Another Pulm Htn case for you

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IceDoc

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What would you do in the following case?
A 54 year old woman with morbid obesity (130kg), Pulmonary Hypertension (PA 96 systolic :wow: ), DM, and anemia who presents for an endometrial ablation.
Cancelling the case is not an option because she is as optimized as she will get, and the procedure is necessary (unless she should simply bleed for the rest of her life). The expected time of the actual procedure is only 20-30min or so.

How would you administer the anesthetic? General? Regional?
What are you specifically worried about in providing an anesthetic for this low risk procedure in a high risk patient? And finally, what extra meds might you want available in your room?

This case was thrown at me on my 7th day as a CA-1. I'm interested to see what plans you have out there. I'll post what we did in a day or two (and it went pretty slick too). :cool:
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-propofol 250 mg....followed by LMA and sevoflurane. Toradol for post op pain
 
militarymd said:
-propofol 250 mg....followed by LMA and sevoflurane. Toradol for post op pain
Click to expand...

Military - I'm still getting a feel for the LMA and patient selection, so maybe you can give me a little guidance. Given that this patient is obese, has probable GERD, probable gastroparesis, and will be in the lithotomy position for a majority of the procedure make her a bad candidate for an LMA?
 
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coccygodynia said:
Military - I'm still getting a feel for the LMA and patient selection, so maybe you can give me a little guidance. Given that this patient is obese, has probable GERD, probable gastroparesis, and will be in the lithotomy position for a majority of the procedure make her a bad candidate for an LMA?
Click to expand...

Use a ProSeal LMA.
 
militarymd said:
-propofol 250 mg....followed by LMA and sevoflurane. Toradol for post op pain
Click to expand...

Military's point is something that I also believe...you can use an LMA safely in a lotta cases that academic attendings would lead you to believe you cant..although this one is pushinn the envelope a little.
There has been more than one study showing you can safely use LMAs in morbidly obese patients...think about it...intubating someone with a blow-spout can be challenging sometimes...eliminate the intubation and it may be even safer...how many problematic issues are you avoiding by not paralyzing and intubating? Alot.
and as long as you don't aggressively mask the patient after induction (most of the time I don't even mask them...push the propofol, wait 'til they're apneic, slide in the LMA) so as not to insufflate the stomach, you're good.
 
coccygodynia said:
Military - I'm still getting a feel for the LMA and patient selection, so maybe you can give me a little guidance. Given that this patient is obese, has probable GERD, probable gastroparesis, and will be in the lithotomy position for a majority of the procedure make her a bad candidate for an LMA?
Click to expand...

Here is something for you to think about:

Of all the patients that you have put to sleep with a rapid sequence induction because "they are at risk of aspiration", how many actually had gastric contents in their oropharynx at the end of the case?

If you are at risk of aspiration, presumably, gastric contents will come up into the oropharynx, but the ETT will prevent the stuff from getting into the lungs, so the stuff should be in the OP at the end of the case.....but that just doesn't happen.
 
militarymd said:
Here is something for you to think about:

Of all the patients that you have put to sleep with a rapid sequence induction because "they are at risk of aspiration", how many actually had gastric contents in their oropharynx at the end of the case?

If you are at risk of aspiration, presumably, gastric contents will come up into the oropharynx, but the ETT will prevent the stuff from getting into the lungs, so the stuff should be in the OP at the end of the case.....but that just doesn't happen.
Click to expand...

This is real life, real world anesthesia folks...put a board examiner "expert" into private practice and most of them wouldnt make it. You don't have to put a-lines, central lines, and PACs in every sick dude. And LMAs will save you a lotta headaches more often than not.
 
Thanks for the advice and future fodder for debates with my attendings.
 
yeah in Britain they do GAs for c-sections w/ LMAs... and no deaths there!!! their only intra-operative death over the last 3 years was due to an exaggerated hypotensive response to pitocin....

then again, i have had 2 patients aspirate "silently" intra-op with LMAs... nothing like chilling by the anesthesia machine and then look over at the patient and see bile going up and down inside the LMA w/ every spontaneous breath!!! thank god both of those patients were young and without comorbidites....
 
In a morbidly obese pt with severe pulmonary HTN, seems to me that an LMA might be a little dicey. Sure the case might be short (definitely not at my institution!!!), but you would still like to avoid hypoxemia and hypercarbia in a pt with pulmonary HTN, and usually with LMAs you get the pt to spontaneously breathe. Under anesthesia, the pt will start breathing at a higher CO2 than without anesthesia...add that to the fact that the pt is morbidly obese and is prone to obstruct their airway more, as well as to atelectasis and hypoxemia... seems to me you are headed down a path opposite of what you want.

I suppose you could place them on the vent (especially with a Proseal LMA), but what if you are unable to obtain a good seal on a pt who would require higher peak pressures for a decent tidal volume? And if atelectasis develops, sigh breaths might be tougher. Plus the GERD, and lithotomy position doesn't help make the case for an LMA. I think just throwing in a tube would be safer, and less of a headache.

That being said, I heard that in Australia or somewhere, they use LMA's even with prone cases all the time without problems... so what do I know?!
 
beezar said:
In a morbidly obese pt with severe pulmonary HTN, seems to me that an LMA might be a little dicey. Sure the case might be short (definitely not at my institution!!!), but you would still like to avoid hypoxemia and hypercarbia in a pt with pulmonary HTN, and usually with LMAs you get the pt to spontaneously breathe. Under anesthesia, the pt will start breathing at a higher CO2 than without anesthesia...add that to the fact that the pt is morbidly obese and is prone to obstruct their airway more, as well as to atelectasis and hypoxemia... seems to me you are headed down a path opposite of what you want.

