PoorInvestment

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Open forum type discussion here. 71 year old cat, nice as can be with early ALS and no other comorbidities presents for ORIF of right ankle. His gait is unstable and he has speech and swallowing difficulty. Site of ankle fracture rules out ankle block. Pt does not want ET tube because of fear of exacerbating swallowing difficulty and family has heard that spinal anesthesia can worsen ALS. What would ya'll do in this situation?

We attempted to appease everyone by using a saphenous/popliteal block-which didn't set up quickly enough for the ortho guys and easily converted to propofol induction w/o NMB and sevo maintainence. No troubles at all. Anyone have lots of experience on these neuro disease types and thoughts on what to do different? Just thought this might be interesting for discussion. Coincidentally, the peripherial blocks were SWEET for post-op pain. Homeskillet was feeling fine.

~PoorInvestment~
 

zippy2u

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Yup, ya did it the right way. Popliteal, saphenous, LMA with sevo. Boot scoot outta the ASC in 45. Regards, ---Zippy
 

Hawaiian Bruin

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What mix did you use for the block? I woulda done the same thing- the pop/saphenous block is money.
 
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huktonfonix

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I woulda done pop/low dose fem or saphenous block with mepivicaine +/- bupivicaine. If hes having trouble talking and swallowing, board answer is to tube him. LMA should be ok though unless he has respiratory muscle compromise. I would think that an LMA may affect his "swallowing" more than an ETT though since it sits in the pharynx. Regardless I would probably avoid muscle relaxants.
 

PoorInvestment

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We actually opted not to use the LMA and just straight tubed him. We were worried about his resp status and aspiration risk with the LMA and the tube actually ended up working great. No trouble at all intra or post op, just induced him nice and deep so we didn't have to NMB him.
Don't recall the exact mix for the blocks, but I think we used a little squirt of 1.5% lido w/epi and then 0.5% marc for the bulk.
 

SleepIsGood

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We actually opted not to use the LMA and just straight tubed him. We were worried about his resp status and aspiration risk with the LMA and the tube actually ended up working great. No trouble at all intra or post op, just induced him nice and deep so we didn't have to NMB him.
Don't recall the exact mix for the blocks, but I think we used a little squirt of 1.5% lido w/epi and then 0.5% marc for the bulk.
perhaps another alternative to 'deepening' him could have been using remifentanil, fast on and off. You dont have to use NMB agents then either. Either way, nice call on avoiding the NMBs I guess.

I know that I've been around attendings that have used NonDepol meds on patients with G-Barre which was in 'remission'. We reversed the guy, he had great 4/4 twitches, mx tone, head lift,etc. He was extubated and did well.

So the question is. Unless this guy doesnt have ACTIVE dz...ie respiratory compromise, would people here use NMB agents? Perhaps prolonged intubation would be necessary, but what if you had to do a appendectomy or something else that required more 'relaxation' that inhalation agents did not afford.
 

huktonfonix

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perhaps another alternative to 'deepening' him could have been using remifentanil, fast on and off. You dont have to use NMB agents then either. Either way, nice call on avoiding the NMBs I guess.

I know that I've been around attendings that have used NonDepol meds on patients with G-Barre which was in 'remission'. We reversed the guy, he had great 4/4 twitches, mx tone, head lift,etc. He was extubated and did well.

So the question is. Unless this guy doesnt have ACTIVE dz...ie respiratory compromise, would people here use NMB agents? Perhaps prolonged intubation would be necessary, but what if you had to do a appendectomy or something else that required more 'relaxation' that inhalation agents did not afford.
Sometimes these patients are sufficienly hypotonic that the agent is enough. Remember that you can always give more but you cant take it away. If the surgeon needs more relaxation then you can give some probably starting at low dose and increasing if needed. You mentioned remifentanil which is a great idea for intubations. 4 mcg/kg has been shown to produce excellent intubating conditions in some studies.
 
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