AKA on a sicko.

[sevoflurane]

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94 y/o for R. AKA.

H/O CAD, CHF, CABG in 2000, MI 2 mo. ago with recent drug il. stents, CRF , DM, PVD, COPD (4l o2 atc), h/o TIA and stroke now with an ugly/smelling gangrenous foot.
Bed bound for months.
On Plavix and ASA
She’s had previous iliac surgery for vascular insufficiency. Surgery scar extends past the inguinal crease.
Echo 2mo. ago shows anterior and lateral wall hypokenesis, lvh and mod-severe pulm htn... Cath shows patent grafts at that time. EF 30%
She arrives straight from dialysis with a hct of 27 and daughter in law who happens to be pediatric cardiologist at your hospital.

It’s 1630 on Friday afternoon and surgeon says we need to take her leg off.

Any thoughts?

 

[zippy2u]

I should be so lucky to live to 94. Smidgeons of prop/Sevo/O2 with LMA and tell the pediatric cardio doc she may die periop. Prolly more than 50% of surgeries in the USA are done at ASCs. Get a job there and ya won't have to deal with this insanity. Regards, ----Zip

 

[coprolalia]

Any thoughts?

Yeah. Pray.

Seriously.

Major pow-wow with the family. Tell 'em Grandma may be at the end of the line here. She's had a long, good life. But, with all the co-morbidities, this makes this a nearly technically impossible case that, even if she doesn't die during the surgery, there's a good chance she's never leaving the hospital. Make sure they understand this.

With that said, this is an ASA 5E case. She's on aspirin and Plavix so a neuraxial is probably, on paper, out of the question if you want to follow the ASRA guidelines to the letter. So, I'd do an extremely gentle and slow induction, pop in an LMA, run her at like 0.5 MAC for the case, and control the intra-op pain gingerly with some narcotics.

Otherwise, if I was feeling brave and had the family's understanding, I could try the epidural. I don't think you're going to be able to do regional in that leg with all the prior surgery, but that also may be worth a shot. But, since it's an AKA, you can't get away with a sciatic block so you'll have to do some sort of femoral/obturator block... or the neuraxial.

This, by the way, is the type of nightmare case that will ensure I don't get any sleep the night before the oral exam.

-copro

 

[sevodude]

If it has to be done and I mean right now has to be done speak to family explain risk and pepare for eidural or other regional.

 

[VentdependenT]

94 y/o for R. AKA.

H/O CAD, CHF, CABG in 2000, MI 2 mo. ago with recent drug il. stents, CRF , DM, PVD, COPD (4l o2 atc), h/o TIA and stroke now with an ugly/smelling gangrenous foot.
Bed bound for months.
On Plavix and ASA
She's had previous iliac surgery for vascular insufficiency. Surgery scar extends past the inguinal crease.
Echo 2mo. ago shows anterior and lateral wall hypokenesis, lvh and mod-severe pulm htn... Cath shows patent grafts at that time. EF 30%
She arrives straight from dialysis with a hct of 27 and daughter in law who happens to be pediatric cardiologist at your hospital.

It's 1630 on Friday afternoon and surgeon says we need to take her leg off.

Any thoughts?

U/S guided Fem-Sci block. Although there is no true consensus about anticoagulation and PNB's I don't think its worth it to jab a needle repeatedly into her groin/ass causing hematomas/femoral artery hole. However depending on how sick she looks and how hard-core you are feeling you can go for it. Just abandon early if need be.

No way in hell I'm doing an epidural or lumbar plexus (which I'd combine with a sciatic).

No ultrasound/against PNB? BBlock & Tube. Have Nicardipine ggt (personal favorite) and sticks of esmolol/ntg ready for extubation.

Outcomes are no better for PNB vs GA for vascular surgery (yeah I know this isn't exactly peripheral vascular surgery but this patient is sick and is a vasculopath..so close enough...for me). You just need to control hemodynamics.

You can take care of that sacral decub while she's in the OR.

Ehhhhhh.......man.......

 

[powermd]

Prepare the family for the worst.
No epidural/spinal with Plavix on board.
Attempt femoral/sciatic block. If no go, then gentle induction, LMA, sevo.

