Clinical case for Jet (and others)

[Noyac]

After wasting the past 10 min of my life reading that BS of a thread from Jet ( ha ha love ya man), I decided to post a case. Not sure how good it will be but here it is:

40 yo M went to the Doc because his leg was swelling mostly around the knee area. US performed and showed no DVT.
CT performed showed cancer throughout the abd and lungs. Primary source unknown at this time. He is added on to the endo schedule for an EGD in hopes of finding something to biopsy.
PMH: obesity BMI 42, DM II, HTN.
Pt originally was thought to have eaten full breakfast but later denied this and stated he only drank a cola at 11am.

Pt is obviously anxious. But very pleasant and cooperative. C/0 R LLE swelling, cough when recumbent, fatigue.

PE:
Airway MP 2 otherwise normal
CNS:anxious cooperative pleasant, no CN deficits
Abd: obese NT nondistended
Chest: distant BS at bases with expiration wheeze
EXT: swelling of R LLE

LABS: WNL's

What's your plan?

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[Planktonmd]

Give him an albuterol neb, then apply some topical Lidocaine to the mouth and pharynx.
put him on his side, give some Propofol and let the GI do the endoscopy.
What else do you want to do?

 

[criticalelement]

check ct to make sure no tumor in and around the tracheal structures more specifically anterior mediastinum. Check his a/w carefully to make sure there are no tumors or obstruction there.
If he is not fasted make sure he is fasted at time of anesthetic
Sure, treat his expiratory wheezes.
sublimaze, lido propofol keep him spontaneously breathing throughoutobviously

 

[Sonny Crocket]

check ct to make sure no tumor in and around the tracheal structures more specifically anterior mediastinum. Check his a/w carefully to make sure there are no tumors or obstruction there.
If he is not fasted make sure he is fasted at time of anesthetic
Sure, treat his expiratory wheezes.
sublimaze, lido propofol keep him spontaneously breathing throughoutobviously

Sublimaze? Really? IT'S CALLED FENTANYL!!

Sorry. Just had to clear that up.

 

[sevoflurane]

Sounds like the dude could have a full stomach...
To me, "Finding something to biposy" can mean this may or may not be an in and out case. Cancer throughout lungs AND abdomen means that he may have a subacute obstruction and that his lungs may not tolerate a little juice down the lungs. I'm leaning towards prop/sux/tube as it seems his AW is not an issue.
Ant. mediastinal masses can obstruct large central vessels and the trachea, so carefull review of the CT scan and the patients symptoms are in order. If need be... prop/tube while maintaining spontaneous ventialtion and negative intrathoracic pressure.

 

[soorg]

Never understood how they got Sublimaze from fentanyl, nor Ofirmev from acetaminophen.

 

[dhb]

EGD

Highlighted the important part, barring any symptoms of abdominal obstruction this is a propofol 5min case

 

[jetproppilot]

LOLLLL!!!!!
Love you too Noy lol

I gotta go with Plank's plan on this one, assuming it's 1PM or later.
Keep it simple.
I'd have a heart to heart conversation with the patient to make sure he understands how important it is that he didn't eat breakfast and if he is denying it, I'm taking his word for it.

 

[deleted171991]

Give him an albuterol neb, then apply some topical Lidocaine to the mouth and pharynx.
put him on his side, give some Propofol and let the GI do the endoscopy.
What else do you want to do?

+1, if properly NPO.

What's so scary about this patient?

 

[OB1🤙]

Cough when recumbent is... weird.

Wheezing without history of copd/asthma is less weird but still of potential concern given the presentation.

Definitely want to see the images from this CT scan...

 

[deleted171991]

Cough when recumbent is... weird.

GERD.

Wheezing without history of copd/asthma is less weird but still of potential concern given the presentation.

Depends on functional capacity. That's what would define my anesthetic plan. He could wheeze just from his weight, especially if the wheezes are at the bases.

Definitely want to see the images from this CT scan...

Again, it depends on what he can(not) do. If good functional capacity, I don't care about his CT, unless I feel there is risk for mediastinal mass.

 

[jetproppilot]

Cough when recumbent is... weird.

Wheezing without history of copd/asthma is less weird but still of potential concern given the presentation.

Definitely want to see the images from this CT scan...

Love you man, but I gotta call you out on this one.
You are there to STUN THE DUDE JUST ENOUGH SO GI COLLEAGUE CAN TAKE A LOOK WITH A SCOPE.
In this case setting, it doesn't matter what the CT Scan shows. This is a
MAC anesthetic for an
EGD.

