How would you handle this case?

[dhb]

This is a case that we will discuss at a resident lecture. No i'm not trying to get my homework done by the sdn community (i have my ideas already)but the data provided is intriguing:

So 55 y/o male 5'6 120 lb to undergo a L4-L5 laminectomy for back pain in 1 month.
He is a smoker, and admits to a moderate alcohol intake, he is allergic to penicilline and was agitated in PACU after an appendicectomy in '99.
Home meds: Propanolol, B complex vitamins, inhaled B-blocker + anti-cholinergic, fentanyl patch since 1 month to control pain.

ECG : RSR, 50/min. Chest film shows emphysema.
Labs : Hb 9.2 G/dl, WBC 6400 /µl, plat 110000 /µl, BUN 59 mg/dl, Creat 1.6 mg/dl, GOT 35 UI/l, GPT 45 UI/l, GGT 229 UI/l, TCA 39 sec, INR 1.4, Na+ 135 meq/l, K+ 3.2 meq/l, Cl- 100meq/l.

Sorry no other data available but i guess you have a month to find out. So how would you manage the case + how would you control post-op pain, can you put an epidural in a patient having back surgery?
Thanks for your thoughts.

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[militarymd]

What I would tell the patient: "you go to sleep now"

"When you wake up, go see your doctor about your CRI"

 

[dhb]

"When you wake up, go see your doctor about your CRI"

well i don't think his CRF is his only problem...

 

[militarymd]

well i don't think his CRF is his only problem...

you're right....inhaling beta-blockers is his other problem.

 

[Lizard1]

you're right....inhaling beta-blockers is his other problem.

 

[apma77]

make sure he's not wheezing preop then give him periop albuterol tx
then put his a$$ to sleep and paralyze til the end
make sure he's strong enough to breath ok before pullin the tube

 

[Noyac]

No you can't put an epidural in. But you can give intrathecal MS.

Why is his INR up?

You may not be able to paralyze if they are monitoring SSEP's/MEP's.

I'd put him to sleep run a propofol infusion with sufenta or fentanyl infusion and a wiff of gas < 1/2 MAC. We do spinal monitoring.

You can make a big deal about the emphysema but its not that big a deal. Especially if he isn't on home O2.

 

[EV-Stentor]

Hey this is a pretty routine case around here..NYC
Like Mil said, its sleep sleep sleep. INR is acceptable if surgeon is not a hacker. No need for A-line here...only one level lami. Routine monitoring plus SSEP & EMG.
Premed with Albuterol nebs, induce with propofol or etomidate / fentanyl & use sux to place tube...will boost that lowish potassium a touch (correct this intra-op with 40meq KCl). SSEP is now pretty much standard in these cases so 0.5 mac Iso and propofol or remi gtt . At the end of case ask surgeon to infitrate with bupivacaine and start the dude on an IV PCA in PACU use fentanyl instead of morphine. CRI and emphysema aren't too severe here..will hydrate appropriately and tell dude to quit smoking and inhaling Beta-blockers Its all good I know what you meant but couldn't resist

 

[jwk]

That unexplained 9.2 Hgb concerns me a little, but other than that, this case wouldn't arouse me too much......unless the end of the story ends up being, "he arrested and died intra-op" in which case I reserve the right to extend and revise my remarks in all future posts in this thread.

 

[jetproppilot]

This is a case that we will discuss at a resident lecture. No i'm not trying to get my homework done by the sdn community (i have my ideas already)but the data provided is intriguing:

So 55 y/o male 5'6 120 lb to undergo a L4-L5 laminectomy for back pain in 1 month.
He is a smoker, and admits to a moderate alcohol intake, he is allergic to penicilline and was agitated in PACU after an appendicectomy in '99.
Home meds: Propanolol, B complex vitamins, inhaled B-blocker + anti-cholinergic, fentanyl patch since 1 month to control pain.

