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.


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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

heartware-hvad-7x4

HeartWare brochure

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

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HeartMate II

heartmate-index_1

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!

Intraoperative cystoscopy and ureteral visualization

Over the years, I’ve been asked to inject various dyes to help light up the urine for visualization of the ureters.  Now, we’ve moved to fluorescein because it “lights up” quicker than other previous dyes.  Why are we always switching?  Drug shortages.

Dosing: 0.25 – 1.0 ml of 10% preparation of sodium fluorescein

Dose: 5 ml. bolus of 10% fluorescein intravenously.

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.**

IndianJAnaesth_2012_56_5_502_103979_u2

**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.

TAVR Team: conscious sedation vs. general anesthesia

Today, we had a guest speaker Christian Spies from Queen’s Hospital in Hawaii who spoke on his experience with his TAVR team and conscious sedation vs. general anesthesia for these patients.  More specifically, we are speaking of the transfemoral route.

Keypoints:

  • Patient selection is key (consider for COPD; bad for OSA)
  • Short surgical time for monitored anesthesia care (MAC)
  • Decrease invasive monitoring (no PA catheter,+/-CVP)
  • No difference in hospital LOS or 1 year mortality rate
  • Move from TEE to TTE if MAC
  • Be prepared to convert MAC to GA (can be difficult in already tenuous patient in a crowded space under the drapes)
  • MAC agents: dexmetetomidine, propofol, ofirimev
  • Decrease pressor use
  • Develop an algorithm for MAC vs. GA and patient selection

From goinggentleintothatgoodnight.com

For my own lit search:


***Update May 1, 2018***

We at Scripps Memorial Hospital in La Jolla do most of our transfemoral TAVRs via conscious sedation assuming appropriate patient selection.  These patients still tend to be the inoperable patients not cleared for open heart AVR (aortic valve replacement).  My techniques and choices for setup have changed over time as I’ve had a chance to fine-tune my plan based on prior experiences with TAVR.  Patients typically come to the hybrid room with a 20g PIV placed by the pre-op RN.

My Setup:

  • 4 channel Alaris pump:
    • dexmedetomidine @ 0.7 mcg/kg/hr until incision –> 0.4 mcg/kg/hr until valve deployment –> off
    • norepinephrine @ 2 mcg/min (titrating on/off, up/down as vitals suggest)
    • Isolyte (IV carrier fluid) @ 200ml/hr until valve deployment –> 50ml/hr
  • Cordis neck line
    • Initially, I would have the interventional cardiologist setup a femoral venous line since they’re getting access to the groin.  However, the cardiologist would use that femoral line for emergent ECMO cannulation and I would lose my venous access and have to depend on a measly 20g PIV.  Nowadays, I try for a short 14g or 16g PIV.  If I can’t get one, the patient gets an awake right IJ cordis for large venous access.
  • Hot line fluid warmer with blood-Y tubing: this is for hookup to a large PIV or cordis line
  • Right radial arterial line
    • I started only placing right radial arterial lines because there was a case of a dissection and I immediately lost my left radial arterial line and couldn’t do pressure monitoring.  I insist on only using the RIGHT radial for my arterial monitoring.  Do not let the cardiologist only give you arterial monitoring based on their femoral arterial access.  It will only give you intermittent monitoring and there are critical points leading up to the deployment where you need CONTINUOUS arterial monitoring.  Therefore, I’ve found the right RADIAL arterial line best for continuous monitoring.
  • Facemask for continuous oxygen at 10L/mim with ETCO2 monitoring
  • For trans-subclavian/axillary approach vs. transfemoral approach TAVR, I’ll put in a supraclavicular block right after Cordis/large-bore PIV venous access for patient comfort while still utilizing conscious sedation/MAC.

My Technique:

  • When the patient gets to the room, transfer patient to OR table.  Start IV fluids @ 200ml/hr.  Cases that go well are about 2 hours from start to end.
  • Facemask O2 at 10L/min.
  • Start sedation: precedex/dexmedetomidine @ 0.7 mcg/kg/hr.  Some patients may receive 1-2mg midazolam x 1 and 25-50mcg fentanyl for radial art line placement.
  • Place right radial art line with lidocaine for skin numbing.  Place PIV with lidocaine.  If unable to get access for PIV, prep neck –> sterile gown/glove/drapes for U/S guided Cordis placement with lidocaine.
  • OR staff preps patient.  Antibiotics prior to incision.
  • At incision –> precedex to 0.4 mcg/kg/hr.  25-50mcg fentanyl PRN discomfort. 10-20mg propofol push for discomfort if needed while large sheath placed for valve deployment.
  • Crossing valve –> BP changes.  Manage with volume or levophed.
  • Valvuloplasty
  • Don’t treat over-drive pacing too aggressively when the valve is deployed.  Typically, once the new valve is in, a little volume will help normalize the BP.
  • Once valve is deployed, turn precedex off.  No other sedation or BP meds needed.  Change IVF rate to 50ml/hr.
  • Patient heads to PACU awake, interactive, and comfortable.

What techniques do you like to do?  Any suggestions on a different approach?