Today's Anesthesia Consult

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Noyac said:
Wow, nice responses everyone. Let me address a few things off the top of my head.

FFP: you wanted to optimize this guy, right? How do you plan to do this? He had no improvement with bronchodilators during the PFT's. He won't stop smoking. He has no coronary issues that can be addressed. It will take many months for him to lose weight if at all.

Those of you that considering a CSE, at what level would you do this? This is an upper abdominal incision ( polyp in transverse colon). Your epidural will be ****. Poor plan IMO.

Those that want to do this under regional, how many of these cases have you done this way? Because if you haven't done quite a few then you are dreaming. Recipe for disaster. This is not the guy to experiment on.

Airway is the least of my worries in this case. Just had to state that one.

Anes121508, while your status says med stud, your responses say CA -1. Keep it up. You are thinking and that is good. But your focus needs some refining. Please take this as a compliment. Don't get caught up in all the details. Think about how you might get this guy through the case safely and then how you might help to make sure he leaves the hospital on his own two feet.
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As I said, it would take a very motivated patient. Smoking cessation, exercise program, significant weight loss, CPAP, treatment of PHTN if the case. Even then, God knows... Obviously, this guy sounds anything but the right patient for these.

I always like to put everything in balance and go from there. Obviously, if he gets diagnosed with colon cancer, the risks/benefits discussion would be different.
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I gotta say Noy, you have the weirdest F'in patients.
 
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So I thought exercise was we had to do the case?

Now that we have discussed, noy, how would u approach it ?(assuming we have to proceed)
 
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Noyac said:
Wow, nice responses everyone. Let me address a few things off the top of my head.

FFP: you wanted to optimize this guy, right? How do you plan to do this? He had no improvement with bronchodilators during the PFT's. He won't stop smoking. He has no coronary issues that can be addressed. It will take many months for him to lose weight if at all.

Those of you that considering a CSE, at what level would you do this? This is an upper abdominal incision ( polyp in transverse colon). Your epidural will be ****. Poor plan IMO.

Those that want to do this under regional, how many of these cases have you done this way? Because if you haven't done quite a few then you are dreaming. Recipe for disaster. This is not the guy to experiment on.

Airway is the least of my worries in this case. Just had to state that one.

Anes121508, while your status says med stud, your responses say CA -1. Keep it up. You are thinking and that is good. But your focus needs some refining. Please take this as a compliment. Don't get caught up in all the details. Think about how you might get this guy through the case safely and then how you might help to make sure he leaves the hospital on his own two feet.
Click to expand...

Hahaha oh man, I fail this one I guess...I'm a CA-3 (just haven't updated the status thing in a while I guess)...don't worry no offense taken, it's all for fun while I try to catch up on game of thrones (or maybe I should be reading an oral board prep book )
 
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FFP said:
As I said, it would take a very motivated patient. Smoking cessation, exercise program, significant weight loss, CPAP, treatment of PHTN if the case. Even then, God knows... Obviously, this guy sounds anything but the right patient for these.

I always like to put everything in balance and go from there. Obviously, if he gets diagnosed with colon cancer, the risks/benefits discussion would be different.
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exactly, so what if he comes back "alive" in3-5 yrs, long shot I know, with colon cancer? Isn't that part of the dilemma here? He is definitely not going to be better off. Let's say he comes back in 1yr. Still worse. Does that change your opinion here?
 
Crash cart said:
I do not place spinals in patients with severe pulmonary HTN. The abrupt hypotension can lead to acute right heart failure and precipitate the classic death spiral.

I would place isobaric marcaine for a hip, for example. But I stay away from the 0.75% / dextrose variety.

Anyone do spinals in folks with severe pulmonary HTN?


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I think there is a recent thread on this issue...many out there saying it's nonsense academic stuff....I'm sure oral examiner wouldn't want to hear that though

Id be crucified for suggesting a spinal in a patient with tight as or severe pulm htn at my academic place
 
anes121508 said:
I think there is a recent thread on this issue...many out there saying it's nonsense academic stuff....I'm sure oral examiner wouldn't want to hear that though

Id be crucified for suggesting a spinal in a patient with tight as or severe pulm htn at my academic place
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Yes you would but I do it all the time. So far no issues. Just be very very careful my young scout.
 
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anes121508 said:
Hahaha oh man, I fail this one I guess...I'm a CA-3 (just haven't updated the status thing in a while I guess)...don't worry no offense taken, it's all for fun while I try to catch up on game of thrones (or maybe I should be reading an oral board prep book )
Click to expand...
I should have known you were more than a CA1. You just need some time to collect the big picture and you will wield the sword.
 
anes121508 said:
So I thought exercise was we had to do the case?

Now that we have discussed, noy, how would u approach it ?(assuming we have to proceed)
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I cancelled it.
But in a more political way than just saying, "oh f*ck no"!
I called the surgeon and then the Gi'****.
The GI'**** cancelled it.
I went on to my double lung/heart/ liver transplant and extubated him to send hi to the floor just in time for dinner and American Idol.
 
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Noyac said:
exactly, so what if he comes back "alive" in3-5 yrs, long shot I know, with colon cancer? Isn't that part of the dilemma here? He is definitely not going to be better off. Let's say he comes back in 1yr. Still worse. Does that change your opinion here?
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It doesn't change my opinion, but it may change my refusal to anesthetize him. It's a discussion about anesthetic risk vs survival without surgery.
 
