Today was an ordinary day. Come in for a minimally invasive aortic valve and call it a day. However, that case was cancelled secondary to UTI. So, I opted to get involved in a different case…. an epicardial lead placement. This was a gentleman I’ll refer to as Mr. Chill. He was getting an epicardial lead placement b/c he was in heart failure and was going to undergo CRT. He already had RA/RV leads and AICD. He was a rather obese gentleman (280lb, 5’6″). He had a history of amphetamine induced cardiomyopathy with an EF of 18%, inferior wall infarct and ant-sept wall infart, LV dilatation. There was noted coronary sinus stenosis hence the need to abandon a coronary sinus lead and just go for the epicardial lead that would be placed via thoracotomy. Aside from his heart history, he also had DM, HTN, AFib, sleep apnea (not using CPAP). He’s on a whole host of meds… preop echo showed EF20%, severely decreased LV systolic function, hypokinesis of LV/RV, mild MR/TR, mod pulm HTN.
I met Mr. Chill in the pre-op holding area while a resident and CRNA were attempting to place PIV. I took a look and you really can’t see anything. So, while they were bringing the U/S, I was able to get a 22G PIV — not worthy of cardiac surgery…but worthy for induction. A right radial a-line was placed with some difficulty (imagine poor EF…difficult to feel pulsatility anywhere). The AICD rep was supposed to be available, but was running late so we were given the green light to go back to the OR. The reason he earned the name Mr. Chill was b/c he was very relaxed and very interactive with us during PIV and a-line. Every now and then he’d doze off, but then we’d say his name and he’d wake back up and interact with us. I’m thinking that’s probably a combo of his OSA and his low flow state.
We brought him back to the OR, placed monitors on him. The EKG appeared to be a wide complex regular sinus rhythm…someone who appeared to have a LBBB. His a-line was reading 110-110SBP. We were pre-oxygenating him for awhile. Induction: lido 100mg, fentanyl 150mcg, etomidate 20mg, roc 70mg…after induction he stayed in the SBP90s. Slowly, he started to drift down while taking over mask ventilation. Luckily, he was an easy mask. Now his SBP 80s, we intubate with a L DLT. Confirmed with ETCO2. SBP hanging in the 70s…multiple boluses of phenylephrine (total 600mcg), ephedrine (30mg), epi (100mcg) the SBP would go up to low 80s, but come back down to 70s. We checked the DLT via FOI…it seemed a bit deep, therefore we pulled it back. Still, we weren’t happy with it and his SBP was sagging, therefore, we took out the DLT and reintubated with an 8.0ETT. Pt was oxygenating well as the SpO2 read 96-98%. Then, his radial aline went to 60s. We cycled NIBP that showed 50s/20s. Then the art line went flat. We started CPR, 1mg EPI followed by atropine. With CPR, the arterial trace looked good reading a pressure in the 80s. PEA was suspect…we ran serial ABG, got femoral access. We came out of it. First ABG showed CO2 70s…ETCO2 was in the 40s. We hyperventilated him and started him on an epi infusion. The AICD rep interrogated his AICD…and we found out that the patient had 4 episodes of VT that was treated by overpacing from the AICD (not shocks). This occurred in the pre-op area prior to going back to the OR and lasted for 35 seconds total.
We cancelled the case and took the patient to the SICU.
Things I took away from this case:
1) Always have the AICD rep interrogate prior to going to OR. Period. It doesn’t matter if everyone in the OR wants you to go… it’s worth waiting. Obviously, Mr. Chill didn’t show any signs of VT to us b/c we were with him in the pre-op area. There were no shocks delivered from the AICD. Had I known he had 4 consecutive VT episodes that were worthy of AICD treatment via pacing, I’d have cancelled the case prior to going back to the OR. Done!
2) With an EF hanging around 10%, this guy is probably living off his sympathetic tone. Do NOT give fentanyl, even if you think he may get tachycardic from the intubation. Give it as it’s needed…even though it’s “cardiac stable”. No one is stable with an EF10%. The last thing I want to do is decrease any tone that may be supporting him. (Sure, maybe it’s a placebo for me… so be it!)
3) This guy’s PEA was most likely caused by hypercarbia. He had a history of OSA and would intermittently fall asleep in the pre-op holding area… he may have been hypoventilating. We didn’t see it on the ETCO2 trace while masking him b/c he probably has a large A-a gradient (ETCO2 registered on our monitors was 45). His lungs are getting well ventilated…but his circulation time is so slow that he’s underperfused. Dead space… and a lot of it.
4) For a guy like this, make sure surgeon and perfusionist are present in the room on induction. They were present here…just an FYI.
5) R2 pads are always good to have in place, just in case. Yes, this guy has an AICD… but at some point the treatment/shock mode will be turned off for the surgery.
6) Go with your gut instinct. If your gut is telling you that he needs some beta activity to get the heart jumpy enough to tolerate induction… then do it.
7) Be a calm, cool cucumber during the resuscitation. Our team did a fabulous job of communicating and getting things done… all b/c of clear, concise communication. It really does make a difference.
8) Debrief. This helps get everything on the table and brainstorm what could have been done differently or better. We’re all colleagues; no one has room to pass judgment. Ever. (If they do, take’em out back and kick ’em in the shins!)