Antithrombin III

The other day we had a patient come in for a CABG. Aside for some coronary artery disease, hypertension, and chronic kidney disease, the patient was pretty healthy. They were not on anticoagulation prior to the procedure.

After I gave full dose heparin for going on bypass (41,000U in this case), the ACT only came up to 422. An additional 10,000U of heparin was given with a repeat ACT of 457. Still, our surgeon was not quite comfortable with that number and requested an additional 10,000U heparin. The ACT came to 477.

If the ACT stayed in the low 400s, would you go on bypass? What if the ACT had not responded to the repeated heparin dosings?

Management of coagulation during cardiopulmonary bypass. Continuing Education in Anaesthesia Critical Care & Pain, Volume 7, Issue 6, 1 December 2007, Pages 195–198, https://doi.org/10.1093/bjaceaccp/mkm036.

Antithrombin III concentrate to treat heparin resistance in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2002 Feb;123(2):213-7.

Would you give antithrombin III or plasma?

Treating Heparin Resistance With Antithrombin or Fresh Frozen Plasma. The Annals of Thoracic Surgery. June 2008Volume 85, Issue 6, Pages 2153–2160.

Is there evidence that fresh frozen plasma is superior to antithrombin administration to treat heparin resistance in cardiac surgery? Interact Cardiovasc Thorac Surg. 2014 Jan; 18(1): 117–120.

We ultimately decided to go on bypass. Repeat ACTs on bypass were in the 500s. No antithrombin was given. After separation from cardiopulmonary bypass and administration of protamine, repeat ACT was 111. Protamine was dosed accordingly to heparin administration and ACTs while on bypass.

Recommendations for the use of antithrombin concentrates and prothrombin complex concentrates. Blood Transfus. 2009 Oct; 7(4): 325–334.

Thrombate (antithrombin III) package insert

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HeartWare vs. HeartMate LVAD

A couple of weeks ago, I took care of a patient who desperately needed to get better from acute CHF.  At that time, we placed the patient on an impella… but the next day, it was deemed that he needed ECMO to reperfuse his organs.  After a week on ECMO with continued impella support, ECMO was titrated down and off while maintaining 3.9L/min flow from the impella.  During the wean off ECMO, the patient had been extubated and was mentating clearly and interacting appropriately.

Fast forward a couple days after getting extubated, the patient was ripe for an LVAD.  But which one? (We ended up placing the patient on HeartWare LVAD).

YouTube: LVAD 101 – Anatomy & Physiology

YouTube: LVAD Pathophysiology


HeartWare

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HeartWare brochure

YouTube vid of HeartWare (no sound) ; Vid of HeartWare with detailed explanation

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HeartMate II

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HeartMate II website

YouTube vid of HeartMate II


Summary

  • Cost-effectiveness: HeartWare > HeartMate II (UK NHS study, April 2014)
  • LV Geometry: HeartWare = HeartMate II (J CT Surg, 2013)
  • Stroke & GI bleed risk: HeartWare > HeartMate II (J Card Surg 2013)
  • Risk of device failure: HeartWare < HeartMate II
  • ENDURANCE trial: Randomized patients eligible for DT 2:1 to the HeartWare centrifugal flow LVAD versus the HeartMate II axial flow LVAD. The trial did reach its primary noninferiority endpoint of stroke free survival at 2 years (55.0% in the HeartWare patients versus 57.4% in the HeartMate II patients). Of note, a change in the design of the HeartWare device during the trial (sintering of the inflow cannula) appeared to decrease the incidence of pump thrombosis. Overall, the stroke rate was higher in the HeartWare arm whereas device malfunctions requiring exchange or urgent transplantation were more common in the HeartMate II arm. Data analysis suggested that better blood pressure control in the HeartWare arm may decrease the stroke rate and a second cohort of patients is being enrolled with more attention being paid to blood pressures management.

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Ventricular Assist Devices: Impella

“There’s an emergent case coming for impella placement.”