ECG : RSR, 50/min. Chest film shows emphysema.
Labs : Hb 9.2 G/dl, WBC 6400 /&#181;l, plat 110000 /&#181;l, BUN 59 mg/dl, Creat 1.6 mg/dl, GOT 35 UI/l, GPT 45 UI/l, GGT 229 UI/l, TCA 39 sec, INR 1.4, Na+ 135 meq/l, K+ 3.2 meq/l, Cl- 100meq/l.

Sorry no other data available but i guess you have a month to find out. So how would you manage the case + how would you control post-op pain, can you put an epidural in a patient having back surgery?
Thanks for your thoughts.

Like Jeff Pisto said back when we were residents at a morning conference,

"Fentanyl, propofol, sux, tube, and go with the flow." Classic line.

Normal GA. Most places arent gonna do SSEPs for a one-level-lam.

Pre-op nebs don't make a difference unless active bronchospasm is present....in other words are useless prophylactically. Mast cell degranulation inhibitors are useful prophylactically. Not B2 agonists.

No need to treat the K+.

Minimal EBL expected so Hb 9 shouldnt be a big deal but I'd T&S anyway.

Very routine case.

Needs to see an internist at some point, like Mil said for all the "workups" post-op....anemia, Cr 1.6, etc

 

[EV-Stentor]

Like Jeff Pisto said back when we were residents at a morning conference,

"Fentanyl, propofol, sux, tube, and go with the flow." Classic line.

Normal GA. Most places arent gonna do SSEPs for a one-level-lam.

Pre-op nebs don't make a difference unless active bronchospasm is present....in other words are useless prophylactically. Mast cell inhibitors are useful prophylactically. Not B2 agonists.

No need to treat the K+.

Minimal EBL expected so Hb 9 shouldnt be a big deal but I'd T&S anyway.

Very routine case.

Needs to see an internist at some point, like Mil said for all the "workups" post-op....anemia, Cr 1.6, etc

Hey Jet, i agree that the K+ is not a big deal but would it be wrong to fix it (probably for one own's sake )?
Oh I meant to thank you for the advice regarding private practice...Gracias dude!

 

[jetproppilot]

Hey Jet, i agree that the K+ is not a big deal but would it be wrong to fix it (probably for one own's sake )?
Oh I meant to thank you for the advice regarding private practice...Gracias dude!

My pleasure, Dude.

Absolutely no harm in fixing it.....but now you're sounding like an internist....creating more work than necessary....

 

[Noyac]

OK, so we all agree that we would do this case without reservations. I wouldn't replace the K+, no pre-op nebs, just Pisto style for me. By the way, no etomidate for me either.

But this is a resident lecture. So lets approach it that way. This guy has emphysema and has a Hgb of 9. This is wrong. His plts are normal but low. His kidneys are failing. And his coags are up.

What do you guys make of this?


I know send him to a internist after the surgery.

 

[dhb]

OK, so we all agree that we would do this case without reservations. I wouldn't replace the K+, no pre-op nebs, just Pisto style for me. By the way, no etomidate for me either.

But this is a resident lecture. So lets approach it that way. This guy has emphysema and has a Hgb of 9. This is wrong. His plts are normal but low. His kidneys are failing. And his coags are up.

What do you guys make of this?


I know send him to a internist after the surgery.

That's sort of where i wanted to go: overall he looks ok but his anemia is disproportionate to his renal failure and his urea too makes me think he could be bleeding in his GI track + his meds propanolol + vitB (+ anemia+ lox plat) makes me think of cirrhosis and portal hypertension... wouldn't you like to take a look at his upper gi before putting him to sleep?

I also think he should see an internist but since surgery is planned in 1 month i'd rather having him go before than after...
I'd give him some Vit K cause his INR is pretty ****ty for someone not on anticoagulation (i think i remember that the difference in coagulation is much steeper at the beginning meaning there is a much bigger difference between INR of 1 and 2 than from 4-8)
Plus i'd like to get his Hb higher since there's time with some iron + vit

 

[Laryngospasm]