You are not the patient's oncologist nor internist nor surgeon nor anesthesiologist looking at a complicated case! You are the anesthesiologist looking at a very SIMPLE case. An E.G.D.
Under M.A.C.

Ten minutes later when the case is done you can redirect your intellect to cases that are truly complicated.

DON'T MAKE SIMPLE CASES COMPLEX.

 

[OB1🤙]

Look, I don't disagree.

This is what I call Simulator Syndrome.

When they put you in the anesthesia simulator, you know SOMETHING awful is gonna happen.

When Noy posts a straightforward case for discussion, you know SOMETHING sinister is lurking.

So yeah, I want to see the CT. But if i imagine what I'd really do in real life, without the priming of "you're doing a case in a simulator," or "this is a case posted for discussion on SDN," then yeah. I have out some propofol and get ready for a straightforward scope.

After I take the 30 seconds it takes to pull up the CT.

 

[jetproppilot]

Look, I don't disagree.

This is what I call Simulator Syndrome.

When they put you in the anesthesia simulator, you know SOMETHING awful is gonna happen.

When Noy posts a straightforward case for discussion, you know SOMETHING sinister is lurking.

So yeah, I want to see the CT. But if i imagine what I'd really do in real life, without the priming of "you're doing a case in a simulator," or "this is a case posted for discussion on SDN," then yeah. I have out some propofol and get ready for a straightforward scope.

After I take the 30 seconds it takes to pull up the CT.

You just wasted 30 seconds of your life looking at that CT. IT ALL ADDS UP, DOCTOR!

lol

 

[OB1🤙]

I'm already on the computer checking the surf report. The CT is loading in the background...

 

[jetproppilot]

I'm already on the computer checking the surf report. The CT is loading in the background...

BOOOOM!!!!!!
Nicely played

 

[Arch Guillotti]

Love you man, but I gotta call you out on this one.
You are there to STUN THE DUDE JUST ENOUGH SO GI COLLEAGUE CAN TAKE A LOOK WITH A SCOPE.
In this case setting, it doesn't matter what the CT Scan shows. This is a
MAC anesthetic for an
EGD.

You are not the patient's oncologist nor internist nor surgeon nor anesthesiologist looking at a complicated case! You are the anesthesiologist looking at a very SIMPLE case. An E.G.D.
Under M.A.C.

Ten minutes later when the case is done you can redirect your intellect to cases that are truly complicated.

DON'T MAKE SIMPLE CASES COMPLEX.

I don't really think it is a mac case if you are giving enough propofol for the pt. to tolerate having a gigantic scope in the throat. The case seems rather ordinary to me although I suspect something sinister is lurking behind the cough and wheeze.

 

[jetproppilot]

I don't really think it is a mac case if you are giving enough propofol for the pt. to tolerate having a gigantic scope in the throat. The case seems rather ordinary to me although I suspect something sinister is lurking behind the cough and wheeze.

You can struggle with the nomenclature all you want. In the end, it doesn't really matter if you think it's a MAC or not. That's not the issue here.
We've all done MACs (or whatever your definition is for the anesthetic we provide as anesthesiologists for this procedure that entails titration of propofol to effect, sans endotracheal tube) for EGDs on thousands among thousands of patients annually, much more critically ill than this dude.
Done carefully, as you know, it can be done and it IS done in ORs and ICUs on a daily basis, safely, over and over and over, Every Day.

 

[pgg]

You just wasted 30 seconds of your life looking at that CT. IT ALL ADDS UP, DOCTOR!

lol

I wouldn't (and don't) look at CTs or CXRs for the vast, vast majority of my patients for anything they're getting done, but for a patient with known cancer mets throughout the chest and abdomen, who can't lie flat and breathe comfortably, I'm going to at least read the report to see what's up with the chest ...

 

[jetproppilot]

I wouldn't (and don't) look at CTs or CXRs for the vast, vast majority of my patients for anything they're getting done, but for a patient with known cancer mets throughout the chest and abdomen, who can't lie flat and breathe comfortably, I'm going to at least read the report to see what's up with the chest ...

LET'S SAY IT'S NOT READILY AVAILABLE.
Are you gonna postpone the case until you see it?

 

[pgg]

LET'S SAY IT'S NOT READILY AVAILABLE.
Are you gonna postpone the case until you see it?

Fair question. The board answer and real life answer is to examine the patient. I'd lay him down in preop and see how he did. If that was reassuring, no, I wouldn't chase down the CT.

