Another case

[Sleeplessbordernights]

91 year old female, 88 lbs 4‘9, scheduled for umbilical hernia repair (1 cm or less), no known comorbidities. Patient is badly scoliotic. Her vitals and labs are all normal. What is you plan? (This is. A case I had today, pretty standard but it kinda went sideways midway trough).

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[ZzzPlz]

Lma

 

[Sleeplessbordernights]

Lma

My attending said it was his last choice so we did not go that way

 

[DocMcCoy]

Given your limited presentation, LMA nearly always at the top of my list in this patient with this problem. That is a small hernia sac and should be about a 30 min case.

I have done a handful of umbilicals/inguinals in cripples with copious old school surgeon placed local and sh*tty MAC.

a lot of the approach is going to depend on how reasonable the surgeon and patient are.

there is nothing in your presentation that suggests difficult airway other than she is small, brittle, and old. If she isn’t kyphotic with a frozen neck and a reassuring airway exam then throw a tube in.

I’ve never spinaled an umbilical hernia, not that would never but plenty of other options for a small hernia so her scoliosis doesn’t mean much to me assuming she can lie flat and bend her neck.

Why was your attending so against a LMA? He must keyed in on something. so what am I missing? clearly you had some fireworks.

 

[Sleeplessbordernights]

Given your limited presentation, LMA nearly always at the top of my list in this patient with this problem. That is a small hernia sac and should be about a 30 min case.

I have done a handful of umbilicals/inguinals in cripples with copious old school surgeon placed local and sh*tty MAC.

a lot of the approach is going to depend on how reasonable the surgeon and patient are.

there is nothing in your presentation that suggests difficult airway other than she is small, brittle, and old. If she isn’t kyphotic with a frozen neck and a reassuring airway exam then throw a tube in.

I’ve never spinaled an umbilical hernia, not that would never but plenty of other options for a small hernia so her scoliosis doesn’t mean much to me assuming she can lie flat and bend her neck.

Why was your attending so against a LMA? He must keyed in on something. so what am I missing? clearly you had some fireworks.

Tbh other than an small mouth the pt did not have any difficult airway signs.
This particular attending does not like LMAs and avoids them as much as she Can. So Yeah she decided to go for a spinal, 10 mg heavy bupi, 25 mcg fent

 

[IMGASMD]

Went high?

Prop sux tube?

 

[amyl]

Ugh. Why? Why annoyingly complicate this dumb case? And I love spinals but twisted old people and short cases are not great combos for spinals. This sounds like an academic center so I’m guessing longer case… I’d do spinal in a pulmonary cripple but you said no comorbidities so I’d guess she’s just old….

 

[deleted162650]

This particular attending does not like LMAs and avoids them as much as she Can. So Yeah she decided to go for a spinal, 10 mg heavy bupi, 25 mcg fent

We all need some negative role models in residency.

 

[coffeebythelake]

91 year old female, 88 lbs 4‘9, scheduled for umbilical hernia repair (1 cm or less), no known comorbidities. Patient is badly scoliotic. Her vitals and labs are all normal. What is you plan? (This is. A case I had today, pretty standard but it kinda went sideways midway trough).

Scoliosis causing significant cardiopulmonary effect? Restrictie lung disease? Pulminary hypertension? Is the patient even able to lay flat? Depending on surgeon and circumstances might consider local plus light sedation. Others already mentioned LMA. Spinal is pretty far down on my list of possibly plans for this pt. Just getting it in might be an exercise in frustration.

 

[MirrorTodd]

Undiagnosed severe AS?

 

[MirrorTodd]

But seriously (and obviously, this question doesn't work) why are you all even doing this case? Is it strangulated or incarcerated or something? Is it causing tons and tons of pain? Is this 91 y/o lady having trouble finding sexual partners cause they are turned off by the hernia?

 

[GassYous]

But seriously (and obviously, this question doesn't work) why are you all even doing this case? Is it strangulated or incarcerated or something? Is it causing tons and tons of pain? Is this 91 y/o lady having trouble finding sexual partners cause they are turned off by the hernia?

This is the truth why waste time

Your attending sounds like a bozo op. Plenty of those in academia unfortunately.

 

[DocMcCoy]

Also, cases with this type of attending tend to go sideways often.

you did say about midway through. I’m guessing difficult spinal. You ended up thinking it was in. Started case and patchy/incomplete/failed necessitating a different plan

 

[IMGASMD]

This is the truth why waste time

Your attending sounds like a bozo op. Plenty of those in academia unfortunately.

I think OP maybe in Mexico? But there are people who like to tempt fate everywhere everyday.

Had a 95 yo with gallstones, wanted a lap chole.

75 yo walking talking had a expansion of his aaa now 6.7cm, wanted operation…. I don’t know what are the right answers.

