ST changes

subee, MSN, CRNA · Sep 15, 2006

Just wanted to get some feedback from other CRNAs on how they would handle this situation: Pt presents from ER for Lap Chole. Pt has flank and abdomenal pain. Past medical hx of GERD and HTN or which he had not taken his labatolol in 2 days. Preop he was hypertensive in the 170's/110 area. Treated in pre-op area with Fentanyl 50mcg for pain and Labatolol IV 20mg in 5 mg increments over 20min prior to OR. On induction RSI with Cricoid technique. 7.5 ett placed and Desflurane used. Induction was without incidence. BP post induction 130's/70's. Within 5min post induction noticable st changes in lead II and V (inversion in II and elevation in V). The anesthetic was deepended and 10mg of Morphine given without any improvement. BP dropped to 60-70/40-50 and 100mcg of neo was given with moderate improvement. Surgeon was notifiied of ST segment changes and saw the ECG tracing on the monitor. He consulted with his attending on the phone and decided to cancel the case since this was not emergant. A nitro infusion was started and over a period of 5min the ST segments began to return to baseline. An intraop EKG was done that showed no sign of ischemia. The patient was emerged from anesthesia and transported to PACU were he remained stable. Cardiac enzymes were sent and were negative. Of note I did not cancel the case but rather the surgeon, however I feel as if my clinical judgement is brought into question by fellow staff especially since I am a new nurse anesthetist. What would you have done?[/quote
By line 4 this patient'w profile was already making me question what the big rush was. This was NOT an emergent case and the BP was dangerously high.
I have never seen a lap. chole. done on a patient from the ER! This patient should have been cleared by cardiology before surgery during which time his BP could be lowered gradually and give you more data about what you're actually dealthing with here.

jwk · Sep 16, 2006

Just wanted to get some feedback from other CRNAs on how they would handle this situation: Pt presents from ER for Lap Chole. Pt has flank and abdomenal pain. Past medical hx of GERD and HTN or which he had not taken his labatolol in 2 days. Preop he was hypertensive in the 170's/110 area. Treated in pre-op area with Fentanyl 50mcg for pain and Labatolol IV 20mg in 5 mg increments over 20min prior to OR. On induction RSI with Cricoid technique. 7.5 ett placed and Desflurane used. Induction was without incidence. BP post induction 130's/70's. Within 5min post induction noticable st changes in lead II and V (inversion in II and elevation in V). The anesthetic was deepended and 10mg of Morphine given without any improvement. BP dropped to 60-70/40-50 and 100mcg of neo was given with moderate improvement. Surgeon was notifiied of ST segment changes and saw the ECG tracing on the monitor. He consulted with his attending on the phone and decided to cancel the case since this was not emergant. A nitro infusion was started and over a period of 5min the ST segments began to return to baseline. An intraop EKG was done that showed no sign of ischemia. The patient was emerged from anesthesia and transported to PACU were he remained stable. Cardiac enzymes were sent and were negative. Of note I did not cancel the case but rather the surgeon, however I feel as if my clinical judgement is brought into question by fellow staff especially since I am a new nurse anesthetist. What would you have done?[/quote
By line 4 this patient'w profile was already making me question what the big rush was. This was NOT an emergent case and the BP was dangerously high.
I have never seen a lap. chole. done on a patient from the ER! This patient should have been cleared by cardiology before surgery during which time his BP could be lowered gradually and give you more data about what you're actually dealthing with here.
1) We see a fair number of "urgent" lap chole's - people with rotten gallbladders that they've ignored, and now present with lots of belly pain, fever, etc.
2) 170/100 is not what I'd term "dangerously high", and in a non-compliant hypertensive patient who probably has lots of pain from his gallbladder, that pressure doesn't surprise me at all.
3) Given the preop history, GERD and hypertension, there is no indication for a cardiology clearance.
4) Not sure why one would deepen the anesthetic when signs of ischemia show up, particularly with desflurane. What was the heart rate during all this time? That hasn't been mentioned yet.

UCDSICURN · Sep 17, 2006

Who's questioning you for being an advocate for the patient? There were changes and you brought them to the attention of the surgeon, who after consultation with another surgeon cancelled the surgery. ST changes/flipped T's. Patient condition definately changed. Sounds like common sense prevailed here. Why risk an intra or post-op MI over an emergent, but not really that emergent chole.

Tranman · Sep 19, 2006

Just wanted to post some generalizations here. Well of course we are all here to advocate for the patient. Unfortunately some of us disagree with one another on how to handle situations like this in the OR. UDSCIRN, don't know if you know the politics of the OR or not. Although it shouldn't matter if cases get cancelled or not, and the patients safety should always come 1st, this is not the reality in many ORs. Frankly I'm surprise the Surgeon cancelled. Many times, surgeons will press Anesthesia to do cases despite putting the patient at risk (low platelets, high coags, low hbg, no cardiac clearance in patients who report recent CP, c-spine fx not yet cleared by nuero, etc).

