Wolff Parkinson White

[TheMightyAngus]

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The other day I saw a dbag on Dr.90210 refuse to perform a cosmetic procedure on a 35yo woman because she had WPW but otherwise healthy.

What do you docs think about that? Good reason to cancel?

Would most gas docs treat this as a routine case and give the green light?

 

[VentdependenT]

The other day I saw a dbag on Dr.90210 refuse to perform a cosmetic procedure on a 35yo woman because she had WPW but otherwise healthy.

What do you docs think about that? Good reason to cancel?

Would most gas docs treat this as a routine case and give the green light?

Thats ridiculous.

If the guy is poopen his pants then he should go grab some amiodarone and tape it to his crossword puzzle. Then he can read about how to dose it on the internet.

 

[fakin' the funk]

Thats ridiculous.

If the guy is poopen his pants then he should go grab some amiodarone and tape it to his crossword puzzle. Then he can read about how to dose it on the internet.

If I remember correctly it was actually the plastic doc (Dr. Rey?) who refused to operate - no anesthesiologist/IM guy involved (that the show let us know of, anyway)

 

[Planktonmd]

Well,

It really depends:
Let's consider these 2 scenarios:
1- 25 Y/O healthy no PMH and does not take any medications going for breast augmentation.
She was diagnosed a year ago with WPW based on a routine EKG done in the process of preparation for a Marathon.
She never had Palpitations and the Cardiologist decided to just watch her since she is asymptomatic.
What's the plan?
2- 25 Y/O healthy does not take any medications going for breast augmentation.
She was diagnosed a year ago with WPW after an ER admission for syncope, she was found to have a HR of 190 and BP of 70/40, required a cardioversion twice and was scheduled for an EP study and possible ablation but never showed up for that.
She did not see a cardiologist.
What's the plan?

 

[CremeSickle]

Scenario #1

Do Op defib/cardio pads avaliable

Scenario #2

Cancel Op for cardiac consult.

Sorry baby, no new jubblies until the ticker is cleared.

 

[powermd]

Both go back to the cardiologist for a note that says they are optimized for surgery. Maybe they will qualify for ablation at this point, maybe not. Either way, they need to be reassessed and given a chance to consider their options for cardiac care. Assuming they come back, ablated or not, they can have a routine MAC/general anesthetic. Defib pads would go on after giving a little midaz. I'd have procainamide ready, and the defib connected. I'd be heavy handed with narcotics to avoid any excess catacholamine load on the heart during stimulation. I'd load her up with fluid quickly, if not sooner in the pre-op area once the IV goes in. If doing a MAC, sedation with precedex +/- propofol +/- remi would be terrific. If doing GA, I'd consider extubating on precedex, or pulling the tube deep. I'd give plenty of anti-puke meds to boot.

Well,

It really depends
Let's consider these 2 scenarios:
1- 25 Y/O healthy no PMH and does not take any medications going for breast augmentation.
She was diagnosed a year ago with WPW based on a routine EKG done in the process of preparation for a Marathon.
She never had Palpitations and the Cardiologist decided to just watch her since she is asymptomatic.
What's the plan?
2- 25 Y/O healthy does not take any medications going for breast augmentation.
She was diagnosed a year ago with WPW after an ER admission for syncope, she was found to have a HR of 190 and BP of 70/40, required a cardioversion twice and was scheduled for an EP study and possible ablation but never showed up for that.
She did not see a cardiologist.
What's the plan?

 

[VentdependenT]

#1. Do case. Have Amiodarone available for push in room. If she can run races without her sympathetic drive sending her ticker into SVT (AVNRT) then she's good to go. Not all WPW is the same....I think anyways.

#2. Ablation, then come back.

 

[Gator05]

Inhalational versus not?

Seems I've read somewhere that inhalationals can block anti- or pro-dromic pathways, thus slowing down or speeding up WPW. Depends on which direction the alternate path is going, ante or retro.

 

[Planktonmd]

I think that in scenario # 1 you can proceed with the surgery, but maybe not in a surgi-center setting.
I would avoid or minimize inhaled agents and do a smooth anesthetic.
Scenario# 2 is obviously a disaster waiting to happen, can you imagine trying to cardiovert a patient with bilateral breast incisions? or giving an anti-arrhythmic treatment in an out patient surgicenter?

The point here is: WPW can create intra-operative and post-operative problems that you don't want to deal with in an out patient surgi-center or a plastic surgeon's office. and after all the Beverly hills stud/surgeon might have been right in not wanting to deal with it.

 

[powermd]

I think that in scenario # 1 you can proceed with the surgery, but maybe not in a surgi-center setting.
I would avoid or minimize inhaled agents and do a smooth anesthetic.
Scenario# 2 is obviously a disaster waiting to happen, can you imagine trying to cardiovert a patient with bilateral breast incisions? or giving an anti-arrhythmic treatment in an out patient surgicenter?

The point here is: WPW can create intra-operative and post-operative problems that you don't want to deal with in an out patient surgi-center or a plastic surgeon's office. and after all the Beverly hills stud/surgeon might have been right in not wanting to deal with it.

I really don't see much difference between the two patients. The first one may be a 'marathon runner', but what does that mean? Some people walk marathons, and/or don't finish. Even if we assume she is in great shape, that doesn't guarantee she won't go into VT/VF when she's under YOUR care. And you should be ready for that. Cardiology optimization, appropriate drugs handy, and the defib pads ON.

 

[Planktonmd]

I really don't see much difference between the two patients. The first one may be a 'marathon runner', but what does that mean? Some people walk marathons, and/or don't finish. Even if we assume she is in great shape, that doesn't guarantee she won't go into VT/VF when she's under YOUR care. And you should be ready for that. Cardiology optimization, appropriate drugs handy, and the defib pads ON.

I don't disagree with you that you should have a cardiology consult on both for your protection but I am not sure that the risk of ventricular arrhythmias is your first concern in someone with an asymptomatic WPW and excellent excercise tolerance.
Why are you concerned about ventricular arrhythmias?