Impella?  I’ve read about these devices and I’m familiar with managing patients on LVADs as well as providing anesthesia for LVAD placement.  But, I’ve never done an Impella on a critically unstable patient.

YouTube video describing the purpose and placement of the Impella

Cath Lab Digest: Overview of Impella 5.0

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Anesthesia & Analgesia; January 2012. Echo rounds: The Use of TEE for Confirmation of Appropriate Impella 5.0 Device Placement.

From A&A Echo Rounds

 YouTube video similar to our axillary artery conduit (we had to go left sided bc of a prior AICD in the patient’s right chest) for Impella 5.0

JCVA, June 2010. Review Articles: Percutaneous LVAD: Clinical Uses, Future Applications, and Anesthetic Considerations.

Awake Tracheostomy

They say that anesthesiology is 95% comfy and relaxed and the other 5% is “oh shit”!  It’s a great career choice — pretty flexible hours, great patient contact, broad spectrum medicine, crisis management, leadership role, etc.

There happened to be an interesting case in the OR — awake tracheostomy for a patient coming in from home.

What’s a tracheotomy?

Evaluation of the airway PPT

The Difficult Airway in Head and Neck Tumor Surgery

Anesthesia for tracheostomy for huge maxillofacial tumor. From SJA: CASE REPORT Year : 2014 | Volume : 8 | Issue : 1 | Page : 124-127

Our patient had two prior tracheotomies all with successful decannulation.  His most recent trach was about 2.5 months ago (which a fiberoptic intubation was used with a 6.0 ETT).   He had a neck cancer with a rapidly growing tongue base tumor that seems to be less responsive to chemo than his shrinking neck tumor.  Because of the enlarging size of the tongue base tumor, he is starting to notice worsening stridor without his trach.  The ENT surgeon evaluated his airway just days before and deemed it unintubateable.  Therefore, my plan was to have a pedi FO scope with 5.0 cuffed ETT (smallest available in our OR), glidescope, emergency cric supplies (14g angio cath, 3cc syringe with plunger removed and 7.0 ETT adapter hooked into the end of the syringe), jet ventilator and tubes, and ENT surgeon.

We decided to use a bit of midazolam as well as Precedex for the awake trach.  The dosing on the package says 1 mcg/kg for 10 minutes then 0.7 mcg/kg/hr.  We started with 0.5 mcg/kg for 10 minutes then 0.5 mcg/kg/hr.  This regimen worked well as we started it in preop and monitored his SpO2 as he dozed off but was easily aroused to voice and gentle touch.

The Role of Dexmedetomidine for Awake Trach

Monitors were placed in the OR and we used a face mask running 10 L/min O2 with ETCO2 monitoring.  Every now and then he would obstruct while lying supine, therefore, we placed a nasal trumpet to aid the obstruction.  The surgeon localized the surgical area. See video for procedure.

The patient coughed once the trachea was perforated, but it was short lived as the surgeons were able to place the trach and hookup to our anesthesia circuit.  After confirming ETCO2, we pushed propofol IV and the remainder of the case was performed under general anesthesia (direct laryngoscopy and biopsy by surgeon).

Key take home points

  • Effective communication with the patient pre-op: expectations, sedation, potential complications.
  • Arm yourself! Do this like you would a difficult airway! Fiberoptic intubation supplies, glidescope, emergency cricothyroidotomy supplies, backup LMA, extra hands on deck (grab your anesthesia colleagues, anesthesia techs, extra help!), ENT… it never hurts to be over prepared!
  • Deliberate, effective communication with the ENT colleague across the drape.
  • Document any intubation performed, tools used, trachs placed so your anesthesia colleagues will know what worked in the past to secure an airway.
  • Breathe a sigh of relief bc these kind of cases are extremely uncommon!  Pat yourself on the back for a job well-done!

Now check out this amazing Case Report on a patient with a massive maxillofacial tumor!

