my call case

[militarymd]

40 something

end stage liver disease from etoh abuse.

tips 2 years ago for variceal hemorrhage and uncontrollable ascites.

has intermittent ascites and encephalopathy

on sodium restricted diet and lasix and aldactone.

on nadolol...even though tips was done already

on low protein diet but ammonia level still 60 to 80....lactulose not effective per family report.

Came to preop from ortho office of closed reduction vs ex-fix vs orif of fore arm fx.

No labs.

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[Noyac]

No labs.

 

[militarymd]

I ordered a cbc and PT/PTT...would you ordered anything else?

 

[Noyac]

I ordered a cbc and PT/PTT...would you ordered anything else?

Not necessarily. Maybe an albumin but whats funny to me is that the orthopods usually order everything under the sun for these pts. I guess your orthopod thinks he can do this with a closed reduction and some sedation.

 

[Jeff05]

K+ would be nice.
i would do a supraclavicular block. i would use u/s if pt is coagulopathic - potentially fewer needle passes and less chance of hitting subclavian a/v.

 

[militarymd]

40 something

end stage liver disease from etoh abuse.

tips 2 years ago for variceal hemorrhage and uncontrollable ascites.

has intermittent ascites and encephalopathy

on sodium restricted diet and lasix and aldactone.

on nadolol...even though tips was done already

on low protein diet but ammonia level still 60 to 80....lactulose not effective per family report.

Came to preop from ortho office of closed reduction vs ex-fix vs orif of fore arm fx.

No labs.

oh I forgot...just finished chemo + radiation for squamous cell of the tongue 2 months ago...and left the hospital 2 weeks ago after getting treated for SBP.

 

[Planktonmd]

Interscalene block.

 

[militarymd]

although not formally diagnosed...based on my exam, she also likely has hepatopulmonary syndrome.

 

[joshmir]

what PE findings help you diagnose that?

also, how does the presence of hepatopulmonary syndrome change your management? are you less likely to use positive pressure ventilation?

 

[militarymd]

what PE findings help you diagnose that?

also, how does the presence of hepatopulmonary syndrome change your management? are you less likely to use positive pressure ventilation?

orthodeoxia...spelling???

not very reponsive to supplement Oxygen..

Management?....I'm was not sure.

 

[Planktonmd]

Hepatopulmonary syndrome is common in end stage liver disease whenever there is significant portal hypertension (even after a TIPPS procedure), and if the patient is having trouble maintaining her oxygenation preop, the phrenic blockade caused by an interscalene block might not be well tolerated.
This could make a supraclavicular or infraclavicular block more attractive.

 

[militarymd]

Portal hypertension DOES NOT cause HPS...and TIPS does NOT treat HPS.

 

[Noyac]

Hepatopulmonary syndrome is common in end stage liver disease whenever there is significant portal hypertension (even after a TIPPS procedure), and if the patient is having trouble maintaining her oxygenation preop, the phrenic blockade caused by an interscalene block might not be well tolerated.
This could make a supraclavicular or infraclavicular block more attractive.

Infraclacviular would be my choice due to location of the injury.

 

[Planktonmd]

Hypoxia in a patient with advanced liver disease could be:
1- Portopulmonary hypertension.
2- Hepatopulmonary syndrome.
3- Pleural effusions related to liver disease.
4- Other nonspecific causes.
In a patient with known protal hypertension it is difficult to clinically differentiate between hepatopulmonary syndrome and portopulmonary hypertension.
But yes, they are 2 seperate entities that are often confused.

 

[Noyac]

Those that want to do a regional technique. Which local and how much?

 

[VentdependenT]

I ordered a cbc and PT/PTT...would you ordered anything else?

BMP for hepatorenal crud.

 

[VentdependenT]

No ISB for me in someone with big gut full of ascites and HPS. I like both diaphragms to work.

As for Regional, screw that. Ascites and liver failure = coagulopathic no matter what the INR/PTT shows. Thats a functional thrombocytopenia no matter how ya cut it. Sorry.

Swollen tongue s/p Chemo-rads? Nice. Hows that airway look? Is she drooling everywhere? Stridorous? Laryngeal involvement?

Asleep FOI. PCA for pain control. No nitrous. Have 2U FFP up. Pt's most likely gonna get em. Stick of ntg and stick of esmolol on hand to keep bp on normotensive side.

 

[Planktonmd]

Those that want to do a regional technique. Which local and how much?

Good point!
the metabolism of both esters and amides will be affected in severe liver disease but I guess as long as you keep your total dose under the toxic dose for that local anesthetic you should be ok.
Example: Lidocaine < 5mg/kg, Bupivacaine < 3mg/kg....
This means you can give up to 42 cc of Bupivacaine 0.5% in a 70kg patient.

 

[jetproppilot]

40 something

end stage liver disease from etoh abuse.

tips 2 years ago for variceal hemorrhage and uncontrollable ascites.

has intermittent ascites and encephalopathy

on sodium restricted diet and lasix and aldactone.

on nadolol...even though tips was done already

on low protein diet but ammonia level still 60 to 80....lactulose not effective per family report.

Came to preop from ortho office of closed reduction vs ex-fix vs orif of fore arm fx.

No labs.

Tell ortho dude to approximate it as best he can with closed reduction and throw a cast on.

A little propofol and ketamine MAC.

He'll save himself a buncha headaches with this conservative approach to her fracture.

And so will you.

Sometimes less is better.

 

[Pilot Doc]

Why not a bier block?

 

[johankriek]

Tell ortho dude to approximate it as best he can with closed reduction and throw a cast on.

A little propofol and ketamine MAC.

He'll save himself a buncha headaches with this conservative approach to her fracture.

And so will you.

Sometimes less is better.

then he is for sure to get a compartment syndrome.. and lose the arm

get the appropriate labs..

patient needs a general anesthetic.. Optimize the patient and put them to sleep.

hard to sedate someone whose respirations are already compromised and labored due to "intermittent ascites"; you are sure to run into some issues unless you are really lucky which i am not. general anesthetic with an ett with 10 per kg of tidal volume. put an invasive bp if you want.

 

[toughlife]

Hepatopulmonary syndrome is common in end stage liver disease whenever there is significant portal hypertension (even after a TIPPS procedure), and if the patient is having trouble maintaining her oxygenation preop, the phrenic blockade caused by an interscalene block might not be well tolerated.
This could make a supraclavicular or infraclavicular block more attractive.

Nice catch. I saw that this week on a somewaht large male pt who was c/o of SOB post IS block.

 

[toughlife]

Those that want to do a regional technique. Which local and how much?

wrong post.

 

[militarymd]

for Plank....ORTHODEOXYIA....


did it with 30 cc of 1 % lidocaine...around the axillary artery...

no sedation...no other labs.

Sodium restricted for the case.

Called the hepatologist to tell him to follow up with the patient if he wants.