militarymd said:
This is the actual CXR that we took in the OR. Her preop film was fairly normal, other than cardiomegaly.
As you can see, the general surgeon actually put in a chest tube for that right upper lobe collapse....I disagreed, but he insisted, and the urologist agreed to it.
All that badness developed after intubation. After the film, I bronched her to look for any gross airway abnormalities (anomalous rul takeoff, huge plug, etc.) I found nothing.
At this point (1000 am still working on the patient for a 730 start), everyone wanted to cancel the case.
I took her to the unit, woke her up, treated her with aggressive pulmonary toilet, and extubated the next day.
Here is what happens next. A week later, cytology from the greenish-brown fluid aspiration shows malignant cells!!! She has a second primary 😱
She is scheduled to come back for a combined neck dissection/nephrectomy!!!
No kidding...this is a real case.....
Any thoughts on how to do the combined case? Anyone?
This time, you will have no access to the neck because of the surgical site.
What was the etiology of the pulmonary whited out areas, and why did they develop after induction? Are they resolved? I wouldnt put her to sleep again until this issue is resolved. Too risky. There is a big possibility she won't survive the surgery, which is 6 hours minimum with deft surgeons (taking into consideration repositioning, down time between procedures, etc), if pulmonary sequelae develop again like they did the first time. There needs to be a cool off period before the huge multi-procedure is done, i.e. chest tube out, pulmonary sequelae resolved, etc.
Anyway, I know you already know all this stuff, but since you asked, heres how I'd do it, assuming the above is accomplished:
1) A-line
2)subclavian 9.0 cordis with PAC. If the subclav is impossible for some reason, I'd do a femoral (which I hate). Doing this case without central venous access is asking for trouble.
3) Standard ASA IV induction. I'd personally achieve somnulence with midazolam, then induce with etomidate, a little sufentanil, and pancuronium (assuming her airway was OK the first time), since her cardiac output is no doubt somewhat rate dependent secondary to poor myocardial compliance, and pancuronium will obviously help you achieve this.
If she tolerated that well, I'd front load with a ton of sufentanil, say 10ug/kg, and use the opiod as a primary part of the anesthetic, effectively minimizing the need for alot of myocardial depressant volatile anesthetic. Then crack a MAC-awake dose of desflurane/sevoflurane.
4)Meticulous temperature maintenance, BAIR Hugger an absolute must (lower body if you have to), fluid warmer for the inevitable transfusion of PRBCS and whatever else you need. Hypothermic induced coagulopathy is something to be avoided in this case.
5) Meticulous urine output observation. At the smallest hint of oliguria, start dopamine 2ug/kg/min
6) Keep her HCT optimized at minimum 28-30
7) Frequent (every hour) blood draws from the A-line for:
a)ABG: an abnormal pH could start a downward spiral. Q hour ABGs will prevent you from missing developing metabolic acidosis, and you can make sure oxygenation and ventilation are kosher.
b)Hb, HCT, platelets: not necessary during the neck part, but if the nephrectomy starts to develop blood loss, you'll be on top of it.
8) Beware of hemodilutionary thrombocytopenia, as it is one of the primary causes of thrombocytopenia in a case requiring alot of crystalloid.
9) A BIS monitor will aid you in depth of anesthesia since this will be a long case.
10) CaCl 1 gram for every four units of transfused PRBCs
11) Since she's such a sick puppy, I'd wanna see a pre-op phosphate level since low phos can contribute to pulmonary failure which is the last thing she needs. If its low pre-op, optimize it.
12) Prevent coagulopathy by being aggressive- be on top of PT, PTT, platelet count, and fibrinogen levels, and transfuse appropriate products for abnormal lab values.
13) Don't extubate her at the end of the case.
