I would appreciate the opinions of my colleagues on an intriguing case I encountered a couple of weeks ago. I was called to see a 63 y.o. male who was involved in a motor vehicle accident with resultant blunt chest and abdominal trauma. He had fractures of the right 4th through 10th ribs, and was hypotensive on arrival to the ED with a systolic BP hovering in the 70's. Paracentesis was positive for gross blood, and the patient was taken immediately to the OR, where exploratory lap demonstrated a small liver laceration, a splenic laceration,and multiple small mesenteric tears. He underwent splenorrhaphy, repair of the mesenteric tears, and hemostasis of the small liver lacerations was obtained. Throughout the OR time, his systolic BP never rose above 90.
The patient was transported to the ICU in hypotensive condition, with SBP hanging around 70-80. He was still intubated and was placed immediately on mechanical ventilation via A/C mode, rate 20, fIO2 100%, VT 900 or so. I happened to be rounding on the unit, and when I walked past this gentleman shortly after his arrival in the ICU, finding him in Trendelenburg position, I was asked by the trauma surgeon to assist in his management.
Physical exam revealed a pt with BP 70/40, HR about 140 (sinus), with an obviously swollen face and neck. There was no tracheal deviation. Coarse rhonchi were present bilaterally, and there was no appreciable difference in breath sounds right compared to left. The abdomen was mildly distended but not tense.
An EKG was performed either in the ED (pre-op) or in the ICU (memory fails me at this moment), demonstrating acute ST segment elevation in the inferior leads, consistent with acute inferior MI.
A Swan-Ganz catheter had been placed in the OR, which demonstrated PA pressures of 50/35, PAWP of 25, and a CVP of 30. The patient came to us on dopamine and epinephrine drips, running rapidly. His initial ionized calcium was 3.7, and this was supplemented with three amps of calcium chloride. The ABG showed a fairly profound metabolic acidosis, with the pH 7.07, and the pCO2 42. pO2 was 80-something.
The patient remained hypotensive. PIP's reached 70 cm H20 on assist-control ventilation, so the patient was changed to pressure control beginning with a set pressure of 40 cm. There was an immediate drop in tidal volumes, with resultant hypoxia. The set pessure was progressively increased until adequate tidal volumes were achieved (the patient ended up requiring a set pressure of 54 cm to avoid hypercarbia and hypoxia). The patient was noted to develop subcutaneous air on the right chest, and a tube thoracostomy was placed by the Trauma service, with about 500 ml of bloody effusion, but no persistent air leak. A stat portable CXR was obtained, demonstrating the chest tube in good position, but no pneumothorax.
The pt remained hypotensive, despite the dopamine and epi (and the addition of levophed), and rapidly arrested. There ensued two hours of intermittent CPR, continued pressors, attempts at correcting the acidosis within reason, and ensuring all the lytes were reasonably normal. Ultimately, the patient did not survive.
Sam Tisherman:
First of all, this patient's ongoing hypotension should have been more aggressively addressed prior to his arrival in the ICU. By the time he got to the ICU and had evidence of an MI and was in deep trouble, the ballgame was over.
This patient should have had a chest tube placed prior to the OR, solely based on the fact that he had multiple rib fractures and was going to be on machanical ventilation. A pneumothorax certainly could have caused his problem.
One modality that might have been very useful in the OR is transesophageal echo. This would have differentiated wall motion abnormalities from an MI or contusion from tamponade or just hypovolemia. We've found it very useful when the PA catheter doesn't give us all the answers.