 

[Sleeplessbordernights]

Also, cases with this type of attending tend to go sideways often.

you did say about midway through. I’m guessing difficult spinal. You ended up thinking it was in. Started case and patchy/incomplete/failed necessitating a different plan

Exactly that, my attending did the spinal because I could not, but the pt had pain once surgery started, they used local, but We started having symptomsof LAST

 

[Sleeplessbordernights]

But seriously (and obviously, this question doesn't work) why are you all even doing this case? Is it strangulated or incarcerated or something? Is it causing tons and tons of pain? Is this 91 y/o lady having trouble finding sexual partners cause they are turned off by the hernia?

Tbh the pt wasnt even aware of her sorroundings but surgery wanted to do it

 

[Radetzky]

Tbh the pt wasnt even aware of her sorroundings but surgery wanted to do it

They did a hernia repair on a demented 90 yr old? Who consented to it?

 

[Planktonmd]

My attending said it was his last choice so we did not go that way

Why?

 

[Planktonmd]

An alternative would be bilateral rectus sheath block then Propofol + Ketamine infusion... but why not just a good old LMA?

 

[JiPo]

Exactly that, my attending did the spinal because I could not, but the pt had pain once surgery started, they used local, but We started having symptomsof LAST

How much local did surgeons use?

Did you end up giving intralipid?

 

[coffeebythelake]

How much local did surgeons use?

This. Thr spinal dose of local is a drop in yhr bucket

 

[JiPo]

This. Thr spinal dose of local is a drop in yhr bucket

Whenever I have small patients, I ask surgeon what local they plan on using, and I tell them the maximum volume they can use. LAST is such a rare event with local infiltration, but I'd like to think that this adds another layer of safety.

 

[dannyboy1]

Prop gtt + surgeons local. Why complicate things.

 

[patriot6]

We all need some negative role models in residency.

This is so true; negative role models are as necessary as positive ones.

I had a similar case in training in a patient with severe AS. My attending insisted on a SAB. I realized just how hard it is to kill people that day as the patient did fine. Of course, there's the alternative too -- when you look at a patient the wrong way and they code.

 

[coffeebythelake]

This is so true; negative role models are as necessary as positive ones.

I had a similar case in training in a patient with severe AS. My attending insisted on a SAB. I realized just how hard it is to kill people that day as the patient did fine. Of course, there's the alternative too -- when you look at a patient the wrong way and they code.

Severe AS for spinal? That's some balls. What was the rationale for it?

 

[patriot6]

Severe AS for spinal? That's some balls. What was the rationale for it?

Nothing that makes sense. In residency, I almost enjoyed the days with off the wall/borderline dangerous plans, or when SHTF… the full stomach IV infiltration during RSI type stuff… There was always this small sense of “well it’s someone else’s problem if something goes awry”. I wonder if that’s how CRNAs feel. I always felt like they were awesome learning opportunities… to experience crisis situations on someone else’s license. Now that I’m out on my own, it’s much different.

 

[nimbus]

Scoliosis causing significant cardiopulmonary effect? Restrictie lung disease? Pulminary hypertension? Is the patient even able to lay flat? Depending on surgeon and circumstances might consider local plus light sedation. Others already mentioned LMA. Spinal is pretty far down on my list of possibly plans for this pt. Just getting it in might be an exercise in frustration.

If the patient can’t lie flat, that’s a good reason to put them to sleep.

 

[DrOwnage]

Low dose Isobaric bupi (7.5-10mg)for patients with mod-severe AS works out fine. Had a regional attending in residency who did it tons of times with no issues.

 

[IMGASMD]

Low dose Isobaric bupi (7.5-10mg)for patients with mod-severe AS works out fine. Had a regional attending in residency who did it tons of times with no issues.

Just need to have someone who has balls to do it. It’s one of those dogmas, if the patient is harmed or dead, won’t be a lot of literature to support its use.

I still remember one of my attending wanted to do a spinal on one of the patients with mod-severe AS. My chief resident at the time basically threw the tray back at him and said, you do it, I am not going to have my name on the chart. I forgot what was the final anesthetics.

Good times good time.

 

[Aheadbyacentury]

Ugh. Why? Why annoyingly complicate this dumb case? And I love spinals but twisted old people and short cases are not great combos for spinals. This sounds like an academic center so I’m guessing longer case… I’d do spinal in a pulmonary cripple but you said no comorbidities so I’d guess she’s just old….

I agree with sometimes things complicating things, but spinal usually simplifies matters. You have no idea how many GU cases that went smoothly because I chose a spinal vs.. a GENERAL..

 

[Aheadbyacentury]

An alternative would be bilateral rectus sheath block then Propofol + Ketamine infusion... but why not just a good old LMA?

YOu would have def. gotten LAST with that.

 

[Aheadbyacentury]

. I wonder if that’s how CRNAs feel.

