Regional Anesthesia for Cardiac Surgery

Gathering data for Cardiac ERAS program for our hospital as well as the SCA. This page will be continuously updated as I find more information.

Resources:



What I’m using these days:

  • August 2020: None as we do not have programmable intermittent bolus pumps for regional.

Gabapentinoids

With an opioid crisis at its peak, physicians need to be more cognizant of the various pain modalities available to patients. Gabapentinoids are one of the many non-opioid options to help with acute and chronic pain.

What are gabapentinoids?

Wikipedia

Analgesic mechanisms of gabapentinoids and effects in experimental pain models: a narrative review. British Journal of Anaesthesia. Volume 120, Issue 6, June 2018, Pages 1315-1334.

AAFP.org

FDA

ACPHospitalist.org

Resources:

Non-opioid IV adjuvants in the perioperative period: pharmacological and clinical aspects of ketamine and gabapentinoids. Pharmacol Res. 2012 Apr;65(4):411-29.

Systemic analgesia and co-analgesia. Acta Anaesthesiol Belg. 2006;57(2):113-20.

A comparison of gabapentin and ketamine in acute and chronic pain after hysterectomy. Anesth Analg. 2009 Nov;109(5):1645-50.

Perioperative gabapentin reduces 24 h opioid consumption and improves in-hospital rehabilitation but not post-discharge outcomes after total knee arthroplasty with peripheral nerve block. Br J Anaesth. 2014 Nov;113(5):855-64.

From BJA Anaesth 2914 Nov. Fig 2.

Post‐operative analgesic effects of paracetamol, NSAIDs , glucocorticoids, gabapentinoids and their combinations: a topical review. Acta Anaesthesiol Scand. 2014 Nov;58(10):1165-81.

What our patients are getting:

  • July 2020
    • Cardiac pre-op: Lyrica 150mg PO

Cardiac myxoma

Myxoma is the most common primary benign cardiac tumor, which could lead to some fatal complications because of its strategic position. Although any age can be affected, it predominates in the age group of 30-60 years of age with more than 75% of the affected being women. The occurrence of myxomas in left and right atrium are 75% and 20% respectively.The majority of myxomas present with systemic emboli, fever and/or weight loss, or intracardiac obstruction to blood flow.1 A ‘tumor plop’ is a sound that typically occurs during early diastole and is believed to be caused by motion of the tumor striking the wall of the endocardium. The treatment is surgical excision and key aims of anesthesia care include constant monitoring of systemic blood pressure, adequate IV fluids, and judicious use of vasoactive medications to prevent a fall in systemic vascular resistance.3

Preop

  • A-line/CVP
  • Assess patient symptomatology: SOB, chest pain, changes in pulse pressure/CVP with positioning, heart sounds
  • Adequate PIV access
  • Vasopressors to help with SVR and heart rate control – mass can act as stenotic valve

Intraop

  • Induction: maintain SVR and consider slowing heart rate if mass blocking valves

Postop

2D TEE: X-plane
2D TEE: color flow through mitral valve
2D TEE: LA myxoma
2D TEE: LA myxoma w color
3D TEE: LA myxoma
From OpenAnaesthesia
2D TEE: measurement of stalk
Resected myxoma

References:

Surgical approach

Cardiac myxomas: 24 years of experience in 49 patients. European Journal of Cardio-thoracic Surgery 22 (2002) 971–977.

Anesthesia management

Hemodynamic management of a patient with a huge right atrium myxoma during thoracic vertebral surgery: A case report. Medicine (Baltimore). 2018 Sep; 97(39): e12543.

Anesthetic Management of a Patient With a Giant Right Atrial Myxoma. Semin Cardiothorac Vasc Anesth. 2016 Mar;20(1):104-9.

Anesthetic management of a patient with asymptomatic atrial myxoma for hernia repair. Anaesth Pain & Intensive Care 2016;20(2):246-248

Giant Left Atrial Myxoma Obstructing Mitral Valve Bloodflow. Anesthesiology 7 2019, Vol.131, 151-152.

Anesthetic Management of a Voluminous Left Atrial Myxoma Resection in a 19 Weeks Pregnant with Atypical Clinical Presentation. Case Reports in Anesthesiology, Volume 2019, Article ID 4181502, 6 pages.

Large myxoma causing cardiac arrest during surgery. A Clinical Reports volume 1, Article number: 24 (2015).

Atrial myxomas causing severe left and right ventricular dysfunction. Annals of Cardiac Anaesthesia. Case Report: Year : 2017  |  Volume : 20  |  Issue : 4  |  Page : 450-452.

