A sad case

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coffeebythelake said:
Maybe not as bad for malpractice insurance... but Are u concerned about violence toward Healthcare workers? Is that more common in Mexico?
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Maybe in the south, im on the northern side and tbh I have never experienced such thing, my father was a family doctor and travelled around slot the country and never had any problems either
 
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Sleeplessbordernights said:
33 year old male pt, 330 lbs, 4.9 f. Absolutely no neck extension nor mouth opening.
is admitted because of a bad fournier gangrene secondary to an over the counter Im inyection of decadron her grandma applied to him because flu symtomps, which turns out to be covid, he is desat to 88, can’t lay flat at all but is otherwise doing fine with mask.

His covid is somewhat stable but the gangrene is not getting better so surgery decides to perform a colostomy.

He arrives to OR stable, sat 88 with mask, I perform a RSI with VL (With my attending besides me) I do it quick and on the first try, however he desats to 20, but is up to 92 after bag ventilation. Other than high plateu and peak pressure, the surgery goes fine on our side, surgery on the other hand has a lot on trouble getting the colostomy, they take 3 hours.

After the second hour I point to my attending that there is a lot of green thick secretion on the OT at firt at the base and slowly but steadly getting to the top. My attending points out we won’t be able to extubate him, we will change the OT at the end of the case.

The colostomy ends but surgery say they want to perform a quick debridement. We help by flipping the pt to one side. As they are doing the debridement I notice the secretions are all the way up in the tube and the pt starts desat to 85, 82, 80. My attending tells surgery to stop, we are gonna change the tube, as we put the pt supine, he desats hard to 20, my attending quickly changes the OT but the pt codes and after 30 min we are not able to bring him back.

This case happened 2 months ago but I have been thinking a lot, maybe we should not waited to change the tube, or we should have aspirated the secretions the moment we noticed them, what do you think?
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Tough case. Didn’t read all the posts above.

only other thing I would add, what size tube did you use? Any anticipated ICU patient, at least 8.0, preferably low pressure cuff tube. Even with a big tube, secretions can be tough.

Also, if it were just airway I would expect the guy to come back after a hypoxic arrest like that. Maybe PE or something?
 
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Also, I would always try to bag before extubating and changing the tube no matter how easy an airway in this situation. Attending probably thought tube was the issues and didn’t want to perseverate/fixate, but given how fast the guy desaturated on induction, have to try to bag him up.

squeezing the bag gives you info, if the ETT is really obstructed the compliance is ridiculous trying to squeeze the bag. Only then would I take out the tube immediately.
 
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dipriMAN said:
Tough case. Didn’t read all the posts above.

only other thing I would add, what size tube did you use? Any anticipated ICU patient, at least 8.0, preferably low pressure cuff tube. Even with a big tube, secretions can be tough.

Also, if it were just airway I would expect the guy to come back after a hypoxic arrest like that. Maybe PE or something?
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even with a massive PE you would still be able to move air and see chest rise. the EtCO2 might crap out though.
 
Well, the guy was circling the bowl with dropping sats when they decided to move him from his side to supine. Agreed its unlikely, but if he had significant CAD, the hypoxemia could be enough to initiate the arrest. A path report would be helpful sorting all this out.
 
coffeebythelake said:
seems unlikely that this would occur exactly the moment that the patient position was changed.
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True but I've heard of a case where a patient was canceled and had a massive mi the next day. And you know that if the case went, it would have been blamed on the anesthesia.
 
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GassYous said:
True but I've heard of a case where a patient was canceled and had a massive mi the next day. And you know that if the case went, it would have been blamed on the anesthesia.
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During residency I preopped a patient at the VA on the night before his surgery. Called my attending and told him he was good to go. He died of MI/cardiac arrest overnight.

Many years ago I examined a patient in preop holding who was tachypneic/dyspneic with rhonchi all over. He was an elderly man with an ankle fracture and he had a medicine clearance note from 2 hours before. Obviously he had aspirated in the interim. I delayed the case and he died that night.

Recently one of my partners had a patient who had an evolving stroke in preop holding. They were lucky it didn’t start 40min later.
 
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nimbus said:
During residency I preopped a patient at the VA on the night before his surgery. Called my attending and told him he was good to go. He died of MI/cardiac arrest overnight.

Many years ago I examined a patient in preop holding who was tachypneic/dyspneic with rhonchi all over. He was an elderly man with an ankle fracture and he had a medicine clearance note from 2 hours before. Obviously he had aspirated in the interim. I delayed the case and he died that night.

Recently one of my partners had a patient who had an evolving stroke in preop holding. They were lucky it didn’t start 40min later.
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My partner interviewed a women on a Friday for a hysterectomy and she presented a vague cardiac history, enough to make his spidey senses tingle. He requested a.cardiology eval. The Gyn called the patient on Mon and explained to the daughter she needed to see a cardiologist. The daughter immediately wanted to know what was wrong with Moms heart and was told the consult was merely precautionary. The daughter informed him Mom had passed suddenly over the weekend.
 
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Angus Avagadro said:
My partner interviewed a women on a Friday for a hysterectomy and she presented a vague cardiac history, enough to make his spidey senses tingle. He requested a.cardiology eval. The Gyn called the patient on Mon and explained to the daughter she needed to see a cardiologist. The daughter immediately wanted to know what was wrong with Moms heart and was told the consult was merely precautionary. The daughter informed him Mom had passed suddenly over the weekend.
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Ouch.
 
The crazy part is she died of acute massive dysfunctional uterine bleeding.
 
