Severe AS in rural icu

[The kitchen sink]

85 yo elderly M no prior recorded hx comes in in hypoxic respiratory failure due to volume overload. Mildly hypertensive. Ekg afib rvr, CXR pulmonary edema, TTE severe AS gradient > 65, area < 0.9, EF 40-45%
Admit to icu on bipap
Diuresed -8L over last few days , difficult to rate control as he is on off and bipap so can’t give PO meds with any consistency but has finally able to tolerate HFNC during daytime so started coreg and losartan per our in house cardiologist. Giving prn iv lopressor to keep HR < 110 but it just doesnt budge

Issue now is that he is slowly becoming alkalotic from the diuresis with bicarb of 44 and intravascularly deplete

What are the options for medical management here? He is getting dry but im worried he is still flashing with that high rate and tight valve and so thats why he can’t come off the bipap/hiflow. I feel like with better rate control, he will improve and auto diurese (normal cr). Is a trial of esmolol warranted? Should he go straight for tavr, or a balloon angioplasty or is he is still too unstable? That would require transfer to a tertiery care center. We only do diagnostic caths here

Thanks for the advice

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[Full Metal IC]

Sick patients with severe AS are notoriously difficult to manage medically. In this case your patient has LV systolic dysfunction as well. Bad combination. Overall, if the patient hasn't improved significantly with diuresis and reasonable attempts at rate control, based on the given information the likelihood that he leaves the hospital without a valve is very low.

If this is an otherwise viable person, reconvene with your cardiologist about getting him to a TAVR-capable center. In the meantime, amiodarone can be very helpful in this scenario to help with rate control which may help stabilize the patient a bit more, but rate control alone probably will not turn him around completely given the underlying HFrEF and severe AS. I would personally avoid IV beta blockers all together if possible in a case like this to avoid worsening the patients hemodynamics.

Obligatory this isn't medical advice.

 

[The kitchen sink]

Sick patients with severe AS are notoriously difficult to manage medically. In this case your patient has LV systolic dysfunction as well. Bad combination. Overall, if the patient hasn't improved significantly with diuresis and reasonable attempts at rate control, based on the given information the likelihood that he leaves the hospital without a valve is very low.

If this is an otherwise viable person, reconvene with your cardiologist about getting him to a TAVR-capable center. In the meantime, amiodarone can be very helpful in this scenario to help with rate control which may help stabilize the patient a bit more, but rate control alone probably will not turn him around completely given the underlying HFrEF and severe AS. I would personally avoid IV beta blockers all together if possible in a case like this to avoid worsening the patients hemodynamics.

Obligatory this isn't medical advice.

Thanks for the advice.

I absolutely agree, he’s not going home with a valve. Question is, can he get there?

 

[timpview]

Only

Thanks for the advice.

I absolutely agree, he’s not going home with a valve. Question is, can he get there?

One plus of working at a rural hospital is you don’t have to answer that question. Ship him and let them figure it out.. but I bet he can get tuned up and get through it… I too would have him on amio for now.

Though Seems like if he’s diuresed 8L and still that hypoxia something else may be in play as well.. leads to the other option of just letting the old guy go peacefully.

 

[deleted980918]

85 yo elderly M no prior recorded hx comes in in hypoxic respiratory failure due to volume overload. Mildly hypertensive. Ekg afib rvr, CXR pulmonary edema, TTE severe AS gradient > 65, area < 0.9, EF 40-45%
Admit to icu on bipap
Diuresed -8L over last few days , difficult to rate control as he is on off and bipap so can’t give PO meds with any consistency but has finally able to tolerate HFNC during daytime so started coreg and losartan per our in house cardiologist. Giving prn iv lopressor to keep HR < 110 but it just doesnt budge

Issue now is that he is slowly becoming alkalotic from the diuresis with bicarb of 44 and intravascularly deplete

What are the options for medical management here? He is getting dry but im worried he is still flashing with that high rate and tight valve and so thats why he can’t come off the bipap/hiflow. I feel like with better rate control, he will improve and auto diurese (normal cr). Is a trial of esmolol warranted? Should he go straight for tavr, or a balloon angioplasty or is he is still too unstable? That would require transfer to a tertiery care center. We only do diagnostic caths here

Thanks for the advice

AC/TEE/cardioversion to restore SR, although may not last long but potentially tune him up prior to transfer to tertiary care for a valve.

 

[chessknt]

Thanks for the advice.

I absolutely agree, he’s not going home with a valve. Question is, can he get there?

Are you asking if he will die in transport? Should be relatively straight forward on bipap wouldn't worry about that.

 

[The kitchen sink]

Are you asking if he will die in transport? Should be relatively straight forward on bipap wouldn't worry about that.