The 10 most stressful situations in anesthesiology from an anesthesiologist’s perspective

These aren’t my own thought, however, I can easily agree with the list below.  One of the things that was left off this list was pediatric hearts.  I had the chance to do a one month pediatric cardiac anesthesia rotation at a very busy Children’s hospital and it was definitely an eye opening experience.  Teeny tiny babies.  Itty bity tubes and IVs.  The heart plumbing/circuitry was anything but normal.  I have the utmost respect for pediatric cardiac anesthesiologists — and that’s coming from an adult cardiac anesthesiologist.

Taken and shared from The Anesthesia Consultant Blog:

TOP 10 MOST STRESSFUL SITUATIONS IN AN ANESTHESIOLOGIST’S JOB

  1. Emergency general anesthesia in a morbidly obese patient. Picture a 350-pound man with a bellyful of beer and pizza, who needs an emergency general anesthetic. When a patient with a Body Mass Index (BMI) > 40 needs to be put to sleep urgently, it’s dangerous. Oxygen reserves are low in a morbidly obese patient, and if the anesthesiologist is unable to place an endotracheal tube safely, there’s a genuine risk of hypoxic brain damage or cardiac arrest within minutes.
  1. Liver transplantation. Picture a patient ill with cirrhosis and end-stage-liver-failure who needs a complex 10 to 20-hour-long abdominal surgery, a surgery whichfrequently demands massive transfusion equal to one blood volume (5 liters) or more. These cases are maximally stressful in both intensity and duration.
  1. An emergency Cesarean section under general anesthesia in the wee hours of the morning. Picture a 3 a.m. emergency general anesthetic on a pregnant woman whose fetus is having cardiac decelerations (a risky slow heart rate pattern). The anesthesiologist needs to get the woman to sleep within minutes so the baby can be delivered by the obstetrician. Pregnant women have full stomachs and can have difficult airway because of weight changes and body habitus changes of term pregnancy. If the anesthesiologist mismanages the airway during emergency induction of anesthesia, both the mother and the child’s life are in danger from lack of oxygen within minutes.
  1. Acute epiglottitis in a child. Picture an 11-month-old boy crowing for every strained breath because the infection of acute epiglottis has caused swelling of his upper airway passage. These children arrive at the Emergency Room lethargic, gasping for breath, and turning blue. Safe anesthetic management requires urgently anesthetizing the child with inhaled sevoflurane, inserting an intravenous line, and placing a tracheal breathing tube before the child’s airway shuts down. A head and neck surgeon must be present to perform an emergency tracheostomy should the airway management by the anesthesiologist fails.
  1. Any emergency surgery on a newborn baby. Picture a one-pound newborn premature infant with a congenital defect that is a threat to his or her life. This defect may be a diaphragmatic hernia (the child’s intestines are herniated into the chest), an omphalocele (the child’s intestines are protruding from the anterior abdominal wall, spina bifida (a sac connected to the child’s spinal cord canal is open the air through a defect in the back), or a severe congenital heart disorder such as a transposition of the great vessels (the major blood vessels: the aorta, the vena cavas and the pulmonary artery, are attached to the heart in the wrong locations). Anesthetizing a patient this small for surgeries this big requires the utmost in skill and nerve.
  1. Acute anaphylaxis. Picture a patient’s blood pressure suddenly dropping to near zero and their airway passages constricting in a severe acute asthmatic attack. Immediate diagnosis is paramount, because intravenous epinephrine therapy will reverse most anaphylactic insults, and no other treatment is likely to be effective.
  1. Malignant Hyperthermia. Picture an emergency where an anesthetized patient’s temperature unexpectedly rises to over 104 degrees Fahrenheit due to hypermetabolic acidotic chemical changes in the patient’s skeletal muscles. The disease requires rapid diagnosis and treatment with the antidote dantrolene, as well as acute medical measures to decrease temperature, acidosis, and high blood potassium levels which can otherwise be fatal.
  1. An intraoperative myocardial infarction (heart attack). Picture an anesthetized 60-year-old patient who develops a sudden drop in their blood pressure due to failed pumping of their heart. This can occur because of an occluded coronary artery or a severe abnormal rhythm of their heart. Otherwise known as cardiogenic shock, this syndrome can lead to cardiac arrest unless the heart is supported with the precise correct amount of medications to increase the pumping function or improve the arrhythmia.
  1. Any massive trauma patient with injuries both to their airway and to their major vessels. Picture a motorcycle accident victim with a bloodied, smashed-in face and a blood pressure of near zero due to hemorrhage. The placement of an airway tube can be extremely difficult because of the altered anatomy of the head and neck, and the management of the circulation is urgent because of the empty heart and great vessels secondary to acute bleeding.
  1. The syndrome of “can’t intubate, can’t ventilate.” You’re the anesthesiologist. Picture any patient to whom you’ve just induced anesthesia, and your attempt to insert the tracheal breathing tube is impossible due to the patient’s anatomy. Next you attempt to ventilate oxygen into the patient’s lungs via a mask and bag, and you discover that you are unable to ventilate any adequate amount of oxygen. The beep-beep-beep of the oxygen saturation monitor is registering progressively lower notes, and the oximeter alarms as the patient’s oxygen saturation drops below 90%. If repeated attempts at intubation and ventilation fail and the patient’s oxygen saturation drops below 85-90% and remains low, the patient will incur hypoxic brain damage within 3 – 5 minutes. This situation is the worst-case scenario that every anesthesia professional must avoid if possible. If it does occur, the anesthesia professional or a surgical colleague must be ready and prepared to insert a surgical airway (cricothyroidotomy or tracheostomy) into the neck before enough time passes to cause irreversible brain damage.