FFP said:
It doesn't change my opinion, but it may change my refusal to anesthetize him. It's a discussion about anesthetic risk vs survival without surgery.
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Yes. After grilling the GI'**** he admitted that he can just do yearly colonoscopies to remove the polyp.
What an idiot.
 
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Noyac said:
exactly, so what if he comes back "alive" in3-5 yrs, long shot I know, with colon cancer? Isn't that part of the dilemma here? He is definitely not going to be better off. Let's say he comes back in 1yr. Still worse. Does that change your opinion here?
Click to expand...

If he continues his current lifestyle, odds are he's going to be on 10L O2 with a DLCO <35% in 1 year. Assuming he also has pHTN, he has about a 5-20% chance of being alive an additional year. Easy cancel.
 
Those of you that considering a CSE, at what level would you do this? This is an upper abdominal incision ( polyp in transverse colon). Your epidural will be ****. Poor plan IMO.

.
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I did an open cholecystectomy under epidural anesthesia last week... the plan was not as ****ty as you imagine!
 
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By the way those who are saying it cannot be done under regional because they've never seen it done that way, remind me of the academic attendings who want to cancel a case because they don't want to stay late, so they come up with all these disastrous scenarios that actually sound convincing but they only happen in their imaginary world!
 
Noyac said:
I cancelled it.
But in a more political way than just saying, "oh f*ck no"!
I called the surgeon and then the Gi'****.
The GI'**** cancelled it.
I went on to my double lung/heart/ liver transplant and extubated him to send hi to the floor just in time for dinner and American Idol.
Click to expand...
Nice!

You extubated a double lung/heart/liver tx in OR and sent to floor post-op? Or was it an ICU parient you took care of?
 
Chloroform4Life said:
Nice!

You extubated a double lung/heart/liver tx in OR and sent to floor post-op? Or was it an ICU parient you took care of?
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:)
I think Noy meant that he was taking care of a patient who had a history of heart/lung/liver transplant who's having some other kind of surgery!
I mean he might be aggressive but extubating a heart/lung/liver transplant in the OR and sending him to the floor might be a bit excessive even for a rock start like Noy. ;)
 
Planktonmd said:
:)
I think Noy meant that he was taking care of a patient who had a history of heart/lung/liver transplant who's having some other kind of surgery!
I mean he might be aggressive but extubating a heart/lung/liver transplant in the OR and sending him to the floor might be a bit excessive even for a rock start like Noy. ;)
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Yes, that makes sense. Otherwise, Noy's balls would have to be so big he wouldn't be able to walk.

I guess doing a heart, double lung, and liver tx at the same time would also be highly unlikely. Especially at nonacademic practices.
 
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Chloroform4Life said:
Yes, that makes sense. Otherwise, Noy's balls would have to be so big he wouldn't be able to walk.

I guess doing a heart, double lung, and liver tx at the same time would also be highly unlikely. Especially at nonacademic practices.
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Yea this multi-transplant patient was probably the same one who just got the first penile transplant... haha
 
Chloroform4Life said:
Yes, that makes sense. Otherwise, Noy's balls would have to be so big he wouldn't be able to walk.
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He extubated him, transferred him to the floor, and made it out in time for dinner!
9C07D218-2FC4-43BA-BA86-46AA758E6444.jpg



--
Il Destriero
 
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Now I want to know how he intubate patients carrying a wheelbarrow in front of him.
 
This thread has gone from a legitimate discussion about management decisions for a very sick patient to a collection of gifs showing off huge nutz. Awesome.
 
Planktonmd said:
By the way those who are saying it cannot be done under regional because they've never seen it done that way, remind me of the academic attendings who want to cancel a case because they don't want to stay late, so they come up with all these disastrous scenarios that actually sound convincing but they only happen in their imaginary world!
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I'm not sure that 100% fair to say. We all believe you that upper abdominal surgeries can be done under regional. (We all know the studies in Europe about them doing heart surgery under epidural) The fact is you need a compliant patient and a complaint surgeon for it to work and you probably have that where you work. About 90% of surgeons, I'd argue, want the patient sleeping and relaxed. It all comes down to surgeon, anesthesiologist, and patient comfort.
 
Chloroform4Life said:
Yes, that makes sense. Otherwise, Noy's balls would have to be so big he wouldn't be able to walk.

I guess doing a heart, double lung, and liver tx at the same time would also be highly unlikely. Especially at nonacademic practices.
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Actually en block (Heart 2 lungs and liver) transplant has been done for patients with advanced CF.
 
Planktonmd said:
Actually en block (Heart 2 lungs and liver) transplant has been done for patients with advanced CF.
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Yes, and also for ESLD with severe pulm HTN, since the pulm HTN is a contraindication to isolated liver transplantation.

http://www.ncbi.nlm.nih.gov/pubmed/21280186

But noone extubated their patient in the OR and sent patient to the floor though. So ladies and gentlemen, you're hearing about it for the first time here on SDN that it could be done. You just need giant testicles.
 
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I don't see a problem placing an SAB opiate (without LA) rather than epidural for pain management. Agree with the PP stating that you don't want to try unrefined techniques in these types of situations. Candid conversation with the family and surgeon re:postop vent. Limit fluids, limit long half-life meds, aline.
 
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