Ken Mattox:
Sorry, but the TEE has been extremely over rated. It has NEVER been useful in causing me to change any diagnosis or treatment mode. Be careful with marrages to this technology in search of an indication. Otherwise, several things come to mind. Did Dr. Stanley Kline see the patient and what was his opinion? He could of had some blunt cardiac trauma with myocardial depression (one should NOT use the term myocardial contusion any more) and I would have inserted an intra-aortic counterpulsation balloon in the OR right after the Swan readings were obtained. THe wide open epi and nor-epi made him worse and you could have switched to Inocore. You did not mention his temperature. With the IABP and any improvement in urinary output and his acidosis, I would have accepted the blood pressure. THis is another example of over committment to BP as a monitor and making the patient worse with excessive alpha pressors, making the acidosis worse yet. cycles upon cycles.
Sam Tisherman:
Dr. Mattox's statement that TEE has NEVER been useful in causing him to change any diagnostic or treatment is a summary judgment on the clinical merits of TEE hat runs contrary to the growing literature that recognize the usefulness of TEE in ICU patients, and not just in cardiology and cardiac anesthesia.
Poelaert JL, Trouerbach J, De Buyzere M, et al. Evaluation of transesophageal echocardiography as a diagnostic and therapeutic aid in a critical care setting. Chest 1995; 107:774-779
Ken Mattox:
I am very well aware of the literature, much of it reported without controls or comparisons. I have written several chapters and articles where I attempted to find value from this technology. Be careful in marrying up to a very expensive device when some of the more traditonal tools work even better. When you protest, it causes one to wonder if you have stock in the company and congress will soon investigate your motives.
Ken Mattox:
Two robins do not a Spring make. Two references (one an editorial) and both from the same institution do not make a case or a practice guideline. Furthermore, the first you quoted merely states that we did it too, but has no real controls to justify this approach TEE, provided any new information to the intensivists.
Chuck Kowalewski:
I seem to remember the same response to esophagogastroduodenoscopy. I agree with the last Mayo Clinics article in the utility of TEE, where it suggests that many patients with unstable hemodynamics have unsuspected, correctable diagnoses even in the face of known diagnoses.
To underscore their point, we just TEE'd a morbidly obese woman with unknown cause of shock. She had typical end-organ reponses (low U.O., cold, clammy, etc). There was no JVD or HJR, but she had "no neck" either. Thermodilutional CO was 2.5 (CI of 1.2). Her CO was unresponsive to fluids or inotropes. She had no history of pain or SOB. Her Aa gradiant was midly elevated; she had an arterial lactate of 4 and her extraction ratio was high. Later she admitted to mild epigastric discomfort. She was WAY too fat for transthoracic echo and her p-CXR was underpenetrated with decreased lung size.
A biplanar TEE was done and found NORMAL ejection fraction with hyperdynamia! (Only mild hypertrophy in the LV.) It also found a very large RA size and moderate TR. Pulmonary arteries could not be well visualized. The TEE took less than 10 minutes and gave us our diagnosis.
We started her on heparin and a V/Q scan confirmed a large mismatch. The next day a venous doppler was also positive. Her shock resolved over the next 48 hours. Review of her history found none of the "classic" risk factors except obesity; her internist is working up hypercoagulopathies.
The point is, there ARE settings for TEE. We should not cut ourselves off from a new technique just because we don't see the utility of it. Ken Mattox:
Heaven help us from ourselves. At least there will be SOME good fall out from the mess that managed health care is causing. It will cause us to focus on what is needed, what has been done for economic return, what has been done for ego and what has been done in order to transfer responsibility to others. When ANYONE puts in an IABP, it is us surgeons who end up with both the patient, the complications, the explanations to the family, and left holding the bag. PLEASE, do NOT start a trip (or initiate a procedure) which you cannot finish!!!
David Crippen:
Allegorically speaking.......Col. Mattox, existential surgeon, reposing Sphinx-like in the steaming Cambodian jungle........ rivulets of sweat pouring down his furrowed brow......surrounded by hoards of slack faced intensivists waiting for the Delphian signal to take over the world...or decrease the peak pressure......Insanity as a perspicacious reaction to an insane world......"The horror.....the horror......." :-)
Ken Mattox:
YES, I, as a cardiac surgeon have very strong feelings about this subject. Cardiologists have NO business getting involved in IABP !! To put in a pump requires a team to regulate it and to watch it perpetually or it can cause its own set of problems. Cardiolgist should NEVER cath patients and especially should NOT do angioplasty in the absence of immediate surgical backup!
