A case for the residents

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Noyac said:
Agreed. This guy is dead if they try to do this endovascularly. But then again he is probably dead either way. I agree that the only way to approach this bad of a scenario is a slash and dive. Get control of the bleeding ASAP.
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Why is he dead if they attempt this endovascular? Aortic occlusion balloons can be deployed REALLY fast with good surgeons, faster than open cross clamp. EVAR for ruptured aortas is a major advance in the salvage of these patients.
 
Modanq said:
Agree. As an anesthesiologist intensivist I have placed 3 REBOAs in the past 12 months. GI bleed, vascular blow out in the unit, and gsw in the bay. Must learn skill. TBH we have equally fast vascular access skills and in dire situations ie REBOA both groins should be stuck simultaneously. One by surgery one by anesthesiology.

Agree with reboa for infrarenal aaa rupture zone 1 deployment. We should also keep it in our back pocket for ob hemorrhaging.
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oh thats cool. how do you do it? how do you confirm you are in the right spot before ballooning? sounds like a cool skill!
 
I’ll echo what others have stated, I find it mind boggling that there is not an anesthesia attending in house at a major tertiary care center if the residents are taking in house call. This is asking for trouble and situations like this to occur.

Regarding the case, I would have the CA 1 call the attending and say put a move on it we are in the OR. Put a non sterile MAC in R IJ while surgeons start prepping. Ready to push sux and tube as soon as attending walks in. Under no circumstance would I induce patient without attending there.
 
At my institution we always have an in house attending but we have run into problems before where the attending is otherwise occupied and an emergency occurs. Because of this issue, where the 2nd emergency is typically a stat section, it is agreed upon that 2 individuals from anesthesia can induce/intubate on their own. This means either two residents or a resident and CRNA.

That said I would absolutely start this case without an attending and most of them would expect it.
 
T-burglar said:
Why is he dead if they attempt this endovascular? Aortic occlusion balloons can be deployed REALLY fast with good surgeons, faster than open cross clamp. EVAR for ruptured aortas is a major advance in the salvage of these patients.
Click to expand...

After seeing you guys talking about this I asked one of our badass trauma surgeons what she thought about Reboa and ruptured AAA. FWIW, according to her she considers it essentially an absolute contraindication for fear of worsening the rupture or causing a retrograde dissection. So I asked what if you had fluoro and she said still no...
 
vector2 said:
After seeing you guys talking about this I asked one of our badass trauma surgeons what she thought about Reboa and ruptured AAA. FWIW, according to her she considers it essentially an absolute contraindication for fear of worsening the rupture or causing a retrograde dissection. So I asked what if you had fluoro and she said still no...
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the difference between a trauma surgeon and a vascular surgeon, I guess. Standard approach to this situation. Get real access while surgeons are getting proximal control with a balloon, airway control, off to the races. I'd ask the trauma surgeon what the alternative would be in this particular situation. Induce and open the patient as is? It'd be a pretty short case...
 
anbuitachi said:
oh thats cool. how do you do it? how do you confirm you are in the right spot before ballooning? sounds like a cool skill!
Click to expand...

https://lifeinthefastlane.com/ccc/resuscitative-endovascular-balloon-occlusion-aorta-reboa/

https://www.smacc.net.au/2015/10/reboa-who-what-and-why-deborah-stein/

The SMACC video is good.

Tips and tricks I've encountered:

Place it early before you lose femoral pulse. Otherwise it's hard to get a fem A stick. Panus, obese, thready pulse, cant tell venous from arterial during hemorrhagic shock.
7 french catheter. Not supplied by the kit.
If you think you need it at minimum place the catheter and use it as your aline. 7 french with side arm femoral arterial line..transduce the catheter.

After you place the balloon you can transducer the tip ie above the balloon and the side arm ie below the balloon. So in the OR setup 2 aline transducers.
The balloon fills with saline and you can titrate the amount of saline to blood pressure needs. More you fill the higher the aortic pressure. You can do a nice trauma resus with the balloon filling. So... Give some blood, fill the tank, release some balloon saline surgeon can operate... if hypotensive then inflate the balloon refill the tank and keep going until surgical control is obtained.

Remember there is an ischemia time with balloon inflation. But in OB hemorrhaging you prob will only need zone 3 deployment.

