A canceled case

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Sleeplessbordernights

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This happened yesterday, and Im a little curious about what do you think.

49 year old male, scheduled for elbow arthrodesis, HIV + under treatment, hep c +, VDRL +, no prior surgeries, cleared by IM. IMC 27, Short and thick neck, bilat lung basal rales sat 92% with no O2.

plan: supraclav block and sedation. I perform the block, after 15 min the pt cant lift his arm, however he still has some sensation to pain (I guess, tbh he was not reliable). We proceed to prop sux tube, but has a difficult airway, CA1 cant intubate, I cant intubate, two attendings fail with VL, just before my attending will cancel he nails the tube.

PT on Volume control, sat wont go past 91%, the pt now has rales on all lung zones. This got my attending nervous and she Chooses to cancel the case to the dismay of the orthopedic team. After reversal he cant lift nor feel his arm. Tbh I think my attending got annoyed and just chose to cancel. I had to explain to the pt why his surgery got canceled. My attending said that she fears pneumocystis jiroveci and that’s why she cancele, still I’m pretty bummed out about this. What do you think?
 
Sleeplessbordernights said:
This happened yesterday, and Im a little curious about what do you think.

49 year old male, scheduled for elbow arthrodesis, HIV + under treatment, hep c +, VDRL +, no prior surgeries, cleared by IM. IMC 27, Short and thick neck, bilat lung basal rales sat 92% with no O2.

plan: supraclav block and sedation. I perform the block, after 15 min the pt cant lift his arm, however he still has some sensation to pain (I guess, tbh he was not reliable). We proceed to prop sux tube, but has a difficult airway, CA1 cant intubate, I cant intubate, two attendings fail with VL, just before my attending will cancel he nails the tube.

PT on Volume control, sat wont go past 91%, the pt now has rales on all lung zones. This got my attending nervous and she Chooses to cancel the case to the dismay of the orthopedic team. After reversal he cant lift nor feel his arm. Tbh I think my attending got annoyed and just chose to cancel. I had to explain to the pt why his surgery got canceled. My attending said that she fears pneumocystis jiroveci and that’s why she cancele, still I’m pretty bummed out about this. What do you think?
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Plan A sounds good: Block and light sedation. I would have given nebs.

When the block wasn't enough (maybe just needed more time), I would have done an LMA instead of a tube.

Even if I had tubed, once I had tubed and done the block and induced I would have proceeded with the surgery. Its a case that needs to get done, and the damage is already done at that point. Now you've put him through the block and GA and he has to do it all again since its not fixed.
 
What was the CD4 count? Did he have infiltrates on imaging? PCP is a bizarre concern to suddenly have and if he is already vented then the die is cast, keeping him vented for a few hours isnt going to change his infection outcome (if he has one). All kinds of reasons for hypoxia in HIV, can get chronic ILD-type lung disease to obstructive pathology as well as the whole gambit of infections depending on CD4 count. Sounds like IM did a crap job clearing him if his sat was 91 and nobody thought to at least ask why and look in to it.
 
I find the idea that this guy has PCP bizarre, especially if he is on HAART. If he is taking his meds and his CD4 is reasonable then there is 0% chance he has PCP. More likely and/or another thing to consider in HIV and in those on HAART is pulmonary hypertension. HIV is a known cause. Obesity and undiagnosed OSA/OHS are another factor to consider. How about covid or post covid lung disease? Not sure I would have simply proceeded with a sat of 92% without an explanation. Once committed with a block and under GA I would have gone forward.
 
Hoya11 said:
Its a case that needs to get done, and the damage is already done at that point. Now you've put him through the block and GA and he has to do it all again since its not fixed.
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Agree 100%. At that point patient has already been subjected to most of the risk of thr anesthetic, why cancel?
 
abolt18 said:
Anyone here mildly concerned about doing a supraclav block in the first place on a dude whose SpO2 is 92% on room air?
Click to expand...

If u use low volumes and ultrasound guidance not that worrisome. I think the literature said 50% phrenic nerve involvement with SCB traditionally but it's much less with new techniques
 
Sleeplessbordernights said:
This happened yesterday, and Im a little curious about what do you think.