No more so if anyone is willing to fix his valve. Otherwise its hospice for him :/

 

[chessknt]

No more so if anyone is willing to fix his valve. Otherwise its hospice for him :/

I guess its local but where I am they TAVR people with dementia and metastatic cancer as long as their life expectancy is beyond the hospice level. Seems absolutely ridiculous to me for a procedure so expensive but there is no rationing of anything in this country. I imagine somewhere would take him to at least do an eval.

 

[aafisahar]

some things you can do to help if transfer is taking >24 hours, put in a central/swan, and diurese until the numbers look pretty. Agree with others, if he's dry as a bone and still hypoxic, look for alternative explanations.

in my experience, these types of patients need to either **** or get off the pot, eg either put in a valve or put him on hospice. If he has critical AS and a bad ventricle, this might be as good as it gets. They aren't going to looking like the ambulatory TAVR that IC/surgery wants them to be. Sometimes, you just got to bite the bullet and do it.

 

[end stage fibro]

these types of patients need to either **** or get off the pot, eg either put in a valve or put him on hospice.

I think this sums it up.

Also agree with everyone mentioning a secondary cause. Pulm htn too far gone?

Also, though a drop in the ocean, would be hitting this guy with all you can eat KCl for the alkalosis

 

[deleted980918]

If TAVR turned down, consider BAV for the time being and see how he does with a improved gradient. If symptoms improved along with his other comorbidities, can then bridge to TAVR in a more controlled setting.

 

[Chemist0157]

If you still think he needs diuresis but are concerned about the alkalosis, you can give KCl. The alkalosis in this setting is from chloride depletion, rebalancing with bicarbonate. Pendrin channel stuff. I occasionally use acetazolamide.

 

[Beeftenderloin]

Why not dig load for a-fib control, even if just to temporize til they can get an intervention? Will help his ventricle too.

 

[The kitchen sink]

If TAVR turned down, consider BAV for the time being and see how he does with a improved gradient. If symptoms improved along with his other comorbidities, can then bridge to TAVR in a more controlled setting.

Yes BAV is definitely another option we are exploring.

 

[The kitchen sink]

Why not dig load for a-fib control, even if just to temporize til they can get an intervention? Will help his ventricle too.

Done, over the weekend we did that good results

 

[The kitchen sink]

I think this sums it up.

Also agree with everyone mentioning a secondary cause. Pulm htn too far gone?

Also, though a drop in the ocean, would be hitting this guy with all you can eat KCl for the alkalosis

Issue is his persistent infiltrates, and mixed hypoxic/hypercapneic respiratory failure. PASP is mild, and RV systolic function is relatively preserved.

Other causes are being worked up. He was treated for CAP.
Vasculitis panel negative. Low suspicion given normal Cr and no proteinuria on UA.

A swan/RHC may be indicated here.

 

[The kitchen sink]

some things you can do to help if transfer is taking >24 hours, put in a central/swan, and diurese until the numbers look pretty. Agree with others, if he's dry as a bone and still hypoxic, look for alternative explanations.

in my experience, these types of patients need to either **** or get off the pot, eg either put in a valve or put him on hospice. If he has critical AS and a bad ventricle, this might be as good as it gets. They aren't going to looking like the ambulatory TAVR that IC/surgery wants them to be. Sometimes, you just got to bite the bullet and do it.

I think we are up to the point of placing a swan bc he appears euvolemic and he is becoming alkalotic.

Tertiery care IC thinks his resp status is too tenuous, and would need intubation for transfer/TAVR. He does not need intubation at all. As for whether he needs it for the procedure, I would defer to the IC and anesthesiologist performing the procedure.
If I get nowhere with the cardiology team, I will speak to a CT surgeon about TAVR.
He is DNR/DNI. Family discussions ongoing.

 

[greatnt249]

I think we are up to the point of placing a swan bc he appears euvolemic and he is becoming alkalotic.

Tertiery care IC thinks his resp status is too tenuous, and would need intubation for transfer/TAVR. He does not need intubation at all. As for whether he needs it for the procedure, I would defer to the IC and anesthesiologist performing the procedure.
If I get nowhere with the cardiology team, I will speak to a CT surgeon about TAVR.
He is DNR/DNI. Family discussions ongoing.

His being DNR/DNI and still considering valve replacement would seem to be conflicting viewpoints. Just because TAVR is not open-heart surgery does not mean TAVR is a benign procedure.

At any rate, ischemic heart disease should also be in differential.

 

[chessknt]

His being DNR/DNI and still considering valve replacement would seem to be conflicting viewpoints. Just because TAVR is not open-heart surgery does not mean TAVR is a benign procedure.

At any rate, ischemic heart disease should also be in differential.