Intraoperative Diagnosis of Left Atrial Myxoma. Anesthesia & Analgesia: January 1995 – Volume 80 – Issue 1 – p 183-184

Anesthetic experiences of myxoma removal surgery in two patients with Carney complex -A report of two cases-. Korean J Anesthesiol. 2011 Dec; 61(6): 528–532.

Echocardiography

Virtual TEE: Cardiac Myxoma

Intraoperative transesophageal echocardiography assessment of right atrial myxoma resulting in a change of the surgical plan. Ann Card Anaesth 2014;17:306-8.

Continuous Regional Anesthesia Catheters

We’re setting up continuous regional anesthesia catheters in our hospital. It hasn’t been easy, but I’ve learned a lot along the way.

From Essentials of Pain Medicine (Fourth Edition)
2018, Pages 135-140.e2

Update on Continuous peripheral nerve block techniques


Continue reading “Continuous Regional Anesthesia Catheters”

The Independence debate in Anesthesia

The independence debate in anesthesia. #anesthesiologist #physician @nmsahq @asahq Physician-led anesthesia care team provides patient safety, which is the #1 priority in patient care. #va #patientsafety #healthcare

June 2019

And here we are again with the CRNA debate. But this time, physicians are lashing back at the hostility and unprofessional manner of the AANA’s most recent statement regarding CRNA independent practice.

The ASA put out a statement that answers the demeaning AANA statement. The current president of the ASA is Dr. Linda Mason, who was a CRNA then chose to complete medical school, anesthesia residency, and cardiothoracic fellowship. Seems like she would be a great voice for physicians in the care team model of anesthesia practice especially since she has perspective from both sides.


Feb 2019

The physician vs. crna debate has reared its ugly head…. yet again. There have been multiple bills presented to suggest crna independence WITHOUT physician anesthesiologist oversight. In 2017, proposals were made to the Veteran’s Affairs to replace physicians with crnas. Here’s what they found when they looked at the VA databases to conclude that nurses will continue with physician oversight in anesthesia:

Current laws in 45 states and the District of Columbia all require physician involvement for anesthesia care and the VA in 2017 decided to maintain its physician-led, team-based model of care. The VA’s Quality Enhancement Research Initiative (QUERI) could not discern “whether more complex surgeries can be safely managed by CRNAs, particularly in small or isolated VA hospitals where preoperative and postoperative health system factors may be less than optimal.”

Here’s my evidence and reasons why I believe the care of the patient is best when it is physician-led. After all, would you want a nurse or assistant doing your actual surgery? The ultimate goal is patient safety.

Physician anesthesiologists have up to 14 years of post-graduate medical education and residency training, which includes 12,000-16,000 hours of clinical training, nearly seven times more training than nurse anesthetists.

From 2010:

From 2011:

From 2017:

From 2019:

Yet, here’s another debate that shows there’s no difference in an anesthesia care team setting with an anesthesia assistant and a crna:

Bottom line in my opinion:

  • Physicians endure years of grueling medical education that starts with the why, how, and treatment of disease. This is followed with years of residency training in anesthesia. There’s also further training in the form of a fellowship for specialized fields.
  • Getting into medical school is an extremely competitive process. You take the top 1% of college graduates and high MCAT scores to get into medical school. The board certification for becoming certified in anesthesiology is quite complex and difficult in both the written and oral board exams.
  • I will continue to be FOR team-based physician-led anesthesia care.

The Independence debate in Anesthesia

The independence debate in anesthesia. #anesthesiologist #physician @nmsahq @asahq Physician-led anesthesia care team provides patient safety, which is the #1 priority in patient care. #va #patientsafety #healthcare

The physician vs. crna debate has reared its ugly head…. yet again.  There have been multiple bills presented to suggest crna independence WITHOUT physician anesthesiologist oversight.  In 2017, proposals were made to the Veteran’s Affairs to replace physicians with crnas.  Here’s what they found when they looked at the VA databases to conclude that nurses will continue with physician oversight in anesthesia:

Current laws in 45 states and the District of Columbia all require physician involvement for anesthesia care and the VA in 2017 decided to maintain its physician-led, team-based model of care. The VA’s Quality Enhancement Research Initiative (QUERI) could not discern “whether more complex surgeries can be safely managed by CRNAs, particularly in small or isolated VA hospitals where preoperative and postoperative health system factors may be less than optimal.”

Here’s my evidence and reasons why I believe the care of the patient is best when it is physician-led.  After all, would you want a nurse or assistant doing your actual surgery?  The ultimate goal is patient safety.