49 year old male, scheduled for elbow arthrodesis, HIV + under treatment, hep c +, VDRL +, no prior surgeries, cleared by IM. IMC 27, Short and thick neck, bilat lung basal rales sat 92% with no O2.

plan: supraclav block and sedation. I perform the block, after 15 min the pt cant lift his arm, however he still has some sensation to pain (I guess, tbh he was not reliable). We proceed to prop sux tube, but has a difficult airway, CA1 cant intubate, I cant intubate, two attendings fail with VL, just before my attending will cancel he nails the tube.

PT on Volume control, sat wont go past 91%, the pt now has rales on all lung zones. This got my attending nervous and she Chooses to cancel the case to the dismay of the orthopedic team. After reversal he cant lift nor feel his arm. Tbh I think my attending got annoyed and just chose to cancel. I had to explain to the pt why his surgery got canceled. My attending said that she fears pneumocystis jiroveci and that’s why she cancele, still I’m pretty bummed out about this. What do you think?
Click to expand...

spo2 92% RA. What happened when you gave a little O2 pre op? what's on the pre op CXR? Any PFTs? Any type of anesthesia history, especially recent, you can look at?

You've already done all the hard work. Your block seems fine. I'd sedate a bit and often that's all you need. Little low dose propofol, maybe some versed or precedex. You could also toss in an LMA, little him breathe some sevo and call it a day. Hard to say for sure since I wasn't there, but I doubt I'd cancel or make the progression that you did.
 
abolt18 said:
Anyone here mildly concerned about doing a supraclav block in the first place on a dude whose SpO2 is 92% on room air?
Click to expand...

Somewhat. I'd want to know some history if there's any there. Look at the CXR. active infection? On Abx? does he respond well to O2? Most likely I'm still blocking that arm.
 
Why was plan B to intubate the patient? Why not an LMA?
Honestly this sounds like one of those typical academic attendings who see zebras every where and like to create drama in the OR at every occasion. These are the attendings you should learn not to resemble if you want to find a job in private practice.
 
Southpaw said:
Somewhat. I'd want to know some history if there's any there. Look at the CXR. active infection? On Abx? does he respond well to O2? Most likely I'm still blocking that arm.
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As above, i just think I'd err on the side of infraclav or axillary.
 
Also, i dont understand why your attending would cancel the case at that point. You already put the patient to sleep, and did a block, and worked really hard to get that tube it!

Now that patient is going to have to come back and do it all again and some other colleague, or potentially you, will have to do it all over again?!!?!
 
abolt18 said:
Anyone here mildly concerned about doing a supraclav block in the first place on a dude whose SpO2 is 92% on room air?
Click to expand...

26B said:
In this patient, my preference would have been infraclav or axillary block for an elbow procedure.
Click to expand...
I don’t like supraclavs for elbows because you can get ulnar sparing and you get phrenic paralysis more often then not. I would have done infraclav or axillary.
 
wouldve done infraclav for this case. no point in doing supra and having a good chance of phrenic nerve paralysis, up to 70% chance.

i don tthink theres anything wrong with doing a tube. sure some of you say do LMA, which is fine too, but dont think tube is wrong either. for me, when in doubt i put in a tube, not LMA. why do i want a supraglottic airway when i can have a secured airway? i can ALWAYS pop in LMA later if i have issue with tube. it's much more annoying popping in a tube after failing or having issues with LMA.

in terms of cancellation, theres nothing wrong with cancellation either. previously patient is 92% on RA. now cant go over 91% on 100% oxygen on mechanical ventilation with rales everywhere. clearly something is wrong. fix it first, then proceed with surgery. surgery is not emergent or urgent.
same if a patient comes in saturating 91% on 100% oxygen with rales everywhere, are you going to proceed? i'm sure all of us here can get the patient thru the case, but why... whats the point. keep the patient intubated, optimize the patient and bring patient back next day or something



and there are 2 residents in this case? just curious
 
abolt18 said:
Also, i dont understand why your attending would cancel the case at that point. You already put the patient to sleep, and did a block, and worked really hard to get that tube it!