Strongly disagree, doing CPR in an 85 year old, especially one who is critically ill is borderline malpractice. It doesnt matter if his heart stops in the cath lab or on a helicopter it is equally futile everywhere. It has never made sense to me that someone cant be allowed to die mid procedure, only afterwards not under your care as a profoundly obstinate and detrimental approach to patient care. If you are going to offer them something talk about the risks, one of which always includes perioperative death, but respect their damn wishes, dont try to override their autonomy with your own biases about what is appropriate (not you specifically, just the generic proceduralist/surgeon/anesthesiologist etc that insist on temporary reversal of code status).

If swans are not commonly used there then the only accurate set of numbers you are going to get are the first ones. Might as well just do a RHC and not leave something useless in his neck.

If wedge is low and infiltrates are bilateral and c/w ARDS review his hx to see if he has any of the ARDS risk factors (? blood transfusions, minor trauma, abdominal surgery)--these might take a while to get better. If you dont have a CT get one--CXR is absolute **** for looking at lung pathology, could be underlying fibrosis everyone is just calling edema because of the clinical scenario.

As for not needing intubation what his need for oxygenation exactly? Sitting on 100% HFNO with no reserve is not acceptable for transport because there is no rescue modality. Being NIPPV dependent is even worse.

 

[Beeftenderloin]

Strongly disagree, doing CPR in an 85 year old, especially one who is critically ill is borderline malpractice. It doesnt matter if his heart stops in the cath lab or on a helicopter it is equally futile everywhere. It has never made sense to me that someone cant be allowed to die mid procedure, only afterwards not under your care as a profoundly obstinate and detrimental approach to patient care. If you are going to offer them something talk about the risks, one of which always includes perioperative death, but respect their damn wishes, dont try to override their autonomy with your own biases about what is appropriate (not you specifically, just the generic proceduralist/surgeon/anesthesiologist etc that insist on temporary reversal of code status).

I don’t necessarily agree with this across the board. The reason we (anesthesia) like to have DNRs suspended perioperatively is because things happen in the OR that can be rapidly reversed. This isn’t some out of hospital cardiac arrest with unknown down time found by some lay person. This is someone being continuously monitored who has zolls on and a defibrillator an arms length away. I had a recent TAVR where the patient coded twice (once from a wire/catheter tickling the ventricle the second from hypotension from rapid pacing at the time of deployment). No chest compressions, no broken ribs, just defib x2 and on with the procedure. These are known risks that we are well prepared for. But I can’t press that shock button if the’re DNR…

 

[The kitchen sink]

Strongly disagree, doing CPR in an 85 year old, especially one who is critically ill is borderline malpractice. It doesnt matter if his heart stops in the cath lab or on a helicopter it is equally futile everywhere. It has never made sense to me that someone cant be allowed to die mid procedure, only afterwards not under your care as a profoundly obstinate and detrimental approach to patient care. If you are going to offer them something talk about the risks, one of which always includes perioperative death, but respect their damn wishes, dont try to override their autonomy with your own biases about what is appropriate (not you specifically, just the generic proceduralist/surgeon/anesthesiologist etc that insist on temporary reversal of code status).

If swans are not commonly used there then the only accurate set of numbers you are going to get are the first ones. Might as well just do a RHC and not leave something useless in his neck.

If wedge is low and infiltrates are bilateral and c/w ARDS review his hx to see if he has any of the ARDS risk factors (? blood transfusions, minor trauma, abdominal surgery)--these might take a while to get better. If you dont have a CT get one--CXR is absolute **** for looking at lung pathology, could be underlying fibrosis everyone is just calling edema because of the clinical scenario.

As for not needing intubation what his need for oxygenation exactly? Sitting on 100% HFNO with no reserve is not acceptable for transport because there is no rescue modality. Being NIPPV dependent is even worse.

Hes on 50% fio2 / 50 lpm HFNC now after diuresis

CT chest consistent with bilateral GGO opacities (wide differential obviously)

 

[The kitchen sink]

His being DNR/DNI and still considering valve replacement would seem to be conflicting viewpoints. Just because TAVR is not open-heart surgery does not mean TAVR is a benign procedure.

At any rate, ischemic heart disease should also be in differential.

And if he is willing to reverse it for the procedure?

 

[greatnt249]

And if he is willing to reverse it for the procedure?

That's all fine and good; we do that all the time for procedures. The intention of my previous post was to bring to light that goals of care need to be brought into the discussion; I can't tell you how many times I've had people referred to us for TAVR evaluation where the patient arrives under the impression that we're just going to "pop in" a valve or that the process will happen quickly and/or without risk of morbidity, or that their lives will be magically better in an instant.