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dipriMAN said:
Tough case. Didn’t read all the posts above.

only other thing I would add, what size tube did you use? Any anticipated ICU patient, at least 8.0, preferably low pressure cuff tube. Even with a big tube, secretions can be tough.

Also, if it were just airway I would expect the guy to come back after a hypoxic arrest like that. Maybe PE or something?
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Covid PE. Those people clot even on full dose heparin.
 
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Ronin786 said:
Reminds me of an argument I had with the MICU when they called me as a resident to exchange an ETT in a patient with some sort of lung CA bleed/DAH. Blood pouring out of the ETT. Flat out had to tell them this patient is too far gone, they're going to die from their bleeding and I want no part in changing the cause of death to a failed airway.

Boards answer in situations of alveolar bleeding involve a DLT and isolation of the affected lung. In my limited experience, when you're called to situations like this, most times it's too far gone and nobody has a true idea of where the bleeding is coming from. DLT in a bloody pair of lungs isn't fun.
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Tried to do this the other week in a patient with a ruptured PA in cath lab. It was a disaster.
 
It can be challenging enough to put in a dlt for an elective vats. I can't imagine trying to shove one of those in and verify tube placement with severe hemorrhage.
 
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We were in the cath lab so we ultimately gave up even trying to use the fiber and just shoved it in under fluoro
 
Hork Bajir said:
That’s where being facile with bronchial blockers comes into play...
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Bronchial blocker to isolate a bleeding lung? Have you actually done this successfully? Sure maybe it won’t kill them as quick as a tube exchange could but I’m skeptical this would be adequate for a massive bleed.
 
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SnapperRocks said:
Bronchial blocker to isolate a bleeding lung? Have you actually done this successfully? Sure maybe it won’t kill them as quick as a tube exchange could but I’m skeptical this would be adequate for a massive bleed.
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Done it once (interventional pulmonology disaster case). Successfully prevented the blood from spilling over into the contralateral lung (at least for the most part), and bought enough time for the patient to get to the hybrid OR for an attempted bronchial artery embo.

Patient still died. This is a bad bad problem to have. But, I do think a bronchial blocker should have a place in your arsenal for dealing with pulmonary hemorrhage. TBH, the quickest and easiest thing is usually to mainstem your ETT... But it all depends on the situation, what equipment is available, what you’re most comfortable/experienced with, and what your goals are (preserving the ability to ventilate at all by protecting the other lung, facilitating therapeutic and diagnostic bronchoscopies, tamponading the bleed, etc - all of which may have different optimal strategies)
 
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Hork Bajir said:
Done it once (interventional pulmonology disaster case). Successfully prevented the blood from spilling over into the contralateral lung (at least for the most part), and bought enough time for the patient to get to the hybrid OR for an attempted bronchial artery embo.

Patient still died. This is a bad bad problem to have. But, I do think a bronchial blocker should have a place in your arsenal for dealing with pulmonary hemorrhage. TBH, the quickest and easiest thing is usually to mainstem your ETT... But it all depends on the situation, what equipment is available, what you’re most comfortable/experienced with, and what your goals are (preserving the ability to ventilate at all by protecting the other lung, facilitating therapeutic and diagnostic bronchoscopies, tamponading the bleed, etc - all of which may have different optimal strategies)
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you can do lung separation by mainsteming your single lumen ETT.
esp if you are saying blood is pouring out
 
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coffeebythelake said:
Rupture PA sounds like call CT surgery and Crack the chest type of situation. Not a let's muck with a DLT situation..
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Ruptured pa will be dead within a minute or so if you can't isolate a safe lung to ventilate. Never seen a pa rupture but I have seen a few cancer/bronchial artery bleeds that have fallen apart very fast until the good lung was isolated.
 
Is the left PA more likely to rupture or something? Cause I don't see the point of right mainstemming (which we know is more likely) the lung if you don't know what side the bleed is coming from.
 
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MirrorTodd said:
Is the left PA more likely to rupture or something? Cause I don't see the point of right mainstemming (which we know is more likely) the lung if you don't know what side the bleed is coming from.
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You know you can guide a SLT and not just shove it down and right mainstem it. Just like when you position the DLT without as much swapping equipment and tools.
 
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If you want to intentionally L-main stem an SLT and don’t have an FOB handy, you can rotate it 180* so the bevel faces the other way then advance it. Greatly increases the chances of it going left.
 
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coffeebythelake said:
Rupture PA sounds like call CT surgery and Crack the chest type of situation. Not a let's muck with a DLT situation..
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Yeah, CT surgery was there and it wasn't a DLT, it was a SLT that we were trying to confirm was mainstemmed. Tons of bleeding regardless of how we positioned it, which is why we were initially unsure. Could temporarily visualize the carina but then on several attempts what we thought was the left turned out to be the right (crapshow disaster with the patient basically coding throughout, so hard to orient yourself with respect to the scope), when we finally turned the fluoro machine on. I like the trick about rotating the tube 180, will have to try that if I'm unlucky enough to be in a similar situation again.

EDIT: sorry, I guess my first post was unclear. When I said "tried to do this," I just meant lung isolation, not with a DLT
 
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SaltyDog said:
If you want to intentionally L-main stem an SLT and don’t have an FOB handy, you can rotate it 180* so the bevel faces the other way then advance it. Greatly increases the chances of it going left.
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Also, turn patients head rightward as you advance. Definitely not foolproof but it does move the ETT tip leftward. Try it with a FOB down the tracheal lumen next time you place a DLT.

Also, a Cohen or EZ-Blocker are both >>>> an Arndt for ease of placement. The Arndt is garbage.
 
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