Latest / Style Points / Anesthesia for Pheochromocytoma with Erin Grawe

Transcript

Anesthesia for Pheochromocytoma with Erin Grawe · Style Points

0:00
Hello and welcome to another episode of Style Points.
0:13
Today I have the pleasure of speaking with Dr. Erin Growey about pheochromocytoma.
0:18
Erin initially was one of the people who oriented me to my job here at the University of Cincinnati.
0:25
Erin, thanks for joining us.
0:28
Thanks for having me, John.
0:29
This is great.
0:31
I am really pleased to talk to you because you have a lot of experience in the perioperative
0:37
space.
0:38
Can you talk a little bit more about your experience with that?
0:40
Sure.
0:41
So my kind of growth and development through the field of anesthesiology has been a little
0:50
bit unique.
0:51
I finished my anesthesia residency and then followed residency up with a fellowship in
0:58
critical care anesthesia and then cardiac anesthesia.
1:04
So when I started my practice about eight years ago, I spent most of my days in the
1:11
operating room or in our ICU, our surgical and cardiovascular ICU.
1:19
And then really through my experiences just developed a passion for perioperative medicine
1:28
and actually became very involved in our preoperative anesthesia evaluation clinic here at University
1:36
of Cincinnati.
1:37
It's called the Center for Perioperative Care or CPC, how most of us refer to it.
1:44
And became medical director of the CPC for about five years and found that I ended up
1:53
spending most of my time outside of the operating room rather than inside the walls of the operating
1:59
room.
2:00
I was spending most of my time either in the preoperative clinic or in the ICU taking care
2:04
of patients postoperatively and really just enjoyed that spectrum of care for patients,
2:13
being able to see them on the preoperative side of things, still being able to manage
2:18
them in the operating room and then taking care of them in the ICU as well.
2:23
And have really just developed my practice over the last eight years to kind of fit that
2:30
model.
2:32
And I think why I developed a keen interest in pheochromocytomas and their management
2:39
perioperatively is because I think all of those phases of care are very, very important
2:48
and really can influence the outcome of a patient after a pheochromocytoma resection.
2:54
So really important attention to detail preoperatively and getting them optimized, their intraoperative
3:02
management and ongoing diligence postoperatively can lead to a really positive and good outcome
3:10
for those patients.
3:12
Well, before we dig into the management of pheochromocytoma, I want to ask you more.
3:17
We get to know your question.
3:19
Let's say that you could have dinner with anyone in the world.
3:22
It could even be somebody from the past or from fiction.
3:24
Who would you have dinner with and why?
3:28
That's a really good question.
3:32
Interestingly, I think it would be Helen Keller.
3:42
And the reason I say that, well, interestingly, I have a son who's in great school and he
3:48
recently had to do a book report on Helen Keller.
3:52
And I think almost all of us know Helen Keller.
3:55
She was a woman that grew up in the early 1900s who at a very young age became blind
4:00
and deaf.
4:02
And when my son was doing this book report, it sort of led to him reading an autobiography,
4:09
which then led to us as a family watching a movie about Helen as a young child and all
4:15
of her struggles.
4:18
So being blind and being deaf, having to kind of live in this very dark, silent world, I
4:26
can't imagine how kind of lonely and isolated that must feel.
4:31
But despite that, she had the perseverance and the strength to kind of overcome that
4:39
and figure out how to communicate and not only how to communicate and interact with
4:45
the world, but also to become a leader and an advocate and an author.
4:50
And she's published and she would speak and she was an activist for patients with
4:55
or people with disability with the help of her kind of lifelong teacher, Ann Sullivan.
5:00
So I'd invite Ann Sullivan to that dinner.
5:04
But just to meet somebody that had that kind of strength and perseverance would be amazing.
5:11
That sounds like it would be very inspiring.
5:15
What an interesting answer.
5:16
Thank you for sharing.
5:17
Yeah, well.
5:18
Let's start off with pheochromocytoma.
5:23
For listeners who may not be familiar with what it is at all, could you explain what
5:26
it is and why it presents unique challenges for us in anesthesia?
5:30
Sure.
5:31
So a pheochromocytoma is a neuroendocrine tumor that releases catecholamines.
5:40
So it's a tumor that develops in individuals about 90% of the time.
5:46
It's an isolated tumor that presents around the third to fourth decade of life.