Now that patient is going to have to come back and do it all again and some other colleague, or potentially you, will have to do it all over again?!!?!
Click to expand...

for patient safety. i would cancel as well. cant get over 91% on 100% fio2 when preop was 92% on 21%?

Next time do a infraclav and call it a day... not that hard. even if you have to intubate, this patient is ventilatable im guessing because apparently 5 people tried to intubate. not sure why they didnt go do a fiberoptic at this point if everyone's failing DL/VLs. were they planning on rotating thru the entire department? if have to do GA, and concerned, just do asleep fiberoptic...

the new pulmonary change could be due to many things... aspiration, flash pulm edema, etc. i would cancel this elective case


honestly in OP's scenario, the cancellation is way less concerning to me than the management of this patient..
 
Agree with above. Nonurgent case sounds like it can wait for optimization.

If I did the case I'd probably go with infraclav but I am much better with supraclav and if you use low volumes and hit the corner pocket it shouldn't be an issue. You can also block the ulnar nerve separately near the elbow if you think you missed it or have the surgeon supplement with their own local at the site. I wouldn't go to general anesthesia right away like that but if I got the tube in and had that much trouble I would just finish the case.
 
I agree with above. Infraclavicular would be better to avoid phrenic nerve paralysis. Would also be terrible if you got a pneumo with supraclavicular.
 
Simba1711 said:
I agree with above. Infraclavicular would be better to avoid phrenic nerve paralysis. Would also be terrible if you got a pneumo with supraclavicular.
Click to expand...

It would be terrible to get a pneumo, period. Infraclav can also cause it. Same w phrenic nerve involvement. The stats quoted in literature are not based on ultrasound use
 
coffeebythelake said:
It would be terrible to get a pneumo, period. Infraclav can also cause it. Same w phrenic nerve involvement. The stats quoted in literature are not based on ultrasound use
Click to expand...

The risk of pneumothorax is negligble with infraclavicular. If you are seeing pleura with ultrasound your probe is too medial.
 
You are not doing an ICB even remotely correctly if there is any chance of PTX or phrenic nerve paresis. Both should approximate 0%.

Back to the decision though, you've already blocked and induced. Rule out an iatrogenic PTX and then let the case proceed. Otherwise, he's likely to come back and have the same issue again (supraclav aside).
 
Sleeplessbordernights said:
This happened yesterday, and Im a little curious about what do you think.

49 year old male, scheduled for elbow arthrodesis, HIV + under treatment, hep c +, VDRL +, no prior surgeries, cleared by IM. IMC 27, Short and thick neck, bilat lung basal rales sat 92% with no O2.

plan: supraclav block and sedation. I perform the block, after 15 min the pt cant lift his arm, however he still has some sensation to pain (I guess, tbh he was not reliable). We proceed to prop sux tube, but has a difficult airway, CA1 cant intubate, I cant intubate, two attendings fail with VL, just before my attending will cancel he nails the tube.

PT on Volume control, sat wont go past 91%, the pt now has rales on all lung zones. This got my attending nervous and she Chooses to cancel the case to the dismay of the orthopedic team. After reversal he cant lift nor feel his arm. Tbh I think my attending got annoyed and just chose to cancel. I had to explain to the pt why his surgery got canceled. My attending said that she fears pneumocystis jiroveci and that’s why she cancele, still I’m pretty bummed out about this. What do you think?
Click to expand...
I'm sorry but this is hilarious
 
Sleeplessbordernights said:
This happened yesterday, and Im a little curious about what do you think.

49 year old male, scheduled for elbow arthrodesis, HIV + under treatment, hep c +, VDRL +, no prior surgeries, cleared by IM. IMC 27, Short and thick neck, bilat lung basal rales sat 92% with no O2.

plan: supraclav block and sedation. I perform the block, after 15 min the pt cant lift his arm, however he still has some sensation to pain (I guess, tbh he was not reliable). We proceed to prop sux tube, but has a difficult airway, CA1 cant intubate, I cant intubate, two attendings fail with VL, just before my attending will cancel he nails the tube.