It is likely, the Resident's decision to call the attending may have been influenced by what bwt02 told him. He could have simply stated that the patient is having ST changes and despite not having BP problems, the ST changes remain. Or he could have said the same and added, and I strongly reccommend we not proceed with this case. Surgeons (and even more so, residents) know very little or next to nothing about anesthesia and rely heavily on our expertise in these situations. And this is where it gets a little confusing. Where 1 anesthesia provider may encourage the surgeon to cancel a case, another may not. Of course cancelling is always safetest b/c there is no continued risk of agitating a stress heart. I'm not sure what was said in this situation.

At my last job, I did not find it neccessary to cancel not 1 case over a year. But a colleague routinely cancel cases. Does that make me a not safe practitioner over my ultra conservative colleague? That's debateable with lots of gray here. Surgeons appreciate us looking out for them, b/c no one wants a bad outcome or to get sued. But cancel too many cases and they get really really upset with anesthesia.

BWT02, letting a surgeon know what's happening with the patient is never a wrong move. Stating them in such a way to manipulate a surgeon's decision is wrong. Now I'm sure you didn't do this, but I have witness CRNAs and MDAs do this to delay and cancel cases. so let's look at the case more specifically. Talk to your colleague and remind them that it was the surgeon who cancelled the case not you, and that you merely brought the patients status to the resident's attention.

I understand that the patient has not been taking his labetalol and that you wanted to get him normotensive prior to surgery. Not bad judgement, but obviously this (I believe) lead to his drastic BP drop after induction. I am suprise that it wasn't immediately after induction. Sounds like this along with the 10mg of MS and deepening the anesthetic didn't help your situation either.

1st, in over 4 yrs of being a CRNA, I haven't had the pleasure of having ST changes post induction. I have had on occassion seen it intra-op and it was always due to a low BP problem and gone after BP was brought up. I have also never given labetalol preop much less 20mg. 20 mg post op max and that was on very rare occasions. Labetalol, like hydralazine can peak in 15-20 mins and can add to the HPN of induction. This is why I'm surprised that his BP was 130 sys post induction, unless you only gave 100mg of Propofol at induction.

Not 2nd guessing you here, but it is possible that his BP was in the 60's which cause the ST changes and only after you saw the ST changes did the BP cuff cycle to reveal his true BP (60's systolic). If this is the case, giving 10mg of MS and deepening the anesthetic is not the right decision b/c it can only worsen the situation. I seriously doubt that the 10mg of MS had anything to do with his HPN though. MS usually takes a good 15min to peak. By deepening the anesthetic, I assume you turned up the gas. Depending on what you use, it takes at least 5 mins before that extra gas can get on board and cause that severe of HPN. It is likely the HPN is due to that labetalol peaking and then aggravated by the extra gas and dehydration. Keep in mind most patients come to the OR dehydrated from not having fluids since the night before.

At a systolic of 60 and ST changes, I would have given more than 100ug of Neo followed by lots of fluid if there are no contraindications to the fluid. 200ug of Neosynephrine and depending on the HR, 5mg of ephedrine to follow as well. I know you said that you hung NTG and that it help after 5 min, so I assume that the BP was within normal limits prior to hanging the NTG. NTG is good for VD of coronaries, but if his ST changes was due to low BP (HPN) which I believe it is, then a NTG gtt, depending on the dose, can actually worsen the problem here. If only after bringing up the BP with VPs and fluids and the ST changes do not improve and the patient is also not Tachy, then I would consider low dose NTG. This may be the case, I don't know.

So back seat driving and Monday quarterbacking is always easier. :rolleyes: acknowledged. What I would have done.... Not given the labetalol preop or at least not 20mg. Setting yourself up for trouble here. a few mg of metoprolol is a better choice. 50ug of Fent and 1-2mg of versed is ok. I agree with JWK, about this patient being an appropriate candidate for surgery and no need for the cardiac clearance. Just curious BWT02, how old is this patient and any Hx of CP, cardiac issues/sx, etc?

If he is older (50's +), only 50ug of Fent for induction, since he had 50 already. 150 mg of Prop, no more. Open up the fluids. Don't give him a lot of gas. Usually prep time takes a while and many many dehydrated patients have precipitous drops in BP during this time d/t to lack of stimulation. Give neosynephrine to keep the BP up and you should be able to avoid post induction ST changes.

I'm glad the EKG, labs, etc were all negative. Count yourself lucky, get what you can out of it and move on. It's a good learning experience.