Physician anesthesiologists have up to 14 years of post-graduate medical education and residency training, which includes 12,000-16,000 hours of clinical training, nearly seven times more training than nurse anesthetists.

From 2010:

From 2011:

From 2017:

 

Yet, here’s another debate that shows there’s no difference in an anesthesia care team setting with an anesthesia assistant and a crna:

Bottom line in my opinion:

  • Physicians endure years of grueling medical education that starts with the why, how, and treatment of disease. This is followed with years of residency training in anesthesia. There’s also further training in the form of a fellowship for specialized fields.
  • Getting into medical school is an extremely competitive process. You take the top 1% of college graduates and high MCAT scores to get into medical school.  The board certification for becoming certified in anesthesiology is quite complex and difficult in both the written and oral board exams.
  • I will continue to be FOR team-based physician-led anesthesia care.

Severe Pre-eclampsia and Anesthesia

Chief Complaint: elevated blood pressures, now with elevated liver enzymes

SUMMARY OF RECOMMENDATIONS
1. Nifedipine 60mg ER BID, next dose at 0900.
2. Continue q4hr blood pressure monitoring; increase to q15mins should she have systolic blood pressure >160 or diastolic blood pressure >110. Please call Perinatologist should that occur.
3. NPO for now.
4. Follow-up serum preeclampsia labs at 1200, along with type & cross x2 units.
5. If AST/ALT continue to rise, would recommend primary cesarean section at that time.
6. Continue magnesium sulfate for now, and for 24 hours postpartum.
7. NICU aware.

PROBLEM LIST
1. INTRAUTERINE PREGNANCY AT 25w6d
2. SUPERIMPOSED PREECLAMPSIA WITH SEVERE FEATURES
3. TRANSAMINITIS, NOT YET 2x THE UPPER LIMITS OF NORMAL

HPI/HOSPITAL COURSE: 37 y.o. G1P0 at 25w6d, hospitalized for exacerbation of chronic hypertension, found to have preeclampsia with proteinuria. Patient received betamethasone and magnesium sulfate course. Since <deleted date> with change of her regimen from labetalol to nifedipine 30mg XR BID, patient had had normal to mild range blood pressures.

Patient had acute exacerbations in her blood pressures to the severe range. Please see my note from <date> in regards to her antihypertensive course. After her 10mg IV hydralazine yesterday evening, starting magnesium sulfate, and increasing her nifedipine to 60mg XR BID, she has now had normal to mild range blood pressures overnight. However, her 0000 and 0600 AM labs show an acute rise in her LFTs above her baseline, with AST now 74 and ALT 81. Platelets remain normal range, as is serum creatinine (0.5). Magnesium level this morning at 6.4, infusion rate decreased to 1gm/hr.

Review of systems: denies headache, visual changes, RUQ or epigastric pain. No contractions, leakage of fluid, or vaginal bleeding. She is feeling fetal movement this morning.

Allergies:
• Amoxicillin Rash
CONV. REACTION:Rash
• Penicillins

Exam:
Vitals:
BP: (!) 140/97
Pulse: 89
Resp: 18
Temp: 36.7 °C (98 °F) 36.7 °C (98 °F)
TempSrc: Oral Oral
SpO2: 98% 98% 98%
Weight:
Height:
General: no acute distress
Cardiovascular: regular rate, normal rhythm. Intact S1/S2
Pulmonary: clear to auscultation bilaterally
Abdomen: gravid, non-tender to palpation
Extremities: non-tender; trace lower extremity edema, symmetric. 2+ brisk patellar reflexes

Ultrasound (12/5): Cephalic presentation. estimated fetal weight 28th percentile, 776g. Normal umbilical artery dopplers.

Labs:
Lab Results
Component Value Date
WBC 14.4 (H)
RBC 4.51
HGB 13.7
HCT 41.3
MCV 91
MCH 30
MCHC 33
RDW 11.8
PLT 313
PRENEUTROABS 9.56 (H)
DIFFTYPE Auto
NEUTOPHILPCT 66.4
LYMPHOPCT 24.0 (L)
MONOPCT 7.9
EOSPCT 0.7
BASOPCT 0.9
NEUTROABS 9.56 (H)
LYMPHSABS 3.46
MONOSABS 1.14 (H)
EOSABS 0.11

Lab Results
Component Value Date
NA 133 (L)
K 4.0
CL 102
CO2 22
GLUCOSE 84
BUN 11
CREATININE 0.5
OSMOLALITY 275 (L)
ALBUMIN 4.0
LABPROT 7.4
CALCIUM 7.0 (CL)
ALKPHOS 91
AST 74 (H)
BILITOT 0.2
ANIONGAP 9
ALT 81 (H)
GFRCNAFA >60
GFRCAFA >60

NST: appropriate for gestational age and magnesium sulfate administration. Baseline 135, mild to moderate variability, occasional 10×10 accelerations. Rare variable decelerations.
Toco: irritability

Assessment/Plan:
37 y.o. G1P0 at 25w6d, admitted for superimposed preeclampsia with severe features.

