What would you suggest? AVR or not?

60-something y/o male patient who isn’t physically active but does ADLs.  Scheduled for CABG but has AI, PVD, EF 40%, HTN, HLD.  Would you suggest an AVR or not…. along with the CABG?

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What would you suggest?

 

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Transcatheter Mitral Valve Replacement

Our hospital will be partaking in the Medtronic APOLLO study.

The data so far from other hospitals in an easy to read format.

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PPT from Duke 2017

Peri-procedural imaging for transcatheter mitral valve replacement. Cardiovasc Diagn Ther. 2016 Apr; 6(2): 144–159.

Role of echocardiography for catheter-based management of valvular heart disease. Journal of Cardiology 69 (2017) 66–73.

EAE/ASE Recommendations for the Use of Echocardiography in New Transcatheter Interventions for Valvular Heart Disease.  J ASE Sept 2011.

Multimodality Imaging in the Context of Transcatheter Mitral Valve Replacement. JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 10, 2015.

Echo in mitral valve intervention. ESC 2012.

Mitral Valve Morphology Assessment: Three-Dimensional Transesophageal Echocardiography Versus Computed Tomography. Ann Thorac Surg 2010;90:1922–9.

Transcatheter Mitral Valve Replacement for Patients With Symptomatic Mitral Regurgitation. JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 69, NO. 4, 2017. 

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Transcatheter Mitral Valve Intervention, An Issue of Interventional Cardiology Clinics, E-Book.

Quantification of Mitral Valve Morphology With Three-Dimensional Echocardiography.  Can Measurement Lead to Better Management? Circulation Journal Official Journal of the Japanese Circulation Society http://www.j-circ.or.jp. 2014.

Transcatheter valve replacement and valve repair: Review of procedures and intraprocedural echocardiographic imaging. Circ Res. 2016;119:341-356.

Philips: TMVR

Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2013;26:921-64.

Transcatheter Mitral Valve Repair. Summer 2014Volume 19, Issue 2, Pages 219–237.

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Mitraclip and TEE for MR

 

Responsibility for your own health

I was shocked to see that the NHS could ban surgery for the obese and smokers.  That’s socialized medicine.  You take a conglomerate group of people (the UK) on a limited budget for healthcare… and basically find the cheapest most cost-effective way to deliver healthcare.  But in a way, it’s empowering patients to take responsibility for their own health.  Smoking, for sure — I agree 100% that surgery should be banned for this population.  Obesity is a bit trickier — there’s genetics and environmental factors at play in this one.  I don’t think anyone chooses to be obese.  But, people do have the power to change their eating and exercise habits.  Despite these efforts, there are some people who are still obese…. and these people should not be faulted.

Why single out the obese and smokers?

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From SlideShare
obesity-and-cv-disease-1ppt-43-728
From SlideShare
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From TobaccoFreeLife.org

Smokers and the obese have elevated surgical risk and mortality, which means more cost to treat and hospitalize and provide ongoing care.

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From HealthStats

I think the NHS is on to something here.  They’re opening doors to moving the liability and responsibility away from physicians and towards patients.  This is a plus.  Outsiders may see it as separatism and elitist to only provide care for people who are healthy.  But look at the facts and the data…. obesity has a lot of co-morbidities associated.  Smoking has a lot of co-morbidities associated as well.  Why should physicians be penalized for re-admissions, poor wound healing, longer hospitalizations when the underlying conditions themselves are already challenging enough?  In fact, I would urge insurance companies to provide incentives to patients/the insured with discounted rates for good and maintained health and wellness.  With all the technologies, medications, and information out there, it’s time patients take responsibility for their own health.  I take responsibility for mine — watching my diet, exercising, working on getting enough rest, maintaining activities to keep my mind and body engaged, meditating for rest and relaxation.  It’s not easy, but my health is 100% my responsibility.  I refuse to pass the buck to my husband, my family, my physician, etc.  I do what I can to optimize my health and future — and if that doesn’t work… I call for backup.