Dan vardi:
It is well known that an arogant surgeon can risk lives and upset the rest of the medical staff and this is a typical inflamatory comment by Dr K. IABP is generally used in a true emergency only and I believe that whoever is trained and quilified to insert it and supervise it should use it, as every other medical technology.
Kelly Randolph RN:
I have been following the discussion about IABP's for several days now with great interest. I work in a small community hospital cath lab. We do DX angiography only, without surgical backup. We have NO CABG program here. Have I raised the hairs on anyone's neck yet?
We routinely place IABP's in this cath lab, around 30 a year. We prefer to place them in a controlled environment that the lab provides. For a small hospital such as this, IABP's play a major role in treatment of refractory chest pain in the patient with acute MI. We place IABP's in the ICU with a c-arm in emergent situations. We have placed them in pts in full arrest without flouro. We have placed them in pts in the ER in full arrest. "We" means a cath lab team including a Cardiologist, an RN, and an RT. We transport the majority of our pts that require a pump to another facility for further treatment quickly. An IABP is not the end of treatment, it is a way of buying time for a very sick patient. And with the development of percutaneous placement, this is not a big deal. Furthermore, we have never had a Thoracic Surgeon refuse to do surgery on one of our patients, not one, for any reason.
If a patient needs surgery and is eligible for it, they should get it, no matter who puts the pump in. We can truly hope that with healthcare reform, we can all develop more of a team spirit. We should be concerned with sick people, not our statistics. This is my humble opinion.
Joseph M. Filakovsky:
In response to Dr. Mattox's comments, I might just like to share how things are done in our facility, a 900 bed university hospital in Connecticut.
Except, for intra-operative emergencies, ALL intra-aortic balloon devices are placed either in the cardiac cath lab or the CCU Special procedure room by CARDIOLOGISTS. It has been years since any of us have seen a balloon pump placed by anyone from the CT surgery section. It used to be a regular, and I might add, appropriate occurance for the surgeons to insert these devices when a cutdown into the femoral artery was required but with the advent of the percutaneous IAB, it is a relatively rare occurance. I might add that this is the procedure for BOTH medical and surgical patients.
Within the unit, these patients are totally managed by the professional nursing staff; if there are problems that can not be remedied by the nurse, the cardiology fellow is consulted. I might also concur with Dr. Mattox that all interventional cardiology procedures here are done with a full OR and surgical backup.
Mike Hansen:
It's apparent that Ken has very strong opinions about letting other people place IABP's. I must say, our group would STRONGLY disagree with him. In our 750-bed hospital, the IABP's are placed by Th-Surgery, cardiologists, or "HEAVEN-FORBID", Us, the intensivists. Yes, I said us! We commonly place IABP's both in the unit as well as in the field when we are called to come and resue a patient that has run in to problems at an outlying hospital. None of us are trained in Th. Surgery or have gone through formal cardiology fellowships. But we have picked up the training in placement of IABP's, and do a very good job. Also, being in the hospital 24-hours a day, seven-days-a-week makes it very convenient for some of the cardiologists to call us at any hour to place a balloon in their patient We are aware of the complications and watch closely for them. In ischemic cardiogenic shock, VSD or just very unstable, unresponsive angina, it can be a timely gift. The hour, or more, that it takes a Th. surgeon or a cardiologist to come in from home can be life-threatening.
Gregg A. Steahr:
My, my; such flame-bait on such a distinguished list serve. At our facility (300+ bed private, 1500 CABG's/yr, about the same interventions, 80% cardiac admits) the majority of IABP's are put in either in the cath lab by the cardiologists or in the units by the PA's. It is rare that a cv surgeon will use one to get off bypass (preferring a VAD instead). There have been occasions where the cv surgeon has called the PA in-house to place a device when they are tied up at another facility.