Another piece of advice is if they rush the patient up to the OR from trauma bay add an extension set to the balloon port otherwise it will get draped into the field. You will need a three way stopcock for that.

You can always leave the sheath in and take out the balloon.

Lastly maybe we can revisit the idea of intraaortic reboa epi pushes...lol that's a controversial topic and prob out of favor but in a last ditch possible...
 
drmwvr said:
the difference between a trauma surgeon and a vascular surgeon, I guess. Standard approach to this situation. Get real access while surgeons are getting proximal control with a balloon, airway control, off to the races. I'd ask the trauma surgeon what the alternative would be in this particular situation. Induce and open the patient as is? It'd be a pretty short case...
Click to expand...

Dead is dead. You cant make things worse. I would side with the trauma surgeon on this one. Plus with the changing surgical training environment some of the i5 straight vascular people dont have that general surgery trauma exposure anymore. I'm pretty sure the ER folks placing these would agree place the reboa if indicated.
 
drmwvr said:
the difference between a trauma surgeon and a vascular surgeon, I guess. Standard approach to this situation. Get real access while surgeons are getting proximal control with a balloon, airway control, off to the races. I'd ask the trauma surgeon what the alternative would be in this particular situation. Induce and open the patient as is? It'd be a pretty short case...
Click to expand...
"The patient was prepped and draped in a sterile fashion, the abdomen was entered via a midline incision, and a large amount of blood was encountered. The abdominal aorta was clamped, the rupture identified and repaired, an the patient was closed primarily. The procedure was a success, however the patient is now decreased."
 
Just double checking what your vascular folks are saying by a quick Google search and REBOA has definitely been used in AAA rupture. Of norte about 5 links down if you Google: AAA REBOA is a Feb 2019 AANA article about it. LOL. Smh. Not that topic again.
 
REBOA isnt the same thing as deploying the AOB for salvage EVAR. And a ruptured AAA isn’t a “Trauma” case.
 
So op, after all the lines, blood, fluids, pressors, tube, balloon/clamp, the patient met Jesus or not?
 
anbuitachi said:
im willing to bet 3 dollars that patient did not walk out of the hospital
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Cleaver way of stating it but you really said nothing. You're counting on the ant spinal artery stroke with the rupture in your phrase "walk".

It'd be an entirely different bet if you bet the pt did not get wheeled out of the hospital to a LTAC with a heart beat.
 
Had this exact case once r2 one r3. Thankfully staff arrived in r2. Not so lucky in r3.

You need art line, massive transfusion pack, 2 periph ivs with at least 1 16g or bigger, and scrubbed surgeons with abdo prepped and draped.

I will do uss brachial art line while i delegate 16g to my junior. No way in **** im waiting for boss man. Im delegating nurse to get him on speaker phone to tell him were cracking on

Induce 2 to 4 midaz, 100 roc, chase 150 phenyl. Alternative etom if i have it. 2 units blood hanging.

Porter ready to do compressions

My guys both aspirated huge volumes.
The second tube is in surgeon cuts and clamps aorta (this should take 1 minute) then empty 6 units of red into him and give him some compressions

If he lives that far its just straightforward aftet that.... Q30min abg and a teg. Calcium products, shift his k, throw in vasc cath. Phone icu

Right now if i get this case, i literally do nada just stand at the head of the bed and bark orders at everyone... Once i get distracted into putting lines and tubes its a disappointing case
 
This was an exciting read. I really want to do this stuff.
 
vector2 said:
After seeing you guys talking about this I asked one of our badass trauma surgeons what she thought about Reboa and ruptured AAA. FWIW, according to her she considers it essentially an absolute contraindication for fear of worsening the rupture or causing a retrograde dissection. So I asked what if you had fluoro and she said still no...
Click to expand...

I think REBOA was invented/started with ruptured AAAs, then adapted to trauma.
 
Would you tell the patient as you wheel back they have a high risk of dying in the OR and are they sure they want surgery? Or would that make the surgeons upset since they have decided to proceed with the case emergently?

I always let people know their risk from anesthesia and that they could die from the anesthesia risk, but I don't tell them what the risks of surgery are given that is not my field. And I've never asked a patient if they really want surgery. Have any of you guys done that?
 