If you really wanted to do spinal/epidural, you could potentially reverse the Plavix with 10-12.5 units of platelets based on this study:

Normalization of platelet reactivity in clopidogrel-treated subjects
J Thromb Haemost. 2007 Jan;5(1):82-90.
PMID: 1723916
http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

94 y/o for R. AKA.

H/O CAD, CHF, CABG in 2000, MI 2 mo. ago with recent drug il. stents, CRF , DM, PVD, COPD (4l o2 atc), h/o TIA and stroke now with an ugly/smelling gangrenous foot.
Bed bound for months.
On Plavix and ASA
She's had previous iliac surgery for vascular insufficiency. Surgery scar extends past the inguinal crease.
Echo 2mo. ago shows anterior and lateral wall hypokenesis, lvh and mod-severe pulm htn... Cath shows patent grafts at that time. EF 30%
She arrives straight from dialysis with a hct of 27 and daughter in law who happens to be pediatric cardiologist at your hospital.

It's 1630 on Friday afternoon and surgeon says we need to take her leg off.

Any thoughts?

 

[VentdependenT]

Prepare the family for the worst.
No epidural/spinal with Plavix on board.
Attempt femoral/sciatic block. If no go, then gentle induction, LMA, sevo.

If you really wanted to do spinal/epidural, you could potentially reverse the Plavix with 10-12-5 units of platelets based on this study:

Normalization of platelet reactivity in clopidogrel-treated subjects
J Thromb Haemost. 2007 Jan;5(1):82-90.
PMID: 1723916

I like open cardiac stents. But I like your style holmes.

 

[Planktonmd]

Induce with a combination of Propofol + ketamine (Not too much of either one).
Insert LMA and maintain anesthesia with a little Sevo + N2O + O2.
Have a little neo drip going in the background.
You can add little touches of ketamine here and there.
Give 25 mcg of Fentanyl toward the end and pull the LMA before turning down your anesthetics, then mask her until conscious enough to go to recovery.
Basically give her smooth GA the way only you the great anesthesiologist knows how 🙂

 

[militarymd]

94 y/o for R. AKA.

H/O CAD, CHF, CABG in 2000, MI 2 mo. ago with recent drug il. stents, CRF , DM, PVD, COPD (4l o2 atc), h/o TIA and stroke now with an ugly/smelling gangrenous foot.
Bed bound for months.
On Plavix and ASA
She's had previous iliac surgery for vascular insufficiency. Surgery scar extends past the inguinal crease.
Echo 2mo. ago shows anterior and lateral wall hypokenesis, lvh and mod-severe pulm htn... Cath shows patent grafts at that time. EF 30%
She arrives straight from dialysis with a hct of 27 and daughter in law who happens to be pediatric cardiologist at your hospital.

It's 1630 on Friday afternoon and surgeon says we need to take her leg off.

Any thoughts?

I've always said this, and I'll continue to say it.

THESE ARE THE EASIEST CASES YOU'LL EVER GET TO DO, as a consultant in anesthesiology.

1) no brainer, they HAVE to go to the OR
2) They're older than dirt, people like this die no matter what
3) Even better that you have a family member who is a trained physician who understands the above.

regional, ga,.....doesn't matter, just avoid hypotension and hypoxia.

I do these with fem/sciatic blocks...with stuff ready for a ga.

 

[toughlife]

Why ketamine and not etomidate given her cardiac hx?

 

[Planktonmd]

Why ketamine and not etomidate given her cardiac hx?

Tachycardia caused by ketamine and the whole concept of sympathetic effects of Ketamine are way over rated.
If you don't believe me ask Dr. Friedberg 🙂🙁😳😀😉😛😎🙄😡😱

 

[VentdependenT]

Why ketamine and not etomidate given her cardiac hx?

doesn't matter what ya give. Give it in an amount to put em to sleep but not slam their CV system down too hard.

You can breathe the old timer down and give em like 20mg of propofol.

It just doesn't matter.

 

[coprolalia]

doesn't matter what ya give. Give it in an amount to put em to sleep but not slam their CV system down too hard.

You can breathe the old timer down and give em like 20mg of propofol.

It just doesn't matter.