 

[criticalelement]

give propofol to someone who has something funny in and around trachea and airway like a tumor obstructing will kill him. I saw a case like this 3 years ago. Anesthesiologist (not me) just signed off on the case. did not review the cat scan result which was (severe airway obstruction) dont remember exactly but it was some sort of tonsilar or head and neck cancer. It was ok when the scope was in stenting the airway but when the scope came out.. cant ventilate, cant intubate situation and the patient wascompletely obstructed.

Check the CT SCAN. It takes less than five minutes. If you cant find it call the radiologist personally. if there is some sort of obstruction give the gastroenterologist lidocaine jelly and say good luck. or if he wants to go through with it do an awake fiberoptic and secure the airway like that. Those of you who say.. takes too much time.. too big of a deal.. HORSE HOCKEY..The consequences of not doing that are too great.

 

[criticalelement]

You can struggle with the nomenclature all you want. In the end, it doesn't really matter if you think it's a MAC or not. That's not the issue here.
We've all done MACs (or whatever your definition is for the anesthetic we provide as anesthesiologists for this procedure that entails titration of propofol to effect, sans endotracheal tube) for EGDs on thousands among thousands of patients annually, much more critically ill than this dude.
Done carefully, as you know, it can be done and it IS done in ORs and ICUs on a daily basis, safely, over and over and over, Every Day.

Critically Ill and having tumors in and around the airway are two seperate animals. They each require and have their own anesthetic considerations.

 

[Noyac]

I love the responses. And almost every response is correct. It just depends on your approach.

There are many approaches that will work here.

Let's switch to "your approach" and why.

BTW, don't let Jet influence your approach.

He's a smart MoFo but there are other ways to skin this cat.

 

[jetproppilot]

Fair question. The board answer and real life answer is to examine the patient. I'd lay him down in preop and see how he did. If that was reassuring, no, I wouldn't chase down the CT.

I'll respond to you, and not this criticalelement clown with 14 posts who is chasing Academic Dogmas.
That's a Straight, Real Life Answer.
Pragmatically speaking, I assume this patient has been, in real life,
SLEEPING EVERY NIGHT....SOMEHOW....AND AWAKENING ALIVE....which means that
50-100mg propofol IV isn't gonna manipulate his pathophysiology in such a dramatic manner to
STRIKE HIM DEAD RIGHT THERE.

Gimme a break, criticalelement.
I do this for a living.

 

[pgg]

SLEEPING EVERY NIGHT....SOMEHOW....AND AWAKENING ALIVE....which means that
50-100mg propofol IV isn't gonna manipulate his pathophysiology in such a dramatic manner to
STRIKE HIM DEAD RIGHT THERE.

Weeeeelllll .... some patients sleep every night in their living room recliner in an upright position because they can't breathe flat. I'm just saying, the story deserves a little bit of thought and scrutiny to make SURE we don't tip someone over the edge.

 

[deleted171991]

They will not lie flat for an EGD. They will lie left lateral with elevated HOB. They can be at 45 degrees for all we care.

 

[jetproppilot]

Weeeeelllll .... some patients sleep every night in their living room recliner in an upright position because they can't breathe flat. I'm just saying, the story deserves a little bit of thought and scrutiny to make SURE we don't tip someone over the edge.

I can ASSURE YOU
Carefully Titrated Propofol for an EGD
WILL NOT
tip this dude over the edge.
And you really don't need the CT.

(are we really having this conversation?)

Look, I realize banter and conversation is great!
I'm also all about
SIMPLICITY and
NOT CREATING SMOKE WHERE NO SMOKE IS NEEDED.

This is an

EGD,

Ladies and Gentlemen.

This isn't a thoracotomy with one lung ventilation and all the s hit you have to worry about in that situation, starting with placement of a double lumen tube....

This isn't a Major Abdominal Case where you're worried about venous access for significant blood loss and Third Space Loss and monitoring blood loss and arterial lines and CVPs......

This is an

EGD.

Where you carefully titrate pharmacologic substances we are all very familiar with to accomplish a

VERY SIMPLE GOAL....

an EGD.

I appreciate all the intellect here. Really. I do.
I also know that this
mental masturbation
Is why
Academic Centers Struggle With Efficiency.

 

[deleted171991]

Agree 100%. I was just too lazy to write it down, and my salad mixer is broken.

 

[jetproppilot]

I love the responses. And almost every response is correct. It just depends on your approach.

There are many approaches that will work here.

Let's switch to "your approach" and why.

BTW, don't let Jet influence your approach.

He's a smart MoFo but there are other ways to skin this cat.

WORD.

LIKE....YOU FEEL LIKE YOU NEED TO INTUBATE THIS CAT?

I don't think you do, but I'm not gonna argue your decision.