MoMoGesiologist said:
Would you tell the patient as you wheel back they have a high risk of dying in the OR and are they sure they want surgery? Or would that make the surgeons upset since they have decided to proceed with the case emergently?

I always let people know their risk from anesthesia and that they could die from the anesthesia risk, but I don't tell them what the risks of surgery are given that is not my field. And I've never asked a patient if they really want surgery. Have any of you guys done that?
Click to expand...
It doesn't even sound like the guy was conscious enough to even hear those risks.
 
MoMoGesiologist said:
Would you tell the patient as you wheel back they have a high risk of dying in the OR and are they sure they want surgery? Or would that make the surgeons upset since they have decided to proceed with the case emergently?

I always let people know their risk from anesthesia and that they could die from the anesthesia risk, but I don't tell them what the risks of surgery are given that is not my field. And I've never asked a patient if they really want surgery. Have any of you guys done that?
Click to expand...

I dont straight up tell them they are likely gonna die but i do tell patients they have a much higher risk of cardiopulmonary issues. obviously not in this case but for other high risk surgeries and patient with it
 
i dont discuss risks for these patients like i do a large elective or non-urgent case. I don't think its humane to look a person in the eye who is actively dying, diaphoretic, and scared to death already , that they will likely be dead soon. I tell them we need to put them to sleep and try to fix the problem and if they say "dont let me die" or "am i going to die?" I usually say something like "I will not let that happen". Give the person hope.
 
T-burglar said:
i dont discuss risks for these patients like i do a large elective or non-urgent case. I don't think its humane to look a person in the eye who is actively dying, diaphoretic, and scared to death already , that they will likely be dead soon. I tell them we need to put them to sleep and try to fix the problem and if they say "dont let me die" or "am i going to die?" I usually say something like "I will not let that happen". Give the person hope.
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what if the family is also there?? are you still going to tell them i will not let that happen?
 
In a case like the one described, the surgeons usually tell them they're not likely to survive as we're rolling to the room. Between the hypotension and narcotic that the helo nurses or sending hospital give, these people are in no condition at all to understand what they're in for. The only patients, IME, that refuse surgery as result of that message are more or less stable, awake and alert.
 
T-burglar said:
i dont discuss risks for these patients like i do a large elective or non-urgent case. I don't think its humane to look a person in the eye who is actively dying, diaphoretic, and scared to death already , that they will likely be dead soon. I tell them we need to put them to sleep and try to fix the problem and if they say "dont let me die" or "am i going to die?" I usually say something like "I will not let that happen". Give the person hope.
Click to expand...

If someone is actively dying, is it more humane to take them back to the OR for a surgery they likely will not survive, or tell them the truth so they can elect not to be operated on and just spend their last moments with their family? Also, people who are close to dying are too sick/distracted to make such big decisions alone and I think doctors should guide them.

Maybe I'm in the minority, but I think as doctors we should be able to tell people they are dying and not tell them a lie like "I will not let that happen". Why give hope to someone who has a high mortality rate? Otherwise we end up with all these vegetables on the vent, ECMO, etc in the ICU. Give them truth.
 
Planktonmd said:
There is nothing wrong with getting the patient to the OR, starting resuscitation and getting everything ready while the attending is on the way.
Since the plan is endovascular repair then induction of anesthesia can wait until everything is ready and your attending is in the room. If they are so anxious to start they can start under local.
If the plan on the other hand is to open the abdomen and clamp the aorta as a life saving procedure then you have no choice, you give minimal anesthesia and SUX then put the tube in with the surgeon standing there scalpel in hand.
Good IV access should be your only focus until you get help.
Click to expand...
The correct answer for any situation involving residents w/o an attending.
pgg said:
It surprises me that there's actually a place that has anesthesia residents taking call in-house call without an attending also in-house. Hard to believe risk management office is OK with that.

At my hospital, residents aren't permitted to start cases without an attending. This rule is an explicit written policy; technically attendings aren't even allowed to tell a resident to go ahead and induce a patient without being physically present. I don't agree with this rule all but there it is. About 10 or 12 years back we had some OB disaster crash from triage into an OR in the middle of the night, and for some reason the attending couldn't be found or reached. The obstetrician was doing the usual babybabybabybabybabybabybabybabygonnadie thing and after some minutes of waiting with no attending in sight or answering pages or the phone, eventually the resident just induced and intubated the patient. The case went fine. The resident was almost fired. As a resident myself at the time, I thought the whole thing was ridiculous.