Strongly disagree, doing CPR in an 85 year old, especially one who is critically ill is borderline malpractice. It doesnt matter if his heart stops in the cath lab or on a helicopter it is equally futile everywhere. It has never made sense to me that someone cant be allowed to die mid procedure, only afterwards not under your care as a profoundly obstinate and detrimental approach to patient care. If you are going to offer them something talk about the risks, one of which always includes perioperative death, but respect their damn wishes, dont try to override their autonomy with your own biases about what is appropriate (not you specifically, just the generic proceduralist/surgeon/anesthesiologist etc that insist on temporary reversal of code status).

If swans are not commonly used there then the only accurate set of numbers you are going to get are the first ones. Might as well just do a RHC and not leave something useless in his neck.

If wedge is low and infiltrates are bilateral and c/w ARDS review his hx to see if he has any of the ARDS risk factors (? blood transfusions, minor trauma, abdominal surgery)--these might take a while to get better. If you dont have a CT get one--CXR is absolute **** for looking at lung pathology, could be underlying fibrosis everyone is just calling edema because of the clinical scenario.

As for not needing intubation what his need for oxygenation exactly? Sitting on 100% HFNO with no reserve is not acceptable for transport because there is no rescue modality. Being NIPPV dependent is even worse.

Chest compressions aren't the only part of a resuscitative effort, and as was pointed above, periprocedurally things can go downhill quickly but also be reversed quickly. I think the intent of my post was misunderstood; what I really meant was the patient really needs to know what they're getting themselves into, and as I mentioned above, just because TAVR is not open-heart surgery does not make it by default a benign procedure; oftentimes patients have the impression that because it is a catheter-based procedure that associated morbidities just disappear, and many times I can't tell if they came to that conclusion on their own or whether the referring doctor made it sound like it was quick and easy.

I can respect a patient's wishes insofar that they respect the opinion of the proceduralist they're asking to take on the procedure. In no way did I say this patient wasn't a TAVR candidate, just that the goals need to be aligned.

Also, I'm curious if we have more information about the valve than what was given (ie peak velocity, is 65 mean or peak gradient, what was LVOT diameter). Reason I ask is if we've truly clarified if the patient has severe aortic stenosis; it wouldn't be the first time that mismeasurements on the echocardiogram have made a valve look worse than it actually is.

 

[The kitchen sink]

That's all fine and good; we do that all the time for procedures. The intention of my previous post was to bring to light that goals of care need to be brought into the discussion; I can't tell you how many times I've had people referred to us for TAVR evaluation where the patient arrives under the impression that we're just going to "pop in" a valve or that the process will happen quickly and/or without risk of morbidity, or that their lives will be magically better in an instant.



Chest compressions aren't the only part of a resuscitative effort, and as was pointed above, periprocedurally things can go downhill quickly but also be reversed quickly. I think the intent of my post was misunderstood; what I really meant was the patient really needs to know what they're getting themselves into, and as I mentioned above, just because TAVR is not open-heart surgery does not make it by default a benign procedure; oftentimes patients have the impression that because it is a catheter-based procedure that associated morbidities just disappear, and many times I can't tell if they came to that conclusion on their own or whether the referring doctor made it sound like it was quick and easy.

I can respect a patient's wishes insofar that they respect the opinion of the proceduralist they're asking to take on the procedure. In no way did I say this patient wasn't a TAVR candidate, just that the goals need to be aligned.

Also, I'm curious if we have more information about the valve than what was given (ie peak velocity, is 65 mean or peak gradient, what was LVOT diameter). Reason I ask is if we've truly clarified if the patient has severe aortic stenosis; it wouldn't be the first time that mismeasurements on the echocardiogram have made a valve look worse than it actually is.

Peak > 65, mean > 40, valve area 0.9, no report on LVOT diameter

 

[chessknt]

I don’t necessarily agree with this across the board. The reason we (anesthesia) like to have DNRs suspended perioperatively is because things happen in the OR that can be rapidly reversed. This isn’t some out of hospital cardiac arrest with unknown down time found by some lay person. This is someone being continuously monitored who has zolls on and a defibrillator an arms length away. I had a recent TAVR where the patient coded twice (once from a wire/catheter tickling the ventricle the second from hypotension from rapid pacing at the time of deployment). No chest compressions, no broken ribs, just defib x2 and on with the procedure. These are known risks that we are well prepared for. But I can’t press that shock button if the’re DNR…

Right but as soon as chest compressions start your outcome starts to become much darker. You can code him for 10-30 minutes to reverse your perioperative accudent isnt going to change the underlying devestation caused by the cardiac arrest and if it is against their wishes to be in such a compromised state I think it is shameful to not let them die without the prolonged icu course after a ‘successful’ resuscitation if it wasn’t in alignment with their wishes.

I have definitely seen the long perioperative code in the reversed code status patient who had a lot of inhumane things done to him afterwards. Soured me on the entire idea beyond a brief attempt.