Yeah, I agree. Whatever flavor you choose, there has to be an understanding with the surgeon that it's not going to be the usual rapid induction, tube, prep, drape, done, tube-out anesthetic that they're probably used to.

-copro

 

[toughlife]

ah ok. I just wanted to make sure i was not missing something important here.

Thanks.

 

[Monty Python]

Tachycardia caused by ketamine and the whole concept of sympathetic effects of Ketamine are way over rated.
If you don't believe me ask Dr. Friedberg 🙂🙁😳😀😉😛😎🙄😡😱

Do a search on GASNet (run by Dr. Keith Ruskin at Yale) for Dr. Friedberg and his ketamine philosophy. It was a months-long international thread about a year ago.

http://anestit.unipa.it/maillist.html

 

[sevoflurane]

So this is what happened:

Thought long and hard about a lumbar plexus block with a sciatic. She's anticoagulated and retroperitoneal hematomas are not compresible. However you could practically see her transverse process... so walking off wouldn't be that hard.

On the other hand, poking around for a femoral around anatomy that has already been basterdized isn't all that fun either.

We used ultrasound. Lots of scar. It took a little longer, but I saw honeycombs... so we put a catheter in it. Knocked out the obturator single shot. Flipped her on her side and put in a sciatic catheter. Mepivicaine-tetracaine + clonidine... topped off with chloroprocaine.

On the way to the OR she got 1u prbc. SASAM +.5mg of midazolam and 25 mcgs of fentanyl put her to sleep. Neo/ntg sticks on hand. + etCO2 through NC. Lido to radial a. then a-line. Still sleeping.

1715ish: Incision- nothing. Cut off her leg and plavix unmasked itself. total loss 300 cc's. 2nd unit hung. Closed up. Total time from incision to last stich: 40 minutes.

Dropped off in pacu. "Is my leg off yet?" 🙁 "Yes dear... surgery is all over. You did great." 😀 No pain.

Although this case went smooth. We were ready to go GA with LMA if we needed it. We were going to use a little propofol for Lma and Des (she's old and didn't want to wait around all day for her to wake up)

 

[sevoflurane]

On the way out of the hospital I popped in my wife's room to see how her transplant was going. She's was on bypass chattn' it up with the CT surgeons. "See you around 8:00pm" she said.

Got home, poured a Guinness stout...

Once again I was reminded how much I love my job. 👍

 

[VentdependenT]

So this is what happened:

Thought long and hard about a lumbar plexus block with a sciatic. She's anticoagulated and retroperitoneal hematomas are not compresible. However you could practically see her transverse process... so walking off wouldn't be that hard.

On the other hand, poking around for a femoral around anatomy that has already been basterdized isn't all that fun either.

We used ultrasound. Lots of scar. It took a little longer, but I saw honeycombs... so we put a catheter in it. Knocked out the obturator single shot. Flipped her on her side and put in a sciatic catheter. Mepivicaine-tetracaine + clonidine... topped off with chloroprocaine.

On the way to the OR she got 1u prbc. SASAM +.5mg of midazolam and 25 mcgs of fentanyl put her to sleep. Neo/ntg sticks on hand. + etCO2 through NC. Lido to radial a. then a-line. Still sleeping.

1715ish: Incision- nothing. Cut off her leg and plavix unmasked itself. total loss 300 cc's. 2nd unit hung. Closed up. Total time from incision to last stich: 40 minutes.

Dropped off in pacu. "Is my leg off yet?" 🙁 "Yes dear... surgery is all over. You did great." 😀 No pain.

Although this case went smooth. We were ready to go GA with LMA if we needed it. We were going to use a little propofol for Lma and Des (she's old and didn't want to wait around all day for her to wake up)

Nice.

 

[Planktonmd]

Do a search on GASNet (run by Dr. Keith Ruskin at Yale) for Dr. Friedberg and his ketamine philosophy. It was a months-long international thread about a year ago.

http://anestit.unipa.it/maillist.html

I am a member of the list 🙂
and I remember the discussion.
I was referring to Friedberg's recent input on this forum before he got banned.

 

[VentdependenT]

I am a member of the list 🙂

Plank, is that why you have his name tattooed on your right butt cheek?

 

[Planktonmd]

Plank, is that why you have his name tattooed on your right butt cheek?