Patients need to change their mindset re: health.  It is not your spouse’s responsibility to track your meds.  It is your responsibility to know your medical conditions and surgical history.  The single most important (and thoughtful) thing a patient can do is keep an up-to-date list of medications, past/current medical history, surgical history, and allergies to bring to every doctor’s appointment and surgery.  This helps streamline and bring to the forefront your conditions and how these will interplay with your medical and surgical plan and postoperative care.  Please do not forget recreational drugs, smoking habit, and drinking habit in this list.  It is very important to know all of these things.  Also, your emotional history is very important.  Depression, anxiety, failure to cope, etc.  This all helps tie in your current living situation with stressors and your medical history.

Links for educating yourself in taking responsibility for your health:

obesity
From SilverStarUK.org

Emergency Checklists

It seems like in today’s day and age, emergencies are occurring everywhere.  From hurricanes to shooters to earthquakes and fires… I think it’s always important to know what to do.  Here are some fabulous checklists I’ve found for getting through those emergencies.  These are not substitutions for knowledge and training.  Clinical judgement warranted.

Emergency Manual from Stanford — Printable PDF

Ariadne Labs OR Crisis Checklist

Ariadne Labs Safe Surgery Checklist Template

Ariadne Labs Ambulatory Safe Surgery Checklist Template

Project Check

Newton-Wellesley’s L&D Checklists

WHO Safe Childbirth Checklist

Checklist for Trauma Anesthesia

ASRA checklist for Local Anesthetic Systemic Toxicity

WHO Surgical Safety Checklist

WHO H1N1 Checklist

Johns Hopkins Central Line Checklist

STS Adult Cardiac Surgery Checklist

Ariadne Labs Cardiac Surgery Checklist

STS General Thoracic Surgery Checklist

STS Congenital Heart Surgery Checklist

University of Kansas Daily ICU Quality Checklist

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Transthoracic Echocardiography (TTE)

Transthoracic echo: a beginner’s guide #tte #cardiac #echo #meded

Knowing how to do a quick focused echo exam can be instrumental in diagnosis as well as treatment.  This has helped me determine how severe cardiac tamponade has been in an emergent case prior to induction when there was no prior echo.  There are so many more useful answers that a bedside echo can provide.  Time to get acquainted.

Helpful links:

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From Visible Heart Lab

Helpful articles:

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From ClinicalGate.com

Enhanced Recovery After Surgery (ERAS)

Enhanced recovery after surgery #ERAS #anesthesia #pain #recovery

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Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J. 2011 Oct; 5(5): 342–348.

Dario Bugada, Valentina Bellini, Andrea Fanelli, et al., “Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach,” Surgery Research and Practice, vol. 2016, Article ID 3561249, 6 pages, 2016. doi:10.1155/2016/3561249

Enhanced Recovery After Surgery: If You Are Not Implementing it, Why Not? PRACTICAL GASTROENTEROLOGY • APRIL 2016.

A Systematic Review of Enhanced Recovery After Surgery Pathways: How Are We Measuring ‘Recovery?’  Session: Poster Presentation. Program Number: P613

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Sturm L and Cameron AL. Fast-track surgery and enhanced recovery after surgery (ERAS) programs. ASERNIP-S Report No. 74. Adelaide, South Australia: ASERNIP-S, March 2009.

Summary of Enhanced Recovery after Surgery Guideline Recommendations. Canada.

Patients Benefit From Enhanced Recovery Programs: Are Better Prepared for Surgery, Have Less Pain, Studies Show. Oct 2016. American Society of Anesthesiologists.

Enhanced Recovery after Surgery Guideline: Perioperative Pain Management in Patients Having Elective Colorectal Surgery: A Quality Initiative of the Best Practice in General Surgery Part of CAHO’s ARTIC program. April 2013.

Preserved Analgesia With Reduction in Opioids Through the Use of an Acute Pain Protocol in Enhanced Recovery After Surgery for Open Hepatectomy. Regional Anesthesia & Pain Medicine: July/August 2017 – Volume 42 – Issue 4 – p 451–457.

Regional Anesthesia for surgery and other comparative studies. Sweden.

ERAS: Role of Anesthesiologist. UTSW.

Stanford Anesthesia ERAS pathway website

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Enhanced Recovery after Surgery Versus Perioperative Surgical Home: Is It All in the Name? Anesthesia & Analgesia: May 2014 – Volume 118 – Issue 5 – p 901–902

The Role of Regional Anesthesia in ERAS pathways. Sept 2015. UCSF.

