ProRealDoc

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This is a case that was posted in the private forum so several of you already saw it. Wanted to share it with everyone else.

Called from ICU to bring pt to OR emergently. On arrival, patient obtunded, tachypneic, tachycardic, hypotensive with SBPs in 80s, hypothermic @ 33.9 and mottled extremities. Pt has right SC TLC. Levo and vaso gtts running.

Surgeons have declared it an emergency and want to go to OR now for exlap. Patient is s/p gastric bypass several years ago.

Here's the ABG and CXR

pH 6.87
pCO2 23
pO2 277
Base Excess -27
Bicarbonate 4
Potassium 4.6
Hemoglobin 7.4
Hematocrit 23
Calcium 1.10
Glucose 138
Lactate 8.0

OR is ready for you. What next?

 
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aredoubleyou

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Tried to get on the private forum, but no repy...wtf


Anyway, before he gets an ex lap he needs the air around the heart removed, lots of fluids, and then work up his belly.
 

ProRealDoc

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Tried to get on the private forum, but no repy...wtf


Anyway, before he gets an ex lap he needs the air around the heart removed, lots of fluids, and then work up his belly.

That would be nice if you had the luxury of time to optimize the patient. The pt has been declared an emergency and you are taking him to the OR now. The OR is calling letting you they are ready and the surgery attending and fellow are ready to go.

So now that I've clarified that, then what? The transporters are ready to push the bed for you.
 

urge

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Nice pericardium.

What are those squiggly lines? He's got 3 of them.
 

aredoubleyou

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I would still insist that the pneumopericardium be drained in a hypotensive patient, in the OR is fine. Still go with lots of fluids, in addition bicarb, blood. If doesnt have an aline place one. TEE if you want, but if the air is removed, likely the heart will improve. Get the dead bowel out, continue to treat the sepsis (abx if not already started). Bear huggers, warmed fluids.
 

urge

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Someone needs to open the pericardium. Preferably not me.

Indeed looks like air. How did they manage to do that?
 

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Nice pericardium.

What are those squiggly lines? He's got 3 of them.
These lines are simply the EKG wires.
But I don't see the TLC that was mentioned.
This guy either ruptured his esophagus or his gastric bypass fell apart and is communicating with the mediastinum.
Take him to the OR, Get good central access, A line, and start aggressive resuscitation (RBC, Crystaloids, other blood products as needed).
Let them open him up and see what's wrong with him.
His chance of surviving is not great but if they can fix the anastomsis he might live.
 

ProRealDoc

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These lines are simply the EKG wires.
But I don't see the TLC that was mentioned.
This guy either ruptured his esophagus or his gastric bypass fell apart and is communicating with the mediastinum.
Take him to the OR, Get good central access, A line, and start aggressive resuscitation (RPC, Crystaloids, other blood products as needed).
Let them open him up and see what's wrong with him.
His chance of surviving is not great but if they can fix the anastomsis he might live.
TLC was being dropped in right after CXR was taken.
 

ProRealDoc

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Kitty kat ekgs? What is an adult doing with those?
Let's just say the pt came from an outside hospital and the critical care team that brought him over was headed by a nurse practitioner who was managing the pt. So that's what they had on him when they dropped him off in the ICU.
 

ProRealDoc

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I would still insist that the pneumopericardium be drained in a hypotensive patient, in the OR is fine. Still go with lots of fluids, in addition bicarb, blood. If doesnt have an aline place one. TEE if you want, but if the air is removed, likely the heart will improve. Get the dead bowel out, continue to treat the sepsis (abx if not already started). Bear huggers, warmed fluids.

would you place a TEE probe in this pt?
 

IN2B8R

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Offer the patient a cheesburger then write for a STAT discharge orders. These former gastric bypass patients perk up real fast once they smell meat.
 

aredoubleyou

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would you place a TEE probe in this pt?
if he had a know hx of cardiac dz, I might. Like plank said, mediastinal processes can often be from esophageal problems, so I'd wait until the surgeons were sure it wasnt the goose.