24 hours with an anesthesiologist

A piece I’d like to submit for: CNN Money 24 hours With….an anesthesiologist

About Kris:

I grew up in a small west Texas town called Abilene, TX. My mom was a standard tiger mom in that she encouraged me to pursue multiple activities while nudging me to do my best. After drama lessons, tennis lessons, basketball, volleyball, piano, violin, band, taekwondo, pageants, and just life, I left Abilene and pursued a biomedical science degree at Texas A&M University.  My earliest memory of wanting to be a doctor started when I was in the third grade.  I hadn’t been feeling well and was diagnosed with pneumonia — I had been reading a book called This is the Child.  My family practice physician Dr. Lawson was about to prescribe me prednisone and I immediately got worried because that was the same medication used to help with the child’s leukemia.  Dr. Lawson picked up on my early curiosity and invited me to hang out with him in his medical office observing patients.  After college, med school proved to be a great experience at University of Texas Medical Branch in Galveston and felt like learning on steroids (as compared to college).  My clinical rotations led me to the path of choosing anesthesiology as a career.  Anesthesia is the perfect combination of anatomy, physiology, pharmacology, psychology, and sociology.  I matched into a terrific internship in Austin, TX and continued my anesthesia training at the prestigious Massachussetts General Hospital.  Following 4 grueling years of training, late nights, memorable cases, and lifelong friendships, I chose to pursue a cardiac anesthesia fellowship at University of California San Diego — a world renowned institution for the treatment of right heart failure following pulmonary thrombosis.  14 years after graduating high school, I have the job of my dreams.  Here’s a sample of my day…

My Day:
Today I’m #2 in our call lineup, which means it will be a pretty busy day. Typically, we have 15 call spots in our main operating room (OR) numbered #1 to #15. #1 position gets the first pick of cases. #2 gets the next pick and so on.

5:45a Early heart day wake up. Today, I will be providing anesthesia to a 70-something year old lady who needs a new heart valve.  On heart days, I wake up at 5:45a to be at work by 6:30. And on regular main OR days, I wake up at 6:15a to be at work by 7:00. Ahhhh… To have more beauty sleep!

6:17a Breakfast in the car – it’s either green juice, Shakeology, or banana on the go!