5:53
More infrequently, about 10% of the time, it's a familial or genetic tumor.
6:02
And sometimes even part of the kind of the umbrella of the multiple neuroendocrine neoplasia
6:08
syndrome, the MEN type 2, if you all remember that from medical school.
6:12
I have to say, I remember studying that as a buzzword for...
6:15
Yes, exactly.
6:16
... kind of memory trick to go along with that.
6:19
Yes, exactly.
6:20
So pheochromocytomas can be a part of MEN type 2 syndrome.
6:27
But 90% of the time, they're an isolated tumor.
6:30
And usually, 90% of the time arise from the adrenal medulla.
6:37
And they are catecholamine secreting tumors.
6:41
And a lot of times, they are identified in patients that have very malignant or severe
6:46
hypertension.
6:49
Because they either have continuous or episodic release of catecholamines, both norepinephrine
6:55
and epinephrine, these patients oftentimes present with syndromes associated with excess
7:03
catecholamines.
7:06
So again, hypertension, sometimes kind of diaphoresis, flushing, arrhythmias, and even
7:15
can develop some renal dysfunction.
7:20
So why this presents challenges for anesthesiologists is that you are receiving a patient in the
7:28
operating room who has for potentially years, sometimes maybe even decades, excess catecholamines.
7:40
And what that does to your physiology and other organ systems management can be quite
7:46
challenging.
7:47
Absolutely.
7:48
I have managed a few pheos in the operating room myself.
7:54
And I remember each one of them individually.
7:57
They are certainly cases to be remembered for the last hemodynamic swings that you see.
8:05
So before we get to the operating room, let's talk about what we do for these patients in
8:11
the preoperative space.
8:13
For you and CPC, what does that look like when a patient gets referred to you with FIA?
8:18
Sure.
8:19
Well, my approach to them on the preoperative side of things kind of fits, I think, three
8:27
buckets.
8:29
Number one being how effectively is their hypertension managed and optimized?
8:38
And I want to spend a little bit of time on this because I can't emphasize the importance
8:43
of this enough.
8:45
And this is usually done on a multidisciplinary level.
8:51
So once a patient is diagnosed with a pheochromocytoma and the decision is made that this patient
8:59
is appropriate for surgical resection, preoperative blood pressure optimization usually occurs
9:07
on a combination of levels.
9:09
At our institution, it's primarily managed by the patient's endocrinologist.
9:14
And we're very fortunate at the University of Cincinnati to have a great division of
9:17
endocrinology who are very proactive and aggressive about managing these patients preoperatively.
9:25
So because these patients, again, live in this chronic state of excess catecholamide
9:32
secretion, they all have a state of chronic hypertension.
9:39
The most important or kind of the initial front line management for hypertension is
9:49
alpha blockade.
9:51
And you always want to start with alpha blockade before any type of beta blockade because you
9:57
don't want unopposed alpha stimulation.
10:03
So usually the first medication that's introduced to these patients, and this occurs anywhere
10:08
from about two to four weeks preoperatively, is the initiation of an alpha blockade.
10:17
And this can occur, or there's a couple of different options, I guess I should say, with
10:22
regards to alpha blockade.
10:25
There's a long acting alpha blockade that I think we're probably all familiar with,
10:29
phenoxybenzamine.
10:31
It's a long acting medication.
10:33
It's a once a day medication, so patients are usually compliant with it.
10:38
The downside of it is that it's not as easily titratable in the outpatient setting.
10:45
More recently we're finding it's hard to get insurance approval.
10:49
So the more short acting alpha blockers such as prazicin or doxicin is actually typically
10:56
what we're seeing most patients come to us on.
10:59
Even though those are TID medications, they're more easily titratable.
11:06
The goal is to titrate those medications until the patient is normotensive essentially.
11:16
And once that patient is normotensive without orthostatic symptoms—I think historically
11:22
the goal was to titrate these patients all the way up to the point that they were getting
11:27
really orthostatic on an outpatient level.
11:29
We've found that sometimes that degree of alpha blockade can lead to post-op or acute
11:36
kidney injury, but at least titrating them to the point that they are normotensive.
11:44
If we find that tachycardia, which can happen with a lot of alpha blockade, occurs, then
11:52
initiation of a beta blocker as a second agent is also very helpful.