Right now it looks pretty "staright forward'" needs air removed around heart, needs fluids and blood, and needs bowel removed. TEE might only redemonstrate the obvious hypovolaemia, might also show you a globably sluggish myocardium w that pH too
 

urge

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Doesn't his pulmonary vasculature look all messed up too? Pulm vein distention from his tamponade?

Urge is vexed.
 

ProRealDoc

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if he had a know hx of cardiac dz, I might. Like plank said, mediastinal processes can often be from esophageal problems, so I'd wait until the surgeons were sure it wasnt the goose.

Right now it looks pretty "staright forward'" needs air removed around heart, needs fluids and blood, and needs bowel removed. TEE might only redemonstrate the obvious hypovolaemia, might also show you a globably sluggish myocardium w that pH too

How about just doing a TTE?
 

urge

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Either have a trauma surgeon or a ct surgeon stick a needle in the icu. If not the general surgeons can do it. He's got to be coding for me to stick the needle. I will stick it though.

Flouro might help.

TEE/TTE will not help because of ........... (fill in the blank).
 
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smgilles

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How about just doing a TTE?
His numbers are close to incompatible with life...how about we throw up a white flag and let them go in peace. Surgery isn't going to save this dude and we don't have to foot the bill.

Severe metabolic acidosis...hypothermic...coagulopathies...etc, etc...
 

Planktonmd

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Pt had the gastric bypass 8 years prior
So what?
An 8 year old anastomsis can still cause problems.
There is nothing to gain from doing an Echo or anything else, the air in the mediastinum in my opinion is just a symptom not the main problem.
I bet my money on a gastro-esophageal problem.
Go to surgery.
 

IlDestriero

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His numbers are close to incompatible with life...how about we throw up a white flag and let them go in peace. Surgery isn't going to save this dude and we don't have to foot the bill.

Severe metabolic acidosis...hypothermic...coagulopathies...etc, etc...
He really is in the hurt locker, but correcting his probable pericardial tamponade should dramatically change things, and keep the team from assassinating the poor guy. Please don't pull the plug yet. And I disagree that surgery will not save him. I've seen similar septic train wrecks walk out of the hospital a couple weeks later. It all depends on if he goes into organ failure or not post op.
 

urge

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the air in the mediastinum in my opinion is just a symptom not the main problem.
I bet my money on a gastro-esophageal problem.
I differ. I think that the problem is the air and that he has nothing else wrong.
 

IlDestriero

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Heart looks tiny to me.
X2. Get the surgeon to put a needle in there ASAP. What do the surgeons think about all that air? If he decompresses and improves, there may be some time to optimize/study him further to develop a better plan. Running screaming into the OR may not be the best course if he perks up.
 

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Air in the pericardium either comes from the lungs as an extension to a pneumothorax or bronchial injury or it comes from the Esophagus.
There is no Pneumothorax so this air is coming from the esophagus or the stomach.
agreed. some variant of boerhaave's sx. esophageal rupture. the pt likely needs a thoracotomy with esophageal repair/resection and mediastinal debridement, not an ex-lap, but i'm no surgeon.

tap that pericardial air, warm the pt up c some blood products and rescuscilloid, aline, (no TEE or TTE...) big bore hosing, all in the OR if you like.

even with all the right stuff, this goose is prolly cooked..
 
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I'm not in anesthesia, but I'll give this a shot because I love this kind of stuff.

Is the pO2 of 277 a typo? Do you really mean 27?

The surgeon has the right mindset for acuity, but this guy doesn't need an exlap. He needs his pericardium opened!

The main thing causing his extreme acidemia is the fact that his heart cannot pump blood forward because of the high air pressure within his distended pericardial sac. He has pneumopericardium causing a tamponade. The air is either coming from his gastric anastomosis, his esophagus, his trachea or bronchioles, or some other fistula we are not seeing. The chance of infection is super high.

The first thing that needs to be done is for his pericardium to be opened. He needs a needle thoracostomy followed by open thoracotomy and a pericardial window stat.

He needs to be intubated.

He needs sepsis protocol.

The next thing is that he needs to have ringers running wide open, and an order for PRBCs, cryo, etc. just in case he goes into DIC, which he will. His calcium should be checked and if low replaced. Maybe some bicarbonate to help normalize his pH.