With preeclampsia with severe features, we do try to wait until 34 weeks for delivery; however, delivery is recommended once in the steroid window for the following: persistent symptoms of preeclampsia (i.e., headache, vision changes, upper abdominal pain), worsening or uncontrolled blood pressure despite medication therapy, development of pulmonary edema, placental abruption, eclampsia, HELLP syndrome (i.e., platelets < 100,000 or LFTs > 2x normal), evidence of acute kidney injury (i.e., creatinine >/= 1.1 mg/dl), eclampsia or non-reassuring fetal testing.

I discussed my concern that her liver enzymes, which had mildly been elevated on admission, are now acutely rising, which would be an indication for delivery at this time. However, at 25+6 weeks, I recommend rechecking her preeclampsia labs again at 1200. If there is a further acute rise, I do recommend delivery via cesarean section at that point.

We discussed the risks/benefits/alternatives of primary cesarean section, as well as the possibility for a classical hysterotomy, in which she would not be allowed to labor in the future. Risks of cesarean section discussed included:

Risks of cesarean section:
1. Bleeding, with the possibility or requiring a transfusion. Risk of transfusion include allergic reaction (1/50,000), transmission of HIV/Hepatitis B or C 1/1.5-1.7 million. The patient is accepting of blood transfusion if needed, and a type and cross x2 units will be ordered at noon.
2. Infection, requiring intravenous antibiotics and potentially prolonged hospital stay
3. Damage to surrounding organs, not limited to baby (<1%), bowel, bladder, nerves, vessels, ureters.
4. Possible need for hysterectomy in the event of irreversible catastrophic bleeding
5. Wound complications not limited to separation and/or infection
6. Medical complications not limited to deep venous thrombosis, pulmonary embolism, cardiovascular accident, myocardial infarction, death.

I would not advise induction of labor at 26 weeks, as the chance of a successful vaginal delivery prior to 28-30 weeks in a primip is low.

Patient will remain NPO and on magnesium sulfate (for maternal seizure prophylaxis and fetal neuroprotection) at this time, as we await her 1200 labs. Will continue q4hr blood pressure monitoring, and she will be given her 60mg XR nifedipine at 0900.

Scientists-discover-critical-molecular-biomarkers-of-preeclampsia
From Debuglies.com

Spinal Anesthesia in Severe Preeclampsia. Anesthesia & Analgesia: September 2013 – Volume 117 – Issue 3 – p 686–693.

PDF version of article above

Subarachnoid block for caesarean section in severe preeclampsia. J Anaesthesiol Clin Pharmacol. 2011 Apr-Jun; 27(2): 169–173.

Comparing the Hemodynamic Effects of Spinal Anesthesia in Preeclamptic and Healthy Parturients During Cesarean Section. Anesth Pain Med. 2016 Jun; 6(3): e11519.

Recent advances in pre-eclampsia management: an anesthesiologist’s perspective! Anaesthesia, Pain & Intensive Care ISSN 1607-8322, ISSN (Online) 2220-5799.

Hemodynamic Changes Associated with Spinal Anesthesia for Cesarean Delivery in Severe Preeclampsia. Anesthesiology 5 2008, Vol.108, 802-811.

ALS and General Anesthesia

#ALS and #anesthesia

I had a case with a patient who was newly diagnosed with ALS.  They had recently had a fall and was coming in for a TEE (for pre-Watchman workup), AV node ablation, and pacemaker placement.  There was some mild lower extremity weakness.  Upper extremity strength seemed to be 5/5.  The patient recently passed a swallow evaluation.  The plan was for a GA.

What is ALS?

als-whats-is-ALS-info
From http://walkforals.ca/what-is-als/

ALS Association: What is ALS?

ALS Association: Signs and Symptoms

 

Considerations in ALS patients for GA:

 

My plan:

  • Induction: propofol, remifentanil. I avoided paralytics.
  • Pain control: remifentanil, local anesthetic by surgeon.
  • Emergence: deep, patient breathing on their own
  • Dropoff in PACU: patient wide awake and comfortable.