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Breakfast on the go!

6:31a I meet the patient and her family in the pre-operative area.  We go over a detailed plan for her anesthesia as well as answer any questions.  One of the best parts of my job is meeting all different types of people.  It’s an amazing feeling to meet people at one of their most vulnerable moments in their lives and win over their trust and respect.  It is my job to safely manage their physiologic processes.  Oftentimes, patients tell me it is the anesthesiologist who is the most important part of a surgery — they understand how easy it is to bring them close to the brink of death and then revive them back to a wakeful state.  It’s incredible the amount of trust patients place in your hands in such a short time after meeting them.

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7:15am The patient is under anesthesia and all invasive monitoring lines (arterial, central venous pressure, cordis, pulmonary artery lines) have been placed.  The transesophageal echocardiogram is performed and results are relayed to the cardiac surgeon.


7:45am Cardiac surgeon makes incision.  The patient is monitored throughout the case.  Multiple screens show all the physiologic monitoring results.

10:00a Bathroom break! Partners/colleagues break each other out so there is always an anesthesiologist monitoring the patient.  It’s also a good time to grab a snack!

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My work bag with some life saving snacks to avoid hangriness!

11:32a Drop first patient off in Cardiac Care Unit and grab some lunch. The doctor’s lounge keeps us fed with soup and salad. Today, I’m feeling the vegetable soup. Grab a quick bathroom break and then to interview the next patient.

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Lunch on the go!

11:45a Electrophysiology study for atrial fibrillation ablation. The view from this OR is such a delight!

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The view from my little nook.

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14:00 I get a call from our anesthesia czar, one of my partners who runs the schedule. He was wondering if I would make my 15:00 hip replacement. After a quick conversation, we decide that I would call him in 30 minutes for an update.

14:33 We are finishing up with the current case and I call the czar back to find out about my next case. I learned that there is an emergent heart that will be started by another colleague and that I will continue the lineup in EP (so my day went from a 16:30 finish on paper to roughly a 19:00 finish). Anytime I am in the top 5 call positions, I know not to make defined plans because you never know if there will be addons or changes to the schedule. This makes my social life a bit frustrating as my non-medical friends have a tough time understanding and adapting to this “you don’t get out of work at 5p?” concept.


15:20p Drop patient off in the Post Anesthesia Care Unit (PACU). Grab a quick snack and head back to EP for the next patient.

15:25p Speak to the next patient who has arrived for an afib ablation as well. Induce and get started with the case.

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19:22 Drop last patient off in the PACU.  As #2 on the call list, I look at my watch and realize that I am #2 at night.  This means I will be the 2nd person they call tonight if extra rooms in the OR get booked (traumas, heart call, etc.).  As much as I’d love to head home and grab a glass of wine and unwind, I meet up a friend for dinner to catch up and relax.

21:42 Head home. Shower. Brush my teeth and get into bed.  There’s always a risk of being called into work.  Tomorrow will be a shorter day.  After the hectic day, I am still thankful for my wonderful job and colleagues.  Looking back at my journey to get here, I smile because I couldn’t be happier.

When the bark is louder than the bite

In residency, you learn to deal with many different personalities.  This ranges from super sweet and helpful to utterly cruel and egotistical.  At MGH, our CA-3 year was spent running the call schedule on night call (the first-call experience).  It’s a terrific experience in prioritizing as well as organizing your team to prepare for what rolls through the OR doors.  Fast forward 4 years and now I’m in private practice.