Another thing I'd be worried about is a possible hyperkalemia coming up, due to acidotic damage of circulating blood cells. That kind of pH is enough to kill off a good portion of them, sending the potassium through the roof. I'd be prepared for that too.
 

aredoubleyou

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How about just doing a TTE?
a preop tte wont tell me anything i dont know and you wont be able to see anything thru the air. TEE to look at the heart post procedure is the only reason I'd put one in....and thats considering he hasnt improved with a window plus ressucitation
 

aredoubleyou

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I'm not in anesthesia, but I'll give this a shot because I love this kind of stuff.

Is the pO2 of 277 a typo? Do you really mean 27?

The surgeon has the right mindset for acuity, but this guy doesn't need an exlap. He needs his pericardium opened!

The main thing causing his extreme acidemia is the fact that his heart cannot pump blood forward because of the high air pressure within his distended pericardial sac. He has pneumopericardium causing a tamponade. The air is either coming from his gastric anastomosis, his esophagus, his trachea or bronchioles, or some other fistula we are not seeing. The chance of infection is super high.

The first thing that needs to be done is for his pericardium to be opened. He needs a needle thoracostomy followed by open thoracotomy and a pericardial window stat.

He needs to be intubated.

He needs sepsis protocol.

The next thing is that he needs to have ringers running wide open, and an order for PRBCs, cryo, etc. just in case he goes into DIC, which he will. His calcium should be checked and if low replaced. Maybe some bicarbonate to help normalize his pH.

Another thing I'd be worried about is a possible hyperkalemia coming up, due to acidotic damage of circulating blood cells. That kind of pH is enough to kill off a good portion of them, sending the potassium through the roof. I'd be prepared for that too.
No reason to think his po2 isnt in the 200's and he'd prolly be coding if he was hanging in the 20's. Its possible that his acidosis is all from global hypoperfusion, but I'm betting on something rotting in his belly or thorax to get the pH and temperature that low. Needs RBCs now, and i agree that DIC is likely. No question, lots of bicarb.
 
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tapping the heart will give him the reserve and HD stability to survive the ex-lap and any subsequent mediastinal exploration he will require...this is assuming he has no known cardiac hx...

realistically tho, wouldnt know how to go about the pericardial tap...
 

urge

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That's it? We are not going to get graded?
 

IN2B8R

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tapping the heart will give him the reserve and HD stability to survive the ex-lap and any subsequent mediastinal exploration he will require...this is assuming he has no known cardiac hx...

realistically tho, wouldnt know how to go about the pericardial tap...
A sub-xiphoid pericardial window, usually done by a CT surgeon.
 

ProRealDoc

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You all brought up excellent points. Pt had hx of hiatal hernia and gastric ulcer which perf'd.


Here's what I did:
-Brought pt to OR
-Pt was 73 kg and without overt signs of poss. diff airway
-RSI with etomidate and roc with thoracic surg team at bedside. Single lumen tube placed.
-No NGT placed
-Stat pericardial window with placement of pericardial and pleural CTs.
-PLacement of left IJ introducer
-No TEE/TTE was done as HDs improved post release of pneumopericardium
-2RBCs and FFPs bolused
-Pt administered 100mcg of fent and placed on 0.5% iso with a BIS as a bonus for the lawyery types.
Given cipro, diflucan, vanc and 100mg of hydrocortisone
-Had tech set up belmont and proceded with volume resusc. with RBC, colloids, FFP and crystalloids.
-Intraop EGD showed a perf'd gastric ulcer into the chest cavity and connecting directly with the pericardium.
-Pt underwent a total gastrectomy with a mid-to-distal esophagectomy
.Weaned off pressors intraop and urine output picked up to about 30-40cc/hr.
-Case lasted 8hrs and pt was dropped off in SICU in HD stable condition with a total of 4 chest tubes and a couple of JP drains and open belly
-EBL was 2500.
- Pt returned to OR for belly closure.
-LFTs peaked at 6000+ but returned to baseline postop.
-Pt remained in non-oliguric renal failure with Creat at 2.6. which eventually resolved.
-He remained in ICU x 10 days and was discharged home at 3 weeks post op.