 

Esophagectomy

The case is booked as an Ivor-Lewis esophagectomy.  Let’s learn a couple of things here from what the surgery will be, to the type of anesthesia, to post-op pain management.

What’s an Ivor-Lewis esophagectomy?

Esophagectomy

Anesthetic monitors:

  • Central line (Cordis for volume in emergency)
  • Vigileo/FloTrac – SVI, SVV, SVR, CO great markers for fluid management
  • BIS
  • UOP

Anesthetic technique:

  • Induction: lidocaine, Propofol, rocuronium/sux (dependent upon if blockage from tumor necessitating RSI or not)
  • Maintenance: sevoflurane
  • Extubation: attempt in OR
  • Fluid management
    • Colloid vs. crystalloid
    • CVP vs. Esophageal doppler vs. pulse pressure vs. stroke volume variation
      • Keep SVI >35 mL/m2 to decrease risk of AKI
  • OLV
    • To reduce lung damage and ARDS
    • 4-6 cc/kg ventilation strategy (lung-protective)
    • Pressure-controlled
    • Optimization of PEEP
    • PIPs <35mmHg, Plateau pressure <25mmHg
  • Pain Management
    • Pre-op adjuvant pain meds:
      • Oxycodone XR 20mg PO if <70y/o or 10mg if >70yo
      • Celecoxib 400mg PO if <70y/o or 200mg if >70yo
      • Pregabalin 150mg PO if <70y/o or 75mg if >70yo
    • Thoracic Epidural: Improved blood flow to anastomotic site, earlier extubation times, reduced pneumonia rates.
  • Vasopressors: phenylephrine. Consider norepinephrine (improved CO), vasopressin if needed.

Case:

40-something year old female who was newly diagnosed with squamous cell cancer of her distal esophagus about 2 months prior.  Presented to ED with N/V, epigastric pain, malnourishment.  Had underone chemo and radiation.  PMH achalasia, endometriosis.  NKDA. Scheduled for Ivor-Lewis esophagectomy.  Pt appeared cachectic, on TPN, 45kg, 5’5″.  L chest port-a-cath in place.

In OR, pt received T7 epidural.  RSI w cricoid pressure throughout.  37Fr L DLT placed gently without resistance.  31cm at teeth noted after fiberoptic bronch check.  20g L radial a-line placed.  Surgeon stated no cervical approach needed, therefore, I placed a R IJ cordis and CVP.  FloTrac for SVI, SVR, SVV, CO.

Albumin for IVF.  Goal SVI >35, CVP 5-10. Phenylephrine for SBP >90.  OGT (resistance met prior to first dark marking on tube that was expected with 6 cm tumor).  BIS goal 40-60.  Epidural initially dosed with 5ml 2% lido with epi.  Another dose given roughly 30 minutes later.  Remaining dosing throughout case with 4ml 0.25% bupi.  Acetaminophen IV 1000mg prior to incision.  Fentanyl IV for abdominal laparoscopy.

Abdominal laparoscopy –> tumor unable to be freed/resected via laparoscopy.  Converted to laparotomy.  Tumor adhered to pericardium.

R thoracotomy: OLV at 200ml TV, RR 21 (volume-restrictive ventilation strategy 4-6ml/kg).  Good lung isolation.  Good anastamosis of tissues.  Two lung ventilation according to surgeon.  Recruit lungs to decrease atelectasis.

Emergence: + Pressure support through DLT.  Extubate in OR.

Lessons learned:

  1. Early communication with surgeon(s).
  2. Lung-protective strategies
  3. Volume restriction for IVF
  4. Appropriate pressor choice
  5. Pain control: thoracic epidural (0.125% bupiv + hydromorphone 10mg/ml), IV low dose ketamine (0.1-1mg/kg/hr), precedex if tolerated, if PO then preop pain meds above.  If not PO, then IV acetaminophen RTC, IV ketorolac RTC (if ok with surgeon).  Continue baseline pain regimen if patient is a chronic pain patient.
  6. Setup is key.  Discuss which side for the cervical approach (if doing) prior to doing neck lines so not in the surgical field.

Resources:

 

Cardiac Arrest in the OR

Cardiac Arrest in the Operating Room:  Resuscitation and Management for the Anesthesiologist Part 1

Moitra, Vivek K.; Einav, Sharon; Thies, Karl-Christian; Nunnally, Mark E.; Gabrielli, Andrea; Maccioli, Gerald A.; Weinberg, Guy; Banerjee, Arna; Ruetzler, Kurt; Dobson, Gregory; McEvoy, Matthew D.; O’Connor, Michael F.

Anesthesia & Analgesia126(3):876-888, March 2018.