12:01
So when a patient arrives in our pre-op clinic, that's kind of the first and foremost thing
12:06
that we identify or look to identify is how appropriately is their blood pressure managed.
12:15
And so when they come into the CPC, we're doing obviously vitals, but also orthostatic
12:20
vitals as well.
12:23
And if we have concerns about their degree of hypertension or we don't feel like they
12:30
are alpha blocked enough, then we're communicating that back with the surgeon as well as the
12:35
endocrinologist who's managing them.
12:37
And it's usually a conversation at that point on which medications to titrate to get
12:44
them appropriately optimized.
12:46
So really important communication with the endocrinologist and the surgeon preoperatively
12:50
is important.
12:53
We find that in our pre-op clinic, we're kind of like the final checks and balance of that
12:56
patient before they enter the operating room.
13:00
So having that communication is really, really important.
13:07
So that was kind of one thing in the pre-op clinic.
13:11
The first kind of aspect that we're looking for and evaluating for the patient.
13:16
The second really is identifying any other comorbidities that can be associated with,
13:26
again, potentially years, maybe even decade of pretty malignant hypertension related to
13:34
that years of excess hypercatecholamine secretion.
13:39
So a very thorough cardiac evaluation is really important.
13:46
We always do an EKG to look for any sort of arrhythmias or ischemic findings on an EKG.
13:55
A preoperative echocardiogram to look for any sort of cardiomyopathy associated with
14:02
the pheochromocytoma is important.
14:08
In kidney function or logic function, it's not uncommon that some of these patients may
14:12
have had strokes in the past or developed some chronic kidney disease.
14:18
And then the third thing we really look at, and this is for every patient coming through
14:21
the preoperative clinic, is assessing functional status, any other comorbidities that we need
14:27
to address and optimize to get the patient through a big abdominal surgery safely.
14:37
And so those are really kind of the three categories of buckets of things that we evaluate
14:42
patients for when they come in to our preop clinic.
14:46
I like that you mentioned one of the very typical buzzwords associated, which is the
14:51
unopposed alpha and we don't want the unopposed alpha.
14:54
Can you talk a little bit about what that actually means and what the consequences would
14:59
be if we decided to ignore that?
15:01
Sure.
15:02
That's a great question.
15:03
So a lot of these tumors, like I said, they secrete catecholamines.
15:10
And the vast majority of them, most of them secrete more norepinephrine than epinephrine.
15:18
And if you remember back, going back to physiology and even pharmacology, norepinephrine is primarily
15:27
an alpha agonist.
15:29
Epinephrine, you see a little bit more of a balance between alpha and beta agonism.
15:34
But if you think about what our alpha one receptors are doing, when those alpha one
15:42
receptors are stimulated, you see a lot of vasoconstriction.
15:46
So these patients live kind of in a very chronic vasoconstrictive state, which also leads to
15:56
a relative volume contraction because you're going to have, if those blood vessels are
16:02
constantly vasoconstricted and those patients are hypertensive, you're going to have a decreased
16:07
amount of salt and water absorption at the kidney level.
16:12
So these patients are dehydrated and very, very clamped down.
16:16
So when we start an alpha blockade, that's really important to start relaxing those blood
16:21
vessels.
16:23
And at the same time, you want to, what we call salt expansion.
16:30
So that when it's done on the outpatient setting is giving them salt tabs so that they
16:37
basically reabsorb water, free water at the kidney level to kind of increase their intravascular
16:46
volume by the time that they reach the operating room.
16:50
If we ignore that concept and let's say as an outpatient started a beta blocker, then
16:59
potentially you're going to have, you're going to block the beta effects, beta one and beta
17:07
two effects.
17:09
And then all of a sudden you're going to have an extreme, what we call unopposed alpha stimulation.
17:16
So a very, very strong vasoconstrictive response and your beta blockers aren't going to necessarily
17:22
touch that at all.
17:25
So that can be problematic for the patient.
17:27
Or if you started them on another agent, like a calcium channel blocker or something like
17:31
that, you're really not addressing the fact that you've got high levels of norepinephrine
17:38
in the system working on your alpha one receptors.
17:43
So the whole concept of this alpha blockade is actually crucial for the management of
17:50
these patients because of their high levels of circulating norepinephrine.
17:56
So you actually wrote the intraoperative protocol pretty recently that we are using for our
18:03
pheochromocytoma patients.