Whenever we place an IABP, we do not transfer the patient to a surgical service nor request they deal with complications. We have had 2 thrombi in the last five years- both dealt with by the vasc. surgeon. The catheters are either removed after the transplant, after the appropriate surgery, or after the patient has recovered or expired. We deal with the family from the beginning to the end and do not expect anyone else to hold the "bag". This road is well travelled here by the cardiologists, ct surgeons, and the facility. Just our (and I suspect many others) perspective.
Mike Hansen:
I obviously touched a nerve in DR. Mattox when I insinuated that someone other than a CV-surgeon might be able to insert and manage an IABP. Granted, there are times, luckily for us, very rarely, that we need to call the surgeon to help us out with a complication, though I cannot remember the last time.
We employ the IABP as a therapy, just like any other therapy...that should be carefully considered as far as the risks, benefits, indications and alternatives. If a patient is having refractory post-MI angina and the cath lab is 5 minues away and is set up, then the patient should go to the lab. If we are in a position where the soonest definitive treatment is 60-120 minutes away and the patient has failed more conservative therapy, then we will offer the IABP...after an informed consent is obtained. We usually have the request to place the IABP from the accepting/consultant cardiologist.
IABP therapy is also like all other therapy in that it has to be evaluated in terms of its benefit to the patient. There are clearly times when we have initially assumed that the balloon was going to function as a bridge to more definitive therapy, but something occurs (cardiac arrest, inoperable disease on cath, etc.) that re-classified the balloon therapy as an "extraordinary therapy" which might no longer be indicated in a given patient. e.g. the inoperable patient in refractory cardiogenic shock, the post-arrest patient that has sustained severe anoxic brain injury , etc. In these cases, we withdraw IABP therapy, just like we might any other therapy that does not have a clear benefit to the patient. Many of these cases never see the surgeon. We also WITHHOLD IABP placement in patients that have a poor chance of benefit (i.e. the risk/benefit ratio is tilted in the wrong direction).
By the number of reponses to this thread, it appears that other institutions also allow someone other than a CT surgeon to place and manage IABP's. Training, knowledge and experience are all important....but I surely don't need to be born with a Bard-Parker #10 blade in my hand to provide good medical care. If I get into trouble, I will call my surgical colleague (not read as adversary) to help me out...just like I would appreciate them calling me when they need someone who can spend more time at the bedside with a patient that has severe ARDS following their best attempts at treating his coronary artery disease, or they have thrown the patient into oliguric renal failure due to their aggressive diuretic philosophies.
Steve Streat:
It seem that downunder many things are reversed - when dealing with surgical catastrophe here in New Zealand I frequently experience quite a different scenario (from `us surgeons' to `we intensivists' being left holding the baby).
I find myself (again) agreeing with Ken in principle about knowing what you know and at least being aware of what you do not know ! We are all here working for one purpose surely - the provision of good patient care - it pays to know when to call for help - whether you are a surgeon or not....
That said, the line between minimally invasive surgery, interventional radiology and critical care is becoming blurred - what matters surely is that you perform (only) whatever procedures you have the knowledge and skill for, do so for the right reasons and with the utmost care and awareness - be the procedure laparoscopic cholecystectomy, aortic aneurysm repair, drainage of obstructed urinary tract, inserion of IABP catheter, percutaneous tracheostomy or simply a central venous line insertion. Done badly - all are potentially lethal.
Speaking of `starting a trip that you cannot finish' - we have done over 200 percutaneous tracheostomies in the last 18 months and have had to ask our surgical colleagues to take one (that is - one) to the OR for bleeding (which they graciously did, he did fine, we were very grateful). All the tracheostomies were done by intensivists in the ICU on the day (or night) they were indicated (no waiting for surgeons, OR time, anaesthetists). Very cost-effective, full cost per tracheostomy less than $US100.