I suppose you could place them on the vent (especially with a Proseal LMA), but what if you are unable to obtain a good seal on a pt who would require higher peak pressures for a decent tidal volume? And if atelectasis develops, sigh breaths might be tougher. Plus the GERD, and lithotomy position doesn't help make the case for an LMA. I think just throwing in a tube would be safer, and less of a headache.

That being said, I heard that in Australia or somewhere, they use LMA's even with prone cases all the time without problems... so what do I know?!
Click to expand...

The text books teach you a lot of stuff, but unfortunately most of the patients have not read the books, and their bodies do whatever they want, so LMA's are fine.
 
What we did:
Discussion before the case centered on her severe pulmonary htn and morbid obesity. To avoid the induction death spiral, we were looking for any technique that would assure no periods of hypoxemia. I'll leave the LMA discussion on morbidly obese pt's in lithotomy position for another day. We chose to administer a spinal anesthetic, with concomitant placement of an epidural catheter. That's it. No sedation, straight from PACU back to floor all without changing her pulmonary physiology at all.

It's much easier to extubate a patient that isn't intubated in the first place.
 
IceDoc said:
What we did:
Discussion before the case centered on her severe pulmonary htn and morbid obesity. To avoid the induction death spiral, we were looking for any technique that would assure no periods of hypoxemia. I'll leave the LMA discussion on morbidly obese pt's in lithotomy position for another day. We chose to administer a spinal anesthetic, with concomitant placement of an epidural catheter. That's it. No sedation, straight from PACU back to floor all without changing her pulmonary physiology at all.

It's much easier to extubate a patient that isn't intubated in the first place.
Click to expand...

nice. :thumbup:
 
IceDoc said:
What we did:
Discussion before the case centered on her severe pulmonary htn and morbid obesity. To avoid the induction death spiral, we were looking for any technique that would assure no periods of hypoxemia. I'll leave the LMA discussion on morbidly obese pt's in lithotomy position for another day. We chose to administer a spinal anesthetic, with concomitant placement of an epidural catheter. That's it. No sedation, straight from PACU back to floor all without changing her pulmonary physiology at all.

It's much easier to extubate a patient that isn't intubated in the first place.
Click to expand...

Pu$$y!!!

What induction death spiral are you talking about....the scenario you presented is something I've done a hundred times...well maybe not a hundred...but definitely in the double digits, and I don't know what you are talking about.

If someone can walk into the hospital, they can go to sleep and wake up without problems.
 
militarymd said:
Pu$$y!!!

What induction death spiral are you talking about....the scenario you presented is something I've done a hundred times...well maybe not a hundred...but definitely in the double digits, and I don't know what you are talking about.

If someone can walk into the hospital, they can go to sleep and wake up without problems.
Click to expand...

Don't anyone take the post in a bad way....it is meant in jest and fun....I don't really think you're weak or anything :)

But honestly, if someone can walk themselves into the hospital, they can have GA.....Whether they can have any surgery is a different story.

Endoablation is probably as stressful as when this 130 kg women takes a dump after 3 days of constipation.
 
militarymd said:
But honestly, if someone can walk themselves into the hospital, they can have GA.....Whether they can have any surgery is a different story.
Click to expand...

Well I wouldn't be so generous as to say "walking." It was more like a macrophage engulfing the table.

Anyway, as you know the pulmonary vasculature constricts in response to hypoxia. How likely is hypoxia in a morbidly obese woman on 3L NC baseline who then gets induced and put in lithotomy just to ensure she has no FRC left? And of course I've never heard of an obese person having any problem with an airway. So if everything isn't exactly smooth (this is July after all), global hypoxia in the lung can lead to significant hypoxic pulmonary vasoconstriction which can dramatically increase the afterload on an already stressed right ventricle leading to a decreased cardiac output, leading to increased hypoxia, more HPV, less CO, etc... hence my 'death spiral'. Exactly how likely is this to occur? I have no idea given my n=1. But that's the beauty of being around more experienced people who have induced multiple people with severe pulm htn (lung Tx) and seen the dramatic effects possible.

So why not use a technique that lets the patient exist at the same pulmonary physiology she always does and minimize any risk for this short and simple procedure? And since it worked out pretty slick, I thought I'd share.
 
IceDoc said:
Well I wouldn't be so generous as to say "walking." It was more like a macrophage engulfing the table.

Anyway, as you know the pulmonary vasculature constricts in response to hypoxia. How likely is hypoxia in a morbidly obese woman on 3L NC baseline who then gets induced and put in lithotomy just to ensure she has no FRC left? And of course I've never heard of an obese person having any problem with an airway. So if everything isn't exactly smooth (this is July after all), global hypoxia in the lung can lead to significant hypoxic pulmonary vasoconstriction which can dramatically increase the afterload on an already stressed right ventricle leading to a decreased cardiac output, leading to increased hypoxia, more HPV, less CO, etc... hence my 'death spiral'. Exactly how likely is this to occur? I have no idea given my n=1. But that's the beauty of being around more experienced people who have induced multiple people with severe pulm htn (lung Tx) and seen the dramatic effects possible.

So why not use a technique that lets the patient exist at the same pulmonary physiology she always does and minimize any risk for this short and simple procedure? And since it worked out pretty slick, I thought I'd share.
Click to expand...

I think that "death spiral" must have happened once to someone 30 years ago, and that guy wrote it up, and now it is gospel.

I live in Alabama....everyone is fat, but you realize that their airways are just like everyone else's....just sometimes, it is hard to do a proper exam because the airway is obscured by a layer of fat.

As an intensivist, I have seen the "death spiral" in these sick patients, and do you know how you treat them?? You INTUBATE, ala GA, them and put them on ventilators, and they get better.
 
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