18:05
So that makes you a great candidate to answer my next question, which is how do we manage
18:10
these patients when they show up in same day surgery?
18:13
Sure.
18:14
I can't speak to being prepared enough.
18:20
So the answer to that question is preparation, preparation, preparation.
18:25
We're going to assume that this patient has been well optimized by their endocrinologist,
18:32
by the surgeon and by our preop clinic.
18:36
So they're going to come in on the, come into the hospital on the day of surgery.
18:43
They will have hopefully taken their alpha blockade and their beta blocker.
18:48
If it's the longer acting phenoxybenzamine, then perhaps we may have them hold it on the
18:53
day of surgery.
18:54
But if it's the short acting parazicin, then we'll have them take their alpha blockade
18:58
and their beta blocker on the morning of surgery.
19:04
All of these patients get a pre-induction arterial line.
19:07
We want adequate IV access on these patients.
19:11
And before you even see these patients in same day surgery, the setup in the operating
19:15
room is extremely important.
19:18
This is not a case that you just kind of have some sticks of phenolephrine laying around
19:24
or maybe some push sticks of nitroglycerin.
19:25
While you absolutely want those things, we have our plump pumps in the room primed and
19:32
ready to go with what we call uppers and downers.
19:36
So antihypertensives, short or very short acting, fast onset antihypertensive agents.
19:45
And then we also have pressors available as well.
19:49
Because we can kind of talk about how this surgery I feel like is actually two surgeries
19:54
and one that you have the first part of the operation is where you have the tumor intact
20:01
and still have ongoing release of those catecholamines.
20:05
And then the second half of the procedure is you have once the tumor has been removed,
20:13
you have a whole second half of the surgery in which you may have an acute drop in your
20:21
catecholamine levels and you're kind of dealing with the hemodynamic consequences of that
20:25
as well.
20:26
I think the key word in what you just said is may have.
20:30
I have certainly experienced piochromocytomas where after resection the blood pressure plummets
20:36
and it's dramatic.
20:37
But I've had other ones that really the blood pressure seems to stay high and I've
20:44
actually taken patients to the ICU on downers instead of uppers as the literature will usually
20:51
suggest that you need to be on.
20:53
Can you explain a little bit about why we don't immediately see a drop in everyone's
20:58
blood pressure after it's resected?
21:00
Well, I think you bring up a good point that if you've taken care of one patient with
21:06
piochromocytoma, you've taken care of one patient with piochromocytoma that they can
21:11
all present and physiologically act a little bit different.
21:18
So that's why preparation and being kind of prepared for any extreme is really important.
21:24
I think one thing that's important to know is that every tumor is a little bit different
21:30
and you will have tumors that are very high secreting tumors.
21:35
And those are patients that they have really, really high levels of metonephrine or noremetonephrine
21:44
preoperatively.
21:46
Those are patients that you may experience more of a rocky road and they really need
21:55
a lot of attention to preoperative optimization and you may have the really high catecholamine
22:04
surges with induction and tumor manipulation as the surgeon starts to dissect out the tumor.
22:13
And with the loss of those very, very high levels of catecholamines after the tumor is
22:17
removed, those are patients that may become really hypotensive and unstable after tumor
22:22
removal, especially because we ask them to take their predsense and their beta blockers
22:27
preoperatively.
22:29
Now you have on the other end of the spectrum, some tumors are not as high secreting as before
22:38
and so they seem to have a little bit less of those fluctuations.
22:44
And those patients may remain hypotensive even after removal because they didn't kind
22:50
of live at a really high catecholamine secreting state.
22:54
The second thing too is some patients may have underlying chronic hypertension in addition
23:01
to their pheochromocytoma that was contributing to their hypertension.
23:05
So those patients may also not drop too low after tumor removal.
23:12
The third thing is that really adequate volume resuscitation preoperatively and intraoperatively
23:21
with the salt expansion and volume resuscitation, that should continue intraoperatively as well.
23:29
So really close attention to volume management will also help minimize those really low lows
23:36
after the tumor is resected.
23:39
So I think there's a lot of caveats and nuances associated with pheochromocytoma management.
23:47
And as you said, it can actually present quite differently depending on the nature of the
23:54
tumor and how well the patient was optimized and their other co-lubidities as well.