As long as you Get The Tube In and don't Create Drama With The Paralysis You Caused With Your Muscle Relaxant You Gave
To Get The Tube In.

Which leads to a very important concept I learned long ago:

LESS IS MORE.

Think about that for a minute.

Let it sink in.

If you're smart,

It will serve you well for the rest of your career.

 

[risnwb]

If no ct available, I topicalized with 4% lido as if I'm gonna do an awake, then I let the gi go to town, with the caveat that if patient isn't tolerating reasonable doses of propofol, we can always pull out the scope, and put in a tube and get patient deeper. Basically as long as spontaneous ventilation is maintained, I agree hat this guy is extremely unlikely to be a lost airway. I mean, if we are concerned about ant mediastinal mass, we do an awake or a spontaneously breathing slowly titrated induction anyway, so what's the harm in trying to do the egd without intubating...

 

[Noyac]

You guys/gals are way too smart. This was a trick case sort of. The point I was going to make is that, all too often we think we need to sedate pts for endoscopy case. When many times, all we need to do is make them comfortable and cooperative.

I didn't have a whole lot of info on this guy but I had what I needed. A motivated pt with a serious issue and he didn't need to be delayed for too long. I could have delayed him til next week but what would that have gained?

I topicalized him as if I was doing an AFOI sans the transtracheal. I gave him zero sedation. Not even any versed.

My point is that, since the advent of propofol, everyone thinks we need to have pts that don't move, don't grosn and are completely still for the entire endo case. This is just so wrong. Btw this pt didn't moan, groan or move. He just watched the screen as if it was youtube.

 

[jetproppilot]

Turns out Noy is smarter than me!!!!
Awesome man.


LESS IS MORE.

 

[Planktonmd]

I don't think zero sedation was absolutely necessary!

 

[Noyac]

I don't think zero sedation was absolutely necessary!

Your correct but that wasn't there point of the case.

 

[BuzzPhreed]

This is an

EGD,

Ladies and Gentlemen.

This isn't a thoracotomy with one lung ventilation and all the s hit you have to worry about in that situation, starting with placement of a double lumen tube....

This isn't a Major Abdominal Case where you're worried about venous access for significant blood loss and Third Space Loss and monitoring blood loss and arterial lines and CVPs......

This is an

EGD.

I'm sure that all the doctors present when Joan River's coded were saying the exact same thing. Just sayin'.

 

[Planktonmd]

I'm sure that all the doctors present when Joan River's coded were saying the exact same thing. Just sayin'.

Yes they said that then ended doing a vocal cord biopsy!

 

[criticalelement]

I cant believe there are so many people who are missing the boat on this one. This is so elementary. it is so elementary people are missing the boat...

 

[RxBoy]

I'll respond to you, and not this criticalelement clown with 14 posts who is chasing Academic Dogmas.
That's a Straight, Real Life Answer.
Pragmatically speaking, I assume this patient has been, in real life,
SLEEPING EVERY NIGHT....SOMEHOW....AND AWAKENING ALIVE....which means that
50-100mg propofol IV isn't gonna manipulate his pathophysiology in such a dramatic manner to
STRIKE HIM DEAD RIGHT THERE.

I agree with Jet here. Propofol is a beautiful drug if you know how to use it. Propofol carefully titrated is an art form. I moonlight doing high turn over back to back MAC cases. One thing I learned is that giving propofol alone is very safe. I find that you run into problems when you start mixing things like fentanyl and versed. Or when you slam 200 of prop when 50 is all you needed.

 

[OB1🤙]

Good case, good points.

LAW 13: THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

 

[Sonny Crocket]

You guys/gals are way too smart. This was a trick case sort of. The point I was going to make is that, all too often we think we need to sedate pts for endoscopy case. When many times, all we need to do is make them comfortable and cooperative.

I didn't have a whole lot of info on this guy but I had what I needed. A motivated pt with a serious issue and he didn't need to be delayed for too long. I could have delayed him til next week but what would that have gained?

I topicalized him as if I was doing an AFOI sans the transtracheal. I gave him zero sedation. Not even any versed.

My point is that, since the advent of propofol, everyone thinks we need to have pts that don't move, don't grosn and are completely still for the entire endo case. This is just so wrong. Btw this pt didn't moan, groan or move. He just watched the screen as if it was youtube.

Nicely done! Good discussion

 

[RxBoy]

My point is that, since the advent of propofol, everyone thinks we need to have pts that don't move, don't grosn and are completely still for the entire endo case.