Being in in hid mid-40's lcertainly made a difference for this pt.
 

fakin' the funk

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This is a great case. It ties together a lot of severe pathophysiology, medical, anesthetic, and surgical mgmt.

My thinking about his pneumopericardium and apparent sepsis is that they probably had a common cause. But I'm not used to thinking like that. Since I'm a medicine intern at the moment I am used to thinking about diagnosing problems in the elderly as accumulations of small minor problems vs. the more Occam's-razor approach in the young (a single unifying theory is more likely to be the right one). And I also didn't have a clue that a perf'd gastric ulcer could basically dissect all the way into the chest like that!

I would venture to say the guy was in both cardiogenic and septic shock, mostly because I was surprised to see the severe hypothermia, which I wouldn't typically associate w/ cardiogenic shock. I think steroids and the pressors mentioned (norepi and vasopressin) were the right way to go.

Now, my questions:

Obviously the surgical team thought he had frank septic peritonitis -- I guess that's where the fluconazole comes in (sepsis from intraabdominal source) -- but where's the anaerobic coverage? Why MRSA coverage?

Can someone clarify for me -- in these cases you want to give pretty minimal anesthesia right (the fentanyl + 1/2 MAC iso) -- but after the hemodynamics improved did you get more leeway with anesthetizing the pt?

Might the mottled extremities have been BECAUSE of the pressors, not despite them?

Transaminases in the 6000's are pretty high for "shock" liver right?
 

sevoflurane

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This is a case that was posted in the private forum so several of you already saw it. Wanted to share it with everyone else.

Called from ICU to bring pt to OR emergently. On arrival, patient obtunded, tachypneic, tachycardic, hypotensive with SBPs in 80s, hypothermic @ 33.9 and mottled extremities. Pt has right SC TLC. Levo and vaso gtts running.

Surgeons have declared it an emergency and want to go to OR now for exlap. Patient is s/p gastric bypass several years ago.

Here's the ABG and CXR

pH 6.87
pCO2 23
pO2 277
Base Excess -27
Bicarbonate 4
Potassium 4.6
Hemoglobin 7.4
Hematocrit 23
Calcium 1.10
Glucose 138
Lactate 8.0

OR is ready for you. What next?

Would anyone switch to epi for this case? Prior to pericardial window?
 

ProRealDoc

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This is a great case. It ties together a lot of severe pathophysiology, medical, anesthetic, and surgical mgmt.

My thinking about his pneumopericardium and apparent sepsis is that they probably had a common cause. But I'm not used to thinking like that. Since I'm a medicine intern at the moment I am used to thinking about diagnosing problems in the elderly as accumulations of small minor problems vs. the more Occam's-razor approach in the young (a single unifying theory is more likely to be the right one). And I also didn't have a clue that a perf'd gastric ulcer could basically dissect all the way into the chest like that!

I would venture to say the guy was in both cardiogenic and septic shock, mostly because I was surprised to see the severe hypothermia, which I wouldn't typically associate w/ cardiogenic shock. I think steroids and the pressors mentioned (norepi and vasopressin) were the right way to go.

Now, my questions:

Obviously the surgical team thought he had frank septic peritonitis -- I guess that's where the fluconazole comes in (sepsis from intraabdominal source) -- but where's the anaerobic coverage? Why MRSA coverage?

Can someone clarify for me -- in these cases you want to give pretty minimal anesthesia right (the fentanyl + 1/2 MAC iso) -- but after the hemodynamics improved did you get more leeway with anesthetizing the pt?

Might the mottled extremities have been BECAUSE of the pressors, not despite them?

Transaminases in the 6000's are pretty high for "shock" liver right?
When I first heard the history from the ICU team, I was also dubious as to whether a GI etiology was to blame. However, the fact that he had developed a hiatal hernia post gastric bypass followed by the discovery of the perf'd ulcer in the OR tied it all together.