24:03
Now when I get a patient that comes to same-day surgery and their blood pressure is 210 over
24:10
120, a lot of times that's a signal to me that I need to talk to the surgeon about potentially
24:16
canceling or postponing a case.
24:20
What if one of these patients comes to same-day surgery and they have a blood pressure that
24:24
is sky high?
24:26
Is this a patient that you would consider going forward with as opposed to a standard
24:31
patient or what's your approach to that sort of situation?
24:34
Sure, that's a great question.
24:38
In pheochromocytoma patients, if a patient presented to same-day surgery with malignant
24:45
pressures like this, I would one, want to verify did they take their home medications,
24:50
their alpha blocker, their beta blocker, any other antihypertensive medications that were
24:56
prescribed.
24:57
If they did and their blood pressure is that high, then that's an indication to me that
25:02
this patient isn't appropriately optimized and I would be having a conversation with
25:05
the surgeon about canceling the case and seeing if we can get the patient optimized.
25:12
Occasionally, if they've come in and they've told me that they haven't taken any of their
25:18
home medications, well then I'll give them medications and in same-day surgery give it
25:25
about an hour, sometimes two hours if we have the ability to delay the case that long and
25:31
see if the blood pressure has come down.
25:35
But because we know that in this procedure there is such a risk for extreme hypertension
25:43
with tumor manipulation, blood pressures starting off in that extreme are really quite scary.
25:54
And we've had a couple of patients that for various reasons have come in with pressures
26:00
that high and we've elected to cancel the case and take a different approach for those
26:05
patients coming in for surgery.
26:09
And I can think of one case that occurred maybe about three or four months ago who was
26:16
a patient who wasn't English speaking and actually the language that they did speak
26:22
was very hard to get a translator for.
26:26
And so medical translation happened through one of the patient's relatives.
26:32
So I think a lot of the medical communication got lost in translation.
26:37
So we don't think the patient was as optimized as they should have been or could have been.
26:42
And there was just so many factors that went into that.
26:46
So ultimately with conversations between the endocrinologist, the surgeon, and the endoseologist
26:52
when we had that experience of the patient showing up to same day surgery with malignant
26:56
range pressures we decided to cancel the case.
26:59
And when we came back to actually do the case a second time we pre-admitted the patient
27:04
to the hospital a day before surgery.
27:08
Actually it might have been two days before surgery.
27:10
Make sure they really got volume expansion through IV fluids.
27:14
We were able to really carefully titrate their medications while being closely monitored
27:20
in an inpatient setting.
27:21
And ultimately the patient had a very successful surgery and resection and very positive outcomes.
27:28
But I think it kind of highlighted the need to kind of come up with some creative solutions
27:37
for these patients to really get them optimized and how important that is.
27:43
That makes a lot of sense.
27:45
So let's talk for a little bit about creating your battle station in the operating room.
27:52
You said you mentioned having uppers and downers.
27:55
And I know that there's a lot of room for a lot of different types of medications to
27:59
be used here.
28:00
What would you personally choose in a patient that you're pretty concerned about?
28:06
Sure.
28:07
So let's talk about I guess our downers first because in the operating room those are potentially
28:13
the first medications that you're going to need.
28:17
In the room spiked on a pump I usually have two downers.
28:23
At our institution we have the availability of clavitapine which is a relatively new diphenhydramine
28:33
calcium channel blocker that is very short acting and very rapid onset and very easily
28:38
titratable.
28:40
So my personal preference is clavitapine along with nitroproside are agents that I have spiked
28:50
ready to go ready to start infusing in the patient.
28:54
In addition to that we have push doses of nitroglycerin available as well.
29:01
I also have on the flip side because again after the tumor is resected I want to have
29:07
pressors available.
29:08
Sure.
29:09
And the two pressors that we will commonly use is norepinephrine or levofed and vasopressin.
29:16
I'll have both of those medications spiked and ready to go.
29:20
In addition to push doses of epinephrine and phenylephrine and norepinephrine if we need
29:26
it for kind of a quick boost in the blood pressure while the infusions kind of get to
29:31
a steady state.
29:33
So those are the medications that I have spiked ready to go.
29:36
We have two fluid sets set up.
29:40
I mentioned I always usually or almost usually always do a pre-induction A line for these
29:46
patients.
29:47
So your pressure tubing for an A line.
29:51
If I'm worried about cardiomyopathy in these patients I will also do a non-invasive cardiac
29:58
output monitor.