Over the same period of time our surgeons have asked us to care for several hundred of their patients who got into trouble with respiratory failure, septic shock, aspiration, renal failure, brain swelling, myocardial infarction, cerebral artery vasospasm, coagulopathic bleeding, pulmonary embolism, airway obstruction, anaphylaxis, meningitis or whatever after an operation of various sorts. We took the patients and cared for them - that's what we're in the business for - most did well and some did not. I guess some patients just seem to need the skills of more than one doctor in order to do well.
What goes around comes around....
Ken Mattox:
Thank you for adding to the debate. I applaud technological advancements. I even have participated in the purchase of at least 3 separate pieces of TEE equipment for three differing services for our hospital: Cardiology/Critical Care, Radiology, and Surgery/Anesthesiology. We have been attempting to measure its cost effectiveness and just when and where it makes any decision making and therapeutic difference. The logics are developed by both the younger and older members of our faculty. So far, it remains a technology in search of an indication. It is much like the helicopters which are very expensively used for many hospitals for marketing purposes. As we did not control the ground in Vietnam, it was logical to use the air for evacuation. Most, if not all helicopter flights in the United States are for short flights, and for marketing purposes, which costs are transferred to the patient and their insurance carrier, including you. (x10 the costs of ground ambulances). Thus the new technology has become a non reversiable burden, not a flying angel of mercy.
David Crippen:
As far as it goes, I think Ken Mattox is mostly correct in the philosophy of his statement. However, like most things in life, the logical extension of his scenario is more complex than he would have us believe.
It seems to me that the insertion of an IABP is usually done under emergent circumstances, and that not all patients with such devices so inserted end up with their chest split. Aggressive support soon after the onset of an acute myocardial infarct improves outcome. The rapid implementation of intra-aortic balloon counterpulsation devices and/or intravenous cardioactive drugs temporarily reduce myocardial oxygen demand, preventing continuing ischemia, and infarct extension.
Sometimes speed is of the essence, which brings up the issue of timing. Who is qualified to determine whether or not these things are indicated and put them in.....balanced against whose turf the procedure belongs on. I was trained in residency and fellowship to do the procedure and to understand the indications, implications and complications. I put in IABP routinely. I explain the situation to the family and/or the patient and get informed consent. I also get advice and consent from the patient's attending physician if the patient is not on my service. I also travel to other hospitals in the Western Pennsylvania area by helicopter for the purpose of putting in portable IABP followed by transfer of the whole patient-IABP unit back to the mother ship for cardiac surgery or angioplasty, which is a VERY big pain for me but I do it because I think it improves patient care. If I had the choice of flying around in a helicopter and sustaining poison oak on the soles of both feet, I would have to think about it.
So Ken Mattox, as the person standing at the bottom of the funnel, presumably hoping that the patient will not fall out the bottom into your lap...ie: will improve as a result of non-surgical therapy, would you rather me put the balloon in at 0300 after your 43 year old patient develops severe chest pain refractory to aggressive medical management and marginal hemodynamics? Would you rather wait until you can crawl out of the sack, drive in and do it yourself...as myocardial muscle slowly fades by the minute? Would you rather me fly out to Lower Podunk State Hospital for the Blind and Criminally Insane, evaluate the situation and put it in there to stabilize the patient, or send him back with rapidly deteriorating heart function so the integrity of your turf is assured? In the end, which alternative do you think yields the most aggregate benefit per incremental decrease in turf occupancy?
It seems to me that the whole point of the team approach to medicine is that some things can and should be started with the intent of others to finish.
Jim Leo:
Actually, the patient arrested and died, after being coded for about two and a half hours. We did not insert an IABP, but I am inclined to agree with the responses to my original presentation, suggesting that it would have been the thing to do to go "the whole 9 yards". At our trauma case review, none of the docs thought the patient would have survived, regardless.