Dwarf Case

I would think yes. But what do I know.

supahfresh said:

So given her prior history, shouldn't we have kept the tube in for a while longer? Any thoughts?

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first, hopefully you didn't tetanus her while she was awake. seond, did you reverse her? okay, she was breathing spontaneously. following commands - are you sure? (ie. calling someone's name and then watching them open their eyes is not "following commands") what about a sustained head lift? large tidal volumes by themselves do not an extubation criteria make (just had a grand rounds on this). i'm not convinced by what you stated thus far that she definitely met extubation criteria.

personally, given the history i would've taken her to the pacu with the tube in. she probably had some chest expansion issues due to the underlying condition. if she was residually weak at all, you pull the tube she loses the airway and - blammo! - she can't support her breathing.

live and learn, dude. hopefully the patient did too.

VolatileAgent said:

first, hopefully you didn't tetanus her while she was awake. seond, did you reverse her? okay, she was breathing spontaneously. following commands - are you sure? (ie. calling someone's name and then watching them open their eyes is not "following commands") what about a sustained head lift? large tidal volumes by themselves do not an extubation criteria make (just had a grand rounds on this). i'm not convinced by what you stated thus far that she definitely met extubation criteria.

personally, given the history i would've taken her to the pacu with the tube in. she probably had some chest expansion issues due to the underlying condition. if she was residually weak at all, you pull the tube she loses the airway and - blammo! - she can't support her breathing.

live and learn, dude. hopefully the patient did too.

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Hindsight is clear and its easy to say one would've done it different.

How many ASA 4s do you take to the PACU intubated? How many double-lumen tube thoracotomies do you keep intubated? Not many in my book, if I can help it.

That being said, difficult airways I'm a little more cautious with, although with the patient responding, good tidal volumes, lifting their head, I probably wouldve pulled it too.
I dont use the nerve stimulator after waking somebody up.

jetproppilot said:

I dont use the nerve stimulator after waking somebody up.

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i hope not. have heard of lawsuits about that.

Anesthesiologists talk about "extubation" criteria a lot....because we extubate a lot of patients.

However, the vast majority of the patients that we extubate do not meet "extubation criteria" as published in the literature....and this is OK because the "cause" of respiratory failure....GA, muscle relaxants, etc....rapidly reverse themselves after the patient is extubated.

On occasion, when you have patients such as this one where they live at the edge of their cardiopulmonary reserve, meeting our lax "extubation criteria" doesn't cut it.

The hard part is identifying the patients who need to meet strigent "extubation criteria".

And Jet is right...hindsight is ALWAYS 20/20...but it allows you to develop experience and judgement for your next cases.....so that hopefully in the future your foresight gets closer to 20/20...remember that your hindsight will always be better.

Given the recognized difficult airway, and having placed an epidural for post-op pain, why not do the case under epidural?? Or better yet, combined spinal epidural?

What happened tothe Epidural?
Was it working ? If so why intubate?

I would have passed the Touhy till I got CSF and threaded a cath. if the epidural was difficult. But thats me.

militarymd said:

Anesthesiologists talk about "extubation" criteria a lot....because we extubate a lot of patients.

However, the vast majority of the patients that we extubate do not meet "extubation criteria" as published in the literature....and this is OK because the "cause" of respiratory failure....GA, muscle relaxants, etc....rapidly reverse themselves after the patient is extubated.

On occasion, when you have patients such as this one where they live at the edge of their cardiopulmonary reserve, meeting our lax "extubation criteria" doesn't cut it.

The hard part is identifying the patients who need to meet strigent "extubation criteria".

And Jet is right...hindsight is ALWAYS 20/20...but it allows you to develop experience and judgement for your next cases.....so that hopefully in the future your foresight gets closer to 20/20...remember that your hindsight will always be better.

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Geez Mil, this post was so good I'm gonna print it and use some masking tape to display it in the living room of my 1970s wood panelled, 1000 square-foot rent house!

Noyac said:

What happened tothe Epidural?
Was it working ? If so why intubate?

I would have passed the Touhy till I got CSF and threaded a cath. if the epidural was difficult. But thats me.

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Not a bad plan. Put it in your memory bank.

Out of curiosity, what neuromuscular blocker did you use?

Military writes about extubation criteria, blah blah blah and you kiss his ass as usual. I give you an alternative route of anesthesia and all I get is "not a bad plan".

Has anyone else noticed the way Jet praises Military? Or is it just me?

I'm starting to think that Jet and Military are the same person.

Just having some fun guys, after a few cocktails.

Love your input thus far.

Noyac said:

Military writes about extubation criteria, blah blah blah and you kiss his ass as usual. I give you an alternative route of anesthesia and all I get is "not a bad plan".