29:59
We use a visual a or flow track here to help kind of really guide fluid management for
30:06
these patients.
30:09
There can also be fluctuations with the patient's blood glucose.
30:13
There can be kind of a surge of insulin with tumor manipulation and there can be some hypoglycemia
30:20
followed by hyperglycemia.
30:23
So I have an insulin infusion but I also have dextrose available.
30:28
The whole case is like a tale of two cities.
30:30
You have two operations in one where you have a very kind of shifting physiologic experience
30:38
at the beginning of the case and you have at the end of the case.
30:42
And so emphasizing preparedness for both of those situations.
30:47
Sure.
30:48
That makes a lot of sense.
30:49
So what would be your approach if during the surgery they're working with their instruments,
30:56
they're watching what they're doing on the screen and all of a sudden you see massive
31:03
kinematic shift on the monitor.
31:05
You see crazy hypertension spikes up to 250.
31:09
What's your first move there?
31:11
Communication.
31:13
Communicate with your surgeon what's going on.
31:15
They're going to be obviously very hyper focused on their surgical technique and quick removal
31:22
of the tumor.
31:23
So telling them what's going on.
31:26
A lot of times if they're at a place in their surgery or their resection where they
31:30
can stop and let things settle out, they'll do that.
31:34
So once you identify it, alert the surgeon and then initiate basically your antihypertensive
31:43
agents either by infusion or push dose, usually a combination of both until you can kind of
31:50
get the patient stabilized toward normal tens of range and then they can again start their
31:55
resection and tumor manipulation.
31:57
And hopefully at this point now that you have some antihypertensive circulating in the system,
32:04
you won't have such a profound hypertensive response to surgical manipulation.
32:08
So communication is really, really important in these cases.
32:14
One thing that you also mentioned before was having adequate IV access on these patients
32:18
and something that we've talked about before when you were writing the protocol was whether
32:23
or not to put a central line in these patients.
32:25
What do you think?
32:26
Should we put a central line in every single one of these patients?
32:30
I think the bigger question is who needs a central line ever?
32:36
Sure.
32:37
So when you think of the reasons why somebody might need a central line, obviously number
32:44
one is adequacy of IV access.
32:47
So if you have a patient come in who's got great peripheral IV targets where you can feel
32:56
like you can get two or more large bore IVs, I'm talking about 16 gauge, 14 gauge IVs,
33:06
then your patient may not need a central line.
33:10
You want enough access to give large volume of fluids rapidly if you need to, transfusion
33:20
if you need to.
33:22
You want a reliable IV for your IV infusions.
33:28
And this is kind of, I think, the crux of the question and every institution might be
33:33
a little bit different and every provider might feel a little bit differently.
33:38
If there's a possibility that they have to run a presser at the end of the case, norepinephrine
33:43
or vasopressin, again, I want a large bore IV that I can do that safely with.
33:51
I know that potentially I'm not going to be doing that for an extended period of time.
33:55
I know that I'm, as a provider, one-on-one with this patient so I can kind of continually
34:01
assess the adequacy of that IV.
34:03
I want to make sure I can see that IV.
34:06
So if the patient's arms are tucked or someplace that I can't visibly assess that IV, I might
34:13
be more hesitant to allow pressers to run through the IV.
34:18
But if I have a situation in which I've got great IV access, I think that the duration
34:25
of infusion isn't going to be terribly long and I can see and assess that IV for a patency,
34:31
then I feel comfortable doing this procedure with peripheral IVs.
34:36
Now on the flip side, if any of those scenarios aren't met, then I have a very, very low
34:43
threshold for putting in a central line.
34:45
And I think most of our colleagues, to be honest with you, would just go to a central
34:49
line like 100% of the time on these patients.
34:58
At our institution, most of our ICUs, especially our surgical ICUs, will not run pressers through
35:07
a peripheral IV.
35:09
So even if I have a patient where I've managed them intraoperatively with pressers, relatively
35:16
low dose pressers through a peripheral IV, if at the end of the case they still require
35:20
those, I will put in a central line before bringing them to the ICU.
35:25
So I want to say that you can do a pheochromocytoma case without a central line, but with an asterisk,
35:34
and understanding that those are the caveats.
35:39
And that also if you feel like you need a central line for hemodynamic monitoring, if
35:44
you want to monitor a CVP, then obviously a central line is another reason, or doing
35:50
that is another reason to put in a central line.