ERAS Pathway Improves Analgesia, Opioid Use and PONV Following Total Mastectomy. Anesthesiology News. May 2016.

Anesthesia Practice and ERAS. Cooper University Hospital. 2017.

ERAS: Anesthesia Tutorial of the Week. Number 204. Nov 2010.

ERAS and Anesthesia. Anesthesia Business Consultants. May 2015.

All about ERAS: Why anesthesiologists need to understand this concept. Becker’s ASC Review. June 2015.

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I’d love to incorporate my findings and use of lidocaine infusions and ketamine infusions on intraoperative and postoperative pain as a multimodal pain management pathway.

Ketamine for intraoperative and postoperative analgesia

Ketamine for improving intraop and postoperative pain. #ketamine #pain #anesthesia #analgesia #meded

I’m always looking for ways to improve myself. Lately, I’m looking at various clinical elements of my practice and select certain endpoints that will better my practice of medicine.

This time, I’ve focused on cutting back on opioids intraoperatively for pain. I’m looking specifically at ketamine, an old drug with multiple benefits (and some downsides). Not only does ketamine help with intraoperative pain, but it also helps with postoperative pain. I’d like to incorporate some type of ERAS model for all of my patients and surgeries.

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Ketamine: (different doses I’ve seen in the literature below)

• Induction: 0.2-0.5 mg/kg

• Infusion: 0.1mg/kg/hr before incision

◦ 2mcg/kg/hr x 24hr (spine)

◦ 0.1-0.15mg/kg/hr x 24-72hrs (UW)

◦ 2mcg/kg/min

◦ 2-8mcg/kg/min

What I’m using nowadays:

  • Oct 2017: Cardiac open hearts: induction bolus=0.5mg/kg; infusion=0.1mg/kg/hr and stopping when last stitch placed.  Patients seem to require less postoperative narcotics.  Looking at time to extubation to see if this is improved.

 

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Is intravenous ketamine effective for postoperative pain management in adults? Medwave2017;17(Suppl2):e6952 doi: 10.5867/medwave.2017.6952

Ketamine: Current applications in anesthesia, pain, and critical care.  Anesth Essays Res. 2014 Sep-Dec; 8(3): 283–290.

Effect of intraoperative infusion of low-dose ketamine on management of postoperative analgesia.  J Nat Sci Biol Med. 2015 Jul-Dec; 6(2): 378–382.

 

Ketamine for Perioperative Pain Management.  Anesthesiology 2005; 102:211–20. 

CLINICAL GUIDELINE FOR USE OF KETAMINE AS AN ADJUVANT ANALGESIC FOR USE BY ANAESTHETISTS ONLY.  NHS Royal Cornwall Guidelines June 2015.

Ketamine as an Adjunct to Postoperative Pain Management in Opioid Tolerant Patients After Spinal Fusions: A Prospective Randomized Trial.  HSS Journal: Volume 4, Number 1.  

The Use of Intravenous Infusion or Single Dose of Low-Dose Ketamine for Postoperative Analgesia: A Review of the Current Literature.  Pain Medicine Volume 16Issue 2pages 383–403February 2015. 

 

Role of Ketamine in Acute Postoperative Pain Management: A Narrative Review.  BioMed Research International. Volume 2015; Article ID 749837, 10 pages.

Ketamine in Pain Management.  CNS Neuroscience & Therapeutics 19 (2013) 396–402. 

Ketamine for the Management of Acute Pain and Agitation in the ICU: Future, Fiction or Just another Drug-Induced Hallucination? Ann Pharmacol Pharm. 2017; 2(11): 1059. 

Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lancet 2017; 390: 267–75.

A comparison between intravenous lidocaine and ketamine on acute and chronic pain after open nephrectomy: A prospective, double-blind, randomized, placebo-controlled study. Saudi J Anaesth 2017;11:177-84.

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Acute and Chronic Post-Thoracotomy Pain, modes of treatment

 

Another project I’m working on is the effect of lidocaine infusions on intraoperative and postoperative pain.