The guy admits to "moderate" alcohol use, we all know what this usually means, a fifth of jack a day. Probably alcohol induced thrombocytopenia, with chronic liver damage resulting in the elevated INR, although the ast/alt ratio is def not classic, but the ggt is high, the anemia is due to the renal insufficiency.
I suppose you could get into the whole diagnosing anemias, platelet disorders etc, but that is the territory of the internist. The case can still be done, but if there is time and non emergent I would reccomend a medicine consult, this dude is much sicker than he appears, and probably has very little reserve. I think with this case you are setting yourself up for trouble if something goes wrong, JMHO

 

[EV-Stentor]

The guy admits to "moderate" alcohol use, we all know what this usually means, a fifth of jack a day. Probably alcohol induced thrombocytopenia, with chronic liver damage resulting in the elevated INR, although the ast/alt ratio is def not classic, but the ggt is high, the anemia is due to the renal insufficiency.
I suppose you could get into the whole diagnosing anemias, platelet disorders etc, but that is the territory of the internist. The case can still be done, but if there is time and non emergent I would reccomend a medicine consult, this dude is much sicker than he appears, and probably has very little reserve. I think with this case you are setting yourself up for trouble if something goes wrong, JMHO

Hey Spasm, I know you are trying to be academic here but "setting yourself up for trouble"? I completely disagree since from what is known right now and can be foreseen there is no contraindication to surgery or general anesthesia.
Let him see the flea who will optimize since we have time but here are my toughts: If you are really worried about portal HTN from cirrhosis (which I agree is possible even with this ast/alt ratio) get an abdominal sono and if unsatisfied check SAAG...>1.1 is diagnostic. Check urine lytes and make sure we don't have Hepato-Renal syndrome on our hands, maybe some FeSO4 and Epogen--depending on findings, see nutritionist ( i am not sure what his albumin is), stop smoking, stop drinking, & vit K.
I am not sure what his exercise tolerance is but if satifactory and given his EKG...no need for echo or other cardiac eval for EtOH induced cardiomyopathy or CAD...i think the CXR only show emphysema and no Cardiomegaly.
Okay I got to run and but just my $.02 for now, thanks.

 

[Noyac]

That's sort of where i wanted to go: overall he looks ok but his anemia is disproportionate to his renal failure and his urea too makes me think he could be bleeding in his GI track + his meds propanolol + vitB (+ anemia+ lox plat) makes me think of cirrhosis and portal hypertension... wouldn't you like to take a look at his upper gi before putting him to sleep?

I also think he should see an internist but since surgery is planned in 1 month i'd rather having him go before than after...
I'd give him some Vit K cause his INR is pretty ****ty for someone not on anticoagulation (i think i remember that the difference in coagulation is much steeper at the beginning meaning there is a much bigger difference between INR of 1 and 2 than from 4-8)
Plus i'd like to get his Hb higher since there's time with some iron + vit

Now we are getting somewhere.
This guy is a wreck. He probably has liver dysfunction. AST and ALT won't show this b/c they can be high, low or normal depending on how long the problem has been there. Albumin would show it and coags, which we have.
This guy has bigger problems than his back pain.
I would do the case if need be but I am sure that the spine guys I work with would not want to proceed without some answers. How to do this case would not be difficult but does it need to be performed b/4 we know what is going on with this guy?

Personally, I would send him to the internist. I would want his coagulopathy corrected and his anemia resolved or at least T&C him. I also wouldn't pass an OG tube during the case.

 

[MTGas2B]

During my anesthesia elective month as an intern I saw single level lamis done under MAC with single shot epidural. No neurosurg residents and a fast surgeon/PA combo. The brave residents would inject in the epidural space in pre-op holding then head back. The conservative ones would place a catheter in holding, double check the block once they were in the room, reinject if necessary, then pull the catheter as prepping started. Then run a light propofol gtt.

This guy INR 1.4, not entirely out of the question. Slow surgery team, then probably contraindicated.