Here, today, if this patient rolled into the OR and for some reason the attending anesthesiologist couldn't be found, the resident would be expected to
- get better access, probably an u/s guided IJ introducer of some sort
- get and give blood, fluids, pressors
And honestly that's really all the patient needs from us at this point. That's doubly true if the surgeon is going to attempt something endovascular. Induction drugs plus opening the belly is a death sentence prior to these two things being in place. If the patient coded the resident could go down the ACLS pathway and intubate the patient.
Click to expand...

Also this.....

If the surgeon really wants to get his "endovascular case" going then throw him a vial of lidocaine and the CA-1 can temporize the situation with ketamine/pressors while the CA-3 helps work on better access/large bore access/invasive lines until the attending arrives

At the inevitable M/M, a discussion of why there is no in-house attending at a residency program hospital will need to be had.
 
I'm just an intern.. but is it easy to place a reboa in this setting of massive rupture? what's the chances of it staying intraluminal and not dissection or simply placed extravascularly?
 
Twiggidy said:
The correct answer for any situation involving residents w/o an attending.


Also this.....

If the surgeon really wants to get his "endovascular case" going then throw him a vial of lidocaine and the CA-1 can temporize the situation with ketamine/pressors while the CA-3 helps work on better access/large bore access/invasive lines until the attending arrives

At the inevitable M/M, a discussion of why there is no in-house attending at a residency program hospital will need to be had.
Click to expand...

probably not in this case but one can easily imagine a case where the patient is saveable but time is crucial and the case has to be done under general. should the residents just watch? should the residents even start the record if no attending is close by? it can go way further than a M/M. if the case goes to court, obviously the attending will have a large part of the blame, but i dont think it automatically means the residents have no responsibility especially when it comes to the jury. perhaps in some situations it should be risk benefit
 
Activate MTP, tell them not to stop sending products until we tell them to stop. Oxygen 100% FM. Access is paramount here. Hang whatever red stuff you can on those 20 gauges. Tell CA-1 to find another IV. Anything. 18,16,14 whatever. I myself would put in a long ultrasound guided 14 gauge AC (use this for volume and pressors and I wanna make sure I have a good IV that I trust if stuff gets bad). Give red stuff, white stuff. Don't stop giving product
Throw bottle of local at surgeon. Tell them to prep the groins. And start doing their thing. Under local. The guys already circling the drain. I'm not about to add some midazolam or fentanyl or anything really...

Art line... luxury.
CVL/Cordis/TEE/cerebral oximetry etc etc etc. AKA: all of the bells and whistles... luxury.

We need volume yesterday and if stuff goes south... fast? No anesthetic. Literally sux/tube and an apology. I don't care about him remembering. I care about keeping him alive. Can add the accoutrements like a-line with the ultrasound after the chest is cracked and aorta clamped. Once the aorta is clamped. You have time to do things properly. Sterile IJ MAC cordis. Brachial art line.

Package and ship to ICU.
 
CodeBlu said:
Activate MTP, tell them not to stop sending products until we tell them to stop. Oxygen 100% FM. Access is paramount here. Hang whatever red stuff you can on those 20 gauges. Tell CA-1 to find another IV. Anything. 18,16,14 whatever. I myself would put in a long ultrasound guided 14 gauge AC (use this for volume and pressors and I wanna make sure I have a good IV that I trust if stuff gets bad). Give red stuff, white stuff. Don't stop giving product
Throw bottle of local at surgeon. Tell them to prep the groins. And start doing their thing. Under local. The guys already circling the drain. I'm not about to add some midazolam or fentanyl or anything really...

Art line... luxury.
CVL/Cordis/TEE/cerebral oximetry etc etc etc. AKA: all of the bells and whistles... luxury.

We need volume yesterday and if stuff goes south... fast? No anesthetic. Literally sux/tube and an apology. I don't care about him remembering. I care about keeping him alive. Can add the accoutrements like a-line with the ultrasound after the chest is cracked and aorta clamped. Once the aorta is clamped. You have time to do things properly. Sterile IJ MAC cordis. Brachial art line.

Package and ship to ICU.
Click to expand...

red and white stuff?? propofol???
 
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