PT on Volume control, sat wont go past 91%, the pt now has rales on all lung zones. This got my attending nervous and she Chooses to cancel the case to the dismay of the orthopedic team. After reversal he cant lift nor feel his arm. Tbh I think my attending got annoyed and just chose to cancel. I had to explain to the pt why his surgery got canceled. My attending said that she fears pneumocystis jiroveci and that’s why she cancele, still I’m pretty bummed out about this. What do you think?
Click to expand...
Probably patient had some PNA or something preop, derecruited badly after multiple attempts at intubation. Did they Desat during intubation attempts?

I agree with above, would have at least tried sedation and block.
 
Sleeplessbordernights said:
This happened yesterday, and Im a little curious about what do you think.

49 year old male, scheduled for elbow arthrodesis, HIV + under treatment, hep c +, VDRL +, no prior surgeries, cleared by IM. IMC 27, Short and thick neck, bilat lung basal rales sat 92% with no O2.

plan: supraclav block and sedation. I perform the block, after 15 min the pt cant lift his arm, however he still has some sensation to pain (I guess, tbh he was not reliable). We proceed to prop sux tube, but has a difficult airway, CA1 cant intubate, I cant intubate, two attendings fail with VL, just before my attending will cancel he nails the tube.

PT on Volume control, sat wont go past 91%, the pt now has rales on all lung zones. This got my attending nervous and she Chooses to cancel the case to the dismay of the orthopedic team. After reversal he cant lift nor feel his arm. Tbh I think my attending got annoyed and just chose to cancel. I had to explain to the pt why his surgery got canceled. My attending said that she fears pneumocystis jiroveci and that’s why she cancele, still I’m pretty bummed out about this. What do you think?
Click to expand...
Ok I'll try to be helpful... In the form of asking questions
1) "cleared by IM" cmon man YOU clear not them
2) what med(s) you do the block with, it seems obvious in retrospect you didn't let the block set up long enough (very common pitfall when it's being done for surgical anesthesia)
3) it was obvious this would be a difficult DL preinduction, already marginally hypoxemic patient why not start with VL and the most experienced operator?
4) after intubation the sat is 91%. You didn't tell us about any other maneuvers or settings bud, and saying Volume Control isn't sufficient. Had you recruited REALLY well? Like REALLY FUXKING WELL because it can be surprising how many 30-for-30s it takes to rerecruit someone after a long apneic time.
5) also ok the sat is 91%, ie preop baseline, this was a difficult intubation and you've invested so much time and energy and resources to get to this point, for an elbow procedure (i.e. a smallish benign procedure), cancelling is just beyond chicken****. Beyond. No intraop CXR? No bronch? Just cancel and wake up? Unbelievable.
6) cancelling intraop for something your attending reasonably suspected preop (Pjp) is also beyond chicken****
7) no one cares about rales, stop it
8) after you woke the pt up and the block was dense, why not just do the case then???

GAHHHHHH it feels like I'm taking crazy pills
 
fakin' the funk said:
Ok I'll try to be helpful... In the form of asking questions
1) "cleared by IM" cmon man YOU clear not them
2) what med(s) you do the block with, it seems obvious in retrospect you didn't let the block set up long enough (very common pitfall when it's being done for surgical anesthesia)
3) it was obvious this would be a difficult DL preinduction, already marginally hypoxemic patient why not start with VL and the most experienced operator?
4) after intubation the sat is 91%. You didn't tell us about any other maneuvers or settings bud, and saying Volume Control isn't sufficient. Had you recruited REALLY well? Like REALLY FUXKING WELL because it can be surprising how many 30-for-30s it takes to rerecruit someone after a long apneic time.
5) also ok the sat is 91%, ie preop baseline, this was a difficult intubation and you've invested so much time and energy and resources to get to this point, for an elbow procedure (i.e. a smallish benign procedure), cancelling is just beyond chicken****. Beyond. No intraop CXR? No bronch? Just cancel and wake up? Unbelievable.
6) cancelling intraop for something your attending reasonably suspected preop (Pjp) is also beyond chicken****
7) no one cares about rales, stop it
8) after you woke the pt up and the block was dense, why not just do the case then???