Before I misinform residents that might take my advise too literal, what noyac mentioned is the other key to my argument. Mac cases that can tolerate some movement, you can almost always get away with propofol. However Im not advocating titrating propofol on 90 year old respiratory cripple, ef of 10%, 4 previous laryngectomies, that needs to be perfectly still for an ophthalmologic procedure. You need to know your limits.

 

[nap$ter]

I cant believe there are so many people who are missing the boat on this one. This is so elementary. it is so elementary people are missing the boat...

you're alone on a boat

 

[sevoflurane]

Well $hit Noy... I expected a full McDonalds stomach with a partial SBO that aspirated on induction and then subsequently went into PEA from some massive ant. mediastinal mass case...

Sneaky Ninja Mofo.

 

[deleted171991]

Well $hit Noy... I expected a full McDonalds stomach with a partial SBO that aspirated on induction and then subsequently went into PEA from some massive ant. mediastinal mass case...

Sneaky Ninja Mofo.

This is not the oral boards.

 

[sevoflurane]

Well I'll share an old case that I'll never forget. This will be quick. There is only one thing to learn.

It involved an unknown ant. mediastinal mass pedi patient that presented to the ED after a MVC. 7 y/o patient arrives to the trauma bay accompanied only be EMS with very little history. The only thing that is known is that child has been seeing an oncologist and was in a bad MVC. GCS is 5 with obvious cranial hematoma and likely IC injury. There is no protected AW. Team decides to go with rapid sequence induction and then proceed to CT. Shortly after induction, HR drops to 20 bpm and BP drops to 40/20. Pressors aren't working nor is volume expansion. Things are going down a dark tunnel really fast.

What do you do?

 

[divinemsm]

What I've noticed over my 3 short years as an attending-is that the real deal seasoned attendings are sometimes too good for their own good. They've seen it all and done it all that nothing fazes them to the point of being lax -sometimes inappropriately. Most times -one's clinical spidey sense is dead on. And this NONSENSE about waiting for muscle relaxant to wear off post tube....in the case of a full stomach-sux or none at all otherwise. I rarely give muscle relaxant for GA tubes -of any type of case-bellies and all-overkill . If you're paying attention-you can tube and extubate and have no significant difference in time finishing case.

 

[deleted171991]

Well I'll share an old case that I'll never forget. This will be quick. There is only one thing to learn.

It involved an unknown ant. mediastinal mass pedi patient that presented to the ED after a MVC. 7 y/o patient arrives to the trauma bay accompanied only be EMS with very little history. The only thing that is known is that child has been seeing an oncologist and was in a bad MVC. GCS is 5 with obvious cranial hematoma and likely IC injury. There is no protected AW. Team decides to go with rapid sequence induction and then proceed to CT. Shortly after induction, HR drops to 20 bpm and BP drops to 40/20. Pressors aren't working nor is volume expansion. Things are going down a dark tunnel really fast.

What do you do?

Change the patient's position?

 

[IveGotTwins]

Well I'll share an old case that I'll never forget. This will be quick. There is only one thing to learn.

It involved an unknown ant. mediastinal mass pedi patient that presented to the ED after a MVC. 7 y/o patient arrives to the trauma bay accompanied only be EMS with very little history. The only thing that is known is that child has been seeing an oncologist and was in a bad MVC. GCS is 5 with obvious cranial hematoma and likely IC injury. There is no protected AW. Team decides to go with rapid sequence induction and then proceed to CT. Shortly after induction, HR drops to 20 bpm and BP drops to 40/20. Pressors aren't working nor is volume expansion. Things are going down a dark tunnel really fast.

What do you do?

Was the intubation successful but yet vitals suboptimal? It sounds like a (missed) failed intubation leading to hypoxia, brady, etc. If the intubation was successful with normal or reassuring O2 sat then I'll have to scratch my head for a minute.

 

[nap$ter]

Well I'll share an old case that I'll never forget. This will be quick. There is only one thing to learn.

It involved an unknown ant. mediastinal mass pedi patient that presented to the ED after a MVC. 7 y/o patient arrives to the trauma bay accompanied only be EMS with very little history. The only thing that is known is that child has been seeing an oncologist and was in a bad MVC. GCS is 5 with obvious cranial hematoma and likely IC injury. There is no protected AW. Team decides to go with rapid sequence induction and then proceed to CT. Shortly after induction, HR drops to 20 bpm and BP drops to 40/20. Pressors aren't working nor is volume expansion. Things are going down a dark tunnel really fast.

What do you do?

when it shows up on the cxr roll him lateral or prone. in addition to normal hypotension/bradycardic/mvc/postintubation rescuscitation/diagnostics...