Has anyone else noticed the way Jet praises Military? Or is it just me?

I'm starting to think that Jet and Military are the same person.

Just having some fun guys, after a few cocktails.

Love your input thus far.

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Yeah, well, Mil has posted about 1.5 million posts here, with 1.49 mil legitimate. So the dudes an ace in my book.

Cheers, Noyac, and welcome to the best f ucking group in SDN.

Looking forward to future posts from you.

Noyac said:

Military writes about extubation criteria, blah blah blah and you kiss his ass as usual. I give you an alternative route of anesthesia and all I get is "not a bad plan".

Has anyone else noticed the way Jet praises Military? Or is it just me?

I'm starting to think that Jet and Military are the same person.

Just having some fun guys, after a few cocktails.

Love your input thus far.

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And geez, if Mil and I were the same person, or together, or whatever, the anesthesia world would be quite different. Not only full of knowledge/academia like the Roizen/Kaye/Tinkers, but with a private practice attitude...

and to be honest, thats never been seen. In the anesthesia arena right now, its one or the other. Clone the two and you'll provide ultimate patient care, surgeons would be ecstatic, and you'd have to buy a condo (like in BLOW) to store all your C notes.

jetproppilot said:

Geez Mil, this post was so good I'm gonna print it and use some masking tape to display it in the living room of my 1970s wood panelled, 1000 square-foot rent house!

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Noyac said:

What happened tothe Epidural?
Was it working ? If so why intubate?

I would have passed the Touhy till I got CSF and threaded a cath. if the epidural was difficult. But thats me.

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This is a not too infrequent question that will come up during the oral board examination.

What to do with a potential difficult airway. Do you meet the problem head on and secure it, or side step it and hope you don't have to deal with it.

As a guy who hates emergencies, I usually would deal with the airway rather than preparing to deal with it in an emergent fashion.

I think that all of us are trained to always prepare for a general anesthetic as a backup no matter what kind of anesthesthetic plan is the primary one.

If you couldn't reintubate her why not give a smidgen of dip and put a LMA #3 in her and turf to pacu on t-piece. Let her chill in PACU for an hr. or 2 and reasses her. Keep her sedated enough so she doesn't cough on LMA. Reminds me of a female resident who was a cocky little thing and took pleasure in braggin' to us male residents about her "oral skills". I told her to put up or shut up, so with a smirk on her face and a wicked gleam in her eyes she spat on a LMA #3 and fully seated the thing in her oropharynx without blinkin' an eye. Damn, we were all envious of her significant other at the time. Regards, ---Zippy

zippy2u said:

I told her to put up or shut up, so with a smirk on her face and a wicked gleam in her eyes she spat on a LMA #3 and fully seated the thing in her oropharynx without blinkin' an eye.

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HAHAHHAHAHHAHAHAHHAHAHAHHAHAHAHAHHAHAHHAHAHAHHAHAHAHHA

jetproppilot said:

HAHAHHAHAHHAHAHAHHAHAHAHHAHAHAHAHHAHAHHAHAHAHHAHAHAHHA

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Damn, I trained at the wrong program.

militarymd said:

This is a not too infrequent question that will come up during the oral board examination.

What to do with a potential difficult airway. Do you meet the problem head on and secure it, or side step it and hope you don't have to deal with it.

As a guy who hates emergencies, I usually would deal with the airway rather than preparing to deal with it in an emergent fashion.

I think that all of us are trained to always prepare for a general anesthetic as a backup no matter what kind of anesthesthetic plan is the primary one.

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Agreed, On the boards I would probably tackle the airway in a controlled fashion rather than meet it in an emergency. I don't want to confuse those who may be taking the boards. But in the real world I would probably do as I said. There is a real difference b/w real world and academics as Jet has mentioned. However, she has been trached b/4 and therefore has the scar in place if you get in trouble. 16g cath throught the scar, jet vent and now figure out how your gonna tube her. I love the fastrack LMA and the Bullard. On the Orals your gonna get in trouble, but you don't have to make it easy for them to get you in trouble. Honestly, I enjoyed my Oral exam but I don't like the way it makes you practice in ways that you might not practice in the real world.
This reminds me a of a case in residency. I was on the CCU rotation and a achondroplastic female was to have a ant. and post cervical fusion. She was a jehova's witness and quite obese. Do to neuro signs she was nasally intubated awake. They did 1/2 of the case and lost too much blood to finish the 2nd 1/2 of the case. She was brought to the CCU to stablize(lots of fluids = edema) and start on EPO to increase her Hct. As you know this will take some time (approx. 1-2 weeks), so she is sedated intubated nasally with an unstable neck. The ICU Rn wants the tube changed to an oral tube (she has a point) but the neck was too unstable. After rounds we hear the RN calling for help. The pt. is extubated "accidentally" (she had her restraints on and was sedated heavily). It took us approx'ly an hour to get the tube in. Not fun. RN was sent home. Case was finished a couple weeks later. whew!

supahfresh said:

The epidural worked great and I think that would have been a great idea to do a combo. I'll ask my attending. Don't you need to put a tube in for these abdominal cases?