That is why they are so cavalier..

 

[Planktonmd]

YOu would have def. gotten LAST with that.

Really? who told you that?
I have been doing bilateral rectus sheath blocks almost daily for years and never had a problem

 

[sevo00]

YOu would have def. gotten LAST with that.

no you wouldn’t

 

[coffeebythelake]

Just need to have someone who has balls to do it. It’s one of those dogmas, if the patient is harmed or dead, won’t be a lot of literature to support its use.

I still remember one of my attending wanted to do a spinal on one of the patients with mod-severe AS. My chief resident at the time basically threw the tray back at him and said, you do it, I am not going to have my name on the chart. I forgot what was the final anesthetics.

Good times good time.

Still sounds like a bad idea, and good luck defending it to your fellow anesthesiologists if something happened to patient. If you really wanted to do neuraxial for a patiwnt with severe AS, I would fluid load them, dose it up slow through an epidural. An art line wouldn't hurt.

 

[Arch Guillotti]

Mod AS never had a problem. “Severe” gives me pause. Depends on how bad it really is.

 

[nimbus]

Aline, phenylephrine drip, and spinal would probably be okay in many cases.

 

[deleted162650]

Isobaric spinal is more hemodynamically gentle than inducing GA in many cases.

 

[DrOwnage]

Isobaric spinal is more hemodynamically gentle than inducing GA in many cases.

I put an isobaric 2.5cc in a patient yesterday for a hip revision. Lasted the whole 3.5 hour operative time, patient was 100/60 the entire case without any pressors. Patient was moving his legs 4.5 hours after the shot. It was glorious.

 

[deleted162650]

patient was 100/60 the entire case

Not only that, but the BP comes down gradually and smoothly over several minutes with iso bupi. It’s very easy to stay on top of and correct if necessary.

I would venture that an isobaric spinal with a neo gtt is the most stable (and easiest to maintain stability) anesthetic you can do.

 

[sethco]

Mod AS never had a problem. “Severe” gives me pause. Depends on how bad it really is.

Out of curiosity, how do you define bad? By symptoms? Indexed Valve Area? Peak/Mean gradient? What about patients with low-output AS?

 

[Arch Guillotti]

Out of curiosity, how do you define bad? By symptoms? Indexed Valve Area? Peak/Mean gradient? What about patients with low-output AS?

Mostly guess

 

[OTCAwesome]

I agree with sometimes things complicating things, but spinal usually simplifies matters. You have no idea how many GU cases that went smoothly because I chose a spinal vs.. a GENERAL..

Why even bother with the spinal for GU cases. I've been doing 99% of mine just under prop/lido mac for a long time now.

 

[coffeebythelake]

Why even bother with the spinal for GU cases. I've been doing 99% of mine just under prop/lido mac for a long time now.

Massive aspiration risk might be one indication. 2nd or 3rd trimester Pregnant patient might be another.

 

[Arch Guillotti]

Why even bother with the spinal for GU cases. I've been doing 99% of mine just under prop/lido mac for a long time now.

obese, reflux, terrible lungs, long procedure, stimulating procedure, difficulty laying flat, etc etc etc

 

[Aheadbyacentury]

Why even bother with the spinal for GU cases. I've been doing 99% of mine just under prop/lido mac for a long time now.

Hard to do a TURP under MAC, and the higher up recalcitrant stones in the kidney or UPJ really need more than a mac. Even an LMA wont do.. If they are just throwing a stent up, MAC all day long, but if they are lasering and basketing and doing all this high up...... it will be problematic

 

[GassYous]

Also if they are bovieing lateral and you don't have an obturator block the legs may come in and you can perf the bladder

 

[JiPo]

obese, reflux, terrible lungs, long procedure, stimulating procedure, difficulty laying flat, etc etc etc

For long procedures or difficulty laying flat, wouldnt you want to tube them?

 

[Aheadbyacentury]

Also if they are bovieing lateral and you don't have an obturator block the legs may come in and you can perf the bladder

For bladder surgery, it is best to check with the urologist.

 

[Velefunt]

I think OP maybe in Mexico? But there are people who like to tempt fate everywhere everyday.

Had a 95 yo with gallstones, wanted a lap chole.

75 yo walking talking had a expansion of his aaa now 6.7cm, wanted operation…. I don’t know what are the right answers.

95yo - symptomatic cholelithiasis can suck daily, proceed with surgery if optimized

75yo - proceed with endovascular AAA repair

To quote the extremes and the borderline ridiculous, we've had people pulled out of hospice for total hips s/p fracture, and we've had people pulled out of stirrups after hours of being complete and pushing, to place a labor epidural. On those days, in my mind, Tina Turner's "Private Dancer" plays on...

Edit: My anesthetic plan would have been iGel if edentulous, otherwise any old LMA would do...