3rd case ever

[cubs3canes]

I am an intern in a categorical program. We get the opportunity to an anesthesia month in our intern year. This great opportunity keeps us motivated to complete the rest of the medicine year and gets us ready to be alone in July earlier.

My first two cases went smooth. Easy bag-mask. Easy intubation (first try ever with a miller).

Third case. 47 yo female with a BMI = 47 redo lap ventral hernia repair. She was cancelled four weeks prior with a diagnosis of pneumonia. She spent 2 days in the hospital and finished her antibiotics. Repeat CXR clear three days ago. She sounds course, but was a big smoker.

Proceed to OR. Easy bag mask..no problem. Slide the tube in easily. First breath okay. Turn on vent. 1 minute later, high pressure alarm. Change to Pressure Ventilation at about 32, then 34 getting TVs of 300. We are ventilating the dead space well. We put her in reverse trandeleberg..it easies up and we able to ventilate. But we cancel the case because we can not lay her flat..no way she would handle pneumoperitonem

Dropped in an a-line and to the PACU. PCO2 is 77...extubated the next day when she normalizes. CXR showed RUL (new pneumonia), could be aspiration versus HAP.

Here is the best part. The CA-1 that I was with went and saw her. She flicked him off and told him that she would never return to our facility. She was pissed that her HERNIA was not repaired.

A great case for me because I am so green.

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[kgal1]

any consideration of open repair?

 

[cubs3canes]

We considered the open repair. The laproscopic surgeon said that the wound infection rate would be to grate for a ventral hernia this large.

 

[Noyac]

Peak pressure of 34 is nothing in these pts. Drive the pressure up to 40 or 45 and see what your TV is increase the rate to blow off CO2. Nothing to it. I would have flipped him off as well.

 

[2ndyear]

How high was your rate? Even with a Vt of 300 you probably could have made some decent ventilation without an obscene rate. I've found that pressure control is bad once they start pumping up the belly. Switch to volume, deal with the high peaks or make them deflate a bit. But if you're ABG CO2 is 77, your end tidal was way high during the case, right?

Thinking down the road though, nothing is going to change in this patient the next time around unless she loses some weight. Now you've got to subject this lady to 2 GA's for one procedure. If the bowel just became strangulated, would the risk of infection from an ex-lap be too great to proceed?

 

[Noyac]

A good policy in my opinion is, if you cancel a case then you make it right for the next time b/c you are going to do it then as well. In other words, you cancel it today and its yours the next time it comes to the OR.

 

[cubs3canes]

Bt I have to go back to stupid medicine at the end of the month. She will not be back for 3-4 months probably.

Some follow-up. She had a subsegmental PE and atelectasis on further investigation that was not present on previous CTs.

Cubs

 

[IN2B8R]

"Some follow-up. She had a subsegmental PE and atelectasis on further investigation that was not present on previous CTs."

Cubs[/QUOTE]

That should not be the sole cause generating your hypercapnia intra-operatively. CO2 is a very diffuseable gas, and unless you have intrapulmonary shunting that is greater than 50%, your CO2 should not climb that high; i.e., you were hypoventilating. High peak pressures (into the mid 40's) in morbidly obese patients like this one can be expected, especially after insuflation of the abdomen and head-down positioning. Hard to believe that the case was cancelled over this... I am not at all surprised that the patient was ticked off at her anesthesia team!