GAHHHHHH it feels like I'm taking crazy pills
Click to expand...
Lol I love your response Funk, but let's not be too hard on OP. They most def did not have a choice on treatment plan and canceling the case etc. They were sidelined as soon as the tube went bad.
 
MirrorTodd said:
Lol I love your response Funk, but let's not be too hard on OP. They most def did not have a choice on treatment plan and canceling the case etc. They were sidelined as soon as the tube went bad.
Click to expand...
Indeed - should have clarified that most of these decisions seem to be the attending's - and I'm mostly addressing OP as "you" as in the "royal you"...man.
 
A couple of thoughts.

This is a pretty specific case and I would be careful that this doesn't find your way back to your attending.

I assume yall tubed for prone position? We do a lot of elbows prone, otherwise I would have just used an LMA like everyone else has mentioned here.
 
Mehd School said:
A couple of thoughts.

This is a pretty specific case and I would be careful that this doesn't find your way back to your attending.

I assume yall tubed for prone position? We do a lot of elbows prone, otherwise I would have just used an LMA like everyone else has mentioned here.
Click to expand...

wtf why. not even lateral? I can't believe the way you people practice. Also you can still do sedation and block in prone position.
 
Mehd School said:
A couple of thoughts.

This is a pretty specific case and I would be careful that this doesn't find your way back to your attending.

I assume yall tubed for prone position? We do a lot of elbows prone, otherwise I would have just used an LMA like everyone else has mentioned here.
Click to expand...

GassYous said:
wtf why. not even lateral? I can't believe the way you people practice. Also you can still do sedation and block in prone position.
Click to expand...
I have NEVER done a prone elbow. Even our most incompetent surgeons can muddle through with a lazy lateral.
 
Newtwo said:
a prone elbow??? What the absolute ****... is that a joke?
Click to expand...
Sure wish it was. Our elbow specialist is world renowned and we do professional baseball players (MLB and minors) nearly every week. I've done an infraclavicular block on a Cy Young winner. This surgeon does them prone.

Also, "I can't believe the way you guys practice". LMAO. Try telling one of the best joint surgeons in the world you don't want to position the patient he likes and tell me how that works out for you. In a given day he does 10-12 elbows. He is fast, and he is good. They got rid of a handicap parking spot to give this guy his own space for his Maybach. He does what he wants.
 
Mehd School said:
Sure wish it was. Our elbow specialist is world renowned and we do professional baseball players (MLB and minors) nearly every week. I've done an infraclavicular block on a Cy Young winner. This surgeon does them prone.

Also, "I can't believe the way you guys practice". LMAO. Try telling one of the best joint surgeons in the world you don't want to position the patient he likes and tell me how that works out for you. In a given day he does 10-12 elbows. He is fast, and he is good. They got rid of a handicap parking spot to give this guy his own space for his Maybach. He does what he wants.
Click to expand...

I mean you're the one doing blocks on professional athletes. That's just pants on head stupid.
 
GassYous said:
I mean you're the one doing blocks on professional athletes. That's just pants on head stupid.
Click to expand...

And? Nobody truly needs a block in an elective case. They could just go home with a few extra percocet. Of course I wish he didn't do them prone. Puts the patient at unnecessary risk and it's a pain in the ass. I'd love to hear some tangible suggestions on how to fix it though.
 
Mehd School said:
Sure wish it was. Our elbow specialist is world renowned and we do professional baseball players (MLB and minors) nearly every week. I've done an infraclavicular block on a Cy Young winner. This surgeon does them prone.