Our ICUs typically like to use clyndamycin for anaerobic coverage and after checking the pt's record, he did received 600mg in the ICU prior to surgery. Some of these choices are surgeon/institution dependent. Cefotetan and cefoxitin are reasonable choices as well. We like clynda because you do not typically adjust the dose in pts with renal insufficiency.

1) When a septic pt comes to the ICU, usually the source in unclear and if no documentation is available to support the presence/absence of an organism, they commonly receive g+ and g- coverage after cultures are drawn and as a temporizing measure until culture results and speciation are available. That's the reason the pt received vanco. Read page 8 of the surviving sepsis campaign article previously posted by periopdoc to get a better sense as to what the current recommendations are.
http://www.survivingsepsis.org/About_the_Campaign/Documents/Final%2008%20SSC%20Guidelines.pdf

2) Pt was in extremis so the depth of anesthetic required to induce and maintain the pt was minimal. I did not have to go much higher than level of iso initially chosen.

3) I am sure the pressors were not helping his underperfused extremities, but in a situation like this, you will have to compromise and do what you think it's best for the pt. You should have seen his ears, they were almost black. I felt much better once they turned pink again the OR. ;)

4) Shock liver is classically seen in hypotensive states as a sign of underperfusion. Nothing surprising there. I am not sure how high is high, have heard they can go up as high as 50X normal
 
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ProRealDoc

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I'm not in anesthesia, but I'll give this a shot because I love this kind of stuff.

Is the pO2 of 277 a typo? Do you really mean 27?

The surgeon has the right mindset for acuity, but this guy doesn't need an exlap. He needs his pericardium opened!

The main thing causing his extreme acidemia is the fact that his heart cannot pump blood forward because of the high air pressure within his distended pericardial sac. He has pneumopericardium causing a tamponade. The air is either coming from his gastric anastomosis, his esophagus, his trachea or bronchioles, or some other fistula we are not seeing. The chance of infection is super high.

The first thing that needs to be done is for his pericardium to be opened. He needs a needle thoracostomy followed by open thoracotomy and a pericardial window stat.

He needs to be intubated.

He needs sepsis protocol.

The next thing is that he needs to have ringers running wide open, and an order for PRBCs, cryo, etc. just in case he goes into DIC, which he will. His calcium should be checked and if low replaced. Maybe some bicarbonate to help normalize his pH.

Another thing I'd be worried about is a possible hyperkalemia coming up, due to acidotic damage of circulating blood cells. That kind of pH is enough to kill off a good portion of them, sending the potassium through the roof. I'd be prepared for that too.

Your points are all well taken. Anesthesiologists are not the sit-and-wait types especially when dealing with emergencies. That's a luxury that is enjoyed by other specialties.

By the way, the pt did not receive any bicarb. He was administered Tham which I prefer in certain settings when acidosis is extreme or there's a high potential for it (liver transplant, etc).
 

IlDestriero

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Your points are all well taken. Anesthesiologists are not the sit-and-wait types especially when dealing with emergencies. That's a luxury that is enjoyed by other specialties.

By the way, the pt did not receive any bicarb. He was administered Tham which I prefer in certain settings when acidosis is extreme or there's a high potential for it (liver transplant, etc).
Hey! Hold on there!
I thought I was the only guy that used Tham!
:laugh:
 

ProRealDoc

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What do you like about tham?
No increase in Na load, no worries about an increase acid load that needs to vented off, urinary excretion, maintains its buffering capacity in hypothermia, can also serve as a fluid replenisher, has an osmotic diuretic effect, etc
 

aredoubleyou

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No increase in Na load, no worries about an increase acid load that needs to vented off, urinary excretion, maintains its buffering capacity in hypothermia, can also serve as a fluid replenisher, has an osmotic diuretic effect, etc
yea, but isn't it really expensive (maybe I'm wrong)...seems like something to be reserved for backup...since that pt coulda handled bicarb just fine. If it isnt expensive maybe I'll start trying it out more.
 

ProRealDoc

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yea, but isn't it really expensive (maybe I'm wrong)...seems like something to be reserved for backup...since that pt coulda handled bicarb just fine. If it isnt expensive maybe I'll start trying it out more.

I don't know how much it costs to tell you the truth.