cardiologist thought it was nuts

I don't think that anesthetizing a patient in an active crisis is the best thing to do.
I spoke with the hospitalist and basically said... "if you feel this is urgent or emergent, and would change your management for this patient, we will proceed recognizing the increased risks. otherwise let's not." Case cancelled.
At my hospital we don't encounter sickle cell patients often. I've taken care of 5 in the last 7 years.

But really?

I would have just done it because of minimal anesthetic risk however silly the indication is. Its not our job to question the indication unless the procedure poses serious risk which this just does not. I think this was an unnecessary cancellation, the guy is 20. Sure it would be optimal to have him through the crisis, but its going to be fine now too and just go with the flow unless dangerous

 

[AKMD_1984]

Are they concerned about 'seeding' from a possible vegetation, hence refractory and persistent bacteremia? If so, it may change management and patient may need surgery.
Auscultation is not always reliable or diagnostic.

I would proceed. Its a low risk procedure. Versed, fentanyl, locally anesthetize the airway, maybe a bump of propofol when scope is being inserted, get in get out.

But thats just my two cents.