Also, "I can't believe the way you guys practice". LMAO. Try telling one of the best joint surgeons in the world you don't want to position the patient he likes and tell me how that works out for you. In a given day he does 10-12 elbows. He is fast, and he is good. They got rid of a handicap parking spot to give this guy his own space for his Maybach. He does what he wants.
Click to expand...
Well you got me there. We just do old folk elbows. Pays the exact same, better actually so im fine with that. Not being head over biscuit is also fine...

But thats good work tho!
 
Sleeplessbordernights said:
This happened yesterday, and Im a little curious about what do you think.

49 year old male, scheduled for elbow arthrodesis, HIV + under treatment, hep c +, VDRL +, no prior surgeries, cleared by IM. IMC 27, Short and thick neck, bilat lung basal rales sat 92% with no O2.

plan: supraclav block and sedation. I perform the block, after 15 min the pt cant lift his arm, however he still has some sensation to pain (I guess, tbh he was not reliable). We proceed to prop sux tube, but has a difficult airway, CA1 cant intubate, I cant intubate, two attendings fail with VL, just before my attending will cancel he nails the tube.

PT on Volume control, sat wont go past 91%, the pt now has rales on all lung zones. This got my attending nervous and she Chooses to cancel the case to the dismay of the orthopedic team. After reversal he cant lift nor feel his arm. Tbh I think my attending got annoyed and just chose to cancel. I had to explain to the pt why his surgery got canceled. My attending said that she fears pneumocystis jiroveci and that’s why she cancele, still I’m pretty bummed out about this. What do you think?
Click to expand...
IMC 27? What position were you in when you tried intubating? Did you get fluoro or CXR when you couldn’t get the sats up? What happened when you extubated?

What’s wrong with the elbow? Chronic or broken with bone sticking out?

Not proceeding with an elective case after messing up the airway is reasonable. I second suspicion of mainstem/tube at carina, particularly if you were able to extubate and sats were fine after.

Also agree that you are taking a big risk of pissing off your attending and program if they find out you posted this here.
 
Mehd School said:
Sure wish it was. Our elbow specialist is world renowned and we do professional baseball players (MLB and minors) nearly every week. I've done an infraclavicular block on a Cy Young winner. This surgeon does them prone.

Also, "I can't believe the way you guys practice". LMAO. Try telling one of the best joint surgeons in the world you don't want to position the patient he likes and tell me how that works out for you. In a given day he does 10-12 elbows. He is fast, and he is good. They got rid of a handicap parking spot to give this guy his own space for his Maybach. He does what he wants.
Click to expand...

So your ortho surgeon is full of himself. Best surgeon in the world demands you do things a certain way despite it being potentially more dangerous to thr patient. Great.
 
SnapperRocks said:
IMC 27? What position were you in when you tried intubating? Did you get fluoro or CXR when you couldn’t get the sats up? What happened when you extubated?

What’s wrong with the elbow? Chronic or broken with bone sticking out?

Not proceeding with an elective case after messing up the airway is reasonable. I second suspicion of mainstem/tube at carina, particularly if you were able to extubate and sats were fine after.

Also agree that you are taking a big risk of pissing off your attending and program if they find out you posted this here.
Click to expand...
Why is it reasonable to cancel an elective case after messing up the airway and securing it? You've already exposed the patient to the greatest risk they're going to encounter. Why cancel when they're going to have to go again and face that same risk again without a guaranteed outcome?

Also if you're comfortable extubating a patient satting 91% on 100% FiO2, why are you not ok proceeding with the case. So much stupidity. If this is PCP (LOL) with a P:F of ~60 then take the patient to the ICU intubated.
 
Ronin786 said:
Why is it reasonable to cancel an elective case after messing up the airway and securing it? You've already exposed the patient to the greatest risk they're going to encounter. Why cancel when they're going to have to go again and face that same risk again without a guaranteed outcome?

Also if you're comfortable extubating a patient satting 91% on 100% FiO2, why are you not ok proceeding with the case. So much stupidity. If this is PCP (LOL) with a P:F of ~60 then take the patient to the ICU intubated.
Click to expand...
Exactly. Extubating on 100% FIO2 satting 91 without a wean to prove shunt would be malpractice in ICU and (I assume) the OR.
 
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