35:53
That makes a lot of sense.
35:54
I definitely agree with you that it's certainly up to the provider, but I think most of the
36:01
time most of us will put in a central line, but I can imagine some exceptions as well.
36:07
Moving on to the ICU, we drop off this patient, and some of us who don't work in the ICU
36:14
like myself would forget about them forever.
36:16
Not really.
36:18
What kind of management would you be doing in the ICU afterwards for these patients?
36:23
Well, if they have that very classic traditional response of hypotension and vasoplesia post
36:31
tumor removal, then it's just going to be close management of their blood pressure and
36:38
their pressors.
36:40
That can sometimes last for up to 24 hours.
36:43
But again, as you said, there are patients that come out even hypertensive, and you're
36:49
titrating your downer, so to speak.
36:53
So ongoing blood pressure management is really the crux of their care over the next 24 hours.
37:01
I mentioned too, glucose management, it can be wildly variable.
37:07
They can kind of have this rebound hyper insulin response where they get hypoglycemic and may
37:12
end up on a dextrose infusion.
37:15
That's very possible as well.
37:18
So these patients continue to require a ton of vigilance over the next 24 hours postoperatively.
37:25
And once they kind of have leveled out to the point where you can kind of get them off
37:31
all of these like vasoactive drips, so to speak, then really the next step is from a
37:37
kind of a longer blood pressure management standpoint.
37:41
These patients don't require their alpha blockade anymore.
37:46
Some of them may require nothing for blood pressure management as an outpatient.
37:51
Some of them, again, have some underlying chronic essential hypertension that they will
37:55
need ongoing management of.
37:58
So figuring out where that patient settles into is important.
38:04
And that occurs days, weeks, even months postoperatively.
38:09
So not only just in the ICU is that important, but close follow up even after the patients
38:15
left the hospital to figure out how this patient's blood pressure is going to be managed on an
38:20
ongoing basis.
38:21
Yeah, that makes a lot of sense.
38:24
Well, to wrap up, I wonder if you could share with us some of your personal style points,
38:30
particular things that you do that you think, believe contribute to your effectiveness,
38:35
success in the operating room.
38:39
Kind of unrelated, pheochromocytoma management.
38:41
Just like a general approach that I take in my career, whether I'm in the operating room
38:49
or I'm in the ICU or I'm in our pre-op clinic.
38:53
And I would give this advice to every young clinician out there is it's not enough to
39:00
identify problems, either with a patient or the system or your environment.
39:06
You have to identify solutions.
39:08
For you to be an effective clinician and for you to earn the respect of your colleagues,
39:15
of surgeons, of hospital administrators, wherever your career may lead you, an effective way
39:24
of doing that is taking the next step is to find a solution to whatever problem that you're
39:31
dealing with and proposing that.
39:34
Now, it has to be within your sphere of influence.
39:36
You don't want to walk around telling everybody else how you think they should be doing their
39:40
jobs.
39:41
I'm glad you said that.
39:42
But if it's within your sphere of influence and you identify a problem with a system or
39:50
an environment that you're working in, then think about how to make it better.
39:54
It's not like you said, you want to be the person that, you know, curses the darkness
39:59
or lights the match.
40:01
So find a solution and work with the people around you to make your, to make patient care
40:10
safer, to make work a more enjoyable place for everybody, to improve efficiency.
40:17
And I think that's probably the kind of the number one thing that I could, advice I could
40:24
give to young clinicians is it's not just enough identifying a problem.
40:31
It's living and owning your kind of world, your patients and the environment that you
40:38
work in to create a better system.
40:40
Well, Erin, thank you so much for joining us.
40:44
I am really pleased that you agreed to come on as a guest.
40:47
I know that myself and many of the department members that I talk to think of you as a big
40:52
sister to the whole department.
40:55
You certainly bring a lot of your own personality and style to the operating room and I appreciate
41:04
you sharing that with us.
41:05
Thanks so much for having me, John.
41:06
This has been awesome.
41:08
And that's it for today's episode of Style Points.
41:12
Remember every time you like and subscribe, an anesthesiologist gets their wings.
41:16
I'm still finding my feet in the podcast world, so any feedback you give me is great.
41:20
You can email it to stylepointspodcast.gmail.com.
41:24
Thanks for listening.