While running the schedule on call, I get a call from the trauma surgeon saying a patient with an epidural hematoma needs to come to the OR emergently and couldn’t wait for another anesthesiologist to be called in from home (home call gives an anesthesiologist 30 minutes to come into the hospital for an emergency).  So, I made the executive decision to pull the anesthesiologist from the elective suboccipital craniotomy case to do the emergency.  It was a crani to crani and neuro to neuro switch… meaning the neuro team and crani trays were already open and ready to go.  It made the most sense in my mind.  Of course, without missing a beat, the “elective” neurosurgeon showed complete disdain of my decision.  To add fuel to the fire, he proceeded to berate the OR nurses, myself, and staff to make sure his displeasure was known.  I stood by my decision because it was the best decision for the emergency craniotomy patient who could have potentially died.  Secondly, I chose not to call in my final anesthesiologist for an elective case as we would have gone on “trauma bypass”.  This means that no traumas or emergencies could come to our hospital.  The “elective” neurosurgeon became more livid by the minute.  2.5 hours after he was supposed to start his case, I finished my first case and was able to get his case started.

Now, who does an elective suboccipital craniotomy for tumor case on a Saturday?  Secondly, he decides to do this in a sitting position — this has it’s own sets of risks.  He needed a precordial doppler, which our hospital did not have, so we called for it from our neighboring sister hospital.  In the meantime, I had another plan…that was to put down a TEE probe to monitor for venous air embolism (VAE).  After speaking to the patient and family, I proceeded to explain the risks/benefits of arterial line, central venous line, transesophageal echo, mechanical ventilation, blood transfusion, and intensive care unit stay.  It’s always a lot for the family to comprehend, especially while meeting them for the first time.  However, it is our job as anesthesiologists to make them comfortable and calm their fears.

**This picture taken from a google search for “precordial doppler”.  It is not my own.**

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**This picture taken from a google search for “precordial doppler”.  It is not my own.**

We get to the room and proceed with vital signs monitoring.  Uneventful induction and intubation.  A right internal jugular vein central venous line is placed (mainly to use as a Bunegin-Albin catheter).   TEE probe placed to look for air in RV and possibly air lock and RV failure –> VAE.  Radial arterial line placed and transduced at the level of the head.  Pt was placed in Mayfield pins and positioned in steep sitting position with reverse Trendelenberg and flexing the legs up.  Neuromonitoring commenced looking for changes in sensory and motor signaling.

All throughout the case, the TEE showed various amounts of air coming through the right side of the heart:

IMG_6787.PNGWith greater amounts of air, there would be a detectable decrease in blood pressure as well as end-tidal CO2.  While the right ventricle was still capable of pushing blood forward, I simply increased the blood pressure pharmacologically and increased the patient’s volume with normal saline from the IV.  Rarely does one get to see this TEE view as most of these cases are monitored non-invasively via pre-cordial doppler or ETCO2 and BP.

Lastly, this patient had a great outcome.  A 2cm x 2 cm hemangioma was resected with minimal disruption or trauma to surrounding tissue.  2 hours after a lengthy 4 hour surgery, the patient was sitting with their family… communicating and interacting with them.  All motor and sensory intact.

Pearls from this case:

1) Always do what is best for the patient.  When a life-and-death situation presents itself, it gets priority.  Period.  It doesn’t matter what pressure or temper tantrums you get from outside parties.  Make the best clinical decision. Organize a plan.  Stick with it.

2) Find out the surgeon’s plan.  This case was not booked in sitting position.  Some of these cases are done in prone position, which makes the likelihood of VAE significantly lower than in sitting position.  Knowing the surgeon’s plan of attack is critical to an anesthetic plan.

3) Read. Read. And read more.  Although I’ve been out of residency and fellowship for 4 years, cases will always test your knowledge as well as make you learn new skills/techniques to better your plan.  Take the time to do your best.  Always review.  Medicine is a lifelong learning career.

4) Don’t sweat the small stuff.  The “elective” neurosurgeon who raised such hell at the beginning of the case was thanking me for my help and expertise by the end of the case.  Learn as much as you can from your residency.  Take the knowledge gained and let your clinical acumen do the talking.  There is no room for ego when taking care of a patient.  Your ability to be well-read, well-trained, and well-respected will dictate the tone.  No fluff is needed when you bring 100% to the table.  Don’t be intimidated by the loud bark.