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Nope. Can be done under epidural or CSE without a tube.

supahfresh said:

Sorry, didn't see this. We used Vec. And no I didn't blast her with the nerve stimulator while she was awake.

Hey, does anyone out there get the pt's hand under the surgery resident's butt and leave the twitch on?

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HAHAHAHHAHAHAHAHAHAH

As someone taking the oral boards next week, with a recognized difficult airway and history of poor post-op respiratory function - she probably should have been done in either of two ways:

1) regional to avoid mucking around with the airway and for post-op pain relief. However, must have a plan b in case of high spinal, patchy regional, or cardiac collapse from the sympathectomy given her history of cardiomyopathy.

2) recognized difficult airway --> probably should have had an awake fiberoptic intubation and SICU monitoring post-op until fully awake, stable hemodynamics, and a negative leak test. An epidural for post op pain is also warranted.

PainPhysicians said:

As someone taking the oral boards next week, with a recognized difficult airway and history of poor post-op respiratory function - she probably should have been done in either of two ways:

1) regional to avoid mucking around with the airway and for post-op pain relief. However, must have a plan b in case of high spinal, patchy regional, or cardiac collapse from the sympathectomy given her history of cardiomyopathy.

2) recognized difficult airway --> probably should have had an awake fiberoptic intubation and SICU monitoring post-op until fully awake, stable hemodynamics, and a negative leak test. An epidural for post op pain is also warranted.

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Dude, those answers are right on for the orals.

But in the real world, I'll sidestep a difficult airway with a spinal needle or a Tuohy any day of the week if possible. Risk benefit ratio very, very much in my favor. Yes, if things go awry, I can fiberoptic the airway or whatever, but you have to look at the statisitics of high spinal/epidural or patchy epidural/spinal in experienced hands. Very, very (did I say VERY?) low.

The board examiners have missed the boat on this one. Tell them on your orals Jet said so. I've done more cases by myself than those academic-watching-residents-do-all-the-work dudes.

zippy2u said:

Reminds me of a female resident who was a cocky little thing and took pleasure in braggin' to us male residents about her "oral skills". I told her to put up or shut up, so with a smirk on her face and a wicked gleam in her eyes she spat on a LMA #3 and fully seated the thing in her oropharynx without blinkin' an eye.

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WOW! You wouldn't happen to have her phone number or e-mail would ya?

supahfresh said:

51 yo achondroplastic dwarf comes in for TAH/BSO. She is 4'8", 200 pounds, has HTN, COPD, dilated cardiomyopathy, and CHF. In 1997, she had a lap chole where hours after the case, she had to be intubated for poor respiratory effort. She was unable to wean and recieved a trach.

She goes to the OR for TAH/BSO. She has a very short, fatty neck, a TMD=3cm, and maybe a mallampati 3. An epidural was placed with some difficulty. Next, she was intubated by direct laryngoscopy which was also difficult but successful after one attempt.

At the conclusion of the case she was following commands, breathing spontaneously with good tidal volumes, and had a sustained tetanus for 5 seconds. After pulling the tube, she became apneic and desaturated very rapidly. She could not be intubated nor ventilated and got an emergent trach.

So given her prior history, shouldn't we have kept the tube in for a while longer? Any thoughts?

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if you have a secure airway and pt is known to be difficult (although tube was inserted w/o difficulties this time), then i would keep the tube in and take it out in PACU when pt is trying to pull it out. i think that would be a better indicator that she is ready then i pull it out in deep and then have issues with airway lateron. LMA is not a bad idea like someone suggested but then again, i have to put a new device in while the one we currently have is pretty secure. just a thought. any comments?

Wow, where did you find this thread?
The moral should be: never give dwarfs general anesthesia unless you absolutely have to.
There was a story in the news in Florida not too long ago about a similar disaster that did not have a happy ending.

Wow.

zippy2u said:

Reminds me of a female resident who was a cocky little thing and took pleasure in braggin' to us male residents about her "oral skills". I told her to put up or shut up, so with a smirk on her face and a wicked gleam in her eyes she spat on a LMA #3 and fully seated the thing in her oropharynx without blinkin' an eye. Damn, we were all envious of her significant other at the time. Regards, ---Zippy

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Planktonmd said:

never give dwarfs general anesthesia unless you absolutely have to.

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That's not PC my friend you should say anesthesiologically challenged

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