 

[Laryngospasm]

Hey Spasm, I know you are trying to be academic here but "setting yourself up for trouble"? I completely disagree since from what is known right now and can be foreseen there is no contraindication to surgery or general anesthesia.
Let him see the flea who will optimize since we have time but here are my toughts: If you are really worried about portal HTN from cirrhosis (which I agree is possible even with this ast/alt ratio) get an abdominal sono and if unsatisfied check SAAG...>1.1 is diagnostic. Check urine lytes and make sure we don't have Hepato-Renal syndrome on our hands, maybe some FeSO4 and Epogen--depending on findings, see nutritionist ( i am not sure what his albumin is), stop smoking, stop drinking, & vit K.
I am not sure what his exercise tolerance is but if satifactory and given his EKG...no need for echo or other cardiac eval for EtOH induced cardiomyopathy or CAD...i think the CXR only show emphysema and no Cardiomegaly.
Okay I got to run and but just my $.02 for now, thanks.

No, stent, not trying to be "academic", just answering noyacs ?, and what I said was to get a consult for these issues if there was time, and there is. As for setting yourself up for trouble if you do an elective lami in a patient like this without further digging I respect your opinion.

 

[dhb]

you're right....inhaling beta-blockers is his other problem.

wow! i only thought of it and got it right now; little brain fart while translating the case

 

[apma77]

this is a pretty straight forward case
just put him to sleep and dont waste time getting more tests

 

[jetproppilot]

Let him see THE FLEA.. .

AHHHHHHH.......a dude who knows the lingo...

 

[dhb]

this is a pretty straight forward case
just put him to sleep and dont waste time getting more tests

Waste time?? the intervention is programmed in 1 month

His Hb is 9 (pretty abnormal for a copd kind of guy) do you want to risk to have to transfuse him or would you rather correct it before (and figureout where it comes from)
His INR is 1.4 wouldn't you like to have it corrected
Wouldn't you like to know if he has portal hypertension and varices before they bust intra-op?

 

[militarymd]

Waste time?? the intervention is programmed in 1 month

His Hb is 9 (pretty abnormal for a copd kind of guy) do you want to risk to have to transfuse him or would you rather correct it before (and figureout where it comes from)
His INR is 1.4 wouldn't you like to have it corrected
Wouldn't you like to know if he has portal hypertension and varices before they bust intra-op?

Why would they bust Intr-op when all the dynamics associated with portal hypertension are reversed under GA.

And what's a flea going to do to decrease his portal hypertension.

 

[dhb]

Why would they bust Intr-op when all the dynamics associated with portal hypertension are reversed under GA.

Not saying that they would, the main points here are his anemia and inr, if you or one of your family members where to be operated on would you okay them with those numbers?
I think there's time to get the guy fix and avoid potential problems.

 

[militarymd]

Not saying that they would, the main points here are his anemia and inr, if you or one of your family members where to be operated on would you okay them with those numbers?

Abso fuc kin lutely.

I think there's time to get the guy fix and avoid potential problems.

You can't fix chronic liver disease....you can only prevent progression....which will ALWAYS progress in alcoholics....so the best way to optimize the patient ....is to do the case ASAP...before the disease gets worse.

 

[EV-Stentor]

Why would they bust Intr-op when all the dynamics associated with portal hypertension are reversed under GA.

And what's a flea going to do to decrease his portal hypertension.[/QUOTE]
Hey Mil I cannot agree with you more..this case can proceed pronto and all the flea will do is start dude on very small dose of Nadolol for variceal rupture prophylaxis that is if the dude's low HR can tolerate it. Some fleas would even recommend a TIPS which would still take longer than 1 month to manifest appreciably in terms of Portal HTN...basically DO the case now

 

[militarymd]

Why would they bust Intr-op when all the dynamics associated with portal hypertension are reversed under GA.

And what's a flea going to do to decrease his portal hypertension.[/QUOTE]
Hey Mil I cannot agree with you more..this case can proceed pronto and all the flea will do is start dude on very small dose of Nadolol for variceal rupture prophylaxis that is if the dude's low HR can tolerate it. Some fleas would even recommend a TIPS which would still take longer than 1 month to manifest appreciably in terms of Portal HTN...basically DO the case now

I believe the a m of gastroenterology has no recommendations for prophylactic